PSYCHIATRIC NURSING 3

Merchie Lissa F. Tandog, RN

ALTERATIONS
IN PATTERNS
OF HEALTH
PSYCHOSIS VS NEUROSIS
NEUROSIS
any long term mental or
behavioral disorder in
which contact with reality is
retained the condition is PSYCHOSIS

recognized by the patient as Mental or behavioral disorder wherein

patient loses contact with reality
abnormal. Essentially Presence of delusions, hallucinations, severe
features anxiety or behavior

thought disturbances, alteration of mood,

exaggerated designed to poverty of thought and abnormal behavior

avoid anxiety (schizophrenia , major disorder of affect

( mania depression), major paranoid states
( anxiety d/o ; hysteria to and organic mental disorder
conversion d/o,
amnesia,fugue,multiple
personality and
depersonalization-
dissociative d/o
;oc d/o)
 ANXIETY RESPONSE AND
ANXIETY DISORDERS
Defining Characteristic
Wide range of disorders from very specific like
phobias to generalized anxiety disorder which
is pervasive and experienced as dread or
apprehension
Excessive anxiety can be crippling which may
result in flight or fight reaction. Fighter is
unable to relax, escaper freezes with anxiety
and may avoid upsetting situations or may
dissociate
 LEVELS
Mild Anxiety is a positive state of heightened awareness
and sharpened senses, allowing a person to learn new
behavior and solve problems

Moderate Anxiety involves decreased perceptual field

(focus on immediate task only). The person can learn new
behavior or solve problem only with assistance

Severe Anxiety involves feelings of dread or terror. The

person cannot be redirected to a task and has physiologic
symptoms ; restless, irritable, angry

Panic Anxiety can involve loss of rational thought,

delusions, hallucinations, and complete physical
immobility and muteness
 ANXIETY AS A RESPONSE TO
STRESS
Stress is the wear and tear that life causes on the
body

General Adaptation syndrome by Hans Selye

(1956)
Alarm Reaction Stage - stress stimulates the body to
send message from hypothalamus to glands and organs to
prepare for potential defense
Resistance Stage the digestive system reduces
function, lungs take in more air, heart beats faster to
areas needed for defenseFIGHT, FLIGHT, OR FREEZE.
Exhaustion Stage occurs when the person responds
negatively to stress. Body stores are depletedcontinuos
physiologic responses
 MANIFESTATIONS
Psychological
Difficulty
in logical thought, increased motor activity
and elevated VS
Physiological
ANS response- sympathetic nerve fibers charge up
at any hint of danger to prepare bodys defense.
Adrenal glands release adrenaline dilate pupils,
increase arterial pressure and heart rate while
constricting the peripheral vessels and shunting
blood from GI and Reproductive system , increasing
glycogenolysis to free glucose for fuel
Parasympathetic nerve fibers reverse the process
which returns the body to normal condition until next
threat
 To reduce uncomfortable feeling:
Defense mechanism
Adaptive behaviors
Using imagery techniques
Practicing sequential relaxation

Slow and steady breathing

Negative responses tension headaches, pain

syndromes, reduced efficiency of immune system
 MANAGEMENT
Assess Level
Mild No direct intervention

Moderate nurse makes certain client can

follow what the nurse is saying. Speak in simple
easy to understand sentences. Redirect if
wandering off
Severe lower persons anxiety level first.
Remain with client, talk in low, calm voice, help
person take deep even breaths
Panic safety is the primary concern. Keep
talking in a comforting manner. Go to a small,
quiet and non-stimulating environment. Reassure
that this will pass. Anxiolytic drug-
Benzodiazepines
ANXIETY DISORDERS
ANXIETY DISORDERS
Anxiety Disorders are diagnosed when anxiety
becomes chronic and permeates major portion of
persons life, resulting in maladaptive behaviors
and emotional disability
Types:
Agoraphobia with or without panic disorder
Panic Disorder
Specific phobia
Social phobia
OCD
Generalized Anxiety Disorder (GAD)
Acute stress disorder
PTSD
ANXIETY DISORDERS
Related Disorders
Anxiety disorder due to general medical
condition (COPD, CHF, neuro, endo
conditions)
Substance-induced anxiety disorder
Separation anxiety disorder- before 18
y.o.
Adjustment disorder-financial, medical,
relationships
INCIDENCE

Anxiety Disorders has the highest

prevalence rate in the US.
1 out of 4 adults in the US is affected

More prevalent in women, people younger

than 45, divorced or separated, and low
socio-economic status
OCD is equally prevalent in men and
women but more common among boys
than girls
ETIOLOGY
Biologic theory
Genetic theory
Panic DO, Social and specific Phobias have
moderate heritabilities
GAD, OCD tend to be more common in

families
Current research indicates clear genetic

susceptibility for anxiety DO, additional

factors are needed to further develop
Neurochemical theory
GABA is dysfunctional in Anxiety DO
Serotonin
 ETIOLOGY- PSYCHODYNAMIC THEORY

Intrapsychic/Psychoanaly Interpersonal
tic Theory Theory
Freud saw the person's Sullivan believed
anxiety as stimulus for anxiety is derived from
problems in
behavior and Defense interpersonal
mechanism is the human relationships.
attempt to reduce anxiety Peplaus theory is being

used to nurture N-C

relationship

Behavioral theory
Anxiety is learned
through experience
CULTURAL CONSIDERATIONS

Asians express anxiety through

somatic symptoms: headache,
backache, fatigue, dizziness and
stomach problems; KORO (shrinking
penis)
Hispanics believes in SUSTO which
is believed to be caused by
supernatural spirits which invades
the body (fright sickness)
 TREATMENT Decatastrophizing

Breaking the cycle of

Calm negative thoughts
Client uses thought

Awareness of Anxiety stopping and

distraction techniques

Listen
Splashing with cold
water in face, shouting,
snapping a rubber
Medications band worn on wrist
Assertive training

Helps a person gain

Environment more control over life
situations
Reframing, positive Using I statements to
talk to others
ANTIANXIETY MEDICATIONS

B ETA-ADRENERGIC BLOCKERS
(Clonidine)
ENZODIAZEPINES (Valium)

A NTI-HISTAMINES (Hydroxyzine)

T RICYCLICS/MAOI (Clonazepam)
S SRI (Prozac, Zoloft)
Panic Disorder
Composed of discrete episodes of panic attacks, 15-30
minutes of rapid, intense, escalating anxiety in which
person feels great emotional fear as well as
physiologic discomfort
Diagnosed when person has recurrent, unexpected
panic attacks followed by at least 1 month of
persistent concern about future attacks or a
significant behavioral change related to that.
75% have spontaneous attacks with no environmental
trigger
Common in people who have not graduated from

college and is not married

MANIFESTATIONS
Physical: (4 or more)
heart palpitations, sweating, tremors,
rapid breathing or shortness of breath,
blurred vision, dizziness, racing
thoughts, chest pain, nausea, abdl
distress, chills, hot flashes
Avoidance behavior
Agoraphobia
Demonstrates concepts of primary
gain and secondary gain
TREATMENT
Cognitive-behavioral technique
Deep breathing
Relaxation exercise
Medications: benzodiazepines, SSRI,
TCA, antihypertensive (clonidine
and propanolol)
NURSING PROCESS
Assessment
Use Hamiltons rating scale for anxiety
Client usually seeks treatment after several attacks
and cannot identify trigger
Automatisms
Depersonalization
Derealization
Disorganized thoughts and loss of ability for rational
thought
Confused and disoriented
Judgment is suspended
Insight can only occur after client education
Self blaming
Alteration sin social life, personal relations
Problems with sleeping and eating habits
DIAGNOSIS
Risk for injury
Anxiety
Situational low self esteem (panic
attacks
Ineffective coping
Powerlessness
Ineffective role performance
Disturbed sleep pattern
GOALS
Free from injury
Verbalize feelings

Demonstrate use of effective coping

mechanisms
Demonstrate effective use of methods to
mange anxiety response
Verbalize sense of personal control

Reestablish adequate nutritional intake

Sleep at least 6 hours per night

INTERVENTION
Promote safety
Provide clam environment

Remain with client

Speak in calm soothing voice and give

brief directions
Teach client relaxation techniques: deep
breathing, guided imagery, progressive
relaxation. Practice these techniques
while calm and not in attack
Client and Family education: coping skills,
meds and therapy, regular exercise
EVALUATION
Does client understand prescribed
meds and is committed to adhering
to it?
Have episodes decreased I frequency
and intensity?
Does client understand various
coping and when to use them?
Does client believe his quality of life
is satisfactory?
Phobias
Irrational fear of a specific object,
activity or situation that causes
extreme distress and interferes with
normal functioning
Types
Agoraphobia
Social phobia/Social Anxiety disorder
Specific phobia
Natural environmental phobia
Blood-injection phobia

Situational phobia

Animal phobia
ONSET AND CLINICAL COURSE
Specific phobia usually occurs in childhood
and adolescent. Those that persist in
adulthood are lifelong 80% of the time
Peak age on onset is middle adolescence
which sometimes merges in a person who
is shy as a child
Course is continuous and may be less
severe in adulthood
Severity fluctuates with life stress and
demand
A
Agliophobia - Fear of pain. C
Agoraphobia - Fear of open spaces or crowds.
Cacophobia - Fear of ugliness.
Catagelophobia - Fear of being
Aichmophobia - Fear of needles or pointed
ridiculed.
objects.
Catoptrophobia - Fear of mirrors.
Amaxophobia - Fear of riding in a car.
Chionophobia - Fear of snow.
Androphobia - Fear of men.
Chromophobia - Fear of colors.
Anginophobia - Fear of angina or choking.
Chronomentrophobia - Fear of clocks.
Anthrophobia - Fear of flowers.
Claustrophobia - Fear of confined
Anthropophobia - Fear of people or society.
spaces.
Aphenphosmphobia - Fear of being touched.
Coulrophobia - Fear of clowns.
Arachnophobia - Fear of spiders.
Cyberphobia - Fear of computers.
Arithmophobia - Fear of numbers.
Astraphobia - Fear of thunder and D
lightening. Dendrophobia - Fear of trees.
Ataxophobia - Fear of disorder or untidiness. Dentophobia - Fear of dentists.
Atelophobia - Fear of imperfection. Domatophobia - Fear of houses.
Atychiphobia - Fear of failure. Dystychiphobia - Fear of accidents.
Autophobia - Fear of being alone.
E
B
Ecophobia - Fear of the home.
Bacteriophobia - Fear of bacteria. Elurophobia - Fear of cats.
Barophobia - Fear of gravity. Entomophobia - Fear of insects.
Bathmophobia - Fear of stairs or steep Ephebiphobia - Fear of teenagers.
slopes. Equinophobia - Fear of horses. - Fear
Batrachophobia - Fear of amphibians. of dogs.
Belonephobia - Fear of pins and needles.
Bibliophobia - Fear of books.
Botanophobia - Fear of plants.
G
Gamophobia - Fear of marriage.
Genuphobia - Fear of knees.
Glossophobia - Fear of speaking in public. M
Gynophobia - Fear of women. Mageirocophobia - Fear of cooking.
Megalophobia - Fear of large things.
H Melanophobia - Fear of the color black.
Heliophobia - Fear of the sun. Microphobia - Fear of small things.
Mysophobia - Fear of dirt and germs.
Hemophobia - Fear of blood.
Herpetophobia - Fear of reptiles.
Hydrophobia - Fear of water. N
Hypochondria - Fear of illness. Necrophobia - Fear of death or dead things.
Noctiphobia - Fear of the night.
Nosocomephobia - Fear of hospitals.
I
Nyctophobia - Fear of the dark.
Iatrophobia - Fear of doctors.
Insectophobia - Fear of insects.
O
Obesophobia - Fear of gaining weight.
K Octophobia - Fear of the figure 8.
Koinoniphobia - Fear of rooms. Ombrophobia - Fear of rain.
Ophidiophobia - Fear of snakes.
L Ornithophobia - Fear of birds.

Leukophobia - Fear of the color white.

Lilapsophobia- Fear of tornadoes and
hurricanes.
Lockiophobia - Fear of childbirth.
P
Papyrophobia - Fear of paper.
Pathophobia - Fear of disease.
Pedophobia - Fear of children.
Philophobia - Fear of love.
Phobophobia - Fear of phobias.
Podophobia - Fear of feet.
Porphyrophobia - Fear of the
color purple.
Pteridophobia - Fear of ferns.
Pteromerhanophobia - Fear of
flying.
Pyrophobia - Fear of fire.
S
Samhainophobia - Fear of
Halloween.
Scolionophobia - Fear of school.
Selenophobia - Fear of the moon.
Sociophobia - Fear of social
evaluation.
Somniphobia - Fear of sleep.
T
Tachophobia - Fear of speed.
Technophobia - Fear of
technology.
Tonitrophobia - Fear of thunder.
Trypanophobia - Fear of needles /
injections.
V-Z
Venustraphobia - Fear of
beautiful women.
Verminophobia - Fear of germs.
Wiccaphobia - Fear of witches
and witchcraft.
Xenophobia - Fear of strangers or
foreigners.
Zoophobia - Fear of animals.
TREATMENT
Behavioral Therapy
Identifyresponses
Teach relaxation techniques
Develop self-esteem and self control: positive
reframing, assertiveness training
Systemic desensitization
Flooding
Medications:benzodiazepines, SSRI,
TCA, antihypertensive (Clonidine and
Propanolol)
Obsessive-Compulsive Disorder
Obsessions are recurrent, persistent, often
irrational, unwanted and seemingly
uncontrollable thoughts, images, impulses that
can cause marked anxiety and interfere with
interpersonal, social and occupational function
Compulsions are ritualistic or repetitive actions
or mental acts that persons carries out which are
used to neutralize the obsessions
Obsessive-Compulsive Disorder is diagnosed
only when these thoughts, images and impulses
consume the person to act out behaviors to a
point that they interfere wit personal, social and
occupational function
COMMON COMPULSIONS
Checking rituals
Counting rituals
Washing and scrubbing skin
Prying and chanting
Touching, rubbing or tapping
Hoarding items
Ordering
Exhibiting rigid performance
Having aggressive urges
ONSET

Can start in childhood especially in males

Gradual

Exacerbated with stress

TREATMENT
Behavior therapy
Exposure- assisting client to deliberately
confront situation or stimuli that he avoids
Response prevention- focus on delaying or
avoiding performance of rituals
Drugs
Benzodiazepines, SSRI, non benzodiazepines
ASSESSMENT
Clients seek consultation only when obsessions
become overwhelming and compulsion interfere with
daily life
Rituals usually began as early as childhood

Tense and anxious

Not willing to have these thoughts

Difficulty in concentration when obsession are strong

Client recognizes obsessions are irrational but he

cannot stop them

Feelings of powerlessness

Ability to fulfill roles decreases

Trouble sleeping and reports loss of appetite and non

completion of personal hygiene tasks
DIAGNOSES
Anxiety
Ineffective coping
Fatigue
Situationallow self esteem
Impaired ski integrity
GOALS
Complete daily routine activities
within a realistic time frame
Demonstrates effective use of
relaxation technique
Discuss feelings with another person
Demonstrates effective use of
behavioral therapy techniques
Spend less time performing rituals
INTERVENTIONS
Do not interrupt the act; allow time to complete
Limit setting; gradually decrease the time and
frequency of rituals
Provide the basic needs

Provide safety

Encourage expression of feelings: rituals,

feelings, obsessions
Medications-anxiolytics

Behavioral therapy- exposure response

prevention
EVALUATION
Treatment effective when
symptoms no longer interfere
with client s ability to carry out
responsibilities
Reports control of life and ability
to tolerate and manage anxiety
with minimal disruption
Generalized Anxiety Disorder
Persons worries excessively and feels
highly anxious 50% of the time for 6
month or more
At least 3 of the following Symptoms:
uneasiness, irritability, muscle tension,
fatigue, difficult thinking and sleep
alterations
Management:
Medications- benzodiazepines used in short-
term basis, SSRIs
non-benzo Buspirone (Buspar)

Behavioral therapy- relaxation training

Post Traumatic Stress Disorder
Always follows a traumatic event which causes
intense fear and/or helplessness in an individual.
Symptoms develop shortly after the event, but may
take years. The duration for symptoms is at least
one month for this diagnosis.
Symptoms include re-experiencing the trauma
through nightmares, obsessive thoughts, and
flashbacks (feeling as if you are actually in the
traumatic situation again). There is an avoidance
component as well. Finally, there is increased
anxiety in general, hypervigilance, possibly with a
heightened startle response (e.g., very jumpy,
startle easy by noises).
MANAGEMENT:
Safety during flashbacks
Cognitive restructuring- assist
individual to view self as survivor
rather than a victim
Support group therapy
Medications (such as antianxiety
meds) can help alleviate some
symptoms during the treatment
process.
Psychophysiologic
Responses,
Somatoform and
Sleep Disorder
SOMATOFORM DISORDERS
Somatization is defined as the transference of
mental experiences and states into bodily
symptoms
SOMATOFORM DISORDERS are complaints

of physical symptoms for which there is no

known organic cause or physiologic mechanism
3 features
Physical complaints suggest major medical illness but
have no demonstrable organic basis
Psychological factors and conflicts seem important in
initiating, exacerbating and maintaining symptoms
Symptoms or magnified concerns are not under
clients conscious control
TYPES:
Pain disorder has the primary physical
symptom of pain which is generally
unrelieved by analgesics and greatly
affected by psychological stressors in
terms of onset, severity, exacerbation and
maintenance
Hypochondriasis- unrealistic fear
(disease phobia) or preoccupation (disease
conviction) of having a serious illness; fear
persist despite medical reassurance
TYPES:
Body Dysmorphic- preoccupation with
an imagined defect in a normal
appearing person; if the individual
actually has a defect, expressed concern
is excessive
Conversion Disorder- loss or change of

physical functioning that cannot be

associated with any organic cause and
seems to be associated with
psychological stressors. La belle
indifference is the key feature
 TYPE
Somatization disorder- is characterized by a
history of multiple physical complaints without
organic basis, occurring before age 30 and persisting
for several years
DSM IV Diagnostic Criteria
Pain symptoms : headache, abdominal pain, joints, back, chest,
rectum, pain during urination, menstruation or sexual
intercourse
GI symptoms: nausea, bloating, vomiting, diarrhea, or

intolerance of several foods

Sexual symptoms: sexual indifference, erectile or ejaculatory

dysfunction, irregular menses, excessive menstrual bleeding,

vomiting throughout pregnancy
Pseudoneurologic symptoms: conversion symptoms impaired

coordination, paralysis r localized weakness, difficulty in

swallowing, loss of touch or pain sensation, blindness
ONSET AND CLINICAL COURSE
Somatization and body dysmorphic disorder
experience symptoms in adolescent
Conversion disorder usually occur between 10-35
years of age pain disorder and Hypochondriasis
occur at any age
All somatoform disorder are chronic and recurrent

Clients with Somatization and Conversion disorder

seeks help after exhausted efforts at finding a
diagnosed medical condition
Those with Hypochondriasis and body dysmorphic
disorder receive psychologicla attention with
comorbid condition
RELATED DISORDERS
Malingering is intentional production of
false or grossly exaggerated physical or
psychological symptoms. It is motivated by
external incentives: avoiding work,
obtaining financial compensation, evading
criminal persecution. Person can stop
symptoms after they get what they want
Factitious disorder/ Munchausen
syndrome occurs when person
intentionally produces or feigns physical
and psychological symptoms solely to gain
attention
ETIOLOGY
Psychosocial theory believe that
people with somatoform DO keep
stress, anxiety or frustration inside
(internalization). He needs the
primary and secondary gains to met
his emotional needs.
Biologic theory stipulates that there
is a difference in the way people with
somatoform disorders regulate and
interpret stimuli
TREATMENT
Managing symptoms and improving quality of life
Depression usually accompanies somatoform
disorders. Clients are given antidepressants:
prozac, zoloft
Group therapy: structured cognitive-behavioral
therapy
ASSESSMENT
Use screening test assessment
History of previous physical problems

Clients brighten up as they are

assessed and given attention
Labile mood

Exaggerated physical symptoms

Little or no insight to behavior

May lose jobs because of frequent

absentism
DIAGNOSES
Ineffective coping
Ineffective denial
Impaired social interaction
Anxiety
Disturbed sleep pattern
Fatigue
Pain
GOALS
Identify relationship between stress an
physical symptom
Verbally express emotional feelings
Follow an establish daily routine
Demonstrate alternative ways to deal
with stress, anxiety and other feelings
Demonstrate healthier behavior
regarding rest, activity, and nutritional
intake
IMPLEMENTATION
Avoid reinforcing the symptoms to reduce
secondary gains
Encourage expression of feelings; focus on
feelings than on symptoms
Set limits on manipulative behaviors in
matter-of-fact manner
Maintenance of long term relationship with
health care provider
Stress-reduction measures
Teach coping strategies
EVALUATION
Client will take fewer visits to MD s
a result of physical complaints
Use less medications
More coping techniques and
increased functional ability
Improved family and social
relationship
DISSOCIATIVE DISORDERS
The main symptom cluster for dissociative
disorders include a disruption in consciousness,
memory, identity, or perception. In other words,
one of these areas is not working correctly and
causing significant distress within the
individual.
splitting off an idea or emotions from ones

consciousness; feeling of being detached from

usual experiences
TYPES:
Dissociative amnesia- is the sudden
inability to recall important personal
information
The primary symptoms are memory gaps related
to traumatic or stressful events which are too
extreme to be accounted for by normal forgetting.
Memory typically returns (and therefore the
disorder dissipates) with time. Therapy can be
useful to help with coping skills, but is not always
needed unless the individual develops excessive
fears or worries, or the memory loss has a drastic
effect on their everyday functioning.
TYPES:
Dissociative fugue- is the sudden,
unexpected flight from home with an
inability to recall events from ones past
This disorder is very rare and occurs most often
during extreme stress (such as wartime or after a
natural disaster).
The primary feature of this disorder is abrupt
travel away from home, an inability to remember
important aspects of ones life, and the partial or
complete adoption of a new identity.
The disorder typically dissipates on its own and it
is extremely rare to last more than one month.
TYPES:
Depersonalization Disorder- is the
feeling of being detached from, and as if
one is an outside observer of ones body
As with other disorders in this category, an
acute stressor is often the precursor to onset
This disorder is characterized by feelings of
unreality, that your body does not belong to
you, or that you are constantly in a dreamlike
state.
The disorder will typically dissipate on its own
after a period of time. Therapy can be helpful
to strengthen coping skills.
 TYPES:
Dissociative Identity Disorder/MPD- presence of
two or more distinct personalities each with its own
pattern of perceiving, relating to, and thinking about
the environment.
DID is associated with severe psychological stress in
childhood, most often ritualistic sexual or physical abuse.
The primary characteristic of this disorder is the existence
of more than one distinct identity or personality within
the same individual. The identities will take control of
the person at different times, with important information
about the other identities out of conscious awareness.
Treatment is difficult for a variety of reasons, including
secrecy on the clients part (unlike the misrepresentation
in the media), making him or her reluctant to seek help,
and the difficulty in diagnosing the disorder once the
client presents. Typically, an individual with DID will
require many years of treatment.
MANAGEMENT
Help client recognize when
dissociation occurs
Psychotherapy- hypnosis
Family or group therapy