PSYCHIATRIC NURSING gestures, object permanence,
classify objects
Psychosexual development Theory
(Sigmond Freud)
• Oral (0-18 mos) – relief of
anxiety through oral gratification of
needs; security and trust
• Anal (18mos- 3 yrs)- learning
independence and control
• Phallic/ oedipal (3-6yrs)-
identification with parent of the same
sex, development of sexual identity
and focus on genital organs
• Latency (6-12yrs)- sexually
repressed and focus on the rel. with
peers of the same sex; superego
• Genital (13-20yrs)- libido
reawakend as genital organs mature
and focus on rel with members of the
opposite sex
Psychosocial Development Theory
(Erikson)
• Oral-sensory (0-18 mos)- trust vs
mistrust
• Musculo-anal (18 mos – 3 yrs)-
autonomy vs shame & doubt
• Locomotor-genital (3-5 yrs)-
initiative vs guilt
• Latency (6-12 yrs)- industry vs
inferiority)
• Adoloscence (12-18 yrs)- identity
vs role confusion
• Young adulthood (18-30 yrs)-
intimacy vs isolation
• Adulthood (30-60 yrs)-
generativity vs stagnation
• Maturity (65-above)- ego
integrity vs despair
Cognitive Development Theory
(Piaget)
• Sensorimotor (0-2yrs)
• Pre--operational (2-6 yrs)-
language, understanding symbolic
Juvenile (6-9 yrs)
- Satisfactory relationships within
• Concret operational (6-12 yrs)-
reversibility and spatiality,
application of rules, thinking is
concrete
• Formal operational (12-15
yrs)- abstract, scientifically, logical
thinking, cognitive maturity
Moral Reasoning (Kohlberg)
Level I Preconventional Level (4-10 yrs)
Stage 1: Punishment & obedience
orientation
“I must follow the rules otherwise I will
be punished”
Stage 2: Instumental Relativist
orientation
“I must follow rules for the reward &
favor it gives”.
Level II: Conventional Level (10-13 yrs)
Stage 3: Good-boy-nice-girl
“I must follow the rules so I will be
accepted”
Stage 4: Society maintaining
orientation
“I must follow rules so there is order in
the society”
Level III: Conventional Level (adolescents
& onwards)
Stage 5: Social contract
orientation
“I must follow rules as there are
reasonable laws for it”
Stage 6: Universal ethical
principle orientation
“I must follow rules because my
conscience tells me”
Healthy Interpersonal Theory
(Sullivan)
Infancy (birth-onset of language)
- Gratification of needs
Childhood (onset of language-6yrs)
- Language and movement to avoid
anxiety
• ↓: Alzheimer’s disease,
Huntington’s chorea, Parkinson’s
peer groups
Preadolescence (9-12 yrs)
- Developing relationships with
persons if the same sex
Early adolescence (12-14 yrs)
- Relationships with member of the
opposite sex
Late adolescence (14-21 yrs)
- Interdependence within the
society; lasting, intimate rel.
Alterations of Body Image
4 Phases:
1. Impact phase- anger & guilt
2. Retreat phase- regress and deny
3. Acknowledgement phase- focus
and strength
4. Reconstruction phase- adapts
Best Responses
C – clarify and validate behaviors
U – use of silence but express presence
R – reflect and focus on feelings
E – encourage clients to express more
fully
Distance (Proxemics)
Intimate: 0-18”
Personal: 18-4 ft.
Social: 4-12 ft.
Public: 12 ft- above
Neurotransmitters
Cholinergic: Acetylcholine
• First neurotransmitter
• Major effector chemical in the ANS
• Synthesized by red meat and
vegetables
• Functions: sleep-wake cycle,
coordination of movement, memory
acquisition and retention
• Inactivated be acetylcholine
• ↑: anxiety
disease and Myasthenia Gravis
Monoamines:
Norepinephrine
• Most prevalent neurotransmitters
in the CNS
• Function: fight or flight
• Inactivated by monoamine
oxidase (MAO) and
catechomethyltransferase (COMT)
• ↑: anxiety, mania and
schizophrenia
• ↓: memory loss, social withdrawal
and depression
Dopamine
• Complex movements and
coordination, sensory integration and
voluntary decision making
• Inactivated by monoamine
oxidase (MAO) and
catechomethyltransferase (COMT)
• ↑: mania and Schizophrenia
• ↓: Parkinson’s Disease and
depression
Serotonin
• Sleep and arousal, libido, appetite,
mood
• Catabolized by MAO
• Contributes to the delusion,
hallucination and withdrawn behavior
in schizophrenia
• ↑: anxiety
• ↓: depression
Amino Acids:
Gamma-amino-butyric-acid (GABA)
• Major inhibitory neurotransmitter
(CNS)
• Interrupts the progression of
electrical impulse at the synapse
 • Function: slow down of bodily
functions and modulates other
neurotransmitters
• Enhanced by benzodiazepines=
calming effect
• Catabolized by GABA
transaminase
• ↓: Huntington’s chorea, anxiety,
schizophrenia and various forms of
epilepsy
Glycine
• Function: inhibition of motor
neurons and regulation of spinal cord
and brainstem reflexes
• ↑: glycin encephalopathy
• ↓: spastic motor movements
Dopamine – Schizophrenia,
Parkinson’s and mania
Acetylcholine- Alzheimer’s
Norepinephrine- Mania
GABA- Anxiety disorders
Serotonin- Depression and anxiety
states
• Cerebral cortex- decision
making and abstract reasoning
• Limbic System- emotional
behavior, memory and learning
• Basal ganglia- coordinate
involuntary movements to muscle
tone
• Hypothalamus- regulating
pituitary hormones, temperature,
appetite, thirst, and libido
• Locus ceruleus- norepinephrine
• Raphe nuclei- serotonin
• Sunstatia nigra- dopamine
• Amygdala- EQ
DSM-IV-TR Organizational framework
I – Clinical disorders and other conditions
that may be a focus of clinical attention
II- Personality disorders and mental
retardation
III- General Medical Conditions
IV- Psychosocial and environment
problems
V- Global Assessment of Functioning
(GAF) Scale- single measure of the
individual’s psychological, social, and
occupational functioning
Psychopharmacology
Antidepressants
• Major depression ( acute, atypical,
bipolar, and dysrhythmic depression)
• Anxiety disorders ( panic
disorders, OCD, social phobia,
generalized anxiety disorder and
PTSD)
• Therapeutic: lag 2-4 weeks
• AVOID ALCOHOL
MAOI: third-line agents (PAMATE)
Tranylcypromine (PAmate),
Maclobemide (MAnerex), Phenelzine
(NArdil)
• Not used so much because they
have potentiollt fatal interactions
• Maclobide does not cause
hypertensive crisis
• The only antidepressant that
inhibit neurotransmitter breakdown
as their primary mechanism of action
• Side effects: CNS (sedation &
hyperstimulation, restlessness and
euphoria) Cardiovascular
(hypotension with no compensatory
tachycardia [can lead to heart
failure], & orthostatic hypotension),
Anticholinergic effects
• Hypertensive crisis- results when
MAOIs are taken with certain drugs
and tyramine-containing foods;
presents with geadache, sweating,
palpitations, stiff neck, and
intracranial hemorrhage
• Phentolamine mesylate
(Regitine)
TCA: second-line agents (TO NO EL
SI)
Imipramine (TOfanil), NOrtriptyline
(aventyl, palmerol), Amitriptyline
(ELavil), Doxepin (SInequan)
• Secondary amines- activating
antidepressants (norepinephrine) can
combat lethargy ( most common
symptom of depression
• Tertiary amines- sedating
antidepressants (serotonin)
Side effects:
• PNS: anticholinergic effects,
cardiac effects ( reflect tachycardia,
arrhythmia, heart block, and MI),
adrenergic effects ( orthostatic
hypertension, prevention of
vasoconstriction)
• Mydriasis and blurred vision may
precipitate acute glaucoma
• Amitriptyline is the most
cardiotoxic
• Improved appetite, urinary
hesistancy ( childhood enuresis)
• TCA overdose: cathartics or
gastric lavage with activated
charcoal
• Not addicting
• Avoid use with: drugs that depress
or stimulate CNS, have
anticholinergic properties, MAOIs
(fatal)
• Antidote: Physostigmine
(Antilirium)
SSRI: first-line agents (PROZOPA)
Fluoxetine (PROzac), Sertraline (ZOloft),
Paroxetine (PAxil)
• Fewer side effects than TCAs
• Side effects: GI symptoms,
hypernatremia (elderly), CNS (dec.
libido, impotence, ejaculatory delay),
akathesia- treated with propanolol
(Inderal) or Benzodiazepine
• Indicated for bulimia, obesity, and
OCD
• Taken in AM for 4 weeks for full
effect
• Antidepressant apathy syndrome-
induced by these drugs; presents
with lack of motivation, indifference,
disinhibition, and poor attention
• Fluoxetine (Sarafen) is approved
for the treatment of bulimia,
premenstrual dysmorphic disorder,
pain mgt. and smoking cessation;
assoc. w/ suicidal and homicidal
behaviors; has long half-life, led
likely to cause withdrawal syndrome
• Paroxetin indicated for the
prevention of depressive relapse; it is
teratogenic
• Abrupt cessation causes SSRI
withdrawal symptoms
Serotonin Syndrome
• Can occur if combined with MAOIs,
St, john’s Wort & Typtophan
• SSRI + MAOI = fatal
• s/s: mental status changes
• discontinue the offending
agent: resolves on its own 24h
Antipsychotics/ Neuroleptics/ major
tranquilizers
• SE dizziness
• Indicated for schizophrenia,
schizoaffective disorder, organic
brain syndrome with psychosis and
delusional disorder
• High Potency: ProHaNaStela
- Fluphenazine (Prolixine),
Haloperidol (Haldol), Thiothixene
(Navane), Triflouperazine
(Stelazine)
- SE: EPS
• Moderate Potency: LoMoTril
- Perphenazine (Trilafon), Loxapine
(Loxitane), Molindone (Moban)
• Low Potency: ThoSeTaMe
- Chlorpromazine (Thorazine),
Thioridazine (Mellari), Taractan,
Serentil
- SE: mopre intense anticholinergic
effects
• Thiorazidine is therapeutic in
children with severe behavioral
problems marked by combativeness
• Fluophenazine decanoate (Prolixin
decanoate) long-acting form
(injectable) of prolixine, lasts 2-3 wks
• Parenteral haloperidol alone or in
combination with the benzodiazepine
lorazepam (Ativan) is used to help
aggressive or psychiatric patients
stay in control
• Haloperidol decanoate is a long-
acting form can be bgiven at 2-4 wks
intervals or longer; px who struggle
for compliance
• Thioridazine has a minimum
upperlimit of 800mg/day bec. Of
possible poigmentary retinopathy
(dec visual acuity, impairs night
vision, and pigmentation deposits in
the fundus)
• Atypical Antipsaychotics: CloRis
- Clozapine (Clorazil), Risperidone
(Risperidal
- Reduced or no risk for EPS
- Increased effectiveness in treating
Extrapyramidal side effects
negative and cognitive symptoms:
dopamine is increased
- Minimal risk of TD
- Absence of prolactin-level
elevation
- Clozapine is the first truly
antipsychotic; available in
injectable form; proven effective
in treating acute mania and
bipolar disorder
- SE: agranulocytosis (neutrophil <
500/mm3), dose related seizures,
excessive salivation and
myocarditis
- Risperidone is the most frequently
prescribed antipsychotic:
injectable long-acting
- SE: orthostatic hypertention,
sedation, appette stimulation,
insomnia, agitation, headache,
anxiety, and rhinitis. Higher doses:
EPSEs and hyperprolactemia
- Olanzapine has a similar side
effect with risperidone
• New generation antipsychotics
- Aripirazole (Abilify)- dopamine
system stabilizers; controls
symptoms without side effects
- Tolerance usually develops be the
third month
- Dec. dose of drugs
- Add a drug to treat EPSE, then
taper after 3rd month on the
antipsychotic
- Use a drug lower EPSE profile
• Side effects
Sedation
Enduce pseudoparkinsonism
Dystonia
Akathisia, atrophine psychosis
Tardive dyskinesia
Effects on hormones
Bradykinesia
Orthostatic hypotension
Pisa effect
• Acute dystonia- acute muscular
rigidity
- Torticollis- neck
- Oculogyric crisis- eyes upward
- Writer’s clamp- hand
- Laryngeal-pharyngeal spasm (life-
threatening)
- Opisthotonus- back
 Occurs in males; high potency
drugs (haloperidol and thiotixine)
 Painful and frightening to the px
 Tx: anticholinergic drugs-  Dantrolene (Dantrium),
congentin, Benadryl Bromocriptine (parlodel) – drug of
• Pseudoparkinsonism- shulling choice
gait/festinating gait, coarse pill-  Antipsychotics should not be
rolling reinstituted for 2 wks
 Symptoms may appear 1-5 days
following initiation of antipsychotic
medication
 Occurs in women, elderly, Anti-extrapyramidal side effects
dehydrated clients Congentin (Benztropine)
Artane (Trihexyphenidyl)
 TX: shifting to an antipsychotic
Benadryl (Diphenhydramine HCL)
medications with s lower incidence
of EPSE or by adding an
Akineton (Biperiden)
Side Effects:
anticholinergic agent or
amantadine (Symmetrl)- • Tardive dyskinesia- stereotyped
involuntary movements
dopamine antagonist
- Late-appearing and irreversible
• Akathisia- continuous
- Symptoms stops with sleep
restlessness, fidgeting, jittery feeling
- Atrophine psychosis
and nervousness
- “red as a beet” (flushed face with
 Most common EPSE and responds
skin hot to touch without fever)
poorly to TX
- “dry as a bone” (dehydration)
 TX: change in antipsychotic med. - “mad as a hatter” (altered mental
With a lower incidence of EPSE or status)
by adding an oral agent such as
 Rereduce / d/c med
beta blocker, anticholinergic, or
 Hydration
benzodiazepine
• Sedation
• Akinesia and bradykinesia
• Photosensitivity
 Akinesia- absence of movement
 Badykinesia- slowed movement • Anticholinergic effects
 Blurred vision will subside after a
 Responds to anticholinergics
few weeks
• Pisa syndrome-leaning towards
 Alert for aggravation of narrow-
onbe side
angle glaucoma, prostatic
• Neuroleptic malignant
hypertrophy (difficult urination) &,
syndrome
triggering of arrhythmias that lead
 Fever, to death
tachycardia,alteredconsciousness,
• Agranulocytosis
automatic hyperactivity
- Feverm malaise, ulcerative sore
(diaphoresis, pallor)
throat and leucopenia
 Potentially lethal
 Emergency & develops abruptly
 Occur in high-potency
 Weekly CBC
antipsychotics (haloperidol) and
 d/c drug immediately ( when WBC
dehydrated px
drops below 50% or < 3,000)
 Onset within a week
• seizures
 Immediately d/c all drugs
• orthostatic hypotension
• hormonal effects

Mood Stabilizers
L – Lethal if > 3 mEq/L (needs
hemodialysis)
I – indicated for bipolar disorders
T – therapeutic range: 0.6-1.2 mEq/L
H – hyponatramia – toxicity
I – increase excretion with mannitol and
diamox
U - uncoordination and coarse hand
tremors= early sign of toxicity
M – metallic taste and fine hand tremors
= normal
*Lithium blood level takenv 8-12 hrs after
the last dosage
*Thiazide and K+ sparing diuretics
increases lithium levels
Anticonvulsants
Carbamazepine (Tegretol), Valproic Acid
(Depakene, Depakote), Lamotrigine
(Lamictal), Gabapentin (Neuorotin),
Topiramate (Topamax), Oxcarbazepine
(Trileptal)
Second line: Lamotrigine (Lamictal)- FDA
approved for bipolar disorder
Third line: Carbamazepine (Tegretol)
• Divalproex is a derivation of
valproic acid (superior therapeutic
index + better toxicity profile +
effectiveness in bipolar subtypes =
surpassed lithium as the most
commonly used drug for bipolar)
• Lamotrigine- delays onset of mood
episodes
• Carbamazepine can cause dec of
serum levels of other
anticonvulsants, benzodiazepines,
anticoagulants, and oral
contraceptives
• Oxcarbazepine- new compound r/t
to carbamazepine that does not
cause the serious adverse reactions;
therapeutic serum level: 15-35
mcg/mL
- Kindling occurs when the brain
becomes neurochemically
sensitisized in events or the effects
of street drugs that eventually seem
to cause the brain to spontaneously
and dysfunctionally respond in
absence of these events
- Theorized to cause cyclical
illnesses such as bipolar illness and
the intermittent symptoms of other
illnesses such aspanic attacks or
craving of substances
 Lamitrogine: dizzinessheadache,
double vision, unsteadiness, sedation
& uncomplicated rash; it inc. the risk
for steven-johnson’s syndrome (fatal)
 Divalproex: GI problems (n/v,
anorexia, diarrhea), neurological
symptoms ( tremor, sedation,
headache, dizziness, ataxia), inc
appetite, & wt. gain; it
thrombocytopenia w/ bruising,
petechiae, hematoma, & bleeding =
dec. dose
 Carbamazepine can cause lethal
overdose
 Topiramate is the only
anticonvulsant mood stabilizer that is
not assoc. w/ wt. gain= assoc. w/ wt.
loss
Calcium Channel Blockers
Verapamil (Calan, Isoptin), Nifedipine
(Adalat, Procardia), Nimodipine (Nimotop)
• Px who have not been responded
well to lithium or aniconvulsants will
not be likely respond to channel
blockers
• Best used in bipolar px w/
hypertension or supraventricular
arrhythmias, or pregnant bipolar
patients bec. Teratogenic risk is
much lower
*Benzodiazepines and antipsychotics are
also used for mood stabilizers in bipolar
disorder
*Olanzepine is FDA approved for the
treatemtn of acute mania
Anxiolytics
Benzodiazepines
Antianxiety: Alprazolam (Xanax),
Chlordiazepoxide (Librium), Clonazepam
(Klonopin) Clorazepam (Tranxene),
Diazepam (Valium), Halazepam
(Paxipam), Lorazepam (Ativan),
Oxazepam (Serax), Prazepawm (Centrax)
Sedative-hypnotic: Estrazolam
(ProSom), Flurazopam (Dalmane),
Termazepam (Halcion), Quazepam
(Doral)
• Not the first line agents for the
anxiety DO
• 5 major affect: reduces anxiety,
promotes sleep, prevents seizures, &
produces amnesia
• IV diazepam & lorazepam are the
first-line agents for status epilepticus
& Clonazepam as anticonvulsant
• Since benzodiazepines have the
same pharmacological effect as
alcohol, 6they can be use to
suppress alcohol withdrawal
syndrome and are the tx of choice
for this indication
- Alcohol and other CNS depressant-
inc sedation and CNS depression
- Antacids- impaired absorption rate
of benzodiazepine
- Phnytoin- inc. anticonvu;sant
serum level
- TCAs- inc sedation, confusion,
impaired major function
- MAOIs- CNS depression
- Succinylcholine- dec.
neuromuscular blockage
- Lorazepam and oxazepam are the
best for elderly
- Common side effects: drowsiness,
sedation, ataxia, dizziness, Feeling of
detachment, inc. irritability or
hostility, retrograde amnesia,
cognitive effects with long-term use
(concentration and memory
interference), tolerance,
dependency, rebound insomnia/
anxiety & dec coordination
Benzodiazepine Withdrawal Syndrome
- Agitation, anorexia, anxiety,
autonomic arousal, dizziness,
generalized seizures, hallucinations,
headache, hyperactivity, insomnia,
irritability, n/v, sensitivity to light &
sounds, tinnitus, & tremulousness
- Paradoxical reactions: agitation,
emotional lability, & occasional rage.
Children, older adults & px w/ poor
impulse control, & organic brain
syndrome are most at risk
Nonbenzodiazepines
Antianxiety: Buspirone (BuSpar),
Propanolol (Inderal), Clonidine
(Catapres)
Sedative-hypnotic: Zolpidem
(Ambien), Zalepton (Sonata)
Antihistamines: Diphenhydramine
(Benadryl), Hydroxyzine (Atarax, Vistaril)
Antidepressants: Trazadone (Dysyrel)
SSRI: Fluoxetin (Prozac)
• SSRIs are the first-line agents for
anxiety spectrum DO
• Clomipramine (Anafil) and
Fluvoxamine (Luvox) are the most
effective drug for COD
• Buspirone has no addictive
potential and FDA approve for GAD;
not effective mgt for drug or alcohol
withdrawal or panic DO; it takes
several wks to take effect
- Hazardour in px taking MAOI bec
of the elevation of BP
- Take w/ food and drink a lot of
grapeful fruit
• Zolpidem is the firsdt of a new
class of compounds for short term tx
of insomnia. It is under schedule IV
controlled substance. SE: daytime
drowsiness, dizziness, & diarrhea
• Antihistamines are not as effective
as benzodiazepine but they do not
cause dependence or abuse and are
 OTC. They have lower seizure
threshold and cause anxiety in
insomnia or some

Antidemantia
Cholinesterase Inhibitors:
• Tacrine (Cognex) is the first
cholinesterase inhibitor but is seldom
prescribed sice it cuases serious
hepatic effects
• Donepezil (Aricept) is a reversivle
inhibitor of cholinesterase that soes
not cauise hepatotoxicity, has a long
half-life, ans can ve taken w/ or w/o
food; GI problems and bradycardia
• Rivestagmine (Exolon) is a
irrcersible inhibitoe of cholinesterase
(until thr enzyme is complete). Half-
life of 2 hrs but inhibition time of 10
hrs; inhibits the action of enzyme
cholinesterase (can metabolize 5000
molecules of acethycholine)- inc.
availability
• Falantamine (Razadyne)
anticholinergic effects
NDMA antagonist
• Memantine (Namenda)- has a long
half-life, only w/ a few drugs and has
few side effects, co-prescribed w/
donepezil; too much NDMA
stimulation= neural death, while too
little= psychotic behavior