FAR EASTERN UNIVERSITY

Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 1 Basic Concepts in Psychiatric Nursing

Outline 1. Maximization of One’s Potential- oriented

1. Mental Health and Mental Illness towards growth and self-actualization
2. The Mental Health Nurse 2. Self-esteem- has realistic awareness of her
3. Developmental Theories abilities and limitations
4. Ego Defense Mechanisms 3. Mastery of the Environment-can deal with
and influence the environment
MENTAL HEALTH AND MENTAL ILLNESS 4. Autonomy and Independence- can work
Difference of Mental Health from Mental Illness interdependently without losing autonomy
Mental Health is a state of (E)emotional, (S)social 5. Reality Orientation- can distinguish the real
and (P)psychological wellness as evidenced by: world from a dream, fact from fantasy
• E -effective behavior and coping, 6. Tolerance of Life’s Uncertainties-can face
• S -satisfying interpersonal relationships, the challenges of day-to-day living with hope
• P -positive self-concept and & positive outlook in life
• E -emotional stability. (WHO) 7. Stress Management– ability to tolerate
anxiety and frustrations
Mental illness is a condition that impacts a person's
thinking, feeling or mood may affect and his or her Factors contributing to Mental Illness
ability to relate to others and function on a daily 1. Individual Factors include biologic make-
basis. Each person will have different experiences, up, anxiety, worries and fears, a sense of
even people with the same diagnosis. disharmony in life and a loss of meaning in
http://www.nami.org one’s life.
2. Interpersonal Factors include ineffective
Mental Disorder (American Psychiatric communication, excessive dependency or
Association, 2000) is defined as “a clinically withdrawal from relationships and loss of
significant behavioral or psychological syndrome or emotional control
pattern that occurs in an individual and that is 3. Cultural and social factors include lack of
associated with present distress (painful symptom) or resources, violence, homelessness, poverty,
disability (impairment in one or more important and discrimination such as racism, classism,
areas of functioning) or with a significantly increased ageism and sexism.
risk of suffering, death, pain, disability, or an
important loss of freedom.” Criteria to Diagnose Mental Disorders
• Lack of personal growth
Factors Influencing Mental Health • Dissatisfactions with one’s characteristics,
• Inherited characteristics accomplishments, abilities
• Social/ cultural • Ineffective or dissatisfying relationships
• Nurturing during childhood • Dissatisfaction with one’s place in the world
• Ineffective coping with life’s events
Nature vs. Nurture
DSM-IV-TR
Components of Mental Health Diagnostic and Statistical Manual of Mental
Mental health has many components and is Disorders (DSM-IV-TR) 4th edition – is a taxonomy
influenced by a wide variety of factors. (Johnson published by the American Psychiatric Association
1997) that describes all the mental disorders with a specific
diagnostic criteria. It is used by all mental health There was a focus on
disciplines and has three purposes: prevention.
1. To provide a standardized nomenclature and
language for all mental health professionals
2. To present defining characteristics or
symptoms that differentiate specific
diagnosis
3. To assist in identifying the underlying causes
of disorder. 21st Century • A diagnosable Mental
disorder
a. Axis I- Clinical Disorder that is the
• A serious emotional
focus of treatment disturbance impairing daily
b. Axis II– Personality Disorder and activities; leading cause of
Mental Retardation Disorder disability
c. Axis III– Medical Indications • An economic burden
d. Axis IV– Psychosocial and • Institutionalization versus
Environmental Problems deinstitutionalization;
e. Axis V- Global Assessment of revolving door effect
Community Based Care
Functioning (GAF) 0-100

Evolution of Mental Health Psychiatric Nursing THE MENTAL HEALTH NURSE

Time Period Concepts of mental illness Psychiatric nursing pertains to:
Ancient times Displeasure of the gods, a. Assessment of behavior, planning and
punishment for sins and wrong evaluation of care for individuals with mental
doings. disorders
b. Promotion of optimal mental health
It was thought to be a natural for individual, through early diagnosis,
phenomenon- a humanistic
treatment and rehabilitation
approach; imbalances of the four
c. Use of therapeutic interactions
humors.
Early Christian Evil spirits possessed the body and
between the nurse and the individual
Times (1100) must be driven out
Renaissance Decline in the belief of possession - Interpersonal process
(1300-1600) mental problems were irreversible. • whereby the nurse through the therapeutic
Scientific inquiry and humanism use of self
Period of A reform movement - chains • assist an individual, family, group or
Enlightenment and removed. Need for medical care community to promote mental health
Creation of Mental recognized. The first mentally ill
Institutions • help prevent mental illness and suffering
patient was treated in hospital.
(Eighteenth • participate in the treatment and rehabilitation
Century) of the mentally ill
Period of Scientific
Research began and legislation • Help find meaning in these experiences
Study (Nineteenth concerning mental health was
Century) enacted. Hospitals for the mentally
Psychiatric Nursing is an interpersonal process
ill were established with long term
custodial care. whereby the professional nurse practitioner assists an
Development of • The start of the mental health individual, family, and community to prevent or cope
Psychopharmacology movement. Large state with the experience of illness and suffering and if
and hospitals were built, necessary, to find meaning in those experiences.
Move towards psychoanalysis developed, and (Travelbee, 1970)
Community Mental community health care centers
Health (Twentieth established.
• A holistic concept of care and Mental Health Psychiatric Nursing is a specialized
Century)
short term care introduced. area of nursing that uses the theories of human
Goals were to return patients behavior and the purposeful use of self, as its art. It
into society, so human service is an interpersonal process whereby it promotes
programs were established. mental health, prevents mental illness, early
identification and intervention of emotional Each individuals The nurse is hopeful The nurse focuses on
problems, and follow-up care to minimize long term has some strengths about the client’s the client’s strengths
and a potential for ability to grow and assets, not on his
effects of mental disturbance.
growth weaknesses and
liabilities
Goals of Psychiatric Nursing Each individual is The nurse The nurse accepts the
• To help the client accepts himself unique and has appreciates the client as a unique
• To promote relationship with other people inherent value uniqueness and human being who has
inherent value of the value and worth
• To learn to function independently on a client exactly as he is
realistic basis All human beings The nurse feels The nurse has the
are sufficiently empathy with the potential for
Roles of a Psychiatric Nurse (Peplau) similar that there is client’s feelings establishing a
a basis for relationship with most
• Creator of the • Socializing agent
understanding and if not all clients
Therapeutic • Counselor communicating
Environment • Teacher with one another
• Technical Nursing Role • Parent surrogate All behavior is The nurse feels The nurse explores the
• Therapist purposeful and is curious about the client’s behavior for
designed to meet a meaning of the the need it is designed
need or to clients behavior to meet or the message
Levels of Care communicate a it is communicating
Level of Goal Interventions message
Care Behavior is The nurse cares The nurse views the
learned as an about clients even clients behavior
Primary Altering the a. Client and family nonjudgmental while
adaptation to an though they may not
Prevention causative or risk teaching earlier stressor and reciprocate her assisting him to learn
factors to hinder b. stress reduction is the best possible feeling more effective
development of c. psychosocial adaptation the adaptation
illness support individual is
Secondary Reducing the a. screening capable of making
at the time.
Prevention effects of mental b. crisis intervention
illness c. suicide prevention All individual The nurse feels The quality of the
learns behavioral competent in her interaction in which the
d. short term
adaptation ability to interact nurse engages with the
counseling primarily in therapeutically with client is a major
e. emergency interaction with persons who are determinant of the
counseling and short significant people mentally ill degree to which the
term hospitalization in his environment
client will be able to
Tertiary Minimizing long a. rehabilitation alter his behavioral
Prevention term residual program adaptations in the
effect b. vocational training direction of a more
satisfying interpersonal
c. after care support
relations
d. partial
hospitalization
options DEVELOPMENTAL THEORIES
Psychosexual Theory by Sigmund Freud
Beliefs, Feelings, and Principles conducive to the 1. Human Behavior is motivated by repressed
Effective Practice of Psychiatric Nursing sexual impulses and desires.
Belief Feeling Principle
2. Behavior is motivated by Subconscious
thoughts and feelings:
Human beings are The nurse feels she The nurse views the a. “A Freudian slip (slips of the tongue)
complex can be helpful to the client as a holistic
Systems of client, since she has being with a were not accidents or coincidence
interrelated parts, expertise in many multiplicity of but rather were indicators of
the whole of which areas of nursing interrelated and subconscious feelings or thoughts
is greater than the interdependent needs that accidentally emerged in casual
sum of the parts
day to day conversation”.
3. Human Personality was believed to function
at Three Levels of Awareness
 4. Believed that a person’s dreams is reflected Anal 1.5-3 y.o. Anus and surrounding area are
more of the subconscious and had significant major source of interest.
Voluntary sphincter control is
meaning (Gabbard, 2000) the goal.
5. Dream analysis is a primary method used in Ego develops gradually
psychoanalysis. It involves discussing a Phallic 3-5 y.o. Genital is the focus.
client’s dreams to discover their true meaning Penis envy & Elektra Complex
and significance. (girls).
Castration fear & Oedipus
6. Free association is another method used to
Complex (boys).
gain access to subconscious thoughts and Latency 5-11 y.o. Complexes are resolved.
feelings. The therapist tries to uncover the extended to Genital focus is turned to social
client’s true thoughts and feelings by saying 13 y.o. activities.
a word and asking the client to respond Formation of Superego.
quickly with the first thing that comes to Genital 11-13 y.o. Development of biologic
overlapping capacity for orgasm.
mind. with Starts to appreciate capacity for
7. Believed that self or ego used ego defense previous True Intimacy.
mechanisms methods of attempting to
protect the self and cope with basic drives or Three Levels of Awareness
emotionally painful thoughts, feelings and Conscious Pre-conscious/ Unconscious
events. These mechanisms operates at the Subconscious
unconscious level of awareness Functions when Ideas and Largest part of the
the person is reactions are mind
awake, aware of stored and
Structures of Personality himself, his partially Serves as storage
Id thoughts, feelings, forgotten or reservoir of
• Sexual and aggressive drive perceptions and painful memories
• Inborn what is going on Acts as & experiences
in the WATCHMAN which are difficult
• Operates on pleasure principle environment it prevents to recall
• Primary thinking process: Imagery unacceptable,
• Irrational and not based on reality disturbing Realm of houghts
unconscious and feelings that
memories from motivate a person
Ego reaching even he is totally
• Chief executive officer the conscious unaware of them.
• Operates on reality principle mind
Can be recalled by
• Secondary thinking process: logical and
Brought into psychoanalysis
reality-oriented consciousness
• Major functions: adaptation to reality, by recall
modulation of anxiety, problem solving,
control and regulates instinctual dives. Use Ego Defense Mechanisms
Functions:
Superego 1. To ward off anxiety
• CONSCIENCE- punishes one for 2. To resolve a conflict
something wrong that was done. 3. To protect self-esteem
• EGO-Ideal, rewards one for something good 4. To protect one’s sense of security
that was done.
• Residue of internalized values and moral *without defense mechanisms, anxiety might
training of early childhood overwhelm and paralyze and interfere with daily
Psychosexual Development living
Phases Age Ranges Developmental Focus *can be therapeutic or pathologic
Oral Birth-18 Mouth is the major site of *supposedly in action by 10 years of age
months tension and gratification
including
biting and sucking activities.
Coping/ Defense Mechanism
Id is present at birth.
Level 1: Psychotic Mechanisms (common to
healthy individuals before age of 5) Displacement
• Delusional Projection • Feelings are transferred or redirect to other
• Denial person or object that is less threatening
• Distortion • Negative DM; 3 entities involved
• Common Example: A husband comes home
Level 2: Immature Mechanisms (common in ages and yells at his wife after a bad day at work
3-15) • Patient Example: Mrs. Faust screams at
• Projection another patient after being told by her
• Schizoid fantasy psychiatrist that she cannot have a weekend
• Hypochondriasis pass.
• Passive-aggressive behavior
• Acting out Dissociation
• Separating and detaching a strong
Level 3: Neurotic Defenses (common to individuals emotionally charged conflict from one’s
aged teenagers and early adult) consciousness
• Intellectualization • “traumatic amnesia”
• Repression • Example: Amnesia that prevents recall of
• Displacement yesterday’s auto accident
• Reaction Formation
• Dissociation Denial
• Failure to acknowledge an unacceptable trait
Level 4: Mature Mechanisms (common well- or situation
adjusted persons) • Common Example: A student refuses to
• Altruism admit that she is flunking a course despite an
• Humor F on the 1st exam.
• Sublimation • Patient Example: Mr. Davis, who is alcohol
dependent, states that he can control his
General Nature of Coping Strategies drinking.
• Adaptive coping – for MILD form of
disorder Regression
• Palliative coping – for MODERATE form of • Returning to an earlier developmental stage
disorder • Common Example: a 6-year old wets the bed
at night since the birth of his baby sister
• Maladaptive coping – for SEVERE form of
disorder • Patient example: Mr. Hivey has isolated
himself in his room and has lain in a fetal
• Dysfunctional coping – for HIGH LEVEL
position since his admission
of form of disorder
Rationalization
Ego Defense Mechanisms
• D (3)– Displacement, Denial, Dissociation • Self-saving with incorrect illogical
explanation
• R (4) –Rationalization, Repression, Reaction
Formation, Regression • Look for reasoning or “because”
• I (3) - Introjection, Intellectualization, • Common Example: A student states, “I got a
Identification C on the test because the teacher asked poor
questions.”
• F (2) – Fixation, Fantasy
• Patient Example: Mr. Jones, a paranoid
• C (2) – Compensation, Conversion
schizophrenic, states that he cannot go to
• U (1) –Undoing work because he is afraid of his co-workers
• P (1) – Projection instead of admitting that he is mentally ill.
• S (5) – Splitting, Sublimation, Suppression,
Substitution, Symbolization Repression
• Unconscious forgetting of an anxiety • Patient example: Sheila states to the nurse,
provoking situation “When I get out of the hospital, I want to be
• Common Example: A car accident victim is a nurse just like you.”
unable to remember details of the impact, but
was aware at the time. Fantasy
• Patient example: Mrs. Yong, a victim of • Magical thinking
incest, does not know why she has always • Example: Daydreaming
hated her uncle
Fixation
Reaction Formation • occurs when a person is stuck in a certain
• Opposite of intention 1 feeling (-) and 1 developmental stage
action (+) or 1 feeling(+) and 1 action (-) • Example: Lack of a clear sense of identity as
• Common Example: An older brother who an adult.
dislikes his younger brother sends him gifts o Oral fixations
for every holiday.
• Patient Example: Miss Marla, who Conversion
unconsciously hates her mother, • Anxiety converted to physical symptoms
continuously tells staff how wonderful her • Presence of physical complaints
mother is. • Common Example: A student awakens with
a migraine the morning of a final examination
Intellectualization and feels ill to take it.
• Excessive use of abstract thinking; technical • Patient example: Mr. Jenson suddenly
explanation develops impotence after his wife discovers
• No emotions involved he is having an affair with his secretary
• Common Example: A wife states to her
husband that a dented car fender is much Compensation
better than a completely wrecked car and • Overachievement in one area to overpower
garage door. weaknesses or defective area.
• Patient Example: Mrs. Mann talks about her • Can also be compensating for another’s
son’s death and bout with cancer as being weaknesses
mercifully short without showing signs of • No relatedness on the weakness compensated
sadness. with strength.
• Common Example: An academically weak
Introjection high school student becomes a star in the
• Acceptance of another’s values and opinions school play.
as one’s own • Patient Example: A schizophrenic patient
• Imitation but no admiration, “like” who is unable to talk to other patients
• Common Example: While her mother is becomes known for his expressive poetry.
gone, a young girl disciplines her brother just
like her mother would.
• Patient Example: Without realizing it, a Undoing
patient talks and acts like his therapist, • Doing the opposite of what have done 1 (-)
analyzing other patients. action, then 1 (+) action; this is constant
• Common Example: After spanking her son, a
Identification mother bakes his favorite cookies.
• A conscious or unconscious attempt to model • Patient Example: After eating another
oneself after a respected person patient’s cookies, Mrs. Donnelly apologizes
• Superficial, imitation with admiration, “like” to the patients, cleans the refrigerator, and
• Common Example: When a little girl dresses labels everyone’s snack with their names.
up like her mother to play house, she tries to
talk and act like her mother. Projection
 • Blaming; Falsely attributing to another • Phobia – Displacement
his/her own unacceptable feelings. • Amnesia – Dissociation
• 2 entities involved always; (Adam to God) • Anorexia – Suppression
• Common Example: A teenager comes home • Bipolar Disorder – Reaction Formation
late from a date and states that her friend did • Borderline – Splitting
not bring her home on time. • Schizophrenia – Regression
• Patient Example: Katrina states that she used • Substance Abuse – Denial
marijuana while her boyfriend made her • Depression – Introjection
smoke it. • OC – Undoing
• Catatonic – Repression
Sublimation
• Channeling instinctual drives to a more
productive activity.
• Positive; 3 entities involved
• Common Example: An adolescent arrested
once for stealing later opens a business
installing security systems in banks.
• Patient Example: A former perpetrator of
incest who fears relapse initiates a local
chapter of Parents United.

Substitution
• Replaces a goal that can’t be achieved for
another that is more realistic.
• Weakness has relatedness to strength
• Example: A student nurse decides to be a
teacher because he or she is unable to master
clinical competencies

Symbolization
• Creates a representation to an anxiety
provoking thing or concept
• Use of tangible things as symbols
• Example: An engagement ring symbolizes
love and a commitment to another person

Suppression
• Voluntary or conscious exclusion from
awareness, anxiety-producing feelings, ideas
and situations
• Common Example: A student states, “ I
cannot think about my wedding tonight. I
have to study.”
• Patient Example: Michelle states to the nurse
that she is not ready to talk about her recent
divorce.

Defense Mechanisms Commonly Used In Each

Respective Disorders
• Paranoid – Projection
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 2 Psychosocial Assessment, NPR, and Therapeutic Communication

Outline: Content of Psychosocial Assessment

1. General Assessment Considerations 1. History
2. Common Behavioral Signs and Symptoms a. Age
3. Nurse-Patient Relationships b. Developmental stage
4. Therapeutic Communication c. Cultural Considerations
d. Spiritual Beliefs
GENERAL ASSESSMENT e. Previous History (Present health
CONSIDERATIONS: PRINCIPLES AND history, Past medical history, Family
TECHNIQUES OF PSYCHIATRIC NURSING history)
INTERVIEW 2. General appearance and Motor Behavior
Guidelines For Patient Interview a. Hygiene and Grooming
• Ensure patient privacy and respect for b. Appropriate Dress
boundaries (most comfortable at 3 to 6 feet; c. Posture
should not be less than 18 inches) d. Eye Contact
• Choose quiet, calm, private setting e. Unusual movements or mannerisms
• Reassure patient i. Automatism- repeated
• Show support and sensitivity purposeless behaviors like
• Listen carefully and objectively drumming fingers, twisting
• Use reliable information sources locks of hair, tapping of foot
• Consider patent’s culture ii. Psychomotor retardation-
slowed movements
Factors Influencing Assessment iii. Waxy flexibility-
maintenance of posture or
• Client Participation / Feedback. Client who
position overtime
is extremely depressed may not have the
f. Speech
energy to answer questions or complete the
i. Neologisms
assessment.
ii. Word salad
• Client’s Health Status. A client who is tired, 3. Mood and Affect
anxious, or in pain may not fully participate Expressed emotions
during assessment. Facial expressions
• Client’s Previous Experiences a. Mood is the client’s pervasive and
Misconceptions about Health Care enduring emotional state.
• Client’s Ability to Understand- Client’s b. Affect is the outward expression of
inability to hear, read, and understands the clients emotional state.
language being used may result to poor i. Blunted affect– little; slow to
gathering of data. respond facial expression
• Nurse’s Attitude and approach. Nurses ii. Flat affect– no facial
must be accepting, nonjudgmental especially expression
during the gathering sensitive information iii. Restricted affect– displaying
from the client. The nurse must be aware of one type of expression
his or her own feelings and responses and iv. Broad affect– full range of
approach assessment matter-of-factly. emotional expression
v. Inappropriate affect–
incongruent with mood or
situation
 Rate Mood example: • manic clients has no concept of time
depressed 0-10 scale • Confusion
4. Thought process and content • Memory (Recent & Remote)
a. Content (What the client is thinking)
b. Process ( How client is thinking) Abnormal Sensory experiences or
• Circumstantial thinking – answers misconceptions
questions but only after giving • Hallucinations– false sensory
excessive unnecessary detail. perceptions
• Delusion – fixed false belief o Auditory – most common type
• Flight of ideas– excessive amount of o Visual – 2nd most common
ideas and rate of speech; composed of o Tactile – Alcoholics
fragmented or unrelated ideas. o Olfactory – dementia; CVA
• Ideas of reference– general events o Gustatory – taste sensations
are directed to him. • Concentration (100-7-7-7; days of
o Example: hearing a speech on the week backward)
the news • Abstract thinking abilities – makes
• Loose associations– disorganized observations or interpretations
thinking jumping from one idea to • Proverb
another. o Similarity of apple and orange
• Tangential thinking – wandering off o Similarity of a television and
the topic newspaper
• Thought blocking – stopping 6. Judgment and insights
abruptly in a middle of a sentence or a. Judgment- interpretation of the
train of thought. environment
• Thought broadcasting – delusional b. Decision making ability
belief that others can hear or know c. Insight- understanding one’s own part
what the client is thinking. in current situation
• Thought insertion– delusional belief 7. Self-Concept
that others are putting ideas or thought a. Personal view of self
into the client’s head. b. Description of physical self
• Thought withdrawal– delusional c. Personal qualities or attributes
belief that others are taking the 8. Roles and Relationships
client’s thought always and is a. Current roles
powerless to stop it. b. Satisfaction with roles
• Word salad– flow of unconnected c. Success at roles
words that convey no meaning. d. Significant relationships
• Clarity of ideas e. Support systems
• Self-harm or suicide urges 9. Physiologic and self-care considerations
o Do you thought of suicide? a. Eating habits
o What thoughts of suicide have b. Sleep patterns
you had? c. Health problems
o What thoughts have you about d. Compliance with prescribed
hurting others? medications
o What is your plan? e. Ability to perform activities of daily
o Duty to warn – Health care living
providers are legally obligated
to warn the person who is the Mental Status Examination
target of threats or plan Definition
5. Sensorium and Intellectual processes A mental status examination (MSE) is an
Orientation (Person, Place and Time + Sphere assessment of a patient’s level of cognitive
or situation) (knowledge-related) ability, appearance, emotional
mood, and speech and thought patterns at the time of the appropriateness and clarity of the
evaluation. It is one part of a full neurologic (nervous answers, and similar characteristics.
system) examination and includes the examiner’s • Thought content. The examiner assesses
observations about the patient’s attitude and what the patient is saying for indications of
cooperativeness as well as the patient’s answers to hallucinations, delusions, obsessions,
specific questions. The most commonly used test of symptoms of dissociation, or thoughts of
cognitive functioning per se is the so-called Folstein suicide.
Mini-Mental Status Examination (MMSE), • Thought process. Thought process refers to
developed in 1975. the logical connections between thoughts and
their relevance to the main thread of
Purpose conversation. Irrelevant detail, repeated
The purpose of a mental status examination is to words and phrases, interrupted thinking
assess the presence and extent of a person’s mental (thought blocking), and loose, illogical
impairment. The cognitive functions that are connections between thoughts, may be signs
measured during the MSE include the person’s sense of a thought disorder.
of time, place, and personal identity; memory; • Cognition. Cognition refers to the act or
speech; general intellectual level; mathematical condition of knowing. The evaluation
ability; insight or judgment; and reasoning or assesses the person’s orientation (ability to
problem-solving ability. locate himself or herself) with regard to time,
place, and personal identity; long- and short-
Precautions term memory; ability to perform simple
A MSE cannot be given to a patient who cannot pay arithmetic (counting backward by threes or
attention to the examiner, for example as a result of sevens); general intellectual level or fund of
being in a coma or unconscious; or is completely knowledge (identifying the last five
unable to speak (aphasic); or is not fluent in the Presidents, or similar questions); ability to
language of the examiner. think abstractly (explaining a proverb);
ability to name specified objects and read or
Description write complete sentences; ability to
A complete MSE is more comprehensive and understand and perform a task (showing the
evaluates the following ten areas of functioning: examiner how to comb one’s hair or throw a
• Appearance. The examiner notes the ball); ability to draw a simple map or copy a
person’s age, race, sex, civil status, and design or geometrical figure; ability to
overall appearance. These features are distinguish between right and left.
significant because poor personal hygiene or • Judgment. The examiner asks the person
grooming may reflect a loss of interest in self- what he or she would do about a
care or physical inability to bathe or dress commonsense problem, such as running out
oneself. of a prescription medication.
• Movement and behavior. The examiner • Insight. Insight refers to a person’s ability to
observes the person’s gait (manner of recognize a problem and understand its
walking), posture, coordination, eye contact, nature and severity.
facial expressions, and similar behaviors.
• Affect. Affect refers to a person’s outwardly Key Terms
observable emotional reactions. It may • Aphasia- the loss of the ability to speak, or to
include either a lack of emotional response to understand written or spoken language. A
an event or an overreaction. person who cannot speak or understand
• Mood. Mood refers to the underlying language is said to be aphasic.
emotional “atmosphere” or tone of the • Cognition- the act or process of knowing or
person’s answers. perceiving.
• Speech. The examiner evaluates the volume • Coma- a state of prolonged unconsciousness
of the person’s voice, the rate or speed of in which a person cannot respond to spoken
speech, the length of answers to questions, commands or mildly painful physical stimuli.
 • Delusion- a belief that is resistant to reason Attention and Calculation:
or contrary to actual fact. Common delusions 4. Serial Sevens: give one point for each correct
include delusions of persecution, delusions answer. Stop after five answers. (5 points)
about one’s importance (sometimes called Recall
delusions of grandeur), or delusions of being 5. Ask for names of 3 objects learned in question
controlled by others. number 3. Give 1 point for each correct answer
• Dementia- a decline in a person’s level of ( 3 points)
intellectual functioning. Dementia includes
memory loss as well as difficulties with Language:
language, simple calculations, planning or 6. Point to a pencil and a watch. Have the patient
decision-making, and motor (muscular name them as you point (2 points)
movement) skills. 7. Have the patient repeat “No ifs, ands and buts.”
• Dissociation- the splitting off of certain (1 point)
mental processes from conscious awareness. 8. Have the patient follow a three-stage
Specific symptoms of dissociation include command: “Take the paper in your right hand.
feelings of unreality, depersonalization, and Fold the paper in half. Put the paper on the
confusion about one’s identity. floor.” (3 points)
• Hallucination- a sensory experience, usually 9. Have the patient read and obey the following
involving either sight or hearing, of “Close your eyes.” (Write it in large letters.) (1
something that does not exist outside the point)
mind. 10. Have the patient write a sentence of his or her
• Illusion- a false visual perception of an own choice. (the sentence should contain a
object that others perceive correctly. A subject and an object and should make sense.
common example is the number of sightings Ignore spelling errors when scoring.) (1 point)
of “UFOs” that turn out to be airplanes or 11. Enlarge the design printed below to 1 to 5 cm
weather balloons. per side and have the patient copy it. (Give one
• Obsession- domination of thoughts or point if all sides and angles are preserved and
feelings by a persistent idea, desire, or image. if the intersecting sides from a quadrangle.) (1
• Organic brain disorder- refers to impaired point)
brain function due to damage or deterioration
of brain tissue.

The Mini-Mental State Examination Total of 29 points

Orientation: Points
1. What is the year? 1 Interpretation:
season? 1 A score of 22 or less suggests cognitive
date? 1 Impairment in a person with an eight Grade
day? 1 education or better.
month? 1
Purposes of Psychosocial Assessment
2. Where are we city or town? 1 • Basis for Care
country? 1 • Baseline data for evaluation
hospital? 1 • Basis for Current mental status
building? 1
Content of the Assessment:
Registration: ALWAYS SEND MAIL THRU POST OFFICE
3. Name 3 objects, taking one second to say each. • A-Affect/Appearance
Then ask the patient all three after you have • S-Speech
said them. Give one point for each correct • M-Motor Behavior/Mood/Memory
answer. Repeat the answers until the patient • T-Thought Process
learns all three. (3 points) • P-Perception
 • O-Orientation • Magical Thinking– primitive thought
process → thoughts alone can change events
Mental Status Exam • Autistic Thinking– regressive thought
Focuses on the client’s cognitive abilities: process → subjective interpretations not
• Orientation to person, time, place, date, validated with objective reality
season, day of the week
• Ability to interpret proverbs Disturbance of Affect
• Ability to perform math calculations • Inappropriate – disharmony between the
• Memorization and short-term recall stimuli & the emotional reaction
• Naming common objects in the environment • Blunted – severe reduction in emotional
• Ability to follow multistep commands reaction
• Ability to write or copy a simple drawing • Flat Affect – absence or near absence of
emotional reaction
COMMON BEHAVIORAL SIGNS AND • Apathy – dulled emotional tone
SYMPTOMS • Depersonalization – feeling of strangeness
Disturbances in Perception: from one’s self
• Illusion – misinterpretation of an actual • Derealization– feeling of strangeness
external stimuli towards environment
• Hallucination – false sensory perception in
the absence of external stimuli Disturbance in Motor Activity
• Echopraxia – imitation of posture of others
Disturbance in Thinking & Speech • Waxy Flexibility – maintaining a position
• Neologism – coining of words that people do for a long period of time
not understand • Ataxia – loss of balance
• Circumstantiality – over inclusion of • Akathisia– extreme restlessness
inappropriate thoughts & details • Dystonia– uncoordinated spastic movements
• Word salad– incoherent mixture of words & of the body
phrases with no logical sequence • Tardive Dyskinesia– involuntary twitching
• Verbigeration – meaningless repetition of or muscle movements
words & phrases • Apraxia – involuntary movements without
• Perseveration – persistence of a response to purpose
a previous question
• Echolalia – pathological repetition of words Disturbance in Memory
of others • Confabulation – filling of memory gaps
• Aphasia – speech difficulty & disturbance • Deja’ vu – second-time like feeling
• Flight of ideas – shifting of one topic from • Jamais vu – feeling of not having been to a
one subject to another in a somewhat related place one has been before
way • Amnesia – memory loss , inability to recall
• Looseness of Association– incoherent, past events
illogical flow of thoughts (unrelated) • Retrograde – distant past
• Clang Association – sound of word gives • Anterograde – immediate past
direction to the flow of thought • Anomia – lack of memory items
• Delusion – persistent false belief, rigidly held
o Delusions of Grandeur– special / Other areas to assess:
important way • Intellectual functioning
o Persecutory – threatened • Insight
o Ideas of Reference – situation / • Judgment
events involve them • Concentration
o Somatic– body reacting in a • Orientation
particular way
 • History and Physiological aspects (not Self-Awareness and Therapeutic Use of Self
included in Mental Status Examination) Therapeutic Use of Self – is using one’s humanity –
personality, experiences, values, feelings,
NURSE-PATIENT RELATIONSHIPS intelligence, needs, coping skills and perceptions to
• are series of planned and purposeful activities help a client grow and change ( Northouse &
between the Nurse and Patient that are Northouse, 1998)
effective to patient’s recovery.
• The nurse and the client work together to According to Peplau (1952), Nurses must have a
assist the client to grow and solve his clear understanding of themselves to promote their
problems. This relationship exists for the client’s growth and avoid limiting client’s choices to
benefit of the client thus at every interaction, those valued by the nurse
the nurse uses self therapeutically.
Self-awareness is a process of understanding one’s
Therapeutic Relationships own values, beliefs, thoughts, feelings, attitudes,
Is a relationship that is established between a health motivations, strengths, and limitations and how
care professional and a client for the purpose of thoughts and behaviors affect others.
assisting the client to solve the problems. The
therapeutic nurse patient relationship is a mutual Therapeutic use of self is when the nurse uses
learning experience and corrective emotional aspects of his or her personality, experience, values,
experiences for the patient. It is based on the feelings, intelligence, needs, coping skills, and
underlying humanity of nurse and patient. In this perceptions to establish relationships with clients that
relationship the nurse uses personal attributes and are beneficial to clients.
clinical techniques in working with the patient to
bring about insight and behavioral changes. The Johari window is a self-awareness tool;
categorizes qualities of self as:
The psychiatric nurse uses tools of self and • open/public
knowledge as the basis of care. The psychiatric nurse • blind/unaware
needs well developed communication skills, • hidden/private
knowledge of nursing and psychological/psychiatric • unknown
theory, and knowledge of resources for community
referrals. The nurse using this set of skills and
knowledge, has the ability to offer interaction to the
client that are compassionate and empathetic, that
provide clients with the ability to see their current
situation in the light and focus on their strength and
abilities.

Components include:
• Trust (nurse is friendly, caring,
understanding, consistent; keeps promises;
listens; is honest)
• Genuine interest
• Empathy (not sympathy)
• Acceptance of person, not necessarily his or • Quadrant 1 Open / Public Self – qualities
her behavior one knows about oneself and others also
• Positive regard (unconditional, knows. Part of self that engages in daily
nonjudgmental attitude) conversation
• Quadrant II Semi Public Self / Blind /
Unaware self – qualities known only to
others
 • Quadrant III Hidden / Private Self – Orientation/Initiating Phase
qualities known only to oneself; includes • Begins when the nurse and client meet and
person secrets and private feelings. ends when the client begins to identify
• Quadrant IV Unknown / Inner Self – an problems to examine.
empty quadrant to symbolize qualities as yet • Sets the contract with the client which
undiscovered by oneself or others includes:
o Time, place and length of sessions
One can increase knowledge of oneself by: o Termination of sessions
1. Listening to oneself o Purpose of meeting
2. Listen to and learn from others o Client responsibilities
3. Disclosing oneself to others o Nurse responsibilities
*A change in one quadrant will affect other • Building of trust
quadrants • Closely observing the client and expects to be
closely observe by the client
Self-Awareness questions: • Makes interference and form judgment about
• Can you identify on time in your past when clients message and behavior
you wanted and or needed the presence of • Asses the client’s health status
another • Prioritizes the client’s problems and
• person to help with something. identifies the client’s goal
• How have you benefited from experience
silence with another? Working Phase
• Can you identify an individual you would • When the nurse and client work together to
seek out for support at a time of crisis? If yes, solve problems and accomplish goals
what qualities does that individual have? • Consists of 2 sub phases:
• How do you see yourself in a helping role o Problem identification– client
with others? identifies the issues or concerns
• Reflect on your activities when reaching out causing the problem
of others for the purpose of giving emotional o Exploitation– Nurse guide the client
support and / or comfort; which activities to examine feelings and responses
seem most effective? and to develop better coping skills
• How do you express caring to others, and a more positive self-image,
especially those with different lifestyles, encouraging behavior change and
abilities, cultural backgrounds, and languages developing independence.
than your own? • The client must feel that the nurse will not
turn away or be upset when experiences,
Phase of Nurse-Patient Relationship issues, behavior and problems are revealed.
Pre-interaction Phase Client may use outrageous behavior.
• Self assessment– the nurse considers her • Nurse must be non-judgmental and refrain
personal strength and limitation in working from giving advice but allowing the client to
with the client analyze situation.
• Before meeting the client, the nurse review • Specific task includes:
the available data, including the medical and o maintaining the relationship
nursing history and talking to other o gathering more data
caregivers who may have information about o exploring perceptions of reality
the client o developing a positive coping
• Anticipate health concerns of issue that may mechanism
arrive o promoting a positive self concept
• Identifies a location and setting that will o verbalization of feelings
foster comfortable, private interaction o facilitating behavior change
• Plan enough time for the initial interaction o promoting independence.
 Termination Phase the client, listening and responding in open
• Begins when the problems are resolved and it manner.
ends when the relationship is ended. 5. Empathy is the ability of the nurse to
• During the ending of the relationship the perceive meanings and feelings of the client
nurse: and to communicate that understanding to
o Reminds the client that termination is the client. Use of reflection, restatement and
near clarification helps relay emphatic messages
o Evaluates the goals achievement with to client.
the client
o Reminisces about the client by Avoiding Behaviors That Diminish The
relinquishing responsibility for his or Therapeutic Relationship
her care 1. Feelings of sympathy and encouraging client
o Achieves a smooth transition for the dependency (Empathy relays concern while
client to other caregiver as needed sympathy shows compassion.. Avoid feeling
o Nurse and client express thought and sorry or pleasing the client)
feelings about termination 2. Inappropriate boundaries ( Professional
• Observe client high level of anxiety during boundaries should be maintained)
this phase, exhibited such as: 3. Nonacceptance and Avoidance ( Avoid
o Hostility, increase dependence, prejudices)
regressive behavior, recall other
separation experience Problems in the Relationship
• The nurse should be firm in maintaining 1. Resistance
professionalism until the end of the 2. Transference occurs when the client
relationship. displaces onto the therapist attitudes &
• She should not promise the client that the feelings that the client originally experienced
relationship will be continued in other relationship (Gabbard 2000)
• The goal of the therapeutic relationship had 3. Countertransference – occurs when the
been met when the client has developed therapist displaces onto the client attitudes
emotional stability, cope positively recognize and feelings from his or her past.
sources of anxiety and independence and able
to perform self-care. Qualities of a Therapeutic Relationship
1. Trust– this is the outcome of honesty,
Components of a Therapeutic Relationship: sincerity, respect and being consistent.
1. Trust– Build when the client feels 2. Respect – call patient by his name; letting the
confidence / reliability in the nurse. Trusting patient decide on his own but with the nurse’s
behaviors includes: friendly, caring, interest, assistance
understanding, consistent, treats client as a 3. Acceptance – accepting patient as he is
human being, approachability, listening, 4. Consistency – promptness
keeps promises, provides schedules of 5. Empathy – understanding the patient’s
activities, and honesty. world from his point of view without losing
2. Genuine Interest occurs when the nurse is objectivity
open, honest and displays congruent behavior
3. Acceptance is made by avoiding judgments Establishing the Therapeutic Relationship
of the person, no matter what the behavior Therapeutic relationships are focused on the needs,
she/he manifested. ( do not accept experiences, feelings, and ideas of the client, not the
inappropriate behavior but the person as a nurse.
worthy individual)
4. Positive Regard. This is the unconditioned, The therapeutic relationship consists of three phases:
nonjudgmental attitude and implies respect. 1. Orientation phase- the nurse and client
Call the client by name, spending time with meet, roles are established, the purposes and
parameters of future meetings are discussed,
 expectations are clarified, and the client’s • Incongruency (when content and process do
problems are identified. not agree; nonverbal is more accurate)
2. Working phase- involves problem
identification, where the client identifies Therapeutic communication is an interpersonal
issues or concerns causing problems, and interaction between the nurse and client during
exploitation, when the nurse guides the client which the nurse focuses on the specific needs of the
to examine his or her feelings and responses, client to promote effective exchange of information.
develop better coping skills and a more
positive self- image, change behavior, and It involves interpersonal interactions between the
develop independence. nurse and the client. It focuses on the client’s specific
needs and is used to:
Two common elements can arise: • Establish the therapeutic relationship
1. Transference is when clients • Identify the client’s most important concerns
unconsciously transfer feelings they • Assess the client’s perceptions
have for significant persons in their life • Recognize the client’s needs
onto the nurse • Guide the client toward satisfactory and
2. Countertransference is when the acceptable solutions
nurse responds to the client based on his
or her own unconscious needs and Four Types of Touch
conflicts 1. Functional-professional touch
3. Termination or resolution phase begins 2. Social-polite touch
when the client’s problems are resolved and 3. Friendship-warmth touch
ends when the relationship is ended. It is 4. Intimacy touch
important to deal with feelings of anger or
abandonment that may occur. Essential Components of Therapeutic
Communication
Behaviors that Diminish Therapeutic 1. Privacy and Respecting Boundaries. The
Relationships most comfortable distance during the
• Inappropriate boundaries (relationship interaction are 3 to 6 feet apart.
becomes social or intimate) 2. Active Listening and Observation
• Feelings of sympathy and encouraging client a. Active Listening means refraining
dependency rather than promoting from other internal mind activities
independence and concentrating exclusively on
• Nonacceptance of client as a person because what the client is saying.
of his or her behaviors, leading to avoidance • Facing the client
of the client • Using moderate eye contact
• Nurse self-awareness is the way to avoid such • Removing physical barriers
problems. • Maintaining open body
posture
THERAPEUTIC COMMUNICATION • Leaning forward
Communication is the process people use to b. Active Observation means
exchange information: observing the speaker’s nonverbal
• Verbal (what is said, or content) actions as he communicates.
• Nonverbal (behavior such as facial 3. Confidentiality means respecting the client’s
expression, tone of voice, hesitancy, distance right to keep private information about his or
from speaker, or process) her mental and physical health and related
• Context (environment or situation, including care. Avoid any promises to keep secrets.
culture) This information may relate to the client’s
• Congruency (when content and process harming himself or others.
agree) 4. Touch
 a. Functional–professional touch is Nurse: "Do you think you
used in examinations or procedures. should tell the doctor?"
b. Social–polite touch is used in Focusing "This point seems worth looking
at more closely."
greeting, such as a handshake, “the air
"You said something earlier that
kisses”, or a gentle hand to guide I want you to go back to."
someone in the correct direction. Exploring "Would you describe that more
c. Friendship–warmth touch involves fully."
a hug in greeting, an arm around the Giving information "My name is…I am a student
shoulder of a good friend or back nurse.."
slapping in some men to greet friends Seeking clarification "What would you say is the
and relatives. main point of what you said?"
5. Self–disclosure means revealing personal Presenting reality "Your mother is not here…I am
a nurse."
information about oneself to clients, such as Patient: "Did you bring my car
biological information and personal ideas, today?"
thoughts, and feelings. (Deering, 1999). Nurse: "No, you do not have a
Nurses should share only their name, marital car. I drove my car here today."
status, number of children and a general idea Voicing doubt “That's hard to believe."
about the residence. "Really?"
Seeking consensual
validation
Therapeutic Communication Techniques
Verbalizing the
Examples implied
Using silence The client says: "We drink and Encouraging "How important is it for you to
smoke a lot here." The student evaluation (asking for change this behavior?"
thinks…how can that the client’s view of the
be…drinking alcohol in a state meaning or
hospital? But says importance of
nothing…using silence…the something)
client then says: "yes we drink a Attempting to " From what you say, I suspect
lot of cokes and smoke a lot." translate into feelings you are feeling relieved."
Accepting "Yes" or "I follow what you Suggested "Let's see if we can figure this
said" collaboration out.."
Giving recognition "I notice you combed your hair." Summarizing "Let's see if we can figure this
Offering self "I'll sit with you awhile." out.."
Using broad openings "What would you like to talk Encouraging "Let's see if we can figure this
about?" formulation of a plan out.."
"Tell me what's bothering you." of action
Using general leads “Go on. " Ummm..I am Identifying themes ...asking client to identify
(using neutral listening" recurrent patterns in thoughts,
expressions to "Tell me about it" feelings, and behaviors
encourage continued "So what do you do each time
talking by the client) you drink too much”
Placing the event in “Was this before or after…?"
time or sequence "What seemed to lead up to…?"
Making observations "You appear tense"
Verbal Communication Skills
"I notice you are biting your Use concrete messages
lips." • Concrete messages are specific and clear;
Encouraging "What do you think is abstract messages are unclear and vague and
description of happening to you right now…?" require interpretation
perceptions • Concrete messages elicit more accurate
Restating Client: "I can't sleep. I stay
awake all night."
responses and avoid the need to go back and
Nurse: "You have difficulty rephrase unclear questions, which interrupts
sleeping" the flow of a therapeutic interaction
Reflecting Patient: "Do you think I should
tell the doctor?"
Therapeutic communication techniques facilitate
interaction and enhance communication between
client and nurse. Techniques that encourage the
client to discuss his or her feelings or concerns in
more depth include:
• Exploring • Restating
• Focusing • Reflecting

Nonverbal Communication Skills

• Facial expression • Eye contact
• Body language • Silence
• Vocal cues

Goals of a Therapeutic Communication Session

• Establishing rapport
• Identifying issues of concern
• Being empathetic, genuine, caring, and
unconditionally accepting of the person
• Understanding the client’s perception
• Exploring the client’s thoughts and feelings
• Developing problem-solving skills
• Promoting the client’s evaluation of solutions

Therapeutic Communication Techniques

Accepting Offering self
Broad Opening Sequencing
Consensual Validation Presenting Reality
Encouraging Comparison Reflecting
Encouraging Description Restating
Encouraging Expression Seeking Information
Exploring Silence
Focusing Suggesting collaboration
General Leads Summarizing
Giving Information Translating into feelings
Giving Recognition Verbalizing the Implied
Making Observation Voicing Doubt
Formulating a plan of action

Non-Therapeutic Communication Techniques

Advising Reassuring
Agreeing Introducing unrelated topic
Belittling feelings Making stereotype
Challenging comments
Defending Rejecting
Disagreeing Requesting an explanation
Disapproving Testing
Giving approval Using denial
Giving literal responses Probing
Interpreting
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 3 Mental Health Psychiatric Nursing Practice

Outline o Abnormalities are associated with

1. Personality Theories and Determinants of Schizophrenia, Attention deficit /
Psychopathology Hyperactivity disorder and Dementia.
a. Biological Foundations • Limbic System
b. Psychosocial Theories o Thalamus– regulates activity,
c. Behavioral Theories sensation and emotion
d. Humanistic Theories o Hypothalamus– Temperature
e. Existential theories regulation, appetite control,
endocrine function, sexual drive and
PERSONALITY THEORIES AND impulsive behavior.
DETERMINANTS OF PSYCHOPATHOLOGY o Hippocampus and amygdala –
Human behavior is the collection of activities involved in emotional arousal and
performed by human beings and influenced by memory
culture, attitudes, emotions, values, ethics, authority, o Memory loss in Dementia, poorly
rapport, hypnosis, persuasion, and/or coercion. controlled emotions in Psychotic or
Manic behavior
Personality is the aggregate of the physical, mental
qualities of the individual as these interact Imaging Techniques
characteristic fashion with his environment. 1. CT scan- some persons with schizophrenia
have been shown to have enlarged ventricles;
this is associated with a poorer prognosis and
BIOLOGICAL FOUNDATIONS marked negative symptoms.
The Nervous System - The neuron is the functional 2. MRI- Solemon and Goldman Rakie (1995)
unit of the nervous system. Humans have about 100 found a 7% reduction in cortical thickness in
billion neurons in their brain. While variable in size persons with schizophrenia.
and shape, all neurons have three parts. Dendrites 3. PET / SPECT- Persons with Alzheimer’s
receive information from another cell and transmit disease have decreased glucose metabolism
the message to the cell body. The cell body contains in the brain and decreased cerebral blood
the nucleus, mitochondria and other organelles flow. Some persons with schizophrenia also
typical of eukaryotic cells. The axon conducts demonstrate decreased cerebral blood flow.
messages away from the cell body.
Neurotransmission Theories
Brain Abnormalities Neurotransmitters- chemical substances
Central Nervous System is composed of: manufactured in the neuron that aid in the
Left Hemisphere transmission of information throughout the body.
• Controls the right side of the body • Are metabolized and inactivated by enzymes
• Center for logical reasoning, analytical primarily Monoamine oxidase (MAO)
functioning such as reading, writing and
mathematical tasks 1. Dopamine – involved in control of complex
movements, motivation, cognition and
Right Hemisphere- center for creative thinking, regulation of emotional responses;
intuition, and artistic abilities synthesized from tyrosine. ( Antipsychotic
• Frontal lobe- control the organization of drugs work by blocking dopamine receptors
thought, body movement, memories, to reduce dopamine activity)
emotions and moral behavior.
 2. Norepinephrine– most prevalent • Functions of the ID
neurotransmitter; plays a role in changes in o Responsible for image formation or
attention, learning & memory, sleep & wish fulfillment
wakefulness and mood regulation. o Reflex method
(Antidepressants blocks reuptake od • Drives of ID and instincts
Norepinephrine) o sexual or libido
3. Serotonin – plays an important role in o aggressive– destructive component
Anxiety, Mood disorders and schizophrenia; • If Id is not controlled individual is antisocial,
plays a role in delusions, hallucinations and lawless as his primitive drive are expressed
withdrawn behavior in schizophrenia; freely
synthesized from tryptophan.
(Antidepressants blocks serotonin reuptake) Ego
• chief executive officer
Other Biological Theories • Operates on reality principle
1. Endocrine Theory– decrease in TSH causes • An integrator / mediator – its main function
depression is to effect an acceptable compromise
2. CSF Metabolite Theory- decrease in HVA between the crude pleasure seeking striving
(Homo Vanillic acid) is present in of the ID and the inhibitions of the
schizophrenia SUPEREGO.
o Decrease in HIAA (Hydroxy Indole
• Secondary process of thinking (logical &
Acetic Acid) is present in oriented on time)
schizophrenia
• Major personality mechanism that mediates
3. Vitamin D Deficiency Theory – Vitamin
between the person and environment
B1, B2, B6, folic acid, Ascorbic Acid,
Vitamin D. • Major functions: Adaptation to reality;
4. Genetics and heredity – Chromosome 14 modulation of anxiety; problem solving;
and 21 are linked to Alzheimer’s Disease control and regulate instinctual drives;
5. Stress and Immune System – A mediate ID drives and demands of reality;
compromised Immune system could evaluate and judge the external world; reality
contribute to the development of a variety of testing store of experiences in “memory”;
illnesses. direct motor activities and action use defense
6. Infection– Streptococcus is linked to OCD mechanism to protect self
(Obsessive compulsive Disorder) • As the individual matures, the EGO becomes
the rational, reasonable, conscious part of
PSYCHOSOCIAL THEORIES personality and strives to integrate the total
Sigmund Freud (1856 – 1939) personality into a smoothly functioning
Psychoanalytic Theory unified, coherent whole.
Human behavior is motivated by repressed sexual o Powerful EGO– mature, effective
impulses and desires. and stable adult life

Three Structures of Personality Superego

Id • The part of psyche that develops when the
• Unconscious part containing the uncultured, standards of the parents and of society are
primitive drives and instincts/ impulses of the • incorporated.
individual. Sexual and aggressive drive • It incorporates the taboos, prohibitions,
• Born with it ideals, standards of the parents and
• Governed by pleasure principle (reduce significant
tension by immediate gratification) tendency • adults with whom the child associates.
to seek pleasure and avoid pain It is without • Angel/ blind / moralist / perfectionist
sense of right and wrong irrational and not • Operates in all levels of the mind but mostly
based on reality carried in the subconscious mind.
 • Conscience, punishes one for something thoughts and feelings by saying a word and asking
wrong that was done the client to respond quickly with the first thing that
• Ego- ideal, rewards one for something good comes to mind.
that was done
• Superego is fully developed at age 7 – age of Believed that self or ego used ego defense
reason. mechanisms methods of attempting to protect the self
• if superego is so strong, the individual is and cope with basic drives or emotionally painful
inhibited, repressed, unhappy and guilt thoughts, feelings and events. These mechanisms
ridden. operates at the unconscious level of awareness.

Behavior is motivated by Subconscious thoughts Defense Example Purpose

Mechanism (Clinical)
and feelings:
Compensation
“A Freudian slip (slips of the tongue) were Making up for a A college student To gain
not accidents or coincidence but rather were perceived weakness academically superiority or to
indicators of subconscious feelings or thoughts that or over achievement weak becomes a overcome
accidentally emerged in casual day to day in a more beauty queen in weaknesses and
comfortable way her school achieve success
conversation”.
Projection
Attributing to one’s A mother told that Protects self-
Three Levels of Awareness own motive to her child doesn’t image
1. Conscious- functions when the person is someone else, for know how to
awake, aware of himself, his thoughts, unacceptable dance ballet. She
feelings, perceptions and what is going on in desires blame it on poor
thoughts or any dance instructors.
the environment wrongful acts.
2. Pre-conscious (Subconscious)- Ideas and Rationalization A client’s inability Cope with
reactions are stored and partially forgotten An act of explaining to stop smoking inability to
o acts as WATCHMAN – it prevents or reasoning away resulting to a bad meet certain
unacceptable, disturbing unconscious unacceptable data, marriage standards
that sounds logical
memories from reaching the Identification A nurse, alone in To avoid self-
conscious mind Projecting the her room, devaluation
o brought into consciousness by recall behavior of delivering a
3. Unconscious- largest part of the mind someone who is lecture she
o serves as storage or reservoir of respected, admired imitates from her
or afraid of mentor
painful memories & experiences Denial A woman told her It isolate a
which are difficult to recall An attempt to father she has person from the
o realm of thoughts and feelings that screen or ignore cancer but impact of a
motivate a person even he is totally unacceptable continues to plan a traumatic
unaware of them. realities by refusing family reunion 2 experience
to acknowledge years in advance
o can be recalled by psychoanalysis them
Displacement A husband and Allows feeling
Believed that a person’s dreams is reflected Redirecting wife are fighting, to be express
more of the subconscious and had significant emotional reaction and as the husband from
meaning (Gabbard, 2000). from one person to becomes more less harmful
another angry, he hit his objects or
dog instead of his people
Dream analysis is a primary method used in wife
psychoanalysis. It involves discussing a client’s Intellectualization A woman tells her It shields a
dreams to discover their true meaning and Act of getting away neighbor that she person from
significance. painful incident loves her child so traumatic stress
with the use of much but fails to or events
rational explanation demonstrate her
Free association is another method used to love to her child
gain access to subconscious thoughts and feelings. Sublimation A father who lost It shields a
The therapist tries to uncover the client’s true Unacceptable his child in a fire, person from
behavior is replaced behaving in
 by a socially joined an irrational and Anal 18-36 mos. Anus and surrounding area are
acceptable impulse organization that impulsive ways major source of interest
or activities educates the Acquisition of voluntary
public on fire sphincter control (toilet
prevention training)
Introjections Without knowing Helps person Phallic/ 3-5 y.o Genital focus of interest ,
Allows the it, a student avoid social Oedipal stimulation of excitement penis
acceptance of delivers a speech, retaliation and is organ of interest for both
behavior into acting like her punishment sexes, Masturbation is common,
oneself professor in a penis envy (wish to possess
speech class penis) seen in girls; oedipal
Regression Terminally ill Allows a person complex (wish to marry
Reversion of cancer patient to return to a opposite sex parent and be rid of
thought or behavior allows her doctor point same sex parent) seen in boys
to a more desirable to visit her more in development and Electra complex in girls
level often when nurturing Latency 5-11 or 13 Resolution of oedipal complex,
and y.o. Sexual drive channeled into
developing socially appropriate activities
were needed such as school work and sports,
and accepted formation of the superego
with comfort Genital 11-13 y.o. Final stages of psychosexual
Reaction A client is angry It allows a development, begins with
Formation about the attention person’s puberty and the biologic
When a person feels and care he is feelings to be capacity for orgasm; involves
opposite of one’s receiving, but acted out in a the capacity for true intimacy
true emotion ant behaves more
aware of it in a calm and acceptable way Erik Erikson’s Psychosocial Theory of Human
collected manner
Undoing A father was very Helps a person
Development
Loosening of acts, angry and hit his to relieve his
thoughts and feeling child with a stick guilty feelings
from the past but the next day he
brought home a
fried chicken
Substitution A mother to adopt To hasten
Replacement of a child looking frustration in
unacceptable goal exactly like her life
into a more realistic dead son but
or attainable objects ended up having Aids in meeting
someone looking goals
a little bit like him

Freud theory of childhood development was based

on the belief that sexual energy, termed libido, was Harry Sullivan’s Stages of Healthy Interpersonal
the driving force of human behavior. Children were Development
thought to progress through 5 stages of Psychosexual Infancy Birth to Primary need for bodily
Development. onset of contact and tenderness
language Prototaxic mode
dominates (no relation
Five Stages of Psychosexual Development between experiences)
Primary zones are oral and
Phase Age Focus anal
Oral Birth to 18 Major site of tension and If needs are met, infant has
mos. gratification is the mouth, lips sense of well-being; unmet
and tongue, including biting and needs lead to dread and
sucking activities. ID present at anxiety
birth and sucking activities, Childhood Language to Parents viewed as source
EGO develops gradually from 5 years of praise and acceptance
rudimentary structure present at Shift to parataxic mode
birth (experiences are
connected in sequence
 to each other) Concrete Operational Reversibility attained; can solve
Primary zone is anal conversation problems; logical
Gratification leads to operation developed and
positive self-esteem applied to concrete problems;
Moderate anxiety leads to cannot solve complex verbal
uncertainty and insecurity; problems
severe anxiety results in Formal Operational Logically solves all types of
self-defeating patterns of (11 y.o. to adulthood) problems; thinks scientifically;
behaviors Solves complex problems;
Juvenile 5-8 years Shift to the syntaxic mode cognitive structures nature
begins (thinking about self
and others based on Lawrence Kohlberg’s Development of Moral
anlysis of experiences in a
variety of situations). Reasoning
Opportunities for approval
and acceptance of others Level Stage Social Orientation
Learn to negotiate own 1 Obedience Orientation and
needs Punishment Reflexes cause
Severe anxiety may result actions
in a need to control or “I must follow the rule otherwise
restrictive, prejudicial I will be punished”
attitudes. Preconventional 2 Instrumental Relativist
Preadolescence 8-12 years Move to genuine intimacy Orientation (Individualism,
with friend of the same sex Instrumentalism and Exchange)
Move away from family as Conforms to obtain rewards or
source of satisfaction in favors “I must follow the rules
relationships for the reward and favor it gives”
Major shifts to syntaxic 3 Good-boy-Nice girl Orientation
mode Seeks good relations and
Capacity for attachment, approval of family group;
love, and collaboration Orientation to interpersonal
emerges or fails to relations of mutuality
develop. “I must follow rules so I will be
Adolescence Puberty to Lust is added to Conventional accepted”
adulthood interpersonal equation. 4 Society-Maintaining Orientation
Need for special sharing Obedience to Law and Order in
relationship shifts to the society; maintenance of social
opposite sex. order shows respect to authority
New opportunities for “I must follow rules so there is
social experimentation order in the society”
lead to the consolidation of 5 Social Contract Reorientation
self-esteem or self- Concerned with individual
ridicule. rights and legal contract; social
If the self-esteem is intact, contract; utilitarian lawmaking
areas of concern expand to perspective
include values, ideals, “I must follow rules as there are
career decisions, and reasonable laws for it”
social concerns. 6 Universal Ethical Principle
Post Orientation (Principled
Jean Piaget’s Theory of Cognitive Development Conventional Conscience)
Sensorimotor Development proceeds from Higher Law and Conscience
(0-2 y.o) reflex activity to representation Orientation
and sensory Orientation to internal decisions
motor solutions to problem of conscience but without clear
rationale or universal; principles
Pre-operational Problems solved through
‘I must follow rules because my
(2-7 y.o.) REPRESENTATION;
conscience tells me”
language development ; (2 –
4 years) thoughts and language
both EGOCENTRIC; cannot
solve conversation problems
 Behaviorist believe that behavior can be changed by
Hildegard Peplau: Therapeutic Nurse- Patient a system or rewards and punishments.
Relationship
She Developed the concept of nurse-patient Ivan Pavlov: Classical Conditioning
relationship which includes four phases: orientation, Behavior can be changed by conditioning with
identification, exploitation, and resolution. During external or environmental conditions or stimuli.
these phases, the client accomplishes tasks and the His experiment with dogs involved his observation
relationship changes, which helps the healing that dogs naturally began to salivate (response) when
process (Peplau, 1952) they saw or smelled food (stimulus). Pavlov set to
1. The orientation phase is directed by the nurse change his salivating response or behavior by
and involves engaging the client in treatment, conditioning. He would ring a bell (new stimulus)
providing explanations and information, and and then produce the food, and the dogs would
answering questions. salivate ( the desired response). He repeated the
2. The identification phase begins when the ringing of the bell along with the presentation of food
client works interdependently with the nurse, many times. Eventually, he could ring the bell and
expresses feelings, begins to feel stronger. the dogs salivate without seeing or smelling the food.
3. In the exploitation phase, the client makes The dogs are “conditioned” or had learned a new
full use of the services offered. response – to salivate when they heard the bell.
4. In the resolution phase, the patient no longer
needs professional services and gives up B.F. Skinner: Operant Conditioning
dependent behavior. Behavior is learned from one’s history or past
experiences that were repeatedly reinforced.
Peplau’s Stages and Tasks of Relationships
Stages Tasks Principles of Operant Conditioning described by
Orientation • Clarification of patient’s problem and Skinner (1974) form the basis of behavior techniques
needs used today:
• Patient asks questions
• Explanation of hospital routines and
1. All behavior is learned.
expectations 2. There are consequences that result from
• Patient harnesses energy toward behavior – reward and punishment.
meeting problems Patient full 3. Behavior that is rewarded with reinforcers
participation is elicited tends to occur.
Identification • Patient responds to persons he or she 4. Positive reinforcers that follow a behavior
perceives as
increase the likelihood that the behavior will
• helpful. Patient feels stronger.
• Expression of feelings recur.
• Clarification of roles of both patient 5. Negative reinforcers that are removed after a
and nurse behavior, increase the likelihood that the
Exploitation • Patient makes full use of available behavior will recur.
services. 6. Continuous reinforcement (a reward every
• Goals such as going home and returning time the behavior occurs is the fastest way to
to work emerge.
• Patient behaviors fluctuate between
increase that behavior, but the behavior will
dependence and independence. not last long after the reward ceases.
Resolution • Patient gives up dependent 7. Random, intermittent reinforcement (a
• behavior Services no longer reward for the desired behavior once in a
• needed by patient. while) is slower to produce an increase in
• Patient assumes power to meet own behavior, but the behavior continues after the
needs, set new goals, and so forth. reward ceases.
BEHAVIORAL THEORIES Behavior modification is a method of attempting to
Behaviorism is a school of psychology that focuses strengthen a desired behavior or response by
on observable behaviors and what one can do reinforcement, either positive or negative.
externally to bring about behavior changes.
Positive reinforcement is applied in this situation. If A - activating event
the desired behavior is assertiveness, whenever the B - belief about A
client uses assertiveness skills in a communication C – emotional reaction
group, the group leader provides positive D – disputing & changing philosophies A
reinforcement by giving client attention and positive E – end result; effective new A does not cause C; B
feedback. causes C

Negative reinforcement involves removing a Victor Frakl’s Logotherapy

stimulus immediately after a behavior occurs so that Logo therapy asserts that life must have meaning
the behavior is more likely to occur again. If a client and therapy is the search for that meaning
becomes anxious when waiting to talk in a group, he
may volunteer to speak first to avoid anxiety. Gestalt Therapy by Frederick “Fritz” Perls
Gestalt therapy emphasizes self-awareness and
Systematic Desensitization can be used to help identifying thoughts and feelings in the here and now
clients overcome irrational fears and anxiety
associated with phobia. Reality Therapy by William Glasser
Reality therapy focuses on the person’s behavior
The client is asked to make a list of situations and how that behavior keeps the person from
involving the phobic object, from the least anxiety- achieving life goals. Belief that patients &
provoking to the most anxiety – provoking. The delinquents share the
client learns and practices relaxation techniques to common characteristics of denying "the reality of the
decrease and manage anxiety. The client is then world around them” instead of fulfilling their needs
exposed to the least anxiety provoking situation, responsibly within the context of reality & society.
using relaxation techniques to manage the resulting The Goal is to help face reality and develop
anxiety. The client is gradually exposed to more and responsible behavior patterns, needs for love &
more anxiety provoking situation until he or she can worth can be met effectively.
manage the most anxiety-provoking situation.

HUMANISTIC THEORIES
Humanism focuses on the positive qualities of the
person, his or her capacity to change (human
potential) and the promotion of self-esteem.

Maslow’s Hierarchy of Needs

Self
actualization
Fulfilment of unique potential
Self-esteem
Self-esteem, respect, prestige

Love and belonging

Giving and receiving affection; companionship; group identification

Safety
Avoiding harm; security and order; physical safety

Physiologic
Biological needs for oxygen water, food, sleep, sex

EXISTENTIAL THEORIES
Albert Ellis Rational Emotive Therapy
People make themselves unhappy through “irrational
beliefs and automatic thinking”—the basis for the
technique of changing or stopping thoughts RET
attacks using ABC theory of personality
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 4 Psychiatric Interventions

Outline: Psychiatric Neurosurgery involves the surgical

1. Biophysical/Somatic Interventions ablation or disconnection of brain tissue with the
a. Psychiatric Neurosurgery intent of altering abnormal affective and behavioral
b. Electroconvulsive states caused by mental illness. It is classified as a
2. Milieu Therapy functional neurosurgical procedure because it
3. Psychosocial Interventions attempts to improve or restore function by altering
a. Therapeutic Community Meetings underlying physiology. The surgical target may be
b. Activities Of Daily Living cerebral cortex, nuclei or pathways that display either
c. Recreational Therapy normal or abnormal physiologic activity. Other
d. Music and Art Therapy functional neurosurgical procedures include the
e. Biblio Therapy surgical treatment of epilepsy in which a temporal
f. Occupational Therapy lobe may be removed or the surgical treatment of
g. Exercise Therapy Parkinson’s Disease in which lesions are made in the
h. Patient Education basal ganglia.
i. Spirituality Groups
j. Group Therapy ELECTROCONVULSIVE THERAPY
k. Treatment Meetings Electroconvulsive Therapy is a treatment in which
4. Supportive Psychotherapy a grand mal seizure is artificially induced by passing
a. Nurse-patient therapy an electrical current through electrode applied to one
b. Group Therapy or both temples.
c. Family Therapy • First introduced by Ugo Cerletti & Luciano
5. Behavior Therapies Bini (Cerletti’s assistant) in 1938.
a. Behavior Modification Therapy • The most common range for affective
b. Skills Training disorders is from 6 to 12 treatments, whereas
c. Self-control as many as 30 may be given in schizophrenia.
d. Respondent Conditioning • It is usually given three times a week on
e. Exposure Methods alternate days.
6. Attitude Therapies
a. Active Friendliness
Indications for use:
b. Passive Friendliness
1. Major depressive illness that has not
c. Kind Firmness
responded to antidepressant medication or
d. Matter Of Fact
inpatients who are unable to take
e. No Demand
medication
7. Psychopharmacology
2. Bipolar disorder in which the patient has
a. Antipsychotic drugs
not responded to medication
b. Antidepressants
3. Acutely suicidal patients who have not
c. Mood Stabilizing Drugs
received medication long enough to
achieve a therapeutic effect.
BIOPHYSICAL/ SOMATIC INTERVENTIONS
PSYCHIATRIC NEUROSURGERY
Contraindications:
1. history of trauma
 2. tumor of the brain; epilepsy • Treatment switch is presses after adjusting the
3. any heart condition ex. Congestive heart dosage and the patient goes into grand mal
failure seizures. The electrical current is given up to
4. hypertension 150 volts for 0.5 to 2 seconds.
5. respiratory failure; acute PTB • When the convulsion subsides and breathing
6. any febrile condition is resumed, turn the patient on his side to
prevent swallowing of saliva.
Equipment Used: • Ventilation and monitoring continues until
1. ECT machines with electrodes with the patient has recovered
perforated rubbers
2. wooden bed with mattress Nursing Interventions after ECT:
3. mouth protector or gag • Let the patient feel comfortable in bed and let
4. small pillows him go to sleep
5. electrode jelly • Monitor respiratory problem
6. towels to wipe perspiration • Avoid draft and exposure
7. restrain (prn) • Re-orient the patient when he wakes-up
8. hypotray with emergency stimulus • Documents all treatments
9. inhalator, resuscitator, aspirator
• After the patient is oriented and has rested, let
10. 3– 4 assistants
him have a shower and start his usual
11. emesis basin
activities
Preparation for ECT
MODERN ELECTROCONVULSIVE THEORY
Before the day of ECT
• Electrical current is passed through the brain
• The patient must complete a thorough for 0.2 to 8 seconds causing a seizure
physical, neurological and laboratory • Seizures are timed and subdivided into motor
examination
convulsions (at least 20 seconds), increase
• Informed consent is obtained heart rate (30-50 sec), and a brain seizures
• NPO after midnight monitored by an electroencephalogram
(EEG)
On the day of ECT • Patient is given an oximeter and anesthetic
• Ask the patient to remove jewelry, hairpins, response is monitored to ensure optimal
eyeglasses, and hearing aids, dentures • Dress oxygenation.
the patient in loose, comfortable clothing
• Have the patient empty the bladder, Preparation for Modern ECT
administer pretreatment medication • pre-treatment evaluation including PE , lab
• Check vital signs work (blood count, blood chemistries,
urinalysis), and baseline memory abilities.
Procedures for ECT • consent
• Make patient lie simply, with the back resting • Routine use of benzodiazepines or
on a pillow to promote hyperextension of the barbiturates for nighttime sedation should be
spine to prevent fractures of vertebrae or eliminated
dislocation
• Let the patient bite the mouth gag Nursing Responsibilities before Modern ECT
• Apply the electrode jelly on the temple to • The patient should not be given anything by
ensure complete contact mouth for approximately 6-8 hours before
• Terminal plugs are inserted into electrodes ECT, except for cardiac antihypertensives
• Two assistants support shoulders and wrist and few other medications.
joints and another to support the knee • Atropine (or glycopyrolate - Robinol) should
be given as ordered. Atropine can be given 1
 hour before treatment or intravenously TALBOT & MILLER 1966
immediately preceding treatment. An ideal psychiatric hospital is not merely a
• The patient should be asked to urinate before sanctuary, a cotton padded milieu that emphasizes the
the treatment fragility, the incompetence, the helplessness, the
• The patient's hairpins, contact lenses, hearing bizarreness of patients. Rather it should reflect a sane
aids and dentures should be removed. society by permitting the optimal use of the intact ego
• Vital signs should be taken capacities through its social organization, its social
• The nurse should be positive about treatment supports and its community values.
and attempt to reduce the patients' anxiety.
GOAL: To organize all interpersonal and
Procedures during Modern ECT environmental forces to develop an atmosphere that
• An intravenous line is inserted facilitates patient’s growth, rehabilitation and
• Electrodes are attached to the proper place or restoration of health.
the head, electrodes are typically held in place
with a rubber strap. 3 Essential feature of the Therapeutic
• The bite block is inserted Environment (Leibenluft & Goldberg 1987)
• Methohexital (Brevital) or another short- 1. distribution of responsibility and decision making
acting barbiturate is given IV 2. high level of interaction between patients and staff
• Succinylcholine (Anectine) a neuromuscular 3. clarity of the role and leadership of the program
blocking agent is given. This causes paralysis
but not sedation, thereby living the patient ELEMENTS OF THE EFFECTIVE MILIEU
conscious but unable to breathe. This prevents 1. Safety – freedom from danger and harm
external manifestations of a grand-mal a. Protection from psychological harm
seizures but not the brain seizures. b. Freedom from physical harm
• The anesthesiologist mechanically ventilates 2. Structure – includes the regulations, daily
the patient with 100% oxygen immediately schedule of activities, physical design of the
before treatment. unit ( a space for socializing, area of privacy,
• 5% to 10% of patients are awake and in telephones, visiting rooms)
agitated state and must be given 3. Norms
benzodiazepine. a. Expectations of behavior
• Observation is necessary until the patient is b. Norm of nonviolence
oriented and steady particularly when the 4. Limit Setting
patient first attempts to stand. a. Acting-out behaviors – self destructive
acts, physical aggressiveness, and sexual
• All aspects of the treatment should be
behavior
carefully documented for the patients’ record.
b. Other behaviors – excessive requests,
attempts to overly personalize the
MILEAU THERAPY
therapeutic relationship, and refusal to
Mileau Therapy is the manipulation of the patient’s participate in treatment activities.
environment by producing changes in the patient’s 5. Balance – involves the process of gradually
personality through the use of group activity. allowing independent behaviors in a dependent
situation.
Milieu Management/Environmental Modification
is the purposeful use of all interpersonal and PSYCHOSOCIAL INTERVENTIONS
environmental forces to enhance mental health of
Psychosocial interventions are nursing activities that
psychiatric patients through the development of a
enhance the client’s social and psychological
therapeutic environment.
functioning and promote social skills, interpersonal
relationships, and communication. These
interventions are used in mental health and other MUSIC ART THERAPY
practice areas. Music and Art Therapy ( Music Appreciation thru
Arts)
THERAPEUTIC COMMUNITY MEETINGS • Music therapy is the opportunity for
Therapeutic Community Meetings – a regular socialization and self-expression and
meeting that all staff and patients attend for the realization affected by certain musical
purpose of welcoming new patients, reviewing unit activities
rules and making general announcements about the • Art therapy is the process of letting the client
day’s activities express his feelings and thoughts through
a. Circle meetings – highlights of the 24 hours. various artistic means particularly sketching
b. Small Group meeting – personal problems and drawing
of clients • One type of therapy with purposeful use of
c. Community Meeting – problems of client music and art as a participative or listening
encountered in the ward of general interest experienced in the treatment of the patient to
d. Treatment planning – treatment regimen of improve and motivate their mental and
a client emotional state. • Designed to increase
e. Discharge Planning Conference – discharge client’s perception, concentration, memory
plan for patient retention, conceptual development, rhythmic
f. Patient government Meeting – officers of behavior, verbal retention, and auditory
the clients discuss issue related to their discrimination.
welfare • Used to stimulate thoughts and feelings.
g. Staff’s Shift-to shift Meeting – endorsement
h. Advisory Board Meeting – discussion of the
Objectives:
demotion and promotion of patient status
• To serve as diagnostic tools
ACTIVITIES OF DAILY LIVING • To uncover emotional traumatic experience
• To provide a medium for stimulation of inner
Activities of Daily Living – an activity done by an
feelings through music and art.
individual which is necessary for the promotion of
good personal hygiene which can be done with or
without assistance / supervision to an individual. BIBLIO THERAPY
Biblio-therapy (Newspaper reading; Literature
• To promote and improve personal hygiene
reading; Film review; Bible reading and others)
and grooming
• Used of literature, film, or feature on creative
• To promote self-independence
writing with group discussion to promote
• To encourage participation
self-acknowledgment and interaction of
• Evaluation through return demonstration thoughts and feelings.
• To develop interpersonal relationship • Is a therapy that enhances client’s awareness
regarding an article or material as well as it
RECREATIONAL THERAPY/ PLAY increases their level of understanding with the
THERAPY information and content of such reading
Recreational Therapy / Play Therapy - is a materials.
technique that makes possible for the client to express • It stimulates the inner self by expressing their
himself through sports. Free play enables the feelings regarding the given story
individual unique opportunity to discharge strong
emotion in a secured environment. A therapy that
OCCUPATIONAL THERAPY
brings fun and form of exercise, socialization with
others, cooperation, diverting client’s attention, Occupational Therapy is any given mental or
promote sportsmanship and expresses feelings and physical given to an individual to recover from a
thoughts. handicap.
Objectives: big boat that floats (ship)? Show
• To improve general performance visual aid / read a poem and ask
• To obtain essential skills for living clients to read.
3. Sharing the World We live In (15 minutes)
• To assist in symptom reduction
• Ask questions using the five “W”
• To increase the sense of accomplishment,
4. Appreciation of the Woks of the World (10
satisfaction and control over one’s own life Minutes)
• To increase social responses • Ask occupations related to the topic
• To increase self-esteem. • Example: Have you ever worked in a ship?
What work can you get in a ship?
EXERCISE THERAPY 5. Climate of Appreciation (10 minutes)
Exercise Therapy – helps channels the negative • Ask participants to summarize what has been
energy of anxiety and agitation into a more talked about.
appropriate outlets
• Appreciate the ideas, contributions shared by
members – no members should be excluded
PATIENT EDUCATION
• Inquire some preferred topics for next week’s
session.
SPIRITUALITY GROUPS
TREATMENT TEAM MEETINGS
GROUP THERAPY
Group Therapy– facilitates awareness and insight
BEHAVIOR THERAPIES
about behavior and to develop plans for change or
BEHAVIOR MODIFICATION
coping.
Increasing the probability that the Behavior will
recur
REMOTIVATION TECHNIQUE
• Conditioning Positive Reinforcement is a
Remotivation technique is a simple group therapy
process by which a behavior is followed with
of an objective nature used in an effort to reach the
a reinforcing stimulus that increase the
unwounded areas of the client’s personality and get
probability that the behavior will recur.
them moving in the direction of reality.
• Negative reinforcement is the process of
• Done once a week for 12 sessions removing a stimulus from a situation
• Type of clients involve - alert and withdrawn immediately after a behavior occurs which
clients increase the probability of the behavior
• Place should be quiet, free from any occurring.
distractions • Shaping Continuous reinforcement is the
• Subjects included are nature, geography, arts, presentation of reinforcing stimuli following
transportation each occurrence of the selected response
• Subjects excluded are love, sex, religion, (used during the initial phases of conditioning
family problems and politics or shaping a behavior. Intermittent
reinforcement is the presentation of the
STEPS reinforcers following the target response
1. Climate of Acceptance (5 minutes) according to a selected number of responses.
• Introduction of participants; don’t miss (ratio schedule)
anyone
2. Bridge to Reality (10-15 minutes) Decreasing the probability that a Behavior will
• Bounce questions from general to specific recur:
o What are the different types or modes Differential reinforcement of other behavior
of transportation? • Extinction is the gradual decrease in the rate
o What are the different kinds or water of responses when the reinforcement is no
transportation? What do you call the longer available.
 • Social extinction is the withdrawal of Reciprocal Inhibition or Counterconditioning is a
attention from a patient when he or she acts process of strengthening alternative responses to fear
inappropriately in a setting. or anxiety associated stimulus.
• Negative consequence is the presentation of
an event immediately following a response. Examples are: Relaxation Techniques: positive
Example: Putting a child in his room reaffirming self-talk, yoga, deep breathing exercises,
immediately after seeing the child playing in meditation, progressive muscular relaxation and
the street. Have a patient apologize to other imagery.
patients and map the floor after throwing
food. Withdraw privileges as EXPOSURE METHODS
a consequence of acting out behavior. Systematic Desentization – planned progressive or
• Time Out is a technique in which the person graduated exposure to stimuli in real life (in vivo /
is removed from a setting in which ongoing imaginal) that elicit fear or anxiety while the anxiety
reinforcers are available. or fear response is suppressed with relaxation.
Example: Patient exhibiting aggressive
behavior that is followed by social Flooding or Implosion is a process in which patients
reinforcement from other patients, the patient imagine or place themselves in the fearful situation.
might be moved to another room in which no
social reinforcement is available. ATTITUDE THERAPIES
Attitude therapies are prescribed ways on how to
SKILLS TRAINING handle mentally ill clients according to the behavioral
Skills Training symptoms they manifested.
• Anger management skills
• Social skills ACTIVE FRIENDLINESS
• Problem-solving skills • For withdrawn, apathetic, fearful,
• Modeling noncombative
• Behavior rehearsal • clients
• Corrective feedback • Treat them with TLC and pay attention on
their personal needs like bathing, combing the
Contingency Contract is the arrangement of hair, cutting fingernails
conditions that enable patients to participate in setting
target behaviors and selecting reinforcers. PASSIVE FRIENDLINESS
Example: a contract specifies that, if the patient • For paranoid, suspicious clients
approaches the nurse for his or her medication at the • Maintain distance as they hate too much
scheduled time, he or she can join a reward walk with closeness until trust has been gained.
the nurse and other patients after dinner.
KIND FIRMNESS
SELF CONTROL • For depressed clients (sad, hopeless, lonely)
Self-Control – used with thought stopping. When the • These clients have inner hostility. Provide a
patient have automatic negative thoughts, patients are monotonous repetitive, boring activity. The
taught to say to themselves “stop” and to substitute a purpose is to help him externalize his anger
positive thought. Token Economy instead of sympathizing with his depressive
mood.
RESPONDENT CONDITIONING • Example; Let client count seashells. Allow it
Respondent Conditioning: Helping patients cope to be repeated several times for a day and
with disturbing stimuli. every day until the client gets bored and throw
the seashells.

MATTER OF FACT
 • For manipulative, demanding and elated • Tract 3: The Mesolimbic Tract is involved in
clients emotional & sensory processes; Relieves or
• Stick to the rules and regulations of the eliminate hallucinations and delusions
hospital and be consistent. • Tract 4: Mesocortical Tract is involved in
cognitive processes; Blockage can intensify
NO DEMAND negative and cognitive problems
• For assaultive, violent, furious clients
• Do not approach client alone, ask members of DIFFERENT DOPAMINERGIC TRACTS IN
the team to surround the client so that hostility THE BRAIN
will not be focused on one individual and tell Substancia nigra (synthesis of dopamine)
him you are there to be of help. If client is • Mesocortical system- involved in negative
being approached alone, he might think that schizophrenia
you are challenging him for a fight. • Mesolimbic system- involved in positive
schizophrenia
PHARMACOLOGY THERAPIES • Tuberoinfundibular system- involved in
Psychotropic Drugs are used primarily to treat acute neuroendocrine control
psychotic symptoms such as agitation, rage, • Nigrostriatal system- involved in
overactivity, hallucinations, delusions, paranoia and extrapyramidal disorder
combativeness.
Positive symptoms- attributed to too much
Pharmacokinetics: dopamine in the limbic area (hyperactive mesolimbic
• Highly lipid soluble drugs accumulate infatty tract)
tissue and are released slowly
• Antipsychotics are metabolized in the liver by Negative symptoms-attributed to too little dopamine
the cytochrome P450 system. Average half- in the cortex (hypoactive mesocortical tract)
life is from 10 – 30 hours
• Impaired hepatic function extends the half- Dopamine
life & effect of the drug • Blocked by antipsychotics
• Dopamine- inhibitor of prolactin à increase
Mechanism of action: Creates a postsynaptic levels of prolactin à galactorrhea in women;
dopamine receptor blockage in limbic system, gynecomastia in men
hypothalamus and central cortex. Can accumulate in • Dopamine- responsible for fine- tuning motor
fatty tissue and continue releasing even if the drug is activity in the basal ganglia à blocked by
discontinued. Cannot cause drug dependency and antipsychotics à parkinsonism
overdosage.
Acetylcholine Receptors (muscarinic receptors)
Dopamine is synthesized primarily in the substancia • blocked by antipsychotic à
nigra and ventral tegmental area and is delivered to antiparasympathetic effects à blurred vision,
distant sites via dopaminergic tracts. tachycardia, constipation and urinary
retention
NEUROCHEMICAL THEORY
• Tract 1: The nigrostriatal tract is involved in Alpha1 Receptor Of Norepinephrine
movement; Traditional antipsychotic • blocked by antipsychotic à responsible for
blockage can cause EPSE’s vasoconstriction in upright position à
• Tract 2: The tuberoinfundibular tract orthostatic hypotension
modulates pituitary function; Traditional
antipsychotic blockage can lead to elevation Undesirable Effects
in prolactin levels • S-edation/sunlight sensitivity/sleepiness
• T-ardive dyskinesia
 • A-nticholinergic/agranulocytosis/akathisia • dopamine precursor –levodopa (Dopar,
• N-euroleptic malignant syndrome Larodopa); carbidopa-levodopa(sinemet)
• C-cardiac effects(Orthostatic hypotension) • Dopamine releaser– Amantadine
• E-xtrapyramidal (dystonia- torticollis, (symmetryl)
oculogyric crisis and opisthotonos; EPSEs) • Dopamine receptor agonist-
Bromocriptine(Parlodel); Pergolide (Permax)
Side effects - PNS • Dopamine-metabolism inhibitor–
• Anticholinergic effects– blocking Selegiline(Eldypryl)
acetylcholine
• Hypotension-blocking of alpha1 receptors Anticholinergic Drugs
which prevents constriction of blood vessels • decrease acetlycholine availability
in upright position • Trihexyphenidyl (Artane); Benztropine
(Cogentin); Biperiden (Akineton);
Side Effects- CNS (PANTD) Diphenhydramine (Benadryl); Ethopropazine
• Pseudoparkinsonism (Parsidol); Procyclidine (Kemadrin)
• Akathisia • A balance of two neurotransmitters
• NMS- neuroleptic malignant syndrome acetylcholine (Ach) and dopamine is required
• Tardive dyskinesia for normal functioning of the estrapyramidal
• Dystonia- torticollis, oculogyric crisis and system.
opisthotonos • Anticholinergics is used to treat EPSEs and
work by restoring the imbalance caused by
CONVENTIONAL ANTOPSYCHOTIC DRUGS antipsychotic drugs
• Phenothiazines- Thorazine, Prolixin, • Benztropine (Cogentin)- Antiparkinson
Mellaril, Stelazine; Navane, Haldol, • Trihexyphenidyl (Artane)- Antiparkinson
Loxitane, Moban) • Biperiden (Akineton)- Antiparkinson
• Non Phenothiazines – Haldol (Haloperidol) • Amitriptyline (Elavil)- Antidepressant
• Nortriptyline (Pamelor)- Antidepressant
High Potency Drugs (causes more EPSE’s) • Imipramine (Tofranil)- Antidepressant
• Fluphenazine (Prolixin) • Desipramine (Norpramin)- Antidepressant
• Haloperidol (Haldol) • Clozapine (Clozaril)- Antipsychotic
• Thiothizine (Navane) • Chlorpromazine (Thorazine)- Antipsychotic
• Trifluoperazine (Stelazine) • Diphenhydramine (Benadryl)- Antihistamine
• Amantadine (Symmetrel)- Dopamine agonist
Moderate Potency Drugs • Propanolol (Inderal)- Beta blocker
• Loxapene (Loxitane) • Diazepam (Valium)- Benzodiazepines
• Molindone (Moban) • Lorazepam (Ativan)- Benzodiazepines
• Perphenazine (Trilafon) • Clonazepam (Klonopin)- Benzodiazepines

Low Potency Drugs (causes less EPSE’s but causes Anticholinergic Symptoms
more intense anticholinergic effects (dry mouth, • Dry mouth- Use ice chips, sugarless candy
blurred vision) and antiadrenergic effect (orthostatic and chewing gums, take meds after meals,
hypotension) frequent mouth rinses
• Chlorpromazine (Thorazine) • Nasal congestion- use of over the counter
• Thioridazine (Mellaril) nasal contestants
• Blurred vision/ photophobia- assess side
Dopaminergic Drugs effect, which should improve with time;
• increase dopamine availability report to physician if no improvement; use
sunglasses, caution when driving
 • Constipation- increase fluid 2500–3000ml decreasing dopamine in brain areas in which
daily and dietary fiber intake; may need a dopamine is hyperactive.
stool softener if unrelieved
• Urinary retention- instruct a client to report Side Effects
any frequency or burning with urination • Headache
• Orthostatic hypotension- instruct client to rise • Anxiety
slowly from sitting or lying position; wait to • Nausea
ambulate until no longer dizzy or lightheaded
Patient Teaching
ATYPICAL ANTIPSYCHOTIC DRUGS • Adhering to medication regimen
• Clozapine (Clozaril), Resperidone
(Risperdal), Olanzapine (Zyprexa), ANTIDEPRESSANT DRUGS
Quetiapine (Seroquel), Ziprasidone (Geodon) Selective Serotonin Reuptake Inhibitor (SSRI)
• Action: dopamine and serotonin antagonists – • SSRI drugs: fluoxetine (Prozac), paroxetine
targets the positive and the negative (Paxil), sertraline (Zoloft), citalopram
symptoms of schizophrenia (Celexa), citalopram (Lexapro)
• Reduced or no risk of EPSE’s Minimal risk of
tardive dyskinesia Side Effects
• Absence of increased Prolactin • Anxiety
• Agitation
Side Effects • Akathisia
• Fewer EPSs • Nausea
• Weight gain • Insomnia
• Agranulocytosis (Clozaril) • Sexual dysfunction (anorgasmia/impotence)

Patient Teaching Patient Teaching

• Adhering to medication regimen • Take in the morning
• Reducing sugar and caloric intake • Take with food
• Clozaril
• Weekly WBC monitoring Tricyclic Antidepressants (TCAs)
• Discontinue medication and seek care at first • TCA durgs: imipramine (Tofranil),
sign of infection desipramine (Norpramin), amitriptyline
(Elavil), doxepin (Sinequan), clomipramine
MAINTENANCE THERAPY (Anafranil)
ANTIPSYCHOTIC DRUGS (Long-acting drugs
in sesame oil) Side Effects
• Fluphenazine Decanoate (Prolixin) – given • Anticholinergic (blurred vision, urinary
every 2-3 weeks interval retention, dry mouth, constipation)
• Haloperidol Decanoate (Haldol) – given 2 to • Orthostatic hypotension Sedation
4 weeks interval • Weight gain Tachycardia
• Risperidone ( Risperdal Consta) • Sexual dysfunction

NEW GENERATIONAL ANTIPSYCHOTIC Patient Teaching

DRUGS • Taking meds in the evening
A dopamine system stabilizer (DSS) – balances • Using caution when driving
dopamine systems by increasing dopamine in the
brain areas in which dopamine is deficient and Monoamine oxidase inhibitors (MAOIs)
 • MAOI drugs: phenelzine (Nardil), • Nausea
tranylcypromine (Parnate), isocarboxazid • Weight loss/ growth retardation
(Marplan) • Irritability

Side Effects Patient Teaching

• Sedation Insomnia Weight gain • Avoiding caffeine, sugar, and chocolate
• Dry mouth Orthostatic hypotension Sexual Taking doses after meals
dysfunction • Drug holidays on weekends and
• Hypertensive crisis with excessive tyramine • holidays to restore normal eating and
or sympathomimetic drugs • growth patterns
• Long-term use can cause dependency
Patient Teaching
• Following tyramine-free diet (avoid aged DISULFIRAM ANTABUSE
cheeses, aged meats, beer and wine, • Uses: Aversion therapy for treatment of
sauerkraut, soy) alcoholism
• Avoiding sympathomimetic drugs Using • Action: Causes an adverse reaction when
caution when driving alcohol is ingested
• 5 – 10 minutes after alcohol ingestion:
o facial and body flushing
o dry mouth
ANTIANXIETY DRUGS o nausea
• benzodiazepines; buspirone (BuSpar) o dizziness and weakness
• Uses: Anxiety disorders, insomnia, OCD, • Severe cases:
depression, PTSD, alcohol withdrawal o chest pain dyspnea
• Action: Moderate the actions of GABA o headache vomiting
o sweating
Side Effects o severe hypotension
• Tolerance and dependence Drowsiness o confusion death
Sedation Poor concentration
• Impaired memory Clouded sensorium Patient Teaching
• Avoiding alcohol (including products such as
Patient Teaching shaving cream, aftershave, cologne, many
• Using caution during driving due to slower OTC medications)
reflexes and response time • Family should never administer without the
• Never discontinuing abruptly as withdrawal person's knowledge
• can be fatal
• Avoiding alcohol

STIMULANT DRUGS
• Stimulant Drugs: CARD Cylert (pemoline);
Adderall (amphetamine) Ritalin
(methylphenidate); Dexedrine
(dextroamphetamine)
• Uses: ADHD, residual ADD in adults, and
narcolepsy

Side Effects
• Anorexia
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 5 Anxiety Disorders

ANXIETY DISORDERS • Separation anxiety disorder

Working with Anxious Clients • Adjustment disorder
1. Be aware of nurse’s own anxiety level
2. Assess the person’s anxiety level Etiologies
3. Speaking in short, simple, and easyto- • Biologic theories: anxiety may have an
understand sentences inherited component; neurotransmitters may
4. Lower the person’s anxiety level to moderate be dysfunctional in persons with anxiety
or mild before proceeding with anything else disorders
5. Talk to the client in a low, calm, and soothing • Psychodynamic theories: overuse of defense
voice mechanisms; results from problems in
6. Walk while talking if the patient cannot sit interpersonal relationships; as “learned”
still behavioral response
7. Ensure safety during panic-level anxiety
8. Remain with the client until the panic recedes Cultural Considerations
9. Short-term use of anxiolytics • Asian cultures often express anxiety through
somatic symptoms such as headaches,
DSM-5 Anxiety-Related Disorders backaches, fatigue, dizziness, and stomach
1. Generalized Anxiety Disorders (GAD) problems
2. Panic Disorder with or without agoraphobia • Hispanics experience high anxiety as
3. Agoraphobia without panic disorder sadness, agitation, weight loss, weakness,
4. Specific Phobia and heart rate changes. The symptoms are
5. Social Phobia believed to occur because supernatural spirits
6. Obsessive-compulsive Disorder (OCD) or bad air from dangerous places and
7. Acute stress disorder cemeteries invades the body
8. Posttraumatic stress disorder (PTSD)
9. Anxiety disorder due to a general medical Treatment
condition Usually involves a combination of medication
(anxiolytics and antidepressants) and therapy
Incidence of Anxiety Disorders
• Anxiety disorders are the most common Cognitive-behavioral therapy:
psychiatric disorders • Positive reframing (turning negative
• More prevalent in women messages into positive ones) Example: “My
• Prevalent in people younger than 45 years heart is pounding; I think I’m going to die”,
• More common in divorced and separated This is just anxiety.
persons • Decatastrophizing (making a more realistic
• More common in persons of lower appraisal of the situation)
socioeconomic status o Example: “What is the worst thing
• Onset and clinical course are variable that could happen?” Splashing the
face with cold water, snapping a
Related Disorders rubber band, shouting
• Anxiety disorder due to a general medical • Assertiveness training (learn to negotiate
condition interpersonal situations) Example: “I feel
• Substance-induced anxiety disorder
 angry when you turn your back while I’m • Hamilton Rating Scale for Anxiety Reports
talking” of several panic attacks May appear “normal”
or may have signs of anxiety
Mental Health Promotion Goal is effective • Anxious, worried, tense, depressed, serious,
management, not total elimination of anxiety. or sad
• Keep a positive attitude and believe in • Fears losing control or going insane
oneself Confused and disoriented Judgment is poor
• Accept that there are events that cannot be during an attack Self-blaming statements
controlled • Alterations in his or her social, occupational,
• Communicate assertively with others or family life Problems sleeping and eating
• Talk about one’s feelings with others
• Express feelings through laughing, crying, Data Analysis: Nursing diagnoses include:
and so forth • Risk for Injury
• Learn to relax • Anxiety
• Exercise regularly • Situational Low Self-Esteem (panic attacks)
• Eat well-balanced meals Ineffective Coping Powerlessness
• Limit intake of caffeine and alcohol • Ineffective Role
• Get enough rest and sleep • Performance Disturbed
• Set realistic goals and expectations • Sleep Pattern
• Find an activity that is personally meaningful
• Learn stress management techniques Outcome Identification:
The client will:
PANIC DISORDER • Be free of injury
Panic Disorder: DSM - Criteria • Verbalize
• Recurrent , unexpected panic attacks • feelings
• Panic attacks followed by a month or more of • Use effective coping techniques Manage own
worry about having additional attacks, worry anxiety response Verbalize sense of personal
about the results of the attacks, and behavior control Reestablish adequate nutritional
changes related to intake Sleep at least 6 hours per night
• the attacks
• Panic disorders possibly ccompanied by Nursing Interventions
agoraphobia • Stay with the patient who is having a panic
attack and acknowledge the patient’s
Panic Disorder discomfort
• Involves 15- to 30-minute episodes of • Maintain a calm style and demeanor Speak in
• intense, escalating anxiety with emotional short, simple sentences, and give one
• fear and physiologic discomfort direction at a time in a calm tone of voice
• Peaks in late adolescence and the mid-30s • If the patient is hyperventilating, provide a
• Can lead to avoidance behavior or brown paper bag and focus on breathing with
• agoraphobia the patient
• Treated with cognitive-behavioral • Allow patient to pace or cry, which allows
release of tension and energy Communicate
• techniques, deep breathing and relaxation,
and medications (benzodiazepines, SSRI to patient that you are in control and will not
let anything happen to them
antidepressants, tricyclic antidepressants, and
antihypertensives) • Move or direct patients to a quieter, less
stimulating environment. Do not touch the
Application of the Nursing Process patient.
Assessment
 • Ask patents to express their perceptions or o Help patients identify possible causes
fears of their feelings
o Listen carefully for patients'
GENERALIZED ANXIETY DISORDER expression of helplessness and
Generalized Anxiety Disorder: DSM IV Criteria hopelessness, ask patients whether
• Excessive worry and anxiety they feel suicidal
• Difficulty in controlling the worry o Plan and involve patient in activities
• Anxiety and worry are evident in three or
more of the following: Nursing Interventions for Problem Solving
o Restlessness • Discuss the present and previous coping
o Fatigue mechanisms with patients Discuss with
o Irritability patients the meaning of problems and
o Decreased ability to concentrate conflicts
o Muscle tension • Uses supportive confrontation and teaching
o Disturbed sleep • Assist patients with exploring alternative
solutions and behaviors Encourage patients
Generalized Anxiety Disorder to test new adaptive coping behaviors (role
• Excessive and uncontrollable worry about playing)
everyday things which often interferes with • Teach patients relaxation exercises Promote
daily functioning. the use of hobbies
• Often worry excessively over things such as • and recreational activities
their job, finances, health, over more minor
matters such as deadlines for appointments. PHOBIC DISORDER
• Subject of the worry constantly changes • A phobia is an illogical, intense, persistent
(Miller/03) fear of a specific object or social situation that
• Worrying becomes habitual way of coping to causes extreme distress and interferes with
prevent a negative occurrence or something normal life functioning.
bad from happening • Agoraphobia, or fear of being outside
• Symptoms include uneasiness, irritability, • Social phobia, anxiety provoked by certain
muscle tension, fatigue, difficulty thinking, social or performance situations
and sleep alterations • Specific phobia, an irrational fear of an object
• Often experience feelings of depression and or situation
possibly pose a danger to self or others
• May use alcohol or other drugs to point of Categories of specific Phobias:
abuse to feel better • Natural environmental phobias: fear of
• Treated with Antidepressants (SSRIs and storms, water, heights, or other natural
SSNRIs) phenomena
• Benzodiazepines can cause dependency and • Blood-injection phobias: fear of seeing one's
tolerance; use on a short term basis until own or others blood, traumatic injury, or an
antidepressant takes effect invasive medical procedure such as an
• Nursing interventions focuses on assisting injection.
clients to reduce levels of anxiety and to • Situational phobias: fear of being in a specific
develop more effective adaptive coping situation such as on a bridge or in a tunnel,
behaviors elevator, small room, hospital, or airplane.
o Provide a calm and quiet environment • Animal phobia: fear of animals or insects
Ask patients to identify what and how • Other types of phobias: fear of getting lost
they feel and others
o Encourage patient to describe and
discuss their feelings Onset and Clinical Course
 • Specific phobias usually occur in childhood • Gymnophobia- fear of nudity.
or adolescence. In some cases, merely • Heliophobia- fear of sunlight.
thinking about or handling a plastic model of • Hemophobia, Haemophobia- fear of blood.
the dreaded object can create fear. • Hexakosioihexekontahexaphobia- fear of the
• Specific phobias that persist into adulthood number 666.
are lifelong 80% of the time. • Lalophobia, Laliophobia- fear of speaking.
• Ligyrophobia- fear of loud noises.
Examples of Phobias • Mysophobia- fear of germs, contamination or
• Acrophobia, Altophobia - fear of heights. dirt.
Algophobia - fear of pain. Androphobia - fear • Necrophobia- fear of death, the dead.
of males. • Neophobia, Cainophobia, Cainotophobia,
• Anthropomorphobia - fear or dislike of Cenophobia, Centophobia, Kainolophobia,
anthropomorphic traits. Kainophobia- fear of newness, novelty.
• Aquaphobia, Hydrophobia - fear of water, • Nyctophobia, Achluophobia, Lygophobia,
specifically the morbid fear of drowning. Scotophobia- fear of darkness.
• Astraphobia, Astrapophobia, Brontophobia, • Osmophobia, Olfactophobia- fear of smells.
Keraunophobia — fear of thunder, lightning • Paraskavedekatriaphobia,
and storms; it occurs especially commonly in paraskevidekatriaphobia,
young children. friggatriskaidekaphobia- fear of Friday the
• Aphenphosmphobia, Chiraptophobia, 13th.
Haphephobia, Haptephobia — fear of being • Phagophobia- fear of being eaten.
touched.
• Radiophobia — fear of radiation or X-rays.
• Aviophobia, Aviatophobia — fear of flying. • Sociophobia — fear/dislike of society or
Bacillophobia, Bacteriophobia, people in general (see also "sociopath").
Microbiophobia — fear of microbes and
• Taphephobia — fear of the grave, or fear of
bacteria.
being placed in a grave while still alive.
• Bathophobia — fear of depth.
• Technophobia — fear of technology.
• Cibophobia, Sitophobia- aversion to food, Triskaidekaphobia, Terdekaphobia- fear of
synonymous to Anorexia nervosa. the number 13.
• Claustrophobia — fear of confined spaces. • Trypanophobia- fear of needles or of pointed
Clinophobia — fear of going to bed or falling objects.
asleep.
• Xenophobia- fear of
• Coulrophobia — fear of clowns (or more
• strangers, foreigners, or aliens.
specifically evil clowns).
• Zoophobias Ailurophobia, Elurophobia,
• Dental phobia, Dentophobia, Odontophobia-
Felinophobia, Galeophobia, Gatophobia-
fear of dentists and dental procedures.
dislike of cats
• Emetophobia — fear of vomiting.
• Apiphobia, Melissophobia- fear of bees.
• Ergasiophobia, Ergophobia — fear of work
• Arachnophobia — fear of arachnids, usually
or functioning, or a surgeon's fear of
specific to spiders.
operating.
• Chiroptophobia — fear of bats.
• Erotophobia — fear of sexual love or sexual
questions. • Cynophobia — fear of dogs or of rabies.
• Genophobia, Coitophobia- fear of sexual • Entomophobia, Insectophobia — fear of
intercourse. Gephyrophobia- fear of crossing insects. (Also the orchid genus
bridges. Entomophobia.)
• Globaphobia- fear of balloons. • Equinophobia, Hippophobia — fear of horses
Treatment and Prognosis
• Glossophobia — fear of speaking in public or
of trying to speak.
Psychopharmacology: anxiolytics; SSRI • Having aggressive urges (throwing one’s
antidepressants; beta blockers to slow heart rate and • child against the wall)
lower blood pressure • Onset and Clinical Course
• Can start in childhood or in the 20s
Behavioral therapies: Systematic desensitization • Affects males and females equally
Flooding • Onset is usually gradual.
OBSESSIVE COMPULSIVE DISORDER • Exacerbation of symptoms may be
(OCD)
• related to stress.
Obsessive-Compulsive Disorder: DSM IV
Criteria • 80% of those treated with behavior therapy
A. Obsessions • and medication report success.
• Intrusive, inappropriate, recurrent and
persistent thoughts, impulses, or images hat Treatment
Behavior therapy techniques:
are distressful or produce anxiety
• Unsuccessful attempts to ignore or neutralize • The specific technique used in BT/CBT is
thoughts or impulses by other thoughts or called Exposure and Ritual Prevention (also
known as Exposure and Response
actions.
Prevention) or ERP; this involves gradually
• Recognition that obsessions are produced by
learning to tolerate the anxiety associated
own thoughts
with not performing the ritual behavior.
• Not simply excessive worry about real-life
patterns Medications:
• SSRI antidepressants, fluvoxamine,
B. Compulsions
clomipramine, buspirone, clonazepam
• Repetitive behaviors, such as
• handwashing, or mental acts, such as Application of the Nursing Process
counting, performed in response to an Assessment
obsession • Yale-Brown Obsessive-Compulsive Scale
• Excessive behaviors or mental acts used to
• Reports of obsessions becoming too
reduce distress or prevent dreaded events overwhelming, compulsions interfere with
daily life
C. Recognition that obsessions or compulsions are
• Tense, anxious, worried, and fretful Ongoing,
unreasonable or excessive
overwhelming feelings of anxiety Intact
intellectual functioning with difficulty
D. Obsessions or compulsions cause distress, are
concentrating Recognizes that the obsessions
time- consuming, and interfere with usual daily
are irrational, but he or she cannot stop them
functioning
• Powerlessness
Common Compulsions are: • Relationships also suffer
• Checking rituals • Trouble sleeping or loss of appetite
• Counting rituals
Data Analysis
• Washing and scrubbing until the skin is raw
• Anxiety
• Touching, rubbing, or tapping ( texture of
• Ineffective Coping
• each material, touching people, walls or
• Fatigue
• oneself)
• Situational Low Self-Esteem
• Hording items
• Impaired Skin Integrity (if scrubbing or
• Ordering (arranging and rearranging
washing rituals)
• furniture)
• Exhibiting rigid performance (getting
• dressed in an unvarying pattern)
Outcome Identification ASD VS. PTSD
The client will: ASD PTSD
• Complete daily routine within realistic time Exposure to a traumatic Same
frame Demonstrate effective use of event
relaxation techniques Discuss feelings with Responses of horror, Same
others Demonstrate effective use of behavior helplessness or fear
therapy techniques Dissociative symptoms Numbing of
• Spend less time performing rituals 1. Absence of responsiveness
emotions, numbing 1. Restricted affect
Interventions 2. Decreased 2. Sense of
• Ensure that basic needs are met awareness of foreshortened
• Provide patient with time to perform rituals surroundings future (no
Explain expectations, routines and changes (daze) expectations)
• Be emphatic towards patients and be aware of 3. Derealization or 3. Inability to recall
their needs to perform rituals depersonalization aspects of the
• Assists patient with connecting behaviors and 4. Amnesia event
feelings Re-experiencing or Same plus
• Structure simple activities, games , or tasks reliving of traumatic hallucinations
for patients event: dreams,
• Reinforce and recognize positive flashbacks, illusions
nonritualistic behaviors. Avoidance of stimuli Same plus decreased
related to trauma: participation in
ACUTE STRESS DISORDER (ASD) feelings, thoughts, activities and
• A dissociative response develops following people detachment for others
the experience of a traumatic situation Increased arousal of Same plus outburst of
• The person has a sense that the event was anxiety: sleep, anger
unreal, thinks he or she is unreal, and forgets disturbance,
some aspects of the event through amnesia, hypervigilance, startled
emotional detachment, and muddled response, irritability
obliviousness to the environment Impairment or distress Same
• Exposure to a traumatic event Responses of of functioning
horror, helplessness or fear Onset: within 4 weeks Onset:
• Dissociative Symptoms: absence of
after the event • Acute- within 6
emotions, numbing decreased awareness of months or more
surroundings (daze) derealization or • Delayed- 6 months
depersonalization amnesia or more
Duration: 2 days to 4 Duration:
POSTTRAUMATIC STRESS DISORDER weeks • Acute- 1-3 months
(PTSD) • Chronic- 3 months
• Following witnessing a terrifying and or more
potentially deadly event, the person re-
experiences all or some of it through dreams
or waking recollections and responds
defensively to these flashbacks
• New behaviors develop related to the trauma
such as sleep difficulties, hypervigilance,
thinking difficulties, severe startle response,
and agitation
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2020 – 2021 Second Semester

Psychiatric Nursing
Module 6 Personality Disorders

Outline ONSET AND CLINICAL COURSE

1. Cluster A Personality Disorders • Personality disorders occur in 10% to 13% of
a. Paranoid Personality Disorder the general population
b. Schizoid Personality Disorder • Incidence is even higher in lower
c. Schizotypal Personality Disorder socioeconomic groups
2. Cluster B Personality Disorders • 40% to 45% of people with a primary
a. Antisocial Personality Disorders diagnosis of major mental illness also have a
b. Borderline Personality Disorders coexisting
c. Histrionic Personality Disorders personality disorder that significantly
d. Narcissistic Personality Disorders complicates treatment
3. Cluster C Personality Disorder • Clients with personality disorders have:
a. Avoidant Personality Disorders o Higher death rates, especially as a
b. Dependent Personality Disorders result of suicide
c. Obsessive Compulsive Disorders o Higher rates of suicide attempts,
4. Related Disorders accidents, and emergency department
a. Depressive Personality Disorder visits
b. Passive-Aggressive Personality o Increased rates of separation, divorce,
Disorder and involvement in legal proceedings
regarding child custody
PERSONALITY DISORDERS o Increased rates of criminal behavior,
Personality: an ingrained, enduring pattern of alcoholism, and drug abuse
behaving and relating to self, others, and the
environment. ETIOLOGY
• Genetics
Personality disorders: when personality traits Temperament
become inflexible and maladaptive and significantly • Psychosocial factors
interfere with how a person functions in society or • Character Self-directedness
cause the person emotional distress; maladaptive • Cooperativeness Self-transcendence
behavior can be traced to early childhood or
adolescence. TREATMENT
• Many people with personality disorders do
DSM-IV-TR Categories not seek treatment because they don’t believe
• Cluster A: people whose behavior is odd or they have a
eccentric (paranoid, schizoid, schizotypal) problem
• Cluster B: people who appear dramatic, • Individual and group therapy may be helpful
emotional, or erratic (antisocial, borderline, to those desiring change, but any changes are
histrionic, narcissistic) slow
• Cluster C: people who are anxious or fearful • Improvement in relationships, improved
(avoidant, dependent, obsessive- basic living skills, relief of anxiety may be
compulsive) Disorders being considered for goals of therapy
inclusion are depressive and passive- • Cognitive-behavioral techniques such as
aggressive thought-stopping, positive self-talk, and
decatastrophizing can be effective
 • Pharmacologic treatment is based on the type CLUSTER A PERSONALITY DISORDERS
and severity of symptoms rather than the PARANOID PERSONALITY DISORDER
particular Clinical Picture
personality disorder itself. Mistrust and suspiciousness, aloof and withdrawn,
Four symptom categories include: guarded or hypervigilant, restricted affect, use the
• Cognitive-perceptual distortions including defense mechanism of projection
psychotic symptoms
• Affective symptoms and mood dysregulation Nursing Interventions
• Aggression and behavioral dysfunction • Approach in a formal, business-like manner, keep
Anxiety commitments, be straightforward, involve them in
formulating their care plans, help them learn to
PHARMACOLOGIC TREATMENT FOR validate ideas before taking action
SYMPTOMS
Cognitive-perceptual disturbances (magical SCHIZOID PERSONALITY DISORDER
thinking, odd beliefs, illusions, suspiciousness, ideas Clinical Picture
of reference, and low-grade psychotic symptoms) Detached from social relationships, restricted affect,
• Low-dose antipsychotic medication aloof and indifferent, no leisure or pleasurable
activities, do not report feeling distressed about lack
Mood dysregulation (emotional instability, of emotion, intellectual and accomplished with
emotional detachment, depression, and dysphoria) solitary interests, indifferent to praise or criticism,
• Lithium, carbamazepine (Tegretol), dissociate from or no bodily or sensory pleasures
valproate (Depakote), low-dose neuroleptics,
SSRIs, MAOIs, atypical antipsychotics Nursing Interventions
Aggression (predatory or cruel behavior, Improve functioning in the community, make
impulsivity, poor social judgment, and emotional referrals to social services, provide care that
lability) accommodates the desire for solitude
• Lithium, anticonvulsant mood stabilizers,
benzodiazepines, and low-dose neuroleptics SCHIZOTYPAL PERSONALITY DISORDER
Clinical Picture
Anxiety Acute discomfort in relationships, cognitive or
• SSRIs, MAOIs, or low-dose antipsychotics perceptual distortions, eccentric behavior, bizarre
• Individual and Group Psychotherapy: speech, affect flat and sometimes inappropriate
Focus is on building trust, teaching basic
living skills, providing support, decreasing Nursing Interventions
distressing symptoms, and improving Promote self-care, social skills, and improved
interpersonal relationships. functioning in the community
• Cognitive-behavioral therapy
o Basic living skills for people with CLUSTER B PERSONALITY DISORDERS
cluster A personality disorders ANTISOCIAL PERSONALITY DISORDER
o Inpatient hospitalization to provide Clinical Picture
safety for people with borderline Pervasive pattern of disregard for and violation of
personality disorder rights of others, deceit and manipulation
o Assertiveness training groups for
people with cluster C personality Application of the Nursing Process
disorders Assessment
o Relaxation or meditation techniques • History: lying, truancy, vandalism, sexual
for people with cluster C personality promiscuity, and substance use in childhood
disorders and adolescence
• General appearance and motor behavior:
appears “normal,” may be charming and
engaging, trying to manipulate Mood and
affect: shallow emotions, “chooses”
 emotions to work to their advantage, no don’t meet client’s expectations; obsessive
genuine feelings of empathy, no guilt, only and ruminative thoughts about abandonment,
remorseful if caught suicide, and self-harm; may have dissociative
• Thought processes and content: views the episodes
world as cold and hostile, thinks everyone • Sensorium and intellectual processes:
else is as ruthless as he or she is, so trusts no oriented; intellectual functions intact; may
one experience transient psychotic symptoms
• Sensorium and intellectual processes: intact such as hallucinations under severe stress;
• Judgment and insight: lacks insight, poor may have flashbacks of abuse (consistent
judgment due to inability to delay with PTSD diagnosis)
gratification, impulsivity, or ethical/legal • Judgment and insight: judgment is poor;
considerations of actions impulsive and reckless behaviors such as
• Self-concept: superficially appears self- lying, shoplifting, gambling are common;
assured and confident, even arrogant, but this limited insight: believes problems are due to
covers low self-esteem; poor relationships others “failing” them
due to exploitation and using others • Self-concept: unstable and shifts rapidly—
• Roles and relationships: has trouble keeping needy one minute, hostile and rejecting the
jobs, being a parent, staying married, and so next; frequent self- injury; lacks consistent
forth view of self
• Roles and relationships: difficulty fulfilling
Intervention roles, especially involving mundane tasks
• Forming therapeutic relationship Limit (school, work); relationships are stormy
setting Confrontation given client’s behavior, but client blames
• Promoting responsible behavior Helping others; clings to people, then rejects them
client solve problems and control emotions angrily; desires relationships/friendships, but
Enhancing role performance behavior drives others away

BORDERLINE PERSONALITY DISORDER Data Analysis

Clinical Picture Nursing diagnoses include:
Pervasive pattern of unstable interpersonal • Risk for Suicide
relationships, self-image, affect, and marked • Risk for Self-Mutilation
impulsivity. • Risk for Other-Directed
• Violence Ineffective Coping
Application of the Nursing Process • Social Isolation
Assessment
• History: disturbed early relationships with Intervention
parents; punitive responses from parents; • Long-term therapy to resolve family
family history of abuse and alcoholism dysfunction and abuse
• General appearance and motor behavior: • Hospitalization when client is exhibiting self-
mildly dysfunctional clients appear normal; harm behaviors or having intense symptoms
severely affected clients may be disheveled, • Brief hospitalizations to stabilize condition
unable to sit still, crying, out of control; very • Promoting the client’s safety
labile emotions • No-self-harm contract
• Mood and affect: dysphoric mood; unhappy, • Promoting the therapeutic relationship
restless, malaise; intense feeling of • Establishing boundaries in relationships
loneliness; boredom; frustration;
• Teaching effective communication skills
abandonment by others; mood is labile and
• Helping the client to cope and control
feelings are intense
emotions Reshaping thinking patterns
• Thought processes and content: polarized
• Cognitive restructuring
thinking/splitting; others are “adored” after a
brief acquaintance, then despised if they • Thought stopping
 • Positive self-talk DEPENDENT PERSONALITY DISORDER
• Decatastrophizing Clinical Picture
• Structuring daily activities Submissive and clinging behavior; excessive need to
be taken care of; pessimistic and self-critical; other
HISTRIONIC PERSONALITY DISORDER people hurt their feelings easily; report feeling
Clinical Picture unhappy or depressed; difficulty making decisions;
Excessive emotionality and attention seeking; seek advice and repeated reassurances
colorful and theatrical speech; overly concerned with
impressing others; emotionally expressive, Nursing Interventions
gregarious, and effusive; emotions are insincere and Help identify strengths and needs; use cognitive
shallow; self- absorbed; uncomfortable when they restructuring; assist in daily functioning; teach
are not the center of attention and go to great lengths problem solving and decision making; refrain from
to gain that status giving advice

Nursing Interventions OBSESSIVE-COMPULSIVE PERSONALITY

Give feedback about social interactions; teach social DISORDER
skills through role playing Clinical Picture
Preoccupation with orderliness, perfectionism, and
NARCISSISTIC PERSONALITY DISORDER control; formal and serious demeanor; constricted
Clinical Picture emotions; stubborn; preoccupied with details, rules,
Grandiose; lack of empathy; need for admiration; lists, and schedules; believe they are right; problems
arrogant or haughty attitude; disparage, belittle, or with judgment and decision making
discount the feelings of others; view their problems
as the fault of others; hypersensitive to criticism and Nursing Interventions
need constant attention and admiration Help accept or tolerate less-than-perfect work; use
cognitive restructuring techniques; encourage to take
risks; practice negotiation
Nursing Interventions
Use self-awareness skills to avoid anger and RELATED DISORDERS
frustration; use matter-of-fact manner; set limits on DEPRESSIVE PERSONALITY DISORDER
rude or verbally abusive behavior Clinical Picture
Sad, gloomy, or dejected affect; persistent
CLUSTER C PERSONALITY DISORDERS unhappiness, cheerlessness, and hopelessness;
AVOIDANT PERSONALITY DISORDER inability to experience joy or pleasure in any activity;
Clinical Picture cannot relax; do not display a sense of humor; brood
Social inhibitions; feelings of inadequacy; and worry over all aspects of daily life; thinking is
hypersensitivity to negative evaluation; avoid negative and pessimistic
situations or relationships that may result in
rejection, criticism, shame, or disapproval; strongly Nursing Interventions
desire closeness and intimacy but fear possible Assess risk for self-harm; encourage to become
rejection and humiliation involved in activities; give factual feedback; use
cognitive restructuring techniques; teach effective
Nursing Interventions social skills
Explore positive self-aspects and reasons for self-
criticism; practice self-affirmations and positive self- PASSIVE-AGGRESSIVE PERSONALITY
talk; cognitive restructuring techniques, such as DISORDER
reframing and decatastrophizing; teach social skills Clinical Picture
Negative attitudes; resent, oppose, and resist
demands expected by others; express resistance
through procrastination, forgetfulness, stubbornness,
and intentional inefficiency
Nursing Interventions
Help examine the relationship between feelings and
subsequent actions; teach appropriate ways to
express feelings directly
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 7 Somatoform Disorders, Dissociative Disorders, and Sleep Disorders

Outline
1. Somatoform Disorders SOMATOFORM DISORDERS
a. Somatization disorder Somatization is the transference of mental
b. Conversion disorder experiences and states into bodily symptoms.
c. Pain disorder
d. Hypochondriasis Somatoform disorders are the presence of physical
e. Body dysmorphic disorder symptoms that suggest a medical condition
2. Dissociative Disorders without a demonstrable organic basis to account fully
a. Depersonalization Disorder for them. The three central features of somatoform
b. Dissociative Amnesia disorders:
c. Dissociative Fugue • Physical complaints suggest major medical
d. Dissociative Identity Disorder illness but have no demonstrable organic
3. Sleep Disorders basis
• Psychological factors and conflicts seem
INTRODUCTION important in initiating, exacerbating, and
The term psychosomatic began to be used to convey maintaining the symptoms
the connection between the mind (psyche) and the • Symptoms or magnified health concerns are
body (soma) in states of health and illness. not under the client’s conscious control
Essentially, the mind can cause the body either the to
create physical symptoms or worsen physical Five Specific Somatoform Disorders
illnesses. Real symptoms can begin, continue, or 1. Somatization disorder: multiple physical
worsened as a result of emotional factors. When a symptoms; combination of pain, GI, sexual,
person is a lot of stress or is not coping with stress, and pseudo neurologic symptoms
symptoms of medical illnesses worsen. In addition, 2. Conversion disorder: unexplained deficits
stress can cause physical symptoms unrelated to a in sensory or motor function associated with
diagnosed medical illness. psychological factors; attitude of la belle
indifference (lack of concern or distress about
Dissociation is a subconscious defense mechanism the functional loss) e.g., blindness, paralysis.
that helps a person protect his or her emotional self 3. Pain disorder: pain unrelieved by
from recognizing the full effects of some horrific or analgesics; psychological factors influence
traumatic event by allowing the mind to forget or onset, severity, exacerbation, and
remove itself from the painful situation or memory. maintenance
Dissociation can occur both during and after the 4. Hypochondriasis: preoccupation with the
event. Dissociative symptoms are seen in clients with fear that one has a serious disease (disease
Post Traumatic Stress Disorder (PTSD). conviction) or will get a serious disease
(disease phobia)
Sleep disorders are a group of conditions that affect 5. Body dysmorphic disorder: preoccupation
the ability to sleep well on a regular basis. Depending with imagined or exaggerated defect in
on the type of sleep disorder, people may have a physical appearance
difficult time falling asleep and may feel extremely
tired throughout the day. The lack of sleep can have DSM-IV Criteria For Somatoform Disorders And
a negative impact on energy, mood, concentration, Related Disorders
and overall health.
 • Malingering is the intentional production of • Investigate the client’s physical health status
false or grossly exaggerated physical or to thoroughly rule out underlying pathology
psychological symptoms; it is motivated by requiring treatment
external incentives such as avoiding work, • History: client likely provides a detailed
evading criminal prosecution, obtaining medical history; quite distressed about his or
financial compensation, or obtaining drugs her health status (except the client with
• Factitious disorder occurs when a person conversion disorder, who displays la belle
intentionally produces or feigns physical or indifference)
psychological symptoms solely to gain • General appearance and motor behavior:
attention. (In malingering and factitious normal
disorders, people willfully control the • Mood and affect: may be labile, shifting from
symptoms. In somatoform disorders, clients sad and depressed (describing physical
do not voluntarily control their physical ailments) to bright and excited (describing
symptoms.) trips to health care providers)
• Munchausen by proxy occurs when a • Thought processes and content: intact;
person inflicts illness or injury on someone content is about physical symptoms; vague in
else to gain the attention of emergency their description but use colorful,
medical personnel or to be a “hero” for saving exaggerated terms
the victim • Sensorium and intellectual processes: alert
and oriented
Etiologies • Judgment and insight: little or no insight;
Psychosocial theories: Unconsciously expressing judgment may be affected by exaggerated
internalized stress through physical symptoms responses to physical health concerns
(somatization) • Self-concept: low self-esteem, lack of
• Primary gains are achieved when the direct confidence, difficulty coping
external benefits of being sick provide relief • Roles and relationships: difficulty fulfilling
of anxiety, conflict, or distress family roles; few friends or social activities
• Secondary gains are obtained when the • may report lack of family support
person receives internal or personal benefits • Physiologic and self-care concerns:
from others because one is sick legitimate health concerns may include
Biologic theories: Familial tendencies; Differences disturbed sleep patterns, poor nutrition, lack
in the way body stimuli are regulated and interpreted of exercise, overuse of prescription
medications
Treatment
• Treatment is focused on managing Nursing diagnoses include:
symptoms, improving quality of life, and • Ineffective Coping
improving coping skills
• Ineffective Denial
• Antidepressants are sometimes used for • Impaired Social Interaction
accompanying depression
• Anxiety
• Referral to a pain clinic is helpful in pain
• Disturbed Sleep Pattern
disorder; use of non-pharmacological
interventions • Fatigue
• Pain
• Involvement in therapy groups to improve
coping and express emotions verbally has
shown some benefit Intervention
• Providing health teaching
Application of the Nursing Process • Assisting client to express emotions
Assessment • Teaching coping strategies
 • Emotion-focused coping strategies • Biological Theories. Loss of one’s own
(progressive relaxation, deep breathing, reality due to epilepsy or tumors / effects
guided imagery, and distractions) of drugs benzodiazepines, barbiturates,
• Problem-focused coping strategies (learning hallucinogens
problem-solving methods, applying the • Learning Theory. A learned response of
process to identified problems, and role- avoiding stress and anxiety
playing interactions with others)
• Make appropriate referrals, such as a pain Evaluation and Diagnosis
clinic for clients with pain disorder • Complete physical examination
• Provide information about support groups in • Mental health evaluation
the community • Interview about childhood and adult trauma
• Encourage clients to find pleasurable and past experiences
activities or hobbies • Blackouts or “lost” time
• Fugues
DISSOCIATIVE DISORDERS • Unexplained possessions
Dissociative disorders have the essential feature of • Relationship changes
a disruption in the usually integrated functions of • Spontaneous trances
consciousness, memory, identity, or environmental • Awareness of other personalities within
perception. This often interferes with the person’s oneself
relationships, ability to function in daily life, and
ability to cope with the realities of the abusive or DEPERSONALIZATION DISORDER
traumatic event. This disturbance varies greatly in
• Persistent or recurrent feeling of being
intensity in different people, and the onset may be detached from the person’s own mental
sudden or gradual, transient, or chronic. processes or body
• Self-awareness is altered or temporarily lost
Characteristics
• Perceive change in consciousness as barrier
• Rare
between her and the outside world
• Disturbances in the normal waking state
• Feels passively watching mental or physical
• Affect fundamental aspects of consciousness, activity
memory, identity, self-perception, and
• Feels that the real world is unreal or distorted
• perception of the environment
• Sudden onset, usually occurring in
• Result from overwhelming stress caused by a adolescence or early adulthood
traumatic event that the person
• Symptom is brief and no lasting effects
• witnessed or experienced, or by some
• Typically progresses, becomes chronic Signs
intolerable internal conflict
and symptoms
Types • Feeling detached from entire being and body
or loss touch of reality
• Depersonalization Disorder
• Sensory anesthesia
• Dissociative Amnesia
• Loss of self-control
• Dissociative Fugue
• Difficulty speaking
• Dissociative Identity Disorder
• Obsessive rumination
Causes of Dissociative Disorder • Disturbed sense of time Treatment
• Psychological Theories. A response to • Many recovers without treatment
severe trauma or abuse Repress the • Treated when condition persistent, recurrent,
unpleasant experience from awareness. If or distressing
repression fails, dissociation occurs as a o Psychotherapy
defense mechanism. o Cognitive-behavioral therapy
o Hypnosis
 o Drugs (SSRIs, TCAs) • Help recognize traumatic event trigger
• Identifying and addressing all stressors • Teach reality-based coping by
linked to onset psychotherapist
• Hypnosis / drug induced semi-hypnotic state
Interventions (urgent)
• Establish therapeutic, non-judgmental • Drugs (Benzodiazepines and SSRIs)
relationship with patient
• Encourage patient to recognize that Nursing Diagnosis: Anxiety
depersonalization is a defense mechanism Short-Term Goal #1: The client will identify signs
• Recognize and deal with anxiety-producing and symptoms of anxiety.
experiences Interventions
• Assist patient in establishing supportive • Work with the client to identify how the
relationships anxiety is manifested.
• Help the client recognize that anxiety is
DISSOCIATIVE AMNESIA handled by dissociating from personal
• Inability to recall important personal identity.
information that cannot be explain by • Encourage the client to verbalize feelings of
ordinary forgetfulness distress. When the stressor responsible for the
• Forgetting basic autobiographical amnesia becomes known (after the client's
information memory returns), explore the trauma and
• Acute memory loss triggered by severe related feelings.
psychological stress
• Aware that they have “lost” sometime Short-Term Goal #2: The client will develop several
effective skills for managing anxiety.
Types Interventions
• Localized amnesia– cannot recall that took • Have the client discuss awareness of and
place during a specific period of time ways to control behaviors indicative of
• Selective amnesia – can recall some but not anxiety.
all of the events during a circumscribed time • Have the client explore current coping
period. mechanisms. Encourage the client to develop
• Generalized amnesia– prolonged loss of and use logical thought processes and refine
memory encompassing an entire lifetime problem-solving skills.
• Continuous amnesia– forgets all events • Teach the client techniques for relieving
from a given time toward to the present. anxiety, such as deep breathing and
• Systematized amnesia– memory loss is progressive muscle relaxation.
limited to a specific type of information (ex. • Have the client develop a support system that
Specific person) can be relied on in times of distress

Causes: DISSOCIATIVE FUGUE

• Stress associated by traumatic experience • Sudden, unexpected travel away from home
• Predisposition or workplace.
• History of physical, emotional, or sexual • Inability to recall past; confusion about
abuse Signs and symptoms: personal identity; occasional formation of
• Disoriented or wander aimlessly new identity during episode.
• Inability to recall information • Degree of impairment varies with duration of
• Unaware of memory disturbance, when fugue and nature of personality state evoked
episode ends • Upon return to pre-fugue state, patient may
have no memory of events that occurred
Treatment during fugue
 • Usually resolves rapidly • Primary personality is religious, with strong
moral sense, while subpersonalities are
Treatment radically different
• Psychotherapy • Primary personality maybe unaware of
• Hypnosis subpersonalities • Subpersonalities are more
• Cognitive therapy likely aware of existence of other
• Group therapy personalities
• Family therapy
• Creative therapies (music or art therapy) Cause / Signs and symptoms
• Cause – history of severe childhood abuse
Nursing Diagnosis: Ineffective Individual Coping • Lack of recall beyond ordinary forgetfulness
Short-Term Goal #1: The client will discuss feelings • Pronounced changes in facial presentation,
about stressful life events. voice behavior
Interventions • Hallucinations (auditory and visual)
• Help the client identify anxiety-provoking • Suicidal tendencies or other self / harming
situations. Have the client explore feelings behaviors
about current life stressors.
• Have the client discuss both positive and Treatment
negative feelings about self and the ability to • Long-term process
make changes. • Goal: To integrate all of patient’s
• Encourage the client to explore repressed personalities and prevent personality from
traumatic experiences as they come into splitting again
conscious memory, focusing on the anxiety • After stabilization, decreasing degree of
that they generate. dissociation, enhancing cooperation and
consciousness among subpersonalities and
Short-Term Goal #2: The client will verbalize ultimately merging then into one personality
constructive ways to cope with stress. • Family and couple therapy
Interventions • Hypnosis
• Teach the client to evaluate past and current • Drugs (Benzodiazepines, SSRI’s and
coping methods. TCA’s)
• Discuss the universal concept of wanting to
move away from or flee painful situations. Nursing Diagnosis: Personal Identity Disturbance
• Work with the client to formulate alternative Short-Term Goal #1: The client will develop an
coping strategies and behaviors. understanding of the relation between anxiety and
• Encourage to identify emotions that occur dissociation.
under stress Monitor for signs of overt
aggression toward self or others Interventions
• Teach effective coping skills • Persevere to establish a therapeutic
• Encourage to use available social support relationship with the client (Because of a
systems. history of abuse, the client finds it difficult to
trust and depend on others)
DISSOCIATIVE IDENTITY DISORDER (DID) • Help the client identify each existing
• Marked by two or more distinct identities or personality. Encourage the client to discuss
subpersonalities how each personality meets particular needs.
• Identities or subpersonalities recurrently take Each personality usually represents
control of client’s consciousness and protection against painful, traumatic
behavior memories.
• Each identity may exhibit unique behavior • Have the client begin to address past
patterns, memories, and social relationships traumatic, anxiety-provoking situations.
 • Help the client identify intense emotions that schizophrenia; general medical or neurologic
occur during severe stress. disorders; pain and abuse
• Slowly promote discussion with the client
about intense feelings associated with past Interventions for Insomnia:
disturbing events. • Reduce noise
• Teach the client how severe anxiety • Avoid napping during the day
precipitates the transition from one • Avoid using the bed and bedroom for
personality to another. activities other than sleep
• Avoid caffeinated beverages after
Short-Term Goal #2: The client will demonstrate the midafternoon
use of effective coping skills. • Limit fluid intake after dinner
• Avoid exercise before bedtime
Interventions • Establish a relaxing routine before bedtime
• Assess the client's current methods of coping, • Establish a regular rise time in the morning
watching for self-destructive behavior. Self- • May use drugs (sedating antidepressants,
mutilating behavior can occur when the nonbenzodiazepines hypnotics, antihistamine
client is dissociating. drugs May use sleep agents (melatonin or
• Instruct the client to use grounding OTC, aromatherapy and hypnotic agents)
techniques, such as finding a safe place, Other Sleep Disorders:
counting, and wrapping up in a blanket. Jet Lag: sleepiness and alertness that occur at an
Grounding techniques help a client stay in appropriate time of day relative to local time;
the present. occurring after repeated travel across more than one
• Work with the client to identify and begin to time zone
use alternative ways of handling stress, such
as journaling, relaxation exercises, and Narcolepsy: overwhelming sleepiness in which the
seeking others to talk to. individual experiences irresistible attacks of
• Help the client identify the consequences of refreshing sleep, cataplexy (loss of muscle tone)
dissociating as a way to cope with stress. and/or hallucinations or sleep paralysis at the
• Don’t encourage to create new personalities beginning or end of sleep disorders.
Don’t suggest to adapt names for
subpersonalities Nightmare Disorder: repeated awakenings from the
• Don’t encourage subpersonalities to function major sleep period or naps with detailed recall of
more autonomously extended and extremely frightening dreams, usually
• Don’t exclude unlikeable subpersonalities involving threats to survival, security or self-esteem
from therapy
Restless Leg Syndrome: insomnia associated with
SLEEP DISORDERS crawling sensations of the lower extremities,
Common sleep disorders: frequently associated with medical conditions such
Insomnia – difficulty initiating or maintaining sleep as medical conditions such as arthritis or pregnancy
Primary/acute insomnia: inability to initiate or
maintain sleep or nonrestorative sleep for at least 1- Sleep Apnea: experience of a lack of airflow. Maybe
month due to disrupted ventilation or airway obstruction
• Causes: chronic stress, hyperarousal, poor
sleep hygiene, environmental noise, or jet lag Sleep Terror disorder: recurrent episodes of abrupt
awakening from sleep usually accompanied by a
Secondary Insomnia- inability to initiate or panicky scream, intense fear, tachycardia, rapid
maintain sleep or nonrestorative sleep due to a breathing and diaphoresis.
psychiatric disorder such as depression, anxiety or
SELF ASSESSMENT
Instruction: Select the best answer. 6. A student explained to the teacher that she
1. The nurse is caring for a client with a had diarrhea the day before the proposal
conversion disorder. Which finding will the defense that is why she was absent. This is an
nurse expect during assessment? example of:
a. Extreme distress over the physical a. Factitious disorder
symptom b. Munchau/sen disorder
b. Indifference about the physical c. Malingering
symptom d. Somatization
c. Labile mood 7. Which statement is typical of a client with
d. Multiple physical complaints illness anxiety disorder?
2. The following statements are indicative that a. “My doctor does not have the
teaching about somatic symptom disorder has necessary competence to treat me.”
been ineffective except one: b. “I have the best doctor that my
a. “The doctor believes I am faking my physical symptoms are gone.”
symptoms” c. “My physician explained to me that
b. “I will feel better when I begin what I am experiencing has medical
handling stress more effectively.” cause.”
c. “If I try harder to control my d. “I am glad that I am referred to a
symptoms, I will feel better.” psychiatric clinic because of my
d. “Nothing will help me feel better physical symptoms.”
physically.” 8. The following are features of somatic
3. Sertraline (Zoloft) has been prescribed for a illnesses, except one:
client with a somatic symptom illness. The a. Voluntarily control the symptoms
nurse instructs the client to watch out for b. Physical symptoms suggest medical
which side effect? illness but no organic basis
a. Sexual dysfunction c. Psychological factors and conflicts
b. Constipation that seem important in initiating,
c. Increased appetite exacerbating and maintaining the
d. Increased flatulence symptoms.
4. Problem-focused coping strategies are d. The symptoms are not under the
designed to accomplish these outcomes, client’s conscious control.
except? 9. Which of the defense mechanisms is
a. Helping the client manage difficult commonly used by clients with somatization
situations more effectively. disorder?
b. Role playing interaction with others. a. Sublimation
c. Teaching the client, the relationship b. Internalization
between stress and physical c. Rationalization
symptoms. d. Projection
d. Helping the client manage the 10. The nurse understands that all are considered
intensity of symptoms secondary gains for clients with somatic
5. Which is true about clients with illness symptoms illness, except one:
anxiety disorder? a. Temporary relief of anxiety
a. They often exaggerate or fabricate b. Acceptable absence from work
physical symptoms. c. Provision of care by others
b. They do not show signs of distress d. Freedom from daily chores.
about their physical symptoms.
c. They inflict others and then save them
to play as hero
d. They may interpret normal body
sensations as signs of disease
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 8 Schizophrenia

Outline • from the GREEK roots SCHIZO (split) and

1. What is Schizophrenia PHRENE (mind)
2. Clinical Incidence • In 1887, Emil Kraepelin (psychiatrist)
3. History of Schizophrenia described the mental illness (1st DSM?)
4. Causes of Schizophrenia • Eugene Bleuler (Swiss psychiatrist), coined
5. Phases of Schizophrenia the word in 1911.
6. Clinical Symptoms
7. Diagnostic Characteristics CAUSES OF SCHIZOPHRENIA
8. Subtypes of Schizophrenia Arguments on causes: no single cause!!!
9. Schizophrenic-Like
10. Nursing Diagnoses 1. Genetic predisposition- 10-20% risk if 1
11. Concepts and Principles of Hallucinations immediate family is affected 40% risk if both
12. Suspicious Client parents or an identical twin but 60% of people
13. Manifestations of Schizophrenia with schizophrenia have no close relatives
14. Psychopharmacology with the illness
scientists also maybe close to identifying
SCHIZOPHRENIA genetic locations of schizophrenia, believed
• Most common and disabling of the psychotic to be on human chromosomes 13 and 8
disorders 2. Biochemical and Neurostructural Theory
• Affects a person’s behavior, emotion and dopamine hypothesis –excessive amount
cognition dysfunction of neurotransmitter receptors
• Clinical symptoms can be draining to both (Kennedy, Pato, Bauer, et al, 1999)
the patient and the family because it’s chronic abnormalities of neurocircuitry or signals
syndrome that typically follows a from neurons (Under research); defective
deteriorating course over time circuit result in bombardment of unfiltered
• There’s difficulty functioning in society, in information, overwhelmed, the mind makes
school and at work errors in perception and hallucinates, draws
• Duration- continuous for at least 6 months incorrect conclusions and becomes
delusional (Kennedy, Pato, Bauer, et al,
CLINICAL INCIDENCE 1999)
• Onset is 16-25 years old 3. Organic or Pathophysiologic Theory- a
• 2x as often in people who are unmarried or functional deficit occurring in the brain
divorced, more likely with people who are caused by stressors such as viral infections,
members of the lower socioeconomic groups toxins, trauma, or abnormal substances (this
• Appears earlier in men than women is a hope) still under thorough investigation
• Approximately 24 million people (or .5-2%) (Well-Connected, 1999)
around the globe suffer from schizophrenia 4. Environmental or Cultural Theory- person
40% of these cases do not receive psychiatric with schizophrenia has faulty reaction to
treatment; results in homelessness, environment, unable to respond selectively to
incarceration or Violence numerous social stimuli; Socioeconomic
areas single-parent homes in deprived areas
HISTORY OF SCHIZOPHRENIA (Kolb, 1982)
1. History of: 5. Perinatal theory (Well-Connected, 1999)
Developing fetus deprived of oxygen during
 pregnancy or malnutrition of the mother • Disorganized speech
during first trimester
6. Psychological or Experential Theory Diagnostic Characteristics
(Kolb,1982) Researchers found that the • Evidence of 2 or more of the following:
prefrontal lobes of the brain are extremely Delusions
responsive to stress; interpersonal conflicts • Hallucinations Disorganized speech
contributing to stress usually imposed by • Grossly disorganized or catatonic behavior
family members; Double-bind situation • Negative symptoms
• Above symptoms present for a major portion
FIVES PHASES OF SCHIZOPHRENIA of the time during a 1-month period
1. Premorbid phase– no clinical symptoms • Significant impairment in work or
2. Prodromal phase– gradual, subtle
interpersonal relations, or self-care below the
behavioral changes (tension, the inability to level of previous function
concentrate,
• Demonstration of problems continuously for
3. insomnia, withdrawal, cognitive deficits)
at least a 6-month interval
4. Onset phase– cognitive deficits have been
proven to exist 20 years before this phase
Classification of Subtypes of Schizophrenia
5. Progressive phase- may recover from the
first episode and experience repeated relapses • Paranoid
6. Chronic or residual phase- repeated • Catatonic
episodes and relapses for a number of years • Disorganized
• Undifferentiated
CLINICAL SYMPTOMS • Residual
POSITIVE SYMPTOMS –overt psychotic or
distorted behavior SCHIZOPHRENIC-LIKE
• Suspiciousness • Brief Psychotic Disorder-maybe seen when
• Conceptual disorganization a person exhibits clinical symptoms of
Hallucinations/hostility illogical thinking, incoherent speech,
• Excitement or agitation delusions, or disorganized behavior after
• Delusions psychological trauma
• Induced Psychotic Disorder-develops in a
NEGATIVE SYMPTOMS- loss of normal function second person as a result of a close
such as affect, motivation or the ability to enjoy relationship with a person who has psychosis
• Schizoaffective disorder-characterized by
activities
depression or elation as the psychosis
• Anergia
symptoms of schizophrenia and MDD
• Alogia • Schizophreniform-when a person exhibits
• Anhedonia features of schizophrenia for more than one
• Affective flattening week but less than 6 months
• Asocial behavior
• Avolition NURSING DIAGNOSIS
• Apathy • Disturbed thought processes related to the
presence of persecutory delusions
DISORGANIZED SYMPTOMS - presence of • Disturbed sensory perception related to the
confused thinking, incoherent speech and presence of visual hallucinations
disorganized behavior (repetition of rhythmic
gestures) • Self-care deficit related to poor personal
• Incoherent speech hygiene
• Cognitive defects/confusion • Impaired verbal communication related to
• Attention deficits thought disturbance (looseness of
• Repetitive rhythmic gestures (walking in association)
circles or pacing)
 • Noncompliance related to refusal to take A-affect is inappropriate
prescribed psychotropic medication
• Disturbed sleep pattern related to the PSYCHOPHARMACOLOGY
presence of auditory hallucinations MOST IMPORTANT
• Social isolation related to homelessness NEUROTRANSMITTERS
• Ineffective coping related to fear • Dopamine-is important in conceptualizing
the pathology and treatment of Schizophrenia
CONCEPTS & PRINCIPLES OF and Parkinsonism
HALLUCINATION • Acetylcholine –is important in
• Possible to replace hallucination with conceptualizing the pathology and treatment
satisfying interactions of Alzheimer’s disease and Parkinsonism
• Can re-learn to focus attention on real things • Norepinephrine –is important in
and people conceptualizing the pathology and treatment
• Hallucinations originate during extreme of Mania and Depression
emotional stress when the patient is unable • GABA (gamma-aminobutyric acid) –is
to cope important in
• Hallucinations are very real to the patient • conceptualizing the pathology and treatment
• Patient will react as the situation is of Anxiety
perceived • Serotonin- is important in conceptualizing
• Concrete experiences, not argument on the pathology and treatment of Mania and
confrontation will correct sensory distortion Depression
• Hallucinations are a substitute for human
relations DOPAMINE
• Brain stem – primary location
SUSPICIOUS CLIENT • Excitatory- general function
• Assign the same staff • Tyrosine- where dopamine is synthesized
• Do not whisper or act secretively in the • Movements- complex, controlled by
presence of the client dopamine Emotion-area of control
• Do not mix medicine with food • Cognition- area of control Motivation-area
• Allow to set extent of closeness and distance of control
• Solitary one-on-one activities then group
• Avoid laughing or talking with others when ACETYLCHOLINE
the client can see but hear • Location-Brain, Spinal Cord, PNS, Skeletal
• Provide meaningful tasks to encourage muscles
feelings of adequacy • Other Functions- Sleep-wake cycle,
• Avoid competitive activities • Activation of muscles General Function-
• Provide appropriate outlets for anger. Excitatory & Inhibitory Synthesis- Choline
• Taste food only if requested by patient (red meat & vegetables)
MANIFESTATIONS NOREPINEPHRINE
S-social isolation • Location- Brain stem
C-catatonic behavior
• Other functions- changes in attention,
H-hallucinations
learning and memory, sleep and wakefulness,
I-Incoherence
mood regulation
Z-zero/lack of interest and initiative
O-obvious failure in development • General Function- excitatory
P-peculiar behavior • Synthesis- tyrosine
H-hygiene and grooming impaired
R-recurrent illusions GABA
E-exacerbations and remissions • Major inhibitory neurotransmitter
N-no organic factor account S/S • Amino acid
I-inability to return to functioning • Modulate other neurotransmitters
 CLASSIFICATION OF TRADITIONAL
SEROTONIN (TYPICAL) ANTIPSYCHOTIC DRUGS BASED
• Brain -location ON POTENCY
• Emotions- function High-Potency:
• Sleep and wakefulness- function • Fluphenazine (Prolixin)
Temperature regulation- function • Haloperidol(Haldol)
• Tryptophan- synthesis (e.g. milk) • Thiotixene(Navane)
• Inhibitory- general function • Trifluoperazine(Stelazine)
• Pain control- function
Moderate-Potency:
• Sexual behavior- function
• Loxapine(Loxitane)
• Food intake control- function
• Molindone (Moban)
• Perphenazine(Trilafon)
IMBALANCES IN NEUROTRANSMITTERS
• Increase in dopamine – schizophrenia Low-Potency:
• Decrease in norepinephrine depression • Chlorpromazine(Thorazine)
• Decrease in serotonin- depression • Chlorprotixene(Taractan)
• Decrease in acetylcholine- Alzheimer’s • Mesoridazine(Serentil)
• Decrease in GABA- anxiety • Thioridazine(Mellaril)

ANTIPSYCHOTICS EFFECT OF ANTIPSYCHOTIC TO FOUR

HISTORY DOPAMINERGIC TRACTS
Chlorpromazine (Thorazine)– first antipsychotic 1. NIGROSTRIATAL SYSTEM: (midbrain,
drug; from the phenothiazine family of drugs; proved thalamus, hypothalamus)
quite sedating (tendency to sleep); historically - pseudo parkinsonism or extrapyramidal
referred as major tranquilizers effect
2. TUBERINFUNDIBULAR SYSTEM:
TYPICAL ANTIPSYCHOTICS (12) (midbrain, hypothalamus)
• Loxapine (Loxitane) - dopamine inhibition of the hypothalamic
• Pherphenazine (Trilafon) hormone prolactin is lifted and can lead
• Trifluoperazine (Stelazine) to gynecomastia and galactorrhea
• Chlorpromazine (Thorazine) 3. MESOLIMBIC SYSTEM: (midbrain to
• Mesoridazine(Serentil) limbic forebrain)
• Molindone (Moban) - a decrease in the symptoms of
• Fluphenazine (Prolixin) schizophrenia (positive)
• Haloperidol (Haldol) 4. MESOCORTICAL SYSTEM: (neocortex
• Thioridazine (Mellaril) to midbrain)
- disorder can be worsened in some
• Dropenidol (Inapsine)
patients like
• Chlorprothixene (Taractan)
• Thiotixene (Navane)
• Risperidone is thought to antagonize serotonin
receptors in the cortex thus liberating dopamine-
contributing to negative symptoms
ATYPICAL ANTIPSYCHOTIC DRUGS (7)
• Positive symptoms- attributed to too much
• Aripiprazole (Abilify)
dopamine in the limbic area (hyperactive
• Quetapine (Seroquel) mesolimbic tract)
• Ziprasodone (Zeldox) • Negative symptoms- attributed to too little
• Sertindole(Serlect) dopamine in the cortex (hypoactive mesocortical
• Clozapine (Clozaril) tract)
• Olanzapine (Zyprexa)
• Respiridone(Respirdal)
INTENDED EFFECTS ACETYLCHOLINE RECEPTORS
• Sedation-decreases insomnia, for agitation, (MUSCARINIC RECEPTORS)
combative persons • blocked by antipsychotic
• Emotional quieting • antiparasympathetic effects
• Decreases confusion and clouding, • blurred vision, tachycardia, constipation and
hallucinations, delusions and illusions urinary retention
• Ambivalence reduced • Alpha1 receptor of norepinephrine blocked
• Thoughts become clearer by antipsychotic
• Improve reasoning • Responsible for vasoconstriction in upright
• Offers more effective communication position
• Negative symptoms reduced • Orthostatic hypotension
• Slow psychomotor activity
UNDESIRABLE EFFECTS
SOME IMPORTANT NOTES: • Sedation/sunlight sensitivity/sleepiness
• Chlorpromazine– more potent in elderly • Tardive dyskinesia
because of decreased protein-binding action • Anticholinergic/aganulocytosis/akathisia
• Oral routes are preferred more • Neuroleptic malignant syndrome
• Liquid forms preferred for non-compliant • C-cardiac effects (Orthostatic hypotension)
patients (should be diluted to counteract • Extrapyramidal(dystonia)
unpleasant taste)-problem of cheeking
• Parenteral preferred for noncompliance and Side Effects: PNS
out patients (Haloperidol decanoate or • Anticholinergic effects– blocking
fluphenazine decanoate)- 1-2X A MONTH acetylcholine
• Hypotension- blocking of alpha1 receptors
PHARMACOKINETICS (TYPICAL) which prevents constriction of blood vessels
CHLORPROMAZINE in upright position
• enters body thru the mouth
• Metabolized in the liver SIDE EFFECTS- CNS
• Accumulate in fatty tissue Parkinsonism
• Chlorpromazine binds with plasma proteins • Motor retardation or akinesia characterized
(only fraction crosses blood-brain barrier) by mask-like appearance, rigidity, tremors,
• Released slowly (even after months of “pill- rolling”, salivation
therapy had stopped)-reason why effect still • Generally occurs after 1st week of treatment
continues; noncompliance may occur or before second month
• Chlorpromazine-enters CNS rapidly
• Administer anticholinergic agent, anti-
• tranquilizing effect occurs within 60 minutes
Parkinson medication (Akineton, Artane)
(oral) and 10 minutes (IM)
• Excreted in the urine (traces of drug
Akathisia
metabolites present even months after
• Constant state of movement, characterized by
therapy had stopped)
restlessness, difficulty sitting still, or strong
urges to move about
DOPAMINE
• Generally occurs two weeks after treatment
• Blocked by antipsychotics
begins
• Dopamine- inhibitor of prolactin: increase
• Rule out anxiety or agitation before
levels of prolactin causing galactorrhea in
administration of an anticholinergic agent
women; gynecomastia in men
• Dopamine- responsible for fine-tuning motor Dystonia
activity in the basal ganglia; blocked by
• Painful and frightening spasms of tongue,
antipsychotic causes parkinsonism
throat, face, jaw, eyes, neck, or back muscles
• Torticollis
 • Oculogyric crisis • Use in elderly – lower doses due to decreased
• Opisthotonos hepatic metabolism capacity
• Anticholinergic drugs • Use in pregnant women- readily passes
• Stay with the patient placental barrier and may cause EPSs to the
fetus
Tardive Dyskinesia • If used with CNS depressants, can cause
• Most frequent serious side effect resulting profound CNS depression
from termination of the drug, during
reduction in dosage, or after long term high CLOZAPINE (CLOZARIL)
dose therapy. Characterized by involuntary • Possible mechanisms of agranulocytosis:
rhythmic, stereotyped movements, tongue • clozapine metabolite, desmethylclozapine,
protrusion, cheek puffing, involuntary may have direct cytotoxic effect on the bone
movements of extremities and trunk marrow cells
• Occurs in approximately 20-25% of patients • Release of granulocyte-stimulating factor
taking antipsychotics for over two years may be suppressed by clozapine, resulting in
• No treatment except discontinuation of the hematologic imbalance
antipsychotic agent • Clozapine may induce antibody formations
that are toxic to peripheral blood neutrophils
Neurologic Malignant Syndrome (NMS) and their
• A potentially fatal syndrome • committed precursors
• May occur anytime during therapy
• Seen during the initiation of therapy, change ANTIPARKINSON DRUG
of therapy, After a dosage increase or when a • Imbalance causing parkinsonism
combination of meds is used. • Balance is accomplished in three ways
• Early sign: rigidity or mental status changes o Drugs are used to increase the level of
• catatonia, tachycardia, tachypnea, labile dopamine (dopaminergic agents)
blood pressure, dysphagia, diaphoresis, o Drugs are used to decrease the level
incontinence, rigidity, myoclonus, tremors, of Ach (anticholinergic agents)
high grade fevers o A combination of these two drugs is
• Discontinue antipsychotic agent. Have used to increase dopamine and
cardiopulmonary support available; decrease Ach simultaneously
administer skeletal muscle relaxant (e.g.
dantrolene) or central acting dopamine ANTICHOLINERGIC DRUGS
agonist (e.g. bromocriptine) • Decrease acetylcholine availability
• Trihexyphenidyl (Artane)
Summary of Side Effects of Neuroleptics • Benztropine (Cogentin)
• Blurred vision • Biperiden (Akineton)
• Constipation • Diphenhydramine (Benadryl)
• Orthostasis Akathisia • Ethopropazine (Parsidol)
• Pseudoparkinsonism • Procyclidine(Kemadrin)
• Urinary retention
• NMS SIDE EFFECTS AND NURSING
• Dystonia INTERVENTIONS FOR
• Anxiety ANTICHOLINERGICS
• Nausea CNS- sedation: help patient get up early and get the
• Tardive dyskinesia day started
• Eyes- Blurred vision, photophobia:
• Agranulocytosis
reassurance (normal vision typically returns
Some Notes: in a few weeks); sunglasses, caution when
driving, tolerance develops
 o Mydriasis: if eye pain develops could
indicate undiagnosed narrow angle
glaucoma- immediate attention is
warranted
• Nose-nasal congestion: otc nasal
decongestant if approved by physician
• Mouth-dry mouth : sugarless hard candy and
chewing gum; frequent rinses; take before
meals
• Heart-tachycardia, palpitations- report to
physician
o Orthostatic hypotension: request
patient to get out of bed slowly, to sit
on the edge of the bed a short while
and rise slowly
• Urinary tract- urinary hesitation: running
water, privacy, warm water over perineum
o Urinary retention: catheterize for
residual fluids, encourage frequent
voiding
• Digestive- constipation: laxatives as ordered,
diet with roughage, 2500 to 3000 ml water
per day
• Skin- decreased sweating- this can lead to
fever; take temperature; if fever occurs,
reduce body temperature
o Temperature: limit strenuous activity,
wear appropriate clothing
Other Treatments
• Psychotherapy-individual, group,
behavioral, supportive or family therapy
maybe used depending on the clinical
symptoms
• Milieu therapy- a structured environment to
minimize environmental and physical stress
and to meet the individual needs of the
patients until they are able to assume
responsibility for themselves
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 9 Mood Disorders

Outline: • Cyclothymia: mood swings not severe

1. Mood Disorders enough to be diagnosed as bipolar disorder
a. Categories • Substance-induced mood disorder
b. Related Disorders • Mood disorder due to a general medical
c. Etiology condition
2. Major Depressive Disorder • Seasonal affective disorder (SAD): mood
a. Diagnostic Criteria affected by seasons
b. Nursing Diagnoses Symptoms can be: increased sleep or
c. Interventions insomnia, increased appetite or loss of
3. Bipolar Disorder appetite, weight gain, interpersonal conflict,
4. Pharmacologic Treatments irritability
a. Antidepressants • Postpartum or “maternity” blues: frequent
i. TCAs normal experience after delivery of a baby
ii. SSRIs characterized by labile mood and affect,
iii. MAOIs crying spells, sadness, insomnia and anxiety
b. Antimanic drugs • Postpartum depression-meets all the
5. Suicide criteria for a major depressive episode with
a. SAD Scale onset within 4 weeks of delivery
b. Etiology • Postpartum psychosis
c. Precipitating Factors
d. Assessment ETIOLOGY
e. Interventions • Biologic theories
• Genetics - first degree relatives (3%-8%)
MOOD DISORDERS - twins (2-4x higher risk than fraternal
• Also called affective disorders, are twins
pervasive alterations in emotions that are • Neurochemical theories- deficits of
manifested by depression, mania or both serotonin occur in people with depression
• Interferes with a person’s life - norepinephrine maybe deficit in
• With accompanying self-doubt, guilt and depression and increased in mania
anger which alter life activities • Kindling- process by which seizure activity
in a specific area of the brain is initially
CATEGORIES stimulated by reaching a threshold of the
• Major depression: 2 or more weeks of sad cumulative effects of stress
mood, lack of interest in life activities, and • Psychodynamic theories
other symptoms 1. Freud: self-depreciation of people with
• Bipolar disorder (formerly called “manic- depression
depressive illness”): mood cycles of mania 2. Bibring: idealistic ego frustrated
and/or depression and normalcy and other 3. Jacobson: ego is a powerless, helpless
symptoms child victimized by the superego
4. Meyer: reaction to a distressing life
RELATED DISORDERS experience
• Dysthymia: sadness, low energy, but not 5. Horney: children raised by rejecting or
severe enough to be diagnosed as major unloving parents were prone to feelings
depression disorder of insecurity and loneliness
 6. Beck: results from specific cognitive • Communication: using therapeutic
distortions in susceptible people. communication

MAJOR DEPRESSIVE DISORDER (MDD) BIPOLAR DISORDER

• 2x in women • Occurs almost equally among men and
• More on divorced women
• 2 weeks • It is more common in highly educated people
• Hallmark signs: anhedonia & sad mood • The mean age for a first manic episode is the
• Endogenous depression- no precipitating early 20s
factor (external); maybe due to biochemical • Involves mood swings of depression (same
imbalances symptoms of major depressive disorder) and
mania.
DIAGNOSTIC CRITERIA OF MAJOR
DEPRESSIVE DISORDER (MDD) CLINICAL MANIFESTATIONS
At least 5 of the following symptoms present during Major symptoms of mania include:
the 2 week period: • Inflated self-esteem or grandiosity
• Flight of ideas
• Interest is lacking in most everything. • Sleep decreased
• Sleep is hard to come by. • Pressured speech
• Appetite is very often depressed. • Agitation (Psychomotor)
• Depressed people can be very tearful. • Distractibility
• Concentration is often lacking. • Excessive involvement in pleasure-seeking
• Activity is decreased. activities with a high potential for painful
• Guilt may bring a negative view of self, consequences
world or future.
• Energy level is decreased. Manic
• Suicide precautions are mandatory. • Mood elevated
• A grandiose delusion
NURSING DIAGNOSES • Need for sleep, eat decreased
• Risk for Suicide • Inappropriate
• Imbalanced Nutrition: Less Than Body • Clanging, loud vulgar
Requirements
• Anxiety Depressed
• Ineffective Coping • Out for suicide
• Hopelessness • Won’t sleep, eat
• Ineffective Role Performance • Negative
• Self-Care Deficit
• Chronic Low Self-Esteem MANIA VS. DEPRESSION
• Disturbed Sleep Pattern
Mania Depression
• Impaired Social Interaction
Appearance Colorful, Sad and gray
flamboyant
INTERVENTIONS
Behavior Psyhomotor Psychomotor
• Safety: providing for the client’s safety and
agitation retardation
the safety of others
Communication Pressured Monotonous
Medications: managing medications
speech, speech
ADLs: promoting activities of daily living
stuttering,
and physical care
cluttering
Relationship: promoting a therapeutic
Nsg Dx Risk for Risk for
relationship
injury injury (self)
• Teaching: providing client and family
(others)
teaching
 Nsg Priority Safety and Safety and 1. Carbamazepine (Tegretol)
nutrition nutrition 2. Lithium Carbonate (Eskalith)
Nutrition Finger foods Increased in 3. Valproic Acid (Depakene)
and high nutrients
calories TRICYCLIC ANTIDEPRESSANTS TCAs
Treatment Lithium, ECT TCA, SSRIs, • TCAs contain three hydrocarbon rings
MAOIs, ECT Inhibits neurotransmitter reuptake (NE and
Milieu Non- Stimulating SE)
stimulating
environment INTENDED EFFECTS
Appropriate Quiet type; Monotonous; • Sedative/hypnotic
activity non- non- • Treatment of chronic pain
competitive competitive • Decreased symptoms of depression
Attitude Matter of fact Kind firnness; • Treatment of anxiety associated with
therapy active depression, alcoholism, neurotic disorders
friendliness • Improved appetite-weight gain
• T-treatment of panic attacks and phobic
PHARMACOLOGIC TREATMENTS attacks
ANTIDEPRESSANTS
TRICYCLIC ANTIDEPRESSANTS TCAs (15) SIDE OR ADVERSE EFFECTS
1. Maptroptiline (Ludiomil) • Weight gain
2. Mirtazapine (Remeron) Agitation
3. Doxepin (Sinequan) • Insomnia
4. Desipramine (Norpramin) • Sedation
5. Nortriptyline (Aventyl, Pamelor)
• Arrhythmias
6. Amoxapine (Asendin)
• Confusion (esp.elderly)
7. Clomipramine (Anafranil)...Best For Ocd
8. Protriptyline (Vivactil) • Orthostatic hypotension
9. Trazodone (Desyryl) • Anticholinergic effects
10. Trimipramine (Surmontil)
11. Bupropion (Wellbutrin) PHARMACOLOGICAL EFFECTS (TCA)
12. Duloxetine(Cymbalta) • Serum level of amines in the depressed
13. Imipramine (Tofranil) person is low
14. Venlafaxine (Effexor) (Snri) • TCA blocks reuptake of amines
15. Amitriptyline (Elavil) o Greater neurotransmitter availability
o Prolonged stimulating action
SELECTIVE SEROTONIN REUPTAKE o Alleviates symptoms
INHIBITORS (SSRIs) • Absorption
1. Flouxetine (Proxac) o Absorbed well in the GIT
2. Fluvoxamine (Luvox) o Metabolized in the liver
3. Paroxetine (Paxil) o Binds with plasma proteins
4. Sertraline (Zoloft) o Peak plasma concentrations reached
at 2-4 hours
MONOAMINE OXIDASE INHIBITORS o Inhibits amine reuptake
(MAOIs)
1. Moclobemide (Manerix)- reversible PNS SIDE EFFECTS
2. Phenelzine (Nardil) • Orthostatic hypotension
3. Tranylcypromine (Parnate)
4. Isocarboxacid (Marplan) CNS SIDE EFFECTS
• Anticholinergic effects
ANTIMANIC • Disorientation
 • Delusions • Therapeutic to panic attacks and
• Sedation dysthymia
• Confusion
• Agitations 4. DOXEPIN (SINEQUAN)
Seizure threshold lowered • Potentiates serotonin; sedating, has
Hallucinations anticholinergic activity; high antianxiety
effects
PRECAUTIONS: • Few cardiovascular effects but can have
• Lower doses or OD for elderly, alcoholics, orthostatic hypotension and weight gain-
history of hepatitis may have antiulcer properties
• Connection to suicide: depressed people are
also suicidal but antidepressants may cause 5. IMIPRAMINE (TOFRANIL)
the “lifting” in these patients which may • Oldest TCA; more effective
warrant close monitoring/suicide precaution • For children enuresis
• Drug interactions with TCAs Teaching • First-line drug in the treatment of panic
patients: OTC avoided-to prevent drug disorder
interactions • The standard by which newer
• Two-four weeks –before full therapeutic antidepressants are measured -care with
effects occur children due to its cardiovascular effects
• Eye pain-report immediately (narrow angle
glaucoma) Adjustment- to medication can 6. MAPROTILINE (LUDIOMIL)
lessen some side effects Slow • potentiates norepinephrine
discontinuation- to avoid nausea, headache • with anticholinergic effects; sedating
and malaise • a strong antianxiety effect
• no cardiovascular risk
INDIVIDUAL TCAs
1. AMITRIPTYLINE (ELAVIL) 7. NORTRIPTYLINE (AVENTYL,
• Prescribed often but not for the elderly PAMELOR)
Highly anticholinergic • for people with history of unfavorable
• One of the most sedating and cardiotoxic responses to antidepressants
antidepressants • for elderly; less orthostatic hypotension
• Parenteral form and in fixed dose sedating; for agitated and insomnia
combination with antipsychotics
Perphenazine (Triavil) 8. PROTRIPTYLINE (VIVACTIL)
• potentiates norepinephrine much more
2. AMOXIPINE (ASENDIN) than serotonin
• metabolite of g drug loxapine • greater incidence of tachycardia,
• blocks dopamine receptors cardiovascular problems and orthostatic
potential for tardive dyskinesia; hypertensions; has anticholinergic effects
not for elderly
9. BUPROPION (WELLBUTRIN)
3. DESIPRAMIN (NORPRAMIN) • inhibits dopamine reuptake
• Metabolite of imipramine • minimal orthostatic hypotension,
Good choice for elderly patients who cardiovascular problems, anticholinergic
are sensitive to anticholinergic side effects and daytime sedation -activating
effects antidepressant
• Minor anticholinergic effects • contraindicated for patients with seizure
• Activating antidepressant (for apathetic, disorders (lowers seizure threshold)
lethargic, hypersomic) • can cause weight loss
• Less sedating • effective replacement for SSRIs
 • reduces craving for cigarettes • Diarrhea
Dizziness
10. NEFAZODONE (SERZONE)
• first line agent for depression TOXICITY
• inhibits serotonin and norepinephrine • Vomiting
reuptake; blocks serotonin receptors • Irritability
• does not cause insomnia, sexual • Tremor
dysfunction, nervousness Myoclonus (twitching of a muscle or group
of muscles)
11. TRAZODONE(DESYREL) • N-nausea
• Potentiates serotonin not norepinephrine
• Almost no anticholinergic effects INTERACTIONS SEROTONIN SYNDROME
• few cardiac effects • Potentially fatal with SSRI + MAOI
• sedating; for insomnia • Hyperreflexia, hyperthermia, myoclonus,
• absorption is increased right after a light NMS
meal • Should:
• adverse reaction is priapism (prolonged o Be aware that a period of 14 days is
penile erection); nurse should stop the required between stopping a MAOI
medication and notify the prescriber and starting a SSRI
o Be aware of a period of 5 weeks is
12. MIRTAZAPINE (REMERON) required between stopping an SSRI
• for major depression only Flouxetine (Prozac) and starting a
• blocks alpha2 receptors which increases MAOI
o Be aware that MAOIs and
norepinephrine and serotonin by utilizing
the presynaptic feedback system (signals clomipramine (Anafranil) should not
need for more of these neurotransmitters) be given concomitantly

13. VENLAFAXINE (EFFEXOR) INDIVIDUAL SSRIs

1. FLOUXETINE (PROZAC)
• SNRI, norepinephrine reuptake inhibitor
• first SSRI; treatment for bulimia
• Few anticholinergic, antihistaminic, or
• Antiadrenergic side effects 2. SERTRALINE (ZOLOFT)
does not exaggerate the effects of alcohol
• potent inhibitor of serotonin reuptake
• Maybe effective in treating SSRI-induced than fluoxetine
sexual dysfunction, panic disorders and
• inhibit ejaculation in men and orgasm in
OCD
women
SELECTIVE SEROTONIN REUPTAKE • orgasmic ability returns after 2-3 days
INHIBITORS (SSRIs) after drug cessation
• First choice for depression
3. PAROXETINE(PAXIL)
• Fewer anticholinergic, cardiovascular and
• most potent SSRI
sedating effects
• Treatment of panic attacks;
• OD dosing
prevention of depression relapse
• Tolerated in the elderly
• side effect: nausea
SIDE EFFECTS • delays or inhibits orgasm
• Decreased libido
4. FLUOVOXAMINE(LUVOX)
• Orgasm decreased
• for OCD
• Weight loss
• Nervousness
 MONOAMINE OXIDASE INHIBITORS •most effective MAOI, most sedative
(MAOIs) deterrent to cocaine abuse and for panic
• Administered to hospitalized patients attacks
• Derivative of isoniazid, iproniazid (Anti-TB) 2. TRANYLCYPROMINE (PARNATE)
• Blocks monoamine oxidase • for severe reactive depression
• Effect from 10 days to 2 weeks • most stimulating
• Causes decreased heart rate, decreased • contraindicated to elderly
vasoconstriction and hypotension (slowed
release of norepinephrine in PNS) REVERSIBLE MAOIs
• Inhibits MAO in the liver, leads to elevated 1. MOCLOBEMIDE (MANERIX)
levels of other drugs metabolized in the liver • inhibition lasts only 24 hours
by MAO
• Side effects: cardiovascular and • taken after meals to reduce tyramine-
anticholinergic effects related responses
• Blood counts and liver function tests before
therapy ANTIMANIC DRUGS
• Lithium (Eskalith)
TYRAMINE INTERACTION Carbamazepine(Tegretol)
• Amino acid, tyramine (precursor of • Valproic Acid (Depakene)
dopamine, epinephrine and norepinephrine) • Lamotigrine (Lamictal)
• Foods: (principle: foods aged, left to spoil)
o A-alcohol/avocado LITHIUM
o B-bananas • Not much significant than sodium
C-chicken liver/ caffeinated coffee/ • Treatment of manic depression
colas/ chocolate • Absorbed in the GIT, peak blood levels of 1-
o D-dairy products/dried fish 3 hours
o S-salami/sausage/soy sauce • Not metabolized, excreted by the kidneys;
o T-tea unchanged
SYMPTOMS OF HYPERTENSIVE CRISIS: • Absorption of lithium and sodium are closely
• Dilation of pupils linked
• Chest tightness • If dietary sodium intake increases, plasma
• High blood pressure lithium levels will drop (lithium excreted
• Palpitation more rapidly)
• Diaphoresis, • If NA in the diet decreases, lithium levels
• Increased heart rate increase
• Stiff neck • 7-10 days for therapeutic effects
• Headache (throbbing, radiating ) • Maintenance level: 0.5-1.5 mEq/L (900-
1200mg/day)
TEACHING PATIENTS: • Side effects that subside: nausea, dry mouth,
• Hypertensive crisis symptoms must be thirst, mild hand tremor, weight gain,
reported immediately insomnia, light- headedness
• OTC drugs (some) must be avoided • Side effects which will not subside:
vomiting, severe tremors, sedation, muscle
• Tyramine-rich foods, avoid except for
reversible MAOI weakness, vertigo
• Contraindication: persons with
• SSRI + MAOI is fatal, so avoid
cardiovascular diseases
• Ten days to 4 weeks before full therapeutic • Interactions: diuretics-decreases lithium
effects occur excretion, low-salt diet increases lithium
• Driving avoided due to drowsiness levels
IRREVERSIBLE MAOIs TEACHING PATIENTS:
1. PHENELZINE (NARDIL)
 • Try not to instill anxiety by preparing • Passive suicidal ideation (e.g. reckless
patients for expected side effects driving, heavy smoking, overeating, self-
• Report immediately side effects which will mutilation, drug abuse)
not subside (vomiting, severe tremors, • Active suicidal ideation-when a person
sedation, muscle weakness, vertigo) thinks about and seeks to commit suicide.
• Elevate feet to relieve ankle edema
• Maintain normal fluid balance of at least 3 SAD PERSON’S SCALE
liters of water per day • Sex Men kill themselves 3x more than
• On side effects that subside, discuss them women though women make attempts 3x
with the patient (nausea, dry mouth, thirst, more often than men
mild hand tremor, weight gain, insomnia, • A-Age High risks groups: 19 years or
light-headedness) younger; 45 years or older, especially the
• Reduce nausea by taking lithium with meals elderly 65 and above
o Sodium intake must be maintained • Depression Studies report that 35-79% of
those who attempt suicide manifested a
CARBAMAZEPINE depressive syndrome
• Antimanic, anticonvulsant • Previous Attempts Of those who commit
• Side effects: drowsiness ,dizziness, suicide, 65- 70% have made previous
unsteadiness, upset stomach vomiting, attempts
headache, anxiety, memory problems, • ETOH Alcohol is associated with up to 65%
diarrhea, constipation, heartburn dry of successful suicides
mouth, back pain • Rational Thinking Loss People with
• Can cause agranulocytosis and aplastic functional or organic psychoses are more apt
anemia to commit suicide than those in the general
population
VALPROIC ACID
• Social Supports Lacking A suicidal person
• ANTIMANIC, ANTICONVULSANT often lacks significant others, meaningful
• Side effects: drowsiness, Dizziness, employment and religious supports
headache, diarrhea, constipation,
• Organized Plan The presence of a specific
heartburn, changes in appetite, weight
plan for suicide signifies a person at high risk
changes, back pain , unusual bruising or
bleeding, tiny purple spots on the skin • No Spouse repeated studies indicate that
• Can cause liver dysfunction, hepatic failure, persons who are widowed, separated,
blood dyscrasias including thrombocytopenia divorced or single at greater risk than those
who are married
Teaching Patients • Sickness Chronic, debilitating and severe
• Other medications should be prescribed to illness is a risk factor
avoid adverse drug interactions
• Report bruising, can be thrombocytopenia
SCORING
• Swallowed, not chewed, cut or crushed to • 0-2: Home with follow up care
avoid irritation 3-4: Close follow up and possible
• Avoid machineries, driving due to hospitalization
drowsiness • 5-6: Strongly consider hospitalization
• Liver and renal functions tests, CBCs to • 7-10: Hospitalize
prevent serious complications
• Take with food to avoid nausea THEORIES OF SUICIDE
Psychodynamic theories
SUICIDE • Describe suicide as a wish to be at peace with
• The intentional act of killing oneself the internalized significant person. Wish to
• Suicidal Ideation- means thinking about be reunited with a deceased loved object
oneself Suicide is an attempt to escape from an
 intolerable situation or intolerable state of NONVERBAL CLUES
mind Behavioral clues: sudden behavioral changes
especially when depression is lifting and when the
Sociological Theories person has more energy available to carry out the
• Durkheim-pioneer of sociological research plan signs: giving away prized possessions, writing
in the study of suicide farewell notes, making out a will and putting
• 3 Principal types: personal affairs in order
o Egotistic suicide- occurs when a
person is insufficiently integrated into Somatic clues: physiological complaints can mask
society psychological pain and internalized stress headaches,
Anomic suicide- occurs when a muscle aches, trouble sleeping, irregular bowel
person is isolated from others through habits, unusual appetite or weight loss
abrupt changes in social norms/status
o Altruistic suicide- occurs as a Emotional clues social withdrawal, feelings of
response to societal demands (deaths hopelessness and helplessness, confusion, irritability
of Buddhist monks who set and complaints of exhaustions
themselves on fire to protest the
Vietnam war) SUICIDE PRECAUTIONS
• Be alert for cries for suicide
PRECIPITATING FACTORS • Expression of feelings
Social isolation- have difficulty forming and • Safe environment
maintaining relationships • Teaching-disturbance in the brain chemistry
• Norman Cousins Story: a woman who and is treatable
committed suicide had written in her diary • Plan for Life”(list of warning signs of
everyday during the week before her death suicidal ideation and actions to take) L-Listen
“Nobody called today. with emotional support
Nobody called today. Nobody called today. • Ask direct questions
Nobody called today...” No suicide contract
Severe life’s events-divorce, death, sickness, legal • Structured schedule and involve in activities
problems, interpersonal discord with others to increase self-worth and divert
attention
Sensitivity to Loss-may react tragically to separation Suicide Precautions
or loss of a loved one (had insecure or unreliable Always remember:
childhood experiences) • That a suicidal person want to die only during
the period of suicidal crisis-during this time
ASSESSING VERBAL & NONVERBAL the person is ambivalent about living and
CLUES dying
VERBAL CLUES: • Suicidal people gives warning
Overt Statements: Persons recovering from depression are high
• “I can’t take it anymore!” risk for 9-15 months after recovery
• “Life’s isn’t worth living anymore.” • Suicidal people are extremely unhappy but
• “I wish I were dead.” not always mentally ill
• “Everyone will be better off if I am dead.”

Covert Statements:
• “It’s ok now, soon everything will be fine,”
• “Things will never work out.”
• “I won’t be a problem much longer.”
• “Nothing feels good to me anymore.”
• “How can I give my body to medical
science?”
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 10 Substance Abuse

Outline: SUBSTANCE ABUSED

1. Substance Abuse ALCOHOL
a. Terms Related to Substance Abuse Etiology
2. Substance Abused • Biologic factors
a. Alcohol Abuse • Genetic vulnerability
b. Sedatives, Hypnotics, and • Neurochemical influences
Anxiolytics • Psychological factors
c. Stimulants: Amphetamines, Cocaine • Familial dynamics
d. Cannabis (Marijuana) • Coping styles
e. Opioids • Social and environmental factors
f. Narcotics/ Heroin
g. Hallucinogens Onset and Clinical Course
h. Inhalants • Typically begins with the first episode of
3. Substance Abuse in Health Professionals intoxication between 15 and 17 years of age
4. Application of the Nursing Process in • More severe difficulties begin in the mid-20s
Substance Abuse to mid-30s
• Alcohol-related breakup of a significant
relationship
SUBSTANCE ABUSE • An arrest for public intoxication or driving
TERMS RELATED TO SUBSTANCE ABUSE while intoxicated
Substance Abuse
• Substance Dependence - maladaptive Evidence of alcohol withdrawal
pattern of substance use leading to clinically • Early alcohol-related health problems
significant impairment or distress as • Significant interference with functioning at
manifested by three or more of the following, work or school
occurring at any time in the same 12 month
period Ethanol
• Intoxication is use of a substance that results • Alcohol dehydrogenase (enzyme) Hydrogen
in maladaptive behavior acetaldehyde(toxic)
• Withdrawal syndrome refers to the negative • Bypass source of aldehyde dehydrogenase
psychological and physical reactions that Energy in the liver acetic acid (non-toxic)
occur when use of a substance ceases or Fatty liver
dramatically decreases • One drink= 1 oz 86 proof “hard liquor”= 5 oz
• Detoxification is the process of safely glass of table wine= 12oz can/bottle of beer
withdrawing from a substance • Legal limit= 5-6 drinks (non-tolerant)
• Substance abuse is using a drug in a way that • Beer=4% alcohol
is inconsistent with medical or social norms • Wine=12% alcohol
and despite negative consequences
• Liquor=40-50% alcohol
• Substance dependence includes problems
• Healthy body can metabolize 10ml of alcohol
associated with addiction such as tolerance,
every 90minutes
withdrawal, and unsuccessful attempts to
stop using the substance • Tolerant drinker- 10-12 drinks before
intoxication
Blackout drinking in which the person continues to
function but has no conscious awareness of his or her Stages of Alcohol Withdrawal
behavior at the time nor any later memory of the 1. 8 hours after the last drink: Mild tremors,
behavior tachycardia, increased BP, diaphoresis,
• As the person continues to drink, he or she nervousness
often develops a tolerance for alcohol; that is, 2. 8-12 hours after the last drink: Gross
he or she needs more alcohol to produce the tremors, hyperactivity, profound confusion,
same effect loss of appetite, insomnia, weakness
• After continued heavy drinking, the person disorientation, illusions, hallucinations and
experiences a tolerance break, which means delusions
that very small amounts of alcohol will 3. 12-48 hours after the last drink: severe
intoxicate the person hallucinations, grand mal seizures
• The later course of alcoholism, when the 4. 3-4 days after the last drink: Delirium
person’s functioning definitely is affected, is tremens, confusion, agitation, hallucinations,
often characterized by periods of abstinence insomnia and tachycardia
or temporarily controlled drinking
CODEPENDENCY
CAGE QUESTIONNAIRE • An over responsible behavior-doing for
• Cutting Down– Have you ever felt you others what they just as well do to themselves
should cut down on your drinking? • Women or wives of alcoholics
• Annoyance- Have people annoyed you by • Codependent individuals find themselves:
criticizing your drinking? • Attempting to control someone else’s
• Guilty- Have you ever felt guilty about your drinking
drinking • Spending inordinate time thinking about the
• Eye opener- Have you ever had a drink first alcoholic person
thing in the morning to steady your nerves or • Covering up the person’s drinking or lying
get rid of hang-over? • Feeling responsible for the person’s alcohol
use
*2-3 yes answers to these questions strongly • Feeling guilty for the alcoholic’s behavior
suggest dependence on alcohol • Avoiding family and social events because of
concerns or shame about the alcoholic’s
ALCOHOL ABUSE behavior
• Alcohol is a legal substance • Allowing moods to be influence by the
• A central nervous system depressant alcoholic
• Assuming the alcoholic’s duties and
• A disease that can be arrested but not cured.
responsibilities
• Used with other substance
• Often bailing the alcoholic out of financial or
legal problems
Intergenerational Transmission
• Awake but unaware
• Blackout Confabulation Aversion therapy - Avoid alcohol during therapy
• Denial, dependence Antabuse – disulfiram
Enabling, co-dependence Belongings – check for alcohol, mouthwash, elixir
• Tolerance increases etc.
• Detoxification- doctor Alcohol
• Central nervous system depressant Complications
• Overdose can result in vomiting, • Korsakoff’s Psychosis (Mind)
unconsciousness, and respiratory depression • Delirium Tremens
• Benzodiazepines used for detoxification • Formication
• Lorazepam (Ativan), chlordiazepoxide
(Librium), or diazepam (Valium) suppress Nursing diagnoses common to psychosocial health
the withdrawal symptoms needs include:
 • Ineffective Denial depressive symptoms, including suicidal
• Ineffective Role Performance ideation, for several days
• Interrupted Family Processes: Alcoholism • Stimulant withdrawal is not treated
• Ineffective Coping pharmacologically

Long term therapy Support system: CANNABIS (MARIJUANA)

• Alcoholic Anonymous • Used for its psychoactive effects
• Alanon • Excessive use of cannabis may produce
• Alateen delirium or cannabis-induced psychotic
disorder; overdoses of cannabis do not occur
Principles of Nursing Care • Withdrawal symptoms: Insomnia, muscle
• Family therapy aches, sweating, anxiety, and tremors
• Provide safety: alcohol free environment • Effects are treated symptomatically
• Increase self-esteem
• Resocialization OPIOIDS
• Central nervous system depressants
SEDATIVES, HYPNOTICS, AND • Overdose can lead to coma, respiratory
ANXIOLYTICS depression, pupillary constriction,
• Central nervous system depressants unconsciousness, and death
• Benzodiazepines alone, when taken orally in • Withdrawal:
overdose, are rarely fatal, but the person will • Short-acting drugs: begins in 6 to 24
be lethargic and confused hours; peaks in 2 to 3 days and
• Barbiturates, in contrast, can be lethal when gradually subside in 5 to 7 days
taken in overdose. They can cause coma, • Longer-acting drugs: begins in 2 to 4
respiratory arrest, cardiac failure, and days, subsiding in 2 weeks
death • Opioids stimulate opioid receptors
• Withdrawal symptoms in 6 to 8 hours or up • Endorphins (neurotransmitter
to 1 week mediating pain attracted) increase
• Withdrawal syndrome is characterized by pain threshold euphoria (better than
symptoms opposite of the acute effects of the sex)
drug:
• Autonomic hyperactivity (increased pulse, NARCOTICS/ HEROIN
blood pressure, respirations, and Heroin- more commonly abused narcotic (fat-
temperature), hand tremor, insomnia, binding)
anxiety, nausea, and psychomotor agitation; • becomes morphine in the brain, trapped,
seizures and hallucinations occur rarely in sustained euphoria
severe benzodiazepine withdrawal • Narcotics- risk for AIDS due to needle
• Detoxification from sedatives, hypnotics, and sharing
anxiolytics is managed by tapering the • Respiratory depression
amount of the drug o Sensitivity to CO2 stimulation by the
medullary center for respiration
STIMULANTS: AMPHETAMINES, COCAINE o Primary cause of death
• Central nervous system stimulants • PNS effects: constipation, decreased gastric,
• Overdoses can result in seizures and coma biliary and pancreatic secretions, urinary
• Withdrawal occurs within hours to several retention, hypotension, reduced pupil size
days o Pinpoint pupils- sign of narcotics
• Withdrawal syndrome: Dysphoria overdose
accompanied by fatigue, vivid and unpleasant Symptom pattern of respiratory depression:
dreams, insomnia or hypersomnia, increased • Person becomes stuporous
appetite, and psychomotor retardation or • Sleeps (Skin is wet and warm)
agitation; withdrawal symptoms are referred • a coma develops accompanied by respiratory
to as “crashing”- -the person may experience depression and hypoxia
 • skin becomes cold and clammy
• pupils dilate Intervention:
• DEATH • Behavioral Modification
• Detoxification
Withdrawal symptoms: • Family Marital Therapy
• Anxiety, restlessness, aching back and legs, • Self Help Groups
cravings, nausea, vomiting, dysphoria, • Medication
lacrimation, rhinorrhea, sweating, diarrhea,
yawning, fever, and insomnia Withdrawal Effects
• Withdrawal does not require pharmacologic • Perceptual and sensory disturbance
intervention (hallucinogens)
• Administration of naloxone (Narcan) is the • Amotivational Syndrome (marijuana)
treatment of choice • Yawning (narcotics)
• Methadone can be used as a replacement for • Anxiety (amphetamine)
heroin, serving to reduce cravings • Tremors ( alcohol )

HALLUCINOGENS Cardinal signs

• Distort reality and produce symptoms similar • Narcotics: pupillary constriction, decreased
to psychosis, including hallucinations BP, paranoia
(usually visual) and depersonalization • Hallucinogen: Bloodshot eyes, dry mouth,
• Toxic reactions to hallucinogens (except cravings for junk foods
PCP) are primarily psychological; overdoses • Sedatives: tremors, sedation
as such do not occur. PCP toxicity can • Stimulants: pupillary dilation, increased BP,
include seizures, hypertension, hyperthermia,
and respiratory depression SUBSTANCE ABUSE IN HEALTH
• Hallucinogens can produce flashbacks that PROFESSIONALS
may persist for a few months up to 5 years Warning signs of abuse include:
• Poor work performance, frequent
Treatment is supportive: absenteeism, unusual behavior, slurred
• Isolation from external stimuli; physical speech, isolation from peers
restraints; (for PCP) medications to control • Incorrect drug counts
seizures and blood pressure; cooling devices; • Excessive controlled substances listed as
mechanical ventilation wasted or contaminated
• Reports by clients of ineffective pain relief
INHALANTS from medications, especially if relief had
• Inhaled for their effects been adequate previously
• Overdose: • Damaged or torn packaging on controlled
• Anoxia, respiratory depression, vagal substances
stimulation, and dysrhythmias • Increased reports of “pharmacy error”
Death may occur from • Consistent offers to obtain controlled
bronchospasm, cardiac arrest, substances from pharmacy
suffocation, or aspiration of the • Unexplained absences from the unit
compound or vomitus • Trips to the bathroom after contact with
• People who abuse inhalants may suffer from controlled substances
persistent dementia or inhalant-induced • Consistent early arrivals at or late departures
disorders such as psychosis, anxiety, or mood from work for no apparent reason
disorders even if the inhalant abuse ceases
• Withdrawal symptoms: none APPLICATION OF THE NURSING
PROCESS: SUBSTANCE ABUSE
Treatment: • The nurse may encounter clients with
Supporting respiratory and cardiac functioning until substance problems in various settings
the substance is removed from the body unrelated to mental health.
 • Seeking treatment of medical problems
related to alcohol use
• Withdrawal symptoms may develop while in
the hospital for surgery or an unrelated
condition
• Be alert to the possibility of substance use in
these situations and be prepared to recognize
their existence and to make appropriate
referrals.

Assessment
• History: chaotic family life, family history,
crisis that precipitated treatment
• General appearance and motor behavior:
depends on physical health; likely to be
fatigued, anxious
• Mood and affect: may be tearful, expressing
guilt and remorse; angry, sullen, quiet,
unwilling to talk
• Thought processes and content: minimize
substance use, blame others for problems,
• Physiologic considerations: may have
trouble eating and sleeping; HIV risk if IV
drug user

Nursing diagnoses common to physical health

needs include:
• Imbalanced Nutrition: Less Than Body
Requirements
• Risk for Infection
• Risk for Injury
• Diarrhea
• Excess Fluid Volume
• Activity Intolerance
• Self-Care Deficits

Interventions
• Providing health teaching for client and
family
• Addressing family issues:
• Codependence
• Changes in roles
• Promoting coping skills
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 11 Eating, Cognitive, and Psychosexual Disorders

Outline: • Restricting subtype loses weight by dieting,

1. Eating Disorders fasting, or excessively exercising
a. Anorexia Nervosa • Binge eating and purging subtype engages in
b. Bulimia Nervosa binge eating followed by purging
2. Child and Adolescent Psychiatric Disorders
a. Mental Retardation Onset and Clinical Course
b. Pervasive Developmental Disorders • Typically begins between 14 and 18 years of
i. Attention Deficit age
Hyperactivity Disorder • Ability to control weight gives pleasure to the
(ADHD) client
3. Cognitive Disorders • Client may feel empty emotionally and be
a. Delirium unable to identify or express feelings
b. Dementia • As illness progresses, depression and labile
4. Sexual Disorders (Paraphilia) moods are common
a. Gender Identity Disorder (GID)
b. Sexual Addiction Treatment for Anorexia Nervosa
Setting depends on severity of illness:
EATING DISORDERS
• Medical management; risk of suicide is
• Eating disorders can be viewed on a significant
continuum: the anorexic eats too little, the • Weight restoration
bulimic eats chaotically, and the obese person
• Nutritional rehabilitation
eats too much.
• Rehydration
• Eating disorders overlap: 50% of clients with
anorexia exhibit bulimic behavior, 35% of • Correction of electrolyte imbalances
normal- weight clients with bulimia have a • Supervised access to a bathroom to prevent
history of anorexia. purging
• More than 90% of clients with eating
disorders are female. Psychopharmacology
• Amitriptyline (Elavil) and the antihistamine
ANOREXIA NERVOSA cyproheptadine (Periactin) can promote
weight gain.
• Refusal or inability to maintain a minimally
normal body weight • Olanzapine (Zyprexa) because of its effect on
• Intense fear of gaining weight or becoming body image distortions
fat • Fluoxetine (Prozac) prevents relapse.
• Significantly disturbed perception of the
shape or size of the body Psychotherapy
• Steadfast inability or refusal to acknowledge • Family therapy
the seriousness of the problem or even that • Individual therapy
one exists
• 85% or less of expected body weight BULIMIA NERVOSA
• Amenorrhea • Characterized by recurrent episodes of binge
eating, then compensatory behaviors to avoid
• Preoccupation with food and food-related
weight gain (purging, use of laxatives,
activities
diuretics, enemas, emetics, fasting, excessive
exercise)
 • Binge eating is done in secret • Neurochemical changes are seen, but it is
• Client recognizes behavior as pathologic, not known if these changes cause the
causing feelings of guilt, shame, remorse, or disorders or are a result of eating disorders
contempt • Developmental Factors
• Usually normal weight o Struggle to develop autonomy and
identity Overprotective or enmeshed
Onset and Clinical Course families Body image disturbance and
• Begins at about age 18 or 19 body image dissatisfaction
• Binge eating begins after an episode of Separation-individuation difficulties
dieting • Family Influences
• Between binges, eating may be restrictive o Families without emotional support
• Food is hidden in the car, desk at work, and o Physical neglect, sexual abuse, or
secret locations around the house parental maltreatment
• Behavior may continue for years before it is o Little care, affection, and empathy
discovered o Excessive paternal control,
• Long-term studies show: 50% recover 20% unfriendliness, or over protectiveness
continue to be bulimic 30% have episodic • Sociocultural Factors
bouts of bulimia o Media
One third of fully recovered clients have a o Pressure from peers, parents, and
relapse. Death rate for bulimia is 3% or less. coaches

Treatment for Bulimia Nervosa APPLICATION OF THE NURSING PROCESS

Most clients are treated on outpatient basis: ASSESSMENT
• Cognitive-behavioral therapy Anorexia Bulimia
• Psychopharmacology nervosa nervosa
o Antidepressants: desipramine History Model child, no Eager to please
(Norpramin), imipramine (Tofranil), trouble, and conform,
amitriptyline (Elavil), nortriptyline dependable avoid conflict,
(Pamelor), phenelzine (Nardil), and (before onset of but may have
fluoxetine (Prozac) anorexia) history of
impulsive
RELATED DISORDERS behavior
• Rumination disorder, pica, and feeding General Slow, lethargic, Normal
disorder are diagnosed in infancy and appearance even appearance,
childhood and motor emaciated; open and
behavior slow to respond talkative
• Binge eating disorder is binge eating without
to questions,
regular use of inappropriate compensatory
difficulty
behaviors
deciding what
• Night eating syndrome (NES) is morning
to sat, reluctant
anorexia, evening hyperphagia (consuming
to answer
50% of daily calories after the last evening
questions fully;
meal), and nighttime awakenings (at least
often wear
once a night) to consume snacks
baggy clothes,
limited eye
ETIOLOGY
contact;
• Biologic Factors: unwilling to
o Genetic vulnerability discuss
o Disruptions in the nuclei of the problems or
hypothalamus relating to hunger and enter treatment
satiety (satisfaction of appetite)
 Mood and Sad and Initially cheerful helpless, and helpless, and
affect anxious, but express ineffective ineffective
seldom laugh or intense emotions Roles and May have Ashamed of
smile of guilt, shame relationships failing grades binging and
and in school; in purging; hides it
embarrassment sharp contrast from others; the
when discussing to previous amount of time
binging and high-level spent buying and
purging performance; consuming food
behaviors withdrawal can interfere
Thought Spend most of Spend most of from peers with role
process and the time the time thinking performance.
content thinking about about food, Physiologic and
food, dieting, dieting, food- self-care
food-related related issues; considerations:
issues; body body image exhaustion,
image disturbance is trouble sleeping,
disturbance is delusional mouth sores,
delusional; dental problems
paranoid ideas
about their Nursing diagnoses may include:
family and • Imbalanced Nutrition: Less Than/More Than
health care Body Requirements
professionals • Ineffective Coping
being the • Disturbed Body Image
“enemy” trying • Other diagnoses such as Deficient Fluid
to make them Volume, Constipation, Fatigue, and Activity
fat Intolerance may be indicated
Sensorium Generally alert, Generally alert,
and oriented, intact; oriented, and Intervention
intellectual severely intact • Establishing nutritional eating patterns
processes malnourished • Helping client identify emotions and develop
client with coping strategies
anorexia, who • Dealing with body image issues
may have mild
• Client and family education- can be used in
confusion and
variety of settings and taught to parents,
slowed
teachers, and caregivers:
thinking and
o Ensuring safety
difficulty with
o Improving role performance
concentration
o Simplifying instructions
and attention
o Providing a structured daily routine
Judgment Very limited
Insight into the
o Providing client and family education
and insight insight and
pathologic
and support
poor judgment nature of their
about health
eating behavior
CHILD AND ADOLESCENT PSYCHIATRIC
status but feel out of
DISORDERS
control
• Psychiatric disorders are not diagnosed as
Self-concept Low self- See the easily in children as they are in adults
esteem, see themselves as because:
themselves as powerless,
powerless,
 o Children lack abstract cognitive • Self-care - Requires complete supervision;
abilities and verbal skills to describe Able to perform simple hygiene – brushing
what is happening teeth and washing hands
o Children are constantly changing and • Educational Level- rarely participates in
developing academic training; learn simple task.
• The most common childhood psychiatric • Social Skills- has limited verbal skills;
disorders include: communicates by acting out
o Pervasive developmental disorders • Psychomotor Skills- poor psychomotor
o Attention deficit hyperactivity skills; Limited ability to perform simple task
disorder (ADHD) • Living Condition- must live in a highly
o Disruptive behavior disorders structured & closely supervised setting
• Economic Situation- may be taught how to
MENTAL RETARDATION use money and help with shopping
DEGREES OF RETARDATION
Mild Retardation (IQ 50 to 70) Profound Retardation IQ below 20
• Self–care ability-able to live independently • Self-care- requires constant assistance
with monitoring and assistance with life supervision
changes, challenges and stresses • Educational Level- can’t benefit from
• Educational level- achieve 4–6th Grade academic training; Master simple self-care
reading skills; may master vocational abilities
training. • Social Skills- has little speech development;
• Social Skills- use social skills in structured No social skills
settings • Psychomotor Skills- lacks both fine and
• Psychomotor Skills- average to good skills; motor skills; Needs constant care and
have minor coordination problems supervision
• Living Situation- must live with the family • Living Condition- must live in a highly
or in community housing structured & closely supervised setting
• Economic Situation- may hold a job, closely • Economic Situation- must depend on others
supervised; can budget or manage money for money management
with guidance.
CAUSES
Moderate Retardation IQ 35-49 • Heredity
• Self-care- requires close supervision; • Tay-Sachs disease or fragile X chromosome
Monitored when performing independent syndrome
activities • Early alterations in embryonic development
• Educational Level- 2nd Grade reading skills; Maternal alcohol intake
can be trained in skills in a sheltered Pregnancy or perinatal problems
workshop setting Fetal malnutrition, hypoxia, infections, and
• Social Skills- has some speech limitations; trauma
Has difficulty following expected social • Medical conditions of infancy
norms. • Infection or lead poisoning
• Psychomotor Skills- has difficulty with • Environmental influences
gross motors kills; Has limited vocational • Deprivation of nurturing or stimulation
opportunities.
• Living Situation- live in a sheltered PERVASIVE DEVELOPMENTAL
community. DISORDERS
• Economic Situation- learn to handle a small • Characterized by pervasive and usually
amount of pocket money and how to manage severe impairment of reciprocal social
change interaction skills, communication deviance,
restricted stereotypical behavioral patterns
Severe Retardation IQ 20 – 34 o Autistic disorder (classic autism)
o Rett’s disorder
 o Childhood disintegrative disorder that is really an "attention surplus" because
o Asperger’s disorder they take in everything around them!
• Present by early childhood 3. Has difficulty awaiting turn in games or
• Little eye contact, few facial expressions, group situations.
does not communicate verbally or with 4. Often blurts out answers to questions before
gestures, doesn’t they have been finished. ADDers are "bottom
• relate to peers or parents, lacks spontaneous line people" with "no mental brakes.”
enjoyment; apparent absence of mood and 5. Has difficulty following through on
affect; cannot instructions from others.
• engage in play or make-believe with toys 6. Has difficulty sustaining attention in tasks or
• Hand flapping, body twisting, head banging play activities. ADDers get bored easily!
• Autism may improve, sometimes However, many can also hyper-focus for long
substantially, as language and periods of time on things that motivate them
communication skills are learned or that they enjoy ("not paying attention" in
• Traits persist into adulthood; few attain class; yet spend hours of attention playing a
favorite video game, etc.)
complete independence, marry, or have
children 7. Often shifts from one unfinished activity to
another.
• Most autistic children are mainstreamed in
8. Has difficulty playing quietly.
school
9. Often talks excessively.
• Medications may be used to target specific 10. Often loses things necessary for tasks or
behaviors: activities at school.
o Antipsychotics for temper tantrums,
aggressiveness, self-injury, ETIOLOGY
hyperactivity, and stereotyped
• Unknown
behaviors
o Naltrexone (ReVia), clomipramine • Environmental toxins
(Anafranil), clonidine (Catapres), and • Prenatal influences
stimulants to diminish self-injury and • Heredity
hyperactive and obsessive behaviors • Damage to brain structure and functions
• Goals are to reduce behavioral symptoms and Treatment
promote learning, development, and • Combination of pharmacotherapy with
language skills behavioral, psychosocial, and educational
interventions
ATTENTION DEFICIT HYPERACTIVITY
DISORDER (ADHD) PSYCHOPHARMACOLOGY
• Inattentiveness, overactivity, and • Stimulants: methylphenidate (Ritalin), an
impulsiveness amphetamine compound (Adderall),
• Important to distinguish ADHD from normal, dextroamphetamine (Dexedrine), and
active behavior, behavioral signs of pemoline (Cylert)
psychosocial stressors, • Common side effects: insomnia, loss of
• inadequate parenting, or other psychiatric appetite, and weight loss or failure to gain
disorders such as bipolar disorder weight
• Can persist into adulthood
STRATEGIES FOR HOME AND SCHOOl
• Often diagnosed when child starts school
• Helping with parenting strategies
The Top 10 Diagnostic Criteria for Attention • Providing consistent rewards and
Deficit Disorder in Children consequences for behavior
1. Often fidgets with hands or feet, or squirms • Offering consistent praise
in/leaves seat. • Using time-out
2. Is easily distracted by extraneous stimuli. The • Giving verbal reprimands
ADD person often has an "attention deficit" • Issuing daily report cards for behavior
 • Using point systems for positive and negative • Improving role performance
behavior • Simplifying instructions
• Using therapeutic play techniques • Providing a structured daily routine
• Providing client and family education and
ASSESSMENT support
• History: fussy as an infant; may not have
noticed the hyperactive behavior until later; COGNITIVE DISORDERS
difficulties in all major life areas; parents feel DELIRIUM
unable to deal with the behavior; • Delirium: a syndrome that involves
unsuccessful attempts to discipline disturbance of consciousness accompanied
• General appearance and motor behavior: by a change in cognition
cannot sit still, darts around the room, • Acute and fluctuating
interrupts, blurts out answers, doesn't pay • Difficulty paying attention, distractibility,
attention, jumps from one topic to another and disorientation
• Mood and affect: labile; verbal outbursts; • Sensory disturbances include illusions,
temper tantrums; anxiety; frustration; misinterpretations, hallucinations
agitation • Disturbances in sleep/wake cycle, anxiety,
• Thought processes and content: intact fear, irritability, euphoria, apathy
• Sensorium and intellectual processes: alert
and oriented; no sensory or perceptual MOST COMMON CAUSES OF DELIRIUM:
alterations; concentration markedly • Physiologic or metabolic infection:
impaired; says, "I don't know" rather than Hypoxemia, electrolyte disturbances, renal or
taking time to answer; unable to complete hepatic failure, hypo/hyperglycemia,
tasks dehydration, sleep deprivation, thyroid or
• Judgment and insight: poor judgment, takes glucocortical disturbances, thiamine or
risks, doesn't perceive potential harm vitamin B12 deficiency, vitamin C, niacin, or
• Self-concept: may be unaware that behavior protein deficiency, cardiovascular shock,
is different from that of others, saying "no brain tumor, head injury, exposure to
one likes me"; generally low self-esteem due gasoline, paint solvents, insecticides, and
to lack of success and difficulty with peer related substances. Systemic: sepsis, urinary
relationships; may see self as stupid tract infection, pneumonia Cerebral:
• Roles and relationships: unsuccessful; meningitis, encephalitis, HIV, syphilis
intrusive and disruptive, incites negative • Drug-related: Intoxication: anticholinergics,
responses from others; parents and teachers lithium, alcohol, sedatives, and hypnotics
chronically frustrated and exhausted Withdrawal: alcohol, sedatives, and
• Physiologic and self-care considerations: hypnotics Reactions to anesthesia
child may be thin if no time taken to eat
properly; trouble settling down for bed; PSYCHOPHARMACOLOGY AND OTHER
sleeps poorly; may have history of injury if MEDICAL TREATMENT
engaged in risky behaviors • If quiet and resting, no medication needed
for delirium
NURSING DIAGNOSES INCLUDE: • If experiencing psychomotor agitation,
• Risk for Injury sedation with an antipsychotic (Haloperidol)
• Ineffective Role Performance may prevent inadvertent self-injury
• Impaired Social Interaction • Delirium induced by alcohol withdrawal is
• Compromised Family Coping treated with benzodiazepines
• Adequate food and fluid (IV Fluids & TPN)
INTERVENTIONS • Physical restraints only when necessary
Can be used in variety of settings and taught to
parents, teachers, and caregivers:
• Ensuring safety
ASSESSMENT 3. Agnosia
• History: medical illness, prescribed 4. Executive functioning – inability to think
medications, alcohol, illicit drugs, and over- abstractly
the-counter medications
• General appearance and motor behavior: ONSET AND CLINICAL COURSE
restless, picking at covers, agitated, getting • Mild (excessive forgetfulness, difficulty
out of bed, or sluggish and lethargic; speech finding words, loses objects, anxiety about
is less coherent as delirium worsens loss of cognitive abilities)
• Mood and affect: client has rapid and • Moderate (confusion, progressive memory
unpredictable mood shifts with wide range of loss, can’t do complex tasks, oriented to
emotions person and place, recognizes familiar people;
• Thought process and content: difficult to by the end of this stage requires assistance
assess thought process accurately due to and supervision)
disorientation and impaired cognition • Severe (personality and emotional changes,
• Sensorium and intellectual processes: delusional, wanders at night, forgets names of
sensory misperceptions, disorientation, spouse and children, requires assistance with
confusion, lack of attention and concentration activities of daily living)
• Judgment and insight: impaired judgment,
varied insight ETIOLOGY
• Roles and relationships: usually no long- • Alzheimer’s disease
term effect unless previous problems existed • Vascular dementia
• Self-concept: frightened or feel threatened; • Pick’s disease
may feel helpless or powerless; may feel • Creutzfeldt-Jakob disease
guilt, shame, and humiliation • Dementia due to HIV
• Physiologic and self-care considerations: • Parkinson’s disease
trouble sleeping, may ignore body cues such • Huntington’s disease
as hunger, thirst, or the urge to urinate or • Dementia due to head trauma
defecate
TREATMENT AND PROGNOSIS
NURSING DIAGNOSES MAY INCLUDE: • Identify and treat underlying cause whenever
• Risk for Injury possible
• Acute Confusion • No therapies have been found to reverse or
• Disturbed Sensory Perception retard degenerative dementias
• Disturbed Thought Processes • Progressive deterioration of physical and
• Disturbed Sleep Pattern mental abilities until death
• Risk for Deficient Fluid Volume • Acetylcholine precursors, cholinergic
• Risk for Imbalanced Nutrition: Less Than agonists, and cholinesterase inhibitors such
Body Requirements as tacrine (Cognex), donepezil (Aricept),
rivastigmine (Exelon), and galantamine
INTERVENTIONS (Reminyl) temporarily slow the progress of
• Promoting for safety dementia
• Managing the client’s confusion • Symptomatic treatment of behaviors such as
• Controlling environment to reduce sensory delusions, hallucinations, outbursts, and
overload labile moods
• Promoting Sleep and Proper Nutrition
ASSESSMENT
DEMENTIA • History: may be unable to provide an
Dementia involves multiple cognitive deficits, accurate and thorough history; interview
primarily memory impairment, and at least one of the family, friends, or caregivers
following: • General appearance: aphasia,
1. Aphasia perseveration, slurring, eventual loss of
2. Apraxia language
 • Motor behavior: apraxia, cannot imitate • Chronic Confusion
demonstrated tasks, finally gait disturbance • Impaired Environmental Interpretation
making unassisted ambulation unsafe, then Syndrome
impossible. May demonstrate uninhibited • Impaired Memory
behavior: inappropriate jokes, sexual • Impaired Socialization
comments, undressing in public, profanity; • Impaired Verbal Communication
familiarity with strangers • Ineffective Role Performance
• Mood and affect: initially anxious and
fearful over lost abilities, labile moods, INTERVENTION
emotional outbursts, catastrophic emotional • Promoting safety
responses; verbal or physical aggression • Promoting adequate sleep, nutrition,
possible; may become emotionally listless, hygiene, and activity
apathetic, withdrawn • Structuring the environment and routine
• Thought processes and content: initially • Providing emotional support
loses ability to think abstractly; cannot solve • Supportive touch
problems; cannot generalize knowledge from • Promoting interaction and involvement
one situation to another; later, delusions of • Reminiscence therapy
persecution are common • Distraction
• Sensorium and intellectual processes: • Time away
initially memory deficits that worsen over • Going along
time; confabulation to fill in memory gaps;
agnosia; cannot write or draw simple objects; RELATED DISORDERS:
inability to concentrate; chronic confusion, • Amnestic Disorder. Disturbance in memory
disorientation (eventually even to person); resulting from the physiologic effects of a
visual hallucinations common general medical condition (stroke, head
• Judgment and insight: initially recognizes injury, carbon monoxide poisoning, chronic
he or she is losing abilities, and then insight alcohol ingestion). Confusion, disorientation,
fades altogether; judgment impaired due to and attentional deficits are common
cognitive deficits; worsens over time; at risk Clients do NOT have the multiple cognitive
for wandering, getting lost, injuring self, deficits seen in dementia such as aphasia,
unable to perceive harm. apraxia, agnosia, and impaired executive
• Self-concept: initially client is frustrated at functions.
• losing things or forgetting, sad about getting • Korsakoff’s Syndrome. Alcohol-induced
old”; sense of self deteriorates until client amnestic disorder resulting from a chronic
doesn’t recognize own reflection in mirror thiamine or vitamin B deficiency Confusion,
• Roles and relationships: can no longer disorientation, and attentional deficits are
work, cannot fulfill roles at home, cannot common. Clients do NOT have the multiple
attend social events, eventually confined to cognitive deficits seen in dementia such as
home; family members often become aphasia, apraxia, agnosia, and impaired
caregivers but feel loved one has become a executive functions
stranger
• Physiologic and self-care considerations: SEXUAL DISORDERS/ PARAPHILIA
disturbances in sleep/wake cycle, ignoring A condition in which the sexual instinct is expressed
body cues to eat, drink, urinate, etc.; lose in ways that are socially prohibited or are
abilities to do personal hygiene, even feeding biologically undesirable
self • Bisexuality: sexual attraction to members of
the opposite sex and the same sex
Nursing diagnoses include: • Masochism: experiencing sexual attraction,
• Risk for Injury urges or arousal when receiving pain
• Disturbed Sleep Pattern (hypoxyphilia)
• Risk for Deficient Fluid Volume
• Risk for Imbalanced Nutrition
 • Sadism: experiencing sexual attraction, SEXUAL ADDICTION
urges or arousal when giving pain • 50% or more of waking hours spent on sexual
• Frotteurism: pleasure from rubbing genitals fantasies/activities
against unconsenting victim • Impairs daily functioning
• Pedophilia: sexual pleasure with children • With or without a partner
below 13 • Cycle: preoccupation, rituals, compulsion,
• Necrophilia: sexual pleasure with the dead shame & guilt, anxiety
and making lewd or obscene remarks
Zoophilia or Bestiality- sexual contact with INTERVENTION
animals • Psychotherapy
• Voyeurism: experiencing intense pleasure • Individual therapy
from watching people undress • Group Psychotherapy
• Transvestism: cross dressing with the • Social skills training
opposite sex • Treatment of co-morbid physical and
• Transsexualism: going from one sex to psychiatric features
another o Hormonal treatments
• Exhibitionism o Medications
• Fetishism - refers to the use of an object, foot o Anti-androgen
apparel, for sexual arousal drugs(Medroxyprogesterone acetate
and Cyproterone acetate)
SEXUAL DYSFUNCTIONS
• Excitement
o Sexual aversion disorder
o Hypoactive sexual desire
o Erectile dysfunction Plateau
o Premature ejaculation
o Sexual arousal
o Sexual pain
• Orgasm
o Orgasm disorder

GENDER IDENTITY DISORDER

A strong and persistent cross-gender identification
• Involves discomfort with one’s sex or the
gender role of that sex
• In Children:
o stated desire or insistence that he or
she is the other sex
o In boys, dressing in female attire; in
girls, wearing only masculine
clothing.
o Make believe play or fantasies of
being the other sex
o Prefers playmates of the other sex.
• In adolescents and adults:
o Stated desire to be the other sex
o Frequently passes as the other sex
o Desires to be treated as the other sex
o Conviction that he or she has typical
feelings and reactions of the other sex
 FAR EASTERN UNIVERSITY
Institute of Nursing
A.Y 2021 – 2022 Second Semester

Psychiatric Nursing
Module 12 Legal Issues that Affects Mental Health Nursing:
Future Trends and Issues is Mental Health Nursing

Outline: o Further improve access to mental

1. The Mental Health Legislation healthcare
2. The Importance of Mental Health Law
3. What is Mental Health Law- Nursing MENTAL HEALTH LAW IN NURSING
4. Salient Parts of the RA No. 11036 Mental Health Law in Nursing
5. Other Mental Health Legal Principles • Mental health nursing students need to
understand their legal duties towards all
THE MENTAL HEALTH/ LEGISLATION clients, including specific laws for care of
LAW detained patients.
Mental health legislation is required to ensure a • Mental health nurses work in a variety of
regulatory framework for mental health services and settings and support and treat people who
other providers of treatment of care, and to ensure have been diagnosed with a mental illness.
that the public and the people with a mental illness • Just like in physical health, nurses can
are afforded protection from the often devastating promote mental health by building good
consequences of mental illness (Ayano, 2018). relationships with patients, encouraging
healthy behaviors’, and recognizing and
World Health Organization treating symptoms early.
All people with mental disorders have the right to • Nurses are expected to function within the
receive high-quality treatment and care delivered legislation, legal policies, statutes relevant to
through responsive health care services. They should the profession and practice setting, and
be protected against any form of inhumane treatment professional standards. Nurses must know the
and discrimination. rights and obligations of nurses in
interactions with patients, families of
patients, other nurses, and other health care
THE IMPORTANCE OF MENTAL HEALTH practitioners.
LAW
World Health Organization THE PHILIPPINE MENTAL HEALTH ACT
• Helps people with a mental disorder to get the RA NO. 11036
best possible care and treatment appropriate • It was signed into law on June 20, 2018 and
to their needs, in the least restrictive took effect on July 5,2018.
environment and in the least intrusive manner • The law aims to establish a national mental
consistent with the effective delivery of that health policy directed towards improving the
care and treatment health of the population in schools,
• All people with mental disorders should be workplaces and communities, underscoring
provided with treatment based in the the basic right of all Filipinos to mental
community health.
• Exceptions: • It also highlights the balanced delivery of
• If there is a risk to self-harm or harm to mental health services (community-based
other people and hospital-based) with more focus on
• If treatment can only be provided in an persons with psychiatric, neurologic, and
institutional setting psychosocial health needs, and overcoming
• It plays an important role in integration society’s attitudinal challenges that they
of mental health in primary health care
 DECLARATION OF POLICY To the mental health professionals:
• The state affirms the basic right of all • Protecting their right to participate in mental
Filipinos to mental health as well as the health planning and development of services,
fundamental right of people who require and ensuring that they have a safe working
mental health services. environment, access to continuing education
• The state commits itself to promoting the and autonomy in their own practice.
well-being of people by ensuring that; mental • Promotion of Mental health in educational
health is valued, promoted, and protected; systems
mental health conditions are treated and
prevented; timely, affordable, high quality, Mental Health Condition
and culturally-appropriate mental health case • Refers to neurologic or psychiatric condition
is made available to the public; mental health characterized by the existence of a
service are free from coercion and recognizable clinically significant
accountable to the service users; and persons disturbance in an individual’s cognition,
affected by mental health conditions are able emotional regulation, or behavior that
to exercise full range of human rights, and reflects a generic or acquired dysfunction in
participate fully in society and work free the neurobiological, psychosocial, or
from stigmatization and discrimination. developmental processes underlying mental
• The state shall comply strictly with its functioning.
obligations under the United Nations
Declaration of Human Rights, the INFORMED CONSENT
Convention on the rights of Persons with • Service users must provide informed consent
Disabilities, and all other relevant in writing prior to the implementation by
international and regional human rights mental health professionals, workers, and
conventions and declarations. The other service providers of any plan or
applicability of Republic Act No 7277, as program of therapy or treatment, including
amended, otherwise known as the “Magna physical or chemical restraint.
Carta for Disabled Persons,” to person with • The Act makes provision to treatment
mental health conditions, as defined herein, is without informed consent, ‘during
expressly recognized psychiatric or neurologic emergencies, or
when there is impairment or temporary loss
PROTECTION OF PATIENTS’ RIGHTS of capacity on the part of a service user’.
The patient’s right to: • All persons, including service users, person
• Protection from torture, cruel, inhumane, with disabilities, and minors, shall be
and degrading treatment presumed to possess legal capacity for the
• Aftercare and rehabilitation; Be adequately purpose of this Act or any other applicable
informed about psychosocial and clinical law, irrespective of the nature or effects of
assessments their mental health conditions or disability.
• Participate in the treatment plan to be • Children shall have the right to express their
implemented views on all matters affecting themselves and
• Evidence-based or informed consent have such views given due consideration in
• Confidentiality accordance with their age and maturity.
• Counsel
LEGAL REPRESENTATIVE AND
To the relatives: SUPPORTED DECISION MAKING
• The act highlights the need to provide LEGAL REPRESENTATIVE
psychosocial support to family members of Legal Representative- A service user may designate
the patient if required and, when informed a person of legal; age to act as his or her legal
patient consent, to include them in the representative through a notarized document
planning and treatment of care. executed for that purpose.
A service user's legal representative shall: Admission to the Hospital
1. Provide the service user with support and 1. Voluntary admission- sought by guardians’
help: represent his or her interests; and patients have the right to demand and obtain
receive medical information about the service release discharge
user in accordance with this Act 2. Involuntary admission- necessary when a
2. Act as substitute decision maker when the person is in danger to self and others, and/or
service user has been assessed by a mental unable to meet basic needs as a result of a
health professional to have temporary psychiatric condition
impairment of decision-making capacity 3. Observational or temporary involuntary
3. Assist the service user vis-a-vis the exercise hospitalization- longer duration than
of any right provided under this Act emergency commitment; the purpose is for
4. Be consulted with respect to any treatment or observation, diagnosis and treatment for
therapy received by the service user. The mental health illness for patients posing
appointment of a legal representative may be danger to self and others
revoked by the appointment of a new legal
representative or by a notarized revocation. Issue of Legal Competence
• All patients must be considered legally
SUPPORTED DECISION MAKING competent until they have been declared
Supported decision making- A service user may incompetent through legal proceeding which
designate up to three (3) persons or "supporters," is determined by courts.
including the service user's legal representative, for • If found incompetent, the court will appoint a
the purposes of supported decision making. legal guardian, who is then responsible for
giving or refusing consent.
These supporters shall have the authority to: • Implied consent- many procedures the nurse
1. access the service user's medical information; performs has element of implied consent such
consult with the service user vis-a-vis any as giving medications. Some institutions
proposed treatment or therapy require informed consent for every
2. be present during service user's medication given.
appointments and consultations with mental
health professionals, workers and other Rights Regarding Restraint and Seclusion
service providers during the course of • Doctrine of least restrictive means of restraint
treatment or therapy for shortest time is always the rule.
• Legal Grounds for restraint use include, when
OTHER MENTAL HEALTH LEGAL behavior is physically harmful to patients or
PRINCIPLES others, when decrease in sensory
Civil rights overstimulation (seclusion is only needed)
All people with mental illness are guaranteed same and when patient anticipates that controlled
rights under our laws as any other citizen. environment would be helpful and request
seclusion
Due process
In courts have recognized involuntary commitment
to mental hospital is “massive curtailment of liberty”
requiring due process protection, including:
• Writ of Habeas Corpus- a procedural
mechanism used to challenge unlawful
detention.
• Least restrictive alternative doctrine-
mandates least drastic means be taken to
achieve specific purpose.