PSYCHIATRIC NURSING

Mental Health
A state of emotional, psychological and
social wellness evidenced by satisfying
interpersonal relationships, effective
behavior and coping, positive self-concept
and emotional stability.
COMPONENTS OF MENTAL
HEALTH
 Autonomy and Independence-can work
interdependently without losing autonomy
Maximization of One’s Potential-oriented towards
growth and self-actualization
Tolerance of Life’s Uncertainties-can face the
challenges of day-to-day living with hope & positive look
Self-esteem-has realistic awareness of her abilities and
limitations
Mastery of the Environment-can deal with and
influence the environment
Reality Orientation-can distinguish the real world
from a dream, fact from fantasy
MENTAL ILLNESS
-State of imbalance characterized by a
disturbance in a person’s thoughts,
feelings and behavior
Criteria to Diagnose Mental Disorders
Dissatisfactions with one’s characteristics,
accomplishments, abilities
Ineffective or dissatisfying relationships
Dissatisfaction with one’s place in the
world
Ineffective coping with life’s events
Lack of personal growth
PSYCHIATRIC NURSING
Interpersonal process whereby the nurse
through the therapeutic use of self assist
an individual family, group or community
to promote mental health, to prevent
mental illness and suffering, to participate
in the treatment and rehabilitation of the
mentally ill and if necessary to find
meaning in these experiences
CORE OF PSYCHIATRIC
NURSING
Interpersonal
relationship
FOCUS: Patient
Foundation
Central Nervous System
Cerebrum
◦ Frontal lobe – control organization of thought,
body movement, memories, emotions and moral
behavior.
 Associated with schizophrenia, attention deficit /
hyperactive disorder and dementia

◦ Parietal lobe – interpret sensations of taste and

touch and assist is spatial orientation.
Foundation
Central Nervous System

◦ Temporal lobes – are centers for the sense

of smell, hearing, memory, and expression
of emotions.

◦ Occipital lobes – assist in coordinating

language generation and visual
interpretation, such as depth perception.
 Neurotransmitters

 Dopamine-controls complex movements, motivation,

cognition, regulates emotional responses
 Serotonin-regulation of emotions, controls food intake, sleep
and wakefulness, pain control, sexual behaviors
 Acetylcholine- controls sleep and wakefulness cycle
(decreased in Alzheimer’s)
 Histamine-controls alertness,peripheral allergic reactions,
cardiac stimulations
 GABA-modulates other neurotransmitters
 Norepinephrine / Epinephrine-causes changes in
attention, learning and memory, mood
Foundation
Neurotransmitters

Sympathetic
Parasympathetic
Increase v/s Decrease v/s
Decrease GI motility Increase GI motility
Decrease GU functionIncrease GU function
Moist mouth Dry mouth
Genetics and Hereditary
Alzheimer’s disease – linked with defects
in chromosomes 14 and 21
Schizophrenia

Mood disorders (depression)

Autism and AD/HD

Sigmund Freud
Father of Psychoanalysis
- “Your behavior today is directly or
indirectly affected by your childhood
days or experiences.

- STRUCTURE – Personality
Structure
Personality Structure
ID (4-5MONTHS)

◦ Impulsive / Instinctual drive

◦ I want to… PLEASURE PRINCIPLE
◦ I want to… PHYSIOLOGIC NEEDS
◦ I want to… PRIMARY PROCESS
Personality Structure

SUPEREGO

◦ Should not
◦ Small voice of GOD
◦ Set norms, standards and values
◦ MORAL PRINCIPLE
◦ Conscience
Personality Structure
EGO

◦ Executive
◦ REALITY PRINCIPLE
◦ Conscious
◦ Competencies
◦ Decision Maker; Problem-Solving; Critical and
Creative thinking
 Imbalances between Personality
Elements

ID
M – anic
A – nti-social
SE
N – arcissistic
 Imbalances between Personality
Elements

SE O – bsessive
Compulsive
ID A – norexia
nervosa
Imbalances between Personality
Elements

EGO Schizophrenia
 Libido

Sexual energy responsible for survival

of human beings
Psychosexual Theory of Freud
ORAL STAGE
18 months
Cry, suck, mouth
EGO @ 6 months
◦ Child cries – fed – successful
◦ Child cries – ignored –
unimportant - narcissistic
FIXATION
 occurs when a person is
stuck in a certain
developmental stage
REGRESSION
Returning to an earlier
developmental stage
Infantile behavior
ANAL STAGE
18 months – 3 years old
SUPEREGO develops
Toilet training
◦ Good Mother – Normal
◦ Bad Mother
 Clean, organized, obedient – OC (anal retentive)
 Dirty, disorganized – Anti-social (anal expulsive)
PHALLIC STAGE
 Preschooler (3 – 6 years old)
 Parent
◦ Oedipus Complex
 Castration Fear
◦ Electra Complex
 Penis Envy
REPRESSION
UNCONSCIOUS forgetting
of an anxiety provoking
concept
SUPRESSION
CONSCIOUS forgetting of an
anxiety provoking situation
IDENTIFICATION
 attempts to resemble or
pattern the personality of a
person being admired of
INTROJECTION
 acceptance of another values
and opinion as one’s own
LATENCY STAGE
 6 to 12 years old
 School
 Reading, writing, arithmetic
Ability to care about and
relate to others outside home
SUBLIMATION
 placing sexual energies
toward more productive
activities
SUBSTITUTION
 replace a goal that can’t be
achieved for another that is
more realistic.
GENITAL STAGE
 12 years old and above
Developing satisfying sexual
and emotional relationships
with members of the opposite
sex
Planning life’s goals
EGO DEFENSE
MECHANISMS
Function-To ward off anxiety
*without defense mechanisms, anxiety
might overwhelm and paralyze us and
interfere with daily living
2 Features:
1. 1.   they operate on an unconscious level
(Except suppression)
2.  2.  they deny, falsify or distort reality to
make it less threatening
EGO DEFENSE
MECHANISMS
Repression vs. Suppression

REPRESSION
◦ Unconscious forgetting of an anxiety provoking
concept

SUPRESSION
◦ Conscious forgetting of an anxiety provoking situation
EGO DEFENSE
MECHANISMS
Regression vs. Fixation
Regression
Returning to an earlier developmental
stage
Fixation
occurs when a person is stuck in a certain
developmental stage
EGO DEFENSE
MECHANISMS
Rationalization vs.
Intellectualization
RATIONALIZATION
◦ Self-saving with incorrect illogical explanation

INTELLECTUALIZATION
◦ Excessive use of abstract thinking; technical
explanation
EGO DEFENSE
MECHANISMS
Displacement vs. Projection vs. Introjection
DISPLACEMENT
◦ Feelings are transferred or redirect to other person or
object that is less threatening
PROJECTION
◦ Blaming; Falsely attributing to another his/her own
unacceptable feelings.
INTROJECTION
◦ Acceptance of another’s values and opinions as one’s
own
EGO DEFENSE
MECHANISMS
Sublimation vs. Substitution
SUBLIMATION
◦ Transfer of sexual energy to a more productive
activity.

SUBSTITUTION
◦ Replaces a goal that can’t be achieved for another that
is more realistic.
EGO DEFENSE
MECHANISMS
Dissociation vs. Isolation

DISSOCIATION
◦ Separating and detaching idea, situation from its
emotional significance.

ISOLATION
◦ Individual strips emotion when talking or responding
about it.
EGO DEFENSE
MECHANISMS
Conversion
◦ Anxiety converted to physical symptoms
Compensation
◦ Overachievement in one area to overpower weaknesses or
defective area.
Undoing
◦ Doing the opposite of what have done
EGO DEFENSE
MECHANISMS
Denial
◦ Failure to acknowledge an unacceptable trait or
situation

Fantasy
◦ Magical thinking

Reaction Formation
◦ Opposite of intention
EGO DEFENSE
MECHANISMS
Acting out
◦ Deals with emotional conflict or stressors by ACTION
rather than reflection or feelings.

Symbolization
◦ Creates a representation to an anxiety provoking thing
or concept

Splitting
◦ Labile emotions; all bad – all good
 DEFENSE MECHANISMS COMMONLY
USED IN EACH RESPECTIVE DISORDERS
◦ Paranoid – Projection
◦ Phobia – Displacement
◦ Amnesia – Dissociation
◦ Anorexia – Supression
◦ Bipolar Disorder – Reaction Formation
◦ Borderline – Splitting
◦ Schizophrenia – Regression
◦ Substance Abuse – Denial
◦ Depression – Introjection
◦ OC – Undoing
◦ Catatonic - Repression
Woman who is angry with her boss writes
a short story about a heroic woman.
Woman who is angry with her boss writes a short
story about a heroic woman.
Four-year old with new baby brother starts
sucking his thumb and wanting a bottle.
Patient criticizes the nurse after her family failed
to visit.
Man who is unconsciously attracted to other
women teases his wife about flirting.
Short man becomes assertively verbal and excels
in business.
Recovering alcoholic constantly preaches about
the evils of drink.
 Man reacts to news of the death of a loved one “ No, I
don’t believe you. The doctor said he was fine.”
 Student is unable to take a final exam because of a
terrible headache.
 After flirting with her male secretary, a woman brings
her husband tickets to a show.
 “I didn’t get the raise because my boss doesn’t like me.”
 Five-year old girl dresses in her mother’s shoes and
dress and meets daddy at the door.
 After his wife’s death, husband has transient complaints
of chest pain and difficulty breathing- the symptoms his
wife had before she died.
 Man forgets wife’s birthday after a marital fight.
 Businessman who is preparing to make an
important speech that day is told by his wife that
morning that she wants a divorce. Although
visibly upset, he puts this incident aside until after
his speech, when he can give the matter his total
concentration.
 A man cannot accept his physician's diagnosis of cancer is correct
and seeking a second opinion.
 Slamming a door instead of hitting as person, yelling at your
spouse after an argument with your boss.
 focusing on the details of a funeral as opposed to the sadness
and grief
stating that you were fired because you
didn't kiss up the the boss, when the real
reason was your poor performance
having a bias against a particular race or
culture and then embracing that race or
culture to the extreme
sitting in a corner and crying after
hearing bad news; throwing a temper
tantrum when you don't get your way
forgetting sexual abuse from your
childhood due to the trauma and anxiety
lifting weights to release 'pent up' energy
 Psychosocial Theory of Development

Erik Erickson
 PSYCHOSOCIAL THEORY –
Erikson’s

0-18 mos. Trust vs. Mistrust

-attachment to mother which lays foundations

for later trust in others
-conflict: general difficulties relating to others.
suspicion, fear of the future
 PSYCHOSOCIAL THEORY – Erikson’s
18 m0s – 3 yrs Autonomy vs.
Shame/Doubt
Gaining some basic control of self and
environment
Conflict: independence-fear conflict, severe
feelings of self-doubt
PSYCHOSOCIAL THEORY –
Erikson’s
3 yrs – 6 yrs Initiative vs. Guilt

-becoming purposeful and directive

-conflict: aggression-fear conflict; sense of
inadequacy and guilt
PSYCHOSOCIAL THEORY –
Erikson’s
6 yrs – 12 yrs Industry vs. Inferiority
Developing social, physical and school skills,
competence
Conflict: sense of inferiority; difficulty learning
and working
PSYCHOSOCIAL THEORY –
Erikson’s
12 yrs – 20 yrs Identity vs. Role Diffusion
Making transition from childhood to adulthood;
developing a sense of identity
Conflict: confusion of who one is, identity
submerged in relationships or group
memberships
PSYCHOSOCIAL THEORY –
Erikson’s
21 yrs – 35 yrs Intimacy vs. Isolation
-establishing intimate bonds of love and friendship
-conflict: emotional isolation
PSYCHOSOCIAL THEORY –
Erikson’s
35 yrs – 55 yrs Generativity vs. Stagnation

-fulfilling life’s goals that involve family, career

and society, developing concerns that embrace
future generations
-conflict: self-absorption. Inability to grow as a
person
PSYCHOSOCIAL THEORY –
Erikson’s
55 yrs – above Integrity vs. Despair
Looking back into one’s life and accepting its
meaning
Conflict: dissatisfaction with life, denial of or
despair over prospect of death
 Cognitive Theory of Development

Jean Piaget
assimilation
 people transform incoming information
so that it fits within their existing schemes
or thought patterns
accommodation
 people adapt their schemes to include
incoming information
PIAGET’S COGNITIVE THEORY
SENSORIMOTOR STAGE-development
proceeds from reflex activity to representation
and sensorimotor solutions to problems
◦ 0 to 18 months
PRE-OPERATIONAL STAGE-
development proceeds from sensorimotor
representation to prelogical thought and
solutions to problems
 can use these representational skills only to view
the world from their own perspective.
 Understand the meaning of symbolic gestures
◦ 2 to 7 years
 CONCRETE OPERATIONAL-development proceeds from
prelogical thought to logical solutions to concrete problems
 understand concrete problems
 cannot yet contemplate or solve abstract problems
 7 to 12 years
 FORMAL OPERATIONAL-development proceeds from
logical solutions to concrete problems to logical solutions to all classes
of problems
 cannot yet contemplate or solve abstract problems
 can also reason theoretically

 12 and above
Harry Stack Sullivan
Interpersonal Theory
 SULLIVAN’S INTERPERSONAL
THEORY
Infancy-anxiety develops as a result of unmet needs by
the mother (bodily needs); needs met, the child has sense of
well-being
◦ 0 to 18 months
Childhood-anxiety as a result of lack of
praise/acceptance from parents
-gratification leads to positive self-esteem
- moderate anxiety leads to uncertainty and insecurity; -
severe anxiety results in self-defeating patterns of behavior
◦ 18 months to 6 years
Juvenile-severe anxiety may result in a need to control
or restrictive, prejudicial attitudes
-learns to negotiate own needs
◦ 6 to 9 years
 Pre-adolescence-capacity to attachment, love and
collaboration emerges or fails to develop
-move to genuine intimacy with friend of the same sex
 9 to 12 years
 Adolescence-if self-system is intact, areas of concern
expand to include values, career decisions and social
concerns
-lust is added to interpersonal equation
-need for special sharing relationship shifts to opposite
sex
-new opportunities for social experimentation lead to
consolidation or self-ridicule
 12 to adulthood
Hildegard Peplau

NURSE PATIENT
RELATIONSHIP
 PEPLAU’S NPR
PRE-INTERACTION
◦ Major task of nurse- to develop self-awareness
ORIENTATION
◦ Major task of the nurse: to develop a mutual
acceptable contract
WORKING
◦ Major task: identification and resolution of
patient’s problem
TERMINATION
◦ Major task: to assist the patient to review what he
has learned and transfer his learning to his
relationship with others
 THERAPEUTIC
COMMUNICATIONS
ORIENTATION
◦ Broad Opening
◦ Recognition
◦ Giving information
◦ Silence
◦ Offering Self – “Do you want me to sit
beside you?”
 THERAPEUTIC
COMMUNICATIONS
 WORKING
 Focusing – “Let us discuss this topic more.”
 Exploring – “Tell me more about it.”
 Encourage Evaluation – “IS this what you want?”
 Reflecting – same idea
 Restating – same statement
 Verbalizing Implied – “Are you going to kill yourself?”
 Seeking Clarification – “May you please repeat that statement”
 General lead – “Please continue.”; “And then?”
 Limit setting – “Stop.”
 Interpreting – “Maybe that thing is very significant to you.”
 THERAPEUTIC
COMMUNICATIONS
TERMINATION
◦ Summarizing – “Let us now sum up. You
have stated earlier…etc.”
◦ “Do you have any questions?”
◦ “Our next therapy…”
◦ Look for changes in behavior
◦ Resistance is a common problem
 Therapeutic Communication
Techniques

Accepting-indicating reception
Eg.”Yes”
“I follow what you said”
Nodding..
 Broad Openings

Allowing the client to take the initiative in

introducing the topic
Eg. “is there something you’d like to talk
about?”
“Where would you like to begin?”
 Consensual Validation

Searching for mutual understanding, for

accord in the meaning of the words
Eg. “Tell me whether my understanding
of it agrees with yours”
“Are you using this word to convey
that. . .?”
 Encouraging Comparison

Asking that similarities and differences be

noted
Eg. “was it something like..?”
“Have you had similar experiences?”
 Encouraging Description of
Perceptions

Asking the client to verbalize what he or

perceives
Eg.”Tell me when you feel anxious”
“What is happening?”
‘What does the voice seem to be saying?”
 Encouraging Expression

Asking client to appraise the quality of

his or her experience
Eg. “what are your feelings in regard
to..?”
“Does this contribute to your distress?”
 Exploring

Delving further into a subject or idea

Eg. “Tell me more about that.”

“Would you describe it more fully?”

“What kind of work?”
 Focusing

Concentrating on a single point

Eg. “This point seems worth looking at
more closely”
“Of all the concerns you’ve mentioned,
which is most troublesome?”
 Formulating a Plan of Action
-Asking the client to consider kinds of
behavior likely to be appropriate in future
situations
Eg. “What could you do to let your anger
out harmlessly?”
“Next time this comes up, what might you
do to handle it?”
 General Leads

Giving encouragement to continue

Eg. “Go on”

“And then?”
“Tell me about it”
 Giving Information

Making available the facts that the client

needs
Eg. “My name is…”
“Visiting hours are…”
“My purpose in being here is… “
 Giving Recognition

Acknowledging, indicating awareness

Eg. “Good morning, Mr. S…”

“You’ve finished your list of things to

do.”
“I noticed that you’ve combed your
hair”
 Making Observations

Verbalizing what the nurse perceives

Eg. “You appear tense..”

“I notice that your biting your lips”

 Offering Self

Making oneself available

Eg. “I’ll sit with you awhile”

“I’ll stay here with you”

“I’m interested in what you think”
Placing Event in Time or Sequence

Clarifying the relationship of events in

time
Eg. “what seemed to lead up to…?
“Was this before or after?”
 Presenting Reality

Offering for consideration that which is

real
Eg. “I see no one else in the room.”
“Your mother is not here; I am a
nurse.”
 Reflecting

Directing client actions, thoughts, and

feelings back to client
Eg. Client: “Do you think I should tell the
doctor…? Nurse: “Do you think you
should?”
 Restating

Repeating the main idea expressed

Eg. Client: I can’t sleep. I stay awake all
night.”
Nurse:You have difficulty sleeping.”
Client:”I’m really mad, and upset”
Nurse: You’re really mad and upset.”
 Seeking Information

Seeking to make clear that which is not

meaningful or that which is vague
“I’m not sure that I follow.”
“Have I heard you correctly?”
 Silence
Absence of verbal communication, which
provides time for for the client to put
thoughts or feelings into words, regain
composure, or continue talking
Eg. Nurses says nothing but continues to
maintain eye contact and conveys interest.
 Suggesting Collaboration

Offering to share , to strive, to work with

the client for his or her benefit
Eg. Perhaps you and I can discuss and
discover the triggers for your anxiety
 Summarizing

Organizing and summing up that which

has gone before
Eg. “Have I got this straight?”
 Translating into Feelings

seeking to verbalize client’s feelings that

he or she expresses only indirectly
Eg. Client: “I’m dead”
Nurse: “Are you suggesting that you feel
lifeless?”
 Verbalizing the Implied

Voicing what the client has hinted at or

suggested
Eg. Client: I cant’ talk to you or anyone.
It’s a waste of time.” Nurse: “Do you feel
that no one understands”
 Voicing Doubt

Expressing uncertainty about the reality

of the client’s perceptions
“Isn’t that unusual?”
“Really?”
“That’s hard to believe.”
 Nontherapeutic Communication
Techniques

Advising-telling the client what to do

Agreeing- indicating accord with the
client
Eg. “I think you should….”
“That’s right”
 Agreeing
Indicating accord with the client
“that’s right.” “I agree”
 Belittling Feelings expressed
Misjudging the degree of the client’s
comfort
Client: “I have nothing to live for..I wish I
was dead”
Nurse: “Everybody gets down in the dumps.”
 Challenging
Demanding proof from the client
“But how can you be President of the
Philippines?”
 Defending
Attempting to protect someone or
something from verbal attack
“This hospital has a fine reputation.”
 Disagreeing

Opposing the client’s ideas

Eg. “That’s wrong”
 Disapproving

Denouncing the client’s behavior or ideas

“That’s bad”
“I’d rather you wouldn’t”
Giving approval
Sanctioning the client’s behavior or ideas
“ That’s good.” “I’m glad that..”
Giving Literal Responses
Responding to a figurative comment as
though it were a statement of fact
Client: “They’re looking in my head with
television camera.”
Nurse: “Try not to watch television.”
Indicating the existence of an
external source
“What makes you say that?”
Interpreting
Asking to make conscious that which is
unconscious
“What you really mean is..”
Introducing an unrelated topic
Changing the subject
Client: “I’d like to die.”
Nurse: “did you have visitors last night?”
Making stereotyped comments
Offering meaningless cliches or trite
comments
“Keep your chin up.”
“Just have a positive outlook.”
Probing
Persistentquestioning of the client
“Now tell me about this problem. I need
to know.”
Reassuring
Indicatingthere is no reason for anxiety
“Everything will be alright.”
Rejecting
Refusing to consider or showing
contempt for the client’s behavior, ideas
“Let’s not discuss..”
Requesting an explanation
Asking the client to provide reasons for
thoughts, feelings, behaviors, events
‘Why do you think that?”
Testing
Appraisingthe client’s degree of insight
“Do you know what kind of hospital this
is?”
Using Denial
Refusing to admit that a problem exists
Client: “I am nothing.”
Nurse: “Of course, you’re something.”
 NON-THERAPEUTIC
COMMUNICATIONS
Overloading – “blah, blah, blah”
Underloading - ignoring
Value Judgment – use of adjectives
False Reassurance – “Don’t worry, you will
be fine later.”
Focusing on Self – “I gave you meds so you
are now feeling good”
Incongruence -
Internal Validation – biased judgment
Giving Advice – “If I were you, ill…
Changing Subject -
LOSS AND GRIEVING
GRIEF- refers to the subjective emotions
and affect that are a normal response to
the experience of loss
ANTICIPATORY GRIEVING- when
people facing an imminent loss begin to
grapple with the very real possibility of
the loss or death in the near future
DISENFRANCHISED GRIEF-grief over
a loss that is not or cannot be
acknowledged openly, mourned publicly
or supported socially
COMPLICATED GRIEVING-when a
person is void of emotion, grieves for
prolonged periods, has expressions of
grief that seem disproportionate to the
event
LOSS
Physiologic Loss
Safe and Security Loss
Love and Belongingness Loss
Self-Esteem Loss
Self-actualization Loss
GRIEVING PROCESS
Denial
Anger
Bargaining
Depression
Acceptance

Dysfunctional grieving – grieving which

extends from 4 to 6 weeks leading to CRISIS
Interventions
Explore client’s perception and meaning of the
loss
Allow adaptive denial
Assist client to reach out for and accept support
Encourage client to examine patterns of coping
in past and present situation of loss
Encourage client to care for himself
Offer client food without pressure to eat
Use effective communication
CRISIS AND ITS
MANAGEMENT
CRISIS
situation that occurs when an individual’s
habitual coping ability becomes ineffective
to merit demands of a situation
TYPES OF CRISES:
MATURATIONAL / DEVELOPMENTAL
◦ Normal expected crisis that runs through age
SITUATIONAL
◦ Unexpected and sudden event in life
ADVENTITIOUS
◦ Calamities, war
Characteristics of a Crisis state
Highly individualized
Lasts for 4-6 weeks
Self-limiting
Person affected becomes passive and
submissive
Affects a person’s support system
PHASES OF A CRISIS
Pre-crisis: State of equilibrium
Initial Impact (may last a few hours to a few
days): High level of stress, helplessness,
inability to function socially
Crisis (may last a brief or prolonged period of
time): Inability to cope, projection, denial,
rationalization
Resolution: attempts to use problem-solving
skills
Post crisis: may have OLOF or may have
symptoms of neurosis, psychosis
CRISIS MANAGEMENT
Role of the nurse is to return the client to
its pre-crisis state by assisting and guiding
them until they achieved their OLOF.
Goal: to enable patient to attain an OLOF
Nurse’s Primary Role: Active and
Directive
Steps in Crisis Intervention
Identifythe degree of disruption the client is
experiencing
Assess the client’s perception of the event
Formulate nursing diagnoses
Involve the patient and family if applicable with
planning
Implement interventions- new and old coping
mechanisms
Evaluate-reassessment, reinforcement
TYPES OF THERAPIES
Treatment Modalities
Individual Psychotherapy
One to one relationship between therapist
and client
For dissociative, anorexia, paranoid,
narcissistic
Change is achieved by the exploration of
feelings, attitudes, thinking behavior and
conflict
SEVEN SUBTYPES:
 CLASSICAL PSYCHOANALYSIS
 Based on Freud’s theory
 To uncover unconscious feelings and thoughts that
interfere with the client’s living a fuller life
 Free association-client is encouraged to say
anything that comes to mind, without censoring
thoughts or feelings
 Dream analysis
 Working through(transference)-process of repeated
interpretation to the person of his or her
unconscious processes has the effect of bringing
about change
 Al relationship
PSYCHOANALYTICAL PSYCHOTHERAPY
Uses dream analysis, transference and free
association
Therapist is much more involved and interacts
with the client more freely
Done through intimate professional relationship
between the nurse/therapist and the client over a
period of time (introductory, working and
termination phase)
SHORT TERM DYNAMIC
PSYCHOTHERAPY
Indication-persons with specific symptom
or interpersonal problem that he/she wants
to work on
Therapist directs the content
Use of transference and dream analysis
Weekly sessions (total number-12 to 30)
Successful for highly motivated individuals
who have insight and with positive
relationship with the therapist
 TRANSACTIONAL ANALYSIS
 Eric Berne
 Each person has three ego states and change from one to
another frequently
 Parent-concepts of standards of behavior and how things
should be done e.g. Go and take out the garbage.
 Adult-rational thinking and data analyzing part of the
personality e.g.Would you please take out the garbage
 Child- feelings associated with persons, things or incidents
represent the need-gratifying aspects of the personality.
E.g. Is that why you married me?To be your garbage man?
 For group, family and individual
 Client to identify ego states for each given situation
 Rewarding of positive or negative behaviors with strokes
 Client work through these behaviors
COGNITIVE PSYCHOTHERAPY
Restructuring or changing ways in which
people think bout themselves
Thought stopping
Positive self-talk
Decatastrophizing
Therapists help patients identify these
thoughts
BEHAVIORAL THERAPY
Changes in maladapted behavior can occur
without insight into the underlying cause
Based on learning theory
Modeling
Operant conditioning
Self-control therapy-combination of
cognitive & behavioral approaches “talking
to self”
Systematic desensitization
Aversion therapy
GESTALT THERAPY
Emphasis on the “here and now”
Only present behavior can be changed, not history
Uncover repressed feelings and needs
Techniques: have a person behave the opposite of
the way he/she feels, presuming that a person can
then come in contact with a submerged part of the
self; in dreams, person is ask to play the roles of
persons in the dream to get in touch with different
repressed feelings
Milieu Therapy
Milieu Therapy
Total environment has an effect on the
individual’s behavior
Components
◦ Physical Environment
◦ Interpersonal relationships
◦ Atmosphere of safety, caring, and mutual
respect
◦ For alcoholics
 PROGRAMS FOR MILIEU
SHOULD HAVE:
 an emphasis on group and social interaction
 No rules and expectations mediated by peer
pressure
 A view of patients’ roles as responsible human
beings
 An emphasis on patients’ rights for involvement in
setting goals
 Freedom of movement and informality of
relationships with staff
 Emphasis on interdisciplinary participation
 Goal-oriented, clear communication
Group Therapy
Group Therapy

Number of people coming together,

sharing a common goal, interest or
concern, staying together and developing
relationships
For PTSD and Alcoholics
Phases
◦ Orientation
◦ Working
◦ Termination
Characteristics of Group Therapy
Universality  “You are not alone”
Instilling hope and inspiration
Developing social skills by interacting
with one another
Feeling of acceptance and belonging
Altruism “Giving of one’s self”
Psychoanalytically oriented group therapy
Psychodrama
Family therapy
Assumption of Family Therapy
◦ For alcoholic and schizophrenic
Assumption of Family Therapy
 Client: Whole family
 Concepts:
◦ The family is the most fundamental unit of the society.
◦ Adaptive or maladaptive patterns of behavior are learned from
the family
◦ Dysfunction in the family = dysfunction in the individual
 Purpose
◦ Improve relationships among family members
◦ Promote family function
◦ Resolve family problems
OTHER TYPES OF THERAPIES
SUPPORT GROUPS
◦ For those with AIDS, Mother-Against-Drug
Dependence

SELF-HELP GROUPS
◦ Alcoholic Anonymous
RULES FOR PSYCHOTHERAPEUTIC
MANAGEMENT
Provide support, treat patients with respect
and dignity
Do not place patients in situations wherein
they will feel inadequate or embarrassed
Treat patients as individuals
Provide reality testing
Handle hostility therapeutically
Provide psychopharmacologic treatment
BEHAVIORAL THERAPIES
Treatment Modalities
 BEHAVIORAL THERAPY
Pavlov’s Classical Conditioning
◦ All behavior are learned

B.F. Skinner’s Operational Conditioning

◦ Reinforcements
BEHAVIORAL THERAPY

Behavioral Modification – Substance

Abuse

Token Economy – Anorexia / Schizo

Systematic Desensitization - Phobia

ATTITUDE THERAPY
Treatment Modalities
 ATTITUDE THERAPY

1. Paranoid – Passive Friendliness

2. Withdrawn – Active Friendliness
3. Depressed / Anorexia – Kind Firmness
4. Manipulative – Matter of Fact
5. Assaultive – No Demand
6. Anti-social – Firm, consistent
PSYCHOSOMATIC
THERAPY
Treatment Modalities
Electroconvulsive Therapy
Electroconvulsive Therapy
Effective in most affective disorders
The induction of a grandmal seizure in
the brain.
Abnormal firing of neurons in the brain
causes an increase in neurotransmitters
Number of Treatments: 6-12 ,3 times a
week, about .5-2seconds
Unilateral or bitemporal
Electroconvulsive Therapy
Indications:
Patients who require rapid response
Patients who cannot tolerate pharmacotherapy
or cannot be exposed to pharmacotherapy
Patients who are depressed but have not
responded to multiple and adequate trials of
medication
Electroconvulsive Therapy
Preparations for ECT:
 Pretreatment evaluation and clearance
 Consent
 NPO from midnight until after the treatment
 Atropine Sulfate-to decrease secretions,
succinylcholine (Anectine)- to promote muscle
relaxation, Methohexital Sodium(Brevital)-
anesthethic
 Empty bladder
 Remove jewelry, hairpins, dentures and other
accessories
 Check vital signs
 Attempt to decrease patient’s anxiety
Electroconvulsive Therapy
Care after ECT:
O2 therapy of 100% until patient can breathe
unassisted
Monitor for respiratory problems, gag reflex
Reorient patient
Observe until stable
Careful documentation.
Male erectile dysfunction
OTHER THERAPIES

NEUROSURGERY
ANXIETY
Peplau’s Levels of Anxiety
 Mild
◦ Associated with the tension of day-today living
◦ Perceptual field increased
◦ More alert than usual
◦ Adaptive
 Moderate
◦ Narrowed perception
◦ Difficulty focusing
◦ Selective inattention
◦ Mild somatic complaints: stomachache and
butterflies in the stomach
Interventions for Mild to Moderate
Anxiety
 Assist the client in identifying anxiety.
 Anticipate anxiety provoking situations.
 Use nonverbal language to demonstrate interest
 Encourage the client to talk about his or her
feelings.
 Avoid closing off avenues of communication
(refrain from offering advice or changing the
topic).
 Encourage problem-solving
 Explore past and present coping behaviors
 Provide outlets for working off excess energy.
Levels of Anxiety
 Severe
◦ Very narrowed perception
◦ Unable to focus on problem solving
◦ Increased physical discomfort
◦ All behavior is aimed at relieving anxiety
◦ Direction is needed to focus attention
 Panic
◦ Awe, dread and terror
◦ Unable to see the whole situation or reality
◦ Distortion of perception
◦ Disorganization of the personality
◦ A frightening and paralyzing experience
 Interventions for Severe and Panic
Levels of Anxiety
 Maintain a calm manner.
 Remain with the person.
 Minimize environmental stimuli.
 Reinforce reality.
 Listen for themes in communication.
 Attend to physical safety and medical needs first.
 Physical limits may need to be set.
 Provide opportunities for exercising.
 Assess the person’s need for medication or seclusion.
ANTI – ANXIETY DRUGS
VALIUM
LIBRIUM
ATIVAN
SERAX
TRANXENE
MILTOWN
EQUANIL
VISTARIL
ATARAX
INDERAL
XANAX
BUSPAR
 ANTI – ANXIETY DRUGS
 Used only in a short time (1-2 weeks)
 Tolerance (after 7 days) and dependence (after 1
month)
 Liver function test
 Monitor for side effects.
 Avoid machines, activities needing concentration
 Z tract if given parenterally
 Avoid mixing with alcohol, antihistamines,
antipsychotics
 Don’t stop abruptly but gradually for 2-6 weeks
 Avoid caffeine
 Categories of
ANXIETY DISORDERS
Anxiety
Disorders

Basic
Anxiety Somatoform
Disorder
Categories of
ANXIETY DISORDERS
Basic Anxiety Disorders
Somatoform Disorders
Dissociative Disorders
BASIC ANXIETY
DISORDER
Basic anxiety disorders

Generalized Anxiety Disorder

Panic
Phobia
PTSD
Obsessive Compulsive
Chronic Anxiety Disorder or Generalized
Anxiety Disorder
 Excessive worry and anxiety for days but
not more than 6 months
 Difficulty in controlling the worry
 Anxiety and worry are evident by 3 or more
of the following :
 Restlessness, Keyed up
 Fatigue and irritability
 Decreased ability to concentrate
 Muscle tension
 Disturbed sleep
 Anxiety or worry causes significant
impairment in interpersonal relationship or
activities of daily living
Post Traumatic Stress Disorders
Post Traumatic Stress Disorders
Disturbing pattern of behavior occurring after a
traumatic event that is outside the range of usual
experience.
Characteristics
◦ Persistent re-experiencing of the trauma
through recurrent intrusive recollections of the
event, through dreams or flashbacks
◦ Persistent avoidance of the stimuli
◦ Feeling of detachment of estrangement from
others
◦ Chemical abuse to relieve anxiety
 Phobias

 Definition
 Persistent, irrational fear of a specific object, activity
or situation that leads to a desire for avoidance or
actual avoidance of the object of fear
 Specific Phobia
 Experience of high level of anxiety or fear provided
by a specific object or situation
 Treatment: Systematic Desensitization
 Defense mechanisms
 Repression and displacement
 Major Types of Phobias
Anxiety about being in places or situation from
which escape might be difficult (or embarassing)
or in which help may not be available in the
event of having an unexpected or situationally
predisposed panic or panic like symptoms.
Agoraphobic fears typically involve
characteristics cluster of situations that include
being outside the home alone: being in a crowd
or standing in a line; being on a bridge; and
traveling on a bus, train or automobile.
Major Types of Phobias
Agoraphobia
◦ Comes from the Greek word “Agora”
◦ Meaning “market place”
◦ Fear of being alone in open or public spaces
Social Phobia
◦ Fear of situations where one might be seen
and embarrassed or criticized
Specific Phobias
◦ Fear of a single object, situation or activity
that cannot be avoided
Obsessive Compulsive Disorder

Obsessions
 Preoccupation with persistent intrusive thoughts,
impulses or images
Compulsions
> Repetitive behaviors or mental acts that the person
feelds driven to perform in order t reduce distress or
prevent a dreaded event or situation

Cues:
 Ritualistic behavior
 Constant doubting if he/she has performed the activity
 Examples Obsessions Compulsions

Washing or cleaning “Wash away my sins”. Young woman repeatedly

Thought appeared after washes hands
sexual encounter with a
married man

Need for order “Everything must be in Arranges and rearranges

place”. items

Germs or dirt “Everything is Avoids touching all

contaminated” objects. Scrubs hands if
she is forced to touch any
object
Symmetry “Secretaries who practice Secretary lines up objects
neatness never gets fired’ in rows on her desk, then
realigns them repeatedly
during the day
 Care Strategies
 Be nonjudgmental and honest; offer empathy and support
 Help patient to recognize the connections between the trauma
experience and their current feelings, behaviors and problems.
 Encourage verbalizations of feelings, especially anger.
 Encourage adaptive coping strategies and techniques
 Encourage patients to establish or reestablish relationships
 Explore shattered assumptions. “I’m a good person. This is a
safe world”.
 Promote discussion of possible meaning of the events.
SOMATOFORM
DISORDERS
Somatoform Disorders
Body Dysmorphic Disorder
Somatization
Conversion Disorders
Hypochondriasis
Psychogenic pain
Body Dysmorphic Disorder
Preoccupation with an imagined defect in
his or her appearance
Somatization
A client expresses emotional turmoil or
conflict through a physical system,
usually with a loss or alteration of
physical functioning
Conversion Disorders
A psychological condition in which an
anxiety-provoking impulse is converted
unconsciously into functional symptoms
Hypochondriasis
Presentationof unrealistic or exaggerated
physical complaints
DISSOCIATIVE
DISORDERS
Dissociative Disorders
Dissociative amnesia
Dissociative fugue
Depersonalization
Dissociative Identity Disorder /
Multiple Identity Disorder
Dissociative amnesia
Characterized by the inability to recall an
extensive amount of important personaal
information because of physical or
psychological trauma
Dissociative fugue
The person suddenly and unexpectedly
leaves home or work and is unable to
recall the past
Depersonalization
Person experiences a strange alteration in
the perception or experience of the self,
often associated with a sense of unreality
Dissociative Identity
Disorder / Multiple Identity
Disorder
A person is dominated by at least one of
two or more definitive personalities at one
time
PSYCHOSOMATIC
DISORDER
Psychosomatic Disorder
- True / unconscious because of
hormonal and bodily changes
- Increase anxiety may result to
asthma, stress ulcers or migraine
SCHIZOPHRENIA
A major form of psychotic disorder that affects a
person’s thinking, language, emotions, social
behavior and ability to perceive reality
At least 2 of 5 types of positive and negative
symptoms
Characteristic Symptoms
Social or occupational dysfunction
◦ IPR
◦ Self care
Duration
◦ Continuous for at least 6 months
Positive and Negative Symptoms
Positive Symptoms
◦ Hallucinations
◦ Delusions
◦ Illusions
◦ Abnormal thought patterns or perceptions
◦ Bizarre behavior
Negative Symptoms

Negative Symptoms
◦ Affective flattening
◦ Anhedonia
◦ Attention impairment
◦ Asocial behavior
◦ Anergia
◦ Autism
◦ Avolition
SCHIZOPHRENIA
First described by Emil Kraeplin and
Eugen Bleuler.
Previously known as dementia precox.
Schizophrenia is a combination of two
Greek words “schizien” and phren
“mind”
• Age of onset: Late teens or early twenties
• Strong genetic compoenent
DELUSIONS
PERSECUTORY
RELIGIOUS
GRANDEUR
IDEAS OF REFERENCE
DISTURBED THOUGHT PROCESSES
 Looseness of Association
 Flight of Ideas
 Ambivalence
 Magical Thinking
 Echolalia / Echopraxia
 Word salad
 Clang association
 Neologism
 Thought blocking
 Concrete association
 Delusion, hallucination, illusion
Bleuler’s Four A’s of Schizophrenia
Affective Disturbances
Autism
Associative
looseness
Ambivalence
Other A’s
◦ Attention defects
◦ Disturbances of activities
SCHIZOPHRENIA

 Brief Psychotic Disorder-maybe seen when a person

exhibits clinical symptoms of illogical thinking,
incoherent speech, delusions, or disorganized behavior
after psychological trauma
 Induced Psychotic Disorder-develops in a second
person as a result of a close relationship with a person
who has psychosis
 Delusional Psychotic Disorder
 Schizoaffective disorder-characterized by depression
or elation as the psychosis symptoms of schizophrenia
and MDD
 Schizophreniform-when a person exhibits features of
schizophrenia for more than one week but less than 6
months
 Subtypes:
 Paranoid-most common form of the illness
Suspicious
 Promote trust
 Short interaction but frequent
 Food in containers (sealed)
 Prepare food in front of them
 Let them seed preparation of drugs

Violent
 Keep door open
 Position near door and with distance of 1 arm length
(patient-nurse)
 Don’t touch
 Maintain eye contact
 Call reinforcements
Subtypes:
 Disorganized-absence of systematized delusions;
presence of incoherence & inappropriate affect
◦ Inappropriate, flat affect
◦ Herbephrenic, flight of ideas

 Catatonic
◦ Risk for suicide
◦ Catatonic stupor, rigidity
◦ Waxy flexibility
Subtypes:

Undifferentiated
◦ unclassified

Residual
◦ No more positive symptoms but withdrawn
NURSING PROCESS
Disturbed Thought Process
Disturbed Sensory Process
Risk for self-directed violence
Risk for other directed violence

Present safety
Present reality
ANTI- PSYCHOTIC
Tara, look natin sina Stella, Mel, at Thor na
nag mo-moulin rouge…. Sssh , alam nyo ba na
ang trio na yan na akala mo may halo ay mga
closet queens pala…, namen”

( Taractan, Loxitane, Stelazine, Mellaril,

Thorazine, Molindone, Seroquel, Serlect,
Trilafon, Haloperidol, Clozapine, Navane )
SCHIZOPHRENIA
STELAZINE MILLARIL
SERENTIL HALDOL
THORAZINE LOXITANE
TRILAFON RISPERDOL
CLOZARIL PROLIXIN
ANTI – PSYCHOTIC DRUGS
 Watch for side-effects
◦ Increase v/s
◦ Constipation / dry mouth
◦ Postural hypotension
◦ Photophobia / photosensitivity
◦ Drowsiness
◦ Agranulocytosis
◦ Extrapyramidal symptoms
 Parkinson’s syndrome
 Akathisia
 Akinesia
 Dystonia – oculogyric crisis, torticollosis, opistothonus
 Tardive dyskinesia
 NMS
UNDESIRABLE EFFECTS
S-edation/sunlight sensitivity/sleepiness
T-ardive dyskinesia
A-nticholinergic/aganulocytosis/akathisia
N-euroleptic malignant syndrome
C-cardiac effects(Orthostatic
hypotension)
E-xtrapyramidal(dystonia
Parkinsonism
Motor retardation or akinesia
characterized by mask-like appearance,
rigidity, tremors, “pill-rolling”, salivation
Generally occurs after 1st week of
treatment or before second month
Administer anticholinergic agent, anti-
parkinson medication (Akineton)
Akathisia
Constant state of movement,
characterized by restlessness, difficulty
sitting still, or strong urges to move about
Generally occurs two weeks after
treatment begins
Rule out anxiety or agitation before
administration of an anticholinergic agent
Acute Dystonic reactions
Irregular,involuntary spastic muscle movement,
wryneck or torticollis, facial grimacing,
abnormal eye movements, backward rolling of
eyes in the sockets
May occur anytime from a few minutes to
several hours after first dose of antipsychotic
drug
Administer anticholinergic agent, have
respiratory support equipment available
Tardive Dyskinesia
Most frequent serious side effect resulting from
termination of the drug, during reduction in
dosage, or after long term high dose therapy.
Characterized by involuntary rhytmic,
stereotyped movements, tongue protrusion,
cheek puffing, involuntary movements of
extremities and trunk
Occurs in approximately 20-25% of patients
taking antipsychotics for over two years
No treatment except discontinuation of the
antipsychotic agent
Neuroleptic Malignant Syndrome
 A potentially fatal syndrome
 May occur anytime during therapy
 Seen during the initiation of therapy, change of therapy,
After a dosage increase or when a combination of meds
is used.
 Early sign: rigidity or mental status changes
 catatonia, tachycardia, tachypnea, labile blood pressure,
dysphagia, diaphoresis, incontinence, rigidity,
myoclonus, tremors, low grade fevers
 Discontinue antipsychotic agent. Have cardiopulmonary
support available; administer skeletal muscle
relaxant(e.g. dantrolene) or central acting dopamine
agonist (e.g. bromocriptine)
 NOTES on SCHIZOPHRENIA

 Distorted EGO
 Disturbed thought process
 Disorganized personality
 Dopamine – increase
 Autism
 Ambivalence
 Associative looseness
 Affect – flat
 Stimulation
 Structure
 Socialization
 Support
Manifestations:
S-social isolation
C-catatonic behavior
H-hallucinations
I-Incoherence
Z-zero/lack of interest and initiative
O-obvious failure in development
P-peculiar behavior
H-hygiene and grooming impaired
R-recurrent illusions
E-exacerbations and remissions
N-no organic factor account S/S
I-inability to return to functioning
A-affect is inappropriate
ANTI-PARKINSONIAN DRUGS
Dopaminergic Drugs
To live (Levodopa), you need a car (carbidopa)
and a man (Amantidine) not your brother
(bromocriptine) per (pergolide) se (selegiline)
ANTI-CHOLENERGIC
BACPAK ( BENADRYL, ARTANE,
COGENTIN, PARSIDOL, AKINETON,
KEMADRIN)
Other Treatments
Psychotherapy-individual, group, behavioral,
supportive or family therapy maybe used
depending on the clinical symptoms
Milieu therapy- a structured environment to
minimize environmental and physical stress and
to meet the individual needs of the patients until
they are able to assume responsibility for
themselves
 Concepts & Principles of Hallucination
 Possible to replace hallucination with satisfying
interactions
 Can re-learn to focus attention on real things and
people
 Hallucinations originate during extreme emotional
stress when the patient is unable to cope
 Hallucinations are very real to the patient
 Patient will react as the situation is perceived
 Concrete experiences, not argument on confrontation
will correct sensory distortion
 Hallucinations are a substitute for human relations
MOOD DISORDER/
AFFECTIVE DISORDER

BIPOLAR DISORDER
Bipolar Disorders
 A distinct period of abnormally and persistently elevated,
expansive or irritable mood lasting at least 1 week
 3 or more of the following
 Psychomotor overexcitability or excitement
 Insomnia with fatigue
 Euphoria or elated mood
 Distractability
 Pressured speech
 Flight of ideas
 Manipulative or demanding behavior
 Destructive or combative behavior
 Delusions of grandeur
 Impaired judgment
Bipolar Disorders

 Risk
◦ Female
◦ 20 years old and above
◦ Stressful life
◦ Obese

◦ Care giver role restrain

 Mania Vs Depression

Mania Depression
Appearance Colorful, flamboyant Sad and gray
Behavior Psychomotor Psychomotor
agitation retardation
Communication Pressured speech Monotonous
Stuttering speech
Cluttering
 Mania Vs Depression

Mania Depression
Nx Risk for Injury (others) Risk for injury (self)
suicidal precaution

Nursing priority Safety and nutrition Safety and Nutrition

Nutrition Finger foods and high Increased in

in calories nutrients
Treatment Lithium; ECT TCA; SSRI; MAOI’s
ECT
 Mania Vs Depression

Mania Depression
Milieu Non-stimulating Stimulating
environment
Appropriate Quiet type; non- Monotonous; Non-
activity competitive competitive
Attitude therapy Matter of fact Kind firmness;
active friendliness
LITHIUM
Level of lithium (0.5 to 1.5 meq/L)
Increase urination (polyuria)
Tremors – fine hand
Hydration
Increase peristalsis
U2 – 4 weeks effective
Increased bowel movements
Mouth is dry
◦ Assess function of kidney
◦ Toxicity: nausea and vomiting, diarrhea
PHARMACOLOGY MOMENTS
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ASENDIN
NORPRAMIN
TOFRANIL
SINEQUAN
ANAFRANIL
AVENTIL
VIVACTIL
ELAVIL
PROZAC
LUVOX
PAXIL
ZOLOFT
ANTIDEPRESSANTS
SSRI
◦ Selective Serotonin Reuptake Inhibitor
◦ Safest
◦ Side effects are low
◦ 1 to 4 weeks
◦ Prozac, Paxil, Zoloft, Luvox
ANTIDEPRESSANTS
TCA
◦ Tricyclic Antidepressants
◦ 2 to 4 weeks
◦ Anticholinergic
◦ amitriptyline, nortiptyline, doxepin
trimipramine, amoxapine, anafranil,
venlafaxine
ANTIDEPRESSANTS
MAOI’s
◦ Increases all neurotransmitters
◦ 2 to 6 weeks
◦ Hypertensive crisis
◦ Don’t take:
 Avocado
 Aged cheese
 Beer/ B6 (tyramine)
 Chocolate
 Fermented foods
 Soy sauce
 Pickles and preserved foods
ANTI- DEPRESSANT
A. TCA
“ knock! Knock! Who’s there? SEVANA to
gagah!”-------- (Sinequam, Elavil, Vivactil,
Ascendin, Norpramin, Aventyl, Tofranil)
B. SSRI
Ngongo: “Paxil ka! Paxil ka! Prozoleta ka lang,
kala ko luv mo ko!” (PRAXIL, PROZAC,
ZOLOFT, LUVOX)
C. MAO
“Naman, parnate ko pa”
(NARDIL, MANERIX, PARNATE)
SUICIDE
The intentional act of killing oneself
Suicidal Ideation- means thinking about oneself
A.Passive suicidal ideation-when a person thinks
about wanting to die or wishes he/she were dead
but has no plans to cause his/her death (e.g.
reckless driving, heavy smoking, overeating,
self-mutilation, drug abuse)
B. Active suicidal ideation-when a person thinks
about and seeks to commit suicide.
SAD PERSON’S SCALE
S-Sex Men kill themselves 3x more than women
though women make attempts 3x more often
than men
A-Age High risks groups:19 years or younger;
45 years or older, especially the elderly 65 and
above
D-Depression Studies report that 35-79% of
those who attempt suicide manifested a
depressive syndrome
 P-Previous Attempts Of those who commit suicide, 65-70% have
made previous attempts
 E-ETOH Alcohol is associated with up to 65% of successful suicides
 R-Rational Thinking Loss People with functional or organic
psychoses are more apt to commit suicide than those in the general
population
 S-Social Supports Lacking A suicidal person often lacks significant
others, meaningful employment and religious supports
 O-Organized Plan The presence of a specific plan for suicide signifies
a person at high risk
 N-No Spouse repeated studies indicate that persons who are widowed,
separated, divorced or single at greater risk than those who are married
 S-Sickness Chronic, debilitating and severe illness is a risk factor
Scoring
0-2 Home with follow up care
3-4 Close follow up and possible
hospitalization
5-6 Strongly consider hospitalization
7-10 Hospitalize
Situation:
Charles Brown, age 52 lost his wife in a
car accident few months ago. Since that
time, he has been severely depressed and
has taken to drinking to numb the pain
How many points according to the SAD
PERSONS SCALE?
Theories of SUICIDE
Psychodynamic theories
describe suicide as a wish to be at peace
with the internalized significant person
Wish to be reunited with a deceased loved
object
Suicide is an attempt to escape from an
intolerable situation or intolerable state of
mind
 Theories of Suicide
 Sociological Theories
 Durkheim-pioneer of sociological research in the study
of suicide
 3 Principal types:
1. Egotistic suicide-occurs when a person is insufficiently
integrated into society
2. Anomic suicide-occurs when a person is isolated from
others through abrupt changes in social norms/status
3. Altruistic suicide- occurs as a response to societal
demands (deaths of Buddhist monks who set themselves
on fire to protest the Vietnam war)
Theories of Suicide
Biochemical
Low serotonin levels
Precipitating factors
Social isolation-have difficulty forming
and maintaining relationships
Norman Cousins Story:
a woman who committed suicide had
written in her diary everyday during the
week before her death “Nobody called
today. Nobody called today. Nobody
called today. Nobody called today…”
Precipitating factors
Severe life’s events-divorce, death,
sickness, legal problems, interpersonal
discord
Sensitivity to Loss-may react tragically
to separation or loss of a loved one (had
insecure or unreliable childhood experiences)
ASSESSING VERBAL & NONVERBAL
CLUES
Verbal Clues:
Overt Statements: “I can’t take it anymore!”;
“Life’s isn’t worth living anymore.”; “I wish I
were dead.”; “Everyone will be better off if I am
dead.”
Covert Statements: “It’s ok now, soon
everything will be fine,” “Things will never
work out.” “I won’t be a problem much longer.”
“Nothing feels good to me anymore.” “How can
I give my body to medical science?”
Nonverbal Clues
Behavioral Clues: sudden behavioral
changes especially when depression is
lifting and when the person has more
energy available to carry out the plan
Signs: giving away prized possessions,
writing farewell notes, making out a will
and putting personal affairs in order
Nonverbal Clues
Somatic clues: physiological complaints
can mask psychological pain and
internalized stress
Headaches, muscle aches, trouble
sleeping, irregular bowel habits, unusual
appetite or weight loss
Nonverbal Clues
Emotional clues
Social withdrawal, feelings of
hopelessness and helplessness, confusion,
irritability and complaints of exhaustions
Suicide Precautions
Execute a “no suicide contract”. The client will
inform the nurse when he/she has suicidal
ideations
Ask direct questions. Find out if the person has
specific plan for suicide. Determine what
method.
Be alert for cries for suicide
Provide a safe environment and protect client
from self
Encourage to ventilate feelings and thoughts
 Suicide Precautions
 Give emotional support
 Make the patient realize that the tendency to commit
suicide is due to the disturbance in the brain chemistry
and is treatable-once they know that an episode of
suicidal thinking will pass, they will likely not act on
the impulse
 Provide structured schedule and involve in activities
with others to increase self-worth and divert attention
 On discharge: help patient create “plan for Life”(list of
warning signs of suicidal ideation and actions to take)
Suicide Precautions
 Always remember:
A. That a suicidal person want to die only during
the period of suicidal crisis-during this time
the person is ambivalent about living and
dying
B. Suicidal people gives warning
C. Persons recovering from depression are high
risk for 9-15 months after recovery
D. Suicidal people are extremely unhappy but not
always mentally ill
Personality behaviors
SAD PERSON’S SCALE Personality
problems
 Schizoid
 Dependent
 Antisocial
 Avoidant
 Histrionic
 Borderline
 Paranoid Personality Disorder
A pervasive pattern of distrust and suspiciousness of
others such that their motives are interpreted as malevolent
◦ Suspicious (e.g. others are exploiting or deceiving him)
◦ Doubt trustworthiness of others
◦ Fear of confiding in others
◦ Fear personal information will be used against him
◦ Interpret remarks as demeaning or threatening
◦ Hold grudges toward others
◦ Becomes angry and threatening when they perceive to
be attacked by others
 Intervention: centered on building trust
 Schizoid Personality Disorder
A pervasive pattern of detachment from social relationships
and a restricted range of expression of emotions in
interpersonal settings
◦ Lacks desire for close relationships or friends including
family
◦ Chooses to be alone
◦ Lack of sexual experiences
◦ Avoids activities
◦ Appears cold and detached
Interventions: building trust followed by
identification and appropriate verbal expression
 Schizotypal Personality Disorder
 A pervasive pattern of social ◦ Ideas of reference
and interpersonal deficits ◦ Magical thinking or odd beliefs
marked by acute discomfort ◦ Unusual perceptual experiences,
with and reduced capacity including bodily illusions
for close relationships as ◦ Peculiar thinking
well as by cognitive or ◦ Vague, stereotypical, over elaborate
perceptual distortions and speech
eccentricities of behavior
◦ Suspiciousness
Interventions: Improving ◦ Blunted or inappropriate affect
Interpersonal ◦ Eccentric appearance or behavior
relationships, social ◦ Few close relationships
skills., and appropriate ◦ Uncomfortable in social situations
behaviors
 Antisocial Personality Disorder
Characterized by deceit,
 Interventions:
manipulation, revenge and ◦ Consistency
harm to others with an ◦ Kind firmness in confronting
absence of guilt or anxiety behaviors and enforcing rules
◦ Violates rights of others and policies
◦ Engages in illegal activities ◦ Limit setting
◦ Aggressive behavior ◦ Decrease impulsivity
◦ Lack of guilt or remorse ◦ Enhance role performance
◦ Irresponsible in work and ◦ Effective use of confrontation
with finances
◦ Impulsiveness
◦ Recklessness
◦ Manipulative
Borderline Personality Disorder
Characterized by pervasive pattern of unstable
interpersonal relationships; self-image and affect;
and marked impulsivity
◦ Frantic avoidance of abandonment; real or imagined
◦ Unstable and intense interpersonal relationships
◦ Identity disturbances
◦ Impulsivity
◦ Self-mutilating behavior
◦ Rapid mood shifts
◦ Chronic feelings of emptiness
◦ Problems with anger
◦ Transient dissociative and paranoid symptoms
Other important information
Priority nursing diagnosis: High risk for
injury directed to self related to self-
mutilation behaviors
Coping mechanisms used: Splitting
◦ Classifying people as either “good” or “bad”
Interventions
Use of empathy.
Recognize the reality of the patient’s pain.
Offer support
Empower and work with the patient to
understand control and change dysfunctional
behaviors.
Provide safe environment
Teach social skills
Make a list of solitary activities to combat
boredom
Narcissistic Personality Disorder
 Grandiose self importance
 Fantasies of unlimited
power, success or brilliance
 Believes he or she is special
 Needs to be admired
 Sense of entitlement
 Takes advantage of others
for own benefit
 Lacks empathy
 Envious of others or others
are envious of him
 Arrogant
A
ne
 Interventions
◦ Supportive confrontation
on what the patient says
and what exists.
◦ Limit setting and
consistency to decrease
manipulation and
entitlement behaviors.
◦ Remain neutral, avoid
power struggles, or
becoming defensive.
Histrionic personality
A pervasive Disorder
pattern of excessive emotionality and
attentive seeking
◦ Overly dramatic
◦ Draws attention to self
◦ Extroverted and thrives on being the center of attraction
◦ Uses somatic complaints to avoid responsibility and support
dependency
◦ Dissociation
Interventions: Positive reinforcement in the form
of attention, recognition or praise are given for
unselfish or other-centered behaviors
Dependent Personality Disorder
A pervasive and excessive need to be taken care of
that leads to submissive and clinging behavior and
fears of separation
◦ Needs others to be responsible for important areas of
life.
◦ Problems with initiating with projects or doing things
on his own because of little self confidence
◦ Performs unpleasant tasks to obtain support from others
◦ Urgently seeks another relationship for support and care
after a close relationship ends
◦ Preoccupied with fear of being alone to care for self
 Interventions: increase responsibility for self in day to day
living; assertiveness training
Avoidant Personality Disorder

A pervasive pattern of social inhibition,

feelings of inadequacy and
hypersensitivity to negative evaluation
◦ Avoids occupations involving interpersonal contact due to
fears of disapproval or rejection
◦ Preoccupied with being criticized or rejected in social
situations
◦ Inhibited and feels inadequate in new interpersonal
situations
◦ Very reluctant to take risks or engage in new activities due
to the possibility of being embarrassed
Obsessive Compulsive Personality
Disorder

 A pervasive pattern of preoccupation with orderliness,

perfectionism and mental and interpersonal control at
the expense of flexibility, openness and efficiency
 Preoccupied with details, lists, rules, organization
 Perfectionist
 Too busy working to have friends or leisure activities
 Unable to discard worthless or worn-out objects
 Reluctant to spend and hoards money
 Rigid and stubborn
Delirium
 Characterized by disturbance of consciousness and a
change in cognition such as impaired attention span and
disturbances in consciousness that develop over a short
period of time.
◦ Always secondary to another condition (medical condition or
substance abuse)
◦ Frequent among the elderly and young febrile children
◦ Fluctuations of consciousness and inoculation through out the
day
 Classified
as mild to severe.
 Sundowning
 Dementia

 Characterized by multiple
cognitive deficits that 4 Symptoms of Dementia
include impairment of ◦ Loss of memory
memory which develops◦ Deterioration of language function
slowly ◦ Loss of ability of think abstractly,
◦ 80-90% irreversible plan, initiate, sequence, monitor or
stop complex behavior
◦ Reversible due to pathologic
process ◦ Loss of ability to perform ADLs
◦ Most common: Alzheimer’s
Dementia
Stages of Dementia
 Stage 2 Moderate (Confusion)
◦ Progressive memory loss
◦ ST memory loss interferes with ADLs
◦ Withdrawn, Denial, Fear of Losing their minds
◦ Depression, Confabulation
◦ Problems increase when stressed
◦ Needs home care or in-home assitance
 Stage 1 Mild (Forgetfulness)
◦ Losses in short term memory
◦ Memory aids compensate
◦ Aware of the problem, disturbed
◦ Not diagnosable at this time
 Stages of Dementia
 Stage 3
Moderate to Severe
(Ambulatory Dementia)
 Loss of reasoning ability,
planning and verbal
communication
 Frustrated, withdrawn, self-
absorbed
 Depression decreases
 Reduced stress threshold
 Institutional care required
 Stage 3
Late
(EndStage)
 Family recognition disappears
 Doesn’t recognize self
 Nonambulatory
 Little purposeful activity
 Often mute, may scream spontaneously
 Forgets most ADLs
 Problems associated with immobility
 Institutional care required
 Return of primitive reflexes
 Delirium Vs Dementia
Delirium Dementia
Onset Usually sudden Usually gradual

Course Usually brief with return Usually long-term

to usual level of and progressive,
functioning occasionally maybe
arrested or
reversed

Age group any elderly

 Sexual Disorders

Homosexuality Voyeurism
Heterosexuality Transvestism
Bisexuality Transexualism
Masochism
Sadism
Frotteurism
Pedophilia
Necrophilia
ALCOHOL
ALCOHOLISM
Intergenerational Transmission
Awake but unconscious
Blackout
Confabulation
Denial, dependence
Enabling, co-dependence
Tolerance increases

Detoxification - doctor
Stages of Alcohol Withdrawal
 I 8 hours after the last drink
◦ Mild tremors, tachycardia, increased BP, diaphoresis,
nervousness
 2 8-12 hours after the last drink
◦ Gross tremors, hyperactivity, profound confusion, loss of
appetite, insomnia, weakness disorientation, illusions,
hallucinations and delusions
 3 12-48 hours after the last drink
◦ * severe hallucinations, grand mal seizures
 4 3-4 days after the last drink
◦ Delirium tremens, confusion, agitation, hallucinations, insomnia
and tachycardia
ALCOHOLISM
Avoid alcohol during therapy
Aversion therapy
Antabuse – disulfiram
Belongings – check for alcohol, mouthwash,
elixir etc.
B1 deficiency
Complication
◦ Wernicke’s Encephalopathy (Motor)
◦ Korsakoff’s Pychosis (Mind)
Deliruim Tremens
Fornication
AUTISM
 Living in their own world
 Appearance – flat (consistent)
 Behavior – ritualistic, repetitive
 Communication – echolalia, incomprehensible

NX: Impaired Verbal Communication

Impaired Social Interaction
Self Mutilation
Risk for Injury
ADHD
 Attention-deficit / hyperactive disorder
 7 years old and above
 Duration: 6 months and above
 Requires 2 settings: home and school

 Appearance: Dirty child

 Behavior: Clumsy, hyperactive, impatient
 Communication: talkative, bursts out

 Structure
 Setting limits
 Schedule
 Safety
Eating Disorders
Anorexia Nervosa
Bulimia Nervosa
Pica
Compulsive Eating Behavior
EATING DISORDERS
 Anorexia Nervosa
Anorexia nervosa is a life threatening eating disorder
characterized by the aforementioned symptoms.
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
 Inability or refusal to acknowledge the seriousness
of the problem
 Onset: 12-15, 17-21 years of age
Etiology
Cultural pressure
Serotonin imbalance controls appetite
and the satiety control center
Family Patterns
◦ Perfectionist
◦ Does not permit verbalization of feelings
◦ Marital problems
Clinical Presentation
 Terrifiedof gaining weight
 Pre-occupied with thoughts of food
 See themselves as fat even when emaciated
 Peculiar handling of food
◦ Cutting food into small bits
◦ Pushing pieces of food around the table
 May develop rigorous exercise program
 Self-induced vomiting, laxatives and diuretics
 Cognition so disturbed that they judge their self-worth
by their weight.
 Clinical Presentation

Low weight Low T3 and T4

Amennorrhea Hypotension
Yellow skin Bradycardia
Cold extremities Hypokalemia
Peripheral edema Anemia
Muscle weakening Pancytopenia
Constipation Decreased bone
density
Signs related to Purging Behaviors
Gastrointestinal
◦ Parotid gland tenderness, Pancreatitis,
esophageal and gastric erosion or rupture
Metabolic
◦ Electrolyte abnormalities hypokalemia
Dental
◦ Erosion of dental enamel of the front teeth
Objectives of care:
Increasing body weight to at least90% of
average weight for age and height
Reestablishing good eating behavior
Increasing self esteem
 Nursing Interventions:

 Monitor daily caloric intake, activity level, weight and

electrolyte status.
 Establish nutritional eating patterns
 Sit with client during meals
 Offer liquid protein supplement if unable to complete a meal
 Observe signs of purging 1-2 hours after meals
 Provide accurate information on nutrition and discuss realistic
and healthy diet
 Help the client identify emotions and develop non-food
related strategies.
 Convey warmth and sincerity
 Ask the client to identify feelings
 Assist the client to change stereotypical beliefs
Nursing Interventions

Assist in identifying at least three positive

characteristics
Teach patient about their illness
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
Clinical Presentation
Binge and Purging behaviors
Have depressive signs and symptoms
Disturbed home life
Major concerns
◦ Interpersonal relationships
◦ Self-concept
◦ Impulsive behaviors
Chemical dependence is also common
Clinical Presentation
Normal to slightly low weight
Dental carries
Parotid swelling
Gastric swelling and rupture
Callusses or scars on the hand
Peripheral edema
Hypokalemia, Hyponatremia
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
Management:
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.