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MENTAL HEALTH PSYCHIATRIC NURSING PRACTICE

PERSONALITY THEORIES & DETERMINANTS OF PSYCHOPATHOLOGY AS


MODELS OF CARE
PSYCHOBIOLOGIC
COGNITIVE
PSYCHODYNAMIC/PSYCHOANALYTIC
INTERPERSONAL
HUMANISTIC
ECLECTIC
PSYCHO-SPIRITUAL
PSYCHOBIOLOGIC theories
Psychobiology : is the scientific study of the relationships among the structure
and function of the brain, biochemical and hormonal processes, genetics,
environmental experiences, and human behavior.
Central Nervous System
Is composed of the brain, the spinal cord, and associated nerves that control
voluntary acts.
Brain
Brain is Divided into:
Cerebrum
Cerebellum
Brain stem
Limbic system
Neurotransmitter : are chemical substances manufactured in neuron that
aid in the transmission of information throughout the body.
Neurotransmitters
Approximately 100 billion of brain cells form groups of neurons, or
nerve cells, that are arranged in networks.

These neurons communicate information with one another by sending


electrochemical messages from neuron to neuron, a process called
neurotransmission.
These electrochemical messages pass from dendrites ( projection from
the cell body), through the soma or cell body, down the axon ( long
extended structures), and across the synapses (gaps between cells) to the
dendrites of the next neuron.
In the nervous system, the electrochemical messages cross the synapses
between neural cells by way of special chemical messengers called
neurotransmitters.
They either excite or stimulate an action in the cells (excitatory) or inhibit
or stop an action (inhibitory).
These neurotransmitters fit into specific receptor cells embedded in the
membrane of the dendrite, just like a certain key shape fits into a lock.
After neurotransmitters are released into the synapse and relay the
message to the receptor cells, they are either transported back from the
synapse to the axon to be stored for later use (reuptake) or metabolized and
inactivated by enzymes, primarily Monoamine Oxidase (MAO).
Major Neurotransmitters associated with Mental disorders:
Dopamine
a neurotransmitter located primarily in the brain stem, has been found to be
involved in the control of complex movements, motivation, cognition,
and regulation of emotional responses.
Dopamine is generally excitatory and is synthesized from tyrosine, a dietary
amino acid.

Dopamine is implicated in Schizophrenia and other psychoses as well as


in movement disorders such as Parkinsons disease.

Antipsychotic medications work by blocking dopamine receptors and


reducing dopamine activity.

Norepinephrine and epinephrine


the most prevalent neurotransmitter in the nervous system, is located
primarily in the brain stem and plays a role in changes in attention,
learning and memory, sleep and wakefulness, and mood regulation.

Excess Norepinephrine has been implicated in several anxiety disorders;

Deficits may contribute to memory loss, social withdrawal, and


depression.

Some antidepressants block the reuptake of Norepinephrine.


Epinephrine has limited distribution in the brain but controls the Fight-or
Flight response in the peripheral nervous system.

Serotonin
a neurotransmitter found only in the brain, is derived from tryptophan, a
dietary amino acid. The function of serotonin is mostly inhibitory, and it is
involved in the control of food intake, sleep and wakefulness,
temperature regulation, pain control, sexual behavior, and
regulation of emotions.

Serotonin plays an important role in anxiety and mood disorders and


schizophrenia. It has been found to contribute to the delusions,
hallucinations, and withdrawn behavior seen in schizophrenia.

Some antidepressants block serotonin reuptake, which results in improved


mood.

Histamine
the role of histamine in mental illness is under investigation.
It is involved in peripheral allergic responses, control of gastric secretions,
cardiac stimulation, and alertness.
Some psychotropic drugs block histamine, resulting in weight gain,
sedation, and hypertension.

Acetylcholine
is a neurotransmitter found in the brain, spinal cord, and peripheral
nervous system, particularly at the neuromuscular junction of skeletal
muscle.
It can be excitatory or inhibitory.

It is synthesized from dietary choline found in red meat and vegetables and
has been found to affect the sleep- wake cycle and to signal muscles
to become active.
Alzheimers disease have decreased acetylcholine- secreting
neurons, and people with myasthenia gravis ( a muscular disorder, causes
muscle weakness).

Glutamate
is an excitatory amino acid that at high level can have major neurotoxic
effects.
Glutamate has been implicated in the brain damage caused by stroke,
hypoglycemia, sustained hypoxia or ischemia, and some degenerative
diseases such as Huntingtons or Alzheimers.

Gamma-aminobutyric acid (GABA)


(GABA):

an amino acid, is the major inhibitory neurotransmitter in the brain and


has found to modulate other neurotransmitter systems rather than to
provide a direct stimulus.

Drugs that increase GABA function, such as benzodiazepines, are used to


treat anxiety and to induce sleep.

Cognitive Framework
Focuses on distorted or negative thought pattern that lead to
maladaptive or symptomatic feelings and behaviors.
a. Distorted thinking leads to and perpetuates maladaptive behaviors.
b. Certain common thought patterns can be identified as misconceptions.
Patterns of thinking are learned, become automatic, and
significantly affect a persons feelings and behaviors.
The amount of perceived control over a situation affects how an
individual responds to stressors and problems.

Internal Locus of control: refer to an individuals belief in his own ability to


affect the outcome of life situations; although many external circumstances
of life cannot be changed, the individual can change his response to the
situation.
External Locus of control: refers to an individuals belief that others
control his life and he is unable to improve his own functioning or well-being;
he may also believe that other people or circumstances have to change for
his own life to improve.
Treatments
Cognitive therapy encompasses various treatment methods in which the
therapist and client work closely to identify maladaptive thought
patterns and develop alternative ways of thinking and behaving.
A. The therapist helps the client to become aware of negative thinking
and recognize the effect of negative thinking on feelings and behaviors.
B. The client is encouraged to practice alternative thought patterns that
lead to healthier behavior.
Rational emotive therapy: developed by Albert Ellis (1913), the therapist
actively disputes a clients irrational beliefs.
Gestalt therapy: based on the collaborative effort of Fritz Perls (1893-1970)
and Paul Goodman (1911- 1972), the therapist promotes the clients selfawareness and increased self-responsibility for meeting needs.
Becks cognitive therapy: developed by Aaron Beck (1921-), the therapist
teaches the client to identify and correct dysfunctional thoughts about
the self, the world, and the future.
Cognitive techniques may be used by the therapist to teach the client new
thinking skills.
a. Cognitive restructuring, teaches the client to change maladaptive beliefs
through positive self-statements and refuting irrational beliefs.
b. Thought stopping, teaches the client to consciously say, stop to
maladaptive thoughts.

Application to Nursing
1. The nurse assesses the clients thought patterns and identifies
misperceptions.

2. The nurse encourages the client to assume responsibility for his behaviors
and fosters awareness of the effect of negative thinking on feelings about
self-image.
3. The nurse uses cognitive techniques in intervention strategies.
COGNITIVE THEORY BY: JEAN PIAGET (1896-1980)
Explore how intelligence and cognitive functioning develop in
children.
He believed that human intelligence progresses through a series of
stages based on age, with the child at each successive stage
demonstrating a higher level of functioning than at previous stages
Piaget strongly believed that biologic changes and maturation were
responsible for cognitive development.
Cognitive Theory
does not specifically address mental illness and treatment, it has
various applications.
a. Understanding the way an individual thinks enables the nurse to
communicate in an age-appropriate manner.
b. Nursing interventions can be adapted to the individuals cognitive level.
The nurse can select teaching strategies according to the clients
age-appropriate cognitive processes.
Ex. The nurse can use dolls or toy medical equipment to try to
explain surgery to a pre-schooler who is about to undergo surgery.
( to relieve anxiety)
PIAGETS COGNITIVE THEORY:
1. Sensorimotor stage: BIRTH to 2 YEARS, The child develops a sense of
self as separate from environment and concept of object permanence; that
is tangible objects do not cease to exist just because they are out of sight.
He or she begins to form mental images.
2. Pre-operational stage : 2 to 6 years: The child develops the ability to
express self with language, understands the meaning of symbolic
gestures, and begins to classify objects.

3. Concrete operations: 6to 12 years: The child begins to apply logic


thinking, understand spatiality and reversibility, and is increasingly social
and able to apply rules; however, thinking is still concrete.
4. Formal operations: 12 to 15 years and beyond: The child learns to think
and reason in abstract terms, further develops logical thinking and
reasoning, and achieves cognitive maturity.
PSYCHOANALYTIC THEORY
supports the notion that all human behaviour is caused and can be
explained (deterministic theory).
Sigmund Freud = The Father of Psychoanalysis (1856- 1939),
developed Psychoanalytic Theory in the late 19th and early 20th centuries in
Vienna, where he spent most of his life.
He developed his initial ideas and explanations of human behaviour from his
experiences with a few clients, all of them women who displayed unusual
behaviours such as disturbances of sight and speech, inability to eat,
and paralysis of limb these symptoms had no physiologic basis, so
Freud considered them to be HYSTERICAL or NEUROTIC BEHAVIOR of
women.
After several years of working with these women,
Freud concluded that many of their problems resulted from
childhood trauma or failure to complete tasks of psychosexual
development.
These women repressed their unmet needs and sexual feelings as
well as traumatic events.
The Hysterical or Neurotic behaviors resulted from these
unresolved conflicts.
PERSONALITY COMPONENTS by: Sigmund Freud (1923- 1962)
Freud conceptualized Personality Structures as having 3 Components:
Id, Ego and Superego.
PERSONALITY STRUCTURES:
Id (evil side) = is the part of ones nature that reflects basic or
innate desires such as pleasure- seeking behaviour, aggression, and
sexual impulses.

Seek instant gratification, causes impulsive unthinking behaviour,


and has no regard for rules or social convention.
Superego (angel) = is the part of a persons nature that reflects
moral and ethical concepts, values and parental and social
expectations; therefore, it is indirect opposition to the Id.
Ego (self)= is the balancing or mediating force between the Id and
the superego.
The ego represents nature and adaptive behaviour that allows a
person to function successfully in the world.
Freud believed that the human personality functions at 3 Levels of
Awareness:
1. Conscious = refers to the perceptions, thoughts and emotions that exist
in the persons awareness, such as being aware of happy feelings or
thinking about a love one.
2. Pre-conscious = thoughts and emotions are not currently in the
persons awareness, but he or she can recall them, with some effort.
Ex. An adult remembering what he or she did, thought, or felt as a child.
3. Unconscious = is the realm of thoughts and feelings that motivate a
person even though he or she is totally unaware of them.
This realm includes most defense mechanism and some instinctual drives or
motivation according to Freuds theories, the person REPRESSES into
unconscious the memory of traumatic events that are too painful to
remember.
Freud believed that much of what we do and say is motivated by our
SUBCONCIOUS thoughts or feelings(those in the preconscious or
unconscious level of awareness).
A Freudian Slip is a term we commonly use to describe Slip of the
Tongue ex. Saying you look portly(slightly overweight) today to an
overweight friend.
Freud believed these slips are not accidents or coincidences but
rather are indications of subconscious feelings or thoughts that
accidentally emerge in casual day to day conversation.
EGO DEFENSE MECHANISMS

Freud believed the SELF or EGO, uses ego defense mechanisms, which are
methods of attempting to protect self and cope w/ basic drives or
emotionally painful thoughts, feelings, or events.
COMMON DEFENSE MECHANISMS:
1. Repression =excluding emotionally painful or anxiety provoking
thoughts & feelings from conscious awareness.
Ex. A woman has no memory before age 7, when she removed from
abusive parents.
2. Projection = attributing ones own feelings or wishes (w/c are
unacceptable to oneself) to another person.
Ex. A frightened client lashes out (scolding) at the nurse, saying the
nurse is timid, fearful person and should not be in the role of nurse.
3. Reaction Formation= acting the opposite of what one thinks or
feels.
Ex. Woman who never wanted to have children becomes a supermom.
4. Displacement = ventilation of intense feelings toward persons
less threatening than the one who aroused those feelings.
Ex. Person who is mad at the boss yells at his or her spouse.
5. Identification = modeling actions and opinion of influential others
while searching for identity, or aspiring to reach a personal, social or
occupational goal.
Ex. Nursing student becoming a critical care nurse bec. This is the
specialty of a clinical instructor she admires.
6. Denial = failure to acknowledge an unbearable condition, failure
to admit the reality of a situation.
7. Undoing = exhibiting acceptable behaviour to make up for or negate
unacceptable behaviour.
Ex. Person who cheats on a spouse brings the spouse a bouquet of roses.
8. Sublimation = substituting a socially acceptable activity for an impulse
that is unacceptable.
Ex. Person who quit smoking sucks on hard candy when urge to smoke arises.

9.Substitution = replacing the desired gratification w/ one that is more


readily available.
Ex. Doctor to Dentist
10. Regression = moving back to a previous developmental stage to feel
safe or have needs met.
Ex. 5 yr old asks for a bottle when new baby brother is being fed.
A man pouts like a 4 yr old if he is not the center of his girlfriends attention.
11. Conversion = expression of an emotional conflict through the
development of a physical symptom, usually sensorimotor in nature.
Ex. Teenager forbidden to see x-rated movies is tempted to do so by friends
and develops blindness, and the teenager is unconcerned about the loss of
sight.
Symptoms w/ no physiologic basis.
5 STAGES OF PSYCHOSEXUAL DEVELOPMENT
Freud based his theory of childhood development on the belief that sexual
energy,
termed LIBIDO, was the driving force of human behaviour. He
proposed that children progresses through 5 stages of psychosexual
development.
1. Oral (birth to 18 mos.)= major site of tension and gratification is the
mouth.= Id present at birth.
2. Anal (18 to 36 mos.) = toilet training, acquisition of voluntary
sphincter control.
3. 3. Phallic/ Oedipal (3 to 5 yrs.) = genital focus of interest, stimulation and
excitement/ masturbation is common.
4. 4. Latency (5 to 11 or 13 yrs) = sexual drives channelled into socially
appropriate activities/ formulation of superego.
5. 5. Genital ( 11 to 13 yrs.)= begin w/ puberty and biologic capacity for
orgasm, involves the capacity for true intimacy.
TRANSFERENCE & COUNTERTRANSFERENCE
Freud developed the concepts of transference and countertransference.

TRANSFERENCE : occurs when the client displaces onto the therapist


attitudes and feelings that the client originally experienced in other
relationship.
Ex. An adolescent female client working w/ a nurse who is about the
same age as the teens parents, might react to the nurse like she
reacts to her parents.
COUNTERTRANSFERENCE : occurs when the therapist displaces onto
the client attitudes or feelings from her or his past.
Ex. Female nurse who has teenage children and who is experiencing
extreme frustration w/ an adolescent client may respond by adopting
a parenteral or chastising tone.
The nurse is countertransfering her own attitudes and feelings
toward her children onto the client. by examining their own feelings and
responses, using self-awareness and talking w/colleagues.
Nurses can deal w/ countertransference
INTERPERSONAL THEORY BY: HARRY STACK SULLIVAN
Harry stack Sullivan (1892-1949) : was an American psychiatrist who
extended the theory of personality development to include the significance of
interpersonal relationships.
Sullivan believed that ones personality involves more than
individual characteristics, particularly how one interacts with others.
He thought that inadequate or nonsatisfying relationships produce
anxiety, which he saw as basis for all emotional problems.
5 LIFE STAGES OF DEVELOPMENT
1. INFANCY (birth to onset of language): the infant learns to trust
others.
2. Childhood (18mos to 6 yrs): the child accepts the influence of others.
3. Juvenile (6 to 9 yrs): the child forms peer relationship.
4. Pre- adolescence ( 9 to 12 yrs): the child forms friendships w/ same
sex peers.
5. Early adolescence (12 to 14 yrs): the child becoming more
independent and begins to establish relationships w/ the opposite
sex.

6. Late adolescence (14 to 21 yrs): the young adult develops enduring


relationship w/ members of the opposite sex.
3DEVELOPMENTAL COGNITIVE MODES
Sullivan described 3 developmental cognitive modes of experience and
believed that mental disorders are related to the persistence of the early
modes.
1. The Prototaxic mode: characteristic of infancy and childhood, involves
brief, unconnected experiences that have no relationship to one another.

Adults w/ schizophrenia exhibit Prototaxic experience.


2. The Parataxic mode: begins in early childhood as the child begins to
connect experiences in sequences

Sullivan explained paranoid ideas and slips of the tongue as a person


operating in the parataxic mode.
3. The Syntaxic mode: w/c begins to appear in school- aged children and
becomes more predominant in preadolescence, the person begins to perceive
him or herself and the world w/in the context of the environment and can
analyze experiences in a variety of settings.
Humanistic Theory
Humanism : focuses on a persons positive qualities, his or her capacity to
change (human potential), and the promotion of self-esteem.
Humanist : do consider the persons past experiences, but they direct more
attention toward the present and future.
Abraham Maslows (1908- 1970) Theory of Human Motivation:
Describes human needs that are organized according to levels
(Hierarchy of Needs), in which individuals move to higher needs or
lower, more basic needs are met.
Physiologic needs : includes the basic needs required to sustain life (air,
food, water).
Safety and security: is the need to establish security, stability and
consistency out of the chaos life. Protection, security, & freedom from harm
or threatened deprivation.

Love and belongingness: refers to an individuals desire for acceptance


and belonging to others. Which include enduring intimacy, friendship, and
acceptance.
Self-esteem and esteem for others: are the needs for self-mastery and
recognition by others. Which include the need for self-respect and esteem
from others.
Self- actualization : the highest need/ level, describes self-awareness and
desire to become the best that one can become. Need for beauty, truth and
justice.
Eclectic Theory
The Eclectic theorist believe in a synergistic personality theory.

Synergism in the case of personality theory, is the belief that no one


theory is entirely correct. It takes two or more theories to produce
what one, by itself, cannot produce. Since personality theory is not an exact
science it would seem ludicrous to narrow the field to what one or even two
theorist believe to be true.

The Psychosocial Stages of Development


The blending together of both Freud's psychosexual stages and Erickson's
psychosocial stages, has given theorists the ability to draw upon a middle
ground.

Cave's Eclectic Theory believes that both sexual and social stimuli are
responsible for the child's development. In the early years one learns about
his or her sexuality and how it relates to those around them. As sexual beings
we explore and experiment within our own social structures.
If children are not allowed to explore,

if it is socially unacceptable to do so, problems can occur and


confusion will most likely result.
The Need For Love and Acceptance
This is the overshadowing need of mankind according to Cave.
Unlike Abraham Maslow, who feels that the safety needs are first and
foremost, Cave feels that one must have a sense of love and
belonging.

If a child knows that they are loved and accepted unconditionally by


the parents, they will be able to endure almost any difficult
circumstance.

PSYCHOSPIRITUALITY
The word Psychiatric comes from two Greek words :
Psyche = Soul
Iateria = healing
Healing of the soul.
Psyche has a variety of meaning:
The breath of life
The seat of feelings and emotions
The part of humans that transcends the earthly
Spirituality = means the things beyond mere biologic existence.
spiritual concerns are considered when advanced directives and
quality of life issues are considered.
According to Jung (1980) = most people will agree, however, that
spirit means something not material, which gives life, dept, and
meaning to existence.

Common Understandings of Spirituality:


1) Have to do with making sense of life;
2) With hopes, plans, and fears;
3) With things that people value;
4) With the way in which individuals relate to others;
5) With issues of meaning and belonging.