Review in Psychiatric Nursing

PSYCHOLOGICAL THEORIES

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

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

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

Mechanism Definition Example

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

A youth with residual muscle damage from poliomyelitis becomes an

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

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

a person having an extramarital affair gives no thought to the possibility of

pregnancy.

persons living near a volcano disregard the dangers involved.

a disabled person plans to return to former activities without planning a

realistic program of rehabilitation.

Displacement Discharging pent-up feelings to a less A man who is angry at his boss comes home and yells at his wife.
threatening object.
Dissociation Unconscious separation of painful A rape victim tells that she felt as if she were outside of her body watching
feelings from an unacceptable idea, what was happening.
situation, or object.

Some dissociation is helpful in keeping

one portion of one's life from interfering
with another (e.g., not bringing problems
home from the office). However,
dissociation is responsible for some
symptoms of mental illness; it occurs in
"hysteria" (certain somatoform and
dissociative disorders) and
schizophrenia, The dissociation of
hysteria involves a large segment of the
consciousness while that in
schizophrenia is of numerous small
portions. The apparent splitting of affect
 from content often noted in
schizophrenia is usually spoken of as
dissociation of affect, though isolation
might be a better term.

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

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

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

The individual deals with emotional

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

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

Projection Blaming someone else for one’s A husband forgets to pay the bill and blames his wife for not reminding him.
difficulties.

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

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

Regression Return to an earlier, more comfortable A 6 year old begins to wet his pants following the birth of his baby sister.
level of functioning.

Repression Involuntary and unconscious forgetting A accident victim becomes amnesic about the details of the accident, but
of painful ideas, feelings and events. was aware at that time.

Restitution Attempting to restore unconscious guilt A nurse who regrets not caring for her mother when she was dying because
feelings. of anger chooses to work with terminal patients.

Sublimation Channeling instinctual drives into A man with excessive sexual drives becomes a successful nude painter.
acceptable activities.

Substitution Replacement of unacceptable objects or A woman who wants to marry a man exactly like her dead father marries
need with one that is more acceptable. someone who looks a little bit like him.

Suppression Conscious exclusion of anxiety A woman says she is not ready to talk about her condition.
producing feelings or ideas from
awareness.

Symbolization An external object is made to symbolize A young woman gives flowers and chocolates to his girlfriend.
an internal feeling or idea.

Undoing Doing something to counteract or relieve A mother spanks her child and brings home a gift for him the next day.
guilt feelings.
THERAPEUTIC COMMUNICATION
Technique Definition
Using Silence Gives person time to think and say more.
Accepting Receiving information in a non-judgmental
manner. Does not necessarily indicate
agreement.
Giving recognition Shows awareness of change or efforts. Does
not imply right or wrong.
Offering self Making self available and showing interest,
concern and desire to understand.
Giving broad openings Clarifies that the lead is to be taken by the
client
Offering general leads Using neutral expressions to encourage the
client to continue talking.
Placing the events in time or Asking for relationships among events.
sequence
Making observations Commenting on what is seen or heard to
encourage discussion of feelings and
thoughts. Helpful with withdrawn patients.
Encouraging descriptions of Asking for client’s views of their situation.
perceptions
Voicing doubt Expressing uncertainty about the reality of
client’s perceptions and conclusions, used
when the nurse wants to explore other
explanations.
Presenting reality Offering a view of what is real and not,
without arguing with the client.
Encouraging comparison Asking for similarities and differences
among feelings, behavior and events.
Restating Repeating the main idea expressed
Reflecting Directing feelings and ideas back to the
client.
Focusing Concentrating on a topic until its meaning
is clear.
Exploring Looking at certain ideas more fully.
However, if the patient chooses not to
elaborate, the nurse should not pry.
Giving information Providing information that will help clients
make better choices.
Seeking clarification Clarifying vague communications, help
clients clarify own thoughts.
Verbalizing the implied Rephrasing or putting into concrete terms
what the client implies to highlight an
underlying message.
Example
Yes.
Uh hmm
I follow what you say
I’m with you
Good morning, Mr. Santos
I noticed you shaved this morning.
You’ve combed your hair
I’ll sit with you for a while.
I would like to spend some time with you.
Where would you like to begin?
What are you thinking about?
What would you like to discuss?
Go on.
And then.
Tell me about it.
What lead up to…?
What happened before?
When did this happen?
You seem restless.
I noticed you’re biting of lips.
You appear tense when you…
What is happening to you right now?
What does the voice seem to be saying?
That doesn’t sound like it.
Isn’t that unusual?
I know the voices are real to you, but I don’t hear them.
You are not in heaven, you are in the hospital.
Has this ever happened to you before?
Is this the way u felt when..?
Pt: I can’t sleep. I stay awake all night.
Nurse: You have difficulty sleeping?
Patient: do you think I should?
Nurse: Do you think you should?
Patient: My brother spends all the money and still has the nerve
to ask for more
Nurse: This makes you angry?
Explain more about…
This point seems worth looking at more closely.
Tell me more about…
Can you describe it more fully?
I am…
My purpose on being here is…
This medication is for…
The rules and regulations of this ward are…
What do you mean by…?
What is the main point of what you just said?
I’m not sure I follow you.
Patient: There is nothing to do at home.
Nurse: It sounds you might be bored at home.
Patient: I can’t talk to you or to anyone. It’s only a waste of
time.
 Nurse: Do you feel no one understands?

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

Technique Definition Example

Reassuring Closes off the communication by giving Don’t worry.
information that is not based on facts and You’ll feel better tomorrow.
truth. Everything will be alright.

Giving approval Encourages the client to continue doing That is good.

something for the sake of the nurse’s
approval rather than for own learning.

Rejection This is a communication barrier since the Talk to the doctor about this.
patient may avoid expressing his or her own
thoughts / feelings to avoid the risk of
rejection.

Disapproving Denies the client’s thoughts and feelings by That is not good.
implying that the nurse has the right to I’d rather you wouldn’t.
judge the client and the client has to please
the nurse.

Agreeing Provides no opportunity for the patient to That’s right.

change their views. I agree.

Disagreeing Challenging the patient to defend his/her I disagree with that.

thoughts and feelings which serves as a
hindrance in the communication process.

Advising Fosters dependency and inhibits the I think you should…

problem-solving process.

Probing Communication barriers that may make the Tell me about…

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

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

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

Requesting an explanation “Why” questions require analysis of the Why did you?
problem which increases anxiety. Patient
may respond defensively.

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

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

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

Using denial Closes off the communication by failing to Patient: I’m nothing
identify the feelings and thoughts of the Nurse: Of course you’re something, everybody’s something.
patient.

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

ADULT MANIFESTATIONS OF ERICKSON’S STAGES OF DEVELOPMENT

Life stage Adult behaviors reflecting mastery
Trust vs. mistrust (0- • Realistic trust of self and others
18 mos.) • Confidence in others
• Optimism and hope
• Shares openly with others
• Relates to others effectively
Autonomy vs. Shame • Self control and willpower
and doubt (18 mos.- 3 • Realistic self concept and self-esteem
yrs.) • Pride and a sense of goodwill
• Simple cooperativeness
• Generosity tempered by withholding
• Delayed gratification when necessary
Initiative vs. Guilt (3- • An adequate conscience
5 yrs) • Initiative balance with restraint
• Appropriate social behaviors
• Curiosity and exploration
• Healthy competitiveness
• Sense of direction
• Original and purposeful activities
Adult behaviors reflecting developmental problems
• Suspiciousness/testing others
• Fear of criticism and affection
• Dissatisfaction and hostility
• Projection of blame and feelings
• Withdrawal from others
Or
• Overly trusting of others
• Naïve and gullible
• Shares too quickly and easily
• Self doubt/self conscious
• Dependence on others for approval
• Feeling of being exposed/ attacked
• Sense of being out of control of the self and one’s life
• Obsessive compulsive behaviors
Or
• Excessive independence or defiance, grandiosity
• Denial of problems
• Unwillingness to ask for help
• Impulsiveness
• Recklessness regarding safety for self and others
• Excessive guilt/embarrassment
• Passivity and apathy
• Avoidance of activities/pleasures
• Rumination and self pity
• Assuming a role as victim/self-punishment
• Reluctance to show emotions
• Underachievement of potentials
Or
• Lack of follow-up on plans

Industry vs. inferiority • Sense of competence
(6-12 yrs.) • Completion of projects
• Pleasure in efforts and effectiveness
• Ability to cooperate and compromise
• Identification with admired others
• Joy of involvement in the world and
with others
• Balance of work and play
Identity vs. role • Confident of self
confusion (12-18 yrs) • Emotionally stable
• Commitment to career planning and
realistic long-term goals
• Sense of having a place in society
• Establishing an intimate relationship
• Fidelity to friends
• Development of personal values
• Testing out adults
Intimacy vs. isolation • Ability to give and receive love
(18-25 or 30 years) • Commitment and mutuality with others
• Collaboration in work and affiliation
• Sacrificing for others
• Responsible sexual behaviors
Generativity vs. • Productive, constructive, creative
stagnation (30-65 activity
years) • Personal and professional growth
• Parental and societal responsibilities
Integrity vs. despair • Feelings of self-acceptance
(65 yrs. to death) • Sense of dignity, worth, and importance
• Adaptation to life according to
limitations
• Valuing one’s life
• Sharing of wisdom
• Exploration of philosophy of life and
death
PIAGET’S COGNITIVE DEVELOPMENTAL THEORY
Sensorimotor Stage (0-2) senses
• Little sense of guilt for actions
• Excessive expressions of emotion
• Labile emotions
• Excessive competitiveness/showing off
• Feeling of unworthiness and inadequacy
• Poor work history (quitting, being fired, lack of promotions,
absenteeism, lack of productivity)
• Inadequate problem solving skills
• Manipulation of others/ violation of others’ rights
• Lack of friends of the same sex
Or
• Overly high achieving/ perfectionists
• Reluctance to try new things for fear of failing
• Feeling unable to gain love of affection unless totally successful
• Being a workaholic
• Feelings of confusion, indecision and alienation
• Vacillation between dependence or independence
• Superficial, short-term relationships with another person
Or
• Dramatic overconfidence
• Acting out behaviors (including alcohol and drug abuse)
• Flamboyant display of sex role behaviors
• Persistent aloneness/isolation
• Emotional distance in all relationships
• Prejudices against others
• Lack of established vocation; many career changes
• Seeking of intimacy through casual sexual encounters
Or
• Possessiveness and jealousy
• Dependency on parents and/or partner
• Abusiveness towards loved ones
• Inability to try new things socially or vocationally (staying in
routine/ mundane job/activities
• Self-centeredness/ self-indulgence
• Exaggerated concern for appearance and possessions
• Lack of interest in the welfare of others
• Lack of civic or professional activities/responsibilities
• Loss of interest in marriage and/or extramarital affairs
Or
• Too many professional or community activities to the detriment
of the family or self
• Sense of helplessness, hopelessness, worthlessness, uselessness,
and/or meaninglessness
• Withdrawal and loneliness
• Regression
• Focusing on past mistakes, failures and dissatisfactions
• Feeling too old to start over
• Suicidal ideas or apathy
• Inability to occupy self with satisfying activities (hobbies,
volunteer work, social events)
Or
• Inability to reduce activities
• Overtaxing strength and abilities
• Feeling indispensable
• Denial of death as inevitable
Preoperational thought stage (2-7)
Preconceptual-learning to think in mental images (2-4)
Intuitive- egocentrism (4-7)
Concrete operational stage (8-12) - more logical and has concepts of morality, numbers and spatial relationships
Formal operational (12- ) - adult logic and reason

RULES FOR PSYCHOTHERAPEUTIC MANAGEMENT Orient patient to time, person and place
Do not touch patients without warning them
Provide support, treat patients with respect and dignity Avoid whispering or laughing when patients are unable to hear all of
Uplift patient’s self-esteem, don’t patronize the conversations
Do not place patients in situations wherein they will feel inadequate Reinforce positive behaviors
or embarrassed Avoid competitive activities with some patients
Treat patients as individuals Do not embarrass patients
Provide reality testing For withdrawn patients, start with one-to-one interactions
Handle hostility therapeutically Allow and encourage verbalization of feelings
Provide psychopharmacologic treatment Be calm when talking to patients
Accept patients as they are but do not accept all behaviors
BASIC PRINCIPLES IN DEVELOPING THERAPEUTIC Keep promises
NURSE-PATIENT RELATIONSHIP Be consistent
Be honest
Do not reinforce or argue a patients hallucinations or delusions
CHARACTERISTICS OF A MENTALLY HEALTHY PERSON

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

CHARACTERISTICS OF MENTAL ILLNESS

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

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

PREVENTION OF MENTAL ILLNESS o Child guidance centers

o Crisis intervention center
PRIMARY PREVENTION- involves the promotion of general mental o Geriatric center
health and protection against the occurrence of specific diseases. Primary • Mental health education
prevention aims to prevent the onset of a disease or a disorder, thereby
reducing the incidence (number of of new cases occurring in a specific SECONDARY PREVENTION- early identification and effective
period in time). treatment of an illness or disorder, with the goal of reducing the
• Elimination of etiological agents prevalence (total number of existing cases in a year) is the aim of
• Reducing risk factors secondary prevention.
• Enhancing host resistance or interfering with disease • Population screening
transmission • Crisis intervention services
• Reducing stress factors • Mental health education
• Counseling
o Student’s counseling TERTIARY PREVENTION- aims to reduce the prevalence of residual
o Marriage counseling defect or disability due to illness or disorder. It involves rehabilitation
o Sex counseling after defect and disability have been fixed. Community reintegration is
o Genetic counseling also part of tertiary prevention.
• Special centers
 CRISIS
• Refers to the state of the reacting individual who finds himself in a hazardous situation in which the habitual problem solving activities are
not adequate and do not lead to rapidly to the previously achieved balance state.

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

CONCEPT OF LOSS

GRIEF- is the process of coping with a loss.

STAGES OF DEATH AND DYING (KUBLER-ROSS)

• Denial and isolation
• Anger
• Bargaining
• Depression
• Acceptance

STAGES OF GRIEF
• Shock and disbelief
• Developing awareness
• Restitution and resolution of the loss

COPING REACTION TO DEATH THROUGHOUT THE LIFE CYCLE

• Toddler (1-3 yo)

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

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

• Preschooler (3-5 yo)

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

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

• School Age (5-12)

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

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

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

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

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

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

SCHIZOPHRENIA

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

BLEULER’S FOUR A’S OF SCHIZOPHRENIA

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

Subtypes: o Posturing
o Stereotyped movements
Paranoid Type o Prominent mannerisms
• Dominant: hallucinations and delusions o Prominent grimaces
• No disorganized speech, disorganized behavior, catatonia, or • Echolalia and echopraxia
inappropriate affect present.
• Preoccupied with 1 or more systematized delusions or with Residual
frequent auditory hallucinations related to a single theme. o No longer has active phase symptoms (e.g. delusions,
hallucinations, or disorganized speech and behaviors)
Disorganized type o However, persistence of some symptoms is noted, e.g.
• Dominant: disorganized speech and disorganized behavior and o Marked social isolation or withdrawal
inappropriate affect. o Marked impairment in role function (wage earner,
• Delusions and hallucinations, if present, are not prominent or student or home maker)
fragmented. o Markedly eccentric behavior or odd beliefs
• Associated features including grimacing, mannerisms and other o Marked impairment in personal hygiene
oddities of behavior. o Marked lack of initiative, interest , or energy
• Incoherence o Blunted or inappropriate affect
• Looseness of associations
• Grossly disorganized behavior Undifferentiated type
• Flat or grossly inappropriate affect o Has active phase symptoms (does have hallucinations,
delusions, and bizarre behaviors). Prominent delusions,
Catatonic hallucinations, incoherence or grossly disorganized behavior.
• Motor immobility (waxy flexibility or stupor) o No clinical presentation dominates e.g.
• Excessive purposeless motor activity (agitation) o Paranoid
• Extreme negativism or mutism o Disorganized
• Peculiar voluntary movements o catatonic

POSITIVE SYMPTOMS OF SCHIZOPHRENIA Abnormal thought form

Hallucinations Bizarre behavior
Delusions Develops over a short time

TYPES OF DELUSIONS Pathoanatomy:

1. Persecutory- suspicious of people and believes that others are Hyperdopaminergic process
trying to harm him, trying to kill and poison him. No structural changes
2. Grandiosity- suddenly the person starts to harbour a false NEGATIVE SYMPTOMS
belief that he is extraordinarily powerful, wealthy and a very Alogia (poverty of speech)
important person. He believes that he can achieve anything Affective flattening
and everything, and feels that all the world is under him. Anhedonia (lack of pleasure)
3. Jealousy or infidelity- false belief that his spouse is unfaithful Attentional impairment
and is having extramarital affairs. Avolition (poor motivation)
4. Control ( Passivity Phenomenon)- false belief that his Asocial behavior
thoughts , actions and feelings are all not his own but are being Anergia (lack of energy)
controlled by some external agencies.
Pathoanatomy:
5. Nihilistic- false belief that the world is going to end or his Nondopaminergic process
body parts are missing. Structural changes
6. Ideas of reference- the person has false idea that people Increased ventricular brain ratio
around him talk about him and make fun of him. Decreased cerebral blood flow
.

SCHIZOPHRENIC PROGNOSIS

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

Etiology: Poor ego boundaries

Fragile ego
BIOLOGICAL Inadequate ego development
Biochemical theories Love-hate relationships
Dopamine hypothesis Arrested psychosexual development
Excessive dopaminergic activity in cortical areas are responsible for the Erikson and Sullivan
acute positive symptoms of schizophrenia. This maybe due to Absence of warm, nurturing attention during the early
increase in the synthesis of dopamine, increase release or turnover childhood years
of dopamine, or increase in number of dopamine receptors Blocks the expression of those same affective responses during
the later years
NEUROSTRUCTURAL THEORIES Disordered social interactions, avoid social interaction due to
Negative symptoms are due to pathoanatomy: increased ventricular painful childhood experiences
brain ratio, brain atrophy, and decreased cerebral blood flow
FAMILY THEORIES
GENETIC THEORIES Lack of loving and nurturing primary caregiver
Inconsistent family behaviors
VIRAL INFECTIONS AND FETAL INSULTS Faulty communication patterns

PSYCHODYNAMIC THEORIES VULNERABLE STRESS MODEL

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

DISRUPTIVE PATIENTS Help patients to participate in decision making as appropriate.

Set limits on disruptive behavior Provide patients with opportunities for non-threatening socialization with
Decrease environmental stimuli the nurse on a one-to-one basis.
Frequently observe escalating patients in order to intervene. Reinforce appropriate grooming and hygiene (assist first if needed)
Modify the environment to minimize objects that can be used as weapons Provide remotivation and resocialization group experiences. Often
Be careful in stating what the staff will do if a patient acts out; however students work with occupational or recreational therapists to provide
follow through once a violation occurs these experiences.
When using restraints, provide for safety by evaluating the patient’s Provide psychosocial rehabilitation.
status of hydration, nutrition, elimination, and circulation.
SUSPICIOUS PATIENTS
WITHDRAWN PATIENTS Be matter-of-fact when interacting with these patients.
Arrange nonthreatening activities that involve these patients in “doing Staff members should not laugh or whisper around patients unless the
something”. patients can hear what is said. The nurse should clarify any
Arrange furniture in a semicircle or around a table so that patients are misconceptions that patients have.
forced to sit with someone. Interactions are permitted in this Do not touch suspicious patients without warning. Avoid close physical
situation, but should not be demanded. Sit in silence with patients contact.
who are not ready to respond. Some will move the chair away
despite the nurses’ efforts
Patients who fear being poisoned should be allowed to open a can of Have staff members available in the dayroom so that patients can talk to
food and serve themselves. Obviously, this maybe difficult top real people or real events
arrange in some hospital settings. Paging systems may reinforce perceptual problems and should be
Maintain eye contact. eliminated if possible.
Do not “slip” medications into juices or food without talking to patients.
Catching the nurse in the act of doing this will reinforce theirDISORGANIZED PATIENTS
suspicious. Remove disorganized patients to a less stimulating environment.
Provide a calm environment; the staff should appear calm.
PATIENTS WITH IMPAIRED COMMUNICATION Provide safe and relatively simple activities for these patients.
Provide opportunities for patients to make simple decisions. Provide information boards with schedules and refer to them often so
Be patient and do not pressure patients to make sense. patients can begin to use this as an orienting function
Do not place patients in group activities that would frustrate them, Help protect each patient’s self esteem by intervening if a patient does
damage their self-esteem, or overtax their availability. something that is embarrassing.
Provide opportunities for purposeful psychomotor activity. Assist with grooming and hygiene.

PATIENTS WITH DISORDERED PERCEPTIONS

Attempt to provide distracting activities.
Discourage situations in which patients talk to others about their
perceptions.
Monitor television selections. If you cannot sensor programs, be
available to explain, discuss, and clarify following programs
Monitor for command hallucinations that may increase the potential for
patients to become dangerous.
PATIENTS WITH ALTERED LEVELS OF ANXIETY

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

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

OTHER PSYCHOTIC DISORDERS

DELUSIONAL DISORDER

Difference between delusional disorder and schizophrenia

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

BRIEF PSYCHOTIC DISORDER

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

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

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

MOOD DISORDERS

MAJOR DEPRESSION Psychomotor retardation or pronounced reduced mental and physical

Chronic Fatigue activity
Psychomotor agitation or pronounced agitated mental and physical Due to a chemical imbalance or deficiency of certain
activity neurotransmitters in the brain. These neurotransmitters are
Sleep disturbances norepinephrine, serotonin and dopamine
Disturbance in appetite Psychodynamic Theories
GI complaints Debilitating Early life experiences
Impaired libido Intrapsychic conflict
Apathy Reactions to life events
Sadness
Hopelessness PSYCHOTHERAPEUTIC NURSE-PATIENT RELATIONSHIP
Helplessness/ ruminations of inadequacy Accept them as they are. Help them focus on the positive.
Thoughts of Death Keep self help strategies simple
Spontaneous crying without apparent cause Be honest to develop trust.
Dependency Be sincere and empathic
Passiveness Point out even small accomplishments and strengths to a depressed
Anhedonia patient
Lack of interest in self care Reward patients who try to be independent
Deep sense or feeling of sadness Should not embarrass patient
Anxiety Never reinforce hallucinations, delusions or irrational beliefs
Unconscious anger or hostility directed inward Recognize anger. Encourage verbalizations
Guilt feelings Spend time with the withdrawn patient
Indecisiveness Provide opportunities for independent decision making without any
Lack of self-confidence pressure

Objective signs of depression:

Alterations in activity PATIENTS WITH LOW SELF-ESTEEM

Psychomotor agitation Encourage to participate in individual and group activities to experience
Unable to sit still accomplishments and receive positive feedback.
Pacing and engaging in hand wringing Provide assertiveness training.
Pulling or rubbing the hair, skin, clothing or other objects Help patients avoid embarrassment through socially unacceptable
Psychomotor retardation behaviors and appearance.
Slowing of speech
Decreased frequency of speech WITHDRAWN PATIENTS
Increased pauses before answering Keep brief but frequent contacts.
Soft or monotonous speech (dysprosody) Include these patients in group activities
Muteness
General slowing of body movements ANOREXIC PATIENTS
Change in sleeping patterns Encourage to eat and spoon feed them if necessary
Change in eating behaviors Allow patients to choose their food
Negligence of personal hygiene Provide small frequent feedings and record intake.
Altered socialization Monitor and record bowel elimination. Since constipation is a side effect
Easily distracted of anti-depressant, include high fiber foods in the patient’s diet.
Underachievement leading to lack of productivity on the job Allow patients to eat food from their home if he prefers it.
Withdrawn
PATIENTS WITH SLEEP DISTURBANCES
Subjective Signs: Depressed patients want to sleep but suffer insomnia. They may be seen
Alterations in affect lying in their beds most of the time but this does not necessarily mean
Overall affective sense is one of low self-esteem that they are sleeping or resting.
Guilt For patients taking TCA, combining the daily dose in just one single dose
Alterations in cognition at bedtime will decrease daytime sleepiness.
Ambivalence and indecision Discouraging patients to have day naps would help in their wanting to
Inability to concentrate sleep at night.
Confusion Depressed patients who prefers to sleep most of the time should not be
Loss of interest and motivation given daytime access to their rooms. Activities could be substituted
Pessimism, self blame, self depreciation for daytime napping.
Self destructive thoughts and thoughts of death and dying
Alterations of a physical nature PATIENTS WITH POTENTIAL FOR SELF-INJURY AND
Complaints of abdominal pain, anorexia, chest pain, dizziness, SUICIDE
fatigue, headache Self-injury- act of deliberate harm to one’s own body
Preoccupation with the body Suicide- intentional, deliberate acts of ending one’s life that are a result
(+) panic attacks of considerable thought and planning
Alterations of perceptions
(+) delusions (somatic and nihilistic) Suicide clusters
(+) hallucinations Mild intent- reflects action of the person who has thought of suicide and
maybe trying to solve a problem situation through suicide threat or
Etiology: gesture.
Biological theories Has intense need for attention and recognition
Done to manipulate or blackmail another
Moderate intent
 Serious to end life but ambivalent Lack of interest
Lethal intent Social withdrawal
Fully expected to die Flat, sad affect
Method and timing are meant to be fatal Decreased interest in sex
Suicidal talks and acts
Assessment of suicidal behavior Gives away personal things
Direct warning
Depressed behavior Mental changes
Frequent talks about death, wanting to be dead, appears to be in deep Negative self concept
thought Negative expectations of the future
Changes in social behavior Impaired concentration
Social withdrawal, suddenly feels very happy after being depressed, Exaggerated view of problems
collects potentially dangerous items, gives away personal things Suicidal ideations and thoughts of death

Assessment of suicidal behavior Care strategies

Making final plans Be available to the patients, have someone to stay with them. Provide
Suicide history structure and assistance
Use of drugs and alcohol Take the patient seriously
Commanding hallucinations Provide one-one supervision
Restrict to the ward
Signs and symptoms Supervise eating, toileting, smoking, sleeping
Make rounds at irregular times
Physiological changes Assess and evaluate for changes
Disturbance in sleep pattern Help patient to evaluate strengths and other ways to cope such as seeking
Fatigue interpersonal support or other anxiety reducing activities
Anorexia with accompanying weight loss Provide a safe environment in which the patient is protected and cared
Constipation or diarrhea for until the impulses are controlled
Shift in mood during the day Maintain a safe unit
Somatic complaints Remove potentially harmful objects and supervise use of razors, mirrors,
Psychomotor retardation pointed objects, lotions, drugs, chemicals…
Agitation and restlessness Use seclusion but ensure that patient is within sight and seconds away
Encourage the patient to verbalize feelings and plans
Behavioral Obtain a “NO SUICIDE” contract
Loss of motivation

BIPOLAR DISORDERS
Psychomotor overexcitability or excitement Objective behaviors
Insomnia with fatigue Disturbances of speech
Euphoria or elated mood Altered Social, interpersonal and occupational relationships
Distractability Manipulation of self esteem of others
Pressured speech Ability to find vulnerability in others
Flight of ideas Ability to shift responsibility
Manipulative or demanding behavior Limit testing
Destructive or combative behavior Alienation of family
Delusions of grandeur Alteration in activity and appearance
Impaired judgment Hyperactive and agitated
Pacing
Continuum of symptoms associated with Mania Flamboyant gestures
Mild (“high”) Colorful dresses
Transient feeling of elation; a high feeling Lack of sleep and poor nutrition
Feelings of well-being, confidence
Minor alterations in habit and activity patterns Subjective behaviors:
Moderate (Hypomania) Alterations in affect
Clear sense of euphoria Alterations of perception
Talkativeness, pressured speech
Flight of ideas Etiology:
Grandiosity, excessive spending Psychodynamic theories
Hypersexuality Family dynamics
Impulsivity Mania as a defense
recklessness
Biological theories
Severe( “mania”/ euphoria) Imbalance between cholinergic and noradrenergic systems.
Hyperactivity Depression-increased cholinergic activities; mania- increased
Talkativeness noradrenergic activity.
Flight of ideas
Inflated self esteem Psychotherapeutic management:
Decreased need for sleep Safety
Distractability Clear, concise directions and comments
Excessive buying, sexual indiscretions Limit setting
Reinforcement of reality
Provide a homogenous group , if possible Behavioral cues
Verbal- raising voice, shouting, speaking profanities, threatens,
MANIPULATIVE PATIENT suspicious, makes demands.
Manipulation refers to a coping strategy that a person employs to get Non-verbal- excessive psychomotor activity, pacing about, fist clenching,
one’s needs met without regard for others intensified facial expression, threatening stances, violent gestures
To cope with unmet needs for trust, security and control
Care strategies
Typical behaviors Check for any history of violence
Assuming instant intimacy Observe current behavior
Using flattery Observe physical distance in approaching the patient
Claiming Entitlement Ensure space on both sides
Splitting Assume an oblique position instead of direct approach
Categorizes providers as ‘good’ or ‘bad’ based on whether the staff has Avoid aggressive posture
done what the patient wants Utilize active listening
Ignites power struggles Utilize restraints or limit setting
Assess patients need for seclusion or physical restraints
Care strategies
Limit setting PHYSICAL RESTRAINT AND SECLUSION
Establish boundaries
Put restrictions on problematic behaviors Indications:
Communicate constantly Prevent imminent harm to the patient or other person
Introduce shift nurses to illustrate shift-shift teamwork Prevent serious disruption of the treatment program or serious damage to
Acknowledge grievances without defensiveness the physical environment
Use clear, direct, specific approach when setting limits To provide control to psychotic symptoms that are severe and causing
Enforce limits consistently serious psychological pain
Use clear, direct, specific approach when setting limits Decrease stimulation a patient receives.
Enforce limits consistently
Let the patient know that you are available and won’t abandon them Important policies to consider:
Firm kindness approach Restraints and seclusions must be ordered by the physician
Informed consent
Sexually provocative behavior Policies should be explained to the relatives
This behavior can be overt or covert and influenced by age, gender, and Explain to the patient the purpose of the restraint and the seclusion
cultural mores Ensure a safe environment
Employed by patients who needs to prove his worth Teamwork is essential
Represents and unconscious bid for friendliness, warmth, attention to Patient should not be abandoned. Must be monitored and evaluated
feelings of loneliness, alienation, or social isolation. regularly
Effort to compensate Nobody except the staff shall remove the restraints
Impaired body image or functioning
Regression Care strategies:
Initial action and objective is to talk down the patient and guide away
Sexually provocative behaviors from the extraneous stimulus
Flirting Give prn medication if ordered and set a contract
Excessive use of flattery Form a four-man restraining team
Touching in sexually suggestive manner Choose a restraint leader and designate the role of each member of the
Commenting on staff’s behaviors or body parts team
Making sexist remarks Present to the patient a “show of force” by gathering sufficient personnel.
Discussing sexual prowess Designate a seclusion marshal who would clear the are of other patients
and any physical obstruction
Sexually provocative behavior care strategies State clearly the purpose and rationale of the procedure
Clarify one’s role as a nurse. Set boundaries Ensure correct team positioning
Redirect personal questioning Ensure that when restraining the patient, care must be observed to avoid
Document interactions and behaviors injury by holding on the patient’s joints
Develop a consistent approach Assume an oblique position in approaching the patient
Evaluate pre-existing problems that may affect behavior Approach the patient calmly and promptly
Set limits on behaviors Use proper body mechanics and maintain physical contact at all times.
Give positive reinforcements when appropriate Use cross chest carry while other members hold the extremities
Restrain the patient on 4 extremities using a double knot type, with a
Violent and agitated behavior fingerbreadth allowance so as not to impede blood circulation.
Ensure proper body position is maintained
Agitation- anxiety associated with severe motor restlessness Isolate the patient with the head away from the door
Potential violence- a growing tension and less ability to control it Give tranquilizers or sedatives prescribed by the physician
Actual violence- an act of aggression towards others, to self or objects in Debrief family with regards to restraining and isolation. Ensure that the
the environment patient’s need for elimination, food intake, comfort and safety are met
Assess if the patient’s behavior is under control and no longer possess a
VIOLENT AND AGITATED BEHAVIOR threat to self or others
 SEXUAL DISORDERS • Orgasm disorder
Inability to achieve orgasm
SEXUAL DYSFUNCTION • Sexual pain disorder
• Characterized by the inhibition of sexual appetite or Suffer genital pain (dyspareunia) before, during and after
psychophysiological changes that compromise the sexual response cycle intercourse
Vaginismus
THE SEXUAL RESPONSE CYCLE
Desire phase PARAPHILIAS
Excitement phase Sexual instinct is expressed in ways that are socially prohibited
Orgasm phase or unacceptable and are biologically undesirable.
Resolution phase
Types:
Types: Pedophilia- victim: <13 y/o; pedophile: >_ 16 y/o or at least 5 years older
• Sexual desire disorder Incest
Have little or have no sexual desire or an aversion to sexual Exhibotionism
contact Fetishism- inanimate objects
• Sexual arousal disorders Frotteurism- rubbing one’s genitals against an unconsenting individuals
Cannot attain the physiologic requirements for sexual intercourse thighs or buttocks
e.g. Sexual masochism
Women-lubrication hypoxyphilia-strangulation/oxygen deprivation
Men- erection Sexual sadism
Voyeurism

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

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

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

Stage Physical Changes Psychosocial changes

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

Perception is more alert than usual Very narrowed perception

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

ANXIETY DISORDERS
Etiology:
PHOBIC DISORDERS Genetic predisposition
Irrational, excessive fear of a condition or object Decreased serotonin
Degree of fear expressed is obviously unusual and out of proportion to
the attending circumstances Symptoms:
e.g. Ritualistic behavior
Claustrophobia (close space) Constant doubting if he\she has performed the activity
Agoraphobia (open space)
Acrophobia(heights) Nursing Care:
Hydrophobia (water) Allow the patient to perform the ritual to decrease the anxiety and energy
Xenophobia (strangers) level
Arachnophobia (spiders) Provide structured activities to decrease the ritual to a degree that is
Zoophobia (animals) comfortable to the patient
Allurophobia (cats)
Chromophobia (colors) Note: The individual recognizes the unreasonableness and absurdity
Mysophobia (dirt) of the obsessions and compulsions but is unable to control it.
Bacillophobia (germs)
POST-TRAUMATIC STRESS DISORDER
Etiology Developed usually after experiencing a traumatic event
Psychoanalytic view
Individual experiences severe diffused anxiety which is only Symptoms:
incompletely resolved by repression and so there is displacement Events are traumatic to anyone and are unusual life events
of the anxiety to an external focus which the individual then Sleep disturbances: Insomnia due to nightmares
tries to avoid Patient may appear to re-experience the event while awake
Psychic numbness: unable to move in life; stuck in the experience of
Treatment for phobic disorders the past
1. Drug treatment- anxiolytics
2. Behavior Therapy Management:
a. Systematic Desensitization Psychotherapy
b. Flooding- sudden exposure of the patient to the phobic Group therapy
situation until he is no more fearful. Anxiolytics
Implosion- flooding carried out in imagination. Nursing Care:
Accept patients and their fears with a non-critical attitude Be nonjudgmental and honest; offer empathy and support;
Provide and involve in activities that do not produce anxiety but will acknowledge any unfairness or injustices to the trauma
increase involvement rather than avoidance Assure patient that what they are feeling are typical reactions to
Help patients with physical safety and comfort needs serious trauma
Help the patient to recognize that their behavior is a method of coping with Help patient to recognize the connections between the trauma
needs experience and their current feelings, behaviors and problems.
Assertiveness training and goal setting Help patients to evaluate past behaviors in the context of the trauma,
not in the context of current values and standards
Encourage safe verbalizations of feelings, especially anger.
OBSESSIVE COMPULSIVE DISORDER Encourage adaptive coping strategies and techniques
Encourage patients to establish or reestablish relationships
Definition:
Obsession- persistent thought that wont go away thru logical effort CHRONIC ANXIETY DISORDER OR GENERALIZED
Compulsion- uncontrollable impulse to repeatedly perform an act ANXIETY DISORDER
Anxiety is directly felt and expressed Listen carefully for patients’ expressions of helplessness and
Difficulty in controlling the anxiety hopelessness; assess for suicidality
Often admitted to the hospital Plan and involve patients in activities such as going for walks and
playing recreational games
Symptoms: Discuss with patients their present and previous coping mechanisms
Excessive worry and anxiety Discuss with patients the meaning of problems and conflicts to
Difficulty in controlling the worry appraise stressors, explore their personal values, and define the
Anxiety and worry are evident in: scope and seriousness of their problems
Restlessness Use supportive confrontation and teaching.
 Fatigue and irritability Assist patients with exploring alternative solutions and behaviors
Decreased ability to concentrate Encourage patients to test new adaptive coping behaviors through
Muscle tension role playing or implementation.
Disturbed sleep Teach patients relaxation exercises
Promote use of hobbies and recreational activities.
Nursing Care:
Provide a calm and quiet environment SOMATOFORM DISORDERS
Ask the patient to identify what and how they feel to increase Have physical symptoms with no known organic or physiological
awareness of what is happening to them cause
Encourage to describe and discuss their feelings with you to increase Defense mechanisms used
awareness of the connection between feelings and behaviors Repression
Help patients to identify possible causes of their feelings Denial
Displacement

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

Primary gain Secondary gain

Characteristics:
No pathology
Doctor shopping
Symptoms are under unconscious control

CONVERSION DISORDER
Repression
Conversion

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

Treatment:
Psychotherapy
Hypnosis

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

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

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

AUTISM
 Withdrawal of the child into the self and into a fantasy world of his own creation. Course is chronic.
Symptoms:
• Failure to form interpersonal relationships
• Impairment in communication
• Bizarre responses to the environment
• Extreme fascination for objects that move (e.g. fans, trains)
• Fluctuating mood sudden crying or laughing
• Self mutilating behaviors

ATTENTION DEFICIT HYPERACTIVITY DISORDER

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

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

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

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

COGNITIVE DISORDERS

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

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

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

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

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

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

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

Nursing Management:
Daily routine
Stress
Safety
Wandering
2. It is a maladaptive behavior
PERSONALITY DISORDERS 3. It is the possession of abnormal personality traits
This involves lifelong, inflexible, and dysfunctional patterns of relating 4. It is a long lasting, most of the time, lifelong problem
and behaving. These dysfunctional patterns and behaviors usually 5. It causes significant impairment in social occupational
cause distress to others. However, they do not find their behaviors functioning
distressing to others. 6. It produces distress to the individual and to others.

Classification of Personality Disorders PARANOID PERSONALITY DISORDER

1. Withdrawn (odd and eccentric) Suspicious
a. Schizotypal Doubt trustworthiness of others
b. Schizoid Fear of confiding in others
c. Paranoid Fear personal information will be used against him
2. Dependent (anxious and fearful) Interpret remarks as demeaning or threatening
a. Avoidant Hold grudges toward others
b. Dependent Becomes angry and threatening when they perceive to be attacked by
3. Inhibited others
a. Obsessive Compulsive
4. Anti-social (dramatic, emotional, flamboyant and erratic) Intervention: centered on building trust
a. Histrionic
b. Borderline SCHIZOID PERSONALITY DISORDER
c. Narcissistic Lacks desire for close relationships or friends
Chooses to be alone
Characteristics of Personality Disorders Lack of sexual experiences
1. It is not a mental illness Avoids activities
Appears cold and detached
NARCISSISTIC PERSONALITY DISORDER
Interventions: building trust followed by identification and appropriate Grandiose self importance
verbal expression Fantasies of unlimited power, success or brilliance
Believes he or she is special
SCHIZOTYPAL PERSONALITY DISORDER Needs to be admired
Ideas of reference Sense of entitlement
Magical thinking or odd beliefs Takes advantage of others for own benefit
Unusual perceptual experiences, including bodily illusions Lacks empathy
Peculiar thinking Envious of others or others are envious of him
Vague, stereotypical, overelaborate speech Arrogant
Suspiciousness
Blunted or inappropriate affect Interventions: supportive confrontation on what the patient sways and
Eccentric appearance or behavior what exists. Limit setting and consistency to decrease manipulation and
Few close relationships entitlement behaviors.
Uncomfortable in social situations
HISTRIONIC PERSONALITY DISORDER- DISORDER- dramatizes all events
Interventions: Improving Interpersonal relationships, social skills., and and draws attention to self
appropriate behaviors Overly dramatic
Draws attention to self
ANTI-SOCIAL PERSONALITY DISORDER Extroverted and thrives on being the center of attraction
Violates rights of others Uses somatic complaints to avoid responsibility and support dependency
Engages in illegal activities Dissociation
Aggressive behavior
Lack of guilt or remorse Interventions: Positive reinforcement in the form of attention,
Irresponsible in work and with finances recognition or praise are given for unselfish or other-centered behaviors.
Impulsiveness
Recklessness DEPENDENT PERSONALITY DISORDER
Manipulative Unable to make daily decisions without much advice and reassurance
Needs others to be responsible for important areas of life.
Interventions: Consistency and firmness in confronting behaviors and Seldom disagrees with others because of fear of loss of support or
enforcing rules and policies. approval
Problems with initiating with projects or doing things on his own
Nursing Care of Antisocial Personality Disorders: because of little self confidence
LONG TERM: helping person to accept responsibility for and Performs unpleasant tasks to obtain support from others
consequences of his actions. Anxious or helpless when alone because of fear of being unable to care
SHORT TERM: minimize manipulation and acting out. for self
• Encourage the patient to talk about his behavior, its limits and Urgently seeks another relationship for support and care after a close
consequences. relationship ends
• Discuss how manipulative behavior prevents him from establishing a Preoccupied with fear of being alone to care for self
close relationship.
• Help the client identify more adaptive strategies. Interventions: increase responsibility for self in day to day living;
• Provide positive reinforcement for non-manipulative behavior because assertiveness training
thay cannot be corrected by punishment.
• Assist him to understand his positive qualities. AVOIDANT PERSONALITY DISORDER
Avoids occupations involving interpersonal contact due to fears of
• Develop trust and rapport.
disapproval or rejection
• Provide group situations for the patient. Uninvolved with others unless certain of being liked
Fears intimate relationships due to fear of shame or ridicule
BORDERLINE PERSONALITY DISORDER- DISORDER- maybe due to neglect, Preoccupied with being criticized or rejected in social situations
over involvement or abusive family. Defense mechanism: splitting Inhibited and feels inadequate in new interpersonal situations
(viewing things as all good or all bad) Believes self to be socially inept, unappealing and inferior to others
Frantic avoidance of abandonment; real or imagined Very reluctant to take risks or engage in new activities due to the
Unstable and intense interpersonal relationships possibility of being embarrassed
Identity disturbances
Impulsivity OBSESSIVE COMPULSIVE PERSONALITY DISORDER
Self-mutilating behavior Preoccupied with details, lists, rules, organization
Rapid mood shifts Perfectionism that interferes with task completion
Chronic feelings of emptiness Too busy working to have friends or leisure activities
Problems with anger Overconscientious and inflexible
Transient dissociative and paranoid symptoms Unable to discard worthless or worn-out objects
Others must do things his or her way in work or task related activity
Interventions: Use of empathy. Recognize the reality of the patient’s Reluctant to spend and hoards money
pain, should offer support and should empower and work with the patient Rigid and stubborn
to understand control and change dysfunctional behaviors. Provide safe
environment.

CHEMICAL DEPENDENCE
 DRUG ABUSE

Reasons for taking drugs:

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

Factors involved in drug abuse:

1. T
h
e

drug is seen as a reinforcer

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

DEPRESSANTS

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

Nursing issues:
Overdose
Disulfiram (Antabuse)- intake of disulfiram with alcohol creates an ill feeling in the person ( sweating, flushing of the face and neck, throbbing
headache, nausea and vomiting, palpitation, dyspnea, tremors and weakness
Interactions
Fetal alcohol Syndrome-
Syndrome- microencephaly, cleft palate, altered palmar creases, cardiac defects, anomalous genitalia, mental retardation, and
depressed sucking reflex
 Withdrawal and
Detoxification
Withdrawal:
tremulousness
nervousness
anxiety
anorexia, n/v
insomnia and other
sleep
disturbances
rapid pulse, increase
blood pressure
profuse perspiration
diarrhea
fever
unsteady gait
difficulty concentrating
exaggerated startle reflex
craving for alcohol and other drugs

Physical complications of alcoholism:

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

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

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

Care of alcoholics in the acute stage of withdrawal

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

3 element of
detoxification:
secure environment
sedation
supplements

BARBITURATES

INHALANTS

OPIOIDS AND
NARCOTICS
 STIMULANTS

COCAINE

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

AMPHETAMINES

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

HALLUCINOGENS

Natural hallucinogens
Mescaline
Psilocybin
Marijuana

Synthetic Hallucinogens
LSD
PCP

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

EATING DISORDERS

ANOREXIA NERVOSA

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

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

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

BULIMIA NERVOSA

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

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

ABUSE

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

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

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