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COMPONENTS OF MENTAL HEALTH
1. SELF-GOVERNANCE – autonomy, a sense of detachment, independence. And a

tendency to look within for guiding values and rules to live by.
2. GROWTH ORIENTATION – willingness to depart from status quo to progress toward
self-realization, androgyny (interaction and balance of feminine and masculine
characteristics in an individual), and maximization of capacities.
3. TOLERANCE OF UNCERTAINTY – faces certainty of living and certainty of death by
means of faith and hope.
4. SELF-ESTEEM – built in self-knowledge and awareness of talents, abilities, and
limitations.
5. MASTERY OF THE ENVIRONMENT- effective, capable, competent, and creative in
dealing with and influencing, the environment.
6. REALITY ORIENTATION – distinguishes fact from fantasy and act accordingly.
7. STRESS MANAGEMENT – experiences depression, anxiety, and so forth in daily life
and can tolerate high level of stress, knowing that the feeling is not going to last forever.
VARIABLES AFFECTING MENTAL HEALTH
1. BIOLOGICAL FACTORS – prenatal and perinatal influences, physical health,

neuroanatomy and physiology.
2. SOCIOCULTURAL FACTORS – family stability, child-rearing patterns, economic level,
housing, membership in a minority, religious influences and values.
3. PSYCHOLOGICAL FACTORS – parent, sibling, and infant/child interactions, IQ, self-
concept, skills, talents, creativity, and emotional developmental level.
MENTAL HEALTH ACCORDING TO ABRAHAM MASLOW
1. They possess the ability to accept themselves, others, and nature. Stated another way,
they have positive self-concepts and relate well with people and their environment.
2. They are able to form close relationship with others and display kindness, patience, and
compassion for others.
3. They perceive the world as it really is and people as they really are. Problem solving
occurs because these people are able to make decisions pertaining to reality rather than
fantasy.
4. They are able to appreciate and enjoy life. Optimism prevails as they respond to people,
places and things in daily encounters.
5. They are independent and autonomous in thought and action and rely on personal
standards of behavior and values.
6. They are creative, using a variety of approaches as they perform tasks or solve
problems.
7. Their behavior is consistent with as they appreciate and respects the rights of others,
display a willingness to listen and learn from others and show reverence for uniqueness
of and difference of others.
MENTAL HEALTH MENTAL ILLNESS

Accepts self or others Feels inadequate
Has poor self-concept
Is able to cope with or tolerate stress Unable to cope
Can return to normal functioning if temporarily Exhibits maladaptive behavior
disturbed
Able to form close and lasting relationship Unable to establish meaningful relationship
Uses sound judgment to make decisions Displays poor judgment
Optimistic Pessimistic
Recognizes limitations (abilities and Does not recognizes limitations
deficiencies)
Can function effectively and independently Exhibits dependency needs because of
feelings of inadequacy
Bernardita T. Hernandez, RN,MAN

Psychiatric and Mental Health Nursing
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Able to distinguish imagined circumstances Unable to perceive reality
from reality
Able to develop potential and talents to the Doesn’t recognize potential and talents
fullest extent because of poor self-concept
Able to solve problems Avoids problem rather than coping with them
or attempting to solve them
Can delay gratification Desires or demands immediate gratification
MH reflects a person’s approach to life by MI reflects a person’s inability to cope with
communicating emotions, giving and receiving, stress, resulting in disruption, disorganization,
working alone as well as with others, inappropriate reactions, unacceptable
accepting authority, displaying a sense of behavior, and the inability to respond
humor, and coping successfully with emotional according to the person’s expectations and the
conflict. demands of society.
MISCONCEPTIONS ABOUT MENTAL ILNESS
1. Abnormal behavior is different, or odd, easily recognized.

2. Abnormal behavior can be predicted and evaluated.
3. Internal forces are responsible for abnormal behavior.
4. People who exhibit abnormal behavior are dangerous.
5. Maladaptive behavior is always inherited.
6. Mental illness is incurable.
THEORETICAL MODELS FOR WORKING WITH PSYCHIATRIC PATIENTS
PSYCHOANALYTICAL MODEL – Sigmund Freud
■ Emphasizes unconscious processes or psychodynamic factors as the basis for motivation

and behavior.
■ Personality is formed in the early childhood
■ Knowledge of how an individual’s drives, instincts, psychic energy or libido, and
psychosexual attitude are formed during the 1st 6 years of life is crucial to the
understanding of personality.
■ Key Concepts:
□ Personality Processes
• Personality consists of 3 processes that function as a whole to bring
about behavior
• Id – the personality at birth, wanting to experience only pleasure.
o This instinctual drive is known as the pleasure principle involving primary
process thinking (fantasies and images)
• Ego – focuses on reality principle (distinguishes reality from fantasy)
o Experiences anxiety and uses defense mechanisms for protection
o Heredity, environmental factors, and maturation influence the formation of ego
• Superego – concerned with right and wrong (conscience)
o Provides the ego with inner control to help cope with the id.
o Formed from the internationalization of what arents teach their children about
right and wrong through rewards and punishments.
o Guilt and inferiority are experienced if the individual cannot live up to parental
standards.
 Levels of Consciousness
• Conscious – material within an individual’s awareness; only small part of
the mind.
• Unconscious – larger area and consists of memories, conflicts,
experiences, and material that have been repressed and cannot be recalled at will.
• Preconscious – memories that can be recalled to consciousness with
some effort.
• Uncovering unconscious material generates an understanding of
behavior that enables individuals to make choices about behavior and thus improve
mental health.

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 Defense Mechanisms – primarily unconscious behavior, however, some are
within voluntary control
• Protect the ego and diminish anxiety
• When used excessively, individuals are unable to face reality and do not
solve their problems.
• 3 kinds of anxiety:
o Reality anxiety – stems from an external real threat.
o Neurotic anxiety – deals with the fear that instincts will cause one to do
something to invite punishment such as being promiscuous.
o Moral anxiety – deals with guilt that is experiences if one acts contrary to
the conscience.
■ Goals of Psychoanalysis
 To bring the unconscious into consciousness so that individuals can work
through the past and understand their past and present behavior.
 By overcoming repression and resistance to exploring feelings and thoughts,
childhood experiences can be analyzed.
 Uncovering the causes of current behaviors can lead to insight.
■ Therapist’s Role
□ Therapist uses free association (letting the patient say everything that comes to mind)
so that repressed materials can be identified and interpreted for patients.
□ Dream analysis helps patients uncover the meaning of dreams, which also increases
awareness about present behavior.
■ Relevance to Nursing Practice
□ Nurse must recognize and understand maladaptive defense mechanisms.
□ Works with the patients to decrease these behaviors and increase adaptive ones.
□ Patients also need assistance with accepting their desires and drives as normal human
phenomena for which they need not feel guilt or shame and with choosing acceptable
ways of expressing them.
DEVELOPMENTAL / PSYCHOSOCIAL MODEL – Erik Erikson
■ Included psychosocial and environmental influences along with Freudan psychosexual

concepts.
■ Key Concepts:
□ Each stage of development is an emotional crisis involving (+) and (-) experiences.
□ Growth mastery of critical tasks is the result of having more (+) that negative
experiences.
□ Deficits in development carries from one stage to the next progressively interfere with
functioning until the individual is no longer capable of growing w/out emotionally
returning to an earlier stage in order to resolve the crisis.
□ An environmental or social tragedy can shake the early foundations of development
(divorce from a spouse threatens the individual’s sense of trust in others and results in
self-doubt.
□ Overcoming delayed or incomplete development is difficult but possible.
■ Relevance to Nursing Practice
□ The nurse conducts an assessment of the patient’s level of functioning through the
interpretation of verbal and nonverbal behaviors and identifies the degree of mastery of
each stage u the patient’s chronological age.
□ These are clues to issues to be addressed in working with the patient.
INTERPERSONAL MODEL – Harry Stack Sullivan
■ The healthy person is a social being with the ability to live effectively in relationship with
others.
■ Mental illness is viewed as any degree of lack of awareness of the processes in IPR.
■ Relationships were viewed as the source of anxiety, maladaptive behaviors, and personality
formation.
■ Key Assumptions:

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□ Human personality is determined in the context of social interactions with other human
being.
□ Anxiety plays a central role (served a primary motivator) in the formation of human
behavior.
□ Interpersonal experiences, rather than intrapsychic ones, determine the personality
organization achieved by human beings.
□ The self-system is an important facet of human personality that forms in reaction to the
experience of anxiety.
• Security mechanism are employed to reduce or avoid the experience of anxiety.
○ Sublimation – unconscious process whereby socially acceptable behavioral
patterns are substituted to satisfy partially the need for a behavioral pattern that
would result in increased anxiety.
○ Selective inattention
○ Dissociation – “the not me”
□ Early life experiences with parents, especially the mother, influence an individual’s
development throughout life.
• Personifications – images that the individual has of the self and other people;
produces this lasting effect.
• These images, compromising feelings, attitudes, and ideas, form as the result of
experiences with anxiety and need satisfaction with the so-called mothering-one
(calm of tolerant mother or an anxious, intolerant mother).
• As child’s development unfolds, these dichotomous personifications become fused, if
not, the individual may go through life with extreme, polarized views of self, others,
and situation.
○ Good me – results from experience of approval and tenderness and is
associated with good feelings and situation.
○ Bad me – experiences resulting from high anxiety situations and are associated
with feelings of shame, guilt, and low self-esteem.
○ Not me – develops in reaction to overwhelming anxiety arising from situations
that provoke feelings of horror or dread.
■ Stages of Development
• Infancy (birth – 1 ½ yrs) – crying is a tool used to establish contact with others
• Childhood (1 ½ - 6 yrs) – language assists with learning to delay the gratification

of needs
• Juvenile period (6 – 9 yrs) – competition, compromise, and cooperation are
tools to develop relationship with peers
• Preadolescence (9 – 12 yrs) – collaboration and capacity for love assist n the

development of “chum” relationships with a person of the same sex
• Adolescence (12 – 14 yrs) – collaboration and capacity for love with sexual
desire to facilitate learning to establish relationship with the opposite sex
• Late adolescence (14 – 21 yrs) – independence to interdependence and
individual learns to form lasting sexual relationships
□ Therapists’ Role
• The focus of therapy is on patient’s current interpersonal relationships and
experience.
• The goals of therapy is to develop mature and satisfactory relationships
relatively free from anxiety.
○ To free the persons from previously ineffective interpersonal patterns acquired
earlier in life.
○ To help the person manage personal anxieties and gain concern for the welfare
of significant others.
• The therapist take an active role as a “participant observer” in experiencing patient’s
interpersonal problems.

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INTELLECTUAL DEVELOPMENT MODEL – Jean Piaget
■ Sensorimotor (Infancy – Toddler)

□ Develops physically
□ Gradual increase in the ability to think and use language
□ Simple reflex responses through repetitive behaviors
■ Preoperational Thought (Preschool)
□ Imitate and play
□ Use symbols and language although interpretation is literal
■ Preoperational Thought (School Age)
□ Understand relationships
□ Basic conceptual thought and intuitive reasoning
■ Concrete Operational (Preadolescent)
□ Thinking is more socialized and logical
□ Increase intellectual and conceptual development
□ Problem solving by inductive reasoning and logical thought
■ Formal Operational (Adolescent)
□ True abstract thought by application of logical tests
□ Achieves conceptual independence and problem solving ability
BEHAVIORAL MODEL – Ivan Pavlov, John Watson, and BF Skinner
■ Therapeutic Approaches:
 Token Reinforcement
 Shaping
 Systematic Desensitization – described by Wolke
□ Counter conditioning technique – extinguish maladaptive responses and replace them
with more acceptable ones.
• Based on the premise that a person can’t be frightened and relaxed at the same
time.
 Rational-Emotive Therapy – Albert Ellis
• Assumptions:
o A person acquires a basic set of values and beliefs early in life and is
governed by them thereafter.
o A person wants to survive and experience happiness which is defined as
needs satisfaction and freedom from pain.
o A person usually strived to belong to and harmonize with a social group or
community.
o A person desires to form more intimate relationships with a few member of
this group.
• Behaviors that support these 4 assumptions are rational and those that don’t are
irrational.
• ABC of personality:
o A – activating event
o B – belief system of the person
o C – emotional consequence
o Illustration -
• Appropriate and inappropriate emotional response to an event is determined by the
belief system of the person not by the event itself.
GENERAL SYSTEMS THEORY – Ludwig Von Bertalanffy
■ Basic Assumptions:
 The human being is a living, open system consisting of interrelated subsystems.
 These interrelated subsystems are components or parts of the total human
organism.
 These subsystems in relation to each other ties the human system together,
forming a whole.

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 Individual subsystems or subwholes possess attributes common with each other
and with the human system as a whole.
 Thus, humans system behaves not a composite of independent elements, but
rather coherently and as an inseparable whole.
 The human system is surrounded by a boundary that separates it from the
surrounding environment.
 The 5 sensory channels plus the verbal and nonverbal behavioral modes of the
human system form the boundary separating the human system from the surrounding
environment.
• Input
• Throughput (process)
• Output
• Feedback
 The human system tends to favor a steady state.
 Disruption of stability results in stress on the total human organism.
■ The goal of nursing is to help the client maintain or regain a steady state or a holistic
theoretical perspective.
NATURAL SYSTEMS THEORY (FAMILY SYSTEMS) – Murray Bowen
■ Assumptions:
□ Human beings and human family are more like than unlike other natural biological
systems.
□ All human behavior is linked to biological functioning. Human emotional functioning is
connected, in as yet unspecified ways, to human biological functioning.
■ 2 Major Interacting Variables that influence human behavior in the relationship system:
□ Anxiety – human reaction to stress, not the stress itself – this gives rise to problems and
symptoms.
□ Level of Differentiation – the degree to which a person defines self in terms of self-
chosen beliefs, principles and convictions versus defining the self by external factors and
emotional forces.
■ Concepts:
□ The concept of differentiation of self stands as the cornerstone of the theory.
• Scale of 1-100 (from less adaptable to highly adaptable).
• Level of solid self vs. pseudo self
○ Solid self – based on clearly defined, self-chosen beliefs, opinions, convictions,
and principles deprived from intellectual functioning.
○ Pseudo self – comprises princip0les, beliefs, philosophical and knowledge
usually acquired through group pressure and often inconsistent with one another.
□ The triangle is the basic building block of an emotional system.
□ The nuclear family system describes and explains family patterns of emotional
functioning.
• Ways of managing anxiety within the nuclear family:
○ Emotional distancing
○ Dysfunction in one spouse
○ Marital conflict
○ Family projection
□ The family projection process occurs when the parents project their own differentiation
on to one or more of their children resulting in dysfunction of the child and children.
□ Emotional cutoff describes how people cope with their unresolved emotional
attachments to their parents.
□ The concept of multigenerational transmission process describes the trajectory of the
family projective process.
□ The concept of sibling position describes how a specific child is selected to become
involved in the family projection process.

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□ The concept of societal regression describes how, like the human family society can lose
contact with intellectually determined principles and resort to increasingly to emotionally
determined decisions to decrease anxiety when subjected to chronic, stress.
GROWTH AND DEVELOPMENT
EXPECTED STAGE OF PLAY DEVELOPMENT

Age Characteristics
1. Exploratory – holding toys; 0-1 yr
2. Toys as adult toys – imitation; 1-7 yrs
3. games and hobbies – 8-12 yrs
Social Characteristics
1. Infancy - Solitary play – alone, but enjoys presence of others; interest centered on own
activity
2. Toddler – Parallel play – plays alongside, not with, another; characteristic of toddlers,
but can occur in other age groups
3. Preschool – Associative play – no group goal; often follows a leader
4. School-age – Cooperative play – organized, rules, leader/follower relationship
established
SCREENING TEST
1. Denver Development Screening Test (DDST) – evaluates children from birth to 6 yrs
in 4 skill areas: personal-social, fine motor, language, gross motor
 Age adjusted for prematurity by subtracting the number of months preterm
 Questionable value in testing children of minority/ethnic groups
2. Standford Binet
3. Intellegence Test – used to determine IQ: mental age x 100 = IQ/Chronological age
TERMS AND CONCEPTS

Process - sequence is orderly and predictable; rate tends to be variable within (more
quickly/slowly) and between (earlier/later) individuals.
Growth – increase in size (height and weight); tends to be cyclical, more rapid in utero, during
infancy, and adolescence.
Development – maturation of physiological and psychosocial systems to more complex state.
Developmental Tasks – skills and competencies associated with each developmental
stage that have an effect on subsequent stages of development.
Developmental milestone – standard of reference to compare the child’s behavior at
specific ages.
Developmental delay(s) – variable of development that lags behind the range at a given
age.
Muscular coordination and control – proceeds in head-to-toe (cephalocaudal), trunk-to-
periphery (proximodistal), gross-to-fine development pattern
ANXIETY / ANXIETY-RELATED DISORDERS
■ Feeling of dread or fear in the absence of an external threat or disproportionate to the nature
of the threat.
Characteristics
□ It is the basic element of behavior.
□ Serves as a signal w/c alerts an individual to defensive action to handle exhibition.
□ Necessary for one’s survival.
□ It is an emotion and a subjective experience of an individual.
□ It is provoked by the unknown. It therefore precedes all new experiences (entering
school, moving to a new place, starting a new job).
□ It is communicated interpersonally.

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Predisposing Conditions
a. prolonged unmet needs pf dependency, security, love and attention
b. stress threatening security of self-esteem
c. unacceptable thoughts or feelings surfacing to consciousness; e.g. rage, erotic impulses,
flashbacks
Theories of Origin
■ FREUD
 It is due to the conflict bet the id and the superego. The ego serves a
battleground as it tries to mediate the demands of the 2 clashing personalities.
■ SULLIVAN
 Believed that through the close emotional bond bet the mother and the child,
anxiety is first conveyed by the mother to the infant.
 Anxiety in later life arises in interpersonal situation.
■ WILL
 Believed that low self-esteem is related to predisposition to anxiety.
 Self-esteem has nothing to do w/ actual abilities or preparedness.
■ LEARNING THEORY
 Parental influence affects how a child responds to anxiety. The parents
appropriate emotional response gives the child security and helps him learn constructive
ways of coping on his own.
Precipitating Factors to Anxiety

1. Threat to biologic integrity – disturbance in homeostasis (temp control, vasomotor
control, etc)
2. Threat to self-esteem – threat to the tendency of an individual toward maintaining
established views of self and the values and patterns of behavior he uses to resist
changes in his view of self
• sense of helplessness
• sense of isolation (alienation)
• sense of insecurity (threat to identity)
Levels of Anxiety
a. MILD – high degree of alertness, mild uneasiness, best for learning
b. MODERATE – heart pounds, skin cold and clammy, poor comprehension, lack of focus
c. SEVERE – hallucinations, delusions, impulsive
d. PANIC –inability to see and hear, inability to function
■ Level Zero: EUPHORIA

□ Exaggerated feeling of well-being hat is not directly proportionate to a specific
circumstances or situation.
□ Usually precedes level 1.
■ Level 1: MILD
□ Increased alertness to inner feelings or the environment.
□ The individual has increased ability to learn, experiences a motivational force, may
become competitive, and has the opportunity to be individualistic.
□ Feeling of restlessness may be present and the individual may not be able to relax.
■ Level 2: MODERATE
□ Narrowing of the ability to perceive occurs.
□ Person is able to focus or concentrate on only one specific thing.
□ Pacing voice tremors, increased rate of verbalization or talking, physiologic changes,
and verbalization about expected danger occurs.
■ Level 3: SEVERE
□ Ability to perceive is further reduced, focus is on small or scattered details.
□ Inappropriate verbalization, or the inability to communicate clearly.

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□ Physiologic responses also occurs as the individual experiences a sense of impending
doom.
■ Level 4: PANIC
□ Complete disruption of the ability to perceive.
□ Disintegration of the personality as the individual becomes immobilized, experiences
difficulty verbalizing, and is unable to focus on reality.
□ Loss of control – physiologic, emotional, and intellectual changes.
PHYSIOLOGIC CHANGES DURING ANXIETY SITUATION

LEVEL MECHANISM EFFECTS
MILD - MODERATE Stimulation of the Autonomic Increased BP, PR, RR
NS (ANS) Pupils dilate
Sweat glands stimulated
Peripheral vasoconstriction
MODERATE - SEVERE Stimulation of Adrenal Medulla Increased catecholamine, blood
glucose, blood flow to GIT and
skeletal muscle
Hyperventilation
SEVERE – PANIC Depletion of Sympathetic Hypotension
Neurotransmitters Dizziness
Fainting
Exhaustion
Weariness
COPING WITH ANXIETY

TYPE DESCRIPTION COMMON USE
ADAPTIVE Solves the problem that is Anxiety about an upcoming case
causing anxiety, so the anxiety presentation is reduced by rehearsing
is decreased. with the group.
The patient is objective, The group wins in the contest.
rational, and productive.
PALLIATIVE Temporarily decreases the Anxiety about the case presentation
anxiety but does not solve the is temporarily reduced by meeting
problem, so the anxiety late. Effective rehearsal is then
eventually returns. possible and winning the contest is
Temporary relief allows the still achievable.
patient to return to problem
solving.
MALADAPTIVE Unsuccessful attempts to Anxiety about the case presentation
decrease the anxiety without is first ignored by the members doing
attempting to solve the their individual thing and then
problem. handled by frantically cramming for a
The anxiety remains. few hours.
They got the 4th place out of the 5
contestants.
DYSFUNCTIONAL Is not successful in reducing Anxiety about the case presentation
the anxiety or solving the is first ignored by going out drinking
problem. with friends and then escaped by
Even minimal functioning “passing out” for the night.
becomes difficult, and new They failed to defend their output and
problems begin to develop. was asked to go through the case
again.

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NURSING INTERVENTIONS IN ANXIETY

GEN PRINCIPLES NRSG CONSIDERATIONS
Assess level of anxiety.  Look for body language, speech patterns, facial expressions,
defense mechanisms, and behavior used.
 Distinguish level of anxiety.
Keep environmental  First action.
stresses/stimulation low  Need to intervene with severe and panic level.
when anxiety is high  Brief orientation to unit or procedures.
 Written information to read later, when anxiety is lower.
 Pleasant, attractive, uncluttered environment.
 Provide privacy if the presence of other patients is
overstimulating.
 Provide physical care if necessary.
 Avoid offering several alternatives or decisions when anxiety is
high.
Assist client to cope with  Acknowledge anxious behavior; reflect and clarify.
anxiety more effectively  Always remain with client.
 Assist client to clarify own thoughts and feelings.
 Encourage measures to reduce anxiety; e.g. exercise, hobbies,
talking with friends, hobbies
 Assist client to recognize his/her strengths and capabilities
realistically.
 Provide therapy to develop more effective coping and
interpersonal skills; e.g. individual, group.
 May need to administer antianxiety medication.
Maintain accepting and  Use an unhurried approach.
helpful attitude toward  Acknowledge client’s distress and concerns about problem.
client  Encourage clarification of feelings and thoughts.
 Evaluate and manage own anxiety while working with client.
 Recognize the value of defense mechanisms and realize that
client is attempting to make the anxiety tolerable in the best way
possible.
 Acknowledge defense but provide reality; e.g. “You do not see
that you have a problem with alcohol but your blood level is
high.”
 Do not attempt to remove a defense mechanism ay any time.
NURSING INTERVENTIONS TO REDUCE ANXIETY

NRSG INTERVENTIONS RATIONALE
1. Provide a calm and quiet environment. Identify and reduce stimulation.
2. Ask the patient to identify what and how he Help patient to increase his recognition of
feels. what is happening to him.
3. Encourage patient to describe and discuss Help patient become aware of the connection
his feelings w/ you. between his feelings and behavior.
4. Help patient to identify possible causes of Assist patient in connecting his feelings with
his feelings. earlier experiences.
5. Listen carefully to patient’s expressions of Assess self-harm. Suicide could be a way of
helplessness and hopelessness. escape from pain.
6. Ask patient if he feels suicidal and has a To initiate suicide precaution if necessary.
plan to hurt himself.
7. Plan and involve patient in activities (going Help patient release nervous energy and to
for walks, recreational games) discourage preoccupation w/ self.
ANXIETY-RELATED DISORDERS
■ PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA

□ Panic disorder is a real illness with both a physical and psychological component.

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□ Panic attack may occur “out of the blue” while the person is engaged in some ordinary
activity (grocery, driving a car, or doing household work).
□ Individual suddenly experiences frightening and uncomfortable symptoms (terror, a
sense of unreality, or a fear of losing control0.
□ Onset during late teens and early 20s.
□ Common in women.
□ Panic attacks are not due to the direct physiologic effects of substance or a general
medical condition.
□ Panic attacks usually last between 1 min and 1 hr.
□ During the panic attack, the individual may experience fear of being alone in a public
place (agoraphobia).
□ After the panic attack, the individual:
• Exhibits concern about having additional panic attacks,
• Worries about implications of the attack or its consequence, or
• Displays a significant change in behavior.
■ PHOBIC DISORDER
□ Most common form of anxiety d/o.
□ Phobia – irrational fear of an object, activity, or situation that is out of proportion to the
stimulus and results in avoidance of the identified object, activity, or situation.
□ Person unconsciously displaces the original internal source of fear or anxiety
(unpleasant childhood experience) to an external source.
□ Agoraphobia
• Most common phobic disorder.
• Fear of being alone in public places from which the person thinks escape would be
difficult or help would be unavailable if he/she were incapacitated.
• Normal activities become restricted and individuals refuse to leave homes.
• Common in women, ages 18-35 year old.
• Clients are likely to develop depression, fatigue, tension and spontaneous obsessive
or panic disorders.
□ Social Phobia
• A compelling desire to avoid situations in which others may criticize a person.
• Persistent, irrational fear of criticism, humiliation, or embarrassment.
• Abuse of alcohol or other drugs may occur.
□ Specific Phobia
• Acrophobia – fear of heights
• Agoraphobia – fear of open places
• Algophobia – fear of pain
• Androphobia – fear of men
• Astrophobia - fear of storms, lighting, or thunder
• Autophobia - fear of being alone
• Aviophobia - fear of flying
• Claustrophobia - fear of enclosed places
• Entomophobia - fear of insects
• Hematophobia - fear of blood
• Hydrophobia - fear of water
• Iatrophobia - fear of doctors
• Necrophobia - fear of dead bodies
• Nyctophobia - fear of night
• Ochlophobia - fear of crowds
• Ophidiophobia - fear of snakes
• Pathophobia - fear of disease
• Sitophobia - fear of flood
• Thanatophobia - fear of death
• Topophobia - fear of a particular place
• Zoophobia - fear of animals
 Nursing Considerations:
• Avoid confrontation and humiliation.

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• Don’t focus on getting patient to stop being afraid.
• Systemic desensitization
• Relaxation techniques (visualization).
• General anxiety measures.
May be managed w/ antidepressants.
■ GENERALIZED ANXIETY DISORDER
□ Associated with disability, medically unexplained symptoms, and overuse of health care
resources.
□ Characterized by:
• Unrealistic or excessive anxiety and worry occurring more days than not in 6-month
period
• Individual is unable to control the worry
• At least 3 of the following symptoms:
○ Restlessness
○ Fatigue
○ Impaired concentration
○ Irritability
○ Muscle tension
○ Sleep disturbance
• Anxiety interferes with social, occupational, or other important areas of functioning,
and is not a direct result of a medical condition or substance abuse.
■ OBSSESSIVE-COMPULSIVE DISORDER
□ Characterized by recurrent obsessions or compulsions (or combination of both) that
interfere with normal life
□ Obsession – a persistent, painful, intrusive thought, emotion, or urge tht one is unable
to suppress or ignore.
• Common obsessive thoughts involve religion, sexuality, violence, the need for
symmetry or exactness, and contamination.
• Considered senseless of repugnant, and they cannot be eliminated by logic or
reasoning.
□ Compulsion – the performance of a repetitious, uncontrollable, but seemingly
purposeful act to prevent some future event or situation.
• Compulsive behaviors: washing of hands, swallowing, stretching, rocking, and
housecleaning.
• Ideal compulsion is an urge to carry out an at within one’s mind (replicating words or
speech in one’s mind or drawing in one’s mind).
• Common in children and adolescents.
□ Resistant to act increases anxiety.
 Nursing Considerations:
• Accept ritualistic behavior – give time.
• Structure environment.
• Provide for physical needs
• Offer alternative activities, especially ones using hands
• Guide decisions, minimize choices
• Encourage socialization
• Group therapy, accept d/o, coping ability
• Managed w/ clomipramine (anafranil)
• Stimulus-response prevention
■ POST-TRAUMATIC STRESS DISORDER
□ Common antecedents of PTSD:
• Sexual and other assaultive violence
• Traumatic losses
• War-related trauma
□ Acute onset if symptoms that last less than 3 months; beyond 3 months, the diagnosis of
chronic onset is used.
□ Clinical symptoms:
• Recurrent and intrusive distressing recollection
• Recurrent distressing dreams

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• Acting or feeling as if events were recurring
• Intense psychological distress to internal or external cues symbolizing an aspect of
the event
• Physiologic reactions on exposure to stimuli that resemble an aspect of the event
• Avoidance of thoughts, feelings, or conversations associated with the trauma
• Avoidance of activities, places, or people associated with the trauma
• Inability to recall an important aspect of the trauma
• Feeling of detachment or estrangement from others
• Restricted affect
• Insomnia
• Labile emotion
• Decreased concentration
• Hypervigilance
• Exaggerated startle response
□ Impaired role, occupational, social, and recreational functioning may occur.
□ Low self-concept and suicidal ideation or thoughts may occur, along with substance
abuse.
■ ACUTE STRESS DISORDER
□ Symptoms occur during or immediately after the trauma, lasts for at least 2 days, or
either resolve within 4 weeks after the conclusion of the event or the diagnosis is
changed to PTSD.
□ Individual experiences dissociative symptoms (numbness or detachment), a reduction in
awareness of surroundings, derealization, depersonalization, or dissociative amnesia.
□ Traumatic event is persistently reexperienced, although the individual avoids stimuli that
arouse recollection of the trauma.
■ SOMATOFORM DISORDER
□ Body Dysmorphic D/O (Dysmorphobia)
• Preoccupation with an imagined defect in his/her appearance.
• Common complaints focus on facial flaws, for which a plastic surgeon or
dermatologist is usually consulted.
• Obsessive-compulsive traits are usually present.
• Common age of onset is from adolescence through the 3rd decade of life.
• Can persist for several years.
□ Somatization D/O
• Free-floating anxiety disorder in which the client expresses emotional turmoil or
conflict through a physical system, usually with a loss or alteration of physical
functioning which is not under voluntary control and is not explained as a known
physical disorder.
• Onset is usually at 25 years.
• Considered to be a chronic illness in persons who demonstrate a dramatic,
confusing, or complicated medical history, because they seek repeated medical
attention.
• When there is a related general medical condition, the physical complains are
exaggerated.
• Anxiety and depression are common; client may make frequent threats or suicide
attempts.
• May also exhibit occupational, interpersonal, or marital difficulties.
• She may frequently submits to unnecessary surgery because client seeks medical
attention.
□ Conversion D/O
• A psychological condition in which an anxiety-provoking impulse is converted
unconsciously into functional symptoms.
○ Motor symptoms or deficit (impaired balance, paralysis, dysphagia, or urinary
retention).
○ Sensory symptoms or deficit (loss of touh or pain sensation, double vision,
blindness, or hallucinations).
○ Seizures or convulsions with voluntary motor or sensory components.

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○ Mixed presentation if symptoms or more than one category.
• La belle indifference – may describe client reactions (showing indifference to the
symptoms and displaying no anxiety).
• Anxiety has been relieved by conversion disorder.
• Primary gain – relief from anxiety obtained by keeping an internal need or conflict
out of awareness.
• Secondary gain – attention, love, financial reward, and sympathy.
• This is different from malingering. Malingering – a conscious effort to stimulate or
feign the symptoms of illness to avoid unpleasant situation.
• Age of onset – late childhood or early adulthood.
□ Pain D/O
• May occur at any stage.
• More on women.
• Complain of chronic pain (headaches and musculoskeletal pain).
• Pain is the predominant focus of the clinical presentation and is severe enough to
warrant clinical attention.
□ Hypochondriasis
• Unrealistic or exaggerated physical complaints.
• Person becomes preoccupied with the fear of developing or already having a
disease or illness inspite of medical reassurance that such an illness does not exist.
• “Professional patients” who shop for doctors because they feel they do not get
proper medical attention.
• Usually accompanied by anxiety, depression, and compulsive personality traits.
• Person may adopt an invalid lifestyle and actually may become bedridden.
□ Undifferentiated Somatoform D/O
• Used when one or more physical complaints (fatigue or loss of appetite) lasts 6
months or longer, and after appropriate evaluation, cannot be explained by a known
general medical condition or the direct effects of a substance.
□ Somatoform D/O not Otherwise Specified
■ DISSOCIATIVE DISORDER
□ Essential feature is a disruption of integrated functions of consciousness, memory,
identity, or perception of the environment.
□ Onset may be sudden, gradual, transient, or chronic.
□ Dissociative Amnesia (psychogenic amnesia)
• Characterized by the inability to recall an extensive amount of important personal
information because of physical or psychological trauma.
• Not a result of delirium or dementia.
• Predisposing factors:
○ Intolerable life situation
○ Unacceptability of certain impulses or acts
○ Threat of physical injury or death.
• Amnesia can be described as:
○ Circumscribed or localized – occurring a few hrs after a traumatic experience
or major event.
○ Selective – inability to recall part of the events of a specific time.
○ Generalized – inability to recall events of one’s entire life.
○ Continuous – inability to recall events after a specific event up to and including
the present.
• Clinical features include:
○ Perplexity
○ Disorientation
○ Purposeless wandering
○ Mild or severe impairment in ability to function
• More common during natural disasters or wartime.
□ Dissociative Fugue (psychogenic fugue)
• Person suddenly and nexpectedly leaves hoe or work and is unable to recall the
past.

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• Assumption of a new identity, either partial or complete, may occur after relocation to
another geographic area where the person is unable to recall his/her previous
identity.
• Seen during times of extreme stress (war, severe conflicts, natural disasters)
□ Dissociative Identity D/O (Multiple Personality D/O)
• As person is dominated by at least one or more definitive personalities at one
time.
• Emergence of various personalities, or “alters” occurs suddenly and is often
associated with psychosocial stress and conflict.
• Each personality is aware of the others to varying degrees.
• One personality can interact with the external environment at any given moment.
• The individual personalities are usually quite discrepant and frequently appear to be
opposites.
• Passive identities have more constricted memories.
• Controlling, hostile, or protective identities have more complete memories.
• More in adult women than adult men.
□ Depersonalization D/O
• Person experiences a strange alteration in the perception or experience of the
self, often associated with a sense of unreality.
• Includes: feelings of being in a dreamlike state, out of the body, mechanical, or
bizarre in appearance.
• Predisposing factors:
○ Fatigue
○ Meditation
○ Hypnosis
○ Anxiety
○ Physical pain
○ Severe stress
○ Depression
• More common among adolescence and young adults.
CRISIS / CRISIS INTERVENTION
Stages of Crisis
a. Denial
b. Increased tension, anxiety
c. Disorganization, inability to function
d. Attempts to organize
e. Attempts to escape the problem, pretends problems doesn’t exist, blames others
f. General reorganization
Precipitating Factors
a. Developmental
• Birth, adolescence
• Midlife, retirement
b. Situational
• Natural disasters
• Financial loss
c. Threats to self-concept
• Loss of job
• Failure at school
• Onset of serious illness

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Characteristics
 Temporary state of disequilibrium precipitated by an event
 Self-limiting – usually 4-6 weeks
 Crisis can promote growth and new behaviors
SITUATIONAL CRISES
Type GRIEVING PATIENT DYING PATIENT RAPE TRAUMA
Assessment Stages of Grief Stages of Dying Stages of Crisis
a. Shock and a. Denial a. acute reaction lasts
disbelief b. Anger 3-4 wks
b. Awareness of c. Bargaining b. Reorganization is
the pain or loss d. Depression long term
c. Restitution e. Acceptance Common Responses to
Acute grief period – 4-8 Rape
wks a. self-blame,
Usual resolution w/in 1 embarrassment
yr b. phobias, fear of
Long term resolution violence, death, injury
over time c. anxiety, insomnia
d. guilt
e. inability to cope
Analysis Potential Problems Potential Problems Potential Problems
a. Family of a. Avoidance a. fears, panic
deceased or behavior reactions, generalized
separated b. Inability to anxiety
- guilt express feelings b. guilt
- anger when in denial c. inability to cope
- anxiety c. Feelings of guilt Current crisis may
b. Patient d. Withdrawal reactivate unresolved
undergoing e. Lonely, trauma
surgery or loss of frightened Follow emergency room
body part f. Anxiety of protocol; may include
- anger patient and family clothing, hair samples,
- withdrawal NPO
- guilt Be alert for potential
- anxiety internal injuries
- loss of role (hemorrhage)
Intervention Apply crisis theory Apply crisis theory Assess for injury (highest
Focus on the here and Support staff having priority)
now feeling of loss Apply crisis theory
Provide support to Keep communication Focus on the here and now
family when loved one open Write out treatments and
dies Allow expressions of appointments for client, as
Encourage feelings anxiety causes
verbalizations of Focus on the here and forgetfulness
feelings now Record all information in
Emphasize strengths Let patient know he is the chart
Increase ability to cope not alone Give client referrals for
Support adjustment to Provide comforting legal assistance,
illness, loss of body environment supportive psychotherapy,
part Be attentive to need for and rape crisis center
privacy Follow up regularly until
Provide physically, client is improved
comforting care (back Save samples for evidence
rubs)
Give sense of control
and dignity
Respect patient’s

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wishes
Evaluation Does client express Has an open, honest Is client at precrisis level of
feelings of disbelief, approach to dying functioning?
anger, and hurt? helped all concerned Are there any unresolved
Are anxiety and grieve together with less emotional responses to the
helplessness gradually fear and avoidance? rape trauma concerned?
replaced by a sense of Did the client feel less Did the client utilize referral
competence? isolated and alone services?
Does client work because of openness,
positively with physical daily support, and
and emotional diligence in spite of
challenges? diagnosis?
Nursing Interventions
1. Help client integrate the traumatic experience.
a. Encourage the client to talk about painful stored memories.
• Have client recall images of traumatic event with as much detail as possible
(called flooding).
• Use empathic responses to the expressed distress (“That must have been hard
for you.”)
• Remain nonjudgmental about client’s shameful or horrific experience.
• Allow client to grieve over losses.
b. Assist the client to challenge the existing ideas about event and substitute more realistic
thoughts and expectations.
2. Assist client with emotional regulation.
3. Enhance the client’s support system.
4. Educate the client regarding the recovery process.
PERSONALITY and PERSONALITY DISORDERS
■ PERSONALITY – the totality of a person’s unique biopsychosocial-spiritual traits and

qualities that consistently influence behavior.
■ PERSONALITY DISORDER – when the person’s personality is maldaptive.
□ A non-psychotic illness characterized by maladaptive behavior, which a person uses to
fulfill his/her needs and bring satisfaction to self.
□ These behaviors begin during childhood or adolescence as a way of coping an remain
throughout most of adulthood, becoming less obvious during middle or late adulthood.
□ Common characteristics:
• A deeply ingrained, inflexible, maladaptive response to anxiety;
• Maladaptation that is most apparent in an interpersonal or social context;
• The capacity to cause others to feel extreme irritation and annoyance; and
• A self-centered, inflexible approach to work, and interpersonal relationships.
□ General descriptions/adjectives:
• Narcissistic
• Unemphatic
• Inordinate sense of entitlement
• Dependent
• Lack of self-insight while giving evidence or pseudo self-knowledge
• Cynical
• Pessimistic
• Depressed
• Subjective
• Lack of self-control
• Egocentric
• Selfish
• Lonely
• Immature

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• Manipulative
• Aggressive
• Impulsive
• Hostile
• Suspicious
■ Theories of Personality Development
■ FRUED’S PSYCHOANALYTIC THEORY
■ 3 major categories:
□ The development of personality
• 3 levels of consciousness:
○ Unconscious
♦ Consists of drives, feelings, ideas, and urges outside of the person’s
awareness.
♦ Most significant level of consciousness because of its effect on behavior.
♦ A considerable amount of psychic energy is used to keep unpleasant
memories stored in the unconscious level.
○ Preconscious or subconscious
♦ Consists of feelings, ideals, drives, and ideas that are out of one’s awareness
but can be readily recalled.
○ Conscious
♦ Aware of the present and controls purposeful behavior.
□ The organization or structure of personality
• Id - An unconscious reservoir of primitive drives and instincts dominated by thinking
and the pleasure principle.
• Ego
○ Meets and interacts with the outside world as an integrator or mediator
○ The executive function of the personality that operates at all 3 levels of
consciousness.
• Superego
○ Acts as the censoring force or conscience of the personality and s composed of
morals, values, and ethics largely derived from one’s parents.
○ Also acts on 3 levels of consciousness.
□ The dynamics of personality
• Each person has a certain amount of psychic energy to cope with the problems of
everyday living.
• The id’s energy is used to reduce tension and may be exhibited by frequency of
urination, daydreaming, or eating.
• The ego’s energy controls the impulsive actions of the id and the moralistic and
idealistic actions of the superego.
• One whose energy is controlled by the superego generally behaves in an everly
moralistic manner because the system monopolizing the psychic energy governs the
person’s behavior.
■ Phases of the psychobiologic process:
□ Oral (0-18 months)
• Pleasure is derived mainly through the mouth by the actions of sucking or biting.
□ Anal (18 months – 3 years)
• Attention focuses on excretory function.
• The foundation is laid for the development of superego.
□ Phallic or oedipal (3-7 years)
• The child identifies with the parent of the same sex;
• Forms a deep attachment to the parent of the opposite sex;
• Develops a sexual identity of male or female role; and
• Begins to experience guilt.
□ Latency (7 years – adolescence)

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• Person learns to recognize and handle reality;
• Has a limited sexual image;
• Develops an inner control over aggressive or destructive impulses; and
• Experiences intellectual and social growth.
□ Genital (puberty/adolescence – adult life)
• Individual develops the capacity for object love and mature sexual identity.
• Identity and independence are established during this phase.
■ ERIKSON’S SYCHOSOCIAL THEORY
■ Emphasizes the concept of identity or an inner sense of sameness that perseveres despite
external changes, identify crises, and identify confusion in the dynamics of personality
development.
■ 8 psychosocial stages:
□ Focuses on the area of conflict and resolution in each of these stages, basic virtues or
qualities acquired, ad positive and negative behavior.
AGE AREA OF CONFLICT (+) OUTCOME (-) OUTCO ME
AND RESOLUTION /
VIRTUES AND
QUALITIES
Infancy Trust vs mistrust Trust self and others Demonstrates an inability

Birth –18 mos Drive and Hope to trust;
Withdrawal, isolation
Toddler Autonomy vs Shame Exercises self control Demonstrates defiance
18 mos – 3 yrs and Doubt and influences the and negativism
Self-control and Will environment directly
power
Preschool Initiative vs Guilt Begins to evaluate own Demonstrates fearful,
3 – 6 yrs Direction and purpose behavior; pessimistic behaviors;
Learns limits on influence Lacks self-confidence
in the environment
School age Industry vs Inferiority Develops a sense of Demonstrates feelings of
6 – 12 yrs Method and confidence; inadequacy, mediocrity,
competence Uses creative energies to and self-doubt
influence the
environment
Adolescence Identity vs Role Develops a coherent Demonstrates inability to
12 – 20 yrs Diffusion sense of self; develop personal and
Devotion and fedility Plans for a future of work vocational identity
/ education
Young Intimacy vs Isolation Develops connection to Demonstrates an
adulthood Affiliation and love work and intimate avoidance of intimacy
20 – 45 yrs relationships and vocational career
commitments
Middle Generativity vs Involved with established Demonstrates lack of
adulthood Stagnation family; interests, commitments;
45 – 65 yrs Productivity and the Expands personal Preoccupation with self-
ability to care for others creativity and productivity centered concerns
Late adulthood Integrity vs Despair Identification of life as Demonstrates fear of
65 + yrs – Renunciation or “letting meaningful death;
death go” and wisdom Life lacks meaning
■ PIAGET’S COGNITIVE DEVELOPMENTAL THEORY
■ Causes of Personality Disorders

□ The person is biologically predisposed or more subject to develop a personality disorder
– improper nutrition, neurologic defects, and genetic predisposition.
□ Childhood experiences foster the development of maladaptive behavior.

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• Parental rewarding of behavior (temper tantrums encourages acting out than
setting limits)
• Creativity is not encouraged in the child; therefore the child does not have the
opportunity to express self or learn to relate to others. This could provide the
opportunity to develop a positive self-concept and sense of self-worth.
• Rigid upbringing – it discourages experimentation and promote the development of
low self-esteem and may also cause feelings of hostility and alienation in the child-
parent relationship.
• Parental fostering of dependency discourages personality development and allows
the child to become conformist rather than an independent being with an opportunity
to develop a positive self-concept.
• Parents and authority figures display socially undesirable behavior and the child
identifies with them (learning theory). As a result of the identification process, the
child imitates behavior that he or she believes to be acceptable by others.
□ Defective egos (Freud) – unable to control their impulsive behavior.
□ Immature or weak ego (Freud) – incomplete or lack of a conscience; feel no guilt or
remorse for socially acceptable behavior.
□ Drive for prestige, power, and possessions – can result in exploitive, manipulative
behavior.
□ Low degree of social interaction (common in urban societies or inner cities)
■ Characteristics of Personality Disorders
□ Person denies the maladaptive behaviors; they have become a way of life.
□ The maladaptive behaviors are inflexible.
□ Minor stress is poorly tolerated, resulting in increased inability to cope with anxiety.
□ The person is in contact with reality, although he/she has difficulty dealing with it.
□ Disturbance of mood, such as anxiety or depression, my be present.
□ Psychiatric help is rarely sought because the person is unaware that his/her behavior is
maladaptive.
■ General diagnostic criteria for PD
□ An enduring pattern of inner experience that deviates markedly from the expectations of
the individual’s culture which is manifested in 2 or more of the following areas:
• Cognition (ways of perceiving and interpreting self, other people, and events)
• Affectivity (range, intensity, lability, and appropriateness of emotional response)
• Interpersonal functioning
• Impulse control
□ The enduring pattern is inflexible and pervasive across a broad range of personal and
social situations.
□ The enduring pattern leads to clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
□ The pattern is stable and of long duration, and its onset can be traced back at least to
adolescence or early adulthood.
□ The enduring pattern is not better accounted for as manifestation or consequence of
another mental disorder.
□ The enduring pattern is not due to the direct physiologic effects of a substance
(drug/medication abuse) or a general medical condition (head trauma).
■ Cluster of PD
□ Odd, Eccentric behavior
□ Emotional, erratic, or dramatic behavior
□ Anxious, fearful behavior
TYPES ASSESSMENT ANALYSIS NURSING

CONSIDERATIONS
Paranoid -Suspiciousness -Interprets actions of -Establish trust
-Hypersensitive, others as personal threat -Be honest and
humorless, serious -Uses projection: nonintrusive
-Prejudice and ideas of externalizes own feelings -Low doses of
reference by projecting own desires phenothiazines to
-Cold, blunted affect and traits to others manage anxiety

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-Quick response with -Holds grudges -Structures social
anger or rage situations
Schizoid -Shy and introverted, -Uses intellectualization: -Same as paranoid
rarely has close friends describes emotional
-Little verbal experiences in matter-of-
interaction fact way
-Cold and detached -Daydreaming may be
more gratifying than real
life
Schizotypal -Seems eccentric and -Similar to schizophrenia, -Same as paranoid
odd fewer and milder, -Low dose neuroleptics
-Sensitive to rejection psychotic episodes may decrease transient
and anger -Problems in thinking, psychotic symptoms
-Vague, stereotypical, perceiving, communicating
overelaborate speech -Common d/o among
-Suspicious of others biological relatives of
-Blunted or schizophrenics
inappropriate affect
Antisocial -Disregard for rights of -Genetic predisposition -Firm limit setting
others -Correlates w/ substance -Confront behaviors
-Lying m cheating, abuse and dependency consistently
stealing, promiscuous problems -Group therapy
behaviors -More common in males
-Appears charming -Rationales and denies
and intellectual, own behaviors
smooth talking
-Unlawful, aggressive
and reckless behaviors
-Lack of guilt, remorse,
and conscience
-Immature and
irresponsible, esp in
finances
Borderline -Seeks brief and -75% are women and -Help person identify and
intense relationships have been sexually verbalize feelings and
-Depression, increase abused control negative
anger, labile mood, -Problems with identity, behaviors
posttraumatic self-image, thinking and -Use empathy
symptoms mood -Behavioral contracts to
-Blames others for own -Uses splitting to avoid decrease self-mutilation
problems pain and to protect self -Journal writing
-Temper tantrums, -Projective identification -Consistent limit setting
physical fights used to protect the self needed
-Impulsiveness, -Biological, environmental, -Supportive confrontation
manipulative and stress-related factors, -Enforce unit rules
-Repetitive self- including traumatic home -Psychopharmacology
destructiveness, self- environment used sparingly for
mutilation, suicidal -Abnormalities in serotonin anxiety, psychotic states,
-Overspending, systems suicidal ideation, mood
promiscuity, -Suicidal behaviors occur swings
compulsive overeating when blocked, frustrated,
or stressed
Narcissistic -Arrogant, appears -Views others as superior -Mirror what person
indifferent to criticism or inferior to self sounds like, esp
while hiding anger, -Shallow relationships with contradictions
rage or emptiness others -Supportive confrontation
-Lacks ability to feel or -Feelings of others not to increase sense of self-
demonstrate empathy understood or considered responsibility
-Sense of entitlement -Uses rationalization to -Limit-setting ans

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-Use others to meet blame others consistency
their own needs -Expects special treatment -Focus on the here-and-
-Displays grandiosity -Needs to be admired now
-Teach that mistakes are
acceptable, imperfections
do not decrease worth
Histrionic -Draws attention to -Cannot deal with feelings -Positive reinforcement
self, thrives on being -Shallow, rapidly shifting for unselfish or other-
the center of attention emotions centered behaviors
-Silly, colorful, -Easily influenced by -Help clarify feelings and
frivolous, seductive, others facilitate appropriate
hurried, restless expression
-Temper tantrums and
outbursts of anger,
overreacts
-Dissociation used to
avoid feelings
-Somatic complaints to
avoid responsibility
and support
dependency
Dependent -Dependent on others -Fears loss of support and -Emphasize decision-
for everyday decisions, approval making to increase self-
passive -Lacks self-confidence responsibility
-Problem initiating -Teach assertiveness
projects or working -Assist to clarify feelings,
independently needs, and desires
-Anxious or helpless
when alone
-Preoccupied with fear
of being alone to care
for self
Avoidant -Timid, socially -Fears intimate -Gradually confront fears
uncomfortable, relationships due to fear of -Discuss feelings before
withdrawn ridicule and after accomplishing a
-Hypersensitive to -Believes self to be goal
criticism socially inept, -Teach assertiveness
-Avoids situations unappealing, or inferior -Increase exposure to
where rejection is a small groups
possibility
-Lacks self-confidence
O-C -Sets high personal -Difficulty expressing -Explore feelings
standards for self and warmth -Help with decision-
others -Rigid and controlling with making
-Preoccupied with others -Confront procrastination
rules, lists, -Perfectionism interferes and intellectualization
organization, details with task fulfillment -Teach that mistakes are
-Overconscientious acceptable
and inflexible
-Rigid and stubborn
-Cold affect, may
speak in monotone
-Indecisive until all
facts accumulated
MOOD / AFFECTIVE DISORDER
■ A group of disorders that involve disturbance in emotion, cognition, and behavior.

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■ Exists when emotional responses are exaggerated, prolonged, or interfere with normal
functioning.
■ Grief – considered a normal response to loss
□ Acute grieving can occur up to 3 months after significant loss
□ Resolution of grief is characterized by grieving person’s ability to remember comfortably
and realistically, both the pleasures and disappointments associated with loss.
□ Grief resolution can take up to 3 years
□ Loss of self-esteem in the grieving person – MOOD D/O
■ Depression – unhappiness that is pathologically intense
□ # 1 mental health problem in the US, common in women
□ an emotional state manifested by:
• sadness
• discouragement
• low self-esteem
• helplessness, hopelessness
• increased risk of suicide
■ Anaclitic depression (children) – deprived of a warm, close experience with another
person.
□ Changes in activity level, social relationship, eating, elimination and sleep patterns
□ Self-destructive behaviors
■ Adolescence – drug abuse, violence, sexually promiscuous behaviors, suicide
■ Mania – an emotional state manifested by:
□ Elevated mood
□ High optimism
□ Increased energy
□ Exaggerated sense of self-esteem
□ Maybe viewed as a reaction formation to underlying depression
Types Of Mood / Affective Disorders
1. NON-PSYCHOTIC D/O
A. CYCLOTHYMIC D/O
 Repeated periods of non-psychotic depression and
hypomania for at least 2 years (1 year for children and adolescents)
 Hypomania or mania is considered a defense (reaction
formation) against the painful experience of depression
 Opposing manifestations:
• Feelings of inadequacy (during depressed periods) and inflated self-
esteem (hypomanic periods)
• Uninhibited people-seeking and social withdrawal
• Sleeping too much and not sleeping enough
• Diminished productivity and increased productivity
B. DYSTHYMIC D/O
 Periods of chronic depression or loss of interest or pleasure in all or almost all usual
activities and past times
 Depressed mood must have been present for 2 years (irritable mood and 1 year for
children and adolescents)
 The chronic nature is a cause for concern because it may be accompanied by a
lifelong struggle against depression that can assume maladaptive forms
2. MAJOR AFFECTIVE D/O
A. BIPOLAR D/O
 One or more manic episodes, with or without subsequent
or alternating major depressive episodes
• Bipolar d/o, single episode – one or more manic episodes
or mixed episodes usually accompanied by major depressive episode
• Bipolar d/o, recurrent – one or more major depressive
episodes accompanied by at least 1 hypomanic episodes
 Most persons who have manic episodes eventually have a
major depressive episodes

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 Only 2% adults with depression have manic episodes
• Disoriented, incoherent
• Persecutory delusions, delusions of grandeur
• Flight of ideas
• Inappropriate dress; excessive makeup and jewelry
• Lacks inhibition
• Uses sarcastic, profane, and abusive language
• Quick tempered, agitated
• Talks excessively, jokes, dances, sings; hyperactive
• Can’t stop moving to eat, easily stimulated by environment
• No appetite
• Weight loss
• Insomnia
• Regressed behavior
• Sexually indiscreet, hypersexual
 Problems Among Bipolar D/O
• Easily stimulated by surroundings
• Aggressive and hostile due to poor self-esteem
• Denial
• Testing, manipulative, demanding behavior
• Superficial social relationship
B. MAJOR DEPRESSIVE D/O

 One or more recurrent major depressive episodes without signs of manic or
hypomanic behavior
 Symptoms usually develop over days to weeks (at least 2 weeks)
 Postpartum D – major depression occurring after childbirth
 Involutional melancholia – occurs around the 6th decade of life
 Agitated D – depressed patient who is agitated
 Retarded D – depressed patient who is almost inert
 Endogenous D – depression that seems to occur without any relationship to external
events
 Reactive / Exogenous D – the cause is evident from the client’s history
Etiology Factors
1. PSYCHOBIOLOGIC THEORY
 Neurotransmitter – serotonin, norephinephrine, dopamine (deficit – depression;
excess – mania)
 Genetic factors – familial tendencies
 Neuroendocrine factors – increase cortisol levels, decrease thyroid levels
 Electrolyte imbalance – increase intracellular Na and Ca
 Disturbances in normal circadian rhythms
 Medications – anxiolytics, antipsychotics, antiHPN, anticonvulsants, Ca channel
blockers, steroids
2. PSYCHOANALYTIC / PSYCHODYNAMIC THEORY
 Anger turned inward (Freud)
 Frustration of oral needs for love and gratification by mothering
figure
 Ambivalent relationship with love object – love and hate (produce
strong guilt feelings)
 Loss of loved object – associated with anger and aggression that
is turned inward on self leading to negative feelings
 Elation or grandiosity can be a defense against underlying
depression or feelings of low self-esteem
 Testing, manipulative behavior results from poor self-esteem
 Reality contact is less disturbed than schizophrenia
3. COGNITIVE THEORY

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 Negative way of thinking about self, future, environment leading to
negative cognitive triad (Beck)
• (-) feelings about self – unattractive, deprived, defeated,
incompetent
• (-) feelings about world – demanding and unyielding
• (-) feelings about future – hopeless, negative, involving failure
4. BEHAVIORAL THEORY
 Learned helplessness (Seligman)
 Passivity – failure to assert are rewarded by the environment
 Lack of (+) reinforcement
5. FAMILY THEORY
 Dysfunctional family patterns lead to child feeling an increased
stress to achieve unrealistic paternal expectations
6. TRANSACTIONAL MODEL
 Interactions of various factors
Depression:
1. Be alert for signs of self-destructive behavior.

2. Remove all potentially dangerous items.
3. Provide strong therapeutic relationship to increase self-worth.
a. Establish authoritative and credible matter-of-fact manner to increase confidence.
b. Place on one-to-one observation and stay with client to help control self-
destructive impulses.
c. Let the client know that the nurse will assist in seeking every possible resources
to ease troubles.
d. Relieve client’s feelings of embarrassment (e.g. “I see you’re upset. You are wise
to seek help.”)
4. Discuss all behavior with team members.
a. Note indirect clues as cry for help (e.g. presence of pills).
b. Observe for sudden increased energy level as indication of possible impending
suicide attempt.
c. Note increase in anxiety, insomnia.
5. Give client a sense of control that through suicide.
a. Assist with problem-solving and decision-making.
b. Develop and use a suicide contract.
c. Avoid excess support, as this encourages dependency and eventual feelings of
abandonment.
6. Provide family therapy where indicated.
a. Avoid taking client’s side as family is not direct cause of suicidal urge.
b. Look for scapegoating or acting out of family destructiveness.
7. Intervene quickly and calmly during actual attempts.
a. Remove the harmful objects from the client.
b. Stay by the client’s side and reassure the client that you are there to help.
c. Avoid judgmental remarks or interpretations (e.g. “Why did you do this?”).
8. Contract with patient.
a. “No suicide,” “No harm,” or “No self-injury” contracts are made between
psychiatric health care professionals and patients who are admitted to a psychiatric
unit with depression and/or suicide ideation or self-injurious acting-out.
b. Patients agree to contract staff if they have an impulse to be self-destructive.
c. Patient is asked to abide by the signed contract.
d. Patient is periodically reminded of the contract.
e. Limit-setting lets patient know that self-destructive acts are not permitted.
f. Staff members will do anything within power to prevent patient self-destruction.

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Bipolar:
1. Institute measures to deal with hyperactivity/agitation.

a. Simplify the environment and decrease environmental stimuli.
• Assign to a single room away from activity.
• Keep noise level low.
• Soft lighting.
b. Limit people
• Anticipate situations that will provoke or overstimulate client (e.g.
activities, competitive situations).
• Remove to quiet areas.
c. Distract and redirect energy.
• Choose activitie4s for brief attention span (e.g. chores, walks).
• Choose physical activities using large movements until acute
mania subsides (e.g. dance).
• Provide writing materials for busy work when acute mania
subsides (e.g. political suggestions, plans).
2. Provide external controls.
a. Assign one staff person to provide controls.
b. Do not encourage client when telling jokes or performing (eg. Avoid laughing).
c. Accompany client to room when hyperactivity is escalating.
d. Guard vigilantly against suicide as elation subsides and moods even out.
3. Institute measures to deal with manipulativeness.
a. Set limits (eg. Limit phone calls when excessive).
• Set firm consistent times for visits – client often late and unaware
of time.
• Refuse unreasonable demands (eg. Ask for date with the nurse).
• Explain restrictions on behavior and reasons so client does not
feel rejected.
b. Communicate using a firm, unambivalent consistent approach.
• Use staff consistency in enforcing rules.
• Remain nonjudgmental (eg. When client disrobes say, “I can’t
allow you to undress here.”).
• Never threaten or make comparisons to others, as it increases
hostility or poor coping.
c. Avoid long, complicated discussions.
• Use short sentences with specific straightforward responses.
• Avoid giving advice when solicited (eg. “I notice you want me to
take responsibility for your life.”).
4. Meet physical needs.
a. Meet nutritional needs.
• Encourage fluids; offer water every hour because client will not
take time to drink.
• Give high calorie finger foods (food on the run) and drinks to be
carried while moving (eg. Cupcakes, sandwiches).
• Serve meals on tray in client’s room when too stimulated.
b. Encourage rest.
• Sedate PRN.
• Encourage short snaps.
c. Supervise bathing routines when client plays with water or is too distracted to
clean self.
5. Administer medications (e.g. Lithium)
6. Help decrease denial and increase client’s awareness of feelings.
a. Encourage expression of real feelings through reflecting.
b. Help client acknowledge the need for help when denying it (eg. “You say you
don’t need love, but most people need love. It’s okay to feel that.”).
c. Function as role model for client by communicating feelings openly.

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d. Help client recognize demanding behavior, (eg. “You seem to want others to
notice you.”).
e. Encourage client to recognize needs of others.
f. Have client verbalize needs directly (eg. Wishes for attention).
RISK FACTORS ASSOCIATED WITH MOOD D/O AND SUICIDAL BEHAVIOR

RISK FACTORS MOOD D/O SUICIDAL BEHAVIOR
SEX D: twice as likely in W than M Increased risk in M
(2:1)
B: more likely in W than M
(1.2:1)
AGE Higher in younger W and older Increase with old age (adolescents
M make more attempts)
MARITAL STATUS Higher in married M and single Lower among married M/W
W
FAMILY HISTORY Higher among 1st degree Higher risk among family members
relatives of suicide victims
PRECIPITATION Birth in family within 6 months Increase with solitariness,
(RECENT LIFE Loss of significant others unemployment, recent loss, recent
EVENTS) Job problems surgery/childbirth, social disgrace
Separation / divorce
Physical illness
OTHERS Higher in fall / winter High risk with alcohol and drug
abuse
Increase with mood d/o
Suicide Risk Factors
S SEX
U UNSUCCESSFUL PREVIOUS ATTEMPTS
I IDENTIFICATION
C CHRONIC
I ILLNESS
D DRUGS / DEPRESSION
A AGE / ALCOHOL
L LETHALITY / LOSS
Behavioral Cues Of Impending Suicide
1. Any sudden change n patient’s behavior (more depressed/elated)

2. Becomes energetic after period of severe depression
3. Improved mood 10-14 days after taking antidepressant may mean sudden suicidal plans
made
4. Finalizes business or personal affairs
5. Gives away valuable possessions or pets
6. Withdraws from social activities and plans
7. Appears emotionally upset
8. Presence of weapons, razors, pills (means)
9. Has death plan
10. Leaves a note
11. Makes direct or indirect statements (e.g. “I may not be around then.”)
Understanding Self-destructive Behavior

 Attempts to cope fail, leaving the client with low self-esteem and feelings of
hopelessness and helplessness.
 Clients feel guilty and overwhelmed in response t precipitating event and may see
suicide as relief.
 Ambivalence about suicide may lead to cry for help or attention.

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 Aggression and rage turned toward self (introjection) or into an attempt to punish
others.
 Most common as depression is lifting:
• 10-14 days after antidepressant medication begun
• new signs of energy or improvement
Etiologic Factors in Suicide

1. BIOLOGIC
2. SOCIOLOGICAL
 Lack of purpose in life – egoistic suicide
 Sense social normlessness – anomic suicide
 Give up their lives for a greater good – altruistic suicide
3. PSYCHOANALYTIC
 2 basic drives
• eros – drive toward life
• thanatos – drive toward death
 when the death drive took precedence over the life drive
 occurs in response to the real or imagined loss of significant object – the iumage of
loved one, with al its concomitant feelings is internalized (anger with no outlet – turned
inward to self)
4. INTERPERSONAL
 Interpersonal discord which leads to conflict and ambivalence about continuing to live
Dynamics
 Perceive him/herself as isolated – actual physical distancing or as a feelings of
loneliness
 Hopeless, helpless, worthless – most predictive of suicide
 Emotional state is characterized by depression and anger
NURSING CONSIDERATIONS FOR ELECTROCONVULSIVE THERAPY (ECT)
1. Prepare patient by explaining procedure and telling the patient about potential temporary
memory loss and confusion.
2. Informed consent, physical exam, lab work
3. NPO after midnight for an early morning procedure
4. Have patient void before ECT
5. Remove dentures, glasses jewelry
6. Usually give muscle relaxant and short-acting anesthesia and barbiturates to prevent
fractures
7. Give Atropine 30 min before treatment to decrease secretions
8. Have oxygen and suction on hand
9. Position client in supine position with arms at the sides during convulsion
10. After procedure, take vital signs (BP, RR/respirations), orient patient
11. Observe patient’s reaction and stay with him
12. Signs of diminished depression appear after 6-12 treatments
13. Observe for sudden improvement and indications of suicidal threats after ECT
SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS
Three inescapable facts that should be taken into account by any effort to explain
schizophrenia:
■ The very high probability that will become clinically apparent in the late adolescence or
early childhood;
■ The role of “stress” in onset and relapse; and
■ The therapeutic efficacy of neuroleptic drugs.
Psychosis – is severe ego dysfunction. It is a disruptive mental state in which an individual

struggles to distinguish the external world from his internally generated perceptions.

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Schizophrenia
 Characterized by a weak ego and a deteriorating personality; one of the
most profound disabling illness.
 Characterized by disturbance in thought and sensory perception
(hallucination, delusion), thought d/o, and by a deterioration in psychosocial function.
 Defense mechanisms used:
 Regression
 Depersonalization
 Projection
 Denial
 Fantasy
 Affects men and women equally (men have usually an earlier age onset
by about 4-6 years)
Sex-Based Differences in Schizophrenia

 Women have later onset.
 Women have a less severe course of illness.
 Women are prescribed 60% of all antipsychotic drugs.
 Thirty (30%) percent of all antipsychotics are prescribed to women during
childbearing years (20-50).
 Dopamine receptor decline is slower in women.
 Women have less cerebral lateralization (may confer greater brain
resilience).
 Women tend to have more positive symptoms and fewer negative
symptoms than men.
 Estrogen modulates dopaminergic functions and may play a role for
women.
 Women have fewer structural brain abnormalities.
 Women have a better response to lower dose of conventional
antipsychotic drugs.
(Promedia Research Center, Women and Schizophrenia, 1997)
 Morel – 1st to name the psychiatric symptoms of schizophrenia –

dementia praecox (1856)
 Kahlbaum – catatonia (1868)
 Hecker – hebephrenia (1870)
 Kraeplin – paranoia (1902)
 Blueler – schizophrenia (early 1990)
 Does not always follow a course of deterioration (dementia was inappropriate)
 Does not always occur early in life (praecox was inappropriate)
 Focused on symptoms rather than outcome
 4 A’s symptom
• affective disturbance – inappropriate, ,blunted, or flattened
• autism – preoccupation with the self with little concern for
external reality
• associative looseness – the stringing together of unrelated
topics
• ambivalence – simultaneously opposite feelings
Criteria for Schizophrenia

1. Characteristic symptoms (at least 2 of the ff):
• delusions
• hallucinations
• disorganized speech
• grossly disorganized behavior
• negative symptoms

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2. Social / occupational dysfunction – work, interpersonal, self-are functioning is
below the level achieved prior to onset
3. Duration – continuous signs of the disturbance for at least 6 months
4. Schizoaffective and mood d/o are not present and are not responsible for the
symptoms
5. Not caused by substance abuse or a general medical condition
Subtypes of Schizophrenia
1. PARANOID
• Preoccupation with one or more delusions (persecution and
grandiosity, and ideas of reference) or frequent auditory hallucinations
• None of the ff is prominent:
o Disorganized speech
o Disorganized behavior
o Flat or inappropriate affect
o Catatonic behavior
2. DISORGANIZED/HEBEPHRENIC
• Most severe form.
• Patients are unable to transform from adolescence to maturity.
• All of the ff are prominent:
o Disorganized behavior
o Flat or inappropriate affect
3. CATATONIC
• May be completely immobile or move all the place.
• At least 2 of the ff:
o Motoric immobility, waxy flexibility or stupor
o Excessive motor activity (purposeless)
o Extreme negativism or mutism
o Peculiar movement, stereotypy of movement, prominent mannerism, or
prominent grimacing
o Echolalia or echopraxia
4. UNDIFFERENTIATED
• Characteristic symptoms (at least 2 of the ff):
o Delusions
o Hallucinations
o Grossly disorganized behavior
o Negative symptoms
• But criteria for paranoid, catatonic, or disorganized subtypes are not met
5. RESIDUAL
• Delusions, Hallucinations, Disorganized speech, Grossly disorganized behavior,
and Negative symptoms are no longer present
• Criteria for paranoid, catatonic, or disorganized subtypes are not met
• There is continuing evidence of disturbance such as the presence of negative
symptoms or criterion A symptom in an attenuated form (odd beliefs, unusual
perception experiences).

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OBEJCTIVE AND SUBJECTIVE BEHAVIORAL D/O IN SCHIZOPHRENIA

OBJECTIVE SUBJECTIVE
Alterations in Personal Relationship Altered Perception
• Decreased attention to appearance • Hallucination
and social amenities related to • Illusion
introspection and autism • Paranoid thinking
• Inadequate or inappropriate Altered Thought
communication • Flight of ideas
• Hostility • Retardation
• Withdrawal • Blocking
• Autism
• Ambivalence
• Loose associations
• Delusion
• Poverty of speech
• Ideas of reference
• Mutism
Alterations in Activity Altered Consciousness
• Psychomotor agitation • Confusion
• Catatonic rigidity • Incoherent speech
• Echopraxia • Clouding
• Stereotypy (persistent repetition of • Sense of “going crazy”
senseless acts or words) Alterations in Affect
• Inappropriate, blunted, flattened, or
labile affect
• Apathy
• Ambivalence
• Anhedonia
Subtypes According to Symptoms

1. Type 1 – Positive Symptoms
• Symptoms are embellishment of normal cognition and perception.
• Believed to be caused by subcortical dopaminergic process affecting cortical areas (too
much dopamine).
2. Type 2 – Negative Symptoms
• Essentially an absence or diminution of what should be.
• Maybe hypodopaminergic process and also caused by cortical structural changes
(cerebral atrophy).
Etiologic Factors
1. BIOLOGIC FACTORS
 Biochemical Influences
 PET (positron emission tomography) produces slice images of radioisotope
density which have indicated relative metabolic underactivity of one frontal lobe of
schizophrenia.
 Decreased activity in the basal ganglia – can be reversed with neuroleptic
treatment.

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 Hallucinations have been correlated with accelerated glucose metabolism in the
left temporal lobe.
 EEG has shown:
• Increased delta activity in the frontal lobe, corresponding to decreased
glucose and blood activity,
• An overactivity of dopamine or insufficiency of norepinephrine at certain
control synapses of the brain,
• An imbalance between 2 substances that could be among the biological
factors present in schizophrenia.
 Genetic Influences
 A higher incidence occurs in the relatives of schizophrenic than in general
population
• 40% if both parents
• 40-50% risk in twins
• 10-15% if only one parent
• 1% of the population
 Monozygotic twins have higher incidence than dizygotic.
 Neurostructural factors – CT and MRI structural abnormalities – enlarged lateral
ventricles, enlarged 3rd ventricles, asymmetries and cortical atrophy)
 Perinatal risk factors – prenatal exposure to influenza, minor malformations
developing during early gestation, and complications of pregnancy particularly labor
and delivery.
 Autoimmune
 When the body’s immune system attacks itself.
 Viral Infection
 Viral infection during pregnancy could also trigger genetic vulnerability.
2. PSYCHODYNAMIC FACTORS
• Focus on the individual’s response to life events.
a. Developmental Theories
 Adolf Meyer (real life events) and Sigmund Freud
(mental processes, unconscious forces that influence the individual) believed that the
seeds of mental health and illness are shown in childhood.
 Erikson – trust vs mistrust is critical to later IPR
 Sullivan – absence of warm, nurturing attention
during early years block the expression of those same affective responses in later
years.
b. Family Theories
 Lack of a loving and nurturing primary caregiver, inconsistent family behaviors, and
faulty communication patterns are thought to be responsible for mental problems in
later life.
 Poor mother child relationship. A schizophrenic mother who is distant, cold and
unfeeling and who provided inadequate care cause the symptoms of schizophrenia.
 Double-bind communication. Two messages that contradict each other is send
causing the child to be confused on what action to engage which immobilizes the
child resulting to anxiety.
c. Vulnerability – Stress Model
 Both biological and psychodynamic predispositions to schizophrenia, when coupled
with stressful life events, can precipitate schizophrenic process.
3. BEHAVIORAL /LEARNING THEORY – psychotic behavior is learned as a result of
reinforcement failures – child does not receive reinforcement for appropriate behavior.
 DISRUPTIVE BEHAVIORS
 Set limits on disruptive behaviors.
 Decrease environmental stimuli.
 Frequently observe escalating patients in order to intervene.
 Modify the environment to minimize objects that can be viewed as a weapon.

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 Be careful in stating what the staff will do if patients act out; however, follow through
once a violation occurs.
 When using restraints, provide for safety by evaluating the patient’s status of
hydration, nutrition, elimination, and circulation.
 WITHDRAWN BEHAVIORS
 Arrange non-threatening activities that involve these patients in “doing something.”
 Arrange furniture in a semicircle or around a table so that patients are forced to sit
with someone. Interactions are permitted in this situation but should not be demanded.
 Help patients to participate in decision making as appropriate.
 Provide patients with opportunities for non-threatening socialization with the nurse on
a one-to-one basis.
 Reinforce appropriate grooming and hygiene.
 Provide remotivation and resocialization group experiences.
 Provide psychosocial rehabilitation (trainingin community living, social skills, and
health care skills).
 SUSPICIOUS BEHAVIORS
 Be matter-of-fact in interacting with these patients.
 Staff members should not laugh or whisper around patients unless the patient can
hear what it said.
 Do not touch suspicious patients without warning. Avoid close physical contact.
 Be consistent in activities.
 Patients who fear being poisoned should be allowed to open a can of food and sere
themselves.
 Maintain eye contact.
 Do not slip medications into juices or foods without talking to patients.
 PATIENTS WITH IMPAIRED COMMUNICATION
 Provide opportunities for patients to make simple decisions.
 Be patient and do not pressure patients to make sense.
 Do not place patients in group activities that would frustrate them, damage their self-
esteem, or overtax their abilities.
 Provide opportunities for purposeful psychomotor activity (painting, exercise, gross
motor game)
 PATIENTS WITH DISORDERED PERCEPTIONS
 Attempt to provide distracting activities.
 Discourage situations in which patients talk to others about their disordered
perceptions.
 Monitor TV selections (horror movies).
 Monitor for command hallucinations that may increase the potential for patients to
become dangerous.
 Have staff members available in the dayroom so that patients can talk to real people
about real people/events.
 DISORGANIZED BEHAVIORS
 Remove disorganized patients to a less stimulating environment.
 Provide a calm environment; the staff should appear calm.
 Provide safe and relatively simple activities for these patients.
 Provide information boards with schedules and refer them often so patients can
begin to use this as an orienting function.
 Help protect each patient’s elf-esteem by intervening if a patient does something that
is embarrassing.
 Assist with grooming and hygiene.
 PATIENTS WITH ALRETED LEVELS OF ACTIVITY
 Hyperactivity
 Allow patients to stand for a few minutes during group meetings.
 Provide a safe environment and a place where patients can pace without inordinately
bothering other patients.

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 Encourage participation in activities or games that do not require fine motor skills or
intense concentration.
 Immobility
 Provide nursing care for catatonic or immobile patients in order to minimize
circulatory problems and loss of muscle tone.
 Maintain bowel and bladder function and intervene before problems arise.
 Observe patients to prevent victimization (physical or verbal) by others.
OTHER PSYCHOTIC DISORDERS
1. SCHIZOAFFECTIVE D/O
 Characterized by both affective and schizophrenic symptoms with substantial
loss of occupational and social functioning.
 Uninterrupted periods of illness during which at some time, there is major
depressive, manic, or mixed episode concurrent with symptoms that meet criterion A
for schizophrenia.
 Schizophrenic symptoms are dominant but are accompanied by major
depressive or manic symptoms.
 Substance abuse or a general medical condition must be ruled out before the
diagnosis.
 Probably occurs more often in women.
2. DELUSIONAL D/O
 Delusions have a basis in reality.
 The patients have never met the criteria for schizophrenia.
 The behavior of these patients is relatively normal except in relation to their
delusions.
 If mood episodes have occurred concurrently with delusions, their total duration
have been relatively brief.
 The symptoms are due directly to a substance abuse or to a medical condition.
 Subtypes:
• Erotomanic
o The patient believes that another person is in love with him.
o Efforts to contact the object of the delusion through telephone calls,
letters, surveillance, or stalking are common.
• Grandiose
o The patient believes he has a great talent or has made an important
discovery.
• Jealous
o The patient believes that his spouse or lover is unfaithful.
o This belief is based on an incorrect inferences supported by dubious
evidence.
• Persecutory
o The patient believes that he is being plotted against, spied on, maligned,
or harassed.
• Somatic
o The patient believes he has a physical deformity, odor, or parasite.
3. BRIEF PSYCHOTIC D/O
 Psychotic disturbances that last less than 1 month and are not related to a mood d/o,
a general medical condition, or a substance induced d/o.
 At least one of the ff:
 Delusions
 Hallucinations
 Disorganized speech
 Grossly or catatonic behavior
4. SCHIZOPHRENIFORM D/O
 Symptoms typical of schizophrenia and last at least 1 month but not longer than 6
months
 Good prognosis:

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 Onset of psychotic symptoms within 4 weeks of the initial change in behavior
 Confusion at the height of the psychotic episode.
 Absence of a flat affect.
 History of good social and occupational functioning prior to the occurrence
COGNITIVE DISORDERS
(Organic Brain Syndrome, Organic Mental D/O, Organic Mental Syndrome)
DIFFERENCES BETWEEN DELIRIUM AND DEMENTIA

FEATURE DELIRIUM DEMENTIA
Onset Acute, often at night Insidious
Course Fluctuating, with lucid intervals, Stable over course of day
during day; worse at night
Duration Hours to weeks Months or years
Awareness Reduced Clear
Alertness Abnormally low or high Usually normal
Attention Lacks direction and selectivity; Relatively unaffected
distractibility; fluctuates over
course of day
Orientation Usually impaired for time, Often impaired
tendency to mistake unfamiliar for
familiar place and persons
Memory Immediate and recent memory Recent and remote memory
impairments impairments
Thinking Disorganized Impoverished
Perception Illusions and hallucinations Often absent
(usually visual) are common)
Speech Incoherent, hesitant, slow or rapid Difficulty in finding words
Sleep-wake cycle Always disrupted Fragmented sleep
Physical illness or Either or both present Often absent, esp in AD
drug toxicity
ALZHEIMER’S DISEASE
 Age-related progressive d/o of the CNS characterized by chronic cognitive dysfunction.

 Alois Alzheimer, a German Neuropathologist, 1st described the condition.
 Revealed brain atrophy and are now referred as neurofibrillary tangles.
4 AA’ of Alzheimer’s Disease (AD)

a. AMNESIA – inability to learn new information or to recall
previously learned information.
b. AGNOSIA – failure to recognize or identify objects despite intact
sensory function.
c. APHASIA – language disturbance that can manifest in both
understanding and expressing the spoken word.
d. APRAXIA – inability to carry out motor activities despite intact
motor function (ability to grab a doorknob but not knowing what to do with it).
Impairment In Activities Of Daily Living (ADL) Based On The Stage Of AD
Mild Impairment Difficulty with balancing a checkbook, preparing complex meal,

managing a difficult medical schedule.
Moderate Impairment Difficulty with simple food preparation, household cleanup, yard
work, some aspects of self-care (remind to use the bathroom,
help with fasters, help with shaving).
Severe Impairment Needs considerable assistance with personal care, feeding,
grooming, toileting.
Profound Impairment Patient is oblivious to surroundings and almost totally dependent

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on caregivers.
Terminal Phase Patient is bed-bound, requiring constant care.
Behavioral Symptoms Associated with AD

 Hallucinations
 Delusions
 Dysphoria and depression
 Fearfulness
 Repetitive purposeless acts
 Avoidance behavior
 Motor restlessness
 Apathy
 Verbal and physical aggression
 Resistance to interventions – nutrition, hygiene, safety
Key Nursing Interventions to Wandering

Possible Causes for Wandering Interventions
 Confusion  Safety first.
 Restlessness  Identification
 Boredom  Medic alert bracelets
 Need for exercise  Motion or sound detectors
 Alternative outlet for energy
 Medications
SEXUAL DISORDERS
 Sexual activity may focus on objects or people.

 It is unacceptable legally when it involves a non-consenting individual, a child, or the use
of objects in a way that could interfere with healthy relationships.
 It in unacceptable morally when it violates the norms, standards, and values of the
culture.
Categories of Sexual Disorders
SEXUAL DYSFUNCTIONS
 Characterized by the inhibition of sexual appetite or psychological changes that
compromise the sexual response cycle.
4 Phases of the Sexual Response Cycle

 Desire
 Excitement
 Orgasm
 Resolution
1. SEXUAL DESIRE DISORDERS

 Little or no desire or have an aversion to sexual contact.
 It effectively stops the sexual response cycle from beginning.
2. SEXUAL AROUSAL DISORDERS

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 Individuals cannot maintain requirements for sexual intercourse (women cannot
maintain the lubrication response of sexual excitement; men cannot maintain an
erection- impotence).
3. ORGASM DISORDERS
 Individuals cannot complete the sexual response cycle because of the inability to
achieve an orgasm (e.g. premature ejaculation).
 It arrests the cycle in the orgasm phase.
4. SEXUAL PAIN DISORDERS
 Individuals suffer genital pain (dyspareunias) before, during, or after sexual
intercourse (e.g. vaginismus – involuntary spasm of the outer third of the vagina).
 This abort the sexual response cycle at any time.
PARAPHILIAS
 A condition in which the sexual instinct is expressed in ways that are socially prohibited
or unacceptable or are biologically undesirable.
 Characterized by intense sexual urges focused on:
 Nonhuman objects
 The suffering or humiliation of oneself or one’s partner
 Children or other non-consenting persons
 Lasts over a period of 6 months
 Can cause distress or impairment in social, occupational, or other important areas of
functioning.
 Paraphiliac behaviors may increase with symptoms of depression.
■ Characteristics of a paraphiliac person.

□ Emotional immaturity
□ Fear of sexual relationship that could result in rejection
□ Shyness
□ The need to prove masculinity, demonstrated by the exhibitionist
□ The need to inflict pain on another to achieve sexual satisfaction
□ The need to endure pain to achieve sexual satisfaction
□ Low or poor self-concept
□ Depression
1. EXHIBITIONISM
 Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
involving exposing one’s genitals to unsuspecting strangers.
 They are stimulated by the effect of shocking his victims.
 Emotional conflict and excessive free time may stimulate exhibitionist activity.
2. FETISHISM
 Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors using
nonliving or inanimate objects (bras, underpants, stockings, and shoes).
 Less common fetish objects include urine-soaked and feces-smeared items.
 The individual often masturbates while holding or rubbing these items.
3. FROTTEURISM
 Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors
involving touching and rubbing against a non-consenting person or buttocks.
 May also attempt to fondle on the person’s breasts or genitals.
 Usually occurs in crowded places where escape into the crowd is possible.
4. PEDOPHILIA
 Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors that
involve sexual activity with a child or children generally 13 years of age or younger.
 The person is at least 16 years of age and at least 5 years older than the
child/children involved.
 Subtypes:
 Ephebophilia – when the victim is his post-pubertal age (sexual arousal is
achieved by looking than touching genital contact.
 Exclusive pedophilia – attracted to children

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 Non-exclusive pedophilia – attracted to adults
 Predatory pedophilia – uses force and threatens to do harm to a child or his pet if
they try to disclose the sexual relationship
 Reported characteristic personality:
 Shyness
 Sensitivity, and isolation in social situations
 Low self-esteem
 Dependency
 Depression
 Low self-confidence
 Use of alcohol and drug
 History of being sexually abused.
 In order to compensate for feelings of powerlessness, the pedophile may need to
feel power over the victim through control and domination.
 Pedophile may seek occupation that provides easy access to children (teaching
school, working in day care setting, coaching, or scout leadership).
 Pedophilic behavior can be expressed for opposite sex children, same sex
children, or both.
 Can also be limited to incest.
 Fondling ad oral sex are typical pedophilic behaviors.
5. INCEST
 Pedophilia with child relatives.
 Involves relationship by blood, marriage (step parents), or live-in partners.
 Families in which incest occurs are generally disorganized and exhibit
disturbed relationships.
 Sex is always involved between the perpetrator and the victim, but the
perpetrator turns to the child for gratification, intimacy, emotional fulfillment, power,
and control.
6. SEXUAL MASOCHISM
 Recurrent intense sexually arousing fantasies, sexual urges, or behaviors
involving the act of being humiliated, beaten, restrained, or otherwise made to suffer.
 Hypoxyphilia is the act of enhancing sexual arousal by strangulation or other
oxygen-depleting activity.
7. SEXUAL SADISM
 Recurrent intense sexually arousing fantasies, sexual urges, or behaviors
involving acts in which the psychological or physical suffering of the victim is sexually
exciting to the person.
 Partners can be consenting or masochistic.
 Behaviors include spanking, whipping, pinching, beating, burning, and
restraining.
8. VOYEURISM
 Act of observing an unsuspecting person who is naked, in the process of
disrobing, or engaging in sexual activity.
 Commonly referred as a “peeping Tom.”
 May masturbate during peeping or upon returning home.
9. NECROPHILIA
 Sexual gratification is obtained from engaging in a sexual relation with a corpse.
10. TELEPHONE SCATOLOGIA
 Sexual gratification from or during lewdness on the phone.
11. ZOOPHILIA
 Involves intense sexual arousal or desire for sexual contact with animals.
12. BESTIALITY
 Sexual contact with animals.
GENDER IDENTITY DISORDERS

 Characterized by discomfort with one’s biological sex or the desire to have the
characteristics of the other sex.

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 Individuals believe that they were born as the wrong sex, and they desire
hormones and surgery to become the opposite sex.
 Can include the desire to live as the other sex or can involve feelings and
reactions of the other sex.
 Preoccupied with getting rid of the primary or secondary sexual characteristics.
 Also called transexualism.
 CORE GENDER IDENTITY
 A subjective sense of knowing to which gender one belongs.
 GENDER IDENTITY
 An inner sense of masculinity or femininity.
 GENDER ROLE
 An outward behavior of a person of being a male or female.
 Criteria:
 A strong and persistent cross-gender identification:
 In children:
• Stated desire or intense that he or she is the other sex.
• In boys, dressing in female attire; in girls, wearing only masculine clothing.
• Make believe play or fantasies of being the other sex,
• Desire to participate in games and past times of other sex.
• Prefers playmates of other sex.
 In adolescents and adults:
• Stated desire to be the other sex.
• Frequently passes as the other sex.
• Desires to be treated as the other sex.
• Conviction that he/she has typical feelings and reactions of other sex.
 Feelings of discomfort with own sex or inappropriateness in gender role of own
sex.
 Procedures prior to sexual reassignment surgery (SRS):
 The individual must be thoroughly assessed for the presence of other psychiatric
disorders that could involve problems with gender identity.
 He/she is generally placed on psychotherapy for 6 – 12 months.
 Some gender identity program requires a written second opinion fro another
physician or psychologist before proceeding with surgical reassignment.
 Hormonal treatment, and living and relationship changes, are slowly made over
months while the individual is in therapy.
 During this time, the individual’s attitudes toward SRS may change and is not
chosen.
 Those who do chose surgery can be helped to live more comfortable and
productive lives.
■ What are the basic principles of doing a sexual assessment.

□ Be comfortable and at ease with the client.
□ Present an open and accepting attitude.
□ Be empathetic.
□ Avoid personal values and biases during the interview.
□ Establish a thorough knowledge base.
□ Establish familiar terminology with the client.
□ Support the expression of feelings and validate them.
□ Ask specific, open-ended questions.
□ Approach emotional or more sensitive questions gradually.
□ Progress from how information was learned, to attitudes, then behavior.
□ State that certain sexual behaviors are common before asking questions about them.
 The nurse must have an accepting, emphatic, and no-judgmental attitude if
patients are to be comfortable enough to disclose problems with sexuality.
 The nurse must accept his/her feelings related to sexuality.

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 A private area to discuss fears or concerns about sexuality and victimization
helps the patients to disclose and discuss their feelings.
 Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for victims.
 The nurse is legally obligated to report suspected and actual sexual abuse of
children to police and/or appropriate agencies.
 Referral of patients.
Psychopharmacology
 Men with paraphilias can be treated with agents to lower testosterone levels,
which reduces their sex drive.
 Antiandrogen therapy with oral and parenteral preparations has been shown to
reduce recidivism in male sexual aggression.
 The use of selective serotonin reuptake inhibitors (SSRIs), including
Fluoxetine (Prozac) and sertraline (Soloft) are being used for paraphiliacs and related
disorders.
 As the activity of serotonin increases, sexual appetite decreases along with
depression and anxiety, which often accompany these disorders.
SUBSTANCE-RELATED DISORDERS
Substance Abuse
 1/3 – ½ of all patients undergoing psychiatric treatment abuser alcohol and/or
drugs.
 Alcoholics have a death rate 2-4x higher than non-alcoholics.
 Cirrhosis, the 10th leading cause of death, other medical problems, homicides,
and suicides are directly related to alcohol use.
CRITERIA FOR SUBSTANCE-RELATED DISORDERS
Substance Dependence
 Maladaptive pattern of substance use as manifested by 3 or more of the following:
 Tolerance
 Withdrawal
 A need for more of the substance than was intended
 Inability to stop using even when wanting to do so
 A great deal of time is spent in acquiring the substance or in recovering from its
effect
 Substance use causes social, occupational, or recreational problems
 Continued using use despite knowledge that the substance is causing physical or
psychological problems
Substance Use
 Maladaptive pattern of substance use leading to clinically significant impairment or
distress as manifested by one or more of the following:
 Failure to fulfill major role obligations at work, school, or home
 Recurrent substance use in hazardous situations
 Recurrent substance-related legal problems
 Continued substance use despite problems
 Has never met the criteria for substance dependence of this class of substance
Substance Intoxication
 The development of a substance-specific syndrome due to a recent ingestion of a
substance
 Clinically significant maladaptive behavioral or psychological changes due to the effect
of the substance on the CNS
 Not due to a general medical condition and not better accounted for by another mental
disorder

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Substance Withdrawal
 The development of a substance-specific syndrome due to the cessation of or reduction
in the intake of a substance
 The substance-specific syndrome causes clinically significant distress or impairment
 Not due to a general medical condition and not better accounted for by a medical
condition
ABUSED SUBSTANCES
ALCOHOL ABUSE
 Alcoholics have a death rate 2-4 times higher than nonalcoholics.

 Approximately 98,000 deaths each year are directly related to alcohol.
 Cirrhosis. The 10th leading cause of death, other medical problems, homicides
(50% alcohol related), and suicides (25% alcohol related) are directly linked to
alcohol use.
 Accidental deaths such as motor vehicle accidents (50% alcohol related), fires
and burns (47% alcohol related), drownings (34% alcohol related), and falls (28%
alcohol related) are examples of the different ways alcohol is lethal.
Etiologic Theories
1. Psychodynamic Theories
 Dependents are viewed as individuals who easily succumb to the escape
provided by alcohol.
 Alcohol dependents have strong oral tendencies related to unresolved needs for
early attachments.
 Attempt to satisfy unconscious oral needs.
 Stereotypical characteristics resulting from being alcohol dependents:
 Dependency
 Low self-esteem
 Passivity
 Introversion
2. Biologic Theories
 Hereditary – children of alcoholic parents, even if raised in an alcohol-free environment
are more likely to become alcoholics.
Pharmacokinetics of Alcohol
Metabolism
 Chemical name – ethanol (CH3CH2OH).
 Primarily metabolized in the liver.
 At each step of the metabolizing process an enzyme breaks down the chemical.
 Enthanol is broken down by alcohol dehydrogenase to acetaldehyde and hydrogen.
 The hydrogen molecule causes the liver to bypass normal energy sources (the hydrogen
from fat) and to use the hydrogen from ethanol.
 Fat accumulates and leads to fatty liver, hyperlipemia, hepatitis, and cirrhosis.
 If the metabolism of acetaldehyde is impaired, it accumulates in the liver, causing cell
death and necrosis.
 Liver cell loss contributes to cirrhosis.
 Acetaldehyde also interferes with vitamin activation.
 Aldehyde dehydrogenase breaks down acetaldehyde to acetic acid, which is an
innocuous substance.

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 When enzymatic action on acetaldehyde is blocked by the aldehyde dehydrogenase
blocker disulfiram (Antabuse), acetaldehyde accumulates, causing severe sickness.
Absorption
 It is absorbed partially from the stomach but mostly from the small intestine.
 If it is ingested by a person with an empty stomach, it is the bloodstream within 20
minutes.
 Alcohol in beer and wine is absorbed more slowly than alcohol in liquor.
 Ethanol content of the following:
 Beer - 4%
 Wine - 12%
 Whiskey – 40-50%
 Alcohol affects the cerebrum and cerebellum before it affects the spinal cord and the
vital centers because the former areas contain more water.
 The rate of absorption largely determines how quickly a person will be intoxicated,
but one’s metabolic rate largely determines how long alcohol will affect the body.
 Tolerance to alcohol occurs and is probably related to elevated hepatic enzymes and
to cellular adaptation.
Physiological Effects
 Disinhibition, impaired judgment, and fuzzy thinking are initial responses to alcohol
ingestion. These signs represents cerebrum intoxication.
 Also depresses psychomotor activity.
 Alcohol has been described as a social lubricant because it relaxes self-imposed
barriers that inhibit sociability.
 Anxiety and tension are relieved, usually for a couple of hours after a drink is taken.
 Eventually, alcoholics drink to avoid the effects of many years of drinking. For instance,
once the anxiety-reducing effect wears off, more tension and anxiety are caused, so the
drinker must consume more alcohol to regain the “anxiety-free” state.
 The presenting complaint of those who seek treatment for alcohol dependence is
nervousness or depression.
Adverse Effects
 CNS effects are related to sedation and toxicity.
 As the vital centers become affected, a slowed stuporous-to-unconscious mental
state develops.
 Large amount can cause sleep, coma, deep anesthesia, and death.
 Common symptoms of intoxication include slurred speech, short attention span,
loud talk, and memory deficit.
 Blackout is a period in which the drinker functions socially but for which the
drinker has no memory.
 Alcohol-withdrawal syndrome is the increased psychomotor activity as a
consequence of alcohol.
 Sedation is the predominant effect of alcohol, but as sedation wears off,
psychomotor activity increases. This is referred as a rebound phenomenon.
 As the CNS becomes more irritated, the normal drinker feels sick and irritable (a
hangover) but lives through it, perhaps vowing “never again.”
 Alcohol hallucinosis, a state of auditory hallucinations, is a phenomenon that alcohol-
dependent people can sometimes experience. The brain begin to “invent” sensory input.
This usually begins 48 hours or so after drinking has stopped.
 The ultimate level of CNS irritability is delirium tremens (DT).
 The body not only invents sensory input but has also extreme motor agitation.
 Hallucination become visual, and the sufferer is tremulous and terrified.
 Tonic-clonic seizures can occur.
 Wernicke-Korsakoff syndrome is a mental disorder characterized by amnesia,
clouding of consciousness, confabulation and memory loss, and peripheral neuropathy.
This results form the poor nutrition of the alcoholic (specifically, inadequate amounts of
thiamine and niacin in the diet) and from the neurotoxic nature of alcohol.

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 PNS
 Cirrhosis and peripheral neuritis are the physical health problems most commonly
associated with alcohol
 Cirrhosis:
 Obstructed blood flow (portal HPN, ascites, and finally esophageal varices)
 Decreased liver cell function
 Low serum albumin levels
 High ammonia and high bilirubin serum levels
 Clotting problems
 Peripheral neuritis:
 Numbness and subsequent injury in the legs
 Changes in gait
 Alcohol is an irritant.
 It burns the mouth and throat and prompts the stomach to secrete more
hydrochloric acid.
 Alcoholics can experience ulcers, gastritis, bleeding, and hemorrhage in the
stomach.
 Malabsorption syndrome is caused by irritation of the intestinal lining.
 Affects B vitamins and lead to a deficiency of vitamin B1 in particular which
contributes to peripheral neuritis.
 Alcohol has a direct effect on muscle tissue, a condition known as alcoholic myopathy.
 Other organs affected:
 Eyes – loss of peripheral and night vision
 Heart – HPN, enlarged left ventricle
 Reproductive organs – impotence, testicles shrink and decreases testosterone
Overdose
 Depress CNS
 Vital centers become anesthesized compromising breathing and heart rate and leading
to a comatose state or death.
 DISULFIRAM (ANTABUSE)
 Inhibits the breakdown of acetaldehyde by the enzyme aldehyde
dehydrogenase.
 Because acetaldehyde is toxic to the body, alcoholics while taking disulfiram will
become ill (sweating, flushing, of the face and neck, tachycardia, hypotension,
throbbing, headache (HA), nausea and vomiting (n & v), palpitations, dyspnea,
tremor, and/or weakness).
 The unpleasant responses to alcohol is intended to help reinforce the alcoholic’s
effort to stop drinking alcohol.
 Disulfiram is usually started to with a single 500 mg dose at bedtime.
 After 1-2 weeks, the dose is reduced to maintenance dose of 250mg/day.
 It is most effective in patients with significant motivation for long-term change.
Fetal Alcohol Syndrome (FAS)

 Pregnant women who drink alcohol run the risk of seriously harming their unborn child.
FAS is the result of alcohol’s inhibiting fetal development during the 1st trimester.
 FAS is the 3rd mot common cause of mental retardation and the only one that is
preventable.
 Characteristic sign – microcephaly and an associated severe mental retardation.
Withdrawal and Detoxification
 Withdrawal from alcohol can be painful, scary and even lethal.
 As the person begins to abstain from alcohol, he/she begins to reap the consequences
of the CNS irritation:
 Tremulousness
 Nervousness
 Anxiety
 Anorexia

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 n&v
 insomnia and other sleep disturbances
 rapid pulse
 high BP
 profuse perspiration
 diarrhea
 fever
 unsteady gait
 difficulty concentrating
 exaggerated startle reflex
 a craving for alcohol or other drugs.
 As the withdrawal symptoms become more pronounced, hallucinations can occur.
 3 S’s of detoxification:
 Secure environment
 Sedation – chlordiazepoxide (librium) 50-100mg
 Supplement – multivitamin, b-complex, vit c, ca, and mg
POTENTIAL ALCOHOL INTOXICATION
ASSESSMENT POTENTIAL NURSING NURSING
DIAGNOSIS CONSIDERATIONS
-Drowsiness -Risk for injury -Monitor VS frequently
-Slurred speech -Allow patient to “sleep it off”
-Tremor -Protect airway from aspiration
-Impaired thinking/memory loss due to vomiting
-Nystagmus -Assess need for IV glucose
-Diminished reflexes -Assess for injuries
-Nausea/vomiting -Assess for signs of withdrawal
-Possible hypoglycemia and chronic alcohol
-Increased respiration dependence
-Belligerence/grandiosity -Counsel about alcohol use
-Loss of inhibitions -Potential problems of alcohol
-Depression poisoning and CNS
depression
ALCOHOL WITHDRAWAL
WITHDRAWAL DELIRIUM NURSING
CONSIDERATIONS
-Tremors -Tremors -Administer sedation as
-Easily startled -Anxiety needed, usu benzodiazepines
-Insomnia -Panic -Monitor VS, particularly BP,
-Anxiety -Disorientation, confusion pulse, temp
-Anorexia -Hallucination -Seizure precaution
-Alcohol hallucinations -Vomiting -Provide quiet, well-lit
-Diarrhea environment
-Paranoia -Orient patient frequently
-Delusional symptoms -Don’t leave hallucinating,
-Ideas of reference confused patient alone
-Suicide attempts -Administer anticonvulsants as
-Grand mal convulsions (esp needed
1st 40 hrs after withdrawal) -Administer IV glucose as
-Potential coma/death needed
-100% mortality rate
COURSES OF WITHDRAWAL FROM ADDICTIVE DRUGS

DRUGS LENGTH OF COMMON DETOX WITHDRAWAL S/Sx
ACUTE DETOX AGENTS
CNS
DEPRESSANTS
Alcohol 3-5 days Librium, Serax, Anxiety, sweat,

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Valium, Vistaril, tremors, flushed
Alcohol* face, irritability,
Valium slow drug taper, up Librium, Valium sleeplessness,
to 2 weeks Librium, confusion, seizures,
Phenobarbital slow drug taper, 2 to Phenobarbital delirium
4 weeks
NARCOTICS
Heroin 3-5 days Methadone or other Yawning, dilated
Morphine 3-5 days tapering opiate or pupils, gooseflesh,
Demerol 3-5 days non-opiate vomiting, diarrhea,
Methadone 2 weeks + withdrawal regimen runny nose and eyes,
sleeplessness,
anxiety, irritability,
elevated BP and
pulse, craving for
narcotics
STIMULANTS
Amphetamines 3-5 days Drug intervention General fatigue,
Cocaine 3-5 days usually not required apathy, depression,
drowsiness,
irritability, paranoia
CANNABIS
Marijuana 2-3 days Drug intervention Few signs of
(metabolites remain usually not required withdrawal, craving
in the body up to 2 for marijuana,
weeks) general anxiety and
restlessness
* - treatment regimen – ½ oz vodka (80-100 poof) with ½ oz water every 1-6 hrs
CHRONIC ALCOHOL DEPENDENCE
Assessment
 Persistent incapacitation
 Cyclic drinking or “binges”
 Daily drinking with increase in amount
 Potential chronic CNS disorder
 Sexual relationships may be disturbed due to poor impulse control
 Others in family may take over alcoholic’s role (eg. Children may take parent’s role,
resulting in loss of childhood opportunities).
 Children often feel shame and embarrassment
 High percentage of children develop problems with alcohol themselves
 Incidence of family violence in increased with alcohol use
Intervention
1. Counseling the alcoholic
a. Identify problems related to drinking – in family relationships, work, medical, and
other areas of life
b. Help patient to see/admit problem
• Confront denial with slow persistence
• Maintain relationship with patient
2. Establish control of problem drinking
a. Concrete support to identify potentially troublesome settings that trigger drinking
behavior
b. Alcoholic Anonymous – valuable mutual support group
• Peers share experiences
• Learn to substitute contact with humans for alcohol
• Stresses living in the present; stop drinking one day at a time

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c. Disulfiram (Antabuse) – drug used to maintain sobriety; based on behavioral
therapy
• Once sufficient blood level is reached, disulfiram interacts with alcohol to provide
severe reaction
• Symptoms of disulfiram-alcohol reaction include flushing, coughing, difficulty
breathing, nausea, vomiting, pallor, anxiety
• Contraindicated in DM, atherosclerotic heart disease, cirrhosis, kidney disease,
psychosis, pregnancy
3. Counsel the spouse of the alcoholic
a. Initial goal is to help spouse focus on self.
b. Explore life problems from spouse’s point of view
c. Spouse can attempt to help alcoholic once strong enough
d. Al-anon: self-help group of spouses and relatives
• Learn “loving detachment” from alcoholic
• Goal is to try to make one’s own life better and not to blame the alcoholic
• Provides safe, helpful environment
4. Counsel children of alcoholic parents
a. Overcome denial of alcoholic parents
b. Establish trusting relationship
c. Work with parents as well; avoid with negative reactions to parents
d. Referral to Alateen: organization for teenagers of alcoholic parent; self-help;
similar to Al-anon.
CHRONIC CNS DISORDERS ASSOCIATED WITH ALCOHOLISM

ALCOHOLIC WERNICKE’S KORSAKOFF’S
CHRONIC BRAIN SYNDROME PSYCHOSIS
SYNROME
(DEMENTIA)
SYMPTOMS -Fatigue, anxiety, -Confusion, diplopia, -Memory disturbance
personality changes, nystagmus, ataxia with confabulation,
depression, -Disorientation, loss of memory or
confusion apathy recent events,
-Loss of memory of learning problem
recent events -Possible problem
-Can progress to with taste and smell,
dependent bedridden loss of reality-testing
state
NURSING -Balanced diet, -IV or IM thiamine, -Balanced diet,
CONSIDERATIONS abstinence from abstinence from thiamine, abstinence
alcohol alcohol from alcohol
SPECIAL POPULATIONS IN PSYCHIATRIC

AND MENTAL HEALTH NURSING
VICTIMS OF VIOLENT BEHAVIORS
 VIOLATION BY CRIME
 Effects:
• Physical violence, injury, and threat to life.
• Victim’s identity is affected even with the loss or destruction of
possession and property.
• Loss of trust (not only in the criminals but in other person as well)
• Loss of a sense of ability to control their own lives and themselves
(autonomy)
• Emotional violation and trauma:

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• Typical reactions: Denial, Fear, Anger, Powerlessness,
Depression
• Sense of failure and guilt.
• Victims usually feel ashamed, unworthy as well contaminated or
“dirty” (though not touched by the perpetrator)
• Fantasies of revenge or a war for legal retribution (typical)
• Disturbed relationship to family and friend.
• Critical questions:
o Why were you there alone at night?
o Why were you carrying so much cash?
o Why didn’t you install that burglar alarm?
 Recovery From Trauma

• Influenced by the severity of trauma,
victim’s resources, and the nature of help provided immediately after the event.
• Three stages:
o Initial disorganization (impact)
o Struggle to adopt (recoil)
o Reconstruction (reorganization)
• IMPACT
• Initial reaction usually lasts from a few
minutes to a few days.
• Common responses: shock, denial,
disbelief, and confusion
• Other responses: paralyzing fear, hysteria,

a sense of helplessness and vulnerability, physiological responses, and disturbed
sleeping and eating.
• Some look calm, organized, and rational,
and take all the necessary actions initially needed.
• Privately, others reactions may occur.
• RECOIL
• Victims begin the struggle to adopt.
• In the beginning, there are periods in which
victims look and act “normal” and are able to carry out daily routines at home and
at work.
• Later, there is a desire to talk about the
details of and feelings about the trauma.
• Victims often feel a need for support and to
be temporarily dependent.
• Fantasies of revenge are natural.
• REORGANIZATION
o May take months or years to accomplish.
o Trauma is not forgotten.
o Anxiety, fear, and anger diminish.
o Victims reconstruct their lives.
o Initially victims review and organize what
happened specifically and why.
o Later, regains sense of control and self-
protection.
o Lingering nightmares, frustrations, and
disillusionment subside as victims engage in life and activities.
o If not effective, clients may experience
degrees of symptoms (depression, and PTSD)
o Even with satisfactory recovery, they sense
that their lives are, and always will be, different as a result of the crime.

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o The goal of recovery is to move from
victim status quo to survivor status by integrating trauma and moving on in
life with restored functioning, a reasonable sense of safety and security, healthy
relationships and self-esteem.
 Management:
• Nurse-Patient Relationship
o Empathy, support, and a
willingness to listen are important in recovery.
o During impact:
o Focus is on the victim’s need
for physical safety and emotional security.
o Reassurance, protection
from further harm, and sometimes medical care are needed.
o Victims may need clear,
simple directions on what to do, where to go and what to avoid.
o Crucial - Avoid
accusations (blaming), intimidations, unnecessary intrusions, and invasion
of privacy.
o Crisis intervention is face-to-
face at the scene of the crime or in the ER.
o For those who are
superficially calm, CI may be needed a few hours or days later when “reality hits.”
o During the Recoil:
o Victims need validation of the
self and of their rights as victims.
o Referrals (victim’s assistance
program and for legal, insurance, or financial assistance)
o Short-term counseling (if
family and friends are not fully available).
o Support groups with other
victims can be useful (during the struggle to adopt).
o During reorganization:
o Long-term counseling to
overcome anxiety, phobias, depression, suicidal ideations and PTSD
• Pharmacology:
o Anxiolytics
(benzodiazepines) to decrease anxiety and facilitate sleep.
 TURTURE AND RITUAL ABUSE

 Effect is more severe because it involves multiple crimes against a victim.
 Used to create fear, humiliation, and submission in individuals, communities, and
societies.
 The threat to further harm to the self and/or family tends to keep the victims silent.
 Involves physical, psychological, pharmacological, mind control, and/or sexual tactics
aimed at damaging the victims, identity, personality, emotional stability, spirit, and
physical integrity.
 Often begin with abduction and detention, and end with execution.
 Effects:
• Physical: Injuries to the head, teeth, and genitals, as well as bone fx,
dislocations, scars, burns, pain and chronic HA.
• Emotional: sense of violation, dehumanization, humiliation, and powerlessness;
loss of trust and self-esteem; identity and personality changes; terror and insecurity;
and damaged social and family relationship.
 Specific Reponses:
Anxiety Alienation
Panic/terror Passivity

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Irritability Depression
Aggression Dissociation
Rage Decreased concentration
Fatigue Sensitivity to stress
Guilt Sexual dysfx
Withdrawal Mistrust
Repression Suspiciousness
Memory disturbance Estrangement
Insomnia Unresponsiveness
Nightmares Suicidal ideation
Flashbacks Emotional lability
Hyper-arousal Self-mutilation
Impulsiveness Spiritual distress
 Victim’s responses are normal and not psychiatric symptoms.

 “Blaming the victim” draws attention away from the individual, social, cultural, and
political variables creating and fostering torture, and from research on strategies for
prevention.
 Recovery
• Major goals:
o Processing and integrating the memories of the experiences, often from
the least to most bizarre experiences.
o Expressing and dealing with the intense emotions, esp anger.
o Developing or reestablishing healthy rel’p with family, friends, and the
community.
• Psychotherapeutic Management:
o Conveying acceptance, caring, and support are crucial if patients are
going to trust enough to discuss their experiences.
 RAPE AND SEXUAL ASSAULT

 An underreported crime in the US.
 Highest risk occurs bet 15-24 y/o (women)
 Rape of men is rarely reported.
 Major problem in reporting – varying laws and attitudes in different states
and communities.
 Generally – it is considered forcible penetration of the victim’s body
by the perpetrators penis without consent.
 Sexual assault – other forms of forced sexual contact.
 It is not sexually motivated, but involves a desire for power and control
and a wish to humiliate the victim.
 Rape by a known assailant is often more traumatizing than rape by
stranger.
 Effects:
• Internal and external bodily injuries
• Threat to life with weapons
• Threat to return and rape again
• To kill if the rape is reported
• Perpetrator may kill the victim during/after the rape
• Victims may live but wish they had dies.
• Powerlessness, loss of control, fear, shame, guilt, humiliation, rage, and
feelings of being contaminated or “dirty” maybe overwhelming.
 Typical reaction:
• Wish to regain a sense of control,
• Retreat to a safe place,
• Take a thorough shower, and
• Destroy any damaged belongings.
• To do so is to destroy most of the evidence.

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 Recover:
• Victim needs assistance, information, and support (despite appearance of calm
composure and denial)
• In the ER – collection of evidence may seem like priority for staff but for the
victim it is perceived as further intrusion.
• Staff – victims may seem resistant and uncooperative, while victims are trying to
protect themselves and regain a sense of control.
• It is in the recoil stage that most victims begin t react emotionally to the
significant effect of rape has on their lives.
• Fear and mistrust are major issues – maybe directed to to persons resembling
the perpetrator or to everyone around them.
• Maybe afraid to leave the one place they designate as safe.
• They are able to go out with families/friends but avoid strangers, places similar to
rape scene, and intimacy.
• If rape occurred in their own residence, they may move or make safety-related
changes.
• May ask for someone to stay with them at night for a while.
• Victims need help in reaffirming that they are worthwhile persons, with dignity
and rights, who did not cause and did not deserve the rape.
• They need to know that their anger is natural
The Needs and Rights of Rape Victims

1. Crisis intervention: information, counseling, and referrals.
2. Help with basic needs: housing, transportation, child care, safety.
3. Medical information and care: information about pregnancy prevention, resting for
STD, follow-up care, and counseling.
4. Advocacy for whatever choices are made about reporting and prosecuting.
5. Protection of rights: to privacy, confidentiality, gentleness, sensitivity, and
explanations of procedures and tests.
6. Protection of rights: to refuse collection of evidence, to determine who will and
will not be present during examinations, to get copies of all medical and legal
reports, and to apply reimbursement thru victim’s compensation.
7. Fairness, information, and protection of legal rights during investigations,
hearings, and trial, including not being asked about prior sexual experiences with
anyone besides the suspect or defendant.
8. Reasonable protection against further harm: escorts to court, restraining order,
additional patrols, even relocation, if necessary.
 Rape trauma symptoms:

• Sleep disturbances, nightmares
• Loss of appetite
• Fears, anxiety, phobias, suspicion,
• Decrease in activities and motivation
• Disruptions in relationships with partner, family and friends
• Self-blame, guilt, shame
• Lowered self-esteem, feelings of worthlessness
• Somatic symptoms
• It is important to remember that victims vacillate in the recoil stage between
repression/suppression and dealing with trauma.
• Victims my avoid future routine gyne exams and prenatal care in order to avoid
re-experiencing the trauma.
• Use of restraints with a victim during an inpatient stay may also reactivate the
trauma symptoms.
• Goals of recovery are the same as all victims of crime.
• Victims need to develop or regain healthy sexual functioning and
relationship.
 Psychotherapeutic Mgt:

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• Victim needs continual empathy, support, and an opportunity to
process the event and intense feeling that result.
• Best approach in collecting evidence is to move slowly and
supportively at the victim’s pace, and to give rationales for and descriptions of
procedures and referrals.
• Female nurses can be particularly helpful to victims (M/F)
• Having one nurse during exam and interrogations can be
reassuring.
• Crisis Intervention is the most appropriate approach during the
impact stage.
• Short term counseling and a rape support group – recoil stage.
• Long term counseling – reorganization stage.
• Victims are 8.7x more likely to attempt suicide than non-vitims.
 Pharmacotherapy
• Benzodiazepines
• Antidepressant-Trazodone (Desyrel)
 Milieu
• Rape support group which encourages anger, overcoming guilt and shame,
building self-esteem and trust, and assisting in regaining control of one’s life and a
sense of safety.
 ADULT SURVIVORS OF SEXUAL ABUSE

 The crimes of childhood sexual abuse (CSA) and incest
are destructive for 2 major reasons:
 The crimes are not one time occurrence
 The perpetrators are usually known and trusted persons.
 20-30% of women have experience CSA (1997)
 Sexual abuse of boys may be higher among male
inpatients.
 Harder for men to reveal the abuse because of the fear of
being seen as weak or gay.
 SA and incest include voyeurism and exhibitionism, w/c
can lead to intercourse and mutilation.
 Male perpetrators:
• Fathers
• Uncles
• Stepdad
• Older bros
• Cousins
• Grandpas
• Neighbors
• Scout leaders
• Camp counselors
• Coaches
• Religious leaders.
 Sexual acts may begin as caressing but usually progress
to molestation by the time the victim is 4 y/o and to oral, anal, and/or vaginal
intercourse by the time the victim is 10 y/o.
• 68% coercion in incest but no violence.
• 29% mild force (pinning the victim)
• 3% some degree of physical violence
 Coercion is possible because of the victim’s dependent,
trusting, and/or loving relationship with the perpetrator.
 Victim is urged to maintain the secret” with various threats:
• Victim will be taken away from the family;
• Perpetrator will be put in a mental hospital;
• Parents will divorce;

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• Other parent will get sick;
• No abuse of siblings if victim is compliant;
• Love will be withdrawn;
• No one would believe the victim anyway;
• There will be physical abuse if the victim does not comply.
 Tho’ there is no physical violence, victims usually fear that
it will occur if they resist the perpetrator.
 Even if young victims wanted to disclose the abuse, they
lack the words and concepts to describe what is happening.
 There is usually an emotional reaction of fear and
confusion, and some physical pain, but not moral or ethical concept of wrong.
 Young victims who have tried to tell a parent/adults were
met with disbelief, denial, or pressure to retract their accusations.
 Authorities and the general public may discount the report
as unreliable, a fantasy, distorted, or faked at the urging of a parent.
 Potential benefits from the sexual relationship:
• Child is made to feel special, with extra attention from and
time with the perpetrator than other children.
• Certain power from trying to please the adult and from
receiving a degree of affection.
• Physical experience of sensual pleasure.
• However, emotional pleasure and concept of sexual are
absent.
 Effects of CSA on the Child
• End result is disturbed GND, ambivalence about the
experience, and denial of what is happening to protect the whole family and/or the
community.
• The young child is fulfilling the roles of child and lover
to the perpetrator, and roles of child and protector to the rest of the
family/community.
• As a result, child beings a long-term of parenting others
to the exclusion of personal needs.
• Basically, child wishes for love, not sex, but eventually
feels guilty, exploited, betrayed, angry, “dirty”, helpless, and responsible.
 Levels of betrayal:
• By the abuser;
• Lack of response from the other parent/adults;
• Lack of response from teachers, doctors, nurses,
and other prof’ls who miss the cues or disbelieve the re[orts; and
• Oneself thru denial of the abuse in order to cope
 Denial, repression, suppression,
rationalization, and even dissociation are mechanisms used by young victims to cope
with this “no win” situations.
 Common reactions:
• Sleep and eating disturbances
• Depression
• Aggression
• An active fantasy life
• Poor impulse control
• Somatization
• Self-destructive behaviors
• Running away
• Truancy.
 The more severe the abuse, the more likely
that repression will begin near puberty.
 Effects of SA on the Adolescent
• SA victims show mostly overt
methods of dysfunctional coping:

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• Impulsive acting out
• Violence toward others
• Self-destructive behaviors
• Self-mutilation
• Sleeping and eating d/o
• Suicide attempts
• Running away
• Truancy
• Delinquency
• Substance abuse
• Sexual acting out
• Prostitution
• Early pregnancy
• Early marriage
• Fantasies of revenge and wish for
the perpetrator’s death.
• They may not even be aware for
their rage, shame, guilt, and confusion and may not realize that their acting out
behaviors are related to abuse.
• Feelings of depersonalization,
dissociation, regression, manipulation, impaired social skills, spiritual distress,
thought and memory disturbances, self-neglect, aimlessness, and withdrawal are
common.
 Effects of CSA on the Adult
• Similar to delayed PTSD.
• There is repression of
memories followed by a breakthrough of unwanted, intrusive memories.
• Memories may begin as
nightmares, flinching and flashbacks.
• Memories may return
gradually in pieces, or in a sudden, overwhelming flood.
• Victims cannot be rushed to
remember the abuse before they are ready to cope with it.
• Coping mechanisms: denial,
dissociation, amnesia, emotional deadening, or repression.
• The inability to handle the
memories of abuse and the painful emotions (anger), often induces the thoughts
of suicide:
o To escape the pain and
depression;
o To “die with the secret”;
o To avoid conflict with the
family and with the perpetrator;
o To stop feeling crazy;
o To end the nightmares and
flashbacks that are so frightening.
• Self harm or mutilation is a
way of dealing with the emotional pain.
• Victims describe several
patterns of their mutilation:
1. When emotions build up; they go numb and have to inflict pain to make sure
they can still feel;
2. When they are feeling unreal, they draw blood to make sure they are unreal;
3. They cause physical pain so they do not have to focus on emotional pain;
4. They punish themselves when they are feeling guilty, ashamed, or fearful (to
reveal the “secret”);
5. Their mutilation relieves the anger/rage (give a “high”)

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• Alcohol and drugs are often

used to avoid or numb the pain and memories.
• Food may provide brief
pleasure or “fill an emptiness inside”, but leads to feeling bloated, guilt and the need
to purge.
• Although sex is not
enjoyable, it can bring relief from loneliness, temporary attention, affection, and
approval.
• Healthy adult relationships
are difficult due to problems with trusting anyone and the history of linking abuse and
love.
 Adult manifestations of
CSA:
Memory disturbances Detachment issues
• • Feeling numb/unreal
Amnesia about the abuse • Disconnected from feelings/ body
• • Feeling as if there are “personalities
Memory gaps about childhood inside”
• • “Out of body” experiences
Inability to think straight
•
Keeping unnecessary secrets
• Control issues
Relationship issues • Fear of authority/rules
• • Need to be in control/fear out of
“Trouble connecting” with others control
• • Pretending to be out of control (or
“Running away” from others helpless)
• • Fear of being vulnerable
Fear of men/women • Ambivalent about taken care of
• • Letting others be in control
Trouble trusting others/motives • Trying to control others
• • Allowing children to be abused
Fear of intimacy,
abandonment/rejection, being
used/abused
•
Unable to maintain intimacy
•
Trouble giving/receiving affection
•
Feeling alienated from others
•
Trouble saying “no”
•
Taking are of others
•
Trouble with parenting
•
Entering abusive relationship
•
Poor choices of partners
Body symptoms Identity issues
• Vague/transient pains • Confusion about identity/roles
• Memories of physical pains • Negative self-image
• Chronic pain/migraine HA • Need to be perfect or perfectly bad

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• Gagging/N and V • Under/overachievement
• Unpleasant sensation when • Need to be totally competent
touched
• Negative/distorted body image
• Self-conscious about body
• Overly conscious of appearance
Anger issues Sexual issues
• Fear of expressing anger • Concealing sexual feelings
• Holding anger in • Discomfort with sexual touching
• Crying instead of being angry • Feeling nonsexual
• Fantasies of revenge • Lacks of orgasms/sexual
• Feeling violent/full of rage dysfunctions
• Fear of violence • Confusion about sexuality/sexual
• Homicidal thoughts identity
• Feeling “dirty”
• Trading sex for favors
• Promiscuity/prostitution
• Wondering if one is gay
Anxiety issues Self-punishment
• Easily startled • Suicidal thoughts/attempts
• Inability to relax • Wanting to die/be dead
• Fear of being attacked/exposed • Self-mutilation
• Hypervigilance • Compulsive eating/dieting
• Feeling like a frightened child • Binging/purging
• Fear of the dark
• Panic attacks
• Phobias/agoraphobia
Addiction issues • Other feelings
• Alcohol/drug abuse or • Low self-esteem/guilt/shame
dependence • Fear of feelings
• Compulsive spending • Feeling stuck
Intrusive thoughts/memories • Feeling like a failure
• Intense nightmares, unwanted • Chronic dissatisfaction
thoughts • “Frozen emotions”
• Flashbacks: feeling, seeing, • Lack of a sense of humor
smelling, tasting, hearing
• Feeling inadequate, “walled in”,
“crazy”
 Recovery
• Similar to PTSD but more
complex, difficult, and lengthy.
• Memories and emotions are
strong, painful, and confusing.
• The intense anger and
ambivalence are hard for the survivor and the nurse to handle.
• The overall goal of recovery
re improved self-esteem and self-acceptance, forgiveness of self, adaptive
coping with life and its stresses, the capacity for intimate relationship, and
genuine sexual pleasure, improvements in mood, and reduced anxiety and
fear.
 Nurse-Patient Relationship
• Much depends on the
nurse’s ability to quickly develop a trusting relationship.
• Empathy, active support,
compassion, warmth, and being non-judgmental are crucial.

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Key Nursing Interventions for Survivors of CSA
• Similar to PTSD but
more complex, difficult, and lengthy.
• Establish a trusting and
supportive environment.
• Accept all feelings and
reactions as normal responses.
• Ask permission before
touching.
• Reinforce that recovery
is possible.
• Educate about the
dynamics of abuse and recovery processes.
• Assist survivors in
understanding current behaviors as reflections of survival strategies used in childhood.
• Facilitate reevaluation of
the sexual abuse, its circumstances, and its effects, but without pressuring.
• Encourage coping
choices that are in survivor’s best interests.
• Discuss safeguarding,
other children if the perpetrator still poses a risk.
• Support choices about
future disclosures, confrontation, or reporting.
• Be aware that family
members and others may feel split loyalty and engage in dysfunctional roles and
interaction patterns.
• Decrease feelings of
isolation, shame, and stigma.
• Encourage self-
acceptance.
• Facilitate
acknowledgement, forgiveness, and love for the “child within”.
• Teach and encourage
stress management and anger reduction.
• Facilitate the transfer of
responsibility and anger to the perpetrator but set limits on acting out fantasies of
revenge.
• Foster separation and
individuation from family and its patterns.
• Help to find meaning in
the experience and mourning of all the loses (grieving is a very painful experience).
• Facilitate the change
from victim to survivor status.
• Facilitate re-
experiencing and reworking of maturation tasks that were missed or experienced
prematurely.
• Educate about life skills,
communication skills, coping, assertiveness, decision making, conflict resolution,
boundary setting, friendship, intimacy, sexuality, and parenting.
• Refer to outpatient
counseling and appropriate support groups.
 VICTIMS OF PARTNER ABUSE

 95% of the abuse is by a
man toward a woman.
 Partner-abuse victims tend to
conceal their victimization.

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 They are aware that their
disclosure will be met with denial or minimization by the partner, friends, relatives, and
by increased abuse of their partners.
 Though it crosses all it is
more often officially reported in the lower socioeconomic class.
 Victims are more likely to be
in contact with reporting agencies (PHN, welfare offices, public clinics, and ER).
 Effects of Partner Abuse
• Learned helplessness
o 3 necessary conditions:
1. Victim’s behavior is not related to the cause of the beatings.
2. Victim has no control over preventing or stopping the beatings.
3. Victim sees little hope of escaping because of the threats of increased
harm.
Common Reasons Why Women Endure Long-term Abuse

1.Situational factors
 Economic dependence.
 Fear of greater physical danger to themselves and their children if they attempt to leave
or have partner arrested.
 Fear of emotional damage to children because of being without a father.
 Fear of losing custody of children.
 Lack of job skills.
 Social isolation resulting in lack of support from family or friends.
 Lack of information re: alternatives.
 Fear of involvement in court processes.
 Fear of retaliation from partner/partner’s family.
2.Emotional Factors
 Poor self-image.
 Being a state of denial, and living a “secret”.
 Fear of loneliness.
 Personal embarrassment and protecting the image of husband and family.
 Insecurity over potential independence and lack of emotional support.
 Guilt about failure of marriage or relationship.
 Fear that partner is “sick” and needs help.
 Belief that partner will change.
 Ambivalence and fear over making formidable life changes and increased responsibility.
3.Cultural factors
 Knowing batterers are not help accountable for their violent actions.
 Believing the abuse is her fault.
 Being raised to be passive and submissive.
 Developing survival skills instead of escape skills.
 Recognizing that the legal system is a male-dominated system.
 She still loves him.
• Cycle of violence – principles

1. Abuse is not constant, nor it is random.
2. There is an ambivalence of power in the relationship.
3. Abuse occurs in a cycle and has three phases that vary in time and intensity.
4. The last stage is the one that convinces the woman that she should stay in the
relationship.
o Tension Building
o Serious Battering Incident
o Honeymoon

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Common Cues to Partner Abuse
¨Repeated, vague symptoms/illnesses that are not confirmed by tests, such as backache,
abdominal pain, indigestion, HA, hyperventilation, anxiety, insomnia, fatigue, anorexia, heart
palpitations.
Ünexplained injuries or ones with unlikely explanations and embarrassment about them.
¨Hidden injuries such as those in areas concealed by clothes or visible on physical or x-ray
exam only.
Ïnjuries with recognizable marks (belt, iron, raised ring, teeth, fingertips, cigarette, gun, or
knife).
¨Multiple fx or bruises in various stages of healing.
¨Jumpiness or flinching in the presence of abuser.
¨Substance abuse and suicidal thoughts or attempts.
Ättempts to conceal fear of the partner.
¨Continual efforts to keep partner from getting angry.
¨Denial of any problems in the rel’p.
¨Lack of rel’p with family/friends.
Ïsolation or confinement to home.
¨Guilt, depression, anxiety, low self-esteem, sense of failure, concealed anger.
¨Continual justification of own actions and whereabouts to partner.
¨Continual justification of the abuser’s actions in public; excusing or rationalizing the behaviors.
¨Believing in family unity at all costs and traditional stereotypes
¨Believing in managing alone, even when help is offered.
Än oversolicitous partner who does not want to leave the victim alone with hospital or agency
staff or even with family and friends.
Helpful Responses to Partner Abuse

¨Be nonjudgmental, objective, and non-threatening.
Äsk directly if abuse is occurring.
Ïdentify the abuser’s behavior as abusive.
Äcknowledge the seriousness of the abuse.
Ässist the victim to assess internal strengths.
Ëncourage use of personal resources.
¨Give the victim list of resources: shelters, financial aid, police, and legal assistance.
Ällow victim to choose own options.
¨Help victim develop a safety/escape plan.
¨Tell the abuser to stop the abuse and get help.
¨Do not disbelieve or blame the victim.
¨Do not get angry with the victim.
¨Do not refuse to help if the victim is not ready to leave the abuser.
¨Do not align with the abuser against the victim.
¨Do not push the victim to leave the abuser before ready.
Most Crucial Information to Document in the Initial Contact

¨Length and frequency of the abuse.
¨Types of abuse (physical, psychological, sexual, financial) and use of weapons.
¨Types and locations of injuries (can be written descriptions, but photographs and body maps
are preferred).
¨Duration of episodes of abuse.
Üse and abuse of substances and medications by victim and abuser.
¨Current location of abuser.
¨Location and safety of children.
¨Types of service desired.
¨Referrals made.
Nursing Interventions for Survivors

¨Reiterating information about abuse, the cycle of violence, and the abuser’s accountability.
¨Building self-esteem and confidence.
¨Sharing of feelings (esp anger, frustration, fear, and anxiety).
¨Decreasing shame, guilt, embarrassment, manipulation, and isolation.
¨Confirming personal rights as well as legal rights.

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¨Teaching stress reduction or management techniques.
¨Teaching communication techniques.
¨Teaching conflict-resolution techniques.
¨Teaching assertiveness training.
¨Decreasing codependency behaviors.
¨Building a new, improved support system.
¨Setting goals, specific planning for immediate future.
¨Resolving grief.
MENTAL ILLNESS IN THE ELDERLY
Losses that Occur More Frequently Among the Elderly

 Loss of health
 Loss of loved one
 Loss of hearing and vision
 Loss of status
 Loss of work
 Loss of income
 Loss of friends
 Loss of cognitive skills
 Loss of home and community
 Loss of mobility
■ Because of the prevalence of mental health disorders in late life, nurses who encounter
older adults in any health care setting should consider the physical, emotional, and social
needs of their patients.
■ Whenever possible, factors that place the elderly at risk of mental illness or problems
stemming from existing mental disorders should be identified and plans developed to meet
the needs.
■ Improving the quality of mental health care for older adults rest on educating health care
providers, the elderly, and their caregivers.
□ SOCIAL SUPPORT
• Education and support are essential component of prevention.
□ COMMUNITY SUPPORT
• Only 15% of community mental health care in the community target the elderly for
outreach and fewer have geriatric specialist.
□ LOCAL ALTERNATIVES TO FORMAL MENTAL HEALTH CARE
• 65% of elderly persons with psychiatric disorders also have a significant medical
disease.
• Many of the chronically mentally ill released from state hospitals during the waves of
deinstitutionalization were reinstitutionalized in nursing homes.
□ CURRENT AND FUTURE TRENDS
• In the last 10 years, day hospital programs for the elderly mentally ill have been seen
tremendous growth due to an increased focus on decreasing inpatient hospital costs.
• Nurses will have increasing responsibility for the assessment and care of mentally ill
in the community.
Using Written Materials to Teach or Assess the Elderly

 Only 50% of people over 65 graduated from HS: consider reading level.
 People are reluctant to disclose they are unable to read.
 Use large print type with high contrast.
 Provide high intensity lighting without glare.
 Encourage person to wear corrective lenses.

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BARRIERS TO MENTAL HEALTH CARE FOR THE ELDERLY
■ Ageism
□ “The commonly held belief that specific mental health conditions experienced by older
persons are part of normal aging and are not treatable.” (National Coalition on Mental
Health and Aging, 1994).
□ Also used to describe stereotyping and devaluation of people solely because of their
age.
□ Behaviors include:
• Intergenerational segregation.
• Contact avoidance.
• Condescending or abusive interpersonal treatment.
• Discrimination in the form of limited access to services and resources.
■ Attitudes
□ Attitudes of the elderly themselves serve as barrier to seeking mental health care.
□ Older adults are more subscribe to age-specific stereotyping than younger adults.
□ Symptoms of treatable disorders are frequently reported by those who believe that
difficulties are part of old age or a normal consequence of difficult life experiences.
□ Older adults are reluctant to seek psychiatric care because an admission of mental
health problem is seen as a weakness and is more stigmatizing than it might be for a
younger person.
□ It may also represent a loss of control and bring forth fears of institutionalization.
■ Finances
□ The cost of mental health care is a major disincentive to providers as well as older adults
who might otherwise seek psychiatric assistance.
■ Inadequate Detection of Mental Illness and Treatment
□ Recognition of mental illness is the first step in treatment, yet many studies demonstrate
psychological disturbances in the elderly are often missed or misdiagnosed.
□ Maybe complicated by:
• Elder’s unwillingness or inability to discuss problems in terms of emotions;
• The connection between mental disorders and physical factors present in chronic or
acute medical conditions;
• The blurring of normal and abnormal findings in the elderly.
PSYCHIATRIC DISORDERS IN THE ELDERLY
■ DEPRESSION
□ One of the most frequently occurring and treatable psychiatric disorders of late life.
□ The effects of depression extend beyond emotionally distressing symptoms of
helplessness, hopelessness, fear, shame, guilt, and anger to physical consequences.
□ Mortality rates increase for some disorders with the coexistence of depression.
□ The National Coalition on Mental Health and Aging estimates 15% of older community
residents suffer depressive symptoms, however MDD occurs in only 1-2%.
□ Depression is an illness that affects mind and body; it causes people to feel miserable
both physically and emotionally.
□ Common physical indicators of depression:
• Sleep disturbances (one of the earliest symptoms)
• Fatigue or loss of energy unrelated to hard work or rest;
• Loss of sexual interest;
• Weight changes (usually weight loss);
• GI complaints (constipation or abdominal distress);
• Multiple vague aches and pains unrelated to a physical cause.
□ ECT is a safe and effective treatment for severely depressed patients, including the very
old.
□ Two important nursing roles are maintenance of safety and education.
□ Suicide is the most tragic effect of depression, and the elderly have the highest rate of
suicide (20% of all reported suicides).

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□ Failed attempts are usually not a “cry for help” but a serious, yet unsuccessful suicide
bid.
□ Refusing to eat, noncompliance with medications, excessive alcohol intake, and physical
risk taking are processes that may result in death but are not recorded as suicide
(chronic suicide).
Predictors of Suicide Risk Among the Elderly

• Age • Financial difficulty
• Male • Social isolation
• White • Impulsiveness
• Chronic or uncontrolled pain • Hopeless/helpless
• Bereavement • Alcohol or drug abuse
• Unmarried (widowed or divorce) • History of previous attempt
• Retirement • MDD, esp psychotic depression
□ Intent maybe signaled by a new preoccupation with religious issues, giving away
possessions, changing a will, or other “new” behaviors.
■ BIPOLAR DISORDER
□ Mania in older adults may be less intense but in the same fashion as with younger
adults.
□ Features:
• Grandiosity
• Disorientation
• Delirium
• Reversible cognitive dysfunction.
□ Nursing interventions:
• Attention to increasingly negative impact of agitation on self care.
• Self-protection in medically compromised elderly.
■ PSYCHOTIC DISORDERS
□ Characterized by:
• Delusion
• Hallucinations
• Thought disorder
• Bizarre behavior
• Evidence of impaired reality testing
□ Late-onset schizophrenia is used to describe those cases that first present after age 45.
□ Paranoid thinking are uncommon in the elderly. It often emerges as a defense
mechanism against a potentially hostile environment.

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Disorders Associated with Secondary Psychosis in the Elderly
Endocrinopathies Neurological Disorders
• Hyperthyroidism/hypothyroidism • Parkinson’s disease
• Addison’s disease • Alzheimer’s disease
• Cushing’s disease • Pick’s disease
• Hyperparathyroidism • Multiinfarct dementia
• Hypoparathyroidism • Seizure disorder
• Hypoglycemia • Hydrocephalus
Vitamin Deficiencies • Demyelinating disease (e.g. MS)
• Thiamine • Neoplasms
• Niacin • Encephalopathies (posttraumatic,
• B12 hepatic, toxic)
• Folate • Viral encephalitis
• Spinocerebellar degeneration
• Neurosyphillis
Other Conditions
• Iatrogenic (secondary to drugs)
• Systemic Lupus Erythematosus
• Temporal arteritis
• Hyponatremia
• Delirium (as a result of hypoxia)
■ ANXIETY DIORDERS
□ Though anxiety is a normal emotion to a danger or unpleasant event, it can be
considered maladaptive when it interferes with functioning.
□ Two anxiety disorders maybe over represented in the elderly:
• Anxiety arising from general medical condition;
• Substance abuse induced anxiety.
Psychological or Somatic Signs and Symptoms of Anxiety

Anorexia Faintness Paresthesia
Backache Fatigue Sexual dysfunction
“Butterflies” in stomach Headache Shortness of breath
Chest discomfort Hyperventilation Stomach pain
Diaphoresis Light-headedness Sweating
Diarrhea Muscle tension Tachycardia
Dizziness Nausea Tremulousness
Dyspnea Pallor Urinary frequency
Dry mouth Palpitations Vomiting
■ SUBSTANCE ABUSE
□ Alcohol Abuse and Dependence
• Because of age-related biological changes and medical disorders, older adults are
greater risk for the hazards and dependence potential of alcohol.
• Potential alcohol-Related Problems in the Elderly
○ Unexpected drug effects
○ Delirium
○ Dementia (Wernicke-Korsakoff synrome)
○ Depression
○ Self-neglect
○ Dehydration
○ Malnutrition
○ Bladder/bowel incontinence
○ Muscle weakness
○ Gait disorders
○ Repeated falls
○ Burns
○ Gastric bleeding

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○ Accidental hypothermia
○ Legal; trouble (esp. DUI)
○ Family discord
Nursing Care of Alcohol Withdrawal Syndrome in the Elderly

• Assess withdrawal symptoms.
• Assess vital signs.
• Educate about withdrawal process.
• Assist with ADLs.
• Reduce environmental stimuli.
• Supplement diet to meet nutritional needs.
• Reorient.
• Provide relaxation exercise.
• Potential alcohol-Related Problems in the Elderly

□ Drug-Abuse
• Problems result from overuse and misuse of prescription and over-the-counter
medications.
• Psychoactive drugs are a major component of the heavy drug use in this age group.
Commonly Used Psychotropic Drugs for the Elderly

Antidepressants Antipsychotics Antianxiety Agents
Secondary amine tricyclics High-potency Benzodiazepines
• Desipramine • Haloperidol (Haldol) appropriate for the elderly
(Norpramin) • Fluphenazine • Lorazepam (Ativan)
• Nortriptyline (Proloxin) • Oxazepam (Serax)
(Pamelor) Low potency Nonbenzodiazepine
Newer agents • Thioridazine • Buspirone (BuSpar)
• Bupropionj (Mellaril)
(wellbutrin) Atypical antipsychotics
• Trazodone (Desyrel)
SSRI
• Fluoxetine (Prozac)
• Paroxetine (Paxil)
• Sertraline (Zoloft)
Guidelines for Use of Psychotropic Drugs in the Elderly

Initial Dose
• Start with a small dose and gradually increase until therapeutic effect or
adverse side effects occur.
• Usually 1/3 – ½ of the younger adult dose is effective.
Daily Dose
• Use the smallest dose that produces relief.
Individualization
• Elderly persons are the most heterogenous age group in American
society.
• Each individual needs thoughtful attention.
• Partial symptoms relief may well be the mot judicious and realistic goal.
Discontinuance
• The elderly should be gradually tapered off psychotropic drugs.
• If elderly patients can manage without drug therapy, they should be
allowed to do so.
□ Factors complicating drug-taking in the elderly

• Living alone.
• Poor vision and hearing
• They may add nonprescription drugs

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• Combine medications with alcohol
• Take medication prescribe for others without the knowledge of their physician.
• Many older adults see multiple physicians.
• Confusion caused by generic and trade names.
Enhancing communication with the Elderly

Considerations Nursing implications
Slowed information Do not rush. Allow adequate time for patient to
processing answer questions.
Avoid undue interruptions.
Establish rapport Offer a handshake.
Make eye contact.
Arrange position at equal or lower level than
patient.
Address patient by title and last name unless
asked to use first name.
Hearing deficits Articulate words clearly.
Face patient when speaking.
Adjust volume of speech to patient’s needs. Do
not shout.
Ensure use of personal hearing aid or amplifier at
correct volume.
Use complementary nonverbal strategies, i.e.
facial expression, gestures.
Visual deficits Provide adequate lighting.
Ensure use of corrective lens.
Competing stimuli Minimize background noise.
Avoid times when patient is excessively tired,
hurting, hungry, or has toileting needs.
Provide privacy.
Education level Match vocabulary to patient’s level of use.
Decreased physical Avoid overtiring.
tolerance
PSYCHOTHERAPEUTIC MANAGEMENT
■ Nurse-Patient Relationship
□ By empathizing with the patient and caregivers and focusing on the needs of the patient,
the nurse can help patients and their families manage the activities and demands of
daily living and improve the overall quality of both physical and mental health.
□ An important geropsychiatric nursing is assisting the patient in meeting basic
physical needs.
■ Pharmacology
Physiologic Changes in the Elderly Resulting in Pharmacokinetic Alteration

Physiologic Change Pharmacokinetic Action
Increased gastric pH Decreased absorption
Increased body fat Decreased fat-soluble drug concentration
Decreased body water Increased water-soluble drug concentration
Increased unbound drug may lead to
Deceased serum albumin increased drug activity
Decreased drug metabolism
Decreased cardiac output Decreased drug excretion
Decreased renal function Decreased dug metabolism
Decreased liver mass, blood flow
Special Considerations for Elderly Patients Taking Psychotropic Drugs

Antidepressant Drugs

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• Orthostatic hypotension is a major concern; nortriptyline and bupropion do not
seem to cause as severe a hypotensive episode.
• Amitriptyline produces the most anticholinergic SE.
• Desipramine, trazodone, buproprion , and SSRI produce the fewest
anticholinergic SE.
• CNS symptoms of toxicity include disorientation, confusion, and memory loss.
• Caution should be observed when TCAs are given to elderly persons with CVD.
• SSRI, Desipramine, and buproprion are “activating” antidepressants and tend to
organize patients. Helpful for patients with hypersomnia.
Antipsychotic Drugs
• Haloperidol, fluphenazine, and thiothixene cause more EPSEs than most other
antipsychotics.
• The elderly are more prone to EPSEs because of age-related CNS changes.
• Thioridazine and the atypical antipsychotic drug have a low incidence of EPSEs.
• The elderly are particularly susceptible to TD.
• Agranulocytosis is most common in elderly women and is a particular risk with
clozapine.
• Anticholinergic SE are particularly troublesome for the elderly.
• Long acting or depot antipsychotics can be used in elderly patients.
Antianxiety Agents: Benzodiazepine
• Up to 1/3 of all elderly persons take these drugs.
• The half-lives of all benzodiazepines are lengthened by age-related changes that
prolong sedation, cause poor coordination, and disorientation, and may lead to
misdiagnosis.
• Benzodiazepines with a long half-life include Chlordiazepoxide (Librium),
Clorazepate (Trnaxene), Diazepam (Valium), and Prazepam (Centrax). They are
not usually prescribed for the elderly.
• Lorazepam (Ativan), Oxazepam (Serax), and Clonazepam (Klonopin) are usually
prescribed.
Antimanic Agent: Lithium
• Because of age-related changes in the kidneys, excretion of lithium is slowed,
creating the opportunity for prolonged SE.
• Sodium depletion from diet or diuretics increases serum lithium levels.
• A lower blood level of lithium as appropriate for elderly patients (0.4-0.8mEq/L).
• Caution should be exercised if lithium is combined with an antipsychotic drug
because of the risk of NMS.
■ Milieu Management
□ The traditional associations of “home” involve control over people who come and go in
personal spaces, furnishings, and appointments.
□ Furniture, at height that facilitates independent mobility, can be placed in conversational
groupings.
□ Common rooms can be equipped with large print books, games with large-print and
pieces, and stimulating pictures.
□ Staff members may wear street clothes rather than traditional uniforms to encourage
social interactions with resident and to eliminate barriers.
□ Remember privacy needs and respect personal space.
Environmental Adaptations
Considerations Interventions
Decreased ability to Use high-contrast colors in vivid hues.
distinguish colors.
Mobility impairments. Ensure nonslip floor surfaces.

Provide adequate, nonglare lightings.
Ensure well-fitting footwear.
Provide chairs and toilets at comfortable height

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with armrests or handrails.
Avoid placing rolling tablets where patients might
attempt to use for stability.
Provide shower stools, nonskid tub guards, and
grab bars.
Provide ambulation rails.
Remove obstacles, clutter, and spills promptly.
Ensure appropriate use of assistive devices.
Inability to read. Mark spaces with pictures or universal symbols.

Decreased Ensure comfortable temperature.
thermoregulation ability. Observe for signs of hypothermia or hyperthermia.
Provide sweaters, blankets.
Ensure safe water temperature.
□ Controlling aggression is a major component of maintaining individual and

environmental safety.
□ Violent behavior may be the result of poor frustration tolerance, ineffective coping
strategies, impulsivity, and real or imagined threats to personal space and individual
territory.
□ Managing environmental stimuli, providing productive outlets for energy, and practicing
redirection are important for reducing outbursts.
□ A primary therapeutic responsibility for nurses in these settings is to prevent
deterioration resulting from the withdrawal and disuse that often accompany
institutional life.
□ Reality Orientation
• Specific treatment modality used to counter intellectual and sensory lo9s in confused
elderly patients.
• It is generally conducted in a group setting by staff members, using natural
conversation with patients to discuss important events or items.
○ Bulletin board with the name of the facility, day, month, year, next meal, weather,
etc.
○ Daily newspapers
○ Current magazines
○ Clocks
○ calendars
□ Reminiscence
• Older adults have a wealth of experiences that can be shared through storytelling.
• The process of recalling past experiences, which allows the listeners insight into the
patient’s history.
• The patient benefits from the opportunity to rethink aspects of the past, put feelings,
thoughts, and actions into perspective and temper them with other experiences.
• Participants are encouraged to share life experiences (vacations, holidays,
milestones, and family events).
• It can help participants establish new relationships while enhancing valuable
communication and socialization skills.
□ Life review
• Uses reminiscence but involves one-to-one interaction rather than group settings.
• The nurse acts as a sounding board for the patient, who reviews life experiences,
reworks, and reframes issues to achieve integrity.
• In doing so, fears, conflicts, past coping mechanisms, unresolved feelings, and
unresolved losses from the past may become evident and promote opportunities for
intervention.
□ Pet therapy
• Animals in residence or visiting can be used to assist older adults in breaking
through apathy or depression by helping fulfill the need to love and be loved.
• It consists of brief sessions in which small, well-behaved animals are provided to
patients for holding, stroking, and playing.

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□ Exercise therapy
• Encouraging socialization and participation in purposeful activities is helpful.
• It can channel the energy of anxiety and provide stimulation needed to assist in the
redevelopment of normalized sleep-wake cycles.
□ Music therapy
• Old songbooks, hymnals, and records offer an array of choices.
• They should be allowed freedom of choice in the type of music used for group
sessions.
□ Horticultural therapy
• Planting and tending to plants can enhance physical condition, relieve tension, and
provide a sense of accomplishment.
SPECIAL THERAPIES
BEHAVIOR THERAPY
 A distinctive approach to influencing interactions between persons, and between

persons and their environment.
 Classical Conditioning
 Origin is credited to Pavlov (1927) and his research on reflexes in laboratory
animals.
 He discovered that the dogs began salivating before they were presented with
food.
 He then simultaneously presented food and the sound of a metronome.
 After several repetitions, the metronome alone was found to elicit secretions of
saliva.
 Respondent conditioning is the process of pairing a neutral stimulus with an
eliciting stimulus so that, ultimately, the neutral stimulus alone elicits the response.
S (food) R (salivation)
(Eliciting Stimulus) (Respondent)
S (food) + (metronome) R (salivation)

(Eliciting Stimulus + Neutral (Respondent )
Stimulus)
CS (metronome) R (salivation)
(Conditioned Stimulus) (Respondent)
 Watson and Rayner (1920) did an experiment with a young child, Albert, and a
white rat (neutral stimulus).
 They paired the presence of the rat with a loud noise that had been observed to
elicit a fear response in Albert.
 After the noise and the rat were presented simultaneously 7x, the rat alone
elicited the fear response in Albert.
 The fear response was also elicited by stimuli characteristics similar to those of
the rat (rabbit, dog, fur).
 Generalization – the process in which a fear response is elicited by stimuli with
similar characteristics.
 Operant Conditioning
 Originally done by BF Skinner.
 Attention is directed to the events that immediately precede and follow a person’s
specific behavior.
 Response – any movement or observable behavior.
 Operant response – the behavior being analyzed.
 Stimulus – an event that immediately precedes or follows a behavior.

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 Three types of stimuli:
• Discriminative stimuli – an event immediately preceding a behavior that
predicts or indicates that a response will be followed by reinforcements.
• Neutral stimuli – an event that is not associated with reinforcement or that has
no effect on changing the probability of behavior.
• Reinforcing stimuli – an event, following a behavior, that strengthens that
behavior and increases the probability of the behavior occurring.
 Primary reinforcers – events of biological importance (food, water, sexual
contact, etc).
 Secondary or generalized reinforcers – events that have been paired
repeatedly with a primary reinforcers (money, tickets, diplomas, attention of others,
etc.).
DS R RS
(Discriminative Stimulus) (Response) (Reinforcing Stimulus)
DS R RS
(Button labeled “Nurse) (Pressing the Button) (Voice of the Nurse)
 This pattern is exemplified in the hospital room where a client wants the nurse’s
attention. He presses a button labeled “nurse” on the paging apparatus. The nurse
responds by saying, “This is Mr. Meñez. May I help you?”
 When a voice responds immediately and consistently, learning occurs. If the
nurse’s voice does not immediately follow pushing the button, extinction occurs.
 If the patient receives painful electrical shock when pushing the button and the
response is suppressed, punishment has occurred. The patient may then exhibit
aggressive response.
 Application:
 It is used with children, adolescents, groups, couples, and families.
 It has been used in inpatient and outpatient settings and in skills-training
programs.
 It has been reported in the treatment of anxiety, sexual disorders, PTSD, and
addictions.
 It also form the basis of self-control treatment programs (e.g. eating, exercise,
and assertive communication).
 Behavior Modification
 Increasing the probability that a behavior will recur
• Conditioning
o It is the strengthening of a response by reinforcement.
o Positive reinforcement
o Negative reinforcement
o Superstitious behavior – a term used for behavior that has been
reinforced by accident.
• Premack Principle – when a person is observed often enjoying a particular
activity, the opportunity to engage in that activity can be used as a reinforcer for
other behaviors that occur less frequently.
• Shaping – a process of reinforcing successive approximations of responses to
increase the probability of a behavior.
 Schedules of reinforcement
• Continuous reinforcement – the presentation of reinforcing stimuli following
each occurrence of the selected response. It is useful primarily during the initial
phase of conditioning or shaping a behavior, and results in a high rate of
behavior.
• Intermittent reinforcement – the presentation of the reinforcer following the
target response according to a selected number of responses. It results in

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behavior that is more resistant to extinction that behavior that has been
reinforced on a continuous schedule.
 Decreasing the probability that a behavior will recur
• Differential reinforcement – technique used to decrease the frequency of a
behavior. When the goal of treatment is to decrease a behavior, another
behavior, incompatible with the target behavior, can be reinforced.
o So the client would not speak in a soft-spoken tone, the groups attention
is available only when the patient speaks in a normal, audible voice.
• Extinction – the gradual decrease in the rate of responses w2hen reinforcement
is no longer available. Emotional responses characteristically occur during
extinction.
o A man rides the elevator. He pushes the button “up”. When he is about to
embark, the door fails to close. He tries to press repeatedly and sometimes
rapidly on the button. He then bangs on the door.
• Negative consequence – the presentation of an event immediately following a
response that decreases the probability of that response recurring.
o Withdrawal of privileges or withholding passes when as a consequence of
his acting-out behavior.
• Time out – a negative-consequence technique in which the person is removed
from a setting where ongoing reinforcers are available.
o A preschooler who becomes aggressive during play ay be moved to
another room where no reinforcement (toy/playmate) is available.
• Response cost – also a negative-consequence technique; the removal of a
reinforcer that is contingent on a specific behavior.
o A patient was required to pay a sum of money during his initial check up.
Certain amount is returned when he goes back for follow-up. The money is
withheld when he is noncompliant.
 Skills Training
• Used to develop new behaviors appropriate for a person’s age and life
situation.
• Positive reinforcement and shaping are the bases for these programs as
well as modeling and imitation.
• Assertiveness training is an example.
 Contingency Contracting
• The arrangement of conditions so that patients are able to participate in
setting target behaviors and selecting reinforcers.
• The therapist and the patients jointly specify what, how, when, and where
behavioral change will occur.
• Criteria for delivery of reinforcement are defined.
• The type, amount, and schedule of reinforcement are specified.
• E.g. a contract specifying that if the patient approaches the nurse to ask
for his medications art the scheduled time, he can go for a walk with the nurse
after lunch.
 Self-Control
• Used with contingency contracting in which patients do the assessment,
change their behaviors, provide their own reinforcement, and evaluate the
results.
 Token Economy
• Use of operant principle in the management of behavior with groups of
patients in in-patient or out patient partial hospital programs.
 Respondent Conditioning
 Helping Patients Cope with Disturbing Stimuli
• Reciprocal Inhibition
o The process of strengthening alternative responses to fear or anxiety
associated with a stimulus called reciprocal inhibition or counterconditioning.
o E.g. relaxation technique (positive, affirming self-talk; deep breathing;
progressive muscle relaxation; and positive imagery).
• Systematic desensitization (Wolpe)

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o The planned progressive exposure to stimuli that elicit fear or anxiety
while the fear response is suppressed.
o Hierarchies of the fear-eliciting stimuli are constructed through a detailed
assessment.
o The stimulus least likely to evoke fear or anxiety is introduced initially,
followed by gradual exposure to more fearful stimuli.
Behavioral Nursing Interventions

 The behavioral nursing process consists of the following:
 Making assessment of behavior and related contingencies.
 Formulating a behavioral nursing diagnosis.
 Outcome identification, and planning ad implementing an intervention program to
have an impact on this behavior.
 Evaluating the results of the intervention.
 Guidelines for Behavioral Nursing Intervention
 Baseline Observations (Assessment)
• Appropriate behavior present
• Inappropriate behavior present
• Age-appropriate behavior absent
• Assessment of these behavioral categories includes:
o Frequency or duration of each response or both
o Description of the stimulus conditions that precede responses and follow
the behavior
o Validation of potential reinforcers
 Problem Specification (Behavioral Nursing Diagnosis)
• Select the response to be changed
• Define the response so everyone can recognize it
• Gather baseline data (frequency, duration of behavior, discriminative and
reinforcing stimuli)
 Formulation of Treatment Plan (outcome Identification)
• State the specific response to be changed
• State how the response is to be changed; include the present status and the
target status of the response;
o Increase the rate of the response
o Decrease the rate of the response
o Teach a new response
• Identify the discriminative and reinforcing stimuli available for use
• Select and write the intervention plan in detail (with rationales)
 Intervention
• Implement the treatment plan as written
• Provide reinforcers for those persons implementing the plan
 Evaluation
• State the outcome of the intervention
• Determine whether the response changed as planned
• Specify what additional changes are required
• State techniques for maintaining the desirable change
ATTITUDE THERAPY
1. ACTIVE FRIENDLINESS (Withdrawn)

• For patients who are apathetic, fearful, non-combative, unmindful of the surroundings.
• An attitude of interest in the immediate well-being of the patient, despite the attitude the
patient himself may be presenting.
• Implies being ready and able to discuss sincerely his activities in the hospital and at
home, giving attention to his needs without waiting for an expression of them.
• Important basic principle is giving attention before the patient requests for it.

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• Common sense and a genuine interest in the patient as a person guide the nurse in its
use.
• Patient will not come to you so you go to the patient and do everything for him/her like
bathing, combing of hair, feeding, cutting of fingernails, etc.
• Mothering role – TLC
2. PASSIVE FRIENDLINESS (Paranoid/suspicious patients)

• Implies an attitude of interest in the patient’s welfare, but one which does not
seek him out t reassure him of that friendliness.
• The nurse is friendly when the patient approaches her at any time.
• The nurse maintains distance; patients hate too much closeness.
3. KIND FIRMNESS and WATCHFULLNESS (Depressed and Suicidal)

• They have inner hostilities so help to channel out their feelings (externalize hostilities
turned towards self) by providing a monotonous, boring, repetitive, ungratifying activities.
• Firmness is a tool for the care of patient only – not a release for the nurse’s own
tensions. Ignore when possible depressed and self-punitive remarks or divert attention
from them.
4. MATTER OF FACT (Manipulative and demanding patients)

• Patient takes pleasure in manipulating people.
• Positively, it means an acceptance of one’s self and one’s role by carrying out the
necessary duties pleasantly and calmly.
• Negatively, it means not getting defensive about the hospital routines, the orders, or the
treatment the nurse must carry out.
• Stick to the rules and regulations in the ward (be consistent).
• Do not argue or get angry but things/activities should be implied in a calm manner.
5. NO DEMAND (Violent / Assaultive / Furious rage)

• Don’t approach the patient alone.
• Ask help of the members of the mental health team.
• If you go to the patient alone, he/she will think that you are challenging him/her to a
fight and he can overpower you.
• Surround the patient with the other members of the team and approach the patient in
all directions.
6. WATCHFULNESS (Suicidal / Escape Precaution)

• Means constant vigilance.
• Patients for whom this attitude is ordered usually feel more secure when they know
that they are being watched.
PHARMACOTHERAPY
ANTIPSYCHOTICS
Group of Antipsychotics
1. Typical – Phenothiazines (Chlorpromazine); Non-Phenothiazines (Haloperidol)
2. Atypical – Clozapine (Clozaryl), Olanzapine (Zyprexa), Risperidone (Risperdal)
Adverse Effects:
1. Acute Dystonic Reactions
• Usually occur with the 1st few days of treatment or when the dosage is increased.
• Muscle spasms (often in the tongue, face, jaw, neck, back, larynx, or eyes)
• Quite painful and even life-threatening when they affect the airway.
• Younger males are at greater risk, as those on high-potency antipsychotics
(haloperidol, fluphenazine (Prolixin), thiothixene (Navane))
• Patients require immediate treatment with anticholinergic agents - Benztropine
(Cogentin); Diphenhydramine (Benadryl); Lorazepam (Ativan)

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2. Pseudoparkinsonism
• Mimics the symptoms of Parkinson’s disease
• Decreased spontaneous movement, muscle rigidity, tremors at rest, a shuffling
gait and a Rabbit syndrome (tremors around the mouth).
• Common among patients taking high-potency drugs and older female patients
• Treated with Benztropine or Amantadine (Symmetrel), Levodopa (Larodopa,
Dopar)
• Bromocriptine (Parlodel) is contraindicated – can produce agitation and can
worsen the underlying psyche condition.
3. Akathisia
• Characterized by anxiety and motor restlessness.
• Patients may rock back and forth in a chair, pace the floor, or be unable to stand still.
• Can mimic the agitation but the feature usually gets worse when the dosage is
increased.
• Treatment calls for dosage reduction.
4. Tardive Dyskinesia
• Usually occurs after years of treatment – facial grimaces, tics, tongue writhing, lip
smacking or puckering (fly-catcher), and abnormal movements in the neck, trunk,
and limbs.
• Usually are irreversible –older patients, Caucasians, females, and those who are in
high-potency antipsychotics are most at risk.
5. Neuroleptic Malignant Syndrome
• Rare, life-threatening – altered consciousness, hyperthermia, muscle rigidity,
unstable BP, tachycardia, myogolinuria, and sweating.
• Elevated WBC, creatinine kinase, and liver enzymes are common.
• Patients require immediate treatment – discontinue med, Bromocriptine may be
prescribed (reverses the dopamine-blocking effects); or Dantrolene (Dantrium)
(muscle relaxant).
6. Anticholinergic Reaction
• Antagonizes alpha-adrenergic and cholinergic receptors – cause peripheral
vasodilation, hypotension, orthostatic hypotension, and tachycardia.
• Cholinergic blockade may also result in constipation, dry mouth, and blurred vision.
• Suggest that the client chew gum or suck on hard candy or ice chips to alleviate dry
mouth. Adequate fluid and fiber may help relieve constipation tho some patients will
also require laxatives.
7. Seizures
• Lowers the brain’s seizure threshold.
• Low potency and clozapine pose the greatest threat.
8. Hyperprolactinemia
• Increase the secretion of prolactin – cause breast engorgement, galactorrhea, and
amenorrhea in female patients.
• Male patients may also develop enlarged breasts and face an increased risk of
impotence and azospermia (absence of sperm in the semen).
• Amantadine or Bromocriptine may also help relieve the problem.
9. Hepatic Changes
• Elevated hepatic enzymes.
10. Photosensitivity
• Advise them to wear a sunscreen and protective clothing.
11. Weight Gain
• Gain between 3 and 9 lbs.
TRADITIONAL AGENTS – PHENOTHIAZINES

DRUG DAILY HALF- ONSET AND COMMENTS
ORAL LIFE DURATION
DOSE (hrs)
Acetophenazine 40-120 mg 10-20 Onset: initial calming Watch for orthostatic
(Tindal) effects – 2-3 hrs; hypotension, sedation,
antipsychotic effect – TD,

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gradually seen over pseudoparkinsonism,
several weeks; NMS, agranulocytosis,
duration: 36-48 hrs urinary retention, blurred
vision, dry mouth, and
constipation.
Chlorpromazine 200-800 mg 30 Onset: initial calming Same as above
(Thorazine) effects –30-60 min;
antipsychotic effect –
seen as above;
duration: 4-6 hrs
Fluphenazine 2-10 mg 4.5-15 Onset: initial calming Same as above
(Prolixin) effects – 1 hr;
seen as above;;
duration: 10-20 hrs
Perphenazine 4-32 mg 9.5 Onset: initial calming Same as above
(Trilafon) effects – 2-6 hrs;
seen as above;;
duration: 6-12 hrs
TRADITIONAL AGENTS – NON-PHENOTHIAZINES
Haloperidol 3-15 mg 21-24 Onset: initial calming Same as above but risk
(Haldol) effects – 2 hrs; of sedation and
antipsychotic effect – hypotension is less than
seen as above;; with phenothiazines; the
duration: 36-48 hrs risk of EPS tho is
greater.
Loxapine 60-100 mg 19 Onset: initial calming Same as above
(Loxitane) effects – 30 min;
seen as above;;
duration: 12 hrs
Molindone 50-225 mg 1.5 Onet: varies; duration Same as haloperidol
(Moban) – 24-36 hrs
Thiotixene 6-60 mg 34 Onset: initial calming Same as above
(Navane) effects – 1-7 days;
2 weeks or more;
duration: up to 12 hrs
ATYPICAL AGENTS
Clozapine 150-450 mg 8-12 Onset: 2-4 wks; Monitor for
(Clozaril) duration: 4-12 wks agranulocytosis and
orthostatic hypotension;
less risk of EPS,
compared to traditional
agents
Olanzapine 5-4 mg 31-54 No available data on Agranulocytosis has not
(Zyprexa) onset and duration of been reported to date;
action watch for OH and
constipation; less risk of
EPS, compared to
traditional agents
Risperidone 2-3 mg 20-24 Onset: 2-4 wks; Same as above
(Risperdal) duration: 2 wks or
more
DRUG & USUAL ACTION NRSG CONSIDERATIONS AND POSSIBLE

ADULT DOSE SIDE EFFECTS

73
7
ANTIANXIETY DRUGS
Benzodiazepines: Produce a calming • To reduce daytime sedation, ask the MD for
Alprazolam effect by enhancing an order for a smaller dosage and allow the
(Xanax) 0.25- the action of the client to nap during the day until the body
0.5mg po BID/TID inhibitory adjusts to the medication.
Chlordiazepoxide neurotransmitter • Offer sugar-free drinks and candy to relieve
(Librium) 5-25mg GABA dry mouth.
po tid/qid • To avoid orthostatic hypotension, have the
Clonazepam client rise slowly.
(Klonopin) 0.05- • Because of lethargy and drowsiness, advise
0.2mg/kg/day po the client to avoid driving and operating heavy
Diazepam (Valium) machinery.
2-10mg po bid-qid
Lorazepam (Ativan)
2-6mg po OD in
divided doses
Antihistamine
Hydroxyzine Antihistamine- • Same as above
(Atarax, Vistaril) receptor blocking
• May be particularly useful in clients with
50-400mg po OD in agent, acts as a
anxiety and insomnia caused by itching or
divided doses nonspecific CNS
pruritus.
depressants.
ANTIDEPRESSANT DRUGS
Tricyclics (TCA) Blocks reuptake of • Before starting therapy, document baseline
Amitrityline (Elavil) norepinephrine and pulse rate, BP, and ECG. Monitor these
75-150mg/day po serotonin into CNS periodically to detect hypotension or
Amoxapine neurons arrhythmias.
(Asendin) 50mg po May also block • This drug is associated with a high incidence
tid dopamine receptors of drowsiness especially when therapy begins.
Desipramine (Amoxapine) Some MDs prefer to administer the entire daily
(Norpramin) 100- May also have dose at bedtime to minimize daytime
200mg day anxiolytic effects drowsiness.
Imipramine (Sinequan) • To reduce orthostatic hypotension, instruct the
(Tofranil) 50- client to rise slowly when sitting to an upright
150mg/day po as position. Measure and document the client’s
maintenance dose supine and standing BP; withhold the drug and
Trimipramine inform the nurse if systolic BP drops more than
(Surmontil) 75- 30 mmHg.
200mg/day • Offer sugar-free drinks and candy to relieve
Daxopin dry mouth.
(Sinequan) 75- • To detect urine retention, monitor urine output.
150mg/day Inform the nurse if output is low.
• Instruct the client to avoid over-the-counter
sympathomimetics (Trimipramine)
• Advise the client to take drug with food or milk
if it causes GI upset. (Trimipramine)
• A good choice for anxious client (Doxapin).
• Dilute the oral concentrate with juice; do not
mix with soda because ther are
incompatible (Doxapin)
• To reduce orthostatic hypotension, instruct the

Monoamine Increases levels of client to rise slowly when sitting to an upright
Oxidase Inhibitors CNS position. Measure and document the client’s
catecholamines by supine and standing BP; withhold the drug and
(MAOI) blocking their inform the nurse if systolic BP drops more than
Isocarboxacid
metabolism by MAO 30 mmHg.
(Marplan) 10-
• Warm the client to avoid foods high in
30mg/day
tyramine or tryptophan (chainti wine, aged

74
7
Phenelzine (Nardil) hard cheese, beer, liquor aged in wooden
15-60 mg/day casks, avocados, chicken livers, bananas,
Tranylcypromine chocolate, soy sauce, and meat tenderizers),
(Pamate) 30- large amount of caffeine, and non-
60mg/day po prescription drugs to prevent hypertensive
crisis.
• Offer sugar-free drinks and candy to relieve
dry mouth.
• To detect urine retention, monitor urine output.
Inform the nurse if output is low.
• Because of drowsiness, advise the client to
avoid driving and operating heavy machinery.
• To reduce orthostatic hypotension, instruct the

Blocks reuptake of client to rise slowly when sitting to an upright
Selective serotonin position. Measure and document the client’s
serotonin supine and standing BP; withhold the drug and
inform the nurse if systolic BP drops more than
Reuptake
30 mmHg.
Inhibitors (SSRI) • Avoid administering late in the day or at
Fluoxetine bedtime because this may cause insomnia.
(Prozac): initially If the client is taking more than 20g/day, give
20mg/day in AM, divided dose at breakfast and lunch.
ten increase as • Offer sugar-free drinks and candy to relieve
tolerated dry mouth.
• This drugs should not be used in

Inhibits reuptake of combination with a MAOI; fatal reactions
Paroxetine HCl serotonin have been reported. Allow 14 days between
(Paxil) 20-50mg po stopping paroxetine therapy and initiating
tid MAOI therapy as well as between stopping
MAOI and starting paroxetine.
• Advise client to refrain from ingesting
alcohol while taking paroxetine.
• Inform clients that some side effects (nausea
and dizziness) may abate after 4-6 wks.
Inhibits reuptake of • Offer sugar-free drinks and candy to relieve
Sertraline (Zoloft) serotonin dry mouth.
50mg po daily • No OTC drugs w/out consulting the MD.
• Same as above (Paroxetine)

• Observe for signs of hyponatremia, esp in
Blocks reuptake of older patients or patients also taking diuretics.
Novel Cyclic norepinephrine and
Antidepre serotonin into CNS • To reduce orthostatic hypotension, instruct the
neurons client to rise slowly when sitting to an upright
ssants position. Measure and document the client’s
Trazodone
supine and standing BP; withhold the drug and
(Desyrel) 150-
inform the nurse if systolic BP drops more than
400mg/day po
30 mmHg.
• Offer sugar-free drinks and candy to relieve
dry mouth.
Inhibits reuptake of • Because of drowsiness, advise the client to
serotonin avoid driving and operating heavy machinery.
Venlafaxine HCl
(Effexor) 75mg po
daily
• This drugs should not be used in

75
7
combination with a MAOI; fatal reactions
have been reported. Allow 14 days between
stopping Venlafaxine therapy and initiating
MAOI therapy as well as between stopping
MAOI and starting Venlafaxine.
• This drug should be given in divided doses and

taken with food to avoid nausea.
Exact mechanism is • It should not be discontinued abruptly.
unknown; used as a • Advise client to refrain from ingesting
Bupropion 2nd choice drug in alcohol while taking venlafaxine.
(Wellbutrin) 100- patient who do not • This drug may cause sexual dysfunction.
150mg po tid respond well to TCA • Offer sugar-free drinks and candy to relieve
dry mouth.
• This drug may increase BP. Monitor the
client’s BP for the 1st 6 weeks.
This drug should not be administered to

•
clients with eating d/o because of the high-
risk of induced seizures.
• Withhold meds and contact MD if CNS effects,
such as agitation or insomnia occur.
• This drugs should not be recommended for
breast-feeding mothers or pregnant
women. Educate female clients about birth
control while taking this meds.
• Monitor for orthostatic hypotension.
• Monitor for weight gain. Rapid weight gain
should be reported stat and measurement of
intake and output instituted.
MOOD STABILIZERS (Used to treat bipolar manic d/o)
Carbamazepine Exact mechanism • This drug my be used in clients who do not
(Tegretol) initially unknown respond to or tolerate lithium.
200mg po bid then • This drugs should not be administered to
200-600mg po in breast-feeding clients.
divided doses • Monitor cardiac functioning because heart
block may occur.
• If the drug is discontinued, the client must be
weaned.
• Monitor BUN values and be alert for
indications of renal failure.
• Instruct patient about CNS effects: drowsiness,
dizziness, and unsteadiness.
• Monitor electrolytes if vomiting or diarrhea
occurs for more than one day.
• Watch for signs of blood dyscrasia (aplastic
anemia or agranulocytosis).
• Be aware that an increased risk of neurotoxicity
exists when carbamazepine is used with
Lithium.
• Emphasize the need for routine blood studies,

Lithium Carbonate Reduces esp at the start of therapy, to monitor for
(Eskalith, Lithane, hyperactivity by therapeutic levels and prevent toxicity.
Lithobid, Lithonate, altering cationic Therapeutic levels are usually 0.5-1.2
Lithotabs) 1,800- exchange at the Na- mEq/L.
2,400mg during K pump. • Monitor for excessive weight gain.
acute mania, 300- • Offer sugar-free drinks and candy to relieve dry
1,200mg/day in mouth.
divided doses for • To relieve hand tremors, have the client perform

76
7
maintenance. an activity that controls tremors, such as
sewing or writing.
• Monitor diarrhea for severity. Have the client
was rectal area as often as needed. Report
this side effect to the nurse.
• Monitor lab results: report WBC over
11,000/microliter.
• If signs of toxicity occur, notify the nurse-
manager or supervisor and withhold meds.
S/sx of toxicity: persistent N&V, severe
diarrhea, ataxia, blurred vision, tinnitus,
excessive output of dilute urine, increasing
tremors, muscle irritability, mental confusion,
nystagmus, and seizures (in order of severity).
• Because of drowsiness, advise the client to
avoid driving and operating heavy machinery.
• Ensure adequate daily fluid intake to help
prevent toxicity.
• This drug my be used in clients who do not

Valproic Acid Exact mechanism respond to or tolerate lithium.
(Depakene) 15-30 not fully understood • Instruct client about potential drowsiness. Allow
mg/kg/dy po in client to nap if drowsy.
divided doses • Watch for signs of blood dyscrasia (aplastic
anemia or agranulocytosis).
• Perform alcohol assessment. Warn client that
alcohol may potentiate CNS effects. Avoid
alcohol.

77
7
ANTICONVULSANTS
Barbiturates • Used for prophylaxis for various seizure types,
May facilitate the
Phenobarbital actions of the principally tonic-clonic and partial seizures.
(Barbital) 100- inhibitory • Primidone is partially metabolized to
300mg/day neurotransmitter Phenobarbital; which adds to its anticonvulsant
effects.
Primidone (Mysoline) • Therapeutic effects require close monitoring of
maintenance dose is blood levels, esp in early therapy – 15-40
250mg po tid or qid mcg/ml (phenobarbilat); 6-12 mcg/ml
(primidone).
• Selection is based on the type of seizures and
may require multiple drug regimens.
• Some degree of CNS depression is common
and frequently decreases or disappears with
continued use. By starting low and gradually
increasing the dose, this side effect may be
minimized.
• Clients should be cautioned to avoid
hazardous activities that require mental
alertness or physical coordination until the
drug’s effects are known.
• Clinicians should be alert to the signs that
precede the3 onset of drug-induced cutaneous
lesions and reactions: high-fever, severe HA,
stomatitis, rhinitis, urethritis, and conjunctivitis.
• Blood counts, hepatic and renal fx should be
tested prior to and periodically throughout
therapy.
• Bone marrow depression progressing to fatal
aplastic anemia has occurred with nearly all
anticonvulsants. Client should report any
unusual bruising, bleeding, or signs of infection
(sore throat, fever).
• Epileptic pregnant women taking barbiturates
or primidone should receive Vit K prophylaxis
one month prior to and during delivery to
reduce the chance of drug-induced
hemorrhagic dse of the newborn. Neonates
should also receive Vit K stat after birth.
ANTIPARKINSONIAN AGENTS (used to treat EPS)

78
7
Anticholinergics  Offer sugar-free drinks and candy

Benztropine Counters EPS to to relieve dry mouth.
mesylate antipsychotic drugs  Monitor bowel movements. If
(Cogentin) 1- by blocking central constipation occurs, document it and ask the
4mg/day po or IM cholinergic nurse-manager about laxative order. Offer hi-
receptors and fiber foods.
Biperiden restoring the  My impair short term memory.
(Akineton) 2- balance of
6mg/day po IV or acetylcholine and
IM dopamine in the
basal ganglia.
Antihistamines A histamine-  May cause sedation. Client should

Diphenhydramine receptor blocking avoid hazardous activity until CNS effects are
(Benadryl) 75- agent: also blocks known.
200mg/day in 3-4 central cholinergic  Offer sugar-free drinks and candy
divided doses po receptors. to relieve dry mouth.
Trihexyphenidyl Same as
 Offer sugar-free drinks and candy
(Artane) 6- anticholinergics
to relieve dry mouth.
10mg/day po  Monitor bowel movements. If
constipation occurs, document it and ask the
nurse-manager about laxative order. Offer hi-
fiber foods.
 My impair short term memory.

79

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1

COMPONENTS OF MENTAL HEALTH

1. SELF-GOVERNANCE – autonomy, a sense of detachment, independence. And a

VARIABLES AFFECTING MENTAL HEALTH

1. BIOLOGICAL FACTORS – prenatal and perinatal influences, physical health,

MENTAL HEALTH ACCORDING TO ABRAHAM MASLOW

MENTAL HEALTH MENTAL ILLNESS

Bernardita T. Hernandez, RN,MAN

MISCONCEPTIONS ABOUT MENTAL ILNESS

1. Abnormal behavior is different, or odd, easily recognized.

THEORETICAL MODELS FOR WORKING WITH PSYCHIATRIC PATIENTS

PSYCHOANALYTICAL MODEL – Sigmund Freud

■ Emphasizes unconscious processes or psychodynamic factors as the basis for motivation

Bernardita T. Hernandez, RN,MAN

DEVELOPMENTAL / PSYCHOSOCIAL MODEL – Erik Erikson

■ Included psychosocial and environmental influences along with Freudan psychosexual

INTERPERSONAL MODEL – Harry Stack Sullivan

Bernardita T. Hernandez, RN,MAN

• Childhood (1 ½ - 6 yrs) – language assists with learning to delay the gratification

• Preadolescence (9 – 12 yrs) – collaboration and capacity for love assist n the

Bernardita T. Hernandez, RN,MAN

■ Sensorimotor (Infancy – Toddler)

BEHAVIORAL MODEL – Ivan Pavlov, John Watson, and BF Skinner

GENERAL SYSTEMS THEORY – Ludwig Von Bertalanffy

Bernardita T. Hernandez, RN,MAN

NATURAL SYSTEMS THEORY (FAMILY SYSTEMS) – Murray Bowen

Bernardita T. Hernandez, RN,MAN

GROWTH AND DEVELOPMENT

EXPECTED STAGE OF PLAY DEVELOPMENT

TERMS AND CONCEPTS

ANXIETY / ANXIETY-RELATED DISORDERS

Bernardita T. Hernandez, RN,MAN

Precipitating Factors to Anxiety

■ Level Zero: EUPHORIA

Bernardita T. Hernandez, RN,MAN

PHYSIOLOGIC CHANGES DURING ANXIETY SITUATION

COPING WITH ANXIETY

Bernardita T. Hernandez, RN,MAN

NURSING INTERVENTIONS IN ANXIETY

NURSING INTERVENTIONS TO REDUCE ANXIETY

■ PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA

Bernardita T. Hernandez, RN,MAN

Bernardita T. Hernandez, RN,MAN

Bernardita T. Hernandez, RN,MAN

Bernardita T. Hernandez, RN,MAN

Bernardita T. Hernandez, RN,MAN

CRISIS / CRISIS INTERVENTION

Bernardita T. Hernandez, RN,MAN

Bernardita T. Hernandez, RN,MAN

PERSONALITY and PERSONALITY DISORDERS

■ PERSONALITY – the totality of a person’s unique biopsychosocial-spiritual traits and

Bernardita T. Hernandez, RN,MAN

■ Theories of Personality Development

■ FRUED’S PSYCHOANALYTIC THEORY

Bernardita T. Hernandez, RN,MAN

■ ERIKSON’S SYCHOSOCIAL THEORY

Infancy Trust vs mistrust Trust self and others Demonstrates an inability

■ PIAGET’S COGNITIVE DEVELOPMENTAL THEORY

■ Causes of Personality Disorders

Bernardita T. Hernandez, RN,MAN

TYPES ASSESSMENT ANALYSIS NURSING

Bernardita T. Hernandez, RN,MAN

Bernardita T. Hernandez, RN,MAN