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The Nature of Mental Health and Contemporary Psychiatric Nursing
Mental Illness, 1 Practice, 171
1 Social Change and Mental Health, 3 10 Communication and the Therapeutic
Mary Ann Boyd Relationship, 173
Cheryl Forchuk and Mary Ann Boyd
2 Cultural Issues Related to Mental Health
Care, 16 11 The Assessment Process, 189
Mary Ann Boyd Mary Ann Boyd

3 Mental Health and Mental Illness, 27 12 Diagnosis and Outcomes Development, 208
Mary Ann Boyd Doris E. Bell and Lorraine D. Williams

4 Patient Rights and Legal Issues, 35 13 PsychiatricMental Health Nursing

Mary Ann Boyd Interventions, 218
Mary Ann Boyd
5 Mental Health Care in the Community, 46
Denise M. Gibson and Robert B. Noud 14 Interventions With Groups, 233
Mary Ann Boyd

UNIT II 15 Family Assessment and Interventions, 246

Mary Ann Boyd
Principles of Psychiatric
Nursing, 61
6 Contemporary Psychiatric Nursing
Practice, 63 Care of Persons With Psychiatric
Mary Ann Boyd Disorders, 263
7 Theoretic Basis of Psychiatric 16 Schizophrenia, 265
Nursing, 74 Andrea C. Bostrom and Mary Ann Boyd
Mary Ann Boyd
17 Schizoaffective, Delusional, and Other
8 The Biologic Foundations of Psychiatric Psychotic Disorders, 311
Nursing, 93 Nan Roberts and Roberta Stock
Susan McCabe
18 Mood Disorders, 333
9 Psychopharmacology and Other Biologic Sandra J. Wood, revised from a chapter by Katharine
Treatments, 124 P. Bailey
Susan McCabe

xvi Contents

19 Anxiety Disorders, 374 UNIT VII

Robert B. Noud and Kathy Lee
Care of Special Populations, 709
20 Personality and Impulse-Control
30 Care of People Who Are Homeless and
Disorders, 420
Mentally Ill, 711
Barbara J. Limandri and Mary Ann Boyd
Ruth Beckmann Murray and Marjorie Baier

21 Somatoform and Related Disorders, 470

31 Issues in Dual Disorders, 728
Mary Ann Boyd
Barbara G. Faltz and Sandra C. Sellin

22 Eating Disorders, 492

Jane H. White 32 Psychosocial Aspects of Medically
Compromised Persons, 746
Gail L. Kongable
23 Substance Use Disorders, 524
Barbara G. Faltz and Richard V. Wing

UNIT V Care Challenges in Psychiatric
Children and Adolescents, 565 Nursing, 769

24 Mental Health Assessment of Children and 33 Stress, Crisis, and Disaster

Adolescents, 567 Management, 771
Vanya Hamrin, Catherine Gray Deering, and Lorraine D. Williams and Mary Ann Boyd
Lawrence Scahill
34 Management of Aggression and
25 Mental Health Promotion With Children Violence, 802
and Adolescents, 586 Sandy Harper-Jaques and Marlene Reimer
Catherine Gray Deering and
Lawrence Scahill
35 Caring for Abused Persons, 823
Mary R. Boyd
26 Psychiatric Disorders Diagnosed in
Childhood and Adolescence, 603
36 Case Finding and Care in Suicide:
Lawrence Scahill, Vanya Hamrin, and
Catherine Gray Deering Children, Adolescents, and Adults, 857
Emily J. Hauenstein

Appendix A
DSM-IV-TR Classification: Axes I and II
Older Aduts, 643 Categories and Codes, 833

27 Mental Health Assessment of Appendix B

the Elderly, 645 Canadian Standards of Psychiatric and
Mary Ann Boyd and Mickey Stanley Mental Health Nursing Practice
(2nd ed.), 892
28 Mental Health Promotion With the
Elderly, 660
Appendix C
Mary Ann Boyd
Brief Psychiatric Rating Scale, 896
29 Delirium, Dementias, and Related
Disorders, 671 Appendix D
Mary Ann Boyd, Linda Garand, Linda A. Gerdner, NANDA Nursing Diagnoses
Bonnie J. Wakefield, and Kathleen C. Buckwalter (20032004), 897
Contents xvii

Appendix E Appendix I
Simpson-Angus Rating Scale, 899 CAGE Questionnaire, 905

Appendix F
Appendix J
Abnormal Involuntary Movement Scale
Specific Defense Mechanisms and
(AIMS), 901
Coping Styles, 906
Appendix G
Simplified Diagnoses for Tardive Glossary, 909
Dyskinesia (SD-TD), 903 Index, 929

Appendix H
Hamilton Rating Scale for Depression, 904

The Nature of
Mental Health and
Mental Illness

Social Change and
Mental Health
Mary Ann Boyd

After studying this chapter, you will be able to:
Identify agents of social change that affect the delivery of mental health care.
Relate the concept of social change to the history of psychiatricmental health care.
Discuss the history of psychiatricmental health nursing and its place within nursing
Analyze the theoretical arguments that shaped the development of contemporary
scientific thought.
Summarize the impact of current economic and political forces on the delivery of
mental health services.

biologic view deinstitutionalization moral treatment psychiatric pluralism
psychoanalytic movement psychosocial theory

social change

4 UNIT I The Nature of Mental Health and Mental Illness

T hroughout history, an interplay of biologic, spiri-

tual, and environmental factors were believed to
cause mental disorders. Acceptable treatment methods
During periods of rapid social change and instability,
there is more general anxiety and fear and subsequently
more intolerance and ill treatment of people with mental
reflected the underlying popular beliefs of the times. disorders. See Table 1-1 for a summary of historical
When the causes of mental disorders were believed to events and correlating perspectives on mental health dur-
be biologic, individuals were treated with the latest bio- ing the Premoral Treatment Era (800 BC to the Colonial
logic therapy. Prehistoric healers practiced an ancient Period).
surgical technique of removing a disk of bone from the
skull to let out the evil spirits. In the early Christian
period (1100 AD), when sin or demonic possession A Revolutionary Idea:
were thought to cause mental disorders, clergymen
treated patients, often through prescribed exorcisms. If
Humane Treatment
such measures did not succeed, patients were excluded The emergence of enlightened political ideas and an
from the community and sometimes even put to death. increasing availability of economic resources in the late
Later in the Medieval era (10001300), many believed 18th century led to the advent of moral treatment in
disorders were products of dysfunctional environments, mental health care, which was characterized by kind-
and individuals were removed from their sick envi- ness, compassion, and a pleasant environment for
ronments and placed in protected asylums. patients. Publicly and privately supported asylums for
The differences in the treatment of mentally ill individuals with mental disorders were built during this
patients typically depends on the communitys per- time, and patients were routinely removed from their
ceived notions and fears of those with mental disor- home environments, which were believed to be causing
ders. History reflects that generally, in periods of rel- the illnesses. It was the first humane treatment period
ative social stability, there is less fear and more since the Greek and Roman eras.
tolerance for deviant behavior, and it is easier for indi- By the height of the French Revolution in 1792,
viduals with mental disorders to live safely within their moral treatment had become standard practice. It was
communities. during this time that Philippe Pinel (17451826) was
appointed physician to Bicetre, a hospital for men that
KEY CONCEPT Social change, the structural and had the unfortunate distinction of being the worst asy-
cultural evolution of society, is constant and at times lum in the world. Pinel believed that the insane were
erratic. Psychiatric mental health care has evolved
sick patients who needed special treatment, and once
within the social framework and cannot be separated
installed in his position, he ordered the removal of the
from economic and political realities.
chains, stopped the abuses of drugging and bloodlet-
ting, and placed the patients under the care of physi-
FAME AND FORTUNE cians. Three years later, the same standards were
extended to Salpetriere, the asylum for female patients.
Joan of Arc (14121431)
At about the same time in England, William Tuke
Famous Warrior
(17321822), a member of the Society of Friends,
Public Personna raised funds for a retreat for members who had mental
Born in 1412 in France, Joan of Arc began hearing disorders. The York Retreat was opened in 1796;
counsel and seeing visions of Saints Catherine and restraints were abandoned, and sympathetic care in
Margaret (two early Christian martyrs) and St.
quiet, pleasant surroundings with some form of indus-
Michael the Archangel at age 12. Initially, the visions
instructed her to be good and to go to church regu- trial occupation, such as weaving or farming, was pro-
larly. Over the years, the visions persisted and vided (Fig. 1-1).
expanded calling her to save France from British While Tuke was influential in England, the Quak-
occupation. Deeply believing that her mission was in ers also exercised their influence in the United States,
response to Gods will, she dressed as a boy and led
where they were instrumental in stopping the practice
an army to defeat the British.
of bloodletting; they also placed great emphasis on
Personal Realities providing a proper religious atmosphere (Deutsch,
At age 19, the simple and faithful maiden was cap- 1949). The Quaker Friends Asylum was proposed in
tured and burned at the stake for heresy. Twenty-
three years later, her conviction was overturned. In
1811 and opened 6 years later in Frankford, Pennsyl-
the 20th century, she was canonized and today she is vania (now Philadelphia), to become the second asy-
the patron saint of France. Some saw Joan of Arc as a lum in the United States. The humane and supportive
messenger from God while others believed that she rehabilitative attitude of the Quakers was seen as an
was the devil. Probably today, neither would apply. extremely important influence in changing tech-
Instead, she might be hospitalized and her visions
explained as symptoms of a mental disorder.
niques of caring for those with mental disorders. As
states were founded, new hospitals were opened that
CHAPTER 1 Social Change and Mental Health 5

Table 1.1 Social Change in the Premoral Treatment Era

Socioeconomic and Political Events Changing Attitudes and Practice

Period and People in Mental Health Care

Ancient Times to 800 BCE Sickness was an indication of the Persons with psychiatric symptoms
displeasure of deities for sins. were driven from homes and
Viewed as supernatural. ostracized by relatives. When
behavioral manifestations were
viewed as supernatural powers, the
persons who exhibited them were
Periods of Inquiry: 800 BCE to Egypt and Greek periods of inquiry. Counseling, work, music were provided
1 CE Physical and mental health viewed as in temples by priests to relieve the
interrelated. Hippocrates argued distress of those with mental
abnormal behaviors were due to disorders. Observation and
brain disturbances. Aristotle related documentation were a part of the
mental to physical disorders. care. The mental disorders were
treated as diseases. The aim of
treatment was to correct imbalances.
Early Christian and Early Power of Christian church grew. St. Persons with psychiatric symptoms
Medieval: 11000 CE Augustine pronounced all diseases were incarcerated in dungeons,
ascribed to demons. beaten, and starved.
Later Medieval: 10001300 In Western Europe, spirit of inquiry First asylums built by Moslems.
dead. Healing by theologians and Persons with psychiatric symptoms
witchdoctors. Persons with were treated as being sick.
psychiatric symptoms were
incarcerated in dungeons, beaten,
and starved. In Mideast, Avicenna
said mental disorders are illnesses.
Renaissance: 13001600 In England, differentiated insane from Persons with psychiatric symptoms
criminal. In colonies, mental illness who presented a threat to society
believed caused by demonic were apprehended and locked up.
possession. Witch hunts were There were no public provisions for
common. persons with mental disorders except
Private hospitalization for the wealthy
who could pay. Bethlehem Asylum
was used as a private institution.

Interior of Bethlehem Asylum, London

Colonial: 17001790 1751: Benjamin Franklin established The beginnings of mental diseases
Pennsylvania Hospital (in viewed as illness to be treated.
Philadelphia)the first institution in
United States to receive those with
mental disorders for treatment and
(continued )
6 UNIT I The Nature of Mental Health and Mental Illness

Table 1.1 Social Change in the Premoral Treatment Era (continued )

Socioeconomic and Political Events Changing Attitudes and Practice

Period and People in Mental Health Care

1773: First public, free-standing

asylum at Williamsburg, Virginia
1783: Benjamin Rush categorized
mental illnesses and began to treat
mental disorders with medical
interventions, such as bloodletting,
mechanical devices.

The Tranquilizer Chair of Benjamin

Rush. A patient is sitting in a chair,
his body immobilized, a bucket
attached beneath the seat. U.S.
National Library of Medicine, Images
from the History of Medicine,
National Institutes of Health, Depart-
ment of Health and Human Services.

were dedicated to the care of patients with mental farm communities, as was the custom during the first
disorders. half of the 19th century, the poor and indigent were
Even with these hospitals, only a fraction of people often auctioned and bought by landowners to provide
with mental disorders received treatment. Those who cheap labor. Landowners eagerly sought them for their
were judged dangerous were hospitalized; those strong backs and weak minds. The arrangement had its
deemed harmless or mildly insane were treated the own economic usefulness because it provided the com-
same as other indigents and given no public support. In munity with a low-cost way to care for its mentally ill.
Some states used almshouses (poorhouses) for housing
the mentally ill.

The 19th and Early

20th Centuries
In 1828, Horace Mann, a representative in the Massa-
chusetts state legislature, saw his plea that the insane
are wards of the state become a reality. State govern-
ments were expected to assume financial responsibility
for the care of people with mental illnesses. This is an
important milestone because it set a precedent for tax-
supported mental health funding. In Canada also, men-
tal health care was embraced as a public responsibility,
FIGURE 1.1 The perspective view of the north front of the
retreat near York. U.S. National Library of Medicine, Images and by 1867 when the British North America Act was
from the History of Medicine. National Institutes of Health, passed, creating the Dominion of Canada, the care of
Department of Health and Human Services. the mentally ill was the responsibility of provinces.
CHAPTER 1 Social Change and Mental Health 7

A SOCIAL REFORMER: Great Britain and other parts of Europe. During the
DOROTHEA LYNDE DIX Civil War, she was appointed to the post of Superinten-
dent of Women Nurses, the highest position held by a
Dorothea Lynde Dix (18021887), a militant crusader
woman during the war.
for the humane treatment of patients with mental ill-
ness, was responsible for much of the reform of the
mental health care system in the 19th century. At LIFE WITHIN EARLY INSTITUTIONS
nearly 40 years of age, Dix, a retired school teacher liv-
The approach inside the institution was one of practical
ing in Massachusetts, was solicited by a young theology
management, not treatment. The patients did not pos-
student to help in preparing a Sunday School class for
sess the interpersonal and social skills to live within a
women inmates at the East Cambridge jail. Dix led the
family setting, let alone in the complex group-living
class herself and was shocked by the filth and dirt in the
environment of a state hospital with others who were
jail. She was particularly struck by the treatment of
equally ill. The major concern was the management of
inmates with mental disorders. It was the dead of win-
a large number of people who had bizarre thoughts and
ter, and no heat was provided. When she questioned
behaviors and who lived in close quarters.
the jailer about the lack of heat, his answer was that
Women had a particularly difficult time and often
the insane need no heat. The prevailing myth was
were institutionalized at the convenience of their
that the insane were insensible to extremes of temper-
fathers or husbands. Because a womans role in the late
ature. Dixs outrage initiated a long struggle in the
1800s was to function as a domestic extension of her
reform of care.
husband, any behaviors or beliefs that did not conform
An early feminist, Dix disregarded the New England
to male expectations could be used to justify the claim
role of a Puritan woman and diligently investigated the
of insanity. These women were literally held prisoner
conditions of jails and the plight of the mentally ill.
for years. In the asylums, women were psychologically
Her solution was state hospitals. She first influenced
degraded, used as servants, and physically tortured by
the Massachusetts legislature to expand the Massachu-
male physicians and female attendants (Lightner, 1999).
setts State Hospital. Then, through public awareness
These institutions had little more to offer than food,
campaigns and lobbying efforts, she managed to con-
clothing, pleasant surroundings, and perhaps some
vince state after state to build hospitals. She also turned
means of employment and exercise. Because the scien-
her attention to the plight of the mentally ill in
tific hypotheses linking mental disorders to brain dys-
Canada, where she was instrumental in creating mental
function were generally ignored, the emphasis in the
hospitals in Halifax, Nova Scotia, and St. John, New-
institutions was on humane custodial care within an
foundland (Fig. 1-2).
efficient organization. Many people believed that this
At the end of Dixs long career, 20 states had
custodial care was the highest possible level of treat-
responded directly to her appeals by establishing or
ment that could be provided.
enlarging state hospitals. Dix played an important role
People with mental disorders who were warehoused
in the establishment of the Government Hospital for
in state mental institutions had little hope of reentering
the Insane in Washington, DC (which later became St.
society. In 1908, Clifford Beers (18761943) published
Elizabeths Hospital). She also extended her work into
an autobiography, A Mind That Found Itself, depicting
his 3-year experience in three different types of hospi-
tals: a private for-profit hospital, a private nonprofit
hospital, and a state institution. In all of these facilities,
he was beaten, choked, imprisoned for long periods in
dark, dank, padded cells, and confined many days in a
straightjacket. At the end of his book, he recommended
that a national society be established for the purpose of
reforming care and treatment, disseminating informa-
tion, and encouraging and conducting research. Beers
cause was supported by a prominent neuropathologist,
Adolf Meyer (18661950), who suggested the term
mental hygiene to denote mental health. By 1909,
Beers formed a National Committee for Mental
Hygiene. Through the committees efforts, child guid-
ance clinics, prison clinics, and industrial mental health
FIGURE 1.2 Dorothea Lynde Dix. U.S. National Library of
approaches were developed.
Medicine, Images from the History of Medicine. National Insti- Early institutions eventually evolved into self-
tutes of Health, Department of Health and Human Services. contained communities that produced their own food
8 UNIT I The Nature of Mental Health and Mental Illness

and made their own clothing. A medical superinten- the McLean Asylum in Massachusetts, firmly believed
dent, who was usually more adept in executive and busi- that patients in mental hospitals should receive nursing
ness ability than in treatment, managed the closed men- care. His attempts to employ nurses proved fruitless.
tal health community. Attendants, many of whom were Cowles encouraged Linda Richards, the United States
untrained, staffed these institutions. Nursing care was first trained nurse, to open a training school for psychi-
not introduced until the very late 1800s. atricmental health nurses (Cowles, 1887). The Boston
City Hospital Training School for Nurses was estab-
lished in 1882 at McLean Hospital.
THE DEVELOPMENT OF Although there was still much social resistance to
PSYCHIATRICMENTAL HEALTH educating women, especially to care for the insane, the
NURSING THOUGHT first candidates for admission to the McLean training
school were both male and female attendants who
Early Views
worked at the McLean Asylum (Campinha, 1987).
The roots of contemporary psychiatricmental health McLean was noteworthy for more than just providing
nursing thought can be traced to Florence Nightingales nurses with the rudiments of caring for the mentally ill.
seminal work Notes on Nursing, originally published in It was the first institution in the United States to pro-
1839 (Nightingale, 1859). The holistic view of the vide men the opportunity to become trained nurses
patient, with the body and soul seen as inseparable and (Mericle, 1983) (Box 1-1).
the patient viewed as a member of a family and commu- Although nurses were trained in the care of patients
nity, was central to Nightingales view of nursing. in psychiatric institutions, their training was financially
Although she did not address the care of patients in asy- and academically dependent on the institutions organi-
lums, Nightingale was sensitive to human emotion and zational structure and was outside mainstream nursing
recommended interactions that today would be classified education. In 1913 at Johns Hopkins Phipps Clinic,
as therapeutic communication (see Chapter 10). This Effie Taylor initiated the first nursing program of study
early nursing leader advocated promotion of health and organized by nurses for psychiatric training. Taylor
development of independence by encouraging patients to sought to integrate the concepts from general and men-
perform their own health care. She believed that this, in tal health nursing into a more comprehensive knowl-
turn, would reduce their anxiety in the face of illness. edge base for all nursing care. She was committed to the
The need for specialized psychiatricmental health concept of wholeness and warned that mental health
nursing was recognized when the humane care that nursing and general nursing could not and should not
characterized the Moral Treatment Era was emerging exist independently of each other. In Taylors classes at
as a model for practice. Dr. Edward Cowles, director of Johns Hopkins, the psychobiologic orientation was

BOX 1.1
History of Psychiatric Mental Health Nursing

1882 First training school for psychiatric nursing at McLean Asylum by E. Cowles; first nursing program to admit men.
1913 First nurse-organized program of study for psychiatric training by Euphemia (Effie) Jane Taylor at Johns Hopkins
Phipps Clinic.
1914 Mary Adelaide Nutting emphasized nursing role development.
1920 First psychiatric nursing text published, Nursing Mental Disease, by Harriet Bailey.
1950 Accredited schools required to offer a psychiatric nursing experience.
1952 Publication of Hildegarde E. Peplaus Interpersonal Relations in Nursing.
1954 First graduate program in psychiatric nursing established at Rutgers University by Hildegarde E. Peplau.
1963 Perspectives in Psychiatric Care and Journal of Psychiatric Nursing published.
1967 Standards of PsychiatricMental Health Nursing Practice published. American Nurses Association (ANA) initiated the
certification of generalists in psychiatric mental health nursing.
1979 Issues in Mental Health Nursing published. ANA initiated the certification of specialists in psychiatric mental
health nursing.
1980 Nursing: A Social Policy Statement published by the ANA.
1982 Revised Standards of Psychiatric and Mental Health Nursing Practice issued by the ANA.
1985 Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice published by the ANA.
1987 Archives of Psychiatric Nursing and Journal of Child and Adolescent Psychiatric and Mental Health Nursing published.
1994 Statement on PsychiatricMental Health Clinical Nursing Practice and Standards of PsychiatricMental Health Clinical
Nursing Practice.
1996 Guidelines specifying course content and competencies published by Society for Education and Research in
PsychiatricMental Health Nursing (SERPN).
2000 Scope and Standards of PsychiatricMental Health Nursing Practice.
CHAPTER 1 Social Change and Mental Health 9

basic to all patients, not just to those labeled mentally deprivation. Moral management (nonrestraint, kind-
ill. Taylor, like Nightingale before her, encouraged ness, and hygiene) in an asylum was the answer. The
nurses to avoid the false dichotomy of mind and body biologic view held that mental illnesses had a biologic
(Church, 1987). She believed that the integrated whole cause and could be treated with physical interventions.
was the focus of nursing. However, biologic science was not far enough
In 1914, distinguished nursing leader and educator advanced to offer reasonable treatment approaches,
Mary Adelaide Nutting (18581948) addressed a confer- and existing primitive physical treatments, such as
ence at the new Psychopathic Hospital in Boston on the venesections (bloodletting) and gyrations (strapping
role of the psychopathic nurse. Her unique message was patients to a rotating board), were either painful or
that nursing care should be based on scientific study and considered barbaric.
conceptualized in terms of diagnosis, care, and treatment.
Meyer and Psychiatric Pluralism
Social Influences
Adolf Meyer attempted to bridge the ideologic gap
The development of nursing thought has been signifi- between the two groups by introducing the concept of
cantly influenced by the larger social climate in which psychiatric pluralism, an integration of human bio-
women in the profession operated. During Cowles era, logic functions with the environment. His approach
women could neither vote nor own property, and nurs- focused on investigating how the organs related to the
ing training reflected the societal view of women as person and how the person, constituted of these organs,
helpmates of men (physicians). In the early 1900s, related to the environment (Neill, 1980). However, the
nurses were expected to stay subservient to physicians biologic explanations were so far removed from later
and administrators and quietly play out the maternal scientific evidence that Meyers concept of psychiatric
role outside the home (Church, 1987). Although this pluralism won little support. The times were right for
may have been an acceptable social policy, it effectively another approach.
barred nurses from obtaining full access to information
they needed to treat their patients properly. For exam-
Freud and the Psychoanalytic Theory
ple, in 1920, Effie Taylor complained bitterly to Adolf
Meyer that nurses were not allowed to view medical Sigmund Freud (18561939) and the psychoanalytic
records, whereas medical students (men) were. movement of the early 1900s promised an even more
Despite the oppressive social climate for psychiatric radical approach to psychiatricmental health care.
nurses, nursing thought continued to develop. The first Freud, trained as a neuropathologist, developed a per-
psychiatric nursing textbook, Nursing Mental Disease, sonality theory based on unconscious motivations for
was written by Harriet Bailey in 1920. The content of behavior, or drives. Using a new technique, psycho-
the book reflected an understanding of mental disor- analysis, he delved into the patients feelings and emo-
ders of the times and set forth nursing care in terms of tions regarding past experiences, particularly early
procedures. childhood and adolescent memories, to explain the
basis of aberrant behavior. He showed that symptoms of
hysteria could be produced and made to disappear while
Modern Thinking patients were in a subconscious state of hypnosis.
As psychoanalytic theory gained in popularity, ideas
of the mindbody relationship were lost. According to
As psychiatricmental health nursing continued to the freudian model, normal development occurred in
develop as a profession in the early part of the 20th cen- stages, with the first three being the most important:
tury, modern perspectives on mental illness were oral, anal, and genital. The infant progressed through
emerging in research, and these new theories would the oral stage, experiencing the world through symbolic
profoundly shape the future of mental health care for all oral ingestion; through the anal stage, in which the tod-
practitioners. Chapter 7 examines the underlying ide- dler developed a sense of autonomy through withhold-
ologies, but it is important to understand their develop- ing; and on to the genital stage, in which a beginning
ment within the social and historical context to appre- sense of sexuality emerged within the framework of the
ciate fully their impact on treatment approaches. oedipal relationship. If there was any interference in
In the early 1900s, two opposing views were held normal development, such as psychological trauma,
regarding mental illnesses: the belief that mental disor- psychosis or neurosis would develop.
ders had biologic origins and the belief that the prob- Primary causes of mental illnesses were now viewed
lems were attributed to environmental and social as psychological, and any physical manifestations or
stresses. The psychosocial theory proposed that men- social influences were considered secondary (Malamud,
tal disorders resulted from environmental and social 1944). It was generally believed within the psychiatric
10 UNIT I The Nature of Mental Health and Mental Illness

community that mental illnesses were a result of dis- INCREASED GOVERNMENT

turbed personality development and faulty parenting. INVOLVEMENT IN MENTAL
Mental illnesses were categorized either as a psychosis HEALTH CARE
(severe) or neurosis (less severe). A psychosis impaired
As scientific advances led to an increased intellectual
daily functioning because of breaks in contact with real-
understanding of the biologic foundations of mental ill-
ity. A neurosis was less severe, but individuals were
ness, social change and historical events fostered a new
often distressed about their problems. The terms psy-
level of empathy on an emotional level. During World
chosis and neurosis entered common, everyday language
War II, mental illness was beginning to be seen as a prob-
and added credibility to Freuds conceptualization of
lem that could happen to anyone. Many normal people
mental disorders. Soon, Freuds ideas represented the
who volunteered for the armed services were disqualified
forefront of psychiatric thought and began to shape
on the grounds that they were psychologically unfit to
societys view of mental health care. Freudian ideology
serve. Others who had already served a tour of duty
dominated psychiatric thought well into the 1970s.
received diagnoses of psychiatric and emotional prob-
Intensive psychoanalysis, which focused on repairing
lems believed to be caused by the war. Consequently, in
the trauma of the original psychological injury, was the
1946, President Truman signed into law the National
treatment of choice. Psychoanalysis was costly, time-
Mental Health Act, which supported research, training,
consuming, and required lengthy training. Few could
and the establishment of clinics and treatment centers.
perform it. Thousands of patients in state institutions
This act created a six-member National Mental Health
with severe mental illnesses were essentially ignored.
Advisory Council that established the National Institute
of Mental Health (NIMH), which was responsible for
Integration of Biologic Theories overseeing and coordinating research and training.
Into Psychosocial Treatment The Hill-Burton Act of 1946 provided substantial
federal support for hospital construction, which facili-
Until the 1940s, the biologic understanding of mental
tated the expansion of psychiatric units in general hos-
illness was fairly unsophisticated and often misguided.
pitals. With the passage of the National Mental Health
Biologic treatments during this century often were
Act, the federal government became more involved in
unsuccessful because of the lack of understanding and
financing and controlling the delivery of care. Under
knowledge of the biologic basis of mental disorders. For
the Acts provisions, the federal government provided
example, the use of hydrotherapy, or baths, was an estab-
grants to states to support existing outpatient facilities
lished procedure in mental institutions. The use of warm
and programs to establish new ones. Before 1948, more
baths and, in some instances, ice cold baths produced
than half of all states had no clinics; by 1949, all but five
calming effects for patients with mental disorders. How-
had one or more. Six years later, there were 1,234 out-
ever, the treatments success was ascribed to its effective-
patient clinics.
ness as a form of restraint because the physiologic
responses that hydrotherapy produced were not under-
stood. Baths were applied indiscriminately and used as a
form of restraint, rather than a therapeutic practice.
Other examples of biologic procedures applied either
indiscriminately or inappropriately include psy-
chosurgery and electroconvulsive therapy (see Chapter Another outcome of the Acts passage was the provision
8). Thanks to modern technology, neurosurgical tech- of training grants to institutions for stipends and fel-
niques and electroconvulsive therapy can be humanely lowships to prepare specialty nurses in advanced prac-
applied with positive therapeutic outcomes for some psy- tice (Chamberlain, 1983). The first graduate nursing
chiatric disorders. program, developed by Hildegarde E. Peplau in 1954 at
Support for the biologic approaches increased as suc- Rutgers University, was in the specialty of psychiatric
cessful symptom management with psychopharmaco- nursing. Subspecialties began to emerge focusing on
logic agents was reported. When a pharmacologic agent children, adolescents, or elderly people. Today in the
made a difference in care, a biologic hypothesis was United States, many masters degree programs offer
considered. Modern psychopharmacology began in the specializations in psychiatricmental health.
1930s, when barbiturates, particularly amobarbital In 1952, Peplau published the landmark work Inter-
sodium (Amytal Sodium), were tried for treating men- personal Relations in Nursing. It introduced psychi-
tal diseases (Malamud, 1944). Psychopharmacology atricmental health nursing practice to the concepts of
revolutionized the treatment of mental illness and led to interpersonal relations and the importance of the ther-
an increased number of patients discharged into the apeutic relationship. In fact, the nursepatient relation-
community and the eventual focus on the brain as the ship was defined as the very essence of psychiatric
key to understanding psychiatric disorders. mental health nursing (see Chapters 6 and 10). This was
CHAPTER 1 Social Change and Mental Health 11

a significant switch in perspective from the neurobio- care. The supporters of this 1963 legislation believed
logic approach that had characterized the discipline the exact opposite of what the supporters of Dorothea
before that time. Peplaus perspective was also impor- Dix believed during the previous century. That is,
tant in its conceptualization of nursing care as truly instead of viewing custodial care as the treatment of
independent of physicians. The nurses use of self as a mental disorders, institutionalization was viewed as
nursing tool was outside the dominance of both hospi- contributing to the illness. The predominant view was
tal administrators and physicians. that many of the problems of mental disorders were
Gradually, nursing education programs in special- caused by the deplorable conditions of the state mental
ized hospitals were phased into generalized programs in institutions and that, if patients were moved into a
nursing (Peplau, 1989). Nursing programs offered in normal community-living setting, the symptoms of
psychiatric hospitals closed. This mainstreaming of mental disorders could easily be treated and eventually
psychiatricmental health nursing education into the would disappear. Thus, deinstitutionalization, the dis-
general nursing curriculum obviated the need for charge of the institutionalized people into the commu-
specialized hospitals. nity, became a national objective. The inpatient popula-
tion fell by about 15% between 1955 and 1965 and by
about 59% during the succeeding decade.
The Late 20th Century The goal of the Community Mental Health Centers
Construction Act was to expand community mental
health services and diminish societys sole reliance on
mental hospitals. Guidelines for implementing the act
In 1955, the Joint Commission on Mental Illness and were somewhat vague, and administering the program
Health was formed to study the problems of mental became the responsibility of the federal government.
health care delivery. During its 6-year existence, the Any mention of the role for or linkages to state hospi-
commission sponsored several scholarly studies and tals was absent.
created an atmosphere conducive to the discussion of The Community Mental Health Construction Act,
new federal policy initiatives that eventually would originally a construction grant, was amended in 1965 to
undermine the traditional emphasis on institutional strengthen the funding for staffing new facilities. Even
care. In 1961, the commission transmitted its final so, the number of community mental health centers
report: Action for Mental Health. The report called (CMHCs) grew slowly. There were a limited number of
for larger investments in basic research; national person- communities with populations large enough to support
nel recruitment and training programs; one full-time the centers and a shortage of trained personnel, even in
clinic for every 50,000 individuals, supplemented by urban areas. In smaller and rural communities, there
general hospital units and state-run regional intensive was often no one (or no mental health provider) pre-
psychiatric treatment centers; and access to emergency pared for the new role. By the spring of 1967, only 173
care and treatment in general, both in mental hospitals funded projects existed.
and community clinics. It was recommended that plan- There was no evidence that deinstitutionalized
ning and implementation of the system would include patients constituted a significant population of those
the consumers and that funding for the construction and receiving services at the new CMHCs. One problem
operation of the community mental health system would was that the treatment of choice in most of the centers,
be shared by federal, state, and local governments. individual psychotherapy, had not proved effective for
Action for Mental Health was presented at a time patients with long-term mental disorders. Many urban
that was politically ripe for the new ideas. The 1960 CMHC patients, as compared with former state hospi-
presidential election of John F. Kennedy brought a new tal patients, tended to be younger and poorer and were
type of leadership to the United States. The ideas disproportionately drawn from minority backgrounds.
expressed in the report clearly shifted authority for In addition, many centers focused on the treatment of
mental health programming to the federal government. alcoholism and drug addiction.
This report was the basis of the federal legislation, the
Mental Retardation Facilities and Community Mental
Sanctioning of Holistic Nursing Care
Health Centers Construction Act, which Kennedy
signed into law in 1963. By 1963, two nursing journals focused on psychiatric
In reality, this act included only some of the ideas nursing: the Journal of Psychiatric Nursing (now the Jour-
proposed by the commission and did not encompass nal of Psychosocial Nursing and Mental Health Services) and
state-run regional intensive psychiatric centers. Sup- Perspectives in Psychiatric Care. In 1967, the Division of
porters of the legislation believed that the new commu- Psychiatric and Mental Health Nursing Practice of the
nity-oriented policy would provide better care and American Nurses Association (ANA) published the
eliminate the need for institutions providing custodial Statement on Psychiatric Nursing Practice. For the first
12 UNIT I The Nature of Mental Health and Mental Illness

time, there was official sanction of a holistic approach to The Age of Managed Care
nursing care, with psychiatricmental health nurses
Both public and private expenditures for health care ser-
practicing in a variety of settings with a variety of clien-
vices have increased in the United States. Financial bar-
tele. The emphasis was on activities ranging from health
riers account for the different resource allocation rules
promotion to health restoration. Since 1967, there have
for financing mental health services compared with gen-
been three more updates of the psychiatricmental
eral health care services, which leads to less overall fund-
health nursing practice statement that continue to
ing for mental health. To control costs, privately
expand the role of the psychiatric nurse and delineate
insured mental health care has been carved out from
practice functions and roles.
the rest of health care and is managed separately. Pri-
vately owned behavioral health care firms not only man-
age care but also provide services through directly
owned or contracted networks of providers. In theory,
Changing Demographics people with psychiatric problems have direct access to
the specialists who provide the best care. In reality, ser-
The social changes of the 1980s set the stage for the
vices are still limited and sometimes withheld. Once care
continuing evolution of mental health care. The popu-
is limited or denied, individuals once again turn to pub-
lation was rapidly aging. Family structure was diversify-
lic funds, which may or may not be available.
ing through divorce, cohabitation, and a variety of fam-
Now, large networks of public and private organiza-
ily configurations. Women entered the work force in
tions share responsibility for mental health care, with
record numbers. Rapid growth of cities, or urbaniza-
the state remaining as the major decision maker for
tion, was the single most characteristic phenomenon in
resource allocation. Emphasis is on reducing expensive
the United States (Aldrich, 1986). The population in
institutional care and increasing the resources devoted
the United States was shifting toward the southwest.
to communities of individuals with mental disorders.
(In 1983, Los Angeles replaced Chicago as the second
The mental health work force is shifting from providing
largest city.) Many of the new residents had migrated to
care in traditional health care institutions to community
the southwest from Mexico and Asian countries; they
settings: clinics, homes, schools, and treatment centers.
had not simply relocated from other areas of the coun-
try. In North America, because of favorable immigra-
tion policies, the population was expected to grow
National Mental Health Objectives
(Deming, 1996).
By the 1990s, wrinkles in the social fabric had begun In 1999, Mental Health: A Report of the Surgeon General
to show. The deinstitutionalization movement, so long was the first report by the Office of the Surgeon Gen-
hailed as an efficient, cost-effective means of reabsorb- eral and supported two main findings (U.S. Department
ing the mentally ill into society, was considered a fail- of Health and Human Services, 1999):
ure. People with mental disorders were discharged into The efficacy of mental health treatments is well
communities that were unprepared to offer them little documented.
in the way of treatment, housing, or vocational oppor- A range of treatments exists for most mental disor-
tunities. These communities were also sometimes vastly ders.
different from the ones they had left behind at the time The following year, another landmark report, Report of
of their hospitalization. In addition, fewer community- the Surgeon Generals Conference on Childrens Mental
based facilities were in place to serve the growing pop- Health: A National Action Agenda, was published. This
ulation of people with mental disorders. report highlights consensus recommendations for iden-
The 2,000 projected CMHCs that should have been tifying, recognizing, and referring children to services,
in place by 1980 never materialized. By 1990, about increasing access to services for families, and identifying
1,300 programs provided various types of psychosocial the evidence in treatment services, systems of care, and
rehabilitation services, such as vocational, educational, financing (U.S. Public Health Service, 2000). In 2001,
or social-recreational services (International Associa- the World Health Organization focused its annual
tion of Psychosocial Rehabilitation, 1990). The World Health Report on mental health, emphasizing the
CMHCs, by and large, ignored the legions of people importance of mental health to the well-being of indi-
with serious mental illnesses. Today mental health ser- viduals (WHO, 2001). In 2003, the Presidents New
vices are inadequate and fragmented. Millions of adults Freedom Commission on Mental Health presented its
and children are disabled by mental illness every year. report on mental illness in the United States. It recom-
When compared with all other diseases, mental illness mended the development of efficient and effective ser-
ranks first in terms of causing disability in the United vices that should be integrated into the community
States, Canada, and Western Europe (World Health (New Freedom Commission on Mental Health, 2003).
Organization [WHO], 2001). See Box 1-2.
CHAPTER 1 Social Change and Mental Health 13


U.S. Goals in a Transformed Mental Throughout history, attitudes and treatment
Health System toward those with mental disorders have drastically
changed as a result of the changing socioeconomic
Goal 1 Americans understand that mental health is
backdrop of our society and the development of new
essential to overall health.
Goal 2 Mental health care is consumer and family driven. theories and study by key individuals and groups.
Goal 3 Disparities in mental health services are eliminated. During the 1800s, as mental illness began to be
Goal 4 Early mental health screening, assessment, and viewed as an illness, more humane and moral treat-
referral to services are common practice. ments began to develop.
Goal 5 Excellent mental health care is delivered and
True social reformers, such as Dorothea Dix,
research is accelerated.
Goal 6 Technology is used to access mental health care Horace Mann, and Clifford Beers, dedicated their
and information. efforts to raising societys awareness and advocating
public responsibility for proper treatment of patients
Source: New Freedom Commission on Mental Health. (2003). with mental disorders.
Achieving the promise: Transforming mental health care in America,
p. 8. DHHS Publication No. SMA-03-3831. Rockville, MD.
Theoretic arguments characterized the evolution
of scientific thought and psychiatric practice. Grad-
ually, the importance of the biologic aspect of men-
tal disorders has been recognized.
One of the most important documents for the Although the need for psychiatricmental health
advancement of a mental health agenda is Healthy People nursing was recognized near the end of the 19th cen-
2010: National Health Promotion and Disease Prevention tury, there was much resistance to training women
Objectives, which contains many health care goals that for the care of the insane. At the urging of Dr.
pertain specifically to mental health (Box 1-3) (U.S. Edward Cowles, director of the McLean Asylum in
Department of Health and Human Services, 2000). The Massachusetts, Linda Richards opened the Boston
challenge before nurses is to strive to meet these goals City Hospital Training School for Nurses in 1882.
while obeying marketplace demands to provide the most Gradually, all psychiatric nursing education in the
cost-effective care possible. This translates into an United States and Canada was phased into basic nurs-
emphasis on preventing the symptoms of mental disor- ing education, and nursing programs offered in psy-
ders and using hospitalization as a treatment of last chiatric hospitals closed. The first graduate program
resort. Devising and implementing a continuum of men- in psychiatricmental health nursing was initiated in
tal health services that provides access for all is an inte- 1954 by Hildegarde Peplau at Rutgers University.
gral part of the strategy for accomplishing these goals.

BOX 1.3
Mental Health and Mental Disorders Objectives for the Year 2010
Mental Health Status Improvement Increase the proportion of adults with mental disor-
Reduce the suicide rate to no more than 6.0 per ders who receive treatment.
100,000 (baseline, 10.8/1,000 in 1998) Increase the proportion of persons with co-occurring
Reduce the suicide attempts by adolescents to no substance abuse and mental disorders who receive
more than 1% (baseline, 2.6% in 1997) treatment for both disorders.
Reduce the proportion of homeless adults who have Increase the proportion of local governments with
serious mental illness (SMI) community-based jail diversion programs for adults
Increase the proportion of persons with serious men- with serious mental illness.
tal illness who are employed State Activities
Treatment Expansion Increase the number of states and the District of
Reduce the relapse rates for persons with eating Columbia that track consumers satisfaction with the
disorders, including anorexia nervosa and bulimia mental health services they receive.
nervosa. Increase the number of states, territories, and the Dis-
Increase the number of persons seen in primary trict of Columbia with an operational mental health
health care who receive mental health screening and plan that addresses cultural competence.
assessment. Increase the number of states, territories, and the Dis-
Increase the proportion of children with mental health trict of Columbia with an operational mental health
problems who receive treatment. plan that addresses mental health crisis interventions,
Increase the proportion of juvenile justice facilities that ongoing screening, and treatment services for elderly
screen new admissions for mental health problems. persons.
14 UNIT I The Nature of Mental Health and Mental Illness

Through key federal and state legislative initia-

tives, mental health services were funded, but remain
inadequate. One Flew Over the Cuckoos Nest. 1975. This classic
The U.S. Surgeon Generals reports, The Presi- film stars Jack Nicholson as Randle P. McMurphy, who
dents New Freedom Commission on Mental takes on the state hospital establishment. This picture
Health, and the goals of Healthy People 2010 continue won all five of the top Academy Awards: Best Picture,
to highlight the need for resources for the care of Best Actor, Best Actress, Best Director, and Best
persons with mental illness. Adapted Screenplay. The film depicts life in an inpa-
tient psychiatric ward of the late 1960s and increased
public awareness of the potential human rights viola-
CRITICAL THINKING CHALLENGES tions inherent in a large, public mental system. How-
ever, the portrayal of electroconvulsive therapy is
1 Compare the ideas of psychiatric care during the stereotyped and inaccurate, and the suicide of Billy
1800s with those of the 1990s and 2000s and identify appears to be simplistically linked to his domineering
the major political and economic forces that influ- mother. Overall, this film probably contributes to the
enced care. stigma of mental illness.
2 Analyze the social, political, and economic changes VIEWING POINTS: This film should be viewed from
that influenced the community mental health move- several different perspectives: What is the basis of
ment. McMurphys admission? How does Nurse Ratchet
3 Present an argument for the moral treatment of peo- interact with the patients? What is missing? What is
ple with mental disorders. different in todays public mental health systems?
4 Trace the history of biologic psychiatry and highlight
major ideas and treatments. An Angel at My Table. 1989, New Zealand. This
thought-provoking three-part television mini-series is
based on Janet Frames autobiography that traces her
life from being a shy, socially inept little girl to New
WEB LINKS Zealands most famous writer/poet. Produced by Jane
Campion and starring Kerry Fox, the story is told in
www.health.gov/healthypeople This is the Healthy three stages of the main characters life: childhood,
People 2010 website. young adulthood, and adulthood. During the second
www.surgeongeneral.com This website of the U.S. period, Janet Frame received an inaccurate diagnosis of
Surgeon General contains major mental health schizophrenia and was hospitalized for 8 years. She
reports. barely avoided a leukotomy.
www.nlm.nih.gov The National Library of Medicine VIEWING POINTS: Observe how the role of the
site offers excellent access to PUBMED for nursing woman in society influenced Janet Frames admission to
articles and mental health information. It provides the hospital. Would she be considered mentally ill and
links to the History in Medicine Library. needing hospitalization by todays standard?
www.mentalhealth.com This site is an excellent Beautiful Dreamers. 1992, Canada. This film is based
resource on disorders and diagnoses and provides on a true story about poet Walt Whitmans visit to an
links to other sites. asylum in London, Ontario, Canada. Whitman, played
www.cmhc.com This site provides access to the by Rip Torn, is shocked by what he sees and persuades
Mental Health Net, self-help groups, professional the hospital director to offer humane treatment. Even-
resources, and discussions. tually, the patients wind up playing the townspeople in
www.mentalhealthcommission.gov This site pro- a game of cricket.
vides access to Achieving the Promise: Transforming VIEWING POINTS: Observe the stigma that is associ-
Mental Health Care in America. Final Report of The ated with having a mental illness.
Presidents New Freedom Commission on Mental Health
( July 2003).
www.samhsa.gov/oas/oasftp.htm This Substance REFERENCES
Abuse and Mental Health Statistics site provides Aldrich, R. (1986). The social context of change. Psychiatric Annals,
national statistics on alcohol, tobacco, and illegal 16(10), 613618.
drug use, substance abuse treatment, and mental Bailey, H. (1920). Nursing mental diseases. New York: Macmillan.
Beers, C. (1908). A mind that found itself. New York: Longmans,
Green, & Co.
www.who.org This site of the World Health Organi- Campinha, J. (1987). The training of a mental nurse: An historical
zation has information on mental health disability look at McLean Training School for Nurses. Virginia Nurse, 55(1),
and programs. 1820.
CHAPTER 1 Social Change and Mental Health 15

Chamberlain, J. (1983). The role of the federal government in the New Freedom Commission on Mental Health. (2003). Achieving the
development of psychiatric nursing. Journal of Psychosocial Nursing promise: Transforming mental health care in America. Department of
and Mental Health Services, 21(4), 1118. Health and Human Services Publication No. SMA-03-3831.
Church, O. (1987). From custody to community in psychiatric nurs- Rockville, MD.
ing. Nursing Research, 36(10), 4855. Nightingale, F. (1859). Notes on nursing: What it is and what it is not.
Cowles, E. (1887, October). Nursing reform for the insane. American London: Harrison & Son.
Journal of Insanity, 44, 176, 191. Peplau, H. (1952). Interpersonal relations in nursing. New York:
Deming, W. G. (1996). A decade of economic change and population Putnam.
shifts in U.S. regions. Monthly Labor Review, 119(11), 314 Peplau, H. (1989). Future directions in psychiatric nursing from the
Deutsch, S. (1949). The mentally ill in America. London: Oxford Uni- perspective of history. Journal of Psychosocial Nursing and Mental
versity Press. Health Services, 27(2), 1821.
International Association of Psychosocial Rehabilitation Services U.S. Department of Health and Human Services. (1999). Mental
(IAPRS). (1990). A national directory: Organizations providing psy- health: A report of the Surgeon General. Washington, DC: U.S.
chosocial rehabilitation and related community support services in the Department of Health and Human Services, Substance Abuse and
United States. Boston: Center for Psychiatric Rehabilitation, Boston Mental Health Services Administration, Center for Mental Health
University. Services, National Institutes of Health, National Institute of Men-
Lightner, D. L. (1999). Asylum prison and poorhouse. The writings and tal Health.
reform work of Dorothea Dix in Illinois. Carbondale and Edwardsville, U.S. Department of Health and Human Services. (2000). Healthy peo-
IL: Southern Illinois University Press. ple 2010 (2nd ed.) With: Understanding and improving health and
Malamud, W. (1944). The history of psychiatric therapies. In J. K. Hall, objectives for improving health. Washington, DC: U.S. Govern-
G. Zilboorg, & H. Bunker (Eds.), One hundred years of American ment Printing Office.
psychiatry, 273323. New York: Columbia University Press. U.S. Public Health Service. (2000). Report of the Surgeon Generals
Mericle, B. (1983). The male as a psychiatric nurse. Journal of Psy- Conference on Childrens Mental Health: A national action agenda.
chosocial Nursing, 21(11), 30. Washington, DC: Department of Health and Human Services.
Neill, J. (1980). Adolf Meyer and American psychiatry today. Ameri- World Health Organization. (2001). The world health report: Mental health
can Journal of Psychiatry, 137(4), 460464. 2001: Mental health: New understanding, new hope. Geneva: Author.

For challenges and updates, go to www.connection.lww.com or refer to the CD-ROM in the back of this book.
Schizophrenia Issues Related
to Mental Health Care
Andrea C. Bostrom and Mary Ann Boyd

Mary Ann Boyd

After studying this chapter, you will be able to:
After studying this chapter, you will be able to:
Identify various cultural and ethnic groups in the United States and Canada.
Compare the concepts of prejudice, discrimination, and stereotyping and their rela-
tionship to stigmatization.
Define the process of stigmatization as an influence in mental health care delivery.
Describe the beliefs about mental health and illness in different cultural groups.
Trace the changing view of families, from causing mental illness to collaborating in
the care.
Discuss the changing family structure and the mental health implications.
Describe the important role of consumer groups in developing awareness of the spe-
cial problems of patients with mental disorders.

affective flattening or blunting affe
acculturation cultural competence discrimination homophobia integration
prejudice segregation stereotyping

culture stigmatization

disorganized symptoms negative symptoms neurocognitive impairment positive

CHAPTER 2 Cultural Issues Related to Mental Health Care 17

A ll cultural groups have sets of values, beliefs, and

patterns of accepted behavior, and it is often diffi-
cult for those of one culture to understand those of
another. This is especially true in regard to mental ill-
nesssome cultures view it as a condition for which the
ill person must be punished and ostracized from society,
whereas other cultures are more tolerant and believe
that family and community members are key to the care
and treatment of the mentally ill.
This chapter examines prejudice, stereotyping, and
stigma and the various minority groups or cultures
that traditionally have been victims of stereotyping
and stigma in the United States. The differences in
cultural and social mores of these groups and the over-
all changing profile of todays American family struc-
ture are explored. When nurses understand different
cultures as they relate to individual feelings and moti-
vations, they will be better equipped to adapt mental
health care to the backgrounds and lifestyles of their

FIGURE 2.1 The process of cultural competence in the

KEY CONCEPT Culture is not only a way of life
delivery of healthcare services. (Adapted with permission
for people who identify or associate with one
from Campinha-Bacote J. [2002]. Transcultural C.A.R.E. Asso-
another on the basis of some common purpose, ciates. www.transcultural.net.)
need, or similarity of background but also the total-
ity of learned, socially transmitted beliefs, values,
and behaviors that emerge from its members inter-
personal transactions. Cultural Terms and Issues
When a minority group succeeds in melding into the
Importance of Culture to predominant culture and assumes not only the language
but also the beliefs, values, and practices of the pre-
Psychiatric Nursing dominant culture, the members are said to be accultur-
Nursing care of people with mental disorders and emo- ated. Many of the immigrants from Europe to the
tional problems often can be more complex because of United States from the late 1800s through the 20th
cultural differences. Nurses and patients backgrounds century are American acculturation success stories.
and cultural heritages may be different; so it is impor- They include Irish Americans, Polish Americans, and
tant for nurses to understand clearly the thinking and Italian Americans. For these groups, English is the pri-
perspectives of other cultures and groups. Because mary language, and they have accepted the customs and
treating mental disorders is intertwined with peoples practices of U.S. culture. Many of their descendants
attitudes about themselves, their beliefs, values, and have intermarried with those of other cultural heritages,
ways of interacting with their families and communities, with the result that these groups are no longer viewed
it is crucial that psychiatric nurses be culturally compe- as minority or ethnic groups. They have become accul-
tent in their practice. turated into the larger, predominant society.
Cultural competence is a process in which the
healthcare professional continually strives to
achieve the ability and availability to work effectively
within the cultural context of the client (family, indi- As cultural groups enter a new society, they may have
vidual or community) (Campinha-Bacote, 2002). It difficulties becoming a part of the larger dominant soci-
is developed through cultural awareness, acquisition ety. Often, minority groups are separated from the
of cultural knowledge, development of cultural skills, majority culture through legally sanctioned societal
and engagement of numerous cultural encounters practices, or segregation. For example, before the
(Fig. 2-1). Brown v. Board of Education decision in 1954, it was
18 UNIT I The Nature of Mental Health and Mental Illness

legally sanctioned in some states that African-American BOX 2.1 RESEARCH FOR BEST PRACTICE
children attend separate schools. Segregation, in this
Depression in Korean Immigrant Wives
case, prevents individuals from having the same oppor-
tunities as other society members. Incorporation of dis- Um, C., & Dancy, B. (1999). Relationship between coping
parate ethnic or religious elements of the population strategies and depression among employed Korean immi-
into a unified society, or integration, provides equality grant wives. Issues in Mental Health Nursing, 20, 485494.
of opportunity for all members of that societys culture, THE QUESTION: What is the correlation of stress and cop-
and although the process may be difficult, it is usually a ing strategies in depression among immigrant women?
desired goal of the disenfranchised minority group. METHODS: Korean immigrant wives volunteered to par-
ticipate in a research study that looked at their coping
Segregation, or staying separate and apart as a group,
strategies and the development of depression. The
may serve desired short-term advantages by providing study group consisted of 282 women ranging in age
support and protection by the group members and from 25 to 55 years (mean age, 41.7 years). Most of
reducing their exposure to direct prejudice, but ulti- these women (92%) arrived in the United States with at
mately, integration offers minorities more economic least a high school education. Most (86%) had children.
All of the women were employed outside the home and
stability, more even-quality services within the domi-
worked from 20 to 84 hours per week.
nant society, and eventually decreased prejudice. FINDINGS: The researchers found that depression was
positively correlated to the management of stress by
working harder at cleaning the house. Depression was
PREJUDICE, DISCRIMINATION, negatively correlated to negotiation (discussion with

The concepts of prejudice, discrimination, and stereo-

typing are important in understanding the life of peo-
ple with mental disorders. Prejudice is a hostile atti-
tude toward others simply because they belong to a GENDER AND CULTURE
particular group that is considered to have objection-
able characteristics. Discrimination is the differential Women within minority groups may experience more
treatment of others because they are members of a par- conflicting feelings and psychological stressors than do
ticular group. It can include ignoring, derogatory name men in trying to adjust to both their defined role in the
calling, denying services, and threatening. Stereotyp- minority culture and a different role in the larger pre-
ing is expecting individuals to act in a characteristic dominant society (see Box 2-1). For men, who usually
manner that conforms to a usually negative perception earn a living and work within the cultural neighborhood,
of their cultural group. Individual characteristics are the socioeconomic status and social position remain the
not considered. Stereotyping occurs because of lack of same. In a qualitative study comparing work and family
exposure to enough people in a particular group. Prej- domains of Caucasian working women with minority
udice, discrimination, and stereotyping lead to a lack of working women, researchers found that the groups dif-
understanding and appreciation of differences among fered in their perceptions of work. Caucasian women
people. view work as a choice, rather than an obligation,
whereas minority women compartmentalized their work
and family lives (Robinson & Swanson, 2002).
People with mental illnesses or emotional problems
often are stigmatized by the society in which they live. Cultural and Religious
Views of Mental Illness
KEY CONCEPT Stigmatization is the process of
assigning negative characteristics and identity to one Religious beliefs often define an individuals relationship
person or group, causing that person or group to feel within a family and community. Many different religions
unaccepted, devalued, ostracized, and isolated from are practiced throughout the world. Judeo-Christian
the larger society ( Jones, et al., 1984). Prejudice, dis- thinking tends to dominate Western societies. Other
crimination, and stereotyping foster stigmatization. religions, such as Islam, Hinduism, and Buddhism, dom-
Although individuals can be victims of stigmatization, inate Eastern and Middle Eastern cultures (Table 2-1).
even large groups within a society can become vic- Because religious beliefs often influence approaches to
tims of stigma, such as those of certain ethnic or cul- mental health, it is important to understand the basis of
tural groups, those of certain socioeconomic status,
various religions that appear to be growing in the
and certainly those with a mental handicap or illness.
United States and Canada.
CHAPTER 2 Cultural Issues Related to Mental Health Care 19

Table 2.1 Worlds Major Religions or Belief Forms

Source of Power or Historical Sacred Texts Key Beliefs or Ethical

Force (Deity) or Beliefs Life Philosophy

God, a unity in tripersonality; Father, Bible Gods love for all creatures is a basic
Son, and Holy Ghost Teachings of Jesus through the belief. Salvation is gained by those
apostles and the church fathers who have faith and show humility
toward God. Brotherly love is
emphasized in acts of charity,
kindness, and forgiveness.
Allah (the only God) Koran (the words of God delivered to God is just and merciful; humans are
Has two major sects: Mohammed by the angel Gabriel) limited and sinful. God rewards the
Sunni (orthodox), traditional and sim- Hadith (commentaries by Mohammed) good and punishes the sinful.
ple practices are followed, human Five Pillars of Islam (religious conduct) Mohammed, through the Koran,
will is determined by outside forces Islam was built on Christianity and guides people and teaches them
Shiite, practices are rapturous and Judaism truth. Peace is gained through sub-
trancelike; human beings have free mission to Allah. The sinless go to
will Paradise, and the evil go to Hell. A
good Muslim obeys the Five Pillars
of Islam.
Brahma (the Infinite Being and Creator Vedas (doctrine and commentaries) All people are assigned to castes
that pervades all reality) Other (permanent hereditary orders,
gods: each having different privileges
Vishnu (preserver) in society; each was created from
Shiva (destroyer) different parts of Brahma):
Krishna (love) 1. Brahmans: includes priests and
2. Kshatriyas: includes rulers and
3. Vaisya: includes farmers, skilled
workers, and merchants
4. Sudras: includes those who
serve the other three castes
(servants, laborers, peasants)
5. Untouchables: the outcats,
those not included in the other
Buddha Tripitaka (scripture) Buddhism attempts to deal with
Individual responsibility and logical or Middle Path (way of life) problems of human existence such
intuitive thinking The Four Noble Truths as suffering and death.
Buddhist subjects include: Eightfold Path (guides for life) Life is misery, unhappiness, and
Lamaism (Tibet), in which Buddhism The Texts of Taoism (include the Tao suffering with no ultimate reality in
is blended with spirit worship Te Ching of Lao Tz%u and The Writ- the world or behind it.
Mantrayana (Himalayan area, Mon- ings of Chuang Tz%u) The cause of all human suffering and
golia, Japan), in which intimate Sutras (Buddhist commentaries) misery is desire.
relationship with a guru and Sangha (Buddhist Community) The middle path of life avoids the
recitations of secret mantras are personal extremes of self-denial
emphasized; belief in sexual sym- and self-indulgence. Visions can be
bolism and demons gained through personal medita-
Chan (China) Zen (Japan), in which tion and contemplation; good
self-reliance and awareness deeds and compassion also
through intuitive understanding facilitate the process toward nir-
are stressed. vana, the ultimate mode of exis-
Satori (enlightenment) may come tence. The end of suffering is the
from sudden insight or through extinction of desire and emotion,
self-discipline, meditation, and and ultimately the unreal self.
instruction Present behavior is a result of past
(continued )
20 UNIT I The Nature of Mental Health and Mental Illness

Table 2.1 Worlds Major Religions or Belief Forms (continued )

Source of Power or Historical Sacred Texts Key Beliefs or Ethical

Force (Deity) or Beliefs Life Philosophy

No doctrine of a god or gods or life Five Classics (Confucian thought) A philosophy or a system of ethics for
after death Analects (conversations and sayings living, rather than a religion that
Individual responsibility and logical of Confucius) teaches how people should act
and intuitive thinking toward one another. People are born
good. Moral character is stressed
through sincerity in personal and
public behavior. Respect is shown
for parents and figures of authority.
Improvement is gained through
self-responsibility, introspection,
and compassion for others.
Gods of nature, ancestor worship, Tradition and custom (the way of the Reverence for ancestors and traditional
national heroes gods) Japanese way of life is emphasized.
Beliefs were influenced by Confucian- Loyalty to places and locations where
ism and Buddhism one lives or works and purity and
balance in physical and mental life
are major motivators of personal
All the forces in nature Tao-te-Ching (The Way and the Power) Quiet and happy harmony with nature
is the key belief. Peace and content-
ment are found in the personal
behaviors of optimism, passivity,
humility, and internal calmness.
Humility is an especially valued
virtue. Conformity to the rhythm of
nature and the universe leads to a
simple, natural, and ideal life.
God Hebrew Bible (Old Testament) Jews have a special relationship with
Torah (first five books of Hebrew Bible) God: obeying Gods law through eth-
Talmud (commentaries on the Torah) ical behavior and ritual obedience
earns the mercy and justice of God.
God is worshiped through love, not
out of fear.
Tribal Beliefs
Animism: Souls or spirits embodied in Passed on through ceremonies, ritu- All living things are related. Respect
all beings and everything in nature als, myths, and legends. Oral his- for powers of nature and pleasing
(trees, rivers, mountains) tory, rather than written literature, the spirits are fundamental beliefs
Polytheism: Many gods, in the basic is the common medium. to meet basic and practical needs
powers of nature (sun, moon, earth, for food, fertility, health, and inter-
water) personal relationships and individ-
ual development. Harmonious living
is comprehension and respect of
natural forces.
Summary of Other Belief Forms
Atheism: the belief that no God exists, as God is defined in any current existing culture of society.
Agnosticism: the belief that whether there is a God and a spiritual world or any ultimate reality is unknown and proba-
bly unknowable.
Scientism: the belief that values and guidance for living come from scientific knowledge, principles, and practices; sys-
tematic study and analysis of life, rather than superstition, lead to true understanding and practice of life.
Maoism: the faith that is centered in the leadership of the Communist Party and all the people; the major belief goal is
to move away from individual personal desires and ambitions, toward viewing and serving all people as a whole.

Adapted from Counseling and development in a multicultural society, by Axelson, J. A., & McGrath, P.
Copyright (1998, 1993, 1985.) Pacific Grove, CA: Brooks/Cole Publishing Company, a division of International Thomson Publishing Inc.
Used with permission of the publisher.
CHAPTER 2 Cultural Issues Related to Mental Health Care 21

CULTURAL GROUPS AND BELIEFS Studies are indicating that Latino Americans tend to
ABOUT MENTAL ILLNESS use all other resources before seeking help from mental
health professionals. Reasons for this include (1) many
African Americans Latino patients believe that mental health facilities do
The African-American population in the United States not accommodate their cultural needs (eg, language,
is expected to reach 40 million by the year 2010 (U.S. beliefs, values) and (2) many still seek help through sup-
Bureau of the Census, 2000). Although African Ameri- portive home care and counseling from the church. If
cans share many beliefs, attitudes, values, and behaviors, bilingual, bicultural mental health facilities are avail-
there are also many subcultural and individual differ- able, Latino patients will seek care. An analysis of a
ences based on social class, country of origin, occupa- household survey from 3,000 respondents in California
tion, religion, educational level, and geographic loca- of immigrants and U.S.-born Mexican Americans found
tion. Many African Americans have extensive family that both groups were more likely to use the general
networks in which members can be relied on for moral medical sector for treating mental health problems
support, help with child rearing, financial aid, and help (Vega, Kolody, & Aguilar-Gaxiola, 2001).
in crises, and in most African American families, elderly
members are treated with great respect. But African
Asian Americans, Polynesians,
Americans with mental illness suffer from the stresses of
and Pacific Islanders
double stigmanot only from their own cultural group
but also from longtime racial discrimination. To make In 2000, more than 11 million Asian Americans, Poly-
matters worse, racial discrimination may come from nesians, and Pacific Islanders lived in the United States.
within the health community itself. Several studies This large multicultural group includes Chinese,
show that diagnoses and treatment for African Ameri- Filipino, Japanese, Asian Indian, Korean, Vietnamese,
cans often are racially biased (Dixon, Green-Paden, Laotian, Cambodian, Hawaiian, Samoan, and Guaman-
et al., 2001; Dixon, Lyles, et al., 2001). One nursing ian people. Most Chinese, Japanese, Korean, Asian
study investigated racial differences in health status and Indian, and Filipino immigrants have migrated to urban
health behavior of African American and Caucasian areas, whereas the Vietnamese have settled throughout
elderly patients. The researchers found that the African the United States.
Americans had significantly lower mental health and Generally, Asian cultures have a tradition of denying
poorer self-perceived health than did their Caucasian or disguising the existence of mental illnesses. In many of
counterparts (Kim, Bramlett, Wright, & Poon, 1998). these cultures, it is an embarrassment to have a family
member treated for mental illness. For example, in both
China and Japan, to disguise the severity of the illness,
Latino Americans
mental disorders are called neurasthenia. Chinese indi-
The number of Latino Americans living in the United viduals may deny depression and express it somatically.
States has been gradually increasing. From 1980 to However, since the 1980s (Parker, Gladstone, & Chee,
2000, there was a 122% increase in population, from 2001), Western influences on Chinese society and on the
14.6 to 32.5 million. It is estimated that there will be 49 detection and identification of depression are likely to
million people of Latino descent by the year 2015 (U.S. have modified the expression of the depressive illness.
Bureau of the Census, 2000). Countries of origin Research regarding specific mental health problems in
include Mexico (60%), Puerto Rico (12%), and Cuba Asian cultures is sparse, but various data suggest high
(5%). Forecasts indicate that within the next 25 years, rates of suicide related to social isolation, increasing use
the Latino population will become the largest minority of alcohol (leading to alcoholism), and increasing soma-
group in the United States. Latino populations are tization (the physical manifestation of psychological dis-
largest in urban areas, such as New York, Chicago, Los turbances) (Herrick & Brown, 1999).
Angeles, San Francisco, and MiamiFort Lauderdale.
Despite great diversity within the group, Latino-
Native Americans
American people are united by language, religion, and
customs as well as attitudes toward self, family, and com- Native American cultures emphasize respect and rev-
munity. Although evidence indicates that second-genera- erence for the earth and nature, from which come
tion Latino Americans speak English as their first lan- survival and comprehension of life and ones relation-
guage, many cities are experiencing an increase of ships with a separate, higher spiritual being and with
bilingual groups. For example, conducting public opin- other human beings. Shamans, or medicine men, are
ion polls in Spanish and in English is vital to the study of central to most cultures. They are healers believed to
the modern Latino electorate. One study found that if possess psychic abilities. Healing treatments rely on
the polls had been conducted only in English, the results herbal medicines and healing ceremonies and feasts.
would have been inaccurate (Hill & Moreno, 2001). Self-understanding derives from observing nature;
22 UNIT I The Nature of Mental Health and Mental Illness

relationships with others emphasize interdependence disabled, psychiatrically impaired, and single-parent
and sharing. families. In the United States, one third of people living
Traditional views about mental illnesses vary among below the poverty line are single mothers and their chil-
the tribes. In some, mental illness is viewed as a super- dren, 27% of African Americans live below the poverty
natural possession, as being out of balance with nature. level, as do 23% of Latino Americans and 12% of Amer-
In certain Native American groups, people with mental icans of European descent (U.S. Bureau of the Census,
illnesses are stigmatized. However, the degree of 2000). Currently in the United States, the poverty level
stigmatization is not the same for all disorders. In tribal for a family of four is income of $18,400 yearly in the 48
groups that make little distinction between physical and mainland states; $23,000 yearly in Alaska; and $21,160
mental illnesses, there is little stigma. In other groups, yearly in Hawaii (Federal Register, 2003).
a particular event, such as suicide, is stigmatized. Dif- Families living in poverty are under tremendous finan-
ferent illnesses may be encountered in different Native cial and emotional stress, which may trigger or exacerbate
American cultures and gene pools. mental problems. Along with the daily stressors of trying
to provide food and shelter for themselves and their fam-
ilies, the lack of time, energy, and money prevents them
Socioeconomic Influences from attending to their psychological needs. Often, these
on Mental Health Care families become trapped in a downward economic spiral,
Besides being stigmatized, cultural and ethnic groups as tension and stress mount. The inability to gain employ-
sometimes are denied access to mental health care ment and the lack of financial independence only add to
because of where and how they live. Those who are the feelings of powerlessness and low self-esteem. Being
without economic resources to afford treatment and self-supporting gives one a feeling of control over life and
those who are unemployed and ineligible for public bolsters self-esteem. Dependence on others or the gov-
assistance often are denied access to mental health care. ernment causes frustration, anger, apathy, and feelings of
Mental health care facilities and programs are also lim- depression and meaninglessness (Axelson, 1999). Alco-
ited for those rural or sparsely populated areas of the holism, depression, and child and partner abuse may
United States. become a means of coping with such hopelessness and
The deinstitutionalization of the mentally ill, which despair. The homeless population is the group most at
followed the passage of the 1963 Mental Retardation risk for being unable to escape this spiral of poverty.
Facilities and Community Mental Health Centers Con-
struction Act, released thousands of people from state GEOGRAPHIC LOCATION AND ACCESS
psychiatric institutions into the communities of the TO MENTAL HEALTH CARE
United States and Canada (see Chapter 1). The health
care system was ill prepared for a mass transition from Most mental health services are located in urban areas
institutional to community-based care and the social because most people live near cities. All age groups in
services needed to help reintegrate patients into work, rural areas have limited access to health care. The lack
school, family, and social relationships. Public and pri- of resources is particularly problematic for children and
vate funding sources were unequipped to deal with the elderly people, who have specialized needs. Rural areas
tremendous costs of providing these community mental are diverse in both geography and culture. Access to
health care services for the mentally ill. Consequently, mental health for those in the deep South is different
both the level of services and reimbursement for those from that for those with the same problems in the
services have remained somewhat limited, particularly Northwest. Treatment approaches may be effective in
for certain segments of the population. one part of the country but not in another.
Although many employers now provide working
people with health insurance that covers mental illness, CHANGING FAMILY STRUCTURE
and other people receive some public assistance for
mental health care through Medicare and Medicaid, Although families may be defined differently within var-
reimbursement for outpatient services often is limited. ious cultures, they all play an important role in the life
In addition, an estimated 44 million people are not cov- of the individual and influence who and what we are.
ered by any of the public and private health care plans Traditionally, families are considered a source of guid-
and cannot afford treatment at all. ance, security, love, and understanding. This is also true
for people who have mental illnesses and emotional
problems. It is often the family who assumes primary
care for the person with mental illness and supports that
Culture of poverty is a term that describes the norms individual throughout treatment. For patients, the family
and behaviors of people living in poverty. Poverty affects unit may provide their only constant support throughout
all cultural groups and other groups, such as the elderly, their lives. Although the nuclear family remains the basic
CHAPTER 2 Cultural Issues Related to Mental Health Care 23

unit of social organization, its structure and size have exceeded 4.4 million. Of the nations 103 million house-
changed drastically in recent times and so have the func- holds in 1999, married couples (with or without children)
tions and roles of family members. accounted for 54.7 million; there were 26.3 million sin-
gle-person households, a significant increase since 1970
(U.S. Bureau of the Census, 2000). The lifestyles chosen
Family Size
as an alternative to the traditional male-female, two-
Family size in the United States has decreased. In 1790, parent, nuclear families are often stigmatized.
about one third of all households, including servants,
slaves, and other people not related to the head, consisted
Single-Parent Families
of seven people or more. By 1960, only 1 household in 20
was this size. Few households contained members not It is estimated that 50% to 60% of all American chil-
related to the head (Taeuber, 1968). The average family dren will reside at some point in a single-parent home.
household in 1999 was 2.61 people (U.S. Bureau of the In the past, one-parent families usually were the result
Census, 2000). of the death of a spouse. Now, one-parent families are
mostly the result of divorce. The divorce rate has been
steadily rising in the United States since the 1960s; by
Changing Roles
1997, more than one of four children lived with only
Womens role in the family has changed drastically in one parent. Of all children in one-parent homes, 84%
the past years. Today, most women, including those who live with their mother. Because women maintaining
are mothers, work, both in dual-income families and sin- families tend to have considerably lower incomes than
gle-parent families. Women make up 45% of the Amer- do their male counterparts, they now make up a dispro-
ican civilian work force. More than half of the female portionate share of the poor population in the United
work force is married. Half the single, never-married States. More than 50% of single women with children
women have children younger than 18 years. More than under the age of 18 years live below the poverty level
75% of divorced, widowed, or separated women have (U.S. Bureau of the Census, 2000).
children, and more than 70% of married women have
children (U.S. Bureau of the Census, 2000). Although
the traditional roles for men and women have changed
somewhat by women entering the work force, working Remarried families or stepfamilies have a unique set of
women still bear the bulk of responsibility for child care problems that are not completely understood. Many
and household duties. They report feeling guilty and parents find that step-parenting is much more difficult
stressed from trying to be everythinga good parent and than parenting a biologic child. The bonding that
a success at a demanding job. Women often become occurs with biologic children rarely occurs with the
emotionally exhausted, particularly during periods of stepchildren, whose natural bond is with a parent not
personal conflict. They are at high risk for depression. living with them. However, it is the step-parent who
often assumes a measure of financial and parental
responsibility. The care and management of children
Mobility and Relocation
often become the primary stressor to the marital part-
Families are more mobile and may change residences ners. In addition, the children are faced with multiple
more often than ever before. Leaving familiar environ- sets of parents whose expectations may differ. They may
ments and readjusting to new surroundings and also compete for the childrens attention. It is not
lifestyles stresses family members. Moreover, these unusual for second marriages to fail because of the
moves impose separation from the extended family, stressors inherent in a remarried family.
which traditionally has been a stabilizing force and a
much-needed support system.
Childless Families
Couples often elect not to have children or to postpone
Unmarried Couples
having them until their careers are well established.
More unmarried couples are cohabitating before or Because having children tends to be an expected adult
instead of marrying. And some elderly couples, most behavior, families who do not have children are stigma-
often widowed, find it economically practical to cohabi- tized by society. For many years, the proportion of cou-
tate without marrying. The number of unmarried cou- ples who were childless declined steadily as socially trans-
ples among the total U.S. population almost tripled mitted and other diseases that caused infertility were
between 1970 and 1980, to an estimated 1.56 million conquered. However, in the 1970s, the changes in the
households shared by two unrelated adults (with or with- status of women reversed this trend. Many people chose
out children) of opposite sex. By 1999, this number not to have children. Couples who voluntarily chose not
24 UNIT I The Nature of Mental Health and Mental Illness

to have children were more stigmatized than were those barriers that discourage people from seeking help (U.S.
who were infertile (Lampman & Dowling-Guyer, 1995). Department of Health and Human Services, 1999). Its
effects are not easily overcome. When people are sub-
jected to stigmatization over a long time, they usually try
Same-Gender Families to conceal their disorders and worry that others may dis-
Among the most stigmatized people are those who are cover the illness. They become discouraged, hurt, and
homosexuals. It is estimated that most lesbian and gay angry and develop low self-esteem (Wahl, 1999).
populations have encountered some form of verbal
harassment or violence in their lives. Homophobia is a STIGMATIZATION AND STRESS FOR
kind of prejudice that leads to discrimination, stereo- FAMILY MEMBERS
typing, and, ultimately, stigmatization.
It is estimated that 1 in every 10 people has a homo- Families often are responsible for a lifetime of coordinat-
sexual orientation. Many argue that this estimate is ing care for relatives with mental illnesses. Unlike many
probably low, and others argue it is too high (Kinsey medical illnesses, psychiatric illnesses usually are chronic,
Institute Bibliography, 1999). Many religions condemn with periods of exacerbation and remission. Stigma
homosexuality. Although at one time people believed affects relatives of patients with mental illness. Family
that being gay or lesbian was a result of faulty parenting members cite that the effects of stigmatization of men-
or personal choice, it is generally accepted that sexual tally ill family members damage their self-esteem and
orientation is determined early in life by a combination make it difficult to make friends or find a job (U.S.
of factors, including genetic predisposition, biologic Department of Health and Human Services, 1999).
development, and environmental events. In the past, it Thus, denial of mental illness is common among family
was also believed that sexual preference could be members. The psychiatric nurse needs to be aware of the
changed through counseling by making a concerted effects of stigma on patients and families and to support
effort to establish new relationships. However, no evi- efforts to change the social view of mental disorders.
dence supports the hypothesis that change in sexual
orientation is possible.
Changing Public Attitude:
National Alliance for the
Stigma and Mental Illness Mentally Ill
As discussed in Chapter 1, patients with mental disorders During most of the 1900s, before the complexity of
have been stigmatized throughout history. Even within mental illnesses and the impact of the environment on
the past 20 years, with a more enlightened view of men- symptom manifestations were recognized, family mem-
tal illness, a stigma remains attached to those with men- bers were cited as causing mental illnesses. They were
tal disorders or those who seek help for mental illness. In placed in the position of seeking treatment for the sick
1999, Mental Health: A Report of the Surgeon General (U.S. family member and then being excluded from the treat-
Department of Health and Human Services) described ment process because they were seen as the culprits.
the negative attitude that continues to persist in the Family members were disrespected, blamed, or
United States. Individuals with mental illnesses typically ignored. This negative treatment of the family was frus-
are characterized in todays society as crazy. trating for both the patient and family and did not pro-
In addition, popular culture (eg, Hollywoods por- vide an atmosphere conducive to collaboration.
trayal of people with mental illness), still seems to Once the fallacy of blaming parents was recognized
stereotype characters as clowns, buffoons, or frighten- and the stigma toward parents lessened, family members
ing, possessed serial killers. These negative labels, became involved in supporting the delivery of services.
misconceptions, and stigma regarding mental illness Through the formation of self-help groups, families
persist for the same reasons that racial and ethnic organized and responded to the inadequacies of the men-
stigma persistsmisunderstanding and fear. tal health system. In 1973, the first organized family
group, Parents of Adult Schizophrenics, was formed in
San Mateo County, California. The idea soon spread,
and within 6 years, there were seven affiliated groups in
California under a new name, Families for the Mentally
Stigmatization is a powerful force in influencing the Disabled. In 1979, groups from across the nation met in
treatment and rehabilitation of the person with a mental Madison, Wisconsin, and formed a new organization, the
disorder. It is estimated that nearly two thirds of people National Alliance for the Mentally Ill (NAMI). The mis-
with mental disorders do not seek treatment. Stigma sion of NAMI is to eradicate mental illness and improve
surrounding mental health treatment is one of many the quality of life for patients. One of the driving goals of
CHAPTER 2 Cultural Issues Related to Mental Health Care 25

NAMI is that the general public will understand that

health care services will have to adapt to meet the men-
mental illnesses are no-fault, biologically based, treat-
tal health care needs of these families.
able, and eventually curable.
In the past, families were stigmatized, but now
NAMI has local chapters with family support groups
families serve as advocates and often are in the fore-
operating in cities or counties that are affiliated with
front of positive legislative changes. The National
state organizations, which in turn are affiliated with the
Alliance for the Mentally Ill (NAMI) campaigns to
national office in Washington, DC. The organization
improve the understanding of mental disorders that
has more than 70,000 member households. At the
should reduce the stigmatization of mental illness.
national level, NAMI promotes federal legislation to
improve the delivery of care. It also rates the care deliv-
ered by the state departments of mental health.
Statewide offices emphasize legislative contacts and CRITICAL THINKING CHALLENGES
advocacy for specific treatment programs. The state
1 Identify a group that you know in your area that has
office distributes educational materials produced by the
been stigmatized and analyze the process of stigma-
national office and other mental health agencies. NAMI
tization of that group.
members often are active at the local level in surveying
2 Compare the stigma of patients with physical ill-
the quality of community mental health services and
nesses to that of those with mental illnesses.
fighting the stigmatization of their ill relatives.
3 Differentiate the concepts of prejudice, discrimina-
tion, and stereotyping and their relationship to
SUMMARY OF KEY POINTS stigmatization.
4 Compare the access to mental health services in your
The United States and Canada consist of various state or county in rural areas to urban areas.
cultural groups with unique values, beliefs, and 5 Define the culture of poverty and discuss how pow-
health care practices. The term culture is defined as a erlessness affects the life of people living in poverty.
way of life that manifests the learned beliefs, values, 6 Trace the structure of the changing family through
and accepted behaviors that are transmitted socially the 1900s to the present.
within a specific group. 7 Discuss how nontraditional family units, such as
Cultural competence consists of cultural aware- single-parent families, stepfamilies, and single-sex
ness, cultural knowledge, cultural skills, and cultural families, are stigmatized by society.
encounters. Developing cultural competence in psy- 8 Describe the role of consumer and government
chiatric nursing practice is an ongoing process in car- groups in the development of awareness of the prob-
ing for patients within the context of their culture. lems of people with mental illnesses.
Many Americans of European descent have been 9 Visit a consumer group, such as a branch of the
acculturated into mainstream American culture. National Alliance for the Mentally Ill, and survey
Some groups, such as African Americans, have been how it advocates for people with mental disorders.
segregated from the predominant society.
Stigmatization occurs as a result of prejudice, dis-
crimination, and stereotyping. Cultural groups and REFERENCES
people with mental illness are stigmatized. Axelson, J. (1999). Counseling and development in a multicultural society.
Stigmatization involves the negative valuation of a Belmont, CA: Wadsworth, Brooks/Cole.
characteristic or trait by society. The people who Campinha-Bacote, J. (2002). A culturally competent model of care. Trans-
cultural C.A.R.E. Associates. Available: www.transcultural.net.
have the traits not only are ostracized by society but Dixon, L., Green-Paden, L., Delahanty, J., Lucksted, A., Postrado,
also view themselves in a negative, demoralizing way. L., & Hall, J. (2001). Variables associated with disparities in treat-
Religious beliefs are closely intertwined with ment of patients with schizophrenia and comorbid mood and anx-
beliefs about health and mental illness. iety disorders. Psychiatric Services, 52(9), 12161222.
Mental illnesses are stigmatized in most cultural Dixon, L., Lyles, A., Smith, C., Hoch, J. S., Fahey, M., Postrado, L.,
Lucksted, A., & Lehman, A. (2001). Use and costs of ambulatory
groups. A variety of cultural and religious beliefs care services among Medicare enrollees with schizophrenia. Psy-
underlie the stigmatization. chiatric Services, 52(6), 786792.
Access to mental health treatment is particularly Herrick, C., & Brown, H. (1999). Mental disorders and syndromes
limited for those living in rural areas or those within found among Asians residing in the United States. Issues in Mental
the culture of poverty. Health Nursing, 20, 275296.
Hill, K. A., & Moreno, D. V. (2001). Language as a variable: English,
The family is an important societal unit that often is Spanish, ethnicity, and political opinion in polling in South
responsible for the care and coordination of treatment Florida. Hispanic Journal of Behavioral Sciences, 23(2), 208228.
of members with mental disorders. The family struc- Jones, E. E., Farina, A., Hastorf, A. H., Markus, H., Miller, D. T., &
ture, size, and roles are rapidly changing. Traditional Scott, R. (1984). Social stigma: The psychology of marked relationships.
New York: Freeman.
26 UNIT I The Nature of Mental Health and Mental Illness

Kim, J., Bramlett, M. H., Wright, L. K., & Poon, L. W. (1998). Racial and Measurements (pp. 2774). New York: Russell Sage Founda-
differences in health status and health behaviors of older adults. tion.
Nursing Research, 47(4), 243250. Um, C., & Dancy, B. (1999). Relationship between coping strategies
Kinsey Institute Bibliography. (1999). Prevalence of homosexuality: Brief and depression among employed Korean immigrant wives. Issues
summary of U.S. studies. Available: www.indiana.edu/~Kinsey/ in Mental Health Nursing, 20, 485494.
resources/bib-homoprev.htm. Accessed: July 28, 2003. U.S. Bureau of the Census. (2000). Statistical abstract of the United
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Parker, G., Gladstone, G., & Chee, K. T. (2001). Depression in the Department of Health and Human Services, Substance Abuse and
planets largest ethnic group: The Chinese. The American Journal Mental Health Administration, Center for Mental Health Services,
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Robinson, J. W., & Swanson, N. (2002). Psychological well-being of Vega, W. A., Kolody, B., & Aguilar-Gaxiola, S. (2001). Help seeking
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For challenges and updates, go to www.connection.lww.com or refer to the CD-ROM in the back of this book.
Mental Health and
Mental Illness
Mary Ann Boyd

After studying this chapter, you will be able to:
Differentiate the concepts of mental health, mental illness, mental disorder, and
mental health problem.
Identify the universality of mental health.
Discuss mental health promotion strategies.
Identify categoric and dimensional diagnoses and their relevance to psychiatric
Differentiate the five axes used in making a psychiatric diagnosis.
Discuss the significance of epidemiology in understanding the impact of mental
Differentiate prevention from treatment approaches.
Discuss the role of evidence-based care in psychiatric nursing.

axes categoric diagnoses dimensional diagnoses epidemiology incidence
indicated preventive interventions maintenance interventions mental disorder
mental health mental health problem mental illness multiaxial diagnostic system
point prevalence prevalence prevention rate risk factors selective preventive
interventions treatment interventions universal preventive interventions

mental disorders

28 UNIT I The Nature of Mental Health and Mental Illness

M ental health and mental illness are not polar

opposites; rather they can be viewed as separate
concepts. A person who is mentally healthy is able to
ment. In reality, most people experience a mental health
problem at one time or another, especially during
stressful periods, such as after a natural disaster, during
deal with normal human emotion, is productive, has wars or national tragedies, after the loss of a loved one,
successful relationships with others, can adapt to or during a serious illness. The term mental health
change, and can cope with adversity. problem refers to signs and symptoms of mental ill-
nesses that do not fit criteria for a specific disorder.


Mental Health Mental health and mental illnesses are often defined by
MENTAL HEALTH a culture. Chapter 2 examines the impact of cultural
beliefs on the treatment of people with mental illness.
Everyone has the potential to be mentally healthy. Men-
Cultural norms and beliefs often outline mentally
tal health is a universal condition that shapes the way we
healthy behavior. For example, in Western society, a
think, feel, and communicate. To be mentally healthy
mentally healthy woman is expected to work and live
means that a person is comfortable with who she or he is
independently, but in some Middle Eastern societies, a
and secure within her/his interpersonal relationships. A
mentally healthy woman is expected to live within her
person can be physically ill, yet be mentally healthy. On
family home and be closely supervised. Sometimes cul-
the other hand, a person can be mentally ill but also be
tural definitions are in conflict with individual needs.
striving for mental health by learning to cope with the
symptoms and treatment of the disorder.
People without a mental illness can have mental
health problems that are distressing and require treat-
Mental Illness
Mental illness is a term used to mean all diagnosable
mental disorders. These disorders are considered syn-
FAME AND FORTUNE dromes or clusters of symptoms that occur together and
Winston Churchill (18741965) that could have multiple causes.
Great Statesman
Public Personna
Winston Churchill, former Prime Minister of England Categoric diagnoses name a disorder after matching a
and one of the greatest statesman of the 20th cen- set of symptoms with known criteria. For example, dia-
tury, led the British people to victory during WWII. He
ultimately had a major role in bringing peace to the
betes mellitus, schizophrenia, and ulcerative colitis are
world. categoric diagnoses. This type of diagnosis is useful in
identifying a disorder but is limited in that it does not
Personal Realities provide information regarding responses to the disor-
Churchills bouts with depression, mania, grandiose
behaviors, and insomnia are well documented. Black der and specific patient needs. Although two individuals
Dog was the name Churchill gave to his unrelenting may acquire the same flu virus, one may experience a
depressive moods that immobilized him for months, high fever, an upset stomach, and a dry, harsh cough,
sometimes years. Several of his ancestors also suffered and the other may have only a mild fever, a slight
mood disorders. In spite of his personal problems, he cough, and no nausea.
instilled in the British people his own fiery resolve and
will to resist the tyranny of war. When Churchill died in Dimensional diagnoses are descriptions of individu-
1965, he received the first state funeral given to a com- als responses and behaviors to illnesses. Human dimen-
moner since that of the Duke of Wellington. sions, such as anxiety, aggression, depression, or self-
Churchills childhood was privileged, but not par- destruction, are experienced on a continuum that ranges
ticularly happy. He was a younger son of the Duke of from normal to abnormal. These responses and behav-
Marlborough and Jennie Jerome, the daughter of an
American business tycoon. Like many Victorian par- iors are viewed in terms of degree, or level, of severity.
ents, Lord and Lady Randolph Churchill were distant For example, the dimension of aggression can be seen on
figures. Letters from his schooldays reveal that a continuum from verbal anger to physical assault. There
Winston was often willful and rebellious. One of can be many dimensional continua (eg, anxiety from mild
Winstons school reports showed him to be last in the to panic, self-destruction from indirect to direct, or
class. He performed particularly badly in composi-
tion, writing, and spelling; yet 70 years later he depression from grief to major depression). Dimensional
would win the Nobel Prize for Literature. diagnoses specify human responses to illness and provide
direction for treatment. The North American Nursing
Source: Storr, A (1989). Churchills Black Dog, Kafkas Mice and other
phenomena of the human mind. Grove/ Atlantic, Inc: New York.
Diagnosis Association (NANDA) taxonomy is dimen-
sional (see Chapter 12).
CHAPTER 3 Mental Health and Mental Illness 29


A diagnosis becomes a way of labeling a particular Selected Culture-Bound Syndromes
patient problem, but there can be negative consequences
DEFINITION: Behaviors limited to specific cultures that
of the label. Stigma associated with mental illness can be
have meaning within that culture
a problem (see Chapter 2). Another problem of labeling BRAIN FAG: Condition experienced by high school or
is that the labeled person loses personal identity and university students in response to the challenges of
becomes a disease. Just as a person with diabetes melli- schooling. Symptoms include difficulties in concentrat-
tus should not be referred to as a diabetic, but rather ing, remembering, thinking. A term originally used in
West Africa.
as a person with diabetes, a person with a mental dis-
FALLING-OUT OR BLACKING OUT: An episode of sudden
order should never be referred to as a schizophrenic or collapse that is sometimes preceded by feelings of
bipolar, but rather as a person with schizophrenia or dizziness. Individuals eyes are usually open, but the
a person with bipolar disorder. Nurses and healthcare person claims an inability to see. Occurs primarily in
professionals must be careful to avoid the pitfalls of neg- southern United States and Caribbean groups.
MAL DE OJO: Known as the evil eye in Mediterranean
ative labeling and stigmatization of patients.
cultures and elsewhere in the world. Symptoms include
fitful sleep, crying without apparent cause, diarrhea,
vomiting, and fever in a child or infants.
Adapted from American Psychiatric Association. (2000). Diagnostic
KEY CONCEPT Mental disorders are health con- and statistical manual of mental disorders, 4th ed, text revision
ditions characterized by alterations in thinking, (pp. 898903). Washington, DC: Author.
mood, or behavior. They are associated with distress
or impaired functioning.
and mental retardation. Axis III includes the general med-
These alterations are unexpected and are outside the ical conditions that must be considered in the diagnosis
limits of expected psychological states, such as the and treatment of the primary psychiatric disorders. Each
normal sadness, grief, and mild depression associated axis is essential to the complete understanding and treat-
with the death of a spouse. Cultural definitions of ment of an individual with psychiatric concerns. For
normal are also taken into consideration. If a example, a person with a major depression (Axis I) may
behavior is considered normal within a specific cul- meet the criteria for having a dependent personality dis-
ture, it is not viewed as a symptom by members of order (Axis II) and may also have diabetes (Axis III). See
that group. For example, it is common in some Table 3-1 for a listing of disorders and conditions that
religious groups to speak in tongues. To an observer, might be considered under each axis and Box 3-2 for a
it appears that the individuals are having hallucina- clinical example.
tions (see Chapter 16), a psychiatric symptom, but this Although the first three axes appear to contain all of
behavior is normal for this group within a particular the diagnostic information, a truly accurate picture of
The diagnosis of mental disorders is based on the
classification system of the fourth edition (text revi- BOX 3.2
sion) of the Diagnostic and Statistical Manual of Mental
Diagnostic Axes and Their Disorders
Disorders (DSM-IV-TR) (American Psychiatric Asso-
and Conditions
ciation, 2000). The DSM-IV-TR system contains sub-
types and other specifiers to describe further the char- Clinical Example
acteristics of the diagnosis as exhibited in a given Axis I: 300.21* Panic Disorder With Agoraphobia
individual. Some disorders are influenced by cultural Axis II: 301.4 Obsessive-Compulsive Personality Disorder
factors and others are culture-bound syndromes that Axis III: 250.00 Diabetes Mellitus
are present only in a particular setting (Box 3-1). Axis IV: Occupational Problems: Frequent Absences From
Although the DSM-IV-TR provides criteria for diag- Axis V: Global Assessment of Function
nosing mental disorders, there are no absolute bound- GAF = 55 (current)
aries separating one disorder from another, and simi- 90 (potential)
lar disorders may have different manifestations at
different points in time. *In this example, code numbers are used and can be found in the
Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text
The DSM-IV-TR diagnostic criteria are based on a revision (DSM-IV-TR). To improve readability, these code numbers
multiaxial diagnostic system that includes five axes, or are not used when discussing the various disorders. The student
domains of information. Axis I includes most clinical dis- will see them used in the clinical setting.
The medical conditions in Axis III are coded according to the
orders and other conditions that may be the focus of clin- International Classification of Diseases (ICD).
ical attention, and Axis II contains personality disorders
30 UNIT I The Nature of Mental Health and Mental Illness

Table 3.1 DSM-IV Multiaxial Diagnoses for Persons With Mental Disorders

Diagnostic Axes and Their Disorders and Conditions

Axis I: Clinical Disorders and Other Conditions Symptoms, Signs, and Ill-Defined Conditions
That May Be a Focus of Clinical Attention Injury and Poisoning
Disorders Usually First Diagnosed During Infancy, Axis IV: Psychosocial and Environmental Problems
Childhood, or Adolescence
Problems with primary support group
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Problems related to the social environment
Mental Disorders Due to General Medical Conditions
Educational problems
Substance-Related Disorders
Occupational problems
Schizophrenia and Other Psychotic Disorders
Housing problems
Mood Disorders
Economic problems
Anxiety Disorders
Problems with access to health care services
Somatoform Disorders
Problems related to interaction with the legal system/
Factitious Disorders
Dissociative Disorders
Other psychosocial and environmental problems
Sexual and Gender Identity Disorders
Eating Disorders Axis V: Global Assessment of Functioning
Sleep Disorders Current =
Impulse Control Disorders (Not Elsewhere Classified) Potential =
Adjustment Disorders Psychologic, social, and occupational functioning on a
Other Conditions That May Be a Focus of Clinical Attention hypothetical continuum of mental healthillness.
Axis II: Personality Disorders and Mental Retardation Scores
Personality Disorders: 91100 Superior functioning, no symptoms
Paranoid Personality Disorder 8190 Absent or minimal symptoms, good function-
Schizoid Personality Disorder ing in all areas
Schizotypal Personality Disorder 7180 If symptoms are present, they are transient
Antisocial Personality Disorder and expectable reactions to psychosocial
Borderline Personality Disorder stressors; no more than slight impairment in
Histrionic Personality Disorder social, occupational, or school functioning
Narcissistic Personality Disorder 6170 Some mild symptoms or some difficulty in
Avoidant Personality Disorder social, occupational, or school functioning,
Dependent Personality Disorder but generally functioning well; has some
Obsessive-Compulsive Personality Disorder meaningful interpersonal relationships
Personality Disorder Not Otherwise Specified 5160 Moderate symptoms or moderate difficulty in
Mental Retardation social, occupational, or school functioning
4150 Serious symptoms or any serious impair-
Axis III: General Medical Conditions ment in social, occupational, or school
Infectious and Parasitic Diseases functioning
Neoplams 3140 Some impairment in reality testing or com-
Endocrine, Nutritional, and Metabolic Diseases and munication or major impairment in several
Immunity Disorders areas, such as work or school, family rela-
Diseases of the Blood and Blood-Forming Organs tions, judgment, thinking, or mood
Diseases of the Nervous and Sense Organs 2130 Behavior is considerably influenced by delu-
Diseases of the Circulatory System sions or hallucinations or serious impairment
Diseases of the Respiratory System in communication or judgment or inability to
Diseases of the Digestive System function in almost all areas
Diseases of the Genitourinary System 1120 Some danger of hurting self or others or
Complications of Pregnancy, Childbirth, and the occasionally fails to maintain minimal
Puerperium personal hygiene or gross impairment in
Diseases of the Skin and Subcutaneous Tissue communication
Diseases of the Musculoskeletal System and Connective 110 Persistent danger of severely hurting self or
Tissue others or persistent inability to maintain
Congenital Anomalies minimal personal hygiene or serious suicidal
Certain Conditions Originating in the Perinatal Period act with clear expectation of death

the individual is incomplete without considering other the primary psychiatric problem. These problems may
factors, such as life stressors and current level of func- be conceptualized in terms of life stressors, which may
tioning. Axis IV concerns any psychosocial or environmen- be negative or positive. For example, a negative life
tal problems that may produce added stress, confound event, such as the death of a spouse, a recent divorce, or
the diagnosis, or must be considered in the treatment of job discrimination, may exacerbate symptoms of
CHAPTER 3 Mental Health and Mental Illness 31

depression. On the other hand, positive stressors, such BOX 3.3

as starting a new job, getting married, or having a baby,
Epidemiologic Terms
may also prompt the symptoms to emerge. Although
the DSM-IV-TR suggests a number of problem areas to In epidemiology, certain terms have specific meanings
be considered, the clinician making the diagnosis relative to what they measure. When expressing the num-
should write out the individuals specific problems on ber of cases of a disorder, population rates, rather than
this axis. raw numbers, are used.
Rate is a proportion of the cases in the population
Ratings given on Axis V provide an estimate of over- when compared with the total population. It is expressed
all functioning in psychological, social, and occupa- as a fraction, in which the numerator is the number of
tional spheres of life. These data are useful in planning cases and the denominator is the total number in the
treatment and measuring its impact. The Global population, including the cases and noncases. The term
Assessment Functioning (GAF) scale usually is used average rate is used for measures that involve rates over
specified time periods:
and is scored from low functioning of 0 to 10, to high
functioning of 91 to 100 (see Table 3-1). This rating Cases in the population
Rate =
may be made at the beginning of treatment, at dis- Total population
charge from the hospital, or at any point thereafter. (includes cases and noncases)
When including this rating, the point of time should
Prevalence refers to the total number of people who
also be indicated, such as current, or at discharge have the disorder within a given population at a specified
from the hospital. time, regardless of how long ago the disorder started.
Point prevalence is the basic measure that refers to
the proportion of individuals in the population who have
IMPORTANCE OF EPIDEMIOLOGY the disorder at a specified point in time. This point can
be a day on the calender, such as April 1, 2010, or a
The occurrence of mental disorders is studied point defined in relation to the study assessment, such
through epidemiological research, just like any other as the day of the interview. This is also expressed as a
disorder. Epidemiology is the study of patterns of fraction:
disease distribution in time and space. It focuses on
cases at t
the health status of population groups, or aggregates, Point prevalence rate =
Population at t
rather than individuals, and it involves quantitative
analysis of the occurrence of illnesses in population Incidence refers to a rate that includes only new cases
groups. Epidemiologic approaches are useful in that have occurred within a clearly defined time period.
understanding the occurrences of mental disorders. The most common time period evaluated is 1 year. The
study of incidence cases is more difficult than a study of
Throughout this book, mental disorders are described prevalent cases because a study of incidence cases
using epidemiologic data. See Box 3-3 for an explana- requires at least two measurements to be taken, one at
tion of terms. the start of the prescribed time period and another at the
end of it.

Interventions in Psychiatric
Mental Health or problem and are not symptoms of the illness but are
factors that influence the likelihood that the symptoms
will appear. The existence of a risk factor does not
A persons mental health can be challenged by a vari- always mean the person will get the disorder or disease,
ety of factors; biologic changes or illnesses, psycho- it just increases the chances. There are many different
logical pressures, interpersonal tension are only a few. kinds of risk factors, including genetic, biologic, envi-
Developing strategies to eliminate or reduce the ronmental, cultural, and occupational. Even gender is a
impact of these destructive factors is a part of normal risk factor for some disorders (eg, more women experi-
growth and development. Relaxation, proper nutri- ence depression than men).
tion, sleep, and a trusting relationship can support Some risk factors can be controlled or changed
ones mental health. through mental health promotion activities; others can-
not. Genetic risk factors cannot be changed because
individuals cannot change the genetic makeup with
which they are born. Risk factors that can be changed
Specific risk factors, or characteristics that increase the include those related to lifestyle behaviors or environ-
likelihood of developing a disorder, can contribute to ment. Someone who is genetically at high risk for bipo-
poor mental health and influence the development of a lar disorder (ie, family members have the disorder), can
mental disorder. Risk factors do not cause the disorder modify lifestyle and environment to decrease the impact
32 UNIT I The Nature of Mental Health and Mental Illness

of these factors. Selecting a job with less stress can still viable, there have been consistent difficulties in
reduce the likelihood of manifestations related to some applying this model to mental disorders. One problem
of the anxiety disorders. However, even if it is possible to is that this model implies a cause and effect. In mental
change behaviors, occupations, and environmental con- health, multiple factors influence the manifestation of
ditions, the actual change can be difficult. Many risky a disorder, not just one factor. In addition, Caplans
behaviors are physically, psychologically, or socially use of the term prevention encompasses preventing
rewarding and pleasurable, such as eating a high-calorie the illness (primary) as well as treating it. Thus, the
meal, engaging in unprotected sexual intercourse, or ambiguous meaning of the term prevention leads to
sustaining an interpersonal relationship with someone considerable confusion about exactly what prevention
who is abusive. One of the challenges of nursing is help- activities are.
ing people identify and monitor their own risk factors.
Two models provide guidance in conceptualizing the
Intervention Spectrum: Prevention,
broad area of mental health promotion and mental ill-
Treatment, Maintenance
ness prevention. The first model, Caplans Model of Pri-
mary, Secondary, and Tertiary Prevention is the older of In 1992, the Institute of Medicine (an advisory group
the two and is accepted worldwide. The second model, to the federal government) established a Committee
the Intervention Spectrum, is newly developed and sup- on Prevention of Mental Disorders to work with the
ported primarily in the United States. National Institute of Mental Health (NIMH) in iden-
tifying current prevention knowledge and recom-
mending future research directions. The committee
Caplans Model of Primary,
quickly recognized the conceptual problems of the tra-
Secondary, and Tertiary
ditional approach of the primary, secondary, and ter-
tiary prevention model. A new definition of the term
In the 1960s, mental health embraced the ideas of pri- prevention was agreed on by this committee. Pre-
mary, secondary, and tertiary prevention from the pub- vention was redefined as only those interventions
lic health field in an attempt to understand how to used before the initial onset of a disorder and became
lower the statistical rates of a disorder within a popula- distinct from treatment. The committee recom-
tion (Caplan, 1964). Through the pioneering works of mended that the mental health intervention spectrum
Gerald Caplan, the field of preventive psychiatry was for mental disorders be used as the standard interven-
born. Using Caplans model, preventive programs are tion system (Fig. 3-1) (Mrazek & Haggerty, 1994). In
organized to achieve three different goals: this model, prevention interventions are classified
Primary prevention seeks to reduce the incidence according to the following:
(rate of occurrence of new cases) of mental disor- Universal preventive interventions: targeted to
ders within a population over time. For example, everyone within a general public or whole popula-
primary prevention interventions targeted at sui- tion group.
cide focus on preventing the development of sui- Selective preventive interventions: targeted to
cidal tendencies in individuals. These interven- an individual or a subgroup of the population
tions include restricting access to suicide methods whose risk for a disorder is higher than average.
(gun control), establishing community-based ser- Indicated preventive interventions: targeted to
vices, and educating the public and health care high-risk individuals who are identified as having
professionals. minimal, but detectable, signs or symptoms fore-
Secondary prevention seeks to lower prevalence shadowing a disorder or biologic markers indicat-
(rate of new and old cases at a point in time). Sec- ing a predisposition but who do not have the dis-
ondary prevention interventions include hotlines order (Mrazek & Haggerty, 1994).
and short-term hospitalizations targeted for those Treatment interventions include case identifica-
on the verge of suicide. tion and standard treatment for all known disorders.
Tertiary prevention seeks to lower the rate of Treatment aims to reduce the likelihood of future co-
residual disability, for example by reducing occu- occurring disorders and the length of stay as well as to
pational and role dysfunctioning (Caplan, 1993). halt the progression of severity of the illness.
In Caplans model, community prevention programs Maintenance interventions, in turn, are those sup-
are organized around either global risk factors, such as portive, educational, or pharmacologic interventions
poverty, prejudice, and inadequate living situations, or that are provided on a long-term basis to individuals
target risk factors, such as biopsychosocial stressors who have received a diagnosis of a disorder. They aim
associated with the risk for a mental disorder. to decrease the disability associated with the disorder.
Although the concept of mental health care in Maintenance components include the patients compli-
terms of primary, secondary, and tertiary prevention is ance with long-term treatment to reduce relapse and
CHAPTER 3 Mental Health and Mental Illness 33



orde for
FIGURE 3.1 The mental health

know treatmen
intervention spectrum for mental

disorders. (Adapted from Mrazek,


n dis

P., & Haggerty, R. [Eds.]. [1994].

te in


g- tion )

Reducing risks for mental disorders:



lo c ce

th du en

Frontiers for preventive interven-

Se wi l: re urr

tion research [p. 23]). Committee

lec e a c
nc o re

on Prevention of Mental Disorders, l ia t (g nd
Institute of Medicine. Washington, m en e a
DC: National Academy Press. Co atm aps
tre rel ation
Unive r e h abilit
rsal g
r - c a re (in

recurrence and the provision of after-care services to lined in the DSM-IV-TR are the standardized,
the patient, including rehabilitation. accepted language in the mental health field. There
are five diagnostic axes: clinical disorders; personal-
EVIDENCE-BASED CARE ity disorders and mental retardation; general medical
problems; psychosocial or environmental problems;
One of the challenges in the psychiatricmental health and overall functioning.
field is to generate interventions for evidence-based Epidemiology is important in understanding the
care. Traditionally, interventions have been developed distribution of mental illness within a given popula-
by clinicians own experiences and have not necessarily tion. The rate of occurrence refers to the proportion
been subjected to rigorous testing. Today, the focus is of the population that has the disorder. The inci-
on developing evidenced-based care that involves defin- dence is the rate of new cases within a specified time.
ing clinical questions and finding evidence that serves as The prevalence is the rate of occurrence of all cases
a basis of practice. Throughout this book, research- at a particular point in time.
supporting interventions are highlighted. Risk factors include factors that can and cannot be
From the evidence, treatment guidelines can be changed. Genetic predisposition cannot be changed,
developed. There is general agreement in the psychi- but lifestyle and behavior can.
atric community that treatment guidelines are useful. Mental health interventions can be viewed along a
These guidelines usually include algorithms (or deci- spectrum of prevention, treatment, and maintenance
sion trees) that can be used in making treatment deci- strategies. They can target an individual or a whole
sions. The best guidelines are evidence based and can population.
be uniformly applied to people with a particular disor- Within the intervention spectrum, prevention is
der. Most of the disorders discussed in this book have categorized according to universal, selective, and
several treatment guidelines. indicated preventive interventions. Prevention is
defined as only those interventions used before the
onset of the disorder.
Mentally healthy people are able to deal with nor-
mal human emotions. Mental disorders are health CRITICAL THINKING CHALLENGES
conditions characterized by alterations in thinking,
mood, or behavior and are associated with distress or 1 Define the differences among the terms mental
impaired functioning. Mental health problems may health, mental disorder, and mental health problem.
need intervention but do not meet criteria for a men- 2 Explain the purposes of the five axes of the DSM-
tal disorder. IV-TR.
Categoric and dimensional diagnoses are used in 3 Define risk factors and identify the different types of
nursing. The use of diagnosis in mental health can be risk factors in psychiatric mental health.
problematic because of the negative association of 4 Compare the spectrum of interventions advocated by
the label mental illness. The categoric diagnoses out- the Committee on Prevention of Mental Disorders
with the traditional view of prevention.
34 UNIT I The Nature of Mental Health and Mental Illness

5 Explain the difference between a categoric and a Health Sciences Center Library of Emory Univer-
dimensional diagnosis. Give examples. sity.
6 Discuss the negative impact of labeling someone h t t p : / / w w w. o t t a w a h o s p i t a l . o n . c a / l i b r a r y /
with a psychiatric diagnosis. ebhce.shtml This website is maintained by Ottawa
7 Define the epidemiologic terms prevalence, incidence, Hospital, a part of the University of Ottawa, Canada.
and rate. www.nurseintraining.8m.com/nursing/careplans.htm
This site includes care plans, a chat room, and Inter-
net hot sites.
www.mentalhealth.com This useful site examines
American Psychiatric Association. (2000). Diagnostic and statistical
many aspects of mental health and mental illness,
manual of mental disorders, 4th ed., text revision. Washington, DC:
including psychiatric diagnosis. Author.
www.ahcpr.gov This website of the Agency for Caplan, G. (1964). Principles of preventive psychiatry. New York: Basic
Healthcare Research and Quality has a repository of Books.
practice guidelines. Caplan, G. (1993). Organization of preventive psychiatry programs.
Community Mental Health Journal, 29(4), 367395.
www.nursingnet.com This nursing student website
Mrazek, P., & Haggerty, R. (Eds.). (1994). Reducing risks for mental dis-
includes nursing care plans. orders: Frontiers for preventive intervention research. Committee on
www.medweb.emory.edu/MedWeb/ This site is Prevention of Mental Disorders, Institute of Medicine. Washing-
maintained by the staff of the Robert W. Woodruff ton, DC: National Academy Press.

For challenges and updates, go to www.connection.lww.com or refer to the CD-ROM in the back of this book.
Mental Health Care
in the Community
Andrea C. Bostrom and Mary Ann Boyd

Denise M. Gibson and Robert B. Noud

After studying this chapter, you will be able to:
After studying this chapter, you will be able to:
Identify the different treatment settings and associated programs along the continuum
of care.
Discuss the role of the nurse at different points along the continuum of care.
Describe current health care trends in psychiatric services.
Explain how the concept of the least restrictive environment influences the assessment
of patients for placement in different treatment settings.
Discuss the influence of managed care on services and use of services in the continuum
of care.

KEY TERMS community treatment board-and-care homes case management clubhouse
model continuum of care coordination of care crisis intervention in-home mental
affective flattening or blunting affe
health care intensive case management intensive residential services intensive
outpatient program least restrictive environment managed care organizations
outpatient detoxification partial hospitalization psychiatric rehabilitation programs
referral reintegration relapse residential services stabilization therapeutic
foster care transfer 23-hour observation

continuum of care

disorganized symptoms negative symptoms neurocognitive impairment positive

CHAPTER 5 Mental Health Care in the Community 47

T he evolution of a behavioral health care system is

affected by scientific advances and social factors.
The long-term nature of mental illnesses requires vary-
The primary goal of the continuum of care is to pro-
vide treatment that allows the patient to achieve the
ing levels of care at different stages of the disorders as
highest level of functioning in the least restrictive
well as family and community support. Treatment costs
environment (see Chapter 4). Treatment is usually
are shared among public and private sectors. A demand
delivered in the community (as opposed to a hospital or
exists for a comprehensive, holistic approach to care
institution) and, ideally, in an outpatient setting
that encompasses all levels of need. Consumers, fami-
(Wasylenki et al., 2000).
lies, providers, advocacy groups, and third-party payers
of mental health care no longer accept long-term insti-
tutionalization, once the hallmark of psychiatric care. COORDINATION OF CARE
Instead, they advocate for short-term treatment in an
environment that promotes dignity and well-being Coordination of care is the integration of appropriate
while meeting the patients biologic, psychological, and services so that individualized care is provided. Appro-
social needs. priate services are those that are tailored to address a
Reimbursement issues have influenced health care. clients strengths and weaknesses, cultural context, ser-
In the United States, health maintenance organizations vice preferences, and recovery goals, including referral
(HMOs), preferred provider organizations (PPOs), to community resources and liaisons with others (e.g.,
Medicaid, and Medicare have set limits on the type and physician, health care organizations, community ser-
length of treatment for which they provide reimburse- vices). Several agencies could be involved, but when
ment coverage, which in turn influences the kind of care is coordinated, a persons needs are met without
care the patient receives. In other countries, other reg- duplication of services. Coordination of care requires
ulatory bodies influence access and treatment options. collaborative and cooperative relationships among
Fragmentation of services is a constant threat. Today, many services, including primary care, public health,
psychiatricmental health nurses face the challenge of mental health, social services, housing, education, and
providing mental health care within a complex system criminal justice, to name a few.
that is affected by financial constraints and narrowed In some instances, a whole array of integrated ser-
treatment requirements. vices are needed. For example, children can benefit from
treatment and specialized support at home and school.
These wraparound services represent a unique set of
Defining the Continuum community services and natural supports individualized
for the child or adult and family to achieve a positive set
of Care of outcomes.
An individuals needs for ongoing clinical treatment
and care are matched with the intensity of profes-
sional health services. The continuum of care for CASE MANAGEMENT
mental health services can be viewed from various Coordinated care is often accomplished through a case
perspectives and ranges from intense treatment (hos- management service model, in which a case manager
pitalization) to supportive interventions (outpatient locates services, links the patient with these services,
therapy). and then monitors the patients receipt of these services.
This type of case management is referred to as the bro-
ker model. Case management can be provided by an
KEY CONCEPT A continuum of care consists of an individual or a team; it may include both face-to-face
integrated system of settings, services, health care and telephone contact with the patient, as well as
clinicians, and care levels, spanning illness-to-wellness contact with other service providers. Intensive case
states. management is targeted for adults with serious mental
illnesses or children with serious emotional disturbances.
In a continuum, continuity of care is provided over Managers of such cases have fewer caseloads and higher
an extended time. The appropriate medical, nursing, levels of professional training than do traditional case
psychological, or social services may be delivered managers.
within one organization or across multiple organiza- Case management is an integral part of mental health
tions. The continuum facilitates the stability, conti- services and is organized around fundamental elements,
nuity, and comprehensiveness of service to an indi- including a comprehensive needs assessment, develop-
vidual and maximizes the coordination of care and ment of a plan of care to meet those needs, a method of
services. ensuring the individual has access to care, and a method
48 UNIT I The Nature of Mental Health and Mental Illness

of monitoring the care provided. Case managers collect a short-term therapeutic interventions and medication
large amount of patient information and are confronted administration. Nurses also facilitate referrals for admis-
with coordinating multiple health care clinicians. One of sion to the hospital or for outpatient services.
the most valuable assets case managers possess is their
ability to synthesize patient data and act as conduits
23-Hour Observation
between patients and the health care system (Williams,
2001). Through case management, access to care is The use of 23-hour observation is a short-term
increased through coordinated efforts that reduce frag- treatment that serves the patient in immediate but
mentation of care and diminish health care costs (Chan, short-term crisis. This type of care admits individuals
Mackenzie, Tin-Fu, & Ka-yi Leung, 2000; Ward, Arm- to an inpatient setting for as long as 23 hours, during
strong, Lelliott, & Davies, 1999). which time services are provided at a less-than-acute
care level. The clinical problem usually is a transient
disruption of baseline function, which will resolve
THE NURSE AS CASE MANAGER quickly. Usually, the individual presents a threat to
Psychiatric nurses serve in various pivotal functions self or others. The nurses role in this treatment
across the continuum of care. These functions can modality is assessment and monitoring. Medications
involve both direct care and coordination of the care also are usually administered. This treatment is used
delivered by others. The case manager role is one in for acute trauma, such as rape, alcohol and narcotic
which the nurse must have commanding knowledge and detoxification, and for individuals with Axis II per-
special training in individual and group psychotherapy, sonality disorders who present with self-injurious
psychopharmacology, and psychosocial rehabilitation. behaviors.
The nurse must have expertise not only in psy-
chopathology and up-to-date treatment modalities, but Crisis Stabilization
also in treating the family as a unit. Modalities include
the therapeutic use of self, networking and social sys- When the immediate crisis does not resolve quickly, cri-
tems, crisis intervention, pharmacology, physical sis stabilization is the next step. This type of care usu-
assessment, psychosocial and functional assessment, and ally lasts fewer than 7 days and has a symptom-based
psychiatric rehabilitation. The repertoire of required indication for hospital admission. The primary purpose
skills includes collaborative, teaching, management, of stabilization is control of precipitating symptoms
leadership, group, and research skills. The nurse as case through medications, behavioral interventions, and
manager probably is the most diverse role within the coordination with other agencies for appropriate after-
psychiatric continuum. care. The major focus of nursing care in a short-term
inpatient setting is symptom management. Ongoing
assessment; short-term, focused interventions; and
MENTAL HEALTH SERVICES IN A medication administration and monitoring of efficacy
CONTINUUM OF CARE and side effects are major components of nursing care
during stabilization. Nurses also may provide focused
Crisis Intervention
group psychotherapy designed to develop and
An organized approach is required to treat individuals in strengthen the personal management strategies of
crisis, including a mechanism for rapid access to care patients. When treating aggressive or violent patients,
(within 24 hours), a referral for hospitalization, or access the nurse monitors the appropriate use of seclusion and
to outpatient services. Crisis intervention treatment is restraints. The 1-hour rule that requires a physician or
brief, usually fewer than 6 hours (see Chapter 33). This licensed independent practitioner to evaluate a patient
type of short-term care focuses on stabilization, symp- within 1 hour after restraint or seclusion applies (Lee &
tom reduction, and prevention of relapse requiring Gurney, 2002).
inpatient services.
Crisis intervention units can be found in the emer-
Acute Inpatient Care
gency department of a general or psychiatric hospital or
in crisis centers within a community mental health cen- Acute inpatient hospitalization involves the most inten-
ter. Patients in crisis demonstrate severe symptoms of sive treatment and is considered the most restrictive
acute mental illness, including labile mood swings, suici- setting in the continuum. Inpatient treatment is
dal ideation, or self-injurious behaviors. Therefore, this reserved for acutely ill patients who, because of a men-
treatment option commands a high degree of nursing tal illness, meet one or more of three criteria: high risk
expertise. Patients in crisis usually require medications for harming themselves, high risk for harming others,
such as anxiolytics or benzodiazepines for symptom or unable to care for their basic needs. Delivery of inpa-
management. Key nursing roles include assessment of tient care can occur in a psychiatric hospital, psychiatric
CHAPTER 5 Mental Health Care in the Community 49

unit within a general hospital, or a state-operated men- of care encompassing behavioral therapy, social skills
tal hospital. training, basic living skills training, education regard-
Admission to inpatient environments can be volun- ing illness and symptom identification and relapse pre-
tary or involuntary (see Chapter 4). The average length vention, community survival skills training, relaxation
of stay for an involuntary admission ranges between 24 training, nutrition and exercise counseling, and other
hours and several days, depending on the state or forms of expressive therapy. Compared with other out-
province laws; whereas the length of stay for a voluntary patient programs, PHPs offer more intensive nursing
admission depends on the acuity of symptoms and the care.
patients ability to pay the costs of treatment. It is
unconstitutional in the United States to confine a non-
Residential Services
dangerous mentally ill person who can survive indepen-
dently with the help of willing and responsible family or Residential services provide a place for people to
friends (Davison, 2000). Nevertheless, the interdiscipli- reside during a 24-hour period or any portion of the
nary treatment team determines that the patient is no day, on an ongoing basis. A residential facility can be
longer at risk to self or others before discharge can publicly or privately owned. Intensive residential
occur. services are intensively staffed for patient treatment.
Length of inpatient stay has continually decreased These services may include medical, nursing, psy-
since the 1980s, a trend attributed mostly to managed care chosocial, vocational, recreational, or other support
and treatment advances, especially medications (Sturm & services. Combining residential care and mental
Bao, 2000). Additional contributors to decreased length health services, this treatment form offers rehabilita-
of stay include cost-containment mechanisms, such as tion and therapy to people with serious and persistent
strict admission criteria, utilization review, case manage- mental illnesses, including chronic schizophrenia,
ment, and contractual arrangements with third-party pay- bipolar disorder, and unrelenting depression. These
ers (Leslie & Rosenheck, 2000). The average length of services may provide short-term treatment for stays
stay for inpatient care decreased from 38.74 days in 1985 from 24 hours to 3 or 6 months or long-term treat-
to 6.51 days at the turn of the century (Hughes, 1999). ment for several months to years.

Partial Hospitalization
During the 1980s, the costs associated with inpatient
adult psychiatric and substance abuse treatment Gheel, Belgium
exceeded the clinical benefits when compared with out- Community With Mission
patient care (Wise, 2000). Partial hospitalization pro- Since the 13th century, the entire village of Gheel,
grams (PHPs) or day hospital care were developed. Belgium has been committed to helping the mentally
Day hospital services complement inpatient mental ill. In this small community, people with mental ill-
health care and outpatient services and provide treat- ness are adopted into families and truly become a
ment to patients with acute psychiatric symptoms who part of their foster family system throughout their
lives. The commitment is carried through from gener-
are experiencing a decline in social or occupational ation to generation. This legendary system of foster
functioning, who cannot function autonomously on a family care for the mentally ill began centuries ago.
daily basis, or who do not pose imminent danger to The following describes how it all began.
themselves or others. It is a time-limited, ambulatory, Dymphna was born in Northern Ireland in the 7th
active treatment program that offers therapeutically century to a pagan chieftain and Christian mother.
Her mother died when Dymphna was young. Her
intensive, coordinated, and structured clinical services father became mentally ill following her death and
within a stable milieu. The aim of PHPs is patient sta- was unable to find a woman to replace her. When
bilization without hospitalization or reduced length of Dymphna was 14, the father wanted to marry his
inpatient care. An alternative to inpatient treatment, daughter. She refused and fled to Gheel with the
PHP usually provides the resources to support thera- assistance of others, including a Christian priest. The
father hunted them down and beheaded Dymphna
peutic activities both for full-day and half-day pro- and the priest. The spot where they were killed
grams. This level of care does not include overnight became a shrine. Miraculous cures of mental ill-
hospital care; however, the patient can be admitted for nesses and epilepsy have been reported at the
inpatient care within 24 hours. The now-dwindling shrine. In the Catholic church, Saint Dymphna is
number of PHPs peaked in 2000 (National Association invoked as the patron of those suffering from ner-
vous and mental illnesses.
of Psychiatric Health Systems, 2002). Admissions and
visits to the PHPs that remain have increased. Source: Goldstein, JL & Godemont, MML (2003). The legend and
lessons of Gheel, Belgium: A 1500-year-old legend, a 21st cen-
In partial hospitalization, the interdisciplinary treat- tury model. Community Mental Health Journal, 39(5), 441438
ment team devises and executes a comprehensive plan
50 UNIT I The Nature of Mental Health and Mental Illness

As a result of deinstitutionalization, many patients skills are used to decrease hospital stays and increase the
who were unable to live independently were discharged functionality of the patient within the home. Individuals
from state hospitals to intermediate- or skilled-care who most benefit from in-home mental health care
nursing facilities. The use of nursing homes for resi- include patients with chronic, persistent mental illness
dential care is controversial because many of these facil- or patients with mental illness and co-morbid medical
ities lack mental health services. Residential care in conditions that require ongoing monitoring.
nursing homes varies from state to state. If a facility In-home mental health care services rely on the skills
serves a primarily geriatric population, placement of of the mental health nurse in providing ongoing assess-
younger persons there can be problematic. If a facility ment and implementing a comprehensive, individual-
with more than 16 beds is engaged primarily in provid- ized treatment plan of care. Components of the care
ing diagnosis, treatment, or care of persons with mental plan and the ongoing assessment include data on men-
disorders (including medical attention, nursing care, tal health status, the environment, medication compli-
and related services), it is designated by the federal gov- ance, family dynamics and home safety, supportive psy-
ernment as an institution for mental disease (IMD). A chotherapy, psychoeducation, coordination of services
Medicare-certified facility having more than 16 beds delivered by other home care staff, and communication
and at least 50% of residents with a mental disorder is of clinical issues to the patients psychiatrist. In addi-
also considered an IMD. An IMD does not qualify for tion, the plan should address care related to collecting
matching federal Medicaid dollars, which means that laboratory specimens (blood tests) and crisis interven-
the state has principal responsibility for funding inpa- tion to reduce rehospitalization (see Box 5-1).
tient psychiatric services (Centers for Medicaid and
Medicare Services, 2002). Outpatient Care
Nursing plays an important role in the care of people
who have severe and persistent mental illnesses and who Outpatient care is a level of care that occurs outside of
require long-term stays at residential treatment facili- a hospital or institution. Outpatient services usually are
ties. Nurses provide basic psychiatric nursing care with a less intensive and are provided to patients who do not
focus on psychoeducation, basic social skills training,
aggression management, activities of daily living (ADLs)
training, and group living. Education on symptom man-
agement, understanding mental illnesses, and medica-
tion is essential to recovery. The Scope and Standards of Reaching Out to Elderly With Psychiatric Illness
PsychiatricMental Health Nursing Practice guide the
Rabins, P. V., et al. (2000). Effectiveness of a nursing-based
nurse in delivering patient care (American Nurses outreach program for identifying and treating psychiatric
Association, American Psychiatric Nurses Association, illness in the elderly. Journal of the American Medical Asso-
International Society of PsychiatricMental Health ciation, 283(21), 28022809.
Nurses 2000). See Chapter 6. THE QUESTION: This study asked whether a nurse-based
mobile outreach program for seriously mentally ill
elderly persons is more effective than usual care in
Respite Residential Care reducing levels of depression, psychiatric symptoms,
and undesirable moves (nursing home placement evic-
Sometimes families of a person with mental illness who tion, board and care placement).
lives at home may be unable to provide care continu- METHODS: A prospective randomized trial was con-
ously. In such cases, respite residential care can provide ducted in six urban public housing sites for elderly per-
short-term necessary housing for the patient and peri- sons in Baltimore, Maryland. A total of 945 (83%) of
1,195 residents underwent screening for psychiatric ill-
odic relief for the caregivers.
ness. Among those screened, 342 screened positive
and 603 screened negative. Residents in three build-
In-home Mental Health Care ings were randomized to receive the PATCH model
intervention, which included educating building staff
If at all possible, a person with a mental illness lives at to be case finders, performing assessment in resident
home, not a residential treatment setting. Choices, not apartments, and providing care when indicated. Resi-
dents in the other three buildings were randomized to
placement; physical and social integration, not segre- receive usual care.
gated and congregate grouping by disability; and indi- FINDINGS: At 26 months, people with psychiatric diag-
vidualized flexible services and support, not standardized noses at the intervention sites had significantly lower
levels of service, are the goals. When a person can live at depression and psychiatric symptom scores than did
home but outpatient care does not meet the treatment those at the nontreatment comparison sites.
IMPLICATIONS FOR NURSING: This research supports the
needs, in-home mental health care may be provided. effectiveness of home visits and providing education to
Many people prefer home care treatment (Wise, 2000). the support network as well as to patients.
In this setting, direct patient care and case management
CHAPTER 5 Mental Health Care in the Community 51

require inpatient, residential, or home care environ- Other Services Integrated into a
ments. Many patients enroll in outpatient services Continuum of Care
immediately upon discharge from an inpatient setting.
Within the continuum of care, other outpatient services
This promotes community reintegration, medication
may be received separately or simultaneously within var-
management and compliance, and symptom manage-
ious settings. They involve discrete services and patient
ment. Patients gain the right to choose home as a place-
variables. Table 5-1 defines the six levels of service vari-
ment option, become more involved in after-care
ables along the continuum. Table 5-2 outlines the patient
support services individualized to the care they need,
and become more socially integrated into society
(Friedrich, Hollingsworth, Hradek, & Culp 1999). Out-
patient services are provided by private practices, clin- Outpatient Detoxification
ics, and community mental health centers.
Except for situations involving severe or complicated
withdrawal, alcohol and drug rehabilitation is now
Intensive Outpatient Programs almost exclusively outpatient based. Community and
domiciliary-based substance detoxification services
The primary focus of intensive outpatient programs have proved effective in providing accessible and con-
is on stabilization and relapse prevention for highly vul- venient treatment options, with only a few severely
nerable individuals who function autonomously on a alcohol-dependent patients requiring hospitalized
daily basis. People who meet these criteria have detoxification (Bennie, 1998). Outpatient detoxifica-
returned to their previous lifestyle, eg, interacting with tion is a specialized form of partial hospitalization for
family, resuming work, or returning to school. Atten- patients requiring medical supervision. During the
dance in this type of program benefits individuals who initial withdrawal phase, use of a 23-hour bed may be
still require frequent monitoring and support within a a treatment option, depending on the stage of with-
therapeutic milieu that enables them to remain con- drawal and the type of addictive substance used. Or
nected to the community. The duration of treatment the patient may be required to attend a detoxification
and level of services rendered are based on the patients program 4 to 5 days per week until symptoms resolve.
immediate needs. Treatment duration usually is time The length of participation depends on the severity of
limited, with sessions offered 3 to 4 hours per day and addiction.
2 to 3 days per week. The treatment activities of the Outpatient detoxification includes the 12-step recov-
intensive outpatient program are similar to those ery model, such as Alcoholics Anonymous (AA) and
offered in PHPs, but PHPs emphasize social skills Narcotics Anonymous (NA), which provides outpatient
training, whereas intensive outpatient programs teach involvement with professionals experienced in addic-
patients about stress management, illness, medication, tion counseling. It encourages abstinence and provides
and relapse prevention. training in stress management and relapse prevention.
Ala-Non and Ala-Teen rely on 12-step support for fam-
ilies, who are usually included in the treatment program
Supportive Employment (Enoch & Goldman, 2002).
Supportive employment services assist individuals to
find work; assess individuals skills, attitudes, behav-
In-home Detoxification
iors, and interest relevant to work; offer vocational
rehabilitation or other training; and provide work There is an increasing shift toward outpatient detoxifi-
opportunities. Supportive employment programs are cation of patients with alcohol addiction. Although a
new, highly individualized, and competitive. They pro- reported 15 million Americans have alcohol problems
vide on-site support and job-coaching services on a and more than 100,000 deaths are attributed to alco-
one-to-one basis. They occur in real work settings and holism, fewer than 5% of people with alcohol problems
are used for patients with severe mental illnesses. The receive formal treatment (Enoch & Goldman, 2002).
primary focus is to maintain attachment between the Except for situations involving severe or complicated
mentally ill person and the work force. Transitional withdrawal or for adolescents, alcohol detoxification
employment programs offer the same support as sup- may be implemented on an outpatient basis. In such
ported employment programs, but the employment is cases, the nurse is required to visit the patient daily for
temporary. This type of work has a time frame agreed medication monitoring during the patients first week of
on by the employer and the participant. The person sobriety. Daily visits are necessary until the patient is in
works at the temporary position until he or she can find medically stable condition. Referrals may come from
permanent, competitive employment (Bustillo, Lau- primary care physicians, court mandates, or employee
rillo, Horan, & Keith, 2001). assistance programs.
52 UNIT I The Nature of Mental Health and Mental Illness

Table 5.1 The Continuum of Behavioral Health Care: Service Variables

Multimodal Intermediate Acute Inpatient

Primary Care Outpatient Outpatient Ambulatory Ambulatory Residential

Service Function
Provision of Decrease Coordinated Stabilization, Crisis Provision of
screening, symptoms treatment to symptom stabilization 24-hour
early related to mild prevent decline reduction, and and acute monitoring,
identification, to moderate in functioning prevention of symptom supervision,
and education; disorders; when relapse reduction; and intensive
medication maintenance of outpatient alternative to intervention
management stability service cannot and prevention
(patient with meet patient of hospitali-
severe need zation
Scheduled Programming
Incorporated Sessions as A minimum of 4 Minimum of 34 Minimum of 4 24 hours per day
with visits for needed with hours per week hours per day, hours per day
general maximum of 3 at least 23 scheduled 47
medical care hours per week days per week days
Crisis Backup Availability
Decision-assis- On-call coverage A 24-hour crisis A 24-hour crisis An organized, 24-hour-per-day
tance pro- and consulta- and consulta- integrated 24- staffing with
grams; estab- tion service tion service hour crisis personnel
lished liaison backup system skilled in crisis
with behavioral with immediate intervention
health spe- access to cur-
cialty care rent clinical
and treatment
Medical Involvement
Not applicable Medical Medical Medical Medical Medical
consultation consultation consultation supervision management
Regular Regular Capable of Capable of Capable of Capable of
appointments appointments admitting admitting admitting admitting
scheduled scheduled within 72 within 48 within 24 within 1 hour
within 35 within 35 hours hours hours
days days
Relationship Within the Active Active Preplanned, Preplanned,
between session and therapeutic; therapeutic consistent, and consistent, and
provider and relationship primarily within therapeutic; therapeutic
patient between within home treatment primarily within
provider and and community setting and within treatment
patient home and treatment setting
community setting
Minimal structure Minimal structure Individualized Regularly High degree of High degree of
via scheduled via scheduled and scheduled, structure and structure,
appointments appointments coordinated individualized scheduling security, and
Responsibility and Control
Patient functions Patient functions Monitoring and Monitoring and Staff aggressively Staff assumes
independently independently support mostly support shared monitors and responsibility
with support with support by patient, with patient, supports for safety and
from family from family family, and family, and patients and security of
and community and community support system support system family patient
(continued )
CHAPTER 5 Mental Health Care in the Community 53

Table 5.1 The Continuum of Behavioral Health Care: Service Variables (continued )

Multimodal Intermediate Acute Inpatient

Primary Care Outpatient Outpatient Ambulatory Ambulatory Residential

Service Examples
Regular medical Outpatient office After-care; Psychosocial Day hospital; Acute inpatient
check-up visit; speciality clubhouse rehabilitation; intensive in- unit; crisis
group; programs day-treatment home crisis stabilization
psychotherapy programs; intervention; bed
intensive outpatient
outpatient; 23- detoxification;
hour respite 23-hour
beds observation

From http://www.aabh.org

Assertive Community Treatment (basic language), vocational, self-care (grooming, bod-

ily care, feeding), and social skills that help patients
The assertive community treatment (ACT) model is
function in the community. These programs promote
a multidisciplinary clinical team approach providing
increased functioning with the least necessary ongoing
24-hour, intensive community services in the individuals
professional intervention. Psychiatric rehabilitation
natural setting that helps individuals with serious mental
provides a highly structured environment, similar to a
illness live in the community. The ACT approach pro-
PHP, in a variety of settings, such as office buildings,
vides a comprehensive range of treatment, rehabilitation,
hospital outpatient units, and freestanding structures.
and supportive services to help patients meet the require-
The mental health nurses role continues to adapt to
ments of community living. One goal of ACT is to
the changing needs of persons with mental illness. As
reduce recurrences of hospitalization. The rationale for
behavioral health care delivery occurs more in outpa-
ACT is that concentrating services for high-risk patients
tient settings, so does the work of the nurse. Most reha-
within a single multiservice team enhances continuity
bilitation programs have a full-time nurse who func-
and coordination of care, improving both the quality of
tions as part of the multidisciplinary team.
care and its cost-effectiveness (Bustillo et al., 2001). Ini-
The psychiatricrehabilitation nurse is concerned
tially, patients receive frequent direct assistance while
with the holistic evaluation of the person and with
reintegrating into the community. Emergency telephone
assessing and educating the patient on compliance
numbers, or crisis numbers, are shared with patients and
issues, necessary laboratory work, and environmental
their families in the event that immediate assistance is
and lifestyle issues. This evaluation assesses the five
needed. The ACT program is staffed 24 hours a day for
dimensions of a personphysical, emotional, intellec-
emergency referral. Mobile treatment teams often are a
tual, social, and spiritualand emphasizes psychiatric
part of the ACT model and provide assertive outreach,
rehabilitation. Issues of psychotropic medication
crisis intervention, and independent-living assistance
evaluation of response, monitoring of side effects, and
with linkage to necessary support services.
connection with pharmacy servicesalso fall to the
Psychiatric Rehabilitation and
the Nurses Role Clubhouse Model
Psychiatric rehabilitation programs, also termed The clubhouse model is a form of psychosocial reha-
psychosocial rehabilitation, focus on the reintegration bilitation that aims to reintegrate a person with mental
of people with psychiatric disabilities into the commu- illness into the community. Fountain House in New
nity through work, education, and social avenues while York city developed the clubhouse model in the 1940s.
addressing their medical and residential needs. The Its belief system involves membership and belonging
goal is to empower patients to achieve the highest level being wanted, needed, and expected. Additional funda-
of functioning possible. Therapeutic activities or inter- mental beliefs include: all members of society can be
ventions are provided individually or in groups. They productive; every human aspires to achieve gainful
may include development and maintenance of daily employment; humans require social contacts, and pro-
and community-living skills, such as communication grams are incomplete if they offer recreational, social,
54 UNIT I The Nature of Mental Health and Mental Illness

Table 5.2 The Continuum of Behavioral Health Care: Patient Variables

Multimodal Intermediate Acute Inpatient

Primary Care Outpatient Outpatient Ambulatory Ambulatory Residential

Level of Functioning
At-risk, Mild to moderate Moderate Marked Severe Significant
subclinical, impairment in impairment in impairment in impairment in impairment
or mild at least one at least one at least one multiple areas with inability
impairment area of daily area of daily area of daily of daily life to maintain
life life life activities of
daily living
without 24-
hour assistance
Psychiatric Signs and Symptoms
At-risk, Mild to moderate Moderate Moderate to Severe to Disabling
subclinical symptoms symptoms severe disabling symptoms
presentation, related to acute related to acute symptoms symptoms related to acute
or mild condition or condition or related to acute related to acute condition or
symptoms exacerbation of exacerbation of condition or condition or exacerbation of
related to severe or severe or exacerbation of exacerbation of severe or
behavioral persistent persistent severe or severe or persistent
health disorder disorder disorder persistent persistent disorder
disorder disorder
Risk, Dangerousness
At-risk or limited Limited, transient Mild instability Moderate Marked instability Significant
with minimal dangerousness with limited instability and/or danger to self
need for and minimal dangerousness and/or dangerousness or others
confinement risk for and low risk for dangerousness with high risk
confinement confinement with some risk for confinement
for confinement
Commitment to Treatment Follow-through
Ability to form Ability to form Ability to sustain Limited ability to Inability to form Inability to form
and maintain and sustain treatment form extended more than treatment
treatment treatment contract with treatment initial contract;
contract contract intermittent contract; treatment requires
monitoring and requires contract; constant
support frequent requires close monitoring and
monitoring and monitoring and supervision
support support
Social Support System
Ability to form Ability to form Ability to form Limited ability Impaired ability Insufficient
and maintain and maintain and maintain to form to access or resources
relationships relationships relationships relationships or use caregiver, and/or inability
outside of outside of outside of seek support family, or to access or
treatment treatment treatment community use caregiver,
support family, or

From http://www.aabh.org/public.

and vocational opportunities but neglect housing needs chiatric illnesses with minimal assistance from mental
(Bustillo et al., 2001). health professionals. Patients who join a clubhouse are
Fountain House seeks to improve its members qual- voluntary members, and they are expected to help oper-
ity of life by organizing daytime support, providing ate the house. Membership is not time limited. Gener-
meaningful daytime activities, and offering opportuni- ally, members do not live in the clubhouse; however, the
ties for paid labor. Clubhouses are a unique treatment clubhouse may have formed relationships with providers
form because they are entirely run by patients with psy- of low-cost housing. Open 365 days a year, services are
CHAPTER 5 Mental Health Care in the Community 55

available any time an individual needs them. Fountain Nurses become involved in relapse prevention pro-
House remains the model for other clubhouses. Today, grams in several different ways. They can act as a refer-
about 200 clubhouses are active across the United ral source for the programs, trainer or leader of the pro-
States. grams, or an after-care source for patients when the
Members of the clubhouse are expected to assist with program is completed. In addition, mental health
household chores, follow instructions of others, volun- nurses can help the patient and family by promoting
teer for tasks, and be punctual. Most new members optimism, sticking to goals and aspirations, and focus-
begin vocational training by participating in work units ing on individual strengths.
at the clubhouse, such as janitorial services, meal prepa-
ration, clerical services, public relations, and mainte-
nance services. As members improve, they may move on Alternative Housing Arrangements
to transitional employment, which is part-time paid Another service related to mental health care involves
work outside the clubhouse setting. When vocational housing. Patients with psychiatric disabilities who are
skills have been acquired, members move into compet- homeless are a vulnerable population. One of the largest
itive employment. hurdles to overcome in treating the severely mentally ill
The role of the staff person in this unique setting is patient is finding appropriate housing that will meet the
different than in other inpatient and outpatient settings. patients immediate social, financial, and safety needs.
Because a clubhouse is operated by its members, staff The course of chronic mental illness, as symptoms wax
roles are limited. The focus of the staff member is to and wane, preys on the stamina of families and care-
accentuate the skills and performance of the members. givers. The prevalence of mental illness among home-
The employee works with, rather than for, the member. less people may range as high as 35% (Tsemberis &
The clubhouse model requires the employee nurse to Eisenberg, 2000). Most individuals live in some form of
function as a member of the clubhouse and supervised or supported community living situation,
be active in all components of the program. Although the which ranges from highly supervised congregate settings
nurse has expertise in pathology of mental illness, the to independent apartments. Those who lack the
focus is strictly on the individuals recovery. Case man- resources to find housing suffer higher rates of substance
agement in the clubhouse setting requires staff to partic- abuse, physical illness, incarceration, and victimization
ipate in work units or transitional employment settings (Tsemberis & Eisenberg). The following discussion
with members. More commonly, a nurse plays a pivotal focuses on four models of alternative housing and the
role in urging a patients participation in a clubhouse pro- role of the nurse. These include personal care homes,
gram and may actually refer patients to the program. board-and-care homes, supervised apartments, and
therapeutic foster care.
Relapse Prevention After-Care
Personal Care Homes
Relapse of mental illness symptoms and substance abuse
is the major reason for rehospitalization in the United Personal care homes operate within houses in the com-
States. Relapse is the recurrence or marked increase in munity. Usually, 6 to 10 people live in one house, with
severity of the symptoms of a disease, especially after a a health care attendant providing 24-hour supervision
period of apparent improvement or stability. Many to assist with medication monitoring or other minor
issues affect a persons well-being. First and foremost, activities, including transportation to appointments,
patients must feel that their lives are meaningful and meals, and self-care skills. The clientele generally are
worthwhile. Homelessness and unemployment create heterogenous and include elderly, mildly mentally
tremendous threats to a persons identity and feelings of retarded, and mentally ill patients whose severity of ill-
wellness. ness is chronic and subacute. Most states require these
Much work has gone into relapse-prevention pro- homes to be licensed.
grams for the major mental illnesses and addiction dis-
orders. Relapse prevention programs involve both
Board-and-Care Homes
patients and families and seek to (1) educate them about
the illness, (2) enable them to cope with the chronic Board-and-care homes provide 24-hour supervision
nature of the illness, (3) teach them to recognize early and assistance with medication, meals, and some self-
warning signs of relapse, (4) educate them about pre- care skills. Individualized attention to self-care skills
scribed medications and the need for compliance, and and other ADLs generally is not available. These
(5) inform them about other disease management homes are licensed to house 50 to 150 people in one
strategies (i.e., stress management, exercise) in prevent- location. Rooms are shared, with two to four occupants
ing relapse. per bedroom.
56 UNIT I The Nature of Mental Health and Mental Illness

Therapeutic Foster Care cally rising as a large proportion of the populace needs
either nursing home care or home health visits (Bartels,
Therapeutic foster care is indicated for patients in need of
Levine, & Shea, 1999). Managed care companies are
a family-like environment and a high level of support.
large companies that contract with private employers,
Therapeutic foster care is available for child, adolescent,
health care plans, and government agencies to manage
and adult populations. This level of care actually places
mental health care on an at-risk basis (Mechanic,
patients in residences of families specially trained to han-
1999). The goals of managed care organizations are
dle individuals with mental illnesses. The training usually
to increase access to care and to provide the most
consists of crisis management, medication education, and
appropriate level of services in the least restrictive set-
illness education. The family provides supervision, struc-
ting. Efforts focus on providing more outpatient and
ture, and support for the individual living with them. The
alternative treatment programs and avoiding costly
person who receives these services shares the responsibil-
inpatient hospitalizations. When properly conducted
ity of completing household chores and may be required
and administered, managed care allows patients better
to attend an outpatient program during the day.
access to quality services while using health care dollars
Supervised Apartments Today, managed behavioral health care has succeeded
in standardizing admissions criteria, reducing length of
In a supervised apartment setting, individuals live in
patient stay, and directing patients to the proper level of
their own apartments, usually alone or with one room-
careinpatient and outpatientall while attempting to
mate, and are responsible for all household chores and
control the costs. Across the continuum of care, nurses
self-care. A staff member or supervisor stops by each
encounter managed care organizations in their work
apartment routinely to evaluate how well the patients
with patients, and they must be familiar with the poli-
are doing, make sure they are taking their medications,
cies, procedures, and clinical criteria established by
and ensure that the household is being maintained. The
managed care organizations. As managed care continues
supervisor may also be required to mediate disagree-
to regulate the delivery of mental health care, services
ments between roommates.
become more limited, and as growing numbers of
patients with severe mental illness reach older age,
Role of the Nurse in Alternative Housing increasing demands are placed on the mental health care
The professional registered nurse typically is not system to accommodate the needs of this population
employed in alternative housing settings. However, (Auslander & Jeste, 2002). Many older adults with men-
nurses play a pivotal role in the successful reintegration tal illness currently receive no community services other
of patients from more restrictive inpatient settings into than medication monitoring. Increasing home health
society. Nurses are employed in partial hospitalization care services for people with mental illness is an impor-
programs, inpatient units, and as case managers. There- tant alternative to institutionalization.
fore, nurses act as liaisons for the residential placement
of patients. Nurses are employed directly as consultants THE NURSES ROLE IN MANAGED CARE
or provide consultation to treatment teams during dis-
charge planning in determining appropriate outpatient Because of shorter inpatient stays, the psychiatric
settings, evaluating medication follow-up needs, and mental health nurses must maximize the short time they
making recommendations for necessary medical care have to educate the mental health patients about their
for existing physical conditions. Feedback from the res- illness, available community resources, and medications
idential care providers and follow-up by the treatment to minimize the potential for relapse. The nurse should
team regarding the patients response to treatment focus on teaching social skills and self-reliance and cre-
interventions are essential. Rehospitalization can be ating empowering environments that, in turn, build
curtailed if the residential care operators identify and self-confidence.
forward specific problems to the treatment teams. The interface of psychiatricmental health nurses
Patient interventions can be modified in an outpatient with managed care organizations is primarily in the
setting. form of providing information regarding the progress
of individual patients to the managed care organization
utilization managers. In many instances, managed care
Managed Care organizations hire psychiatric nurses for crisis interven-
Managed care continues to tailor the delivery of health tion and case management. Nurses also may advocate
care in all settings. The concept of managed care for funding to place patients in other portions of the
emerged in efforts to coordinate patient care efficiently continuum and be required to provide substantiating
and cost-effectively. Federal expenditures are dramati- documentation and information regarding the medical
necessity of the transfer.
CHAPTER 5 Mental Health Care in the Community 57

PUBLIC AND PRIVATE COLLABORATION from one care unit to another. The processes of referral
and transfer to other levels of care are integral for effec-
Managed Medicaid behavioral health care is an
tive use of services along the continuum. These processes
emerging reform within the managed care arena.
are based on the individuals assessed needs and the orga-
With Medicaid expenditures doubling since 1988,
nizations capability to provide the care. Figure 5-1
many states are actively involved in Medicaid reforms
depicts the process of assessment, treatment, transfer, and
(Gold & Mittler, 2000). These reform efforts have
referral when considering appropriate levels of care.
been characterized by many publicprivate sector col-
laborations. What impels this movement is the intent
to preserve the strength of public mental health sys- DISCHARGE PLANNING
tems while bringing the technologies and strengths of
Discharge planning begins upon admission of the indi-
the private sector to public mental health reform
vidual at any level of health care. Most facilities have a
efforts. The need for publicprivate collaboration
written procedure for the discharge planning. This pro-
prompted the National Association of State Mental
cedure often provides for a transfer of clinical care
Health Program Directors (NASMHPD), an organi-
information when a person is referred, transferred, or
zation representing the 55 state and territorial public
discharged to another facility or level of care. All dis-
mental health systems, and the American Managed
charge planning activities should be documented in the
Behavioral Healthcare Association (AMBHA), an
clinical record, including the patients response to pro-
organization representing private managed behavioral
posed after-care treatment, follow-up for psychiatric
health care firms, to set guidelines for this type of
and physical health problems, and discharge instruc-
joint venture. Nurses can expect to see more strategic
tions. Medication education, fooddrug interactions,
alliances and joint ventures between the public and
drugdrug interactions, and special diet instructions (if
private sectors.
applicable) are extremely important in ensuring patient
safety. Discharge planning is an integral part of psychi-
atric nursing care and should be considered a part of the
Nursing Practice in The psychiatric rehabilitation process. In addressing an indi-
viduals biopsychosocial needs, one can coordinate
Continuum of Care after-care and discharge interventions for optimal out-
Throughout this chapter, the nurses role in different comes. The overall goal of discharge planning is to pro-
settings has been explained. Regardless of the situation vide the patient with all the resources he or she needs to
or setting, the nurse conducts an assessment at the point function as independently as possible in the least
of first patient contact. The individuals needs are then restrictive environment and to avoid rehospitalization.
matched with the most appropriate setting, service, or Recognizing that individuals may have psychiatric reha-
program that will meet those needs. bilitation needs in more than one domain, Hochberger
Choosing the level of care begins with an initial (1995) developed a discharge checklist. She stipulated that
assessment of the patients biologic, psychological, and six domains are pertinent to the successful discharge of
social functioning to determine the need for care, the psychiatric patients: (1) medications, (2) ADLs, (3) mental
type of care to be provided, and the need for additional health after-care, (4) residence, (5) follow-up in physical
assessment. The nurse must discuss with the patient health care, and (6) special education, financial, or other
suicidal and homicidal thoughts. Nurses also need to needs. Hochbergers discharge checklist (Box 5-2) does not
consider financial issues because funding considerations substitute for a nursing assessment or any other profes-
may play a part in placement options. Other factors sional assessment. Instead, it is a tool to facilitate interdis-
affecting the selection of care include the type of treat- ciplinary planning for after-care and discharge.
ment the individual seeks, his or her current physical The nurse can optimize discharge plan compliance by
condition and ability to consent to treatment, and the involving the patient at various levels in the psychiatric
organizations ability to provide direct care or to deflect milieu. Because patients with mental illnesses may have
care to another service provider. limited cognitive abilities and residual motivational and
Based on the results of the initial assessment, the nurse anxiety problems, nurses should explain in detail all after-
may admit the patient into services provided at that care plans and instructions to the patient. It is helpful also
agency or initiate a referral or transfer to provide the to schedule all after-care appointments before the patient
intensity and scope of treatment required by the individ- leaves the facility. The nurse should then give the patient
ual at that point in time (Fig. 5-1). Referral involves send- written instructions about where and when to go for the
ing an individual from one clinician to another or from appointment and a contact persons name and telephone
one service setting to another for care or consultation. number at the after-care placement. Finally, the nurse
Transfer involves formally shifting responsibility for the should review emergency telephone numbers and con-
care of an individual from one clinician to another or tacts and medication instructions with the patient.
Continuum flowchart Selection of care flowchart

Nurse Point of
plans the care contact with
process for individual

Conduct data
of the

Initial Refer
screening or
assessment Transfer
program plan
services for
within call Provide Need more
setting services data? No


Develop a Analyze
referral, Further data gathered data
transfer, or Assessment

Admit to setting (for Needs identified

example, inpatient, and prioritized
Provide No residential, partial
continuing Discharge? hospitalization,
care outpatient)

Yes Yes further?

Transfer or
Release refer to other
from system settings/ Need
Care, treat Treatment
services treatment? Discharge
or refer Yes No decisions

FIGURE 5.1 Continuum and selection of care flowchart.

CHAPTER 5 Mental Health Care in the Community 59

BOX 5.2 settings, nurses function as members of a multidisci-

Mental Health Discharge Checklist plinary team and assume responsibility for assess-
ment and selection of level of care, education, evalu-
Name: ation of response to treatment, referral or transfer to
Patient ID number:
a more appropriate level of care, and discharge plan-
Medication ning. Discharge planning provides patients with all
Medication supply or prescription the resources they need to function effectively in the
Number of days medication supplied for
Medication educationdrug dosage, time, how to take
community and avoid rehospitalization.
Special instructions Managed care influences the continuum of care
Activities of Daily Living by standardizing admissions criteria and clinical
Hygiene instructions guidelines for practitioners, encouraging alternative
Activities requiring assistance treatment programs that avoid costly inpatient hos-
Safety instructions pitalizations, and providing consumers with an inte-
Work, work training grated network of credentialed specialty behavioral
Activity, rest
health providers to help meet their needs within the
Special instructions
Mental Health After-care
Psychiatrist or therapist
Community mental health center or agency CRITICAL THINKING CHALLENGES
Nurse specialist or visiting nurse
Psychiatric social worker 1 Define the continuum of care and discuss the impor-
Community support group tance of the least restrictive environment.
Day care program referral
2 Differentiate the role of the nurse in each of the fol-
Residence lowing continuum settings:
Boarding home a. Crisis stabilization
Group home
b. In-home detoxification
Nursing home c. Partial hospitalization
Family residence d. Assertive community treatment
Residential health care facility 3 Compare alternative housing arrangements, includ-
Own home or lives alone ing personal care homes, board-and-care homes,
therapeutic foster care, and supervised apartments.
Follow-up Medical Care
4 Envision using more than one service at a time.
Appointment with medical doctor
What combinations of services could benefit patients
Visiting nurse or nurse practitioner
Medical clinic appointment and families?
Diet or fluid instructions
Dental care REFERENCES
Special Needs American Nurses Association, American Psychiatric Nurses Associa-
Sexually transmitted diseases and AIDS prevention tion. (2000). International Society for Psychiatric-Mental Health
education Nursing Practice. The scope and standards of psychiatric-mental health
Symptom recognition education nursing practice. Washington, DC: American Nurses Publishing.
Transportation needs Auslander, L., & Jeste, D. (2002). Perceptions of problems and needs
Financial assistance for service among middle-aged and elderly outpatients with schiz-
Additional Comments ophrenia and related psychotic disorders. Community Mental Health
Journal, 38(5), 391402.
From Hochberger, J. M. (1995). A discharge checklist for psychiatric
Bartels, S., Levine, K., & Shea, D. (1999). Community-based long-
patients. Journal of Psychosocial Nursing, 33(12), 36. term care for older persons with severe and persistent mental illness
in an era of managed care. Psychiatric Services, 50(9), 11891197.
Bustillo, J. R., Laurillo, J., Horan, W. P., & Keith, S. J. (2001). The psy-
chosocial treatment of schizophrenia. American Journal of Psychiatry,
SUMMARY OF KEY POINTS 158(2), 163175.
Centers for Medicaid and Medicare Services. (May 15, 2002). Institutions
The continuum of care is a comprehensive system for mental disease. Author: Baltimore, MD. Available:
of services and programs designed to match the www.cms.hhs.gov/medicaid/services/imd.asp. Accessed: June 29,
needs of the individual with the appropriate treat- 2003.
Chan, S., Mackenzie, A., Tin-Fu, N. G. D., & Ka-yi Leung, J. (2000).
ment in settings that vary according to levels of ser- An evaluation of the implementation of case management in the
vice, structure, and intensity of care. community of psychiatric nursing service. Journal of Advanced
The psychiatricmental health nurses specific Nursing, 31(1), 144156.
responsibilities vary according to the setting. In most Davison, G. (2000). Stepped care: Doing more with less? Journal of
Consulting and Clinical Psychology, 68(4), 580585.
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Enoch, M., & Goldman, D. (2002). Problem drinking and alcoholism. Rabins, P. V., Black, B. S., Roca, R., German, P., McGuire, M., Robbins,
American Family Physician, 65(3), 441448; 449450. B., Rye, R., & Brant, L. (2000). Effectiveness of a nurse-based out-
Friedrich, R., Hollingsworth, B., Hradek, E., et al. (1999). Family reach program for identifying and treating psychiatric illness in the
and client perspectives on alternative residential settings for per- elderly. Journal of the American Medical Association, 283(21),
sons with severe mental illness. Psychiatric Services, 50(4), 28022809.
509514. Sturm, R., & Bao, Y. (2000). Psychiatric care expenditures and length
Gold, M., & Mittler, J. (2000). Medicaid-complex goals: Challenges for of stay: Trends in industrialized countries. Psychiatric Services,
managed care and behavioral health. Health Care Financing Review, 51(3), 7.
22(2), 85101. Tsemberis, S., & Eisenberg, R. (2000). Pathways to housing: Supported
Hochberger, J. (1995). A discharge checklist for psychiatric patients. housing for street-dwelling homeless individuals with psychiatric
Journal of Psychosocial Nursing and Mental Health Services, 33(12), disabilities. Psychiatric Services, 51(4), 487493.
3538. Ward, M., Armstrong, C., Lelliott, P., & Davies, M. (1999). Training,
Hughes, W. (1999). Managed care, meet community support: Ten rea- skills and caseloads of community mental health support workers
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For challenges and updates, go to www.connection.lww.com or refer to the CD-ROM in the back of this book.

Principles of

Psychiatric Nursing
Mary Ann Boyd

After studying this chapter, you will be able to:
Explain the biopsychosocial model as a conceptual framework for understanding
and treating mental health problems.
Delineate the scope and standards of psychiatricmental health nursing practice.
Discuss selected challenges of psychiatricmental health nursing.
Discuss the basic tools of psychiatric nursing.
Identify ethical frameworks and principles used in the practice of psychiatric nursing.
Discuss the impact of psychiatricmental health nursing professional organizations
on practice.

advanced practice psychiatricmental health nurse autonomy basic level of practice
beneficence clinical decision making critical pathways interdisciplinary approach
interdisciplinary treatment plan multidisciplinary approach standards of care

biopsychosocial model nursing process

64 UNIT II Principles of Psychiatric Nursing

T his chapter introduces the biopsychosocial model

as the organizational thread for the rest of the
book. The scope of practice of the psychiatric nurse is
then explained, followed by a discussion of the stan-
dards of care that serve as a basis of practice. These Socio-
standards are integral to the understanding of the day- Biologic biologic Social
to-day practice of psychiatricmental health nursing
and should be familiar to any student involved in men-
tal health nursing practice. The discussion of the chal- psycho-
lenges of psychiatric nursing sets the stage for the rest social
Psycho- Psycho-
of the text through an overview of the dynamic nature
biologic social
of this specialty.

The Biopsychosocial Psychological

Model in Psychiatric
Mental Health Nursing
Contemporary psychiatric nursing uses theories from
the biologic, psychological, and social sciences as a basis
FIGURE 6.1 Biopsychosocial model. (Adapted from
of practice. This holistic approach, referred to as the Abraham, I., Fox, J., & Cohen, B. [1992]. Integrating the bio
biopsychosocial model, is necessary to truly understand into the biopsychosocial: Understanding and treating bio-
the individual who has a mental disorder or emotional logical phenomena in psychiatric mental health nursing.
problems. The model is ideal for organizing nursing Archives of Psychiatric Nursing, 6[5], 298.)
care and is used throughout this text for organizing the-
oretic knowledge and the nursing process.
and responses to mental disorders. Although mental
KEY CONCEPT The biopsychosocial model con- disorders have a biological component, they are often
sists of three separate but interdependent domains: manifested in psychological symptoms and physical
biologic, psychological, and social. Each domain has an changes. The person with a thought disorder may have
independent knowledge and treatment focus but can bizarre behavior that needs to be interpreted within the
interact and be mutually interdependent with the other context of the neurobiologic dysfunction of the mental
domains (Fig. 6-1). disorder.
Many psychiatric nursing interventions are based on
knowledge generated within this domain. Cognitive
approaches, behavior therapy, and patient education are
The biologic domain consists of the biologic theories all based on the use of theories from the psychological
related to mental disorders and problems as well as all domain. These interventions are explained in Unit 3.
of the biologic activity related to other health problems. Psychiatricmental health interventions are also based on
Today, there is evidence of neurobiologic changes in the use of interpersonal communication techniques,
most psychiatric disorders. Within this domain, there which require nurses to develop awareness of their own,
are also theories and concepts used as a basis of inter- as well as their patients, internal feelings and behavior.
ventions focusing on the patients physical functioning, For mental health nurses, understanding their own and
such as exercise, sleep, and adequate nutrition. In addi- their patients intrapersonal dynamics and motivation is
tion, the neurobiologic theories also serve as a basis for critical in developing a therapeutic relationship and moti-
understanding and administering pharmacologic agents vating patients to learn and understand their disorders
(see Chapters 8 and 9). and participate in their management. Motivating patients
to engage in learning activities best occurs within the con-
text of a therapeutic relationship (see Chapter 10).
The psychological domain contains the theoretical basis
of the psychological processesthoughts, feelings, and
behavior (intrapersonal dynamics) that influence ones The social domain includes theories that account for the
emotion, cognition, and behavior. The psychological influence of social forces encompassing the patient, fam-
and nursing sciences generate theories and research ily, and community within cultural settings. This knowl-
that are critical in understanding patients symptoms edge base is generated from social and nursing sciences
CHAPTER 6 Contemporary Psychiatric Nursing Practice 65

and explains the connections within the family and com- BOX 6.1
munities that affect the mental health and treatment of
Psychiatric Mental Health Nursings
people with mental disorders. Psychiatric disorders are
Phenomena of Concern
not caused by social factors, but their manifestations and
treatment can be significantly affected by the society in ACTUAL OR POTENTIAL MENTAL HEALTH PROBLEMS OF
which the patient lives. Family support can actually PATIENTS PERTAINING TO
improve treatment outcomes. Moreover, family factors, Maintaining optimal health and well-being and pre-
including origin, extended family, and other significant venting psychobiologic illness
Self-care limitations or impaired functioning related
relationships, contribute to the total understanding and to mental, emotional, and physiologic distress
treatment of patients. Community forces, including cul- Deficits in the functioning of significant biologic,
tural and ethnic groups within larger communities, emotional, and cognitive systems
shape patients manifestation of disorders, response to Emotional stress or crisis related to illness, pain, dis-
treatment, and overall view of mental illness. ability, and loss
Self-concept and body image changes, developmen-
tal issues, life process changes, and end-of-life
Standards of Care and Problems related to emotions, such as anxiety,
Professional Practice anger, powerlessness, confusion, fear, sadness, lone-
liness, and grief
The practice of psychiatric nursing is regulated by law Physical symptoms that occur along with altered
but guided by standards of care. The legal authority to psychological functioning
Psychological symptoms that occur along with
practice nursing is granted by the states and provinces, altered physiologic functioning
but professional standards of care or professional Alterations in thinking, perceiving, symbolizing,
nursing activities are set by professional nursing organi- communicating, and decision making
zations. The American Nurses Association (ANA) and Difficulties in relating to others
the psychiatric nursing organizations (discussed later in Behaviors and mental states that indicate the
patient is a danger to self or others or has a severe
this chapter) collaborate in specifying the health prob- disability
lems that match the skills of psychiatric nurses and set Symptom management, side effects, and toxicities
standards of care and professional practice. associated with psychopharmacologic intervention
and other aspects of the treatment regimen
Interpersonal, organizational, sociocultural, spiritual,
SCOPE OF PSYCHIATRICMENTAL or environmental circumstances or events that have
HEALTH NURSING AREAS OF CONCERN an affect on the mental and emotional well-being of
the individual, family, or community
The areas of concern for the psychiatricmental health
nurse include a wide range of actual or potential mental From American Nurses Association, American Psychiatric Nurses
health problems, such as emotional stress or crisis, self- Association, International Society of PsychiatricMental Health
Nurses. (2000). Scope and standards of psychiatricmental health
concept changes, developmental issues, physical symp- nursing practice (pp. 2841). Washington, DC: American Nurses
toms that occur with psychological changes, and symp- Publishers.
tom management of patients with mental disorders. To
understand the problem and select an appropriate inter-
vention, integration of knowledge from the biologic,
Each standard has a rationale and measurement crite-
psychological, and social domain is necessary. Box 6-1
ria that are indicators for meeting the standard. The fifth
presents details on the actual and potential mental health
standard, implementation, has several subcategories that
problems of patients to whom psychiatric nurses attend.
specify standards for each intervention. These standards
of care represent the nursing professions commitment to
STANDARDS OF CARE the general public. It is important that nurses know their
practice standards and are able to practice at this level.
The standards of care are organized around the nursing
Nurses ultimately are held accountable for practicing
process and include six components: assessment, diag-
according to their standards. In Canada, nursing stan-
nosis, outcome identification, planning, implementa-
dards are organized into themes (Box 6-3).
tion, and evaluation (Box 6-2).

KEY CONCEPT The nursing process is the basis of STANDARDS OF PROFESSIONAL

clinical decision making and nursing actions (American PERFORMANCE
Nurses Association, American Psychiatric Nurses Asso- Developing and maintaining competency is the
ciation, & International Society of PsychiatricMental
responsibility of a professional psychiatricmental
Health Nurses, 2000).
health nurse. All nurses are expected to achieve
66 UNIT II Principles of Psychiatric Nursing

BOX 6.2
Standards of Care

Standard I. Assessment Standard Vc. Self-care Activities

The psychiatricmental health nurse collects patient health The psychiatricmental health nurse structures interven-
data. tions around the patients activities of daily living to foster
Rationale: self-care and mental and physical well-being.
The assessment interviewwhich requires linguistically Standard Vd. Psychobiologic Interventions
and culturally effective communication skills, interviewing, The psychiatricmental health nurse uses knowledge of
behavioral observation, database record review, and com- psychobiologic interventions and applies clinical skills to
prehensive assessment of the patient and relevant sys- restore the patients health and prevent further disability.
temsenables the psychiatricmental health nurse to Standard Ve. Health Teaching
make sound clinical judgements and plan appropriate
The psychiatricmental health nurse, through health teach-
interventions with the client.
ing, assists patients in achieving satisfying, productive,
Standard II. Diagnosis and healthy patterns of living.
The psychiatricmental health nurse analyzes the assess- Standard Vf. Case Management
ment data in determining diagnoses.
The psychiatricmental health nurse provides case man-
Rationale: agement to coordinate comprehensive health services and
The basis for providing psychiatricmental health nursing ensure continuity of care.
care is the recognition and identification of patterns of Standard Vg. Health Promotion and Health
response to actual or potential psychiatric illnesses, mental Maintenance
health problems, and potential morbid physical illness.
The psychiatricmental health nurse employs strategies
Standard III. Outcome Identification and interventions to promote and maintain mental health
The psychiatricmental health nurse identifies expected and prevent mental illness.
outcomes individualized to the patient. Standard Vh. Psychotherapy
Rationale: The APRN-PMH uses individual, group, and family psy-
Within the context of providing nursing care, the ultimate chotherapy, and other therapeutic treatments to assist
goal is to influence health outcomes and improve the patients in preventing mental illness and disability, treating
patients health status. mental health disorders, and improving mental health sta-
Standard IV. Planning tus and functional abilities.
The psychiatricmental health nurse develops a plan of Standards VI. Prescription Authority and Treatment
care that is negotiated among the patient, nurse, family, Agents
and health care team and prescribes evidence-based inter- The APRN-PMH uses prescriptive authority, procedures,
ventions to attain expected outcomes. and treatments in accordance with state and federal laws
Rationale: and regulations, to treat symptoms of psychiatric illness
and to improve functional health status.
A plan of care is used to guide therapeutic intervention
systematically, document progress, and achieve the Standard VI. Consultation
expected patient outcomes. The APRN-PMH provides consultation to enhance the abili-
Standard V. Implementation ties of other clinicians to provide services for patients and
effect change in systems.
The psychiatricmental health nurse implements the inter-
ventions identified in the plan of care. Standard VI. Evaluation
Rationale: The psychiatricmental health nurse evaluates the patients
progress in attaining expected outcomes.
In implementing the plan of care, psychiatricmental
health nurses use a wide range of interventions designed Rationale:
to prevent mental and physical illness and promote, main- Nursing care is a dynamic process involving change in the
tain, and restore mental and physical health. Psychi- patients health status over time, giving rise to the need for
atricmental health nurses select interventions according new data, different diagnoses, and modifications in the
to their level of practice. plan of care. Therefore, evaluation is a continuous process
(Note: VaVg are basic level interventions. VhVj are of appraising the effect of nursing and the treatment regi-
advanced practice interventions.) men on the patients health status and expected health out-
Standard Va. Counseling comes.
The psychiatricmental health nurse uses counseling inter-
ventions to assist patients in improving or regaining their
previous coping abilities, fostering mental health, and pre-
venting mental illness and disability.
From American Nurses Association, American Psychiatric Nurses
Standard Vb. Milieu Therapy
Association, International Society of PsychiatricMental Health
The psychiatricmental health nurse provides, structures, Nurses. (2000). Scope and standards of psychiatricmental health
and maintains a therapeutic environment in collaboration nursing practice (pp. 2841). Washington, DC: American Nurses
with the patient and other health care clinicians. Publishers.
CHAPTER 6 Contemporary Psychiatric Nursing Practice 67

BOX 6.3 BOX 6.4

Canadian Standards of Psychiatric and Functions of PsychiatricMental
Mental Health Nursing Practice (2nd ed.) Health Nurses

Standards Theme Basic Level Functions

I. Provides competent professional care through the Health promotion and health maintenance
helping role. Intake screening and evaluation
II. Performs/refines client assessments through the Case management
diagnostic and monitoring function. Milieu therapy
III. Administers and monitors therapeutic interven- Promotion of self-care activities
tions. Psychobiologic interventions
IV. Effectively manages rapidly changing situations. Complementary interventions
V. Intervenes through the teachingcoaching function. Health teaching
VI. Monitors and ensures the quality of health care Counseling
practices. Crisis care
VII. Practices within organizational and work-role Psychiatric rehabilitation
structures. Advanced Level Functions
Psychopharmacology interventions
The Canadian Federation of Mental Health Nurses, Standards
Committee. (1998). The Canadian standards of psychiatric and
Psychotherapy interventions
mental health nursing practice (2nd ed.). Community interventions
Case management activities
Clinical supervisory activities

competency in psychiatric nursing practice as specified Basic Level

by the standards of professional performance within
According to the Scope and Standards of Psychiatric
the Scope and Standards of PsychiatricMental Health
Mental Health Nursing, the basic level of practice
Nursing in the areas of quality of care, performance
includes two nursing groups. The first group consists
appraisal, education, collegiality, ethics, collaboration,
of registered nurses who practice in psychiatric set-
research, and resource utilization (ANA et al., 2000)
tings as staff nurses, case managers, nurse managers,
(Table 6-1).
or in other nursing roles. The second is the psychi-
atricmental health nurse (RN-PMH) who has a bac-
calaureate degree in nursing and has worked in the
field for at least 2 years. Both groups of nurses are
The two levels of practice in psychiatricmental health expected to adhere to the scope and standards of prac-
nursing are basic and advanced. These levels are differ- tice (ANA et al., 2000). Nursing practice at this level
entiated by educational preparation, complexity of prac- is characterized by interventions that promote and
tice, and performance of nursing function (Box 6-4). foster health, assess dysfunction, assist patients to

Table 6.1 Standards of Professional Performance

Standard I Quality of care Systematically evaluates the quality of care and effectiveness of
psychiatricmental health nursing practice
Standard II Performance appraisal Evaluates own psychiatricmental health nursing practice in relation to profes-
sional practice standards and relevant statutes and regulations
Standard III Education Acquires and maintains current knowledge in nursing practice
Standard IV Collegiality Interacts and contributes to the professional development of peers, health care
clinicians, and others
Standard V Ethics Determines and implements assessments, actions, and recommendations on
behalf of patients in an ethical manner
Standard VI Collaboration Collaborates with the patient, significant others, and health care clinicians in
providing care
Standard VII Research Contributes to nursing and mental health through the use of research methods
and findings
Standard VIII Resource utilization Considers factors related to safety, effectiveness, and cost in planning and
delivering patient care

From American Nurses Association, American Psychiatric Nurses Association, International Society of PsychiatricMental Health Nurses.
(2000). Scope and standards of psychiatricmental health nursing practice (pp. 2841). Washington, DC: American Nurses Publishers.
68 UNIT II Principles of Psychiatric Nursing

regain or improve their coping abilities, maximize Advanced Level

strength, and prevent further disability (ANA et al.,
The advanced practice psychiatricmental health
p. 13). The nurse performs a wide range of interven-
nurse (APRN-PMH) is also a licensed registered nurse
tions, including health promotion and health mainte-
but is educationally prepared at the masters level and is
nance strategies, intake screening and evaluation, case
nationally certified as a specialist by the American
management, milieu therapy, promotion of self-care
Nurses Credentialing Center (ANCC). The APRN-
activities, psychobiologic interventions, complemen-
PMH is either a clinical nurse specialist or a nurse
tary interventions, health teaching, counseling, crisis
practitioner in psychiatric nursing. The advanced level
care, and psychiatric rehabilitation (Table 6-2). An
also includes nurses with doctoral preparation who
overview of psychiatric nursing interventions is pre-
have earned a doctorate in nursing science (DNS,
sented in Chapter 13.

Table 6.2 Basic Psychiatric Nursing Interventions

Area Interventions

Health promotion and maintenance Conducts health assessment and targets high-risk situations and potential
complications of disorder and treatment. Interventions include, but are
not limited to, assertiveness training, stress management, parenting
classes, and health teaching.
Intake screening and evaluation Conducts intake assessment; makes triage decisions. Facilitates patient mov-
ing into appropriate service. Interventions include, but are not limited to,
data collection guided by principles of human behavior and the interview-
ing process. Refers patient for additional assessment when needed.
Case management Supports the patients highest level of functioning, self-efficacy, and optimal
health. Interventions include risk assessment, supportive counseling prob-
lem solving, teaching medication and health status monitoring, compre-
hensive care planning, and coordination of other health services.
Milieu therapy Assesses and develops the therapeutic potential of a particular environment.
Interventions focus on the physical environment, social structure interac-
tion processes, and culture of the setting.
Promotion of self-care activities Supports independence in self-care activities of daily living. Interventions
include, but are not limited to, teaching medication regimen and symptom
management, fostering recreational activities, and facilitating develop-
ment of practical skills for community life.
Psychobiologic interventions Assesses holistically and treats patients responses to actual and potential
health problems. Interventions include, but are not limited to, administer-
ing, monitoring, and overseeing pharmacotherapeutic treatment, relax-
ation techniques, nutrition and diet regulation, exercise and rest sched-
ules, preoperative and postoperative care of patient receiving
electroconvulsive therapy, and medication education.
Complementary interventions Wide range of interventions include diet and nutrition regulation, relaxation
techniques, therapeutic touch, mindfulness meditation, and guided
Health teaching Identifies learning needs related to biologic, pharmacologic, physical,
sociocultural, or psychological aspects of care. Interventions include for-
mal and informal approaches, developing real-life experiences, and role
Counseling Supports problem solving of an immediate difficulty and constructive per-
sonal change. Interventions include time-limited sessions with patient,
family, or group.
Crisis care Supports the resolution of an immediate crisis or emergency. Interventions
include crisis intervention, stabilization, and direct counseling services
using supportive problem solving and mobilization of resources.
Psychiatric rehabilitation Facilitates symptom management and relapse prevention within a rehabilita-
tion and recovery context. Interventions include developing a collabora-
tive partnership with the patient, supporting the development of life
skills, and identifying and using environmental support.

Adapted from American Nurses Association, American Psychiatric Nurses Association, and International Society of PsychiatricMental
Health Nurses. (2000). Scope and standards of psychiatricmental health nursing practice (pp. 1317). Washington, DC: American Nurses
CHAPTER 6 Contemporary Psychiatric Nursing Practice 69

DNSc) or a doctor of philosophy (PhD) degree. The important because they are individualized to a patients
APRN-PMHs responsibilities include the complete needs. They are sometimes approved by third party
delivery of direct primary mental health services, payers who reimburse the cost of the service. In this
including, but not limited to, formulating differential text, the emphasis will be on developing nursing care
diagnoses; ordering, conducting, and interpreting per- plans because they serve as a basis of practice even if the
tinent laboratory and diagnostic studies and proce- interventions are included in a multidisciplinary or
dures; conducting individual, family group, and net- interdisciplinary individual treatment plan.
work psychotherapy; and prescribing, monitoring
managing, and evaluating psychopharmacologic and
related medication.
Many psychiatric institutions use critical pathways to
ensure a quality level of care in a cost-effective way.
Tools of Psychiatric These care paths are similar to individual treatment
Nursing Practice plans in that all the disciplines interventions are
included on one plan. They are different in that critical
CLINICAL DECISION MAKING pathways are designed for a hypothetical patient who
Decision making is a type of critical thinking and is at has typical symptoms and who follows an expected
the core of clinical practice. Clinical decision making is course of treatment. Care paths are not developed for
a specific type of critical thinking that focuses on the each patient. Instead, each facility or agency has only a
choices made in clinical settings. In addition to the few psychiatricmental health care paths that are used
complex decisions, such as collecting, processing, and to guide care. In addition, critical pathways are used in
organizing information, and formulating nursing determining appropriate length of treatment within a
approaches, many moment-to-moment decisions are particular setting, hospital, clinic, or home. Each prob-
made, such as deciding whether a patient can leave a lem is assigned an expected length of stay within each
unit or whether a patient should receive a medication. type of setting. If a patient is not improving according
The development and implementation of efficacious to the time designated on the care path, the patient and
interventions involves critical analysis of patient, family, caregivers are evaluated by others in the system.
and community data and making decisions about care.
Although nurses are often leaders in the implementation
of prevention programs to designated populations, most Interdisciplinary Approach
nurses focus on the delivery of care to individuals. Treat- and the Nurses Role
ment decisions for individual patients with psychiatric
mental health problems are multifaceted. There are a Several professionals other than nurses and physicians
variety of theoretical perspectives from which the patient provide mental health services to people with emotional
can be viewed, and each has a treatment component problems and mental disorders. These professionals come
(Chapters 7 and 8). Nurses are responsible for familiariz- from a variety of disciplines and provide services based on
ing themselves with the many treatment possibilities and their training and licensure, which may vary from state to
for determining which approach fits a particular patient. state. Psychiatricmental health care has a long tradition
of using a multidisciplinary approach, with several dis-
ciplines providing service to a patient at one time. In the
hospital, a patient may be seeing a psychiatrist for man-
Just like patients in medicalsurgical settings, patients agement of the disorder symptoms and for prescribed
receiving psychiatric mental health services have a writ- medications; a psychiatric social worker for individual
ten plan of care. If only nursing care is being provided, psychotherapy; a psychiatric nurse for management of
such as in home care, a nursing care plan may be used. responses related to the mental disorder, administration
If other disciplines are providing services to the same of medication, and monitoring side effects; and an occu-
patient, which often occurs in a hospital, an individual pational therapist for transition into the workplace. In the
treatment plan may be used with or instead of a tradi- community clinic, a patient may meet weekly with a ther-
tional nursing care plan. When an interdisciplinary plan apist, monthly with a mental health provider who pre-
is used, components of the nursing care plan should scribes medication, and twice a week with a group leader
always be easily identified. The nurse provides the care in a day treatment program. All of these professionals
that is judged to be within the scope of practice of the bring a specialized skill to the patients care.
psychiatricmental health nurse. Thus, the traditional However, a multidisciplinary approach is not quite the
nursing care plan may or may not be used, depending ideal for patient care because the care can be fragmented
on institutional policies. Whether a nursing care plan or when approaches are independent of each other. An
an individual treatment plan is used, these plans are interdisciplinary approach, in which interventions
70 UNIT II Principles of Psychiatric Nursing

from the different disciplines are integrated into delivery tion through journals, electronic databases, and continu-
of patient care, is ideal. In this model, a nurse and a psy- ing education programs takes time and vigilance but pro-
chologist may simultaneously intervene with a patient on vides a sound basis for application of new knowledge.
changing a behavior related to medication compliance. Not only do nurses need to access current research
An interdisciplinary approach differs from a multidisci- studies but they also must evaluate the usefulness of the
plinary one because it requires a close working relation- studies. For instance, one research study supporting a par-
ship among personnel from the different disciplines who ticular treatment approach may not be as meaningful as
no longer provide services independently of one another. several statistically significant studies. On the other hand,
results of a small study can sometimes have useful clinical
INTERDISCIPLINARY TREATMENT applications, even though findings are not reported in
PLANS terms of statistical significance. Psychiatric nurses are
challenged to improve patient care by integrating knowl-
When an interdisciplinary plan is used, components of edge into a biopsychosocial model that includes all human
the nursing care plan should always be easily identified. responses to potential or actual health problems.
Whether a nursing care plan or an individual treatment
plan is used, these plans are important because they are
individualized to a patients needs. The psychiatric OVERCOMING THE STIGMA
mental health nurse can expect to collaborate with other Nurses can play an important role in dispelling myths
professionals in all settings, including hospital and com- of mental illnesses. Stigma often prevents individuals
munity. It is usually the nurse who coordinates the deliv- from seeking help for mental health problems (see
ery of the care of these different disciplines. Chapter 2). The issue of stigma, identified as a major
problem in Mental Health: A Report of the Surgeon Gen-
eral (U.S. Department of Health and Human Services,
Challenges of 1999), should be addressed by every nurse, whether or
not the nurse practices psychiatric nursing. To reduce
Psychiatric Nursing the burden of mental illness and improve access to care,
The challenges of psychiatric nursing are increasing in nurses can educate all of their patients about the etiol-
the 21st century. New knowledge is being generated, ogy, symptoms, and treatment of mental illnesses.
technology is shaping health care into new dimensions,
and nursing practice is becoming more specialized and
autonomous. This section discusses a few of the chal-
Additional continuing challenges for psychiatric nurses
include providing nursing care within integrated com-
KNOWLEDGE DEVELOPMENT, munity-based services where culturally competent,
high-quality nursing care is needed to meet the emerg-
Results of new research efforts continually redefine our ing mental health care needs of patients. In caring for
knowledge base relative to mental disorders and their patients who require support from the social welfare sys-
treatment. For example, in the 1900s, the cause of schiz- tem in the form of housing, job opportunities, welfare,
ophrenia was hypothesized to be overactivity of and transportation (U.S. Department of Health and
dopamine. Later, it was discovered that other neuro- Human Services, 1999), nurses need to be knowledge-
transmitters seemed to play a role as well. As a result, able about these systems. Moreover, in some settings,
new medications with various side effect profiles became the nurse may be the only one who has a background in
available, requiring nurses to redefine their monitoring medical disorders, such as human immunodeficiency
and interventions related to medication administration. virus, acquired immunodeficiency syndrome, and other
Meanwhile, the presence of comorbid medical disor- somatic health problems. Assertive community treat-
ders gains increasing importance in the treatment of ment reduces inpatient service use, promotes continuity
mental disorders. For example, hypertension, hypothy- of outpatient care, and increases the stability of people
roidism, hyperthyroidism, and diabetes mellitus all affect with serious mental illnesses (see Chapter 6). The nurse
the treatment of psychiatric disorders. The challenge for is involved in moving the currently fragmented health
psychiatric nurses today is to stay abreast of the advances care system toward one focusing on consumer needs.
in total health care in order to provide safe, competent Nurses have an opportunity to participate in the
care to individuals with mental disorders. Additional development of a health care system that calls for par-
challenges for psychiatric nurses include updating their ity, that is, equality between mental health and other
knowledge so that significant results of studies can be health coverage. In 1998, the Federal Mental Health
applied to the care of patients. Accessing new informa- Parity Act went into effect. Under this law, group health
CHAPTER 6 Contemporary Psychiatric Nursing Practice 71

plans providing mental health benefits may not impose For nurses to provide patient care within ethical
a lower lifetime or annual dollar limit on mental health frameworks, they need knowledge of basic rights and
benefits than the limit that exists for medicalsurgical ethical principles, conceptual models as ways of think-
benefits. Financial barriers that have prevented many ing about ethical dilemmas, and opportunities to
people from accessing services are slowly being explore and resolve clinical dilemmas. Knowledge of
removed. As people access services, it is important that the legal issues and patients rights that have been dis-
nurses step forward to provide quality, evidenced-based cussed in this chapter should be used in making clini-
care to individuals and their families. cal decisions. Nursing actions in the United States are
guided by the Code for Nurses With Interpretive State-
IMPACT OF TECHNOLOGY ments, adopted by the ANA in 2001. The Code serves
to inform both the nurse and society of the profes-
The impact of technologic advances on the delivery of sions expectations and requirements in ethical matters
psychiatric nursing care is unprecedented. Nurses are (Box 6-5) and provides a framework within which
challenged to continue to develop their technical and nurses can make ethical decisions. This document is
computer skills and to use this technology in improv- currently being revised as a code of ethics for nurses.
ing care. For example, telemedicine is a reality and
takes many forms, from communicating with remote
sites to completing educational programs. It is impor-
tant that patients have the opportunity to use technol- NCLEX Note
ogy to learn about their disorders and treatment.
Because many of the disorders can affect cognitive Tracking ethical decisions that the psychiatric nurse
encounters in the inpatient versus outpatient setting
functioning, it is also important that software programs may be a topic for examination.
be developed that can be used by these individuals to
facilitate cognitive functioning.
Another challenge related to new technology is that In Canada, the Canadian Nurses Association (2002)
associated with maintaining patient confidentiality. sets ethical behavior expected of registered nurses. The
Patient records, once stored in remote areas and rarely groups Code of Ethics for Registered Nurses is structured
viewed, are now readily available and easily accessed. around primary values central to ethical nursing prac-
Nurses need to be vigilant in maintaining privacy and tice (Box 6-6).
confidentiality. Moreover, documentation skills need to
be updated continually to reflect quality patient care
within the changing health care environment.
PsychiatricMental Health
Nursing Organizations
Ethical Frameworks Whereas the establishment and reinforcement of stan-
Ethical issues are clearly inherent in mental health care. dards go a long way toward legitimizing psychiatric
The interests of the patients, nurses, health care team, mental health nursing, it is professional organizations that
and society may be in conflict and may manifest in any provide leadership in shaping mental health care. They do
number of psychiatricmental health care delivery set- so by providing a strong voice for meaningful legislation
tings. Ethical conflicts can occur when the patient is that promotes quality patient care and advocates for maxi-
being guided by the principle of autonomy and the mal use of nursing skills.
nurse by the principle of beneficence. The fundamental The ANA is one such organization. Although its focus
ethical principles of autonomy and beneficence are in is on addressing the emergent needs of nursing in gen-
conflict in many clinical situations. eral, the ANA supports psychiatricmental health nurs-
According to the principle of autonomy, each person ing practice through liaison activities, such as advocating
has the fundamental right of self-determination. Accord- for psychiatricmental health nursing at the national and
ing to the principle of beneficence, the health care state levels and working closely with psychiatricmental
provider uses knowledge of science and incorporates the health nursing organizations.
art of caring to develop an environment in which indi- The American Psychiatric Nurses Association (APNA)
viduals achieve their maximal health care potential. and the International Society of PsychiatricMental
Health Nurses (ISPN) are two organizations for psychi-
NCLEX Note atric nurses that focus on mental health care. The APNA
is the largest psychiatricmental health nursing organiza-
Be prepared to think in terms of patient scenarios that
tion, with the primary mission of advancing psychi-
depict the principles of beneficence versus autonomy. atricmental health nursing practice; improving mental
health care for culturally diverse individuals, families,
72 UNIT II Principles of Psychiatric Nursing

BOX 6.5 BOX 6.6

Code for Registered Nurses Canadian Code of Ethics Values
1. The nurse, in all professional relationships, practices A value is something that is prized or held dear; some-
with compassion and respect for the inherent dig- thing that is deeply cared about. This code is organized
nity, worth, and uniqueness of every individual, around eight primary values that are central to ethical
unrestricted by considerations of social or economic nursing practice:
status, personal attributes, or the nature of health SAFE, COMPETENT AND ETHICAL CARE:
problems. Nurses value the ability to provide safe, competent and
2. The nurses primary commitment is to the patient, ethical care that allows them to fulfill their ethical and
whether an individual, family, group, or community. professional obligations to the people they serve.
3. The nurse promotes, advocates for, and strives to HEALTH AND WELL-BEING:
protect the health, safety, and rights of the patients. Nurses value health promotion and well-being and assist-
4. The nurse is responsible and accountable for individ- ing persons to achieve their optimum level of health in
ual nursing practice and determines the appropriate situations of normal health, illness, injury, disability, or at
delegation of tasks consistent with the nurses the end of life.
obligation to provide optimum patient care. CHOICE:
5. The nurse owes the same duties to self as to others, Nurses respect and promote the autonomy of persons
including the responsibility to preserve integrity and and help them to express their health needs and values
safety, to maintain competence, and to continue per- and also to obtain desired information and services so
sonal and professional growth. they can make informed decisions.
6. The nurse participates in establishing, maintaining, DIGNITY:
and improving health care environments and condi- Nurses recognize and respect the inherent worth of each
tions of employment conducive to the provision of person and advocate for respectful treatment of all persons.
quality health care and consistent with the values of CONFIDENTIALITY:
the profession through individual and collective Nurses safeguard information learned in the context of a
action. professional relationship and ensure it is shared outside
7. The nurse participates in the advancement of the the health care team only with the persons informed con-
profession through contributions to practice, educa- sent, or as may be legally required, or where the failure
tion, administration, and knowledge development. to disclose would cause significant harm.
8. The nurse collaborates with other health profession- JUSTICE:
als and the public in promoting community, national, Nurses uphold principles of equity and fairness to assist
and international efforts to meet health needs. persons in receiving a share of health services and
9. The profession of nursing, as represented by associ- resources proportionate to their needs and in promoting
ations and their members, is responsible for articula- social justice.
tion of nursing values, for maintaining the integrity ACCOUNTABILITY:
of the profession and its practice, and for shaping Nurses are answerable for their practice, and they act in
social policy. a manner consistent with their professional responsibili-
ties and standards of practice.
American Nurses Association. (2001). Code for nurses with inter- QUALITY PRACTICE ENVIRONMENTS:
pretive statements. Washington, DC: Author. Nurses value and advocate for practice environments that
have the organizational structures and resources neces-
sary to ensure safety, support, and respect for all persons
in the work setting.
groups, and communities; and shaping health policy for
the delivery of mental health services. The ISPN consists Source: Canadian Nurses Association. (2002). Code of ethics for
of three specialist divisions: the Association of Child and registered nurses. Author.
Adolescent Psychiatric Nurses, the International Society
of Psychiatric Consultation Liaison Nurses, and the Soci-
ety for Education and Research in PsychiatricMental
Health Nursing. The purpose of ISPN is to unite and SUMMARY OF KEY POINTS
strengthen the presence and the voice of psychiatricmen- The biopsychosocial model focuses on the three
tal health nurses and to promote quality care for individu- separate but interdependent dimensions of biologic,
als and families with mental health problems. Both orga- psychological, and social factors in the assessment
nizations have annual meetings at which new research is and treatment of mental disorders. This comprehen-
presented. Student memberships are available. sive and holistic approach to mental disorders is the
In Canada, the Canadian Nurses Association (CAN) foundation for effective psychiatricmental health
is a federation of 11 provincial and territorial registered nursing practice and is used as the basic organiza-
nurses associations. CNA speaks for Canadian registered tional framework for this book.
nurses and represents Canadian nursing to other organi- The Scope and Standards of PsychiatricMental
zations on national and international levels. The mem- Health Nursing, published in 2000, established the
bership of approximately 110,000 registered nurses is areas of concern, standards of care according to the
broad and diverse and reflects the face of nursing today.
CHAPTER 6 Contemporary Psychiatric Nursing Practice 73

nursing process, and standards of nursing perfor- 4 Discuss the purposes of the following organizations
mance and differentiates between the functions of in promoting quality mental health care and sup-
the basic and advanced practice nurse. porting nursing practice.
Nursing care plans and interdisciplinary treat- a. American Nurses Association (www.nursing-
ment plans are written plans of care that are devel- world.org)
oped for each patient. Clinical decision-making skills b. American Psychiatric Nurses Association
are needed for developing and revising these tools. (www.apna.org)
The psychiatricmental health nurse interacts with c. International Society of PsychiatricMental
other disciplines and many times acts as a coordinator Health Nurses (www.ispn-psych.org)
in the delivery of care. There is always a plan of care d. Canadian Nurses Association (www.cna-nurses.ca).
for a patient, but it may be a nursing care plan or an 5 Compare the ethical concepts of autonomy and benef-
individualized treatment plan that includes other dis- icence. Focus on the difference between legal conse-
ciplines. Critical pathways, different from individual- quences and ethical dilemmas.
ized care plans, are used throughout the care contin- 6 Contrast multidisciplinary and interdisciplinary prac-
uum to ensure quality care and cost-effectiveness. tice. Describe how and when nursing care plans and
New challenges facing psychiatric nurses are integrated care paths should be used.
emerging. Interpretation of research findings will
assume new importance in the care of individuals with
psychiatric disorders. The roles of nurses are expand- WEB LINKS
ing as nursing care becomes an established part of the
community-based health care delivery system. www.nursingworld.org This is the American Nurses
Standards for ethical behaviors for professional Association website.
nurses are set by national professional organizations www.ispn-psych.org This is the site of the Interna-
such as the American Nurses Association and the tional Society of PsychiatricMental Health Nurses.
Canadian Nurses Association. www.apna.org This is the American Psychiatric
Several professional nursing organizations pro- Nurses Association website.
vide leadership in shaping mental health care, www.surgeongeneral.com At the Surgeon Generals
including the American Nurses Association, the website, one can obtain a copy of Mental Health:
American Psychiatric Nurses Association, the Inter- Report of the Surgeon General.
national Society of PsychiatricMental Health www.cna-nurses.ca This is the Canadian Nurses
Nurses, and the Canadian Nurses Association. Association website.
www.cfmhn.org This is the Canadian Federation of
Mental Health Nurses website; it has the Canadian
standards of psychiatric nursing practice.
1 Explain the biopsychosocial model and apply it to REFERENCES
the following three clinical examples: Abraham, I., Fox, J., & Cohen, B. (1992). Integrating the bio into the
a. A first-time father is extremely depressed after the biopsychosocial: Understanding and treating biological phenom-
ena in psychiatricmental health nursing. Archives of Psychiatric
birth of his child, who is perfectly healthy. Nursing, 6(5), 296305.
b. A child is unable to sleep at night because of ter- American Nurses Association. (2001). Code for nurses with interpretive
rifying nightmares. statements. Washington, DC: Author.
c. A older woman is resentful of moving into a senior American Nurses Association, American Psychiatric Nurses Associa-
citizens residence even though the decision was hers. tion, & International Society of PsychiatricMental Health
Nurses. (2000). Scope and standards of psychiatricmental health nurs-
2 Compare the variety of patients for whom psychi- ing practice. Washington, DC: American Nurses Publishing.
atricmental health nurses care. Factors to be con- The Canadian Federation of the Mental Health Nurses, Standards
sidered are age, health problems, and social aspects. Committee (1998). The Canadian standards of psychiatric and mental
3 Visit the ANA website (www.nursingworld.org) for a health nursing (2nd ed.). The Canadian Federation of the Mental
description of the psychiatricmental health nurses Health Nurses.
Canadian Nurses Association Code for Nurses. (2002). Code of ethics
certification credentials. Compare the basic level for registered nurses. Ottawa, Ontario: Author.
functions of a psychiatric nurse to those of the U.S. Department of Health and Human Services. (1999). Mental
advanced practice psychiatric nurse. health: A report of the Surgeon General. Rockville, MD: Author.

For challenges and updates, go to www.connection.lww.com or refer to the CD-ROM in the back of this book.
Theoretic Basis of
Psychiatric Nursing
Mary Ann Boyd

After studying this chapter, you will be able to:
Discuss the need for a theory-based practice and supporting research.
Identify the underlying theories that contribute to the understanding of human
beings and behavior.
Compare the key elements of each theory that provides a basis for psychiatricmen-
tal health nursing practice.
Identify common nursing theoretic models used in psychiatricmental health nursing.

behaviorism classical conditioning cognition connections countertransference
defense levels diathesis disconnections disinhibition empathy empathic
linkage expressed emotion family dynamics formal support systems informal
support systems interpersonal relations modeling object relations operant
behavior role self-efficacy self-system shaping social distance transaction


74 74
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 75

T his chapter presents an overview of the biologic,

psychological, and social theories that serve as the
knowledge base for psychiatricmental health nursing
the model, certain genes or genetic combinations pro-
duce a diathesis, or constitutional predisposition to a
disorder. When diathesis is combined with environ-
practice. Many of the theories underlying psychiatric mental stressors, abnormal behavior results. The
nursing practice are evolving and have limited research diathesis-stress model suggests that for a mental disor-
support. Lack of research does not necessarily mean der to develop, both the diathesis and stress must inter-
that theories are useless, but researchers must acknowl- act, that is, an individual with a predisposition toward a
edge the limitations of existing experimentation and disorder must be challenged by a stressor. This model
knowledge. In this chapter, published research support is supported by several research studies. For example,
for the theories and their applicability in psychiatric one study showed how attribution of negative life
nursing practice are discussed. events predict alcohol use in undergraduate college stu-
dents (Goldstein, et al., 2001).
Biologic Theories
Biologic theories are clearly important in understanding Psychological Theories
the manifestations of mental disorders and caring for peo-
ple with these illnesses. Chapter 8 explains many of the
important neurobiologic theories, and Chapter 9 focuses Psychodynamic theories explain the mental or emo-
on psychopharmacology. Many of the biologically tional forces or developing processes, especially in early
focused interventions explained in Chapter 13 have their childhood, and their effects on behavior and mental
theoretic roots in basic nursing knowledge. This chapter states. The study of the unconscious is part of psycho-
describes two well-known biologic theoretic approaches dynamic theory, and many of the models that are
used to understand the expression of mental disorders. important in psychiatric nursing began with the Aus-
trian physician Sigmund Freud (18561939). Since his
GENERAL ADAPTATION SYNDROME time, Freuds theories have been enhanced by so-called
interpersonal and humanist models. Psychodynamic
Hans Selyes landmark studies on stress described the
theories initially attempted to explain the cause of men-
interaction of environmental events and biologic
tal disorders, but etiologic explanations were not sup-
response (Selye, 1956). Selye looked for a link between
ported by controlled research. However, these theories
illness and stressful events and identified the general adap-
proved to be especially important in the development of
tation syndrome (GAS), describing a three-stage process:
therapeutic relationships, techniques, and interventions
alarm reaction
(Table 7-1).
He hypothesized that during the alarm stage, patients PSYCHOANALYTIC THEORY
exhibit an adrenocortical response associated with
In Freuds psychoanalytic model, the human mind was
fight-or-flight behavior. During the resistance phase,
conceptualized in terms of conscious mental processes
the body adapts to stress but functions at a lower than
(an awareness of events, thoughts, and feelings with the
optimal level. If the adaptive mechanisms fail or wear
ability to recall them) and unconscious mental processes
out, the individual enters the third stage of exhaustion.
(thoughts and feelings that are outside awareness and
At this point, the negative effects of the stressor spread
are not remembered).
to the entire organism, and Selye believed that ensuing
illnesses could ultimately lead to death.
Todays research supports the relationship between Study of the Unconscious
illness and stressful events but raises questions about
Freud believed that the unconscious part of the human
some of Selyes basic ideas (see Chapter 33). Although
mind is only rarely recognized by the conscious, as in
there is support for biologic responses to stress, Selyes
remembered dreams (see Movies at the end of this
ideas of a general physical reaction to diverse environ-
chapter). The term preconscious was used to describe
mental stimuli are being questioned. Many responses,
unconscious material that is capable of entering con-
such as those within the neuroendocrine system, are not
general at all, but very specific.

DIATHESIS-STRESS MODEL Personality and Its Development

Another perspective related to biology is the diathesis- Freuds personality structure consisted of three parts:
stress model, an integration of the concepts of genetic the id, ego, and superego (Freud, 1927). The id was
vulnerability and environmental stressors. According to formed by unconscious desires, primitive instincts, and
76 UNIT II Principles of Psychiatric Nursing

Table 7.1 Psychodynamic Models

Theorist Overview Major Concepts Applicability

Psychoanalytic Models
Sigmund Freud Founder of psychoanalysis. Believed that Id, ego, superego Individual therapy
(18561939) the unconscious could be accessed Consciousness approach used for
through dreams and free association. Unconscious mental enhancement of personal
Developed a personality theory and processes maturity and personal
theory of infantile sexuality. Libido growth
Object relations
Anxiety and defense
Free associations,
transference, and
Anna Freud Application of ego psychology to psy- Refinement of con- Individual therapy, child-
(18951982) choanalytic treatment and child analy- cepts of anxiety, hood psychoanalysis
sis with emphasis on the adaptive defense mechanisms
function of defense mechanisms.
Neo-Freudian Models
Alfred Adler First defected from Freud. Founded the Inferiority Added to the understand-
(18701937) school of individual psychology. ing of human motivation
Carl Gustav Jung After separating from Freud, founded the Redefined libido Personalities are often
(18751961) school of psychoanalytic psychology. Introversion assessed on the introver-
Developed new therapeutic Extroversion sion and extroversion
approaches. Persona dimensions
Otto Rank Introduced idea of primary trauma of Birth trauma Recognized the importance
(18841939) birth. Active technique of therapy Will of feelings within psy-
including more nurturing than Freud. choanalysis
Emphasized feeling aspect of analytic
Erich Fromm Emphasized the relationship of the indi- Society and individual Individual desires are
(19001980) vidual to society. are not separate formed by society
Melanie Klein Devised play therapy techniques. Pioneer in object Developed different ways
(18821960) Believed that complex unconscious relations of applying psychoanaly-
fantasies existed in children younger Identification sis to children; Influenced
than 6 months of age. Principal source present-day English and
of anxiety arose from the threat to American schools of child
existence posed by the death instinct. psychiatry
Karen Horney Opposed Freuds theory of castration Situational neurosis Beginning of feminist
(18851952) complex in women and his emphasis Character analysis of psychoana-
on the oedipal complex. Argued that lytic thought
neurosis was influenced by the society
in which one lived.
Interpersonal Relations
Harry Stack Sullivan Impulses and striving need to be under- Participant observer Provided the framework for
(18921949) stood in terms of interpersonal Parataxic distortion the introduction of the
situations. Consensual validation interpersonal theories in
Humanist Theories
Abraham Maslow Concerned himself with healthy rather Needs Used as a model to under-
(19211970) than sick people. Approached individu- Motivation stand how people are
als from a holistic-dynamic viewpoint. motivated and needs
that should be met
Frederick S. Perls Awareness of emotion, physical state, Reality Used as a therapeutic
(18931970) and repressed needs would enhance the Here-and-now approach to resolve cur-
ability to deal with emotional problems. rent life problems that
are influenced by old,
unresolved emotional
Carl Rogers Based theory on the view of human poten- Empathy Individual therapy approach
(19021987) tial for goodness. Used the term client Positive regard that involves never giv-
rather than patient. Stressed the rela- ing advice and always
tionship between therapist and client. clarifying clients feelings
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 77

unstructured drives, including sexual and aggressive ten- sexual desire was controlled and not expressed, tension
dencies that arose from the body. The ego consisted of resulted and was transformed into anxiety (Freud, 1905).
the sum of certain mental mechanisms, such as percep- Freud believed that adult sexuality was an end product of
tion, memory, and motor control, as well as specific a complex process of development that began in early
defense mechanisms. The ego controlled movement, childhood and involved a variety of body functions or
perception, and contact with reality. The capacity to areas (oral, anal, and genital zones) that corresponded to
form mutually satisfying relationships was a fundamen- stages of relationships, especially with parents.
tal function of the ego, which is not present at birth but
is formed throughout the childs development. The
superego was that part of the personality structure asso-
ciated with ethics, standards, and self-criticism. A childs Freud developed psychoanalysis, a therapeutic process of
identification with important and esteemed people in accessing the unconscious and resolving the conflicts
early life, particularly parents, helped form the superego. that originated in childhood with a mature adult mind.
As a system of psychotherapy, psychoanalysis attempted
to reconstruct the personality by examining free associ-
Object Relations and Identification
ations (spontaneous, uncensored verbalizations of what-
Freud introduced the concept of object relations, the ever comes to mind) and the interpretation of dreams.
psychological attachment to another person or object. Therapeutic relationships had their beginnings within
He believed that the choice of a love object in adult- the psychoanalytic framework.
hood and the nature of the relationship would depend
on the nature and quality of the childs object relation-
Transference and
ships during the early formative years. The childs first
love object was the mother, who is the source of nour-
ishment and the provider of pleasure. Gradually, as the Transference is the displacement of thoughts, feelings,
child separated from the mother, the nature of this ini- and behaviors originally associated with significant oth-
tial attachment influenced any future relationships. The ers from childhood onto a person in a current therapeu-
development of the childs capacity for relationships tic relationship (Moore & Fine, 1990). For example, a
with others progressed from a state of narcissism to womans feelings toward her parents as a child may be
social relationships, first within the family and then directed toward the therapist. If a woman were uncon-
within the larger community. Although the concept of sciously angry with her parents, she may feel unexplain-
object relations is fairly abstract, it can be understood in able anger and hostility toward her therapist. In psycho-
terms of a child who imitates her mother and then analysis, the therapist uses transference as a therapeutic
becomes like her mother in adulthood. This child has tool to help the patient understand emotional problems
incorporated her mother as a love object, identifies with and their origin. Countertransference, on the other
her, and becomes like her as an adult. This process hand, is defined as the direction of all of the therapists
becomes especially important in understanding an feelings and attitudes toward the patient. Feelings and
abused child who, under certain circumstances, perceptions caused by countertransference may interfere
becomes the adult abuser. with the therapists ability to understand the patient.

Anxiety and Defense Mechanisms NEOFREUDIAN MODELS

For Freud, anxiety was a specific state of unpleasantness Many of Freuds followers ultimately broke away, estab-
accompanied by motor discharge along definite path- lishing their own form of psychoanalysis. Freud did not
ways, the reaction to danger of object loss. Defense receive criticism well. The rejection of some of his basic
mechanisms protected a person from unwanted anxiety. tenets often cost his friendship as well. Various psycho-
Although they are defined differently than in Freuds day, analytic schools have adopted other names because
defense mechanisms still play an explanatory role in con- their doctrines deviated from freudian theory.
temporary psychiatricmental health practice. Defense
mechanisms are discussed in the chapter on Communi-
Adlers Foundation for Individual
cation and Therapeutic Relationship (Chapter 10).
Alfred Adler (18701937), a Viennese psychiatrist and
founder of the school of individual psychology, was a
The energy or psychic drive associated with the sexual student of Freud who believed that the motivating force
instinct, called the libido, literally translated from Latin in human life is a sense of inferiority. Avoiding feelings
to mean pleasure or lust, resided in the id. When of inferiority leads the individual to adopt a life goal
78 UNIT II Principles of Psychiatric Nursing

that is often unrealistic and frequently expressed as an disturbances to the primary trauma of birth, he
unreasoning desire for power and dominance. Because described individual development as a progression from
inferiority is intolerable, the compensatory mechanisms complete dependence on the mother and family to
set up by the mind may get out of hand, resulting in physical independence coupled with intellectual depen-
self-centered neurotic attitudes, overcompensation, and dence on society, and finally to complete intellectual
a retreat from the real world and its problems. and psychological emancipation. Rank believed in the
Today, Adlers theories and principles have been importance of will, a positive guiding organization in
adapted and applied to both psychotherapy and education. the integration of self.
Adlerian theory is based on principles of mutual respect,
choice, responsibility, consequences, and belonging.
Erich Fromm and Melanie Klein
(Play Therapy)
Jungs Analytical Psychology
Other psychoanalytic theorists include Erich Fromm and
One of Freuds earliest students, Carl Gustav Jung Melanie Klein. Erich Fromm (19001980), an American
(18751961), a Swiss psychoanalyst, created a model psychoanalyst, focused on the relationship of society and
called analytical psychology. Jung believed in the existence the individual. He argued that individual and societal
of two basically different types of personalities: extro- needs are not separate and opposing forces; their rela-
verted and introverted. Extroverted people tend to be tionship with each other is determined by the historic
generally interested in other people and objects of the background of the culture. Fromm also believed that the
external world, whereas introverted people tend to be needs and desires of individuals are largely formed by
interested in themselves and their internal environment. their society. For Fromm, the fundamental problem of
Although he argued that both tendencies exist in the nor- psychoanalysis and psychology was to bring about har-
mal individual, the libido usually channels itself mainly in mony and understanding of the relationship between the
one direction or the other. Jung rejected Freuds distinc- individual and society (Fromm-Rieichmann, 1950).
tion between the ego and superego. Instead, he devel- Melanie Klein (18821960), an Austrian psychoana-
oped the concept of persona (what a person appears to be lyst, devised play therapy techniques to demonstrate
to others, in contrast with what he or she actually is) that how a childs interaction with toys revealed earlier
was similar to the superego ( Jung, 1966). infantile fantasies and anxieties. She believed that com-
plex unconscious fantasies existed in children younger
Horneys Feminine Psychology than 6 months of age. She is generally acknowledged as
a pioneer in presenting an object relations viewpoint to
Karen Horney (18851952), a German American psy- the psychodynamic field, introducing the idea of early
chiatrist, challenged many of Freuds basic concepts and identification, a defense mechanism by which one pat-
introduced principles of feminine psychology. Recog- terns oneself after another person, such as a parent.
nizing a male bias in psychoanalysis, Horney was the Her theoretic inferences were based on her clinical
first to challenge the traditional psychoanalytic belief observations (Klein, 1963).
that women felt disadvantaged because of their genital
organs. Freud believed that women felt inferior to men
because their bodies were less completely equipped, a Harry Stack Sullivan: Interpersonal
theory he described as penis envy. Horney rejected Forces
this concept, as well as the oedipal complex, arguing Interpersonal theories were developed as an alternative
that there are significant cultural reasons why women explanation for human development and behavior.
may strive to obtain qualities or privileges that are Although there are similarities between psychoanalytic
defined by a society as being masculine. For example, and interpersonal theories, the major difference is that
university education, the right to vote, and economic interpersonal theories acknowledge the importance of
independence have been available to women only individual relationships in personality development.
recently. She argued that women truly were at a disad- Instincts and drives are less important. Childhood rela-
vantage because of the authoritarian culture in which tionships with parenting figures are especially significant
they lived (Horney, 1939). and are believed to influence important adult relation-
ships, such as the choice of a mate.
Other Neofreudian Theories Harry Stack Sullivan (18921949), an American psy-
chiatrist, extended the concept of interpersonal
Otto Rank: Birth Trauma
relations to include characteristic interaction patterns.
Otto Rank (18841939), an Austrian psychologist and Sullivan studied personality characteristics that could be
psychotherapist, was also a student of Freud. Introduc- directly observed, heard, and felt. He believed that the
ing a theory of neurosis that attributed all neurotic health or sickness of ones personality was determined
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 79

by the characteristic ways in which one dealt with other physical and psychological stimuli in the environment
people. Health also depended on the constantly chang- (Perls, 1969).
ing physical, social, and interpersonal environment as
well as past and current life experiences (Sullivan,
Abraham Maslows Hierarchy
of Needs
Abraham Maslow (19211970) developed a humanistic
theory that is used in psychiatricmental health nursing
Humanistic theories were generated as a reaction today. His major contributions were to the area of needs
against psychoanalytic premises of instinctual drives. and motivation (Maslow, 1970). Maslow advocated
Humanistic therapies are based on the views of human viewing human behavior from a perspective of needs.
potential for goodness. Instead of focusing on instinc- Human beings have a hierarchy of needs that range from
tual drives, humanist therapists focus on ones ability to basic food, shelter, and warmth to a high-level require-
learn about oneself, acceptance of self, and exploration ment for self-actualization (Fig. 7-1). This model is used
of personal capabilities. Within the therapeutic rela- in understanding individual needs. For example, the
tionship, the patient begins to view himself or herself need for food and shelter must be met before caring for
as a person of worth. A positive attitude is developed. the symptoms of a mental illness.
The focus is not on investigation of repressed memo-
ries, but on learning to experience the world in a dif-
ferent way.
Rogers Client-Centered Therapy
Several concepts that are traced to the psychodynamic the-
Carl Rogers (19021987), an American psychologist, ories are important in the practice of psychiatricmental
developed new methods of client-centered therapy. health nursing, such as interpersonal relationships, defense
Rogers defined empathy as the capacity to assume the mechanisms, transference, countertransference, and inter-
internal reference of the client in order to perceive the nal objects. In particular, a therapeutic interpersonal rela-
world in the same way as the client (Rogers, 1980). To tionship is a core of psychiatricmental health nursing
use empathy in the therapeutic process, the counselor intervention. Through the strength and support of the
must be nondirect, but not passive. Thus, the coun- therapeutic relationship, patients can examine and solve
selors attitude and nonverbal communication are cru- mental health problems (see Chapter 10 for nursing inter-
cial. He also advocated that the therapist develop ventions).
unconditional positive regard, a nonjudgmental caring
for the client (Rogers, 1980). Genuineness is also
important in a therapist, in contrast with the passivity of
the psychoanalytic therapist. Rogers believed that the
therapists emotional investment (ie, true caring) in the
client is essential in the therapeutic process. SELF-
Development of full
Gestalt Therapy personal potential
Another humanistic approach created as a response to
the psychoanalytic model was Gestalt therapy, devel- ESTEEM NEEDS
Self-worth, positive self-image,
oped by Frederick S. (Fritz) Perls (18931970), a Ger- sense of competence
man-born former psychoanalyst who immigrated to the
United States. Perls believed that modern civilization LOVE AND BELONGING NEEDS
inevitably produces neurosis because it forces people to Affection and acceptance from family
and friends, enduring intimacy
repress natural desires and frustrates an inherent human
tendency to adjust biologically and psychologically to SAFETY AND SECURITY NEEDS
the environment. Neurotic anxiety results. For a person Shelter from harm, predictable
to be cured, unmet needs must be brought back to social and physical environment
awareness. He did not believe that the intellectual
insight gained through psychoanalysis enabled people Air, water, food, shelter, sleep, exercise,
to change. Instead, he devised individual and group elimination, sexual expression, health care
exercises that enhanced the persons awareness of emo-
tions, physical state, and repressed needs as well as FIGURE 7.1 Maslows hierarchy of needs.
80 UNIT II Principles of Psychiatric Nursing


One important group of theories that serves as a Edward L. Thorndike
knowledge base for psychiatricmental health nursing A pioneer in experimental animal psychology, Edwin L.
practice is the behavioral theories, which have their Thorndike (18741949) studied the problem-solving
roots in the discipline of psychology. Behavioral theo- behavior of cats to determine whether animals solved
ries attempt to explain how people learn and act. problems by reasoning or instinct. He found that nei-
Behavioral theories never attempt to explain the cause ther choice was completely correct; animals gradually
of mental disorders; instead, they focus on normal learn the correct response by stamping in the stimulus-
human behavior. Research results are then applied to response connection. The major difference between
the clinical situation. Thorndike and behaviorists such as Watson was that
Thorndike believed in the importance of the effects
EARLY STIMULUS-RESPONSE that followed the response or the reinforcement of the
THEORIES behavior. He was the first reinforcement theorist, and
his view of learning became the dominant view in
Pavlovian Theory
American learning theory ( Thorndike, 1916).
One of the earliest behavioral theorists was Ivan P.
Pavlov (18491936), who noticed that stomach secre- B. F. Skinner
tions of dogs were stimulated by triggers other than food
reaching the stomach. He found that the sight and smell One of the most influential behaviorists, B. F. Skinner
of food triggered stomach secretions, and he became (19041990) recognized two different kinds of learning,
interested in this anticipatory secretion. Through his each involving a separate kind of behavior. Respondent
experiments, he was able to stimulate secretions with a behavior, or the end result of classical conditioning, is
variety of other laboratory nonphysiologic stimuli. elicited by specific stimuli. Given the stimulus, the
Thus, a clear connection was made between thought response occurs automatically. The other kind of learning
processes and physiologic responses. is referred to as operant behavior. In this type of learning,
In Pavlovs model, there is an unconditioned stimu- the distinctive characteristic is the consequence of a par-
lus (not dependent on previous training) that elicits an ticular behavioral response, not a specific stimulus. The
unconditioned (ie, specific) response. In his experi- learning of operant behavior is also known as conditioning,
ments, meat was the unconditioned stimulus, and sali- but it is different from the conditioning of reflexes. If a
vation was the unconditioned response. Pavlov would behavior occurs and is followed by reinforcement, it is
then select other stimuli, such as a bell, a ticking probable that the behavior will recur. For example, if a
metronome, and a triangle drawn on a large cue card, child climbs on a chair, reaches the faucet, and is able to
presenting this conditioned stimulus just before the get a drink of water successfully, it is more likely that the
meat, the unconditioned response. If the conditioned child will repeat the behavior (Skinner, 1935).
stimulus was repeatedly presented before the meat,
eventually salivation was elicited only by the condi-
tioned stimulus. This phenomenon was called classical Cognitive Theories
(pavlovian) conditioning (Pavlov, 1927/1960). The initial behavioral studies focused attention on
human actions without much attention to the internal
thinking process. As complex behavior was examined
John B. Watson and the
and could not be accounted for by strictly behavioral
Behaviorist Revolution
explanations, thought processes became new subjects
At about the same time Pavlov was working in Russia, for study. Cognitive theories, an outgrowth of different
John B. Watson (18781958) initiated the psychological theoretic perspectives, including the behavioral and the
revolution known as behaviorism in the United States. psychodynamic, attempted to link internal thought
He developed two principles: frequency and recency. processes with human behavior.
The principle of frequency states that the more often a
given response is made to a given stimulus, the more
likely the response to that stimulus will be repeated.
The principle of recency states that the more recently a
given response to a particular stimulus is made, the Acquiring behaviors by learning from other people is the
more likely it will be repeated. Watsons major contri- basis of social cognitive theory developed by Albert
bution was the rejection of the distinction between Bandura (b. 1925). Bandura developed his ideas after
body and mind and his emphasis on the study of objec- being concerned about violence on television contribut-
tive behavior (Watson & Rayner, 1917). ing to aggression in children. He believes that important
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 81

behaviors are learned by internalizing behaviors of oth- BOX 7.1 RESEARCH FOR BEST PRACTICE
ers. His initial contribution was identifying the process of
Aggression and Best Therapy
modeling: pervasive imitation, or one person trying to
be like another. According to Bandura, the model may
Lanza, M.L., Anderson, J., Boisvert, C.M., LeBlanc, A., Fardy,
not need to be a real person, but could be a character in M., & Steel, B. (2002). Assaultive behavior intervention in
history or generalized to an ideal person (Bandura, 1977). the Veterans Administration: Psychodynamic group psy-
The concept of disinhibition is important to chotherapy compared to cognitive behavior therapy.
Banduras model and refers to the situation in which Perspective Psychiatric Care, 38(3), 8997.
someone has learned not to make a response; then, in a THE QUESTION: Of psychodynamic group psychotherapy
given situation, when another is making the inhibited and cognitive behavior therapy, which has a better out-
response, the individual becomes disinhibited and also come for men with assaultive behavior problems?
METHODS: To test the efficacy of a psychodynamic psy-
makes the response. Thus, the response that was chotherapy group (PPG) and a cognitive-behavior group
inhibited now becomes disinhibited through a (CBG) for male veterans with a history of assault, a
process of imitation. For example, during severe diet- study was conducted in the Veterans Administration
ing, an individual may have learned to resist eating large with 27 male subjects. The men were assigned ran-
amounts of food. However, when at a party with a domly to a central group, PPG, or CBG. Data collected
included the Addiction Severity Index, the Overt Aggres-
friend who eagerly fills a plate at a buffet, the person sion Scale, and the State-Trait Anger Expression Inven-
also eats large amounts of food. tory. Analyses included an overall comparison of the
In the instance of disinhibition, the desire to eat is groups as well as repeated-measures analyses and
already there, and the individual indulges that desire. adjustments for covariates.
However, in another instance, called elicitation, there is FINDINGS: The men in the PPG showed a trend toward
improvement of overt aggression and significant
no desire present, but when one person starts an activ- improvement of trait aggression compared with the
ity, others want to do the same. An example of this men in the CBG. There were no differences in stated
occurs when a child is playing with a toy, and the chil- aggression or efforts to control aggression. Both the
dren also want to play with the same toy even though PPG and CBG are effective treatments for aggression.
they showed no interest in it before that time. IMPLICATIONS FOR NURSING: This study provides hope to
those who have difficulty controlling impulsive,
An important concept of Banduras is self-efficacy, a aggressive behavior. It is possible to decrease aggres-
persons sense of his or her ability to deal effectively sive behavior with more than one intervention.
with the environment (Bandura, 1993). Efficacy beliefs
influence how people feel, think, motivate themselves,
and behave. The stronger the self-efficacy, the higher
the goals people set for themselves and the firmer their and his colleagues developed cognitive therapy, a suc-
commitment to them. cessful approach for the treatment of depression (see
Chapter 18) (Beck, Thase, & Wright 2003).
American psychiatrist Aaron T. Beck (b. 1921) of the HEALTH NURSING
University of Pennsylvania devoted his career to under-
standing the relationship between cognition and mental Basing interventions on behavioral theories is wide-
health. For Beck, cognitions are verbal or pictorial spread in psychiatric nursing. For example, patient edu-
events in the stream of consciousness. He realized the cation interventions are usually based on learning prin-
importance of cognitions when treating people with ciples derived from any number of the behavioral
depression, finding that the depression improved when theories. Teaching patients new coping skills for their
patients began thinking differently (Box 7-1). symptoms of mental illnesses is usually based on behav-
He believed that people with depression had faulty ioral theories. Changing an entrenched habit involves
information-processing systems that led to biased cogni- helping patients identify what motivates them and how
tions. These faulty beliefs cause errors in judgment that these new lifestyle habits can become permanent. In
become habitual errors in thinking. These individuals psychiatric units, behavioral interventions include the
incorrectly interpret life situations, judge themselves too privilege systems and token economies.
harshly, and jump to inaccurate conclusions. A person
may truly believe that he or she has no friends and there-
fore no one cares. On examination, the evidence for the
Developmental Theories
beliefs is based on the fact that there has been no contact The developmental theories explain normal human
with anyone because of moving from one city to another. growth and development and focus on change over time.
Thus, a distorted belief is the basis of the cognition. Beck Many developmental theories are presented in terms of
82 UNIT II Principles of Psychiatric Nursing

stages based on the assumption that normal develop- college students who measured low on identity also
ment proceeds longitudinally from the beginning to the scored low on intimacy ratings (Orlofsky, Marcia, &
ending stage. Although this approach is useful, unless a Lesser, 1973). These results lend support to the idea that
stage model is truly supported by evidence, the model identity precedes intimacy. In still another study, intimacy
does not represent reality. was found to begin developing early in adolescence,
before the development of identity (Ochse & Plug, 1986).
Studying fathers with young children, Christiansen and
Palkovitz (1998) found that generativity was associated
with a paternal identity, psychosocial identity, and psy-
Freud and Sullivan both published treatises on stages of chosocial intimacy. In addition, fathers who had a reli-
human development, but Erik Erikson (19021994) gious identification also had higher generativity scores
outlined the psychosocial developmental model that is than did others. These studies suggest that these well-
most often used in nursing. Eriksons model was an known stages may be neither fixed nor sequential.
expansion of Freuds psychosexual development theory. Evidence also suggests that girls development is dif-
Whereas Freud emphasized intrapsychic experiences, ferent than boys. One study shows that generativity
Erikson recognized the importance of culture. He (defined as the need or drive to produce, create, or effect
believed that similar events may be experienced differ- a change) is associated with well-being in both males and
ently depending on a persons reaction, family back- females, but in males, generativity is related to the urge
ground, and cultural situation. for self-protection, self-assertion, self-expansion, and
Each of Eriksons eight stages is associated with a spe- mastery. In women, the antecedents may be the desire for
cific task that can be successfully or unsuccessfully contact, connection, and union (Ackerman, Zuroff, &
resolved. The model is organized according to develop- Moskowitz, 2000).
mental conflicts by age: basic trust versus mistrust,
autonomy versus shame and doubt, initiative versus guilt,
industry versus inferiority, identity versus role diffusion,
intimacy versus isolation, generativity versus stagnation,
and ego integrity versus despair. Successful resolution of One of the most influential people in child psychology
a crisis leads to essential strength and virtues. For exam- was Jean Piaget (18961980), who contributed more
ple, a positive outcome of the trust versus mistrust crisis than 40 books and 100 articles on child psychology
is the development of a basic sense of trust. If the crisis is alone. Piaget viewed intelligence as an adaptation to the
unsuccessfully resolved, the infant moves into the next environment. He proposed that cognitive growth is like
stage without a sense of trust. According to this model, a embryologic growth: an organized structure becomes
child who is mistrustful will have difficulty completing more and more differentiated over time. Piaget devel-
the next crisis successfully and, instead of developing a oped a system that explains how knowledge develops
sense of autonomy, will more likely to be full of shame and changes. Each stage of cognitive development rep-
and doubt (Erikson, 1963). resents a particular structure with major characteristics
(Table 7-2). Piagets theory was developed through
observation of his own children and therefore never
Identity and Adolescence
received formal testing.
However, one of Eriksons major contributions was the The major strength of his model was its recognition
recognition of the turbulence of adolescent development. of the central role of cognition in development and the
Erikson wrote extensively about adolescence, youth, and discovery of surprising features of young childrens
identity formation. When adolescence begins, childhood thinking. For psychiatricmental health nursing,
ways must be given up, and body changes must be rec- Piagets model provides a framework on which to define
onciled with the individuals social position, previous his- different levels of thinking and use the data in the
tory, and identifications. An identity is formed. This task assessment and intervention processes. For example,
of reconciling how young people see themselves and how the assessment of concrete thinking would be typical of
society perceives them can become overwhelming and people with schizophrenia who are unable to perform
lead to role confusion and alienation (Erikson, 1968). abstract thinking.

Research Evidence for CAROL GILLIGAN: GENDER

Two major areas of study support Eriksons models. One Carol Gilligan (b. 1936) argues that most development
area of research focuses on the developmental stages and models are male centered and therefore inappropriate for
the second on gender differences. In one early study, male girls and women. For Gilligan, attachment within
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 83

Table 7.2 Behavioral Theorists

Theorist Overview Major Concepts Applicability

Edwin R. Guthrie Continued with understanding condition- Recurrence of Important in analyzing
(18861959) ing as being important in learning responses tends to habitual behavior
follow a specific
Ivan P. Pavlov Classical conditioning Unconditioned stimuli Important in understanding
(18491936) Unconditioned learning of automatic
response responses such as habit-
Conditioned stimuli ual behaviors
John B. Watson Introduced behaviorism, believed that Principle of frequency Focuses on the relationship
(18781958) learning was classical conditioning Principle of recency between the mind and
called reflexes; rejected distinction body
between mind and body
Reinforcement Theories
B. F. Skinner Developed an understanding of the Operant behavior Important in behavior
(19041990) importance of reinforcement and dif- Respondent behavior modification
ferentiated types and schedules Continuous reinforce-
Intermittent reinforce-
Edward L. Thorndike Believed in the importance of effects Reinforcement Important in behavior mod-
(18741949) that followed behavior ification programs

Cognitive Theories
Albert Bandura Developed social cognitive theory, a Modeling Important in helping
(b. 1925) model for understanding how behavior Disinhibition patients learn appropri-
is learned from others Elicitation ate behaviors
Aaron Beck Conceptualized distorted cognitions as Cognitions Important in cognitive
(b. 1921) a basis for depression Beliefs therapy
Kurt Lewin Developed field theory, a system for Life space Important in understanding
(18901947) understanding learning, motivation, Positive valences motivation for changing
personality and social behavior Negative valences behavior
Edward Chace Tolman Introduced the concept of cognitions: Cognition Important in Identifying
(18861959) believed that human beings act on persons beliefs
beliefs and attitudes and strive toward

relationships is the important factor for successful female advocate separation as the primary goal of human
development. After comparing male and female person- development immediately place women at a disadvan-
ality development, she highlighted the differences tage. By negating the value and importance of attach-
(Gilligan, 1982). Although the first primary relationship ments within relationships, the natural development of
of both boys and girls is with the mother, in developing women is impaired. If Eriksons model is applied to
identity, boys separate from their mother and girls attach. women, their failure to separate then becomes defined
Thus, girls probably learn to value relationships and as a developmental failure (Gilligan, 1982). Currently,
become interdependent at an earlier age. They learn to there is considerable debate whether or not Eriksons
value the ideal of care, begin to respond to human need, developmental model is applicable to women.
and want to take care of the world by sustaining attach-
ments so no one is left alone. According to Gilligan,
female development does not follow a progression of
stages but is based on experiences within relationships.
However, some researchers suggest that relationships Jean Baker Miller (b. 1927) conceptualizes female
may also be equally important for boys in their develop- development within the context of experiences and rela-
ment of a strong sense of self (Nelson, 1996). tionships. Consistent with the thinking of Carol Gilli-
Gilligans conclusion that female development gan, the Miller relational model views the central orga-
depends on relationships has implications for everyone nizing feature of womens development as a sense of
who provides care to women. Traditional models that connection to others. The goal of development is to
84 UNIT II Principles of Psychiatric Nursing

increase a womans ability to build and enlarge mutually based on systems theory describing a phenomenon in
enhancing relationships (Miller, 1994, p. 83). Connec- terms of a set of interrelated parts, in which the change
tions (mutually responsive and enhancing relation- of one part affects the total functioning of the system. A
ships) lead to mutual engagement (attention), empathy, system can be open and interacting in the environ-
and empowerment. In those relationships in which ment or closed, completely self-contained and not
everyone interacts beneficially, mutual psychological influenced by the environment. The family is viewed
development can occur. Disconnections (lack of mutu- organizationally as an open system in which one mem-
ally responsive and enhancing relationships) occur when bers actions influence the functioning of the total sys-
a child or adult expresses a feeling or explains an experi- tem. Family theories that are important in psychi-
ence and does not receive any response from others. atricmental health nursing are based on systems
The most serious types of disconnection arise from the models but have rarely been tested for wide-range
lack of response that occurs after abuse or attacks. validity. Most of the theoretic explanations have
The theory is currently evolving. Research is ongo- emerged from case studies involved in treatment, rather
ing, but there is support for the importance of relation- than from systematic development of theory based on
ships in female development (Gilligan, 1994; Miller & large samplings. Consequently, the limitation of avail-
Stiver, 1997). There is a report of one psychiatric unit able research should be considered when these models
organized around this model in which the emphasis is are used to understand family interactions and plan
on changing the responses of individuals to remain con- patient care.
nected to others, rather than trying to change their fun-
damental personality (Riggs & Bright, 1997).
Family theories are especially useful to nurses who are
assessing family dynamics and planning interventions.
Developmental theories are used in understanding Family systems models are used to help nurses form
childhood and adolescent experiences and their mani- collaborative relationships with patients and families
festations as adult problems. When working with chil- dealing with health problems. Generalist psychi-
dren, nurses can use developmental models to help atricmental health nurses will not be engaged in fam-
gauge development and mood. However, because ily therapy. However, they will be caring for individuals
most of the models are based on the assumptions of and families. Understanding family dynamics is impor-
the linear progression of stages and have not been ade- tant in every nurses practice. Many family interventions
quately tested, applicability has limitations. In addi- are consistent with these theories (see Chapter 15).
tion, these models were based on a relatively small Many of the symptoms of mental disorders, such as hal-
number of children who typically were raised in a lucinations or delusions, have implications for the total
Western middle-class environment. Most do not family and affect interactions.
account for gender differences and diversity in
lifestyles and cultures.
Social Theories A useful theory for understanding caregiving activities
Numerous social theories underlie psychiatricmental within a community is balance theory, proposed in 1966
health nursing practice. In Chapter 2, some of the by sociologist Eugene Litwak (b. 1925). This theory
sociocultural issues and various social groups were iden- explains the importance of informal and formal support
tified. The nursing profession serves a specific societal systems in the delivery of health care.
function (caregivers and families). This section repre- Formal support systems are large organizations,
sents a sampling of important social theories that nurses such as hospitals and nursing homes, that provide care
may use. This discussion is not exhaustive and should be to individuals. Informal support systems are family,
viewed by the student as including some of the theoretic friends, and neighbors. Litwak found that individuals
perspectives that may be applicable. with strong informal support networks actually live
longer than those without this type of support. In addi-
tion, those without informal support have significantly
FAMILY DYNAMICS higher mortality rates when the causes of death are acci-
Family dynamics are the patterned interpersonal and dents (eg, smoking in bed) or suicides (Litwak, 1985).
social interactions that occur within the family structure A key concept in balance theory is social distance, the
over the life of a family. Family dynamics models are degree to which the values of the formal organization
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 85

and primary group members differ. The formal and society. For example, the universal roles of healer may
informal groups are considered to be balanced when be assumed by a nurse in one culture and a spiritual
they are at a midpoint of social distance, that is, close leader in another. Societal expectations, social status,
enough to communicate, but not so close to destroy and rights are attached to these roles. Psychological
each other, neither enmeshment nor isolation (Litwak, theories, which are concerned about roles from a dif-
Messeri, & Silverstein, 1990; Messeri, Silverstein, & ferent perspective, focus on the relationship of an indi-
Litwak, 1993). If the primary groups and the formal viduals role: the self. The responsibilities of a parent
care system begin performing similar caregiving ser- are often in conflict with the personal needs for time
vices, the formal system increases the social distance by alone. All of the neofreudian and humanist models that
developing linkages with the primary group. Thus, a have been discussed focus on reciprocal social relation-
balance is maintained between the two systems. For ships or interactions that determine how the mind
example, if a patient relies only on the health care develops.
provider for care and support (eg, calls the nurse every
day, visits the physician weekly, refuses any help from
family), the individual will be linked with an informal
support system for help with some of the caregiving
tasks. If the individual refuses any health promotion
interventions from providers, the patient will be Role theories emphasize the importance of social inter-
directly approached by the health care team. action in either the individuals choice of a particular
role or societys recognition of it. Psychiatricmental
health nursing uses role concepts in understanding
group interaction and the role of the patient in the
family and community (see Chapters 14 and 15). In
addition, milieu therapy approaches discussed in later
Balance theory is a practical model for conceptualizing chapters are based on the patients assumption of a role
delivery of mental health care in the community, partic- within the psychiatric environment.
ularly in rural areas where resources are limited. By
using the framework of formal and informal support
systems and social distance, mental health services can Sociocultural Perspectives
be developed and evaluated from this perspective.
Nurse researchers at the Southeastern Rural Mental
Health Research Center at the University of Virginia,
Charlottesville, developed a model for establishing link- American anthropologist Margaret Mead (19011978)
ages of formal and informal caregivers for mental health is widely known for her studies of primitive societies
service for those with serious mental illnesses in rural and her contributions to social anthropology. She con-
areas (Fox, Blank, Kane, Hargrove, & David, 1994). In ducted studies in New Guinea, Samoa, and Bali and
this model, case managers adjust the social distance devoted much of her studies to the patterns of child
between the formal and informal systems by identifying rearing in various cultures. She was particularly inter-
communication barriers and helping the two groups ested in the cultural influences determining male and
work together. For example, a patient misses an female behavior (Mead, 1970). Although her research
appointment because of a lack of transportation. The was often criticized as not having scientific rigor and
case manager helps the patient communicate the prob- being filled with misinterpretations, it became accepted
lem to the system to obtain another appointment. as a classic in the field of anthropology (Torrey, 1992).
Informal caregivers are valued by the case manager, The importance of culture in determining human
who recognizes the important services performed by behavior was acknowledged.
family and friends. Thus, linkages between mental
health providers (formal support) and the consumer
network (informal support) are reinforced.
Concern about the impact of culture on the treatment
Role Theories of children with psychiatric and emotional problems
led Madeleine Leininger (b. 1924) to develop a new
field, transcultural nursing, directed toward holistic,
A role describes an individuals social position and congruent, and beneficent care. Leininger developed
function within an environment. Anthropologic theo- the theory of culture care diversity and universality,
ries explain members roles that relate to a specific which focused on diverse and universal dimensions of
86 UNIT II Principles of Psychiatric Nursing

Cultural care

Cultural & social structure dimensions

Kinship & values & Political &
social factors lifeways legal factors
Environmental context
Language & ethnohistory
Religious &
care expressions,
patterns & practices
Technological Educational
factors factors
Holistic health (well-being)
Individuals, families, groups, communities, & institutions
diverse health systems

Nursing Professional
or folk
care systems

Nursing care decisions & actions

Cultural care preservation & maintenance

Cultural care accommodation & negotiation
Cultural care repatterning & restructuring

Cultural congruent nursing care

Code Influences

FIGURE 7.2 Leiningers Sunrise Model to depict theory of cultural care diversity and
universality. (Adapted from Leininger, M. [Ed.]. [1991]. Culture care diversity and uni-
versality: A theory of nursing. New York: National League for Nursing.)

human caring. Thus, nursing care in one culture is dif- APPLICABILITY OF SOCIOCULTURAL
ferent from that in another because definitions are dif- THEORIES TO PSYCHIATRICMENTAL
ferent. Because caring is an integral part of being HEALTH NURSING
human, as well as a learned behavior, caring is cultur-
The use of sociocultural theories is especially important
ally based (Leininger, 1999). Leininger developed a
for psychiatricmental health nurses. In any individual
model to depict her theory symbolically (Fig 7-2).
or family assessment, the sociocultural aspect is integral
According to Leininger, the model depicts the world
to mental health. It would be impossible to complete an
view, religion, kinship, cultural values, economics,
adequate assessment without considering the role of the
technology, language, ethnohistory, and environmental
individual within the family and society. Interventions
factors that are predicted to explain and influence cul-
are based on the understanding and significance of fam-
ture care (1993, p. 27).
ily and cultural norms. It would be impossible to interact
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 87

with the family in a meaningful way without an under- Peplau also emphasized the importance of empathic
standing of the familys cultural values. In the inpatient linkage, the ability to feel in oneself the feelings expe-
setting, the nurse is responsible for designing the social rienced by another person or people. The interpersonal
environment of the unit as well as ensuring that the transmission of anxiety or panic is the most common
patient is safe from harm. To accomplish this complex empathic linkage. According to Peplau, other feelings,
task, an understanding of the unit as a small social com- such as anger, disgust, and envy, can also be communi-
munity helps the nurse use the environment in patient cated nonverbally by way of empathic transmission to
treatment (see Chapter 13). In addition, many group others. Although the process is not yet understood, she
interventions are based on sociocultural theories (see explains that empathic communication occurs. She
Chapter 14). believes that if nurses pay attention to what they feel
during a relationship with a patient, they can gain
invaluable observations of feelings a patient is experi-
Nursing Theories encing and has not yet noticed or talked about.
The self-system is an important concept in Peplaus
A number of nursing theories are applicable to psychi-
model. Drawing from Sullivan, Peplau defined the self as
atricmental health nursing. Nursing theories are use-
an anti-anxiety system and a product of socialization.
ful in conceptualizing the individual, family, or commu-
nity and in planning nursing interventions. Chapter 13
explains the actual implementation of the interventions. NCLEX Note
The use of a specific theory depends on the patient. For
example, in people with schizophrenia who have prob- Peplaus model of anxiety continues to be an important
lems related to maintaining self-care, Dorothea Orems concept in psychiatric nursing. Severe anxiety inter-
theory of self-care may be useful. By contrast, Hilde- feres with learning. Mild anxiety is useful for learning.
garde Peplaus theories may be appropriate when the
nurse is developing a relationship with the patient. The self proceeds through personal development
Because of the wide range of possible problems requir- that is always open to revision but tends toward a cer-
ing different approaches, familiarity with a variety of tain stability. For example, in parentchild relation-
nursing theories is essential. The following discussion ships, patterns of approval, disapproval, and indiffer-
includes nursing models typically used in psychi- ence are used by children to define themselves. If the
atricmental health nursing. verbal and nonverbal messages have been derogatory,
children incorporate these messages and also view
INTERPERSONAL RELATIONS MODELS themselves negatively. The concept of need is impor-
tant to Peplaus model. Needs are primarily of biologic
Hildegarde Peplau: The Power of origin but need to be met within a sociocultural envi-
Empathy ronment. When a biologic need is present, it gives rise
Hildegarde Peplaus (19091999) theoretic perspectives to tension that is reduced and relieved by behaviors
continue to be an important base for the practice of meeting that need. According to Peplau, nurses are not
psychiatricmental health nursing. Influenced by Harry concerned about needs per se, but recognize the
Stack Sullivan, Peplau introduced the first systematic patients patterns and style of meeting their needs in
theoretic framework for psychiatric nursing and relation to their health status. Nurses interact with the
focused on the nursepatient relationship in her book patient to identify available resources, such as the quan-
Interpersonal Relations in Nursing in 1952 (Peplau, 1952). tity of food, availability of interpersonal support, and
Although her work continues to stimulate debate, she support for interaction patterns that help patients
led psychiatricmental health nursing out of the obtain what is needed. Anxiety is a key concept for
confinement of custodial care into a theory-driven pro- Peplau, who contends that professional practice is
fessional practice. One of her major contributions was unsafe if this concept is not understood.
the introduction of the nursepatient relationship
(see Chapter 10). KEY CONCEPT Anxiety is an energy that arises
Peplau believed in the importance of the environ- when expectations that are present are not met.
ment, defined as those external factors considered
essential to human development (Peplau, 1992): cul-
tural forces, presence of adults, secure economic status If anxiety is not recognized, it continues to rise and
of the family, and a healthy prenatal environment. She escalates toward panic. There are various levels of anxi-
believed in the importance of the interpersonal envi- ety, each having its observable behavioral cues (Box 7-2).
ronment, which included interactions between person These cues are sometimes called defensive, but Peplau
and family, parent and child, or patient and nurse. argues that they are often relief behaviors. For
88 UNIT II Principles of Psychiatric Nursing

BOX 7.2 philosopher who was a survivor of Nazi concentration

camps. Existentialists believe that humans seek meaning
Levels of Anxiety in their life and experiences. Suffering is a feeling of
MILD: Awareness heightens displeasure ranging from simple and transitory mental,
MODERATE: Awareness narrows physical, or spiritual discomfort to extreme anguish,
SEVERE: Focused narrow awareness and to those phases beyond anguish, namely, the malig-
PANIC: Unable to function nant phase of despair. Despair can be experienced as
not caring; the terminal phase that follows is apa-
thetic indifference (Travelbee, 1971). Travelbee also
example, some people may relieve their anxiety by applied the concept of hope and defined it as a mental
yelling and swearing, whereas others seek relief by state characterized by the desire to gain an end or
withdrawing. In both instances, anxiety was generated accomplish a goal combined with some degree of expec-
by an unmet self-system security need. tation that what is desired or sought is attainable.
Travelbee expanded the area of concern of psychi-
atricmental health illness to include long-term physi-
Ida Jean Orlando cal illnesses. Focusing her attention on individuals who
In 1954, Ida Jean Orlando (b. 1926) studied the factors must learn to live with chronic illness, she believed that
that enhanced or impeded the integration of mental the nurses spiritual values and philosophical beliefs
health principles in the basic nursing curriculum. From about suffering would determine the extent to which
this study, she published, The Dynamic NursePatient the nurse could help ill people find meaning in these
Relationship, to offer the nursing student a theory of situations.
effective nursing practice. She studied nursing care of Travelbees model was never subjected to empiric
patients on medicalsurgical units, not people with psy- testing, and because of the philosophical underpin-
chiatric problems in mental hospitals. Orlando identi- nings, it is unlikely that scientific research will be use-
fied three areas of nursing concern: the nursepatient ful. However, her use of the interpersonal process as a
relationship, the nurses professional role, and the iden- nursing intervention and her focus on suffering and ill-
tity and development of knowledge that is distinctly ness helped to define areas of concern and psychiatric
nursing (Orlando, 1961). A nursing situation involves nursing practice.
the behavior of the patient, the reaction of the nurse,
and anything that does not relieve the distress of the
patient. Patient distress is related to the inability of the
Jean Watson
individual to meet or communicate his or her own The science of caring was initiated by Jean Watson
needs (Orlando, 1961; 1972). (b. 1940). Watson believes that caring is the foundation
Orlandos contribution to nursing practice helped of nursing and recommends that specific theories of
nurses focus on the whole patient, rather than on the caring be developed in relation to specific human con-
disease or institutional demands. Her ideas continue ditions and health and illness experiences (Watson,
to be useful today, and current research supports her 1990). She distinguishes between caring and curing, the
model (Olson & Hanchett, 1997). A small nursing work of medicine. The science of caring is based on 7
study investigated whether Orlandos nursing theory- assumptions and 10 carative factors (Box 7-3).
based practice had a measurable impact on patients Watsons theory is especially applicable to the care
immediate distress (n  19) when compared with non- of those who seek help for mental illness. This model
specified nursing interventions (n  11) (Potter & emphasizes the importance of sensitivity to self and
Bockenhauer, 2000). Orlandos approach consisted of others, the development of helping and trusting rela-
the nurse validating the patients distress before taking tions, the promotion of interpersonal teaching and
any action to reduce it. Patients being cared for by the learning, and provision for a supportive, protective,
Orlando group experienced significantly less stress and corrective mental, physical, sociocultural, and spir-
than those being cared for with traditional nursing itual environment. Research studies supporting the
care. model use qualitative approaches (Baldursdottir &
Jonsdottir, 2002).


Joyce Travelbee Imogene M. King
Influenced not only by Peplau and Orlando, Joyce The theory of goal attainment developed by Imogene
Travelbee provided an existential perspective to nursing King (b. 1923) is based on a systems model that includes
based on the works of Victor Frankl, an existential three interacting systems: personal, interpersonal, and
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 89

BOX 7.3
Nursing: Human Science and Human Care (Society)
Assumptions and Factors in Care
Assumptions (Groups)
1. Caring can be effectively demonstrated and prac-
ticed only interpersonally. PERSONAL
2. Caring consists of factors that result in the satisfac- SYSTEMS
tion of certain human needs. (Individuals)
3. Effective caring promotes health and individual or
family growth.
4. Caring responses accept a person not only as he or
she is now but also as what he or she may
5. A caring environment offers the development of
potential while allowing the person to choose the
best action for himself or herself at a given point in
6. Caring is more "healthogenic" than is curing. It
integrates biophysical knowledge with knowledge
of human behavior to generate or promote health
and provide ministrations to those who are ill. A
science of caring is complementary to the science FIGURE 7.3 Imogene Kings conceptual framework for
of curing. nursing: dynamic interacting systems.
7. The practice of caring is central to nursing.
Carative Factors
1. Formation of a humanisticaltruistic system of system interacting with the environment. The variables
values in nursing situations are as follows:
2. Instillation of faith or hope Geographic place of the transacting system, such
3. Cultivation of sensitivity to ones self and to others as the hospital
4. Development of a helping, trusting relationship
Perceptions of nurse and patient
5. Promotion and acceptance of the expression of pos-
itive and negative feelings Communications of nurse and patient
6. Systematic use of the scientific problem-solving Expectations of nurse and patient
method for decision making Mutual goals of nurse and patient
7. Promotion of interpersonal teaching and learning Nurse and patient as a system of interdependent
8. Provision for a supportive, protective, and correc-
roles in a nursing situation (King, 1981, p. 88)
tive mental, physical, sociocultural, and spiritual
environment The quality of nursepatient interactions may have
9. Assistance with the gratification of human needs positive or negative influences on the promotion of
10. Allowance for existential-phenomenologic force health in any nursing situation. It is within this interper-
sonal system of nurse and patient that the healing process
is performed. Interaction is depicted in which the out-
come is a transaction, defined as the transfer of value
social. She believes that human beings interact with the between two or more people. This behavior is unique,
environment and that the individuals perceptions influ- based on experience, and is goal directed (Fig. 7-3).
ence reactions and interactions (Fig. 7-3). For King, Kings work reflects her understanding of the sys-
nursing involves caring for the human being, with the tematic process of theory development. She is a con-
goal of health defined as adjusting to the stressors in temporary nursing theorist, and her model continues to
both internal and external environments. She defines be developed and applied in different settings, including
nursing as a process of human interactions between psychiatricmental health care. The King model was
nurse and patient whereby each perceives the other and applied in group therapy for inpatient juvenile offend-
the situation; and through communication, they set ers, maximum security state offenders, and community
goals, explore means, and agree on means to achieve parolees (Laben, Dodd, & Snead, 1991). This model
goals (King, 1981, p. 144). This model focuses on the has also been used as a nursing framework for individ-
process that occurs between a nurse and a patient. The ual psychotherapy (DeHowitt, 1992).
process is initiated to help the patient cope with a health
problem that compromises his or her ability to maintain
Betty Neuman
social roles, functions, and activities of daily living
(King, 1992). Betty Neuman (b. 1924) also used a systems approach as
In this model, the person is goal oriented and pur- a model of nursing care. Neuman wanted to extend care
poseful, reacting to stressors and is viewed as an open beyond an illness model, incorporating concepts of
90 UNIT II Principles of Psychiatric Nursing

problem finding and prevention and the newer behav- independence of the individual and on self-care activi-
ioral science concepts and environmental approaches to ties (Campbell & Soeken, 1999). Although many psy-
wellness. Neuman developed her framework in the late chiatric disorders have an underlying problem, such as
1960s as chairwoman of the University of California at motivation, these problems are generally manifested as
Los Angeles graduate nursing program. The purpose of difficulties conducting ordinary self-care activities (eg,
the model is to guide the actions of the professional personal hygiene) or developing independent thinking
caregiver through the assessment and intervention skills.
processes by focusing on two major components: the
nature of the relationship between the nurse and Other Nursing Theories
patient, and the patients response to stressors. The
patient may be an individual, group (eg, a family), or a Other nursing models are applied in psychiatric set-
community. The nurse is an intervener who attempts tings. Martha Rogers model of unitary human beings
to reduce an individuals encounter with stress and to and Calista Roys adaptation model have been the basis
strengthen the persons ability to deal with stressors. of many psychiatric nursing approaches.
The patient is viewed as a collaborator in setting health
care goals and determining interventions. Neuman was SUMMARY OF KEY POINTS
one of the first psychiatric nurses to include the concept
of stressors in understanding nursing care. The biologic framework forms a new basis for
The model continues to be developed and applied. nursing considerations based on such models as
For example, the latest edition of the Neuman sys- diathesis-stress and imbalances in brain chemistry.
tems model is applied to a diversity of settings, The traditional psychodynamic framework helped
including community health, family therapy, renal form the basis of early nursing interpersonal inter-
nursing, perinatal nursing, and mental health nursing ventions, including the development of therapeutic
of older adults (Neuman, Newman, & Holder, 2000). relationships and the use of such concepts as trans-
The model has also been applied to nursing care of ference, countertransference, empathy, and object
patients with multiple sclerosis (Knight, 1990) and relations.
quality-of-life indicators defined as a perception of The behavioral theories are often used in strate-
good physical health, being comfortable with socioe- gies that help patients change behavior and thinking.
conomic status, and developing a psychospiritual self Sociocultural theories remain important in under-
(Hinds, 1990). The Neuman Systems Model Trustee standing and interacting with patients as members of
Group, Inc. was established in 1988 to preserve, pro- families and cultures.
tect, and perpetuate the integrity of the model for the Nursing theories form the conceptual basis for
future of nursing. nursing practice and are useful in a variety of psychi-
atricmental health settings.

Dorothea Orem
Self-care is the focus of the general theory of nursing
initiated by Dorothea Orem in the early 1960s. The 1 Discuss the importance of the biologic theories in
theory consists of three separate parts: a theory of self- mental health practice. Compare Selyes model with
care, theory of self-care deficit, and theory of nursing the diathesis-stress model.
systems (Orem, 1991). The theory of self-care defines 2 Discuss the similarities and differences between
the term as those activities performed independently by Freuds ideas and the neofreudians, including Jung,
an individual to promote and maintain personal well- Adler, Horney, and Sullivan.
being throughout life. The central focus of Orems the- 3 Compare and contrast the basic ideas of psychody-
ory is the self-care deficit theory, which describes how namic and behavioral theories.
people can be helped by nursing. Nurses can help meet 4 Compare and differentiate classic conditioning from
self-care requisites through five approaches: acting or operant conditioning.
doing for; guiding; teaching; supporting; and providing 5 Define the following terms and discuss their applic-
an environment to promote the patients ability to meet ability to psychiatricmental health nursing: classical
current or future demands. The nursing systems theory conditioning, operant conditioning, positive reinforce-
refers to a series of actions a nurse takes to meet the ment, and negative reinforcement.
patients self-care requisites. This system varies from 6 List the major developmental theorists and their
the patient being totally dependent on the nurse for main ideas.
care, to needing only some education and support. 7 Discuss the cognitive therapy approaches to mental
Orems model is used extensively in psychiatricmental disorders and how they can be used in psychiatric
health nursing because of its emphasis on promoting mental health nursing practice.
CHAPTER 7 Theoretic Basis of Psychiatric Nursing 91

8 Define formal and informal support systems. How Viewing Points: Observe Janet Frames childhood
does the concept of social distance relate to these two development. Does she fit any of the models that are
systems? discussed in this chapter? Consider her life in light of
9 Compare and contrast the basic ideas of the nursing Gilligan and Millers theories that it is important for
theorists. women to have a sense of connection.

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For challenges and updates, go to www.connection.lww.com or refer to the CD-ROM in the back of this book.
The Biologic
Foundations of
Psychiatric Nursing
Susan McCabe

After studying this chapter, you will be able to:
Describe the association between biological functioning and symptoms of psychi-
atric disorders.
Describe approaches researchers have used to study the central nervous system and
the significance of each approach.
Locate brain structures primarily involved in psychiatric disorders; describe the pri-
mary functions of these structures.
Assess symptoms of common psychiatric disorders in terms of central nervous sys-
tem functioning.
Describe the mechanisms of neuronal transmission.
Identify the location and function of neurotransmitters significant to hypotheses
regarding major mental disorders.
Discuss the basic utilization of new knowledge gained from fields of study, includ-
ing psychoendocrinology, psychoimmunology, and chronobiology.
Discuss the role of genetics in the development of psychiatric disorders.

amino acids animal model autonomic nervous system basal ganglia biogenic
amines biologic markers circadian cycle chronobiology cortex frontal,
temporal, parietal, and occipital lobes genome hippocampus limbic system
neurohormones neuropeptides psychoendocrinology psychoimmunology
receptors risk factors symptom expression synapse zeitgebers

neurotransmitters plasticity

94 UNIT II Principles of Psychiatric Nursing

A ll behavior recognized as human results from

actions that originate in the brain and its amazing
interconnection of neural networks. Modern research
King George III (17391830)
has increased understanding of how the complex cir- Bipolar Illness Misdiagnosed
cuitry of the brain interacts with external environment, Public Personna
memories, and experiences. Through the spinal column Crowned King of England at age 22, George III
and peripheral nerves, along with other systems, such as headed the most influential colonial power in the
the endocrine and immune systems, the brain con- world at that time. England thrived in the peacetime
stantly receives and processes information. As the brain after the Seven Years War with France, but simultane-
ously taxed its American colonies so heavily and res-
shifts and sorts through the amazing amount of infor- olutely that the colonies rebelled. Could the Ameri-
mation it processes every hour, it decides on actions and can Revolution be blamed on King George IIIs
initiates behaviors that allow each person to act in (17391820) state of mind?
entirely unique and very human ways.
Personal Realities
At age 50, the king first experienced abdominal pain
and constipation, followed by weak limbs, fever,
Foundational Concepts tachycardia, hoarseness, and dark red urine. Later, he
experienced confusion, racing thoughts, visual prob-
This chapter reviews the basic information necessary for lems, restlessness, delirium, convulsions, and stupor.
understanding neuroscience as it relates to the role of His strange behavior included ripping off his wig and
running about naked. Although he recovered and did
the psychiatricmental health nurse. It will review basic not have a relapse for 13 years, he was considered to
central nervous system (CNS) structures and functions; be mad. Relapses after the first relapse became more
basic mechanisms of neurotransmission; general func- frequent and the king was eventually dethroned by
tions of the major neurotransmitters; basic structure and the Prince of Wales.
function of the endocrine system; genetic research; cir- Was Georges madness in reality a genetically
transmitted blood disease that caused thought dis-
cadian rhythms; neuroimaging techniques; and biologic turbances, delirium, and stupor? The genetic disease
tests. The chapter assumes that the reader has a basic porphyria is caused by defects in the bodys ability to
knowledge of human biology, anatomy, and pathophysi- make haem. The diseases are generally inherited in
ology. It is not intended as a full presentation of neu- an autosomal dominant fashion. The retrospective
roanatomy and physiology, but rather as an overview of diagnosis was not made until 1966 (Macalpine &
Hunter, 1966). Before that, it was believed that he
the structures and functions most critical to understand- suffered bipolar disorder.
ing the role of the psychiatricmental health nurse. Other members of the royal family who suffered
from this hereditary disease were Queen Anne of
Great Britain, Frederic the Great of Germany, George
THE BIOLOGICAL BASIS IV of Great Britain (son of George III), and George IVs
OF BEHAVIOR daughter, Princess Charlotte, who died during child-
birth from complications of the disease.
As our understanding of the brain grows, evidence accu-
Source: Macalpine, I. and Hunter, R. (1966). The insanity of King
mulates that most human behaviors have a biological George 3d: a classic case of porphyria. British Medical Journal,
basis. Whether it is responding angrily, impulsively 5479(1), 6571.
making a purchase, or struggling to make a decision,
behaviors are in large part rooted in the neurocircuitry
of the brain. So when common psychiatric symptoms stand the scientific rationale for many of the nursing
manifest as abnormal behaviors (eg, seeing things that are care and treatment decisions presented in this book.
not there, attempting suicide, talking in odd or unusual As you read this chapter, think about what you know
ways), we look to the brain. Symptom expression is a about the symptoms of mental illness. Psychiatricmental
term referring to the behavioral symptoms seen in men- health nurses must be able to make the connection
tal illness and the link to the neurobiologic basis of the between (1) patients psychiatric symptoms, (2) the prob-
symptom. Because symptoms of psychiatric illness erupt able alterations in brain functioning linked to those
mainly as behavioral disturbance, and because the symptoms, and the (3) rationale for treatment and care
behavioral symptoms are linked to anomalies in brain practices. Knowledge of the CNS is an inescapable
functioning, psychiatricmental health nurses need to aspect of modern psychiatric nursing.
understand disease symptoms in relationship to brain
Animal Modeling
Just as a breathing problem is often a symptom of
respiratory disorders, psychiatric symptoms are often How do scientists come to know about the workings of
indicators of a CNS problem. Understanding this the brain? Animal modeling is the most common
fundamental concept makes it much easier to under- research method for studying the CNS. It involves using
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 95

nonhuman organisms (animals such as rats and mice) to entire human genome sequence would fill a thousand
study biological processes and how certain diseases 1,000-page telephone books. Now that it is completed,
affect those processes. Animal models resemble humans the genome map can be used for studying the function
in anatomical structure, function, and genetics, allowing of each gene and the disease-inducing capacity of those
for research and learning that would not be possible to genes when they malfunction.
do with humans. Using animals, scientists can induce A gene comprises short segments of DNA and is
disease that occurs in humans and test treatments before packed with the instructions for making proteins that
attempting to treat humans who have that disease. Com- have a specific function. When genes are absent or mal-
mon examples of using animals to study human illness function, protein production is altered, and bodily func-
include studying cancer in mice, studying tissue reac- tions are disrupted. In this fashion, genes play a role in
tions to transplanted cells in pigs, and analyzing DNA cancer, heart disease, diabetes, and many psychiatric
from a fly to study the genetic links of disease. Rats and disorders.
mice are used in more than 90% of all medical research, There are about 100,000 genes in the human
and breeding mice for research is now a $200 million per genome, with the brain accounting for only about 1%
year business in the United States (ORourke & Lee, of the bodys DNA. Genes direct protein production.
2003; Orth & Tabrizi, 2003). Animal models allow Gene expression is the result of the genes direction, or
researchers to examine diseases such as high blood pres- the production of these proteins. It is not a static con-
sure, Parkinsons illness, depression, and Alzheimers, as dition fixed at some point in neuronal development.
well as the neurobiology of normal behaviors, such as Individual nerve cells may respond to neurochemical
eating, mating, and learning. Researchers can then use changes outside of the cell, producing different proteins
the animal model to study what controls a behavior or for adaptation to the new environment. This dynamic
the way a disease progresses and how symptom expres- nature of gene function highlights the manner in which
sion occurs. Animal models are increasingly being used the body and the environment interact and in how envi-
to explore psychiatric illnesses such as schizophrenia, ronmental factors influence gene expression.
bipolar disorder, and anxiety disorders, and to expand
our knowledge of the illnesses, including the genetic
Population Genetics
basis for common psychiatric disorders. Every drug used
to treat psychiatric disorders was first researched and The study of molecular genetics in psychiatric disorders
tested in animal models. is in its infancy. Because the exact genetic basis of psy-
chiatric disorder remains unclear, and animal models
are hard to produce for some disorders, much of what
we know about the genetics of psychiatric disorders
It has been known for some time that family members comes from studies that trace given disorders within
of individuals who have one of the major mental disor- groups of people. This technique, called population
ders, such as schizophrenia, mania, or panic disorder, genetics, involves the analysis of genetic transmission of
have an increased risk for the same disorder. Animal a trait within families and populations to determine
models have greatly increased the ability of researchers risks and patterns of transmission. The risk for a given
to understand the influence of genetics on symptom disorder occurring in the general population can then
expression in psychiatric disorders, and many of the be compared with the risk within families and between
common psychiatric disorders that nurses encounter groups of relatives. These studies rely on the initial
have a known genetic component. As genetic knowl- identification of an individual who has the disorder and
edge increases, treatments that work at the genetic level include the following principal methods:
are rapidly being developed ( Johnson & Brensinger, Family studiesanalyze the occurrence of a disor-
2000). der in first-degree relatives (biologic parents, sib-
Genetic processes control how humans develop from a lings, and children), second-degree relatives
single-cell egg into an adult human. Genes control the (grandparents, uncles, aunts, nieces, nephews, and
regrowth of hair and skin cells, the growth and connec- grandchildren), and so on.
tion of nervous system cells, and our biological reaction Twin studiesanalyze the presence or absence of
to stress. Genes make humans dynamic organisms, capa- the disorder in pairs of twins. The concordance rate
ble of growth, change, and development. The Human is the measure of similarity of occurrence in indi-
Genome Project, started in 1990, mapped the complete viduals with similar genetic makeup.
set of human genes, or genome, carried by all of us and Adoption studiescompare the risk for the illness
transmitted to our offspring. The human genome is now developing in offspring raised in different environ-
completely identified, providing researchers with a road ments. The strongest inferences may be drawn
map of the exact sequence of the 3 billion nucleotide from studies that involve children separated from
bases that make up human organisms. If printed out, the their parents at birth.
96 UNIT II Principles of Psychiatric Nursing

Few traits are completely heritable. Color blindness Risk Factors

and blood type are examples of traits that exist because
The concept of genetic susceptibility suggests that an
of heredity alone. Monozygotic twins have identical
individual may be at increased risk for a psychiatric dis-
genetic contributions; therefore, both would have color
order. Research into risk factors is an important avenue
blindness or the same blood type if they expressed that
of study. Just as knowledge of risk factors for diabetes
gene. This is 100% concordance. If a disorder were
and heart disease led to development of preventative
completely unrelated to genetics, then monozygotic
interventions, learning more about risk factors for psy-
twins would have the same concordance rates as dizy-
chiatric disorders will lead to preventative care prac-
gotic (fraternal) twins, who share roughly the same pro-
tices. Specific risk factors for psychiatric disorders are
portion of genes that ordinary siblings do50%. If
just beginning to be understood, and some of the envi-
there is a genetic contribution with environmental
ronmental influences listed previously may be examples
influence, the concordance rates would be less than
of risk factors. These events, circumstances, or demo-
100% for monozygotic twins but significantly greater
graphic information are more likely to occur in individ-
than for dizygotic twins. Such is the case with several
uals who experience a particular psychiatric disorder. In
psychiatric disorders. Although no conclusive evidence
the absence of one specific gene for the major psychi-
exists for a complete genetic cause of most psychiatric
atric disorders, risk factor assessment may be a logical
disorders, significant evidence suggests strong genetic
alternative for predicting who is more likely to experi-
contributions exist for most (Harrison & Owen, 2003
ence psychiatric disorders or certain conditions, such as
Green et al., 2003; Lea, 2000; McGuffin et al., 2003;
aggression or suicidality. This is a growing area of
Merikanga & Avenevoli, 2000).
psychiatric nursing.
It is likely that psychiatric disorders are polygenic.
This means that more than one gene is involved in pro-
ducing a psychiatric disorder and that the disorder
develops from genes interacting, which produces a risk Current Approaches and
factor, and environmental influences that lead to the
expression of the illness. The environmental factors
Technologic Advances
may include stress, infections, poor nutrition, cata- Neuroscience researchers have used several approaches
strophic loss, complications during pregnancy, and to the study of the CNS structure and function. These
exposure to toxins. Thus, genetic compositions convey approaches occur with both human research and animal
vulnerability, or a risk for the illness, but the right set of models. The approaches, highlighted in Table 8-1,
environmental factors must be present for the disease to include the following:
develop in the at-risk individual. Comparative
When considering information regarding risks for Developmental
genetic transmission of psychiatric disorders, it is Chemoarchitectural
important to remember several key points: Cytoarchitectural
Psychiatric disorders have been described and Functional
labeled quite differently across generations, and These different approaches to studying the CNS have
errors in diagnosis may occur. significantly increased our understanding of normal
Similar psychiatric symptoms may have considerably CNS functioning and how disease affects behavior and
different causes, just as symptoms such as chest contributes to the development of psychiatric disorders.
pain may occur in relation to many different causes. Research shows that areas of the brain, and the groups
Genes that are present may not always cause the of nerve cells that comprise that area, often work
appearance of the trait. together as functional units. A hierarchy of function
Several genes work together in an individual to exists in which primary sensory input is used in an
produce a given trait or disorder. increasingly more complex and integrated manner
A biologic cause is not necessarily solely genetic in across areas of the brain. In addition, some areas of the
origin. Environmental influences alter the bodys brain, such as those that control basic levels of alertness
functioning and often mediate or worsen genetic and attention, must work correctly for information to
risk factors. be received, understood, and used by higher levels of
As the public awareness of genetic evidence grows, it the brain to organize a response. The brains functional
is likely that a psychiatricmental health nurse will be units work together to control or contribute to specific
faced with patients or family members requesting behaviors or emotions.
genetic testing or needing information regarding their The integrated approach to brain development is the
likelihood of risk for a psychiatric disorder. As a result, term used to describe the interactive working of brain
psychiatric nurses increasingly will need skills in genetic areas and function. Understanding the work as an inte-
teaching and counseling. gration of parts allows us to understand that specific
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 97

Table 8.1 Approaches to the Study of Neuroanatomy

Approach Purpose Potential Limitations

Comparative Explores and compares behavior across Difficult to correlate animal behavior to human
animal nervous systems from a simple especially emotional
primitive cordlike structure in some New brain structures do not necessarily corre-
species to the large complex of the late to new behavior
human brain
Developmental Studies nervous system structure within an Impossible to follow one human beings neu-
individual or species of animal across dif- ronal development
ferent stages of development Individual variation in development complicates
comparisons of individuals across a specific
point of time in development
Chemoarchitecture Identifies differences in location of neuro- Boundaries between regional changes are sub-
chemicals such as neurotransmitters tle and may vary across individuals
throughout the brain
Cytoarchitecture Identifies differences or variations in cell Boundaries between regional changes are sub-
type, structure, and density throughout the tle and may vary across individuals
brain mapping these variations by location
Functional Identifies location of predominant control Several regions or stuctures within the brain
over various behavioral functions within may contribute to one behavior, making pre-
the brain dominant control difficult to assign
Studies often conducted on the basis of dys- Controversy exists in correlating normal brain
function from a localized injury to the brain function to damaged brain tissue

areas of the brain control specific function. For exam- NEUROIMAGING

ple, there is a speech area in the brain, a mood area, an
Since the 1980s, technologic advances in neuroimaging
appetite area, and so on. Understanding the function of
techniques have been a major aid to the current under-
areas of the brain allows nurses to assess a patients
standing of how the human brain functions. As knowl-
symptoms as, in large part, an expression of a problem
edge grows, neuroimaging techniques are moving from
with a specific brain area. Just as a person with an irreg-
research to routine clinical use, requiring psychi-
ular radial heart beat is experiencing disruption in nor-
atricmental health nurses to understand this technol-
mal cardiac function, a person who fails to eat because
ogy. Two basic neuroimaging methods are structural
of depression is experiencing a disruption in the brains
and functional neuroimaging.
normal appetite and mood function.

KEY CONCEPT Plasticity is the ability of the Structural Neuroimaging

brain to change its structure and function in various
ways to compensate for changes in the neuronal envi- Structural neuroimaging techniques were the first form
ronment (Mohr & Mohr, 2001). of neuroimaging that allowed visualization of brain
structures. Structural images show what normal struc-
Neuroplasticity is an increasingly important concept tures of the brain look like and allow clinicians to iden-
when describing brain function. The changes in neural tify tissue abnormalities, changes, or damage. Com-
environment can come from internal sources, such as a monly used structural neuroimaging techniques include
change in electrolytes, or from external sources, such as computed axial tomography (CT) scanning and mag-
a virus or toxin. With neuroplasticity, nerve signals may netic resonance imaging (MRI). Although these tech-
be rerouted, cells may learn new functions, sensitivity or niques are useful in identifying what the brain looks like,
number of cells may increase or decrease, or some nerve they do not reveal anything about how the brain works.
tissue may be regenerated in a limited way. Brains are
most plastic during infancy and young childhood, when
Computed Axial Tomography
large adaptive learning tasks should normally occur.
With age, brains become less plastic, which explains why CT scanning first allowed scientists and clinicians to see
it is easier to learn a second language at the age of 5 years structures inside the brain without more invasive and
than 55 years. Neuroplasticity contributes to under- potentially dangerous methods. CT scans still use an
standing how function may be restored over time after x-ray beam passed through the head in serial slices.
brain damage occurs or how an individual may react High-speed computers measure the decreased strengths
over time to continuous pharmacotherapy regimens. in the x-ray beam that results from absorption, and the
98 UNIT II Principles of Psychiatric Nursing

computer assigns a shade of gray that reflects that period. Some tubes are now being made of clear plastic
change. The degree of energy absorbed by a tissue is to decrease the claustrophobic sensation.
proportionally related to its density. For example, cere-
brospinal fluid (CSF) decreases the least, so it appears
Functional Neuroimaging
the darkest, whereas bone absorbs the most and appears
light. White matter and gray matter are more difficult Although structural imaging identifies what the brain
to discriminate with CT technology. looks like, the scans do not show how the brain is work-
CT scans can be done with or without contrast ing. Functional neuroimaging techniques measure phys-
material. If a contrast agent is used, an iodinated or iologic activities, providing insight into how the brain
other material is intravenously administered to works. These methods let researchers study such activi-
enhance the CT image. Although CT scanning is a rel- ties as cerebral blood flow, neuroreceptor location and
atively safe, noninvasive procedure, the contrast mate- function, and distribution patterns of specific chemicals
rial may have some adverse effects in some patients. within the brain. Single photon emission computed
Some patients receiving contrast materials report a tomography (SPECT) and positron emission tomogra-
metallic taste in the mouth, and some experience mild phy (PET) are the primary methods used to observe
nausea, rashes, or joint pain. In rare instances, severe metabolic functioning. Both procedures require adminis-
allergic responses, including anaphylaxis, may develop, tering radioactive substances that emit charged particles,
so nurses must closely monitor patients who have which are then measured by scanning equipment.
received contrast media. In addition, because the equip- Because these procedures measure function, the patient
ment itself may frighten the patient, the nurse should is usually asked to perform specific tasks during the test.
educate the patient about the scan. Some patients may The Wisconsin Card Sorting Test (WCST), which is
need to be accompanied during the procedure for on- commonly used, requires the individual to sort cards with
going reassurance. different numbers, colors, and shapes into piles based on
specified rules. This task requires use of the brains
frontal lobe, an important area for concept formation and
Magnetic Resonance Imaging
decision making, and an area that often is disrupted in
MRI is performed by placing a patient into a long tube many psychiatric disorders. Figure 8-1 illustrates the dif-
that contains powerful magnets. The magnetic field ferences between the frontal lobe activity of a pair of
causes hydrogen-containing molecules (primarily water) twins, one with schizophrenia and one without.
to line up and move in symmetric ways around their axes.
The magnetic field is then interrupted in pulses, causing
Positron Emission Tomography
the molecules to turn 90 or 180 degrees. Electromagnetic
energy is released when the molecules return to their PET measures glucose consumption in various brain
original position. The energy released is related to the regions. Because cells use glucose as fuel for cellular
density of the tissue and is detected by the MRI device, action, the higher the rate of glucose use detected by
resulting in a scan measurement of the density of exam- the PET scan, the higher the rate of metabolic activity
ined tissue. The CT scan is limited to one-dimensional in different areas of the brain. Abnormalities in glucose
images, but the MRI can produce three-dimensional consumption, indicating more or less cellular activity,
images extremely clearly, allowing for discrimination of are found in Alzheimers disease, seizures, stroke,
white and gray matter and other subtle changes in tissue. tumor, and a number of psychiatric disorders. Scanning
MRI scans produce more information than CT may be performed while the individual is at rest or per-
images, but they also are more complicated and costly. forming a cognitive task. PET scans are often used to
In addition, MRI scans cannot be used for all patients. measure regional cerebral blood flow and neurotrans-
Because MRI uses magnet energy, individuals with mitter system functions.
pacemakers, metal plates, bone replacements, aneurysm
clips, or other metal in their body cannot undergo the
Single Photon Emission Computed
procedure; pregnant women also cannot have MRI
scans. In addition, the loud noise of the equipment and
the very narrow tube in which the patient must lie still SPECT is helpful in measuring regional cerebral blood
trigger claustrophobic responses in some people. Ade- flow. Evidence documents the use of SPECT scans in
quate preparation of the patient by the nurse should differentiating depression from dementia (Cho et al.,
eliminate any surprises. Assistance with shallow breath- 2002). Well documented in Alzheimers disease (Vercel-
ing techniques, mental distractions, or other anxiety- letto et al., 2002), decreased cerebral blood flow in
reducing strategies may help. Many MRI facilities are specific areas of the brain is not found in depression.
equipped with music to mask the whirring of the equip- SPECT scans are also used to confirm changes in cere-
ment and provide a distraction through the long testing bral blood flow caused by certain drugs. For example,
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 99

FIGURE 8.1 Differences in the

frontal lobe activity of a pair of
twins, one with the mental dis-
order of schizophrenia, and one
who does not have the disor-
der. Figure courtesy of Drs. K. F.
Berman and D. R. Weinberger,
Clinical Brain Disorders Branch,
National Institute of Mental

caffeine and nicotine cause a generalized decrease in cere- are used primarily as research tools, they also are
bral blood flow. New compounds have been developed becoming useful in clinical practice.
recently to visualize the numbers or density of receptors
in various areas of the brain, which may assist in under-
standing the effects of psychopharmacologic medications Neuroanatomy of the
and neuroplastic changes in brain tissue over time.
Central Nervous System
With advances in brain science comes greater under-
Bridging the Structure-Function Gap standing of the biological basis of mental illnesses.
As structural and functional neuroimaging techniques Therefore, psychiatricmental health nurses must
advance, attempts are being made to develop imaging increasingly be aware of the anatomic intricacy of the
procedures that detail structure and function at the CNS as a foundation for modern psychiatric nursing
same time. Magnetic resonance spectroscopy (MRS) assessments and interventions.
and functional magnetic resonance imaging (fMRI) are Although this section discusses each functioning area
examples. The fMRI is useful for showing structure of the brain separately, each area is intricately con-
while localizing functioning and providing clear, high- nected with the others and each functions interactively.
resolution images. Like other forms of neuroimaging, The CNS contains the brain, brain stem, and spinal
the fMRI is noninvasive, but it requires no radioactive cord, whereas the total human nervous system includes
agent, making it economical and safer than PET and the peripheral nervous system (PNS) as well. The PNS
SPECT (Hennig, Speck, Koch, & Weiller, 2003). consists of the neurons that connect the CNS to the
MRS uses the same machinery as fMRI and provides muscles, organs, and other systems in the periphery of
precise and clear images of neuronal membranes as well the body. Whatever affects the CNS may also affect the
as measures of metabolic cellular function (Heerschap, PNS, and vice versa.
Kok, & Van De, 2003). In addition to these proce-
dures, electromagnet encephalography (EEG/MEG)
is being used. This procedure combines traditional
EEG measurement (discussed later in this chapter) The largest part of the human brain, the cerebrum fills
with imaging to visualize cellular electrical activity in the entire upper portion of the cranium. The cortex, or
the brain. Table 8-2 summarizes these neuroimaging outermost surface of the cerebrum, makes up about
methods. Although these neuroimaging procedures 80% of the human brain. The cortex is four to six
100 UNIT II Principles of Psychiatric Nursing

Table 8.2 Methods of Neuroimaging

Method Description Considerations

Structural Imaging
Computed tomography Uses X-ray technology to measure tissue Contrast medium may produce allergic reac-
(CT), also called com- density, is readily available, can be tions; individuals with increased risk for con-
puterized axial tomog- completed quickly, and less costly, may trast media complications include those with
raphy (CAT) be used for screening, but many disease History of previous reactions
states are not clearly seen, use of con- Cardiac disease
trast medium improves resolution Hypertension
Sickle cell disease
Contraindications for use of contrast:
Iodine/shellfish allergies
Renal disease
Magnetic resonance Uses a magnetic field to magnetize hydro- Patients may experience headaches, dizziness,
imaging (MRI) gen atoms in soft tissue, changing their and nausea: symptoms of anxiety, claustro-
alignmentthis creates a tiny electric phobia, or psychosis can increase; contraindi-
signal, which can be received to produce cated when patients have:
an image; produces greater resolution Aneurysm clips
that a CT, diagnosing more subtle patho- Internal electrical, magnetic, or mechanical
logic changes devices, such as pacemakers
Metallic surgical clips, sutures; and dental
work distort the image Claustrophobia
Functional Neuroimaging
Positron emission Uses positron emitting isotopes (very short Images appear blurry, lacking anatomic detail,
tomography (PET) lived radioactive entities such as oxygen- but have been extremely useful in research to
15) to image brain functioning; isotopes study distribution of neuro-receptors and the
are incorporated into specific molecules action of pharmacologic agents; invasive pro-
to study cerebral metabolism, cerebral cedure, use of radioactivity limits the number
blood flow, and specific neurochemicals of scans done with a single individual
Single photon emission Like PET, SPECT uses radioisotopes that Less resolution than the PET, but inhalation
computed tomography produce only one photon; these isotopes methods may be used, allowing for some
(SPECT) are readily available from commercial repeated studies
sources and are accessible in many clini-
cal centers
Functional magnetic res- Combines spatial resolution of MRI with the Requires no radiation and can be completely
onance imaging (fMRI) ability to image neural activity; methods noninvasive; individual can be imaged many
are still very early in development times, in different clinical states, before or
after treatments; removes many of the ethical
constraints when studying children and ado-
lescents with psychiatric disorders
Magnetic resonance Uses the same imaging equipment of the Noninvasive, repeatable, may be ideal for longi-
spectroscopy (MRS) fMRI; by altering scanning parameters, tudinal studies, but has limited spatial resolu-
signals represent specific chemicals in tion, especially with molecules that occur in
the brain low concentrations

cellular layers thick, and each layer is composed of cell and deepest groove, the longitudinal fissure, separates
bodies mixed with capillary blood vessels. This mixture the cerebrum into left and right hemispheres. Although
makes the cortex gray brown, thus the term gray matter. these two divisions are nearly symmetric, there is some
The cortex contains a number of bumps and grooves in variation in the location and size of the sulci and gyri in
a fully developed adult brain, as shown in Figure 8-2. each hemisphere. Substantial variation in these convo-
This wrinkling allows for a large amount of surface lutions is found in the cortex of different individuals.
area to be confined in the limited space of the skull. The
increased surface area allows for more potential con-
nections between cells within the cortex. The grooves
are called fissures if they extend deep into the brain and The cerebrum can be roughly divided into two halves,
sulci if they are shallower. The bumps or convolutions or hemispheres. For most people, one hemisphere is
are called gyri. Together, they provide many of the land- dominant, whereas about 5% of individuals have mixed
marks for the subdivisions of the cortex. The longest dominance. Each hemisphere controls functioning
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 101

Parietal lobe Corpus sulcus
Central callosum
Parietal lobe
Frontal lobe Longitudinal Frontal lobe

Occipital lobe

Lateral lobe Cerebellum
Limbic system

Brain stem
lobe Brain stem
FIGURE 8.2 Lateral and medial surfaces of the brain. Left, the left lateral surface of the brain.
Right, the medial surface of the right half of a sagittally hemisected brain.

mainly on the opposite side of the body. The left hemi- Frontal Lobes
sphere, dominant in about 95% of people, controls
The right and left frontal lobes make up about one fourth
functions mainly on the right side of the body. The
of the entire cerebral cortex and are proportionately
right hemisphere provides input into receptive nonver-
larger in humans than in any other mammal. The pre-
bal communication, spatial orientation and recognition;
central gyrus, the gyrus immediately anterior to the cen-
intonation of speech and aspects of music; facial recog-
tral sulcus, contains the primary motor area, or homun-
nition and facial expression of emotion; and nonverbal
culi. Damage to this gyrus, or to the anterior
learning and memory. In general, the left hemisphere is
neighboring gyri, causes spastic paralysis in the opposite
more involved with verbal language function, including
side of the body. The frontal lobe also contains Brocas
areas for both receptive and expressive speech control.
area, which controls the motor function of speech. Dam-
In addition, the left hemisphere provides strong contri-
age to Brocas area produces expressive aphasia, or diffi-
butions to temporal order and sequencing, numeric
culty with the motor movements of speech. The frontal
symbols, and verbal learning and memory.
lobes are also thought to contain the highest or most
The two hemispheres are connected by the corpus
complex aspects of cortical functioning, which collec-
coliseum, a bundle of neuronal tissue that allows infor-
tively make up a large part of what we call personality.
mation to be exchanged quickly between the right and
Working memory is an important aspect of frontal lobe
left hemispheres. An intact corpus coliseum is required
function, including the ability to plan and initiate activity
for the hemispheres to function in a smooth and coor-
with future goals in mind. Insight, judgment, reasoning,
dinated manner.
concept formation, problem-solving skills, abstraction,
and self-evaluation are all abilities that are modulated and
Lobes of the Brain
affected by the action of the frontal lobes. These skills are
The lateral surface of each hemisphere is further often referred to as executive functions because they mod-
divided into four lobes: the frontal, parietal, tempo- ulate more primitive impulses through numerous con-
ral, and occipital lobes (Fig. 8-2). The lobes works in nections to other areas of the cerebrum.
coordinated ways, but each is responsible for specific When normal frontal lobe functioning is altered,
functions. An understanding of these unique functions executive functioning is decreased, and modulation of
is helpful in understanding how damage to these areas impulses can be lost, leading to changes in mood and
produces the symptoms of mental illness and how med- personality. The importance of the frontal lobe and its
ications that affect the functioning of these lobes can role in the development of symptoms common to psy-
produce certain effects. chiatric disorders are emphasized in later chapters that
102 UNIT II Principles of Psychiatric Nursing

BOX 8.1 Corpus callosum Cingulate sulcus

(body) (marginal branch)
Superior Central
Frontal Lobe Syndrome frontal sulcus
gyrus pellucidum
Corpus callosum
Corpus callosum (splenium)
In the 1860s, Phineas Gage became a famous example of Rostrum
frontal lobe dysfunction. Mr. Gage was a New England Genu Parietooccipital
railroad worker who had a thick iron-tamping rod pro- sulcus
pelled through his frontal lobes by an explosion. He sur- sulcus Thalamus
vived, but suffered significant changes in his personality.
Mr. Gage, who had previously been a capable and calm
supervisor, began to show impatience, liable mood, dis- gyrus Calcarine
respect for others, and frequent use of profanity after his
injury (Harlow, 1868). Similar conditions are often called
Hypothalamic Cerebellum
frontal lobe syndrome. Symptoms vary widely from indi- sulcus Primary fissure
vidual to individual. In general, after damage to the dor- Hypothalamus Vermis
solateral (upper and outer) areas of the frontal lobes, the Uncus Inferior
symptoms include a lack of drive and spontaneity. With Rhinal sulcus gyrus Pons
damage to the most anterior aspects of the frontal lobes, Occipitotemporal
the symptoms tend to involve more changes in mood and gyrus Medulla
affect, such as impulsive and inappropriate behavior.
FIGURE 8.3 Gyri and sulci of the cortex.

parietal lobes contribute to the ability to recognize

objects by touch, calculate, write, recognize fingers of the
opposite hands, draw, and organize spatial directions,
such as how to travel to familiar places.

Temporal Lobes
The temporal lobes contain the primary auditory and
olfactory areas. Wernickes area, located at the posterior
aspect of the superior temporal gyrus, is primarily
responsible for receptive speech. The temporal lobes also
integrate sensory and visual information involved in con-
trol of written and verbal language skills as well as visual
recognition. The hippocampus, an important structure
The skull of Phineas Gage, showing the route the tamping discussed later, lies in the internal aspects of each tempo-
rod took through his skull. The angle of entry of the rod
ral lobe and contributes to memory. Other internal struc-
shot it behind the left eye and through the front part of the
brain, sparing regions that are directly concerned with vital tures of this lobe are involved in the modulation of mood
functions like breathing and heartbeat. and emotion.

Occipital Lobes
discuss disorders such as schizophrenia, attention- The primary visual area is located in the most posterior
deficit hyperactivity disorder, and dementia. Box 8-1 aspect of the occipital lobes. Damage to this area results
describes how altered frontal lobe function can affect in a condition called cortical blindness. In other words,
mood and personality. the retina and optic nerve remain intact, but the indi-
vidual cannot see. The occipital lobes are involved in
Parietal Lobes many aspects of visual integration of information,
including color vision, object and facial recognition,
The postcentral gyrus, immediately behind the central and the ability to perceive objects in motion.
sulcus, contains the primary somatosensory area (Fig. 8-3).
Damage to this area and neighboring gyri results in
Association Cortex
deficits in discriminative sensory function, but not in the
ability to perceive sensory input. The posterior areas of Although not a lobe, the association cortex is an impor-
the parietal lobe appear to coordinate visual and tant area that allows the lobes to work in an integrated
somatosensory information. Damage to this area pro- manner. Areas of one lobe of the cortex often share
duces complex sensory deficits, including neglect of con- functions with an area of the adjacent lobe. When these
tralateral sensory stimuli and spatial relationships. The neighboring nerve fibers are related to the same sensory
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 103

modality, they are often referred to as association areas. ganglia have many connections with the cerebral cortex,
For example, an area in the inferior parietal, posterior thalamus, midbrain structures, and spinal cord. Damage
temporal, and anterior occipital lobes integrates visual, to portions of these nuclei may produce changes in pos-
somatosensory, and auditory information to provide the ture or muscle tone. In addition, damage may produce
abilities required for basic academic skills. These areas, abnormal movements, such as twitches or tremors. The
along with numerous connections beneath the cortex, basil ganglia can be adversely affected by some of the
are part of the mechanisms that allow the human brain medications used to treat psychiatric disorders, leading
to work as an integrated whole. to side effects and other motor-related problems. The
primary subdivisions of the basal ganglia are the puta-
men, globus pallidus, and caudate.
Subcortical Structures
Beneath the cortex are layers of tissue composed of the
axons of cell bodies. The axonal tissue forms pathways Limbic System
that are surrounded by glia, a fatty or lipid substance, The limbic system is essential to understanding the
which have a white appearance and give these layers of many hypotheses related to psychiatric disorders and
neuron axons their namewhite matter. Structures inside emotional behavior in general. Basic emotions, needs,
the hemispheres, beneath the cortex, are considered sub- drives, and instinct begin and are modulated in the lim-
cortical. Many of these structures, essential in the regula- bic system. Hate, love, anger, aggression, and caring
tion of emotions and behaviors, play important roles in are basic emotions that originate within the limbic sys-
our understanding of mental disorders. Figure 8-4 pro- tem. Not only does the limbic system function as the
vides a coronal section view of the gray matter, white seat of emotions, but, because emotions are often gen-
matter, and important subcortical structures. erated based on our personal experiences, the limbic
system also is involved with aspects of memory.
Hypothesized changes in the limbic system play a sig-
Basal Ganglia
nificant role in many theories of major mental disor-
The basal ganglia are subcortical gray matter areas in ders, including schizophrenia, depression, and anxiety
both the right and the left hemisphere that contain many disorders (discussed in later chapters). The limbic sys-
cell bodies or nuclei. The basal ganglia are involved with tem is called a system because it comprises several
motor functions and association in both the learning and small structures that work in a highly organized way.
the programming of behavior or activities that are repet- These structures include the hippocampus, thalamus,
itive and, done over time, become automatic. The basal hypothalamus, amygdala, and limbic midbrain nuclei.

Transverse Cingulate
fissure gyrus
Lateral ventricle
Caudate nucleus
Internal capsule Insula
(posterior limb)
Thalamus FIGURE 8.4 Coronal section
Lateral sulcus of the brain, illustrating the
corpus callosum, basal ganglia,
Putamen temporal
and lateral ventricles.
Basal ganglia
Globus pallidus Inferior
Parahippocampal gyrus
Third ventricle gyrus
104 UNIT II Principles of Psychiatric Nursing

Corpus callosum Hypothalamus

Anterior nucleus Fornix
of thalamus Basic human activities, such as sleeprest patterns, body
temperature, and physical drives such as hunger and sex,
nuclei are regulated by another part of the limbic system that
rests deep within the brain and is called the hypothala-
mus. Dysfunction of this structure, whether from disor-
Septum ders or as a consequence of the adverse effect of drugs
used to treat mental illness, produces common psychi-
atric symptoms, such as appetite and sleep problems.
body Nerve cells within the hypothalamus secrete hor-
mones: for example, antidiuretic hormone, which when
Hippocampus sent to the kidneys, accelerates the reabsorption of
FIGURE 8.5 The structures of the limbic system are inte- water; and oxytocin, which acts on smooth muscles to
grally involved in memory and emotional behavior. Theories promote contractions, particularly within the walls of
link changes in the limbic system to many major mental dis- the uterus. Because cells within the nervous system pro-
orders, including schizophrenia, depression, and anxiety duce these hormones, they are often referred to as neu-
rohormones and form a communication mechanism
through the bloodstream to control organs that are not
See Figure 8-5 for identification and location of the directly connected to nervous system structures.
structures within the limbic system and their relation- The pituitary gland, often called the master gland, is
ship to other common CNS structures. directly connected by thousands of neurons that attach it
to the ventral aspects of the hypothalamus. Together with
the pituitary gland, the hypothalamus functions as one of
Hippocampus the primary regulators of many aspects of the endocrine
The hippocampus is involved in storing information, system. Its functions are involved in control of visceral
especially the emotions attached to a memory. Our emo- activities, such as body temperature, arterial blood pres-
tional response to memories and our association with sure, hunger, thirst, fluid balance, gastric motility, and
other related memories are functions of how informa- gastric secretions. Deregulation of the hypothalamus can
tion is stored within the hippocampus. Although mem- be manifested in symptoms of certain psychiatric disor-
ory storage is not limited to one area of the brain, ders. For example, in schizophrenia patients often wear
destruction of the left hippocampus impairs verbal heavy coats during the hot summer months and do not
memory, and damage to the right hippocampus results appear hot. Before the role of the hypothalamus in schiz-
in difficulty with recognition and recall of complex ophrenia was understood, psychological reasons were
visual and auditory patterns. Deterioration of the nerves used to explain such symptoms. Now it is increasingly
of the hippocampus and other related temporal lobe clear that such a symptom relates to deregulation of the
structures found in Alzheimers disease produces the dis- hypothalamuss normal role in temperature regulation
orders hallmark symptoms of memory dysfunction. and is a biologically based symptom (Shiloh et al., 2001).

The amygdala is directly connected to more primitive
Sometimes called the relay-switching center of the centers of the brain involving the sense of smell. It has
brain, the thalamus functions as a regulatory struc- numerous connections to the hypothalamus and lies
ture to relay all sensory information, except smell, sent adjacent to the hippocampus. The amygdala provides
to the CNS from the PNS. From the thalamus, the an emotional component to memory and is involved in
sensory information is relayed mostly to the cerebral modulating aggression and sexuality. Impulsive acts of
cortex. The thalamus relays and regulates by filtering aggression and violence have been linked to dysregula-
incoming information and determining what to pass tion of the amygdala, and erratic firing of the nerve cells
on or not pass on to the cortex. In this fashion, the in the amygdala is a focus of investigation in bipolar
thalamus prevents the cortex from becoming over- mood disorders (see Chapter 18).
loaded with sensory stimulus. The thalamus is thought
to play a part in controlling electrical activity in the
Limbic Midbrain Nuclei
cortex. Because of its primary relay function, damage
to a very small area of the thalamus may produce The limbic midbrain nuclei are a collection of neurons
deficits in many cortical functions, producing behav- (including the ventral tegmental area and the locus
ioral abnormalities. ceruleus) that appear to play a role in the biologic basis
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 105

of addiction. Sometimes referred to as the pleasure cen- The brain stem, located beneath the thalamus and
ter or reward center of the brain, the limbic midbrain composed of the midbrain, pons, and medulla, has
nuclei function to reinforce chemically certain behav- important life-sustaining functions. Nuclei of numer-
iors, ensuring their repetition. Emotions such as feeling ous neural pathways to the cerebrum are located in the
satisfied with good food, the pleasure of nurturing brain stem. They are significantly involved in mediating
young, and the enjoyment of sexual activity originate in symptoms of emotional dysfunction. These nuclei are
the limbic midbrain nuclei. The reinforcement of activ- also the primary source of several neurochemicals, such
ities such as nutrition, procreation, and nurturing as serotonin, that are commonly associated with psychi-
young are all primitive aspects of ensuring the survival atric disorders. Table 8-3 summarizes some of the key
of a species. When functioning in abnormal ways, the related nuclei.
limbic midbrain nuclei can begin to reinforce unhealthy The cerebellum is in the posterior aspect of the
or risky behaviors, such as drug abuse. Exploration of skull, beneath the cerebral hemispheres. This large
this area of the brain is in its infancy but offers poten- structure controls movements and postural adjust-
tial insight into addictions and their treatment. ments. To regulate postural balance and positioning,
the cerebellum receives information from all parts of
the body, including muscles, joints, skin, and visceral
organs, as well as from many parts of the CNS.
Closely associated with the spinal cord, but not lying
The extrapyramidal motor system is a bundle of entirely within its column, is the autonomic nervous
nerve fibers connecting the thalamus to the basal gan- system, a subdivision of the PNS. It was originally
glia and cerebral cortex. Muscle tone, common reflexes, given this name for being independent of conscious
and automatic voluntary motor functioning, such as thought, that is, automatic. However, it does not neces-
walking, are controlled by this nerve track. Dysfunction sarily function as autonomously as the name indicates.
of this motor track can produce hypertonicity in muscle This system contains efferent (nerves moving away
groups. In Parkinsons disease, the cells that compose from the CNS), or motor system neurons, which affect
the extrapyramidal motor system are severely affected, target tissues such as cardiac muscle, smooth muscle,
producing many involuntary motor movements. A and the glands. It also contains afferent nerves, which
number of medications, which are discussed in Chapter are sensory and conduct information from these organs
9, also affect this system. back to the CNS.
The pineal body is located above and medial to the The autonomic nervous system is further divided into
thalamus. Because the pineal gland easily calcifies, it the sympathetic and parasympathetic nervous systems.
can be visualized by neuroimaging and often is a medial These systems, although peripheral, are included here
landmark. Its functions remain somewhat of a mystery, because they are involved in the emergency, or fight-
despite long knowledge of its existence. It contains or-flight, response as well as the peripheral actions of
secretory cells that emit the neurohormone melatonin many medications (see Chapter 9). Figure 8-6 illustrates
and other substances. These hormones are thought to the innervations of various target organs by the auto-
have a number of regulatory functions within the nomic nervous system. Table 8-4 identifies the actions of
endocrine system. Information received from the sympathetic and parasympathetic nervous systems
lightdark sources control release of melatonin, which on various target organs.
has been associated with sleep and emotional disorders.
In addition, a modulation of immune function has been
postulated for melatonin from the pineal gland. Neurophysiology of the
The locus ceruleus is a tiny cluster of neurons that
fan out and innervate almost every part of the brain,
Central Nervous System
including most of the cortex, the thalamus and hypo- At their most basic level, the human brain and connect-
thalamus, cerebellum, and the spinal cord. Just one neu- ing nervous system are composed of billions of cells
ron from the ceruleus can connect to more than 250,000 (Fig. 8-7). Most are connective and supportive glial cells
other neurons. Although it is very small, because of its with ancillary functions in the nervous system.
wide-ranging neuronal connections, this tiny structure
has influence in the regulation of attention, time per-
ception, sleeprest cycles, arousal, learning, pain, and
mood and seems most involved with information pro- About 10 billion cells are nerve cells, or neurons,
cessing of new, unexpected, and novel experiences. Some responsible for receiving, organizing, and transmitting
think its function/dysfunction may explain why individ- information. Each neuron has a cell body, or soma,
uals become addicted to substances and seek out risky which holds the nucleus containing most of the cells
behaviors, despite awareness of negative consequences. genetic information. The soma also includes other
106 UNIT II Principles of Psychiatric Nursing

Table 8.3 Classic and Putative Neurotransmitters, Their Distribution and

Proposed Functions

Neurotransmitter Cell Bodies Projections Proposed Function

Dietary precursor: Basal forebrain Diffuse throughout the Important role in learning
choline Pons cortex, hippocampus and memory
Other areas Peripheral nervous Some role in wakefulness,
system and basic attention
Peripherally activates mus-
cles and is the major
neuro chemical in the
autonomic system
Dopamine Substantia nigra Striatum (basal gan- Involved in involuntary
Dietary precursor: Ventral tegmental area glia) motor movements
tyrosine Arcuate nucleus Limbic system and Some role in mood states,
Retina olfactory bulb cerebral cortex pleasure components in
Pituitary reward systems, and
complex behavior such
as judgment, reasoning,
and insight
Norepinephrine Locus ceruleus Very widespread Proposed role in learning
Dietary precursor tyro- Lateral tegmental area and others throughout the cor- and memory, attributing
sine throughout the pons and medulla tex, thalamus, cere- Value in reward systems,
bellum, brain stem, fluctuates in sleep and
and spinal cord wakefulness
Basal forebrain, thala- Major component of the
mus, hypothalamus, sympathetic nervous sys-
brain stem and tem responses, including
spinal cord fight or flight
Serotonin Raphe nuclei Very widespread Proposed role in the con-
Dietary precursor: tryp- Others in the pons and medulla throughout the cor- trol of appetite, sleep,
tophan tex, thalamus, cere- mood states, hallucina-
bellum, brain stem, tions, pain perception,
and spinal cord and vomiting
Histamine Hypothalamus Cerebral cortex Control of gastric secre-
Precursor histidine Limbic system tions, smooth muscle
Hypothalamus control, cardiac stimula-
Found in all mast cells tion, stimulation of sen-
sory nerve endings, and
Amino Acids
CABA Derived from glutamate without local- Found in cells and Fast inhibitory response
ized cell bodies projections through- post-synaptically, inhibits
out the central ner- the excitability of the
vous system (CNS), neurons and therefore
especially in intrin- contributes to seizure,
sic feedback loops agitation, and anxiety
and interneurons of control
the cerebrum
Also in the extrapyra-
midal motor system
and cerebellum
Glycine Primarily the spinal cord and brain stem Limited projection, but Inhibitory
especially in the Decreases the excitability
auditory system and of spinal motor neurons
olfactory bulb but not cortical
Also found in the
spinal cord, medulla,
midbrain, cerebel-
lum, and cortex
Glutamate Diffuse Diffuse, but especially Excitatory
in the sensory Responsible for the bulk of
organs information flow
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 107

Table 8.3 Classic and Putative Neurotransmitters, Their Distribution and

Proposed Functions (Continued)

Neurotransmitter Cell Bodies Projections Proposed Function

Endogenous opioids, A large family of neuropeptides, which Widely distributed Suppresses pain, modu-
(ie, endorphins, has three distinct subgroups, all of within and outside lates mood and stress
enkephalins) which are manufactured widely of the CNS Likely involvement in
throughout the CNS reward systems and
Also may regulate pituitary
hormone release
Implicated in the patho-
physiology of diseases
of the basal ganglia
Melatonin Pineal body Widely distributed Secreted in dark and sup-
One of its precursors within and outside pressed light, helps regu-
serotonin of the CNS late the sleepwake cycle
as well as other biologic
Substance P Widespread, significant in the raphe sys- Spinal cord, cortex, Involved in pain transmis-
tem and spinal cord brain stem and sion, movement, and
especially sensory mood regulation
neurons associated
with pain perception
Cholecystokinin Predominates in the ventral tegmental Frontal cortex where it Primary intestinal hormone
area of the midbrain is often colocalized involved in satiety, also
with dopamine has some involvement in
Widely distributed the control of anxiety
within and outside and panic
of the CNS

organelles, such as ribosomes and endoplasmic reticu- layer of phospholipid molecules with embedded pro-
lum, both of which carry out protein synthesis; the teins. Some of these proteins provide water-filled chan-
Golgi apparatus, which contains enzymes to modify the nels through which inorganic ions may pass (Fig. 8-8).
proteins for specific functions; vesicles, which transport Each of the common ionssodium, potassium, cal-
and store proteins; and lysosomes, responsible for cium, and chloridehas its own specific molecular
degradation of these proteins. Located throughout the channel. These channels are voltage gated and thus
neuron, mitochondria, containing enzymes and often open or close in response to changes in the electrical
called the cells engine, are the site of many energy- potential across the membrane. At rest, the cell mem-
producing chemical reactions. These cell structures brane is polarized with a positive charge on the outside
provide the basis for secreting numerous chemicals by and about a 270-millivolt charge on the inside, owing to
which neurons communicate. the resting distribution of sodium and potassium ions.
It is not just the vast number of neurons that accounts As potassium passively diffuses across the membrane,
for the complexities of the brain but the enormous num- the sodium pump uses energy to move sodium from the
ber of neurochemical interconnections and interactions inside of the cell against a concentration gradient to
between neurons. A single motor neuron in the spinal maintain this distribution. An action potential, or nerve
cord may receive signals from more than 10,000 sources impulse, is generated as the membrane is depolarized
of interconnections with other nerves. Although most and a threshold value is reached, which triggers the
neurons have only one axon, which varies in length and opening of the voltage-gated sodium channels, allowing
conducts impulses away from the soma, each has numer- sodium to surge into the cell. The inside of the cell
ous dendrites, receiving signals from other neurons. briefly becomes positively charged and the outside neg-
Because axons may branch as they terminate, they also atively charged. Once initiated, the action potential
have multiple contacts with other neurons. becomes self-propagating, opening nearby sodium
Nerve signals are prompted to fire by a variety of channels. This electrical communication moves into the
chemical or physical stimuli. This firing produces an soma from the dendrites or down the axon by this
electrical impulse. The cells membrane is a double mechanism.
108 UNIT II Principles of Psychiatric Nursing

Ciliary ganglion

Iris and ciliary muscles

Dilator Sphenopalatine ganglion


Submandibular ganglion Lacrimal gland (secretory)


Submandibular and sublingual

Otic ganglion glands (secretory)


X Parotid gland (secretory)

Sweat glands tor

Parasympathetic is
2 inhibitory to sphincters
3 Motor to esophagus,
stomach, and intestine Inhibitory

5 Accelerator
Sympathetic is
6 motor to sphincters
Inhibitory to esophagus,
7 stomach, and intestine

Greater splanchnic nerve
Lesser splanchnic nerve

12 Least splanchnic

2 Superior mesenteric ganglion

Inferior mesenteric ganglion

4 Inhibitory



Pelvic nerve Vas


FIGURE 8.6 Diagram of the autonomic nervous system. Note that many organs are innervated by
both sympathetic and parasympathetic nerves. (Adapted from Schaffe, E. E., & Lytle, I. M. [1980].
Basic physiology and anatomy. Philadelphia: J. B. Lippincott.)
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 109

Table 8.4 Peripheral Organ Response in the Autonomic Nervous System

Sympathetic Response Parasympathetic Response

Effector Organ (Mostly Norepinephrine) (Acetylcholine)

Iris sphincter muscle Dilation Constriction
Ciliary muscle Relaxation Accommodation for near vision
Sinoatrial node Increased rate Decrease in rare
Atria Increased contractility Decrease in contractility
Atrioventricular node Increased contractility Decrease in conduction velocity
Blood vessels Constriction Dilation

Bronchial muscles Relaxation Bronchoconstriction
Bronchial glands Secretion

Gastrointestinal Tract
Motility and tone Relaxation Increased
Sphincters Contraction Relaxation
Secretion Stimulation

Urinary Bladder
Detrusor muscle Relaxation Contraction
Trigone and sphincter Contraction Relaxation

Uterus Contraction (pregnant) Variable

Relaxation (nonpregnant)
Contraction No effect
Pilomotor muscles
Increased secretion No effect
Sweat glands
Increased secretion
Salivary, lachrymal
Increased secretion

SYNAPTIC TRANSMISSION the cytoplasm of the neuron, but most synthesis occurs
in the terminals or the neuron itself. Some neurochem-
For one neuron to communicate with another, the elec-
icals can reduce the membrane potential and enhance
trical process described must change to a chemical com-
the transmission of the signal between neurons. These
munication. The synaptic cleft, a junction between one
chemicals are called excitatory neurotransmitters. Other
nerve and another, is the space where the electrical
neurochemicals have the opposite effect, slowing down
intracellular signal becomes a chemical extracellular
nerve impulses, and these substances are called
signal. Various substances are recognized as the chemi-
inhibitory neurotransmitters.
cal messengers between neurons.
As the electrical action potential reaches the ends of
the axon, called terminals, calcium ion channels are
KEY CONCEPT Neurotransmitters are small opened, causing an influx of Ca++ ions into the neuron.
molecules that directly and indirectly control the open- This increase in calcium stimulates the release of neuro-
ing or closing of ion channels. transmitters into the synapse. Rapid signaling between
neurons requires a ready supply of neurotransmitter.
Neurotransmitters are small molecules that These neurotransmitters are stored in small vesicles
directly and indirectly control the opening or closing of grouped near the cell membrane at the end of the axon.
ion channels. Neuromodulators are chemical messen- Because nerve terminals do not have the ability to man-
gers that make the target cell membrane or postsynap- ufacture proteins, the transmitters that fill these vesicles
tic membrane more or less susceptible to the effects of are small molecules, such as the bioamines (dopamine
the primary neurotransmitter. Some of these neuro- and norepinephrine) or the amino acids (glutamate
chemicals are synthesized quickly from dietary precur- or -aminobutyric acid [GABA]). The actions of these
sors, such as tyrosine or tryptophan, or enzymes inside small molecules are discussed later in this chapter. When
110 UNIT II Principles of Psychiatric Nursing


endoplasmic Lysosome
Ribosomes Golgi

Initial segment
of axon Rough
Oligodendrocyte endoplasmic
CNS Nucleus
PNS Nucleolus

Schwann's cell Myelin Mitochondria

Collateral branch

Axon Transport Dendrites


FIGURE 8.7 Cell body and organelles of an axon.

stimulated, the vesicles containing the neurotransmit- lates adjacent neurons. This is the process of neuronal
ter fuse with the cell membrane, and the neurotrans- communication.
mitter is released into the synapse (Fig. 8-9). The neu- Embedded in the postsynaptic membrane are a num-
rotransmitter then crosses the synaptic cleft to a ber of proteins that act as receptors for the released neu-
receptor site on the postsynaptic neuron and stimu- rotransmitters. The lock-and-key analogy has often

Double layer of
phospholipid molecules Pore Ions
(ion channels)

Cell membrane
Cell membrane Cell membrane

Ion channel (closed) Ion channel (open)

FIGURE 8.8 Initiation of a nerve impulse. The initiation of an action potential, or nerve impulse,
involves the opening and closing of the voltage-gated channels on the cell membrane and the pas-
sage of ions into the cell. The resulting electrical activity sends communication impulses from the
dendrites or axon into the body.
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 111

1. Action potential
invades presynaptic Na+ Na+

Na+ channels

Na+ Na+
2. Terminal depolarized
opens voltage-dependent
Na+ Na+
Ca++channels Ca++
3. Ca mediates Ca++
vesicle fusion with
presynaptic membrane

4. Exocytosis releases 9. Diffusion

transmitter molecules into
synaptic cleft
Ions 8. Reuptake

5. Transmitter molecules bind to

postsynaptic receptors and activate
ion channels

6. The resulting conductance change can

either depolarize or hyperpolarize the 7. Current flow spreads
membrane, depending on which ionic to adjacent areas of
conductance the transmitter controls postsynaptic membrane

FIGURE 8.9 Synaptic transmission. The most significant events that occur during synaptic trans-
mission: (1) the action potential reaches the presynaptic terminal; (2) membrane depolarization
causes Ca++ terminals to open; (3) Ca++ mediates fusion of the vesicles with the presynaptic mem-
brane; (4) transmitter molecules are released into the synaptic cleft, by exocytosis; (5) transmitter
molecules bind to postsynaptic receptors and activate ion channels; (6) conductance changes cause
an excitatory or inhibitory postsynaptic potential, depending on the specific transmitter; (7) cur-
rent flow spreads along the postsynaptic membrane; (8) transmitter remaining in the synaptic cleft
returns to the presynaptic terminal by reuptake; or (9) diffuses into the extracellular fluid. (Adapted
and reproduced with permission from Schauf, C., Moffett, D., & Moffett, S. [1990]. Human physiol-
ogy. St. Louis: Times Mirror/Mosby.)

been used to describe the fit of a given neurotransmitter picked up by an adjacent neuron, again converted to an
to its receptor site. Each neurotransmitter has a specific electrical action potential, and then to a chemical signal,
receptor, or protein, for which it and only it will fit. The occurs billions of times a day in billions of different brain
target cell, when stimulated by the neurotransmitter, will cells. It is this electrical-chemical communication process
then respond by evoking its own action potential and that allows the structures of the brain to function
either producing some action common to that cell or act- together in a coordinated and organized manner.
ing as a relay to keep the messages moving throughout When the neurotransmitter has completed its
the CNS. This pattern of the electrical signal from one interaction with the postsynaptic receptor and stimu-
neuron, converted to chemical signal at the synaptic cleft, lated that cell, its work is done, and it needs to be
112 UNIT II Principles of Psychiatric Nursing

removed. It can be removed by natural diffusion away RECEPTOR ACTIVITY

from the area of high neurotransmitter concentration
Both presynaptic and postsynaptic receptors have the
at the receptors by being broken down by enzymes in
capacity to change, developing either a greater-than-
the synaptic cleft, or through reuptake through
usual response to the neurotransmitter, known as super-
highly specific mechanisms into the presynaptic
sensitivity, or a less-than-usual response, called subsensi-
tivity. These changes represent the concept of
Many psychopharmacologic agents, particularly
neuroplasticity of brain tissue discussed earlier in the
antidepressants, act by blocking the reuptake of the
chapter. The change in sensitivity of the receptor is
neurotransmitters, thereby increasing the available
most commonly caused by the effect of a drug on a
amount of chemical messenger. Presynaptic binding
receptor site or by disease that affects the normal func-
sites for neurotransmitters may serve not only as reup-
tioning of a receptor site. Drugs can affect the sensitiv-
take mechanisms but also as autoreceptors to perform
ity of the receptor by altering the strength of attraction
various regulatory functions on the flow of neurotrans-
or affinity of a receptor for the neurotransmitter, by
mitter into the synapse. When these presynaptic
changing the efficiency with which the receptor activity
autoreceptors are saturated, the neuron knows it is time
translates the message inside the receiving cell, or by
to slow down or stop releasing neurotransmitter. The
decreasing over time the number of receptors.
neurotransmitters taken back into the presynaptic neu-
These mechanisms may account for the long-term,
ron may be stored in vesicles for re-release, or they may
sometimes severely adverse, effects of psychopharmaco-
be broken down by enzymes, such as monoamine oxi-
logic drugs, the loss of effectiveness of a given medica-
dase, and removed entirely.
tion, or the loss of effectiveness of a medication after
The primary steps in synaptic transmission are
repeated use in treating recurring episodes of a psychi-
summarized in Figure 8-10. The preceding discussion
atric disorder. Disease may cause a change in the nor-
contains only the basic mechanisms of neuronal com-
mal number or function of receptors, thereby altering
munication. Many other factors that modulate or
their sensitivity (Garcia, Marin, & Perillo, 2002). It has
contribute to the communication between neurons
been hypothesized that depression is caused by a reduc-
are only beginning to be discovered. Examples
tion in the normal number of certain receptors, leading
include peptides that are released into the synapse and
to an abnormality in their sensitivity to neurotransmit-
thought to behave like neurotransmitters or that also
ters such as serotonin and norepinephrine. A decreased
can appear in combination with another neurotrans-
response to continued stimulation of these receptors is
mitter. These peptides, known as co-transmitters, are
usually referred to as desensitization or refractoriness.
believed to have a modulatory effect on the primary
This suspected subsensitivity is referred to as down-
regulation of the receptors.

The nervous system uses many different neurochemicals
for communication, and each specific chemical messen-
ger requires a specific receptor on which the chemical
can act. More than 100 different chemical messengers
have been identified, with new ones being uncovered fre-
quently as research on the functioning of the brain
becomes more and more precise. In addition to the sheer
number of receptors needed to accommodate these
chemicals, the neurotransmitters may produce different
effects at different synaptic sites. The ability of a neuro-
transmitter to produce different actions is, in part,
because of the specialization of its receptors. The differ-
ent receptors for each neurochemical messenger are
referred to as receptor subtypes for the chemical. Each
major neurotransmitter has several different subtypes of
receptors, allowing the neurotransmitter to have differ-
FIGURE 8.10 Cholinergic pathways. HC, hippocampal for- ent effects in different areas of the brain. For example,
mation; PSG, parasympathetic ganglion cell; RF, reticular for-
mation; T, thalamus. (Adapted from Nolte, J., & Angevine, J.
dopamine, a common neurotransmitter discussed in the
[1995]. The human brain: In photographs and diagrams. St. next section, has five different subtypes of receptors that
Louis: Mosby.) have been identified. Numbers usually name the receptor
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 113

subtypes. In the example of dopamine, the various sub- Understanding both the action of ACh and the receptor
types of receptors are called D1, D2, D3, and so on. subtypes for this neurotransmitter assists psychiatric
Understanding the different subtypes helps in under- mental health nurses in understanding the complex side
standing both the effects and side effects of medications effects of common medications used to treat mental
used to treat mental disorders. disorders.
Cholinergic neurons, so named because they contain
ACh, follow diffuse projections throughout the cerebral
cortex and limbic system, arising primarily from cell
Many substances have been identified as possible chem- bodies in the base of the frontal lobes. Pathways from
ical messengers, but not all chemical messengers are this region also project throughout the hippocampus
neurotransmitters. Classic neurotransmitters are those (Fig. 8-10). These connections suggest that ACh is
that meet certain criteria agreed on by neuroscientists. involved in higher intellectual functioning and memory.
The traditional criteria include the following: Individuals who have Alzheimers disease or Down syn-
The chemical is synthesized inside the neuron. drome often exhibit patterns of cholinergic neuron loss
The chemical is present in the presynaptic terminals. in regions innervated by these pathways (such as the
The chemical is released into the synaptic cleft and hippocampus), which may contribute to their memory
causes a particular effect on the postsynaptic difficulties and other cognitive deficits. Some choliner-
receptors. gic neurons are afferent to these areas bringing infor-
An exogenous form of the chemical administered mation from the limbic system, highlighting the role
as a drug causes identical action. that ACh plays in communicating emotional state to the
The chemical is removed from the synaptic cleft cerebral cortex. ACh is an excitatory neurotransmitter,
by a specific mechanism. meaning that when released into a synapse, it causes the
Neurotransmitters can be grouped into categories postsynaptic neuron to initiate some action.
that reflect chemical similarities of the neurotransmit- The subtypes of ACh receptors are divided into two
ter. Common practice classifies certain chemicals as groups: the muscarinic receptors and the nicotinic
neurotransmitters even though their ability to meet the receptors. Many psychiatric medications are anticholin-
strict traditional definition may be incomplete. For the ergic agents, which block the effects of the muscarinic
purposes of this section, the classification of neuro- ACh receptors. This blocking effect of ACh causes com-
transmitters will use this common system of classifying mon side effects, such as dry mouth, blurred vision, con-
neurotransmitters. Common categories of neurotrans- stipation, urinary retention, and tachycardia, which are
mitters include: seen in many psychotropic medications. Excessive
cholinergic neurotransmitters blockade of ACh can cause confusion and delirium,
biogenic amine neurotransmitters (sometimes especially in elderly patients, as discussed in Chapter 29.
called monoamines or bioamines);
amino acid neurotransmitters;
neuropeptide neurotransmitters.
Biogenic Amines
Neurotransmitters are also classified by whether their The biogenic amines (bioamines) consist of small mol-
action causes physiologic activity to occur or to stop ecules manufactured in the neuron that contain an
occurring. All of the neurotransmitters commonly amine group, thus the name. These include dopamine,
involved in the development of mental illness or that norepinephrine, and epinephrine, which are all synthe-
are affected by the drugs used to treat these illnesses are sized from the amino acid tyrosine; serotonin, which is
excitatory except one, GABA, which is inhibitory. The synthesized from tryptophan; and histamine, manufac-
significance of this concept is discussed later. Neuro- tured from histidine. Of all the neurotransmitters, the
transmitters are found wherever there are neurons. biogenic amines are most central to current hypotheses
Neurons are contained in both the CNS and the PNS, of psychiatric disorders and thus are described individ-
and psychiatric mental disorders occur in the CNS, so ually in more detail.
neurotransmitters are discussed from the perspective of
the CNS.
Dopamine is an excitatory neurotransmitter found in
distinct regions of the CNS, and it is involved in cogni-
Acetylcholine (ACh) is the primary cholinergic neuro- tion, motor, and neuroendocrine functions. Dopamine
transmitter. Found in the greatest concentration in the levels are decreased in Parkinsons disease, and abnor-
PNS, ACh provides the basic synaptic communication mally high production of dopamine has been associated
for the parasympathetic neurons and part of the sympa- with schizophrenia, discussed in more detail in Chapter
thetic neurons, which send information to the CNS. 16. Dopamine is also the neurotransmitter that stimulates
114 UNIT II Principles of Psychiatric Nursing

the bodys natural feel good reward pathways, produc-

ing pleasant euphoric sensation under certain condi-
tions. Abnormalities of dopamine use within the reward
system pathways are suspected to be a critical aspect of
the development of drug and other addictions. The
dopamine pathways are distinct neuronal areas within
the CNS in which the neurotransmitter dopamine pre-
dominates. Three major dopaminergic pathways have
been identified.
The mesocortical and mesolimbic pathways originate
in the ventral tegmental area and project into the medial
aspects of the cortex (mesocortical) and the medial
aspects of the limbic system inside the temporal lobes,
including the hippocampus and amygdala (mesolimbic).
Sometimes they are considered to be one pathway and at
other times two separate pathways. The mesocortical
pathway has major effects on cognition, including such
functions as judgment, reasoning, insight, social con-
science, motivation, the ability to generalize learning,
and reward systems in the human brain. It contributes to
some of the highest seats of cortical functioning. The
mesolimbic pathway also strongly influences emotions
and has projections that affect memory and auditory
reception. Abnormalities in these pathways have been
associated with schizophrenia. FIGURE 8.11 Dopaminergic pathways. C, caudate nucleus;
Another major dopaminergic pathway begins in the H, hypothalamus; HC, hippocampal formation; P, putamen;
S, striatum; V, ventral striatum. (Adapted from Nolte, J., &
substantia nigra and projects into the basal ganglia,
Angevine, J. [1995]. The human brain: In photographs and
parts of which are known as the striatum. Therefore, diagrams. St. Louis: Mosby.)
this pathway is called the nigrostriatal pathway. This
influences the extrapyramidal motor system, which
serves the voluntary motor system and allows involun- Many of the medications that are most effective on
tary motor movements. Destruction of dopaminergic the acute symptoms of psychosis have a strong attrac-
neurons in this pathway has been associated with tion or affinity for D2 receptors and a weaker but mod-
Parkinsons disease. est correlation with D1 receptors. Because D2 recep-
The next or last dopamine pathway originates from tors predominate in the nigrostriatal pathway,
projections of the mesolimbic pathway and continues medications that have a weaker blockade of D2 will
into the hypothalamus, which then projects into the have fewer extrapyramidal motor system effects. Side
pituitary gland. Therefore, this pathway, called the effects and adverse effects from the involuntary motor
tuberoinfundibular pathway, has an impact on endocrine system are at times extremely debilitating to individu-
function and other functions, such as metabolism, als. Based on the assumption that these dopamine
hunger, thirst, sexual function, circadian rhythms, diges- receptor subtypes have different functions in the CNS,
tion, and temperature control. Figure 8-11 illustrates new medications are being designed to affect more pre-
the dopaminergic pathways. dominantly one subtype than another, presumably
Scientists have identified at least five subtypes of avoiding effects on systems containing other subtypes
dopamine receptors in the CNS. These subtypes are dis- and thus avoiding potential side effects of the medica-
tributed differently throughout the brain. For example, tion. Researchers are attempting to develop new
the D1 subtype receptor and its related receptor sub- antipsychotic medications that avoid or minimize the
type, D5, predominate in areas that affect memory and effects on D2 and therefore diminish the occurrence of
emotions, such as the cortex, hippocampus, and amyg- extrapyramidal effects.
dala. They have not been detected in the substantia
nigra. D2 receptors are richly distributed throughout
neurons in the extrapyramidal motor system, whereas
D4 receptors are richly distributed in the frontal cortex, Norepinephrine was first demonstrated to be the pri-
with few in the nigrostriatal system. Antipsychotic med- mary neurotransmitter of the PNS in 1946. Whereas it
ications, discussed in Chapter 9, act by blocking the is commonly found in the PNS, norepinephrine is crit-
effects of dopamine at the receptor sites. ical to CNS functioning as well. Norepinephrine is an
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 115

excitatory neurochemical that plays a major role in gen- Table 8-4 lists the effects of ACh on various organs in
erating and maintaining mood states. Decreased norep- the parasympathetic system.
inephrine has been associated with depression, and
excessive norepinephrine has been associated with
manic symptoms (Montgomery, 2000). Because norep-
inephrine is so heavily concentrated in the terminal Serotonin (also called 5-hydroxytryptamine or 5-HT) is
sites of sympathetic nerves, it can be released quickly to primarily an excitatory neurotransmitter that is diffusely
ready the individual for a fight-or-flight response to distributed within the cerebral cortex, limbic system, and
threats in the environment. For this reason, norepi- basal ganglia of the CNS. Serotonergic neurons also pro-
nephrine is thought to play a role in the physical symp- ject into the hypothalamus and cerebellum. Figure 8-13
toms of anxiety. illustrates serotonergic pathways. Serotonin plays a role
Nerve tracts and pathways containing predominantly in emotions, cognition, sensory perceptions, and essen-
norepinephrine are called noradrenergic and are less tial biologic functions, such as sleep and appetite. During
clearly delineated than the dopamine pathways. In the the rapid-eye-movement (REM) phase of sleep, or the
CNS, noradrenergic neurons originate in the locus dream state, serotonin concentrations decrease, and mus-
ceruleus, where more than half of the noradrenergic cles subsequently relax. Serotonin is also involved in the
cell bodies are located. Because the locus ceruleus is one control of food intake, hormone secretion, sexual behav-
of the major timekeepers of the human body, norepi- ior, thermoregulation, and cardiovascular regulation.
nephrine is involved in sleep and wakefulness. From the Some serotonergic fibers reach the cranial blood vessels
locus ceruleus, noradrenergic pathways ascend into the within the brain and the pia mater, where they have a
neocortex, spread diffusely (Fig. 8-12), and enhance the vasoconstrictive effect. The potency of some new med-
ability of neurons to respond to whatever input they ications for migraine headaches is related to their ability
may be receiving. In addition, norepinephrine appears to block serotonin transmission in the cranial blood ves-
to be involved in the process of reinforcement, which sels. Descending serotonergic pathways are important in
facilitates learning. Noradrenergic pathways innervate central pain control. Depression and insomnia have
the hypothalamus and thus are involved to some degree been associated with decreased levels of 5-HT, whereas
in endocrine function. Anxiety disorders and depression mania has been associated with increased 5-HT. Some of
are examples of psychiatric illnesses in which dysfunc- the most well-known antidepressant medications, such
tion of the noradrenergic neurons may be involved. as Prozac and Zoloft, which are discussed in more depth

FIGURE 8.12 Noradrenergic pathways. H, hypothalamus; FIGURE 8.13 Serotonergic pathways. H, hypothalamus; S,
LC, locus ceruleus; RF, reticular formation; T, thalamus. septal nuclei; T, thalamus. (Adapted from Nolte, J., &
(Adapted from Nolte, J., & Angevine, J. [1995]. The human Angevine, J. [1995]. The human brain: In photographs and
brain: In photographs and diagrams. St. Louis: Mosby.) diagrams. St. Louis: Mosby.)
116 UNIT II Principles of Psychiatric Nursing

in Chapter 9, function by raising serotonin levels within decreased GABA activity is involved in the develop-
certain areas of the CNS (Harmer, Hill, Taylor, Cowen, ment of seizure disorders.
& Goodwin, 2003). Obsessive-compulsive disorder, panic Two specific subtype receptors have been identified
disorder, and other anxiety disorders are believed to be for GABA: A and B. Two classes of medication, benzo-
associated with dysfunction of the serotonin pathways, diazepine antianxiety drugs and sedative-hypnotic bar-
explaining why these antidepressants have several uses in biturate drugs, work because of their affinity for GABA
treating mental disorders (Kapczinski, Lima, Souza, & receptor sites. Interest in the beneficial effects of these
Schmitt, 2003). drugs has led to increased interest in GABA receptor
Numerous subtypes of serotonin receptors also exist, sites. Researchers are finding endogenous chemicals
and each of these appears to have a distinct function. that bind to the same receptor sites as benzodiazepines
5-HT1a is involved in the control of anxiety, aggression, and serve as natural inhibitory regulators (Fritschy &
and depression. Drugs such as lysergic acid diethylamide Brunig, 2003).
(LSD) affect 5-HT2 and produce hallucinatory effects.
Glutamate, the most widely distributed excitatory
Histamine has only recently been identified as a neuro- neurotransmitter, is the main transmitter in the asso-
transmitter. Its cell bodies originate predominantly in ciational areas of the cortex. Glutamate can be found
the hypothalamus and project to all major structures in in a number of pathways from the cortex to the thal-
the cerebrum, brain stem, and spinal cord. Its functions amus, pons, striatum, and spinal cord. In addition,
are not well known, but it appears to have a role in auto- glutamate pathways have a number of connections
nomic and neuroendocrine regulation. Many psychi- with the hippocampus. Some glutamate receptors
atric medications can block the effects of histamine may play a role in the long-lasting enhancement of
postsynaptically and produce side effects such as seda- synaptic activity. In turn, in the hippocampus, this
tion, weight gain, and hypotension. enhancement may have a role in learning and mem-
ory. Too much glutamate is harmful to neurons, and
Amino Acids considerable interest has emerged regarding its neu-
rotoxic effects.
Amino acids are the building blocks of proteins and Conditions that produce an excess of endogenous
have many roles in intraneuronal metabolism. In addi- glutamate can cause neurotoxicity by overexcitation of
tion, amino acids can function as neurotransmitters in neuronal tissue. This process, called excitotoxicity,
as many as 60% to 70% of the synaptic sites in the increases the sensitivity of glutamate receptors, pro-
brain. Amino acids are the most prevalent neurotrans- duces overactivation of the receptors, and is increas-
mitters. Virtually all of the neurons in the CNS are acti- ingly being understood as a critical piece of the cascade
vated by excitatory amino acids, such as glutamate, and of events involved in physical symptoms of alcohol
inhibited by inhibitory amino acids, such as GABA and withdrawal in dependent individuals. Excitotoxicity is
glycine. Many of these amino acids coexist with other also believed to be part of the pathology of conditions
neurotransmitters. such as ischemia, hypoxia, hypoglycemia, and hepatic
failure. Damage to the CNS from chronic malfunction-
-Aminobutyric Acid ing of the glutamate system may be involved in the psy-
chiatric symptoms seen in neurodegenerative diseases
GABA is the primary inhibitory neurotransmitter for such as Huntingtons, Parkinsons, and Alzheimers dis-
the CNS. The pathways of GABA exist almost exclu- eases; vascular dementia; amyotrophic lateral sclerosis;
sively in the CNS, with the largest GABA concentra- and acquired immune deficiency syndrome (AIDS)-
tions in the hypothalamus, hippocampus, basal gan- related dementia (MacGregor, Avshalumov, & Rice,
glia, spinal cord, and cerebellum. GABA functions in 2003). Degeneration of glutamate neurons has more
an inhibitory role in control of spinal reflexes and recently been implicated in the development of schizo-
cerebellar reflexes. It has a major role in the control phrenia (Kurup & Kurup, 2003).
of neuronal excitability through the brain. In addi-
tion, GABA has an inhibitory influence on the activ-
ity of the dopaminergic nigrostriatal projections.
GABA also has interconnections with other neuro- Peptides are short chains of amino acids. Neuropep-
transmitters. For example, dopamine inhibits cholin- tides exist in the CNS and have a number of important
ergic neurons, and GABA provides feedback and bal- roles as neurotransmitters, neuromodulators, or neuro-
ance. Dysregulation of GABA and GABA receptors hormones. Neuropeptides were first thought to be pitu-
has been associated with anxiety disorders, and itary hormones, such as adrenocorticotropin, oxytocin,
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 117

and vasopressin, or hypothalamic-releasing hormones have become more fully understood and defined, new
(e.g., corticotropin-releasing hormone and thy- information suggests that dysfunction of these rhythms
rotropin-releasing hormone [TRH]). However, when may not only result from a psychiatric illness but also
an endogenous morphine-like substance was discovered contribute to its development. Therefore, the following
in the 1970s, the term endorphin, or endogenous mor- sections provide a brief overview of psychoendocrinol-
phine, was introduced. Although the amino acids and ogy, psychoimmunology, and chronobiology.
monoamine neurotransmitters can be produced directly
from dietary precursors in any part of the neuron, neu-
ropeptides are, almost without exception, synthesized PSYCHOENDOCRINOLOGY
from messenger RNA in the cell body. Currently, two Psychoendocrinology examines the relationships
types of neuropeptides have been identified. Opioid among the nervous system, endocrine system, and
neuropeptides, such as endorphins, enkephalins, and behavior. Messages are conveyed within the endocrine
dynorphins, function in endocrine functioning and pain system mainly by hormones, and neurohormones are
suppression. The nonopioid neuropeptides, such as those substances excreted by special neurons within the
substance P and somatostatin, play roles in pain trans- nervous system. Neurohormones are cellular substances
mission and in endocrine functioning. and are secreted into the bloodstream and transported to
There are considerable variations in the distribution a site where they exert their effect. Of the several types
of individual neuropeptides, but some areas are espe- of hormones, peptides are the most common hormones
cially rich in cell bodies containing neuropeptides. in the CNS.
These areas include the amygdala, striatum, hypothala- The hypothalamus sends and receives information
mus, raphe nuclei, brain stem, and spinal cord. Many of through the pituitary, which then communicates with
the interneurons of the cerebral cortex contain neu- structures in the peripheral aspects of the body.
ropeptides, but there are considerably fewer in the thal- Figure 8-14 presents an example of the communica-
amus and almost none in the cerebellum. tion of the anterior pituitary with a number of organs
By now, it should be obvious that the complexities of and structures. Axes, the structures within which the
neuronal transmission are enormous. Psychiatricmental
health nurses have a significant role in assessing symp-
toms and administering and monitoring medications for
patients with psychiatric disorders. Knowledge of neu- BRAIN NEURONS
(Peptides & neurotransmitters)
rotransmitters is essential because even a single dose of
a drug affecting this system may cause relief of symptoms
or have adverse effects. The actions of psychopharmaco- HYPOTHALAMUS
logic agents and related nursing responsibilities are dis-
cussed more fully in Chapter 9. In addition, many nurs-
ing interventions designed to effect changes in such
functions as sleep, diet, stress management, exercise, CRH TRH GHRH GnRH
and mood modulation affect these neurotransmitters SRIF

and neuropeptides, directly or indirectly. More research

is clearly needed to understand the biopsychosocial PITUITARY
aspects of nursing care.

New Fields of Study ACTH TSH GH LH & FSH Prolactin Oxytocin

As the complexity of the nervous system and its interre-

lationship with other body systems and the environment ADRENAL THYROID
muscle, fat, MUSCLES
has become more fully understood, new fields of study and bone

have emerged. From the discussion of neuroanatomy Neurohormones excreted by hypothalamus Hormones released by pituitary
and neurotransmitters, it is logical to deduce that under- Corticotropin-releasing hormone (CRH)
Thyrotropin-releasing hormone (TRH)
Adrenocorticotropic hormone (ACTH)
Thyroid-stimulating hormone (TSH)
standing the endocrine system and its interrelationship Growth hormonereleasing hormone (GHRH) Growth hormone (GH)
Somatotropin release-inhibiting factor (SRIF) Luteinizing hormone (LH)
with the nervous system is essential. Although it has long Gonadotropin-releasing hormone (GnRH) Follicle-stimulating hormone (FSH)
Prolactin-releasing factor (PRF)
been observed that individuals under stress have com- Prolactin-inhibiting factor (PIF)
promised immune systems and are more likely to
FIGURE 8.14 Hypothalamic and pituitary communication
acquire common diseases, only recently have changes in system. The neurohormonal communication system
the immune system been noted as widespread in some between the hypothalamus and the pituitary exerts effects
psychiatric illnesses. In addition, as biologic rhythms on many organs and systems.
118 UNIT II Principles of Psychiatric Nursing

Hypothalamus from cancer and serious infections, as is the case with

TRH AIDS. Evidence suggests that the nervous system reg-
ulates many aspects of immune function. Specific
+ immune system dysfunctions may result from damage
to the hypothalamus, hippocampus, or pituitary and
T4 T3 Pituitary
may produce symptoms of psychiatric disorders.
Figure 8-16 illustrates the interaction between stress
TSH - - and the immune system. This figure also demon-
+ T4 T3 strates the true biopsychosocial nature of the complex
interrelationship of the nervous system, the endocrine
T3 system, the immune system, and environmental or
- I- emotional stress.
T4 Immune dysregulation may also be involved in the
T4 development of psychiatric disorders. This can occur by
Thyroid allowing neurotoxins to affect the brain, damaging neu-
Extrathyroidal conversion sites
(liver, kidney, other) roendocrine tissue, or damaging tissues in the brain at
locations such as the receptor sites. Some antidepres-
FIGURE 8.15 Hypothalamicpituitarythyroid axis. The reg-
ulation of thyroid-stimulating hormone (TSH or thyrotropin)
sants have been thought to have antiviral effects. Symp-
secretion by the anterior pituitary. Positive effects of thy- toms of diseases such as depression may follow an occur-
rotropin-releasing hormone (TRH) from the hypothalamus rence of serious infection, and prenatal exposure to
and negative effects of circulating triiodothyronine (T3) and infectious organisms has been associated with the devel-
T3 from intrapituitary conversion of thyroxine (T4). opment of schizophrenia. Stress and conditioning have
specific effects on the suppression of immune function
neurohormones are providing messages, are the most (Ekman, Persson, & Nilsson, 2002; Friedman, 2000;
often studied aspect of the neuroendocrine system. Ishihara, Makita, Imai, Hashimoto, & Nohara, 2003). In
These axes always involve a feedback mechanism. For many cases, individuals with SLE experience symptoms
example, the hypothalamuspituitarythyroid axis of depression, insomnia, nervousness, and confusion.
regulates the release of thyroid hormone by the thy- Although there is still much to learn about the relation-
roid gland using TRH hormone from the hypothala- ship of psychiatric disorders and the immune system, it
mus to the pituitary and thyroid-stimulating hormone is clear that psychiatricmental health nurses must
(TSH) from the pituitary to the thyroid. Figure 8-15 develop and implement interventions designed to
illustrates the hypothalamicpituitarythyroid axis. enhance immune function in psychiatric patients.
The hypothalamic pituitarygonadal axis regulates
estrogen and testosterone secretion through luteiniz-
ing hormone and follicle-stimulating hormone.
Interest in psychoendocrinology is heightened by Chronobiology involves the study and measure of time
various endocrine disorders that produce psychiatric structures or biologic rhythms. Some rhythms have a cir-
symptoms. Addisons disease (hypoadrenalism) pro- cadian cycle, or 24-hour cycle, whereas others, such as the
duces depression, apathy, fatigue, and occasionally menstrual cycle, operate in different periods. Rhythms
psychosis. Hypothyroidism produces depression and exist in the human body to control endocrine secretions,
some anxiety. Administration of steroids can cause sleepwake, body temperature, neurotransmitter synthe-
depression, hypomania, irritability, and in some cases, sis, and more. These cycles may become deregulated and
psychosis. Some psychiatric disorders have been asso- may begin earlier than usual, known as a phase advance,
ciated with endocrine system dysfunction. For exam- or later than usual, known as a phase delay.
ple, some individuals with mood disorders show evi- Zeitgebers are specific events that function as time
dence of dysregulation in adrenal, thyroid, and growth givers or synchronizers and that set biologic rhythms.
hormone axes. Light is the most common example of an external zeit-
geber. The suprachiasmatic nucleus of the hypothala-
mus is an example of an internal zeitgeber. Some theo-
rists think that psychiatric disorders may result from
Psychoimmunology is the study of immunology as it one or more biologic rhythm dysfunctions. For exam-
relates to emotions and behavior. The immune system ple, depression may be, in part, a phase advance disor-
protects the body from foreign pathogens. Overactiv- der, including early morning awakening and decreased
ity of the immune system can occur in autoimmune time of onset of REM sleep. Seasonal affective disorder
diseases such as systemic lupus erythematous (SLE), may be the result of shortened exposure to light during
allergies, or anaphylaxis. Too little activity may result the winter months. Exposure to specific artificial light
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 119

Central nervous system

IL-1, IL-6, TNF, Thymosin
Stress, psychiatric illness Immune system

Endocrine system CRH

Thoracic duct
Thyrotropin Endorphins Prolactin/ Autonomic
growth nervous system
Sympathetic chain
Spinal cord Lymph nodes


Peyer's patches

Adrenal glands

Bone marrow

Infection, autoimmune disorders, neoplastic disease Peripheral blood leukocytes

FIGURE 8.16 Examples of the interaction between stress or psychiatric illness and the immune
system through the endocrine system. CRH, corticotropin-releasing hormone; IL, interleukin; TNF,
tumor necrosis factor; ACTH, adrenocorticotropic hormone; LH, luteinizing hormone; FSH, follicle-
stimulating hormone.

often relieves symptoms of fatigue, overeating, hyper- occur only in the presence of the psychiatric disorder
somnia, and depression. and include such findings as laboratory and other diag-
nostic test results and neuropathologic changes notice-
able in assessment. These markers increase diagnostic
certainty, reliability, and may have predictive value,
Diagnostic Approaches allowing for the possibility of preventive interventions
Now that we understand more about neural transmis- to forestall or avoid the onset of illness.
sion, brain functioning, and psychopharmacology, focus In addition, biologic markers could assist in develop-
is shifting to applying the knowledge in order to find ing evidence-based care practices. If markers can be used
biologic markers for the psychiatric disorders previ- reliably, it would be much easier to identify the most
ously thought to have only a psychological component. effective treatments and to determine the expected
Biologic markers are diagnostic test findings that prognosis for given conditions. The psychiatricmental
120 UNIT II Principles of Psychiatric Nursing

health nurse should be aware of the most current carbamazepine or high doses of estrogen, may alter the
information on biological markers so that information, test results, producing false-positive results. Overall, a
limitations, and results can be discussed knowledgeably positive result, or abnormal nonsuppression, appears to
with the patient. indicate major depression, but a negative result does not
rule out depression. Considerable controversy exists
regarding the clinical usefulness of this test.
Although no commonly used laboratory tests exist
that directly confirm a mental disorder, laboratory tests
For many years, laboratory tests have attempted to are still an active part of care and assessment of psychi-
measure levels of neurotransmitters and other CNS atric patients. Many physical conditions mimic the
substances in the bloodstream. Many of the metabolites symptoms of mental illness, and many of the medica-
of neurotransmitters can be found in the urine and CSF tions used to treat psychiatric illness can produce health
as well. However, these measures have had only limited problems. For these reasons, the routine care of
utility in elucidating what is happening in the brain. patients with psychiatric disorders includes the use of
Levels of neurotransmitters and metabolites in the laboratory tests such as complete blood counts, thyroid
bloodstream or urine do not necessarily equate with studies, electrolytes, hepatic enzymes, and other evalu-
levels in the CNS. In addition, availability of the neu- ative tests. Psychiatricmental health nurses need to be
rotransmitter or metabolite does not predict the avail- familiar with these procedures and assist patients in
ability of the neurotransmitter in the synapse, where it understanding the use and implications of such tests.
must act, or directly relate to the receptor sensitivity.
Nonetheless, numerous research studies have focused
on changes in neurotransmitters and metabolites in
blood, urine, and CSF. These studies have provided EEG is a tried and true method for investigating what
clues but remain without conclusive predictive value is happening inside the living brain. Developed in the
and therefore are not routinely used. 1920s by Hans Berger, an EEG measures electrical
Another laboratory approach to the study of some of activity in the uppermost nerve layers of the cortex.
the psychiatric disorders is the challenge test. A chal- Usually, 16 electrodes are placed on the patients scalp.
lenge test has been most often used in the study of panic The EEG machine, equipped with graph paper and
disorders. These tests are usually conducted by intra- recording pens, is turned on, and the pens then trace
venously administering a chemical known to produce a the electrical impulses generated over each electrode.
specific set of psychiatric symptoms. For example, lac- Until the use of CT in the 1970s, the EEG was the only
tate or caffeine may be used to induce the symptoms of method for identifying brain abnormalities. It remains
panic in a person who has panic disorder. The biologic the simplest and most noninvasive method for identify-
response of the individual is then monitored. These ing some disorders. It is increasingly being used to
tests have been developed primarily for research pur- identify individual neuronal differences and most
poses. However, endocrine stimulation tests, such as the recently to predict a persons response to common anti-
TRH stimulation test and the dexamethasone suppres- depressant medication (Cook, et al., 2002).
sion test, have some limited clinical utility. An EEG may be used in psychiatry to differentiate
In the TRH stimulation test, TRH is administered possible causes of the patients symptoms. For example,
and the TSH blood level is measured over time, usually some types of seizure disorders, such as temporal lobe
at intervals during a period of 3 to 4 hours. The patient epilepsy, head injuries, or tumors, may present with
with hypothyroidism has an elevated TSH level. A predominantly psychiatric symptoms. In addition,
blunted TRH stimulation test has been proposed as a metabolic dysfunction, delirium, dementia, altered lev-
biologic marker for major depression; however, only els of consciousness, hallucinations, and dissociative
about 30% of individuals with major depression show states may require EEG evaluation.
the response. The dexamethasone suppression test Spikes and wave-pattern changes are indications of
involves administering 1 mg dexamethasone at 11 PM. brain abnormalities. Spikes may be the focal point from
Cortisol blood levels are then measured. In the healthy which a seizure occurs. However, abnormal activity often
individual, dexamethasone suppresses cortisol levels, is not discovered on a routine EEG while the individual
but results of numerous studies suggest that there is is awake. For this reason, additional methods are some-
nonsuppression in certain types of depression. Typi- times used. Nasopharyngeal leads may be used to get
cally, the cortisol levels are measured before adminis- physically closer to the limbic regions. The patient may
tering the dexamethasone and then again at 8 AM, 4 PM, be exposed to a flashing strobe light while the examiner
and 11 PM on the following day. Many medical condi- looks for activity that is not in phase with the flashing
tions, such as diabetes mellitus, obesity, infection, preg- light or may be asked to hyperventilate for 3 minutes to
nancy, recent surgery, and use of medications, such as induce abnormal activity if it exists. Sleep deprivation
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 121

may also be used. This involves keeping the patient EPs are used primarily in the assessment of demyelinat-
awake throughout the night before the EEG evaluation. ing disorders, such as multiple sclerosis.
The patient may then be drowsy and fall asleep during However, brain electrical activity mapping (BEAM)
the procedure. Abnormalities are more likely to occur studies, which involve a 20-electrode EEG that gener-
when the patient is asleep. Sleep may also be induced ates computerized maps of the brains electrical activity,
using medication; however, many medications change have found a slowing of electrical activity in the frontal
the wave patterns on an EEG. For example, the benzodi- lobes of individuals who have schizophrenia. These
azepine class of drugs increases the rapid and fast beta findings are consistent with other findings that suggest
activity. Many other prescribed and illicit drugs, such as a hypofrontality in schizophrenia (see Chapter 16).
lithium, which increases theta activity, can cause EEG Nonetheless, neurophysiologic methods provide only
alterations. In addition to reassuring, preparing, and edu- rough approximations compared with current structural
cating the patient for the examination, the nurse should and functional neuroimaging techniques.
carefully assess the history of substance use and report
this information to the examiner. If a sleep deprivation
EEG is to be done, caffeine or other stimulants that
Integration of the
might assist the patient in staying awake should be with- Biologic, Psychological,
held because they may change the EEG patterns. and Social Domains
Basic knowledge in the neurosciences has become
Polysomnography essential content for the practicing psychiatric nurse. In
Polysomnography is a special procedure that involves a truly holistic biopsychosocial model, all psychological
recording the EEG throughout a night of sleep. This and social influences are seen as interacting with the
test is usually conducted in a sleep laboratory. Other complex human biologic system. For example, treat-
tests are usually performed at the same time, including ment of generalized anxiety disorder would involve
electrocardiography and electromyography. Blood oxy- addressing etiologies in each of these areas (see Fig.
genation, body movement, body temperature, and 8-17). As research continues to increase our under-
other data may be collected as well, especially in standing of the biologic dimension of psychiatric disor-
research settings. This procedure is usually conducted ders and mental health, nursing care will focus on
for evaluating sleep disorders, such as sleep apnea, human biology in increasingly sophisticated ways. Psy-
enuresis, or somnambulism. However, sleep pattern chiatric nurses must integrate this information into all
changes are frequently researched in mental disorders aspects of nursing management, including:
as well. Assessmentgenetic, physical, and environmental
Researchers have found that normal sleep divisions factors that contribute to the symptoms of psychi-
and stages are affected by many factors, including atric disorders; biologic rhythm changes; cognitive
drugs, alcohol, general medical conditions, and psychi-
atric disorders. For example, REM latency, the length
of time it takes an individual to enter the first REM Possible dysregulation of
episode, is shortened in depression. Reduced delta sleep SNS
Serotonin dysfunction
is also observed. These findings have been replicated so GABA and benzodiazepine
frequently that some researchers consider them bio- receptor dysfunction Social
logic markers for depression. Genetic factors High-stress lifestyle
Increased consumption of Multiple life stresses
anxiety-provoking substances
Endocrine dysfunction, e.g.,
Other Neurophysiologic Methods hypothyroidism

Evoked potentials (EPs), also called event-related poten-

tials, use the same basic principles as an EEG. They
measure changes in electrical activity of the brain in spe- Psychological
Inaccurate assessment of
cific regions as a response to a given stimulus. Electrodes perceived environmental dangers
placed on the scalp measure a large waveform that stands Unresolved unconscious
out after the administration of repetitive stimuli, such as Hypersensitivity to stress
a click or flash of light. There are several different types and anxiety-provoking
of EPs to be measured, depending on the sensory area
affected by the stimulus, the cognitive task required, or
the region monitored, any of which can change the FIGURE 8-17 Biopsychosocial etiologies for patients with
length of time until the wave occurrence. EPs are used generalized anxiety disorders. GABA  -aminobutyric acid;
extensively in psychiatric research. In clinical practice, (SNS  sympathetic nervous system)
122 UNIT II Principles of Psychiatric Nursing

abilities that may effect or complicate interven- Biologic markers are physical indicators of distur-
tions; and risk factors that may predict develop- bances within the central nervous system that differ-
ment of psychiatric symptoms or disorders. entiate one disease process from another, such as
Diagnosisdifficulties related to diet, exercise, or biochemical changes or neuropathologic changes.
sleep that may change the individuals biology; These biologic markers can be measured by several
quality-of-life difficulties based on biologic methods of testing, including challenge tests,
changes; knowledge deficits concerning the bio- electroencephalography, polysomnography, evoked
logic basis of psychiatric disorders or treatment. potentials, computed tomography scanning, mag-
Interventionsdesigned to modify biologic netic resonance imaging, positron emission tomog-
changes and physical functioning; designed to raphy, and single photon emission computed tomog-
enhance biologic treatments; or modified to con- raphy, all of which the psychiatric nurse must be
sider cognitive dysfunction related to psychiatric familiar with.
disorders. Although no one gene has been found to produce
any psychiatric disorder, significant evidence indi-
SUMMARY OF KEY POINTS cates there is for most psychiatric disorders a genetic
predisposition or susceptibility. For individuals who
Neuroscientists now view behavior and cognitive have such genetic susceptibility, the identification of
function as a result of complex interactions within risk factors is crucial in helping to plan interventions
the central nervous system and its plasticity, or its to prevent development of that disorder or to pre-
ability to adapt and change in both structure and vent certain behavior patterns, such as aggression or
function. suicide.
Each hemisphere of the brain is divided into four
lobes: the frontal lobe, which controls motor speech
function, personality, and working memoryoften CRITICAL THINKING CH.ALLENGES
called the executive functions that govern ones ability
to plan and initiate action; the parietal lobe, which 1 Explain the significance of mental disorders being
controls the sensory functions; the temporal lobe, described as polygenetic.
which contains the primary auditory and olfactory 2 A patient who is scheduled for magnetic resonance
areas; and the occipital lobe, which controls visual imaging asks how this test can possibly help
integration of information. explain why he is all nerved up. He states that
The structures of the limbic system are integrally his friend had a CT scan, and he wants that
involved in memory and emotional behavior. Dys- instead. What would the nurse say to assist this
function of the limbic system has been linked with patient understanding the difference between the
major mental disorders, including schizophrenia, two tests?
depression, and anxiety disorders. 3 Five different approaches to the study of neu-
Neurons communicate with each other through roanatomy are discussed in this chapter. Define
synaptic transmission. Neurotransmitters excite or each approach and discuss its utility in understand-
inhibit a response at the receptor sites and have been ing mental disorders.
linked to certain mental disorders. These neuro- 4 A woman who has experienced a ministroke con-
transmitters include acetylcholine, dopamine, norep- tinues to regain lost cognitive function months
inephrine, serotonin,  aminobutyric acid, and gluta- after the stroke. Her husband takes this as evidence
mate. that she never had a stroke. How would you
Psychoendocrinology examines the relationship approach patient teaching and counseling for this
between the nervous system and endocrine system couple to help them understand this occurrence if
and the effects of neurohormones excreted by special the stroke did damage to her brain?
neurons to communicate with the endocrine system 5 Your patient has impaired executive functioning.
in effecting behavior. Psychoimmunology focuses on Consider what would be a reasonable follow-up
the nervous system as regulating immune function, schedule for this patient for counseling sessions.
which may play a significant role in effecting psy- Would it be reasonable to schedule visits at 1:00 PM
chological states and psychiatric disorders. Chrono- weekly? Is the patient able to keep to this sched-
biology focuses on the study and measure of time ule? Why or why not? What would be the best
structures or biologic rhythms occurring in the body schedule?
and associates dysregulation of these cycles as con- 6 Mr. S. is unable to sleep after watching an upsetting
tributing factors to the development of psychiatric documentary. Identify the neurotransmitter activity
disorders. that may be interfering with sleep. (Hint: Fight or
CHAPTER 8 The Biologic Foundations of Psychiatric Nursing 123

7 Describe what behavioral symptoms or problems Harlow, J. M. (1868). Recovery after severe injury to the head. Publi-
may be present in a patient with dysfunction of the cation of the Massachusetts Medical Society, 2, 327.
Harmer, C. J., Hill, S. A., Taylor, M. J., Cowen, P. J., & Goodwin, G.
following brain area: M. (2003). Toward a neuropsychological theory of antidepressant
a. Basal ganglia drug action: Increase in positive emotional bias after potentiation
b. Hippocampus of norepinephrine activity. American Journal of Psychiatry, 160,
c. Limbic system 990992.
d. Thalamus Harrison, P. J. & Owen, M. S. (2003). Genes for Schizophrenia?
Recent findings and their pathophysiological implications. Lancet
e. Hypothalamus 361 (9355), 417419.
f. Frontal lobe Heerschap, A., Kok, R. D., & Van De, W. (2003). Antenatal proton
8 Compare and contrast the functions of the sympa- MR spectroscopy of the human brain in vivo. Childrens Nervous
thetic and parasympathetic nervous systems. System, 17, 4446.
9 Discuss the steps in synaptic transmission, begin- Hennig, J., Speck, O., Koch, M. A., & Weiller, C. (2003). Functional
magnetic resonance imaging: A review of methodological aspects
ning with the action potential and ending with how and clinical applications. Journal of Magnetic Resonance Imaging,
the neurotransmitter no longer communicates its 18(1), 115.
message to the receiving neuron. Ishihara, S., Makita, S., Imai, M., Hashimoto, T., & Nohara, R.
10 Examine how a receptors usual response to a neu- (2003). Relationship between natural killer activity and anger
rotransmitter might change. expression in patients with coronary heart disease. Heart Vessels,
18(2), 8592.
11 Compare the role of dopamine and acetylcholine in Johnson, K. A., & Brensinger, J. D. (2000). Genetic counseling and
the CNS. testing. Clinics of North America, 35(3), 615621.
12 Explain how dopamine, norepinephrine, and sero- Kapczinski, F., Lima, M. S., Souza, N., JS, & Schmitt, R. (2003).
tonin all contribute to endocrine system regulation. Antidepressants for generalized anxiety disorder (Cochrane
Suggest some other transmitters that may affect Review). Cochrane Database System Review 2003;2:CD003592.
Kurup, R. K., & Kurup, P. A. (2003). Hypothalamic digoxin: Central
endocrine function. role in conscious perception, neuroimmunoendocrine integration
13 Discuss how the fields of psychoendocrinology, and coordination of cellular functionrelation to hemispheric
psychoimmunology, and chronobiology overlap. dominance. Medical Hypotheses, 60(2), 243257.
14 Compare the methods used to find biologic mark- Lea, D. H. (2000). A clinicians primer in human genetics: What
ers of psychiatric disorders reviewed in this chapter. nurses need to know. Nursing Clinics of North America, 35(3),
Consider the potential risks and benefits to the MacGregor, D. G., Avshalumov, M. V., & Rice, M. E. (2003). Brain
patient. edema induced by in vitro ischemia: Causal factors and neuropro-
15 Determine the actions you would take in preparing tection. Journal of Neurochemistry, 85(6), 14021411.
a patient for an MRI scan. McGuffin, P., Rijsdijk, F., Andrew, M., Sham, P., Katz, R., & Cardno,
A. (2003). The heritability of bipolar affective disorder and the
genetic relationship to unipolar depression. Archives of General
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and Other Biologic
Susan McCabe

After studying this chapter, you will be able to:
Explain the key role of neurotransmitter chemicals and their receptor sites in the
action of psychopharmacologic medications.
Explain the four action sites where current psychotropic medications work: recep-
tors, ion channels, enzymes, and carrier proteins.
Define the three properties that determine the strength and effectiveness of a
Describe the hypothesized mechanism of action for each class of psychopharmaco-
logic medication.
Describe the target symptoms and major side effects of various classes of psy-
chotropic medications.
Suggest appropriate nursing methods to administer medications that facilitate efficacy.
Implement interventions to minimize side effects of psychopharmacologic medications.
Differentiate acute and chronic medication-induced movement disorders.
Identify aspects of patient teaching that nurses must implement for successful main-
tenance of patients using psychotropic medications.
Analyze the potential benefits of other forms of somatic treatments, including elec-
troconvulsive therapy, light therapy, and nutrition therapy.
Evaluate potential causes of noncompliance and implement interventions to improve
compliance with treatment regimens.

absorption adherence adverse reactions affinity agonists akathisia
antagonists bioavailability biotransformation compliance desensitization
distribution dystonia efficacy excretion first-pass effect half-life
intrinsic activity kindling metabolism pharmacogenomics phototherapy
protein binding pseudoparkinsonism selectivity side effects solubility
tardive dyskinesia target symptoms therapeutic index tolerance toxicity

psychopharmacology receptors

CHAPTER 9 Psychopharmacology and Other Biologic Treatments 125

T hroughout history, treatment choices for mental

disorders have been linked to the prevailing assump-
tions about the etiology of these illnesses. In the early
psychopharmacologic therapy, other biologic treat-
ments (sometimes referred to as somatic treatments) are
used. These therapies include electroconvulsive therapy,
1900s, Emil Kraeplin classified mental disorders based light therapy, and nutritional therapy and are discussed
on clusters of observed symptoms, providing the basic later.
tenets of the contemporary biologic approach to under-
standing and treating psychiatric disorders. However,
this approach fell out of favor as psychoanalytic, psy- Pharmacodynamics
chodynamic, interpersonal, and other therapies flour-
A comparatively small amount of medication can have a
ished, and mental disorders were assumed to have pri-
significant and large impact on cell function and result-
marily a psychological etiology. In the 1950s, when it
ing behavior. When tiny molecules of medication are
was discovered that the phenothiazine medications,
compared with the vast amount of cell surface in the
such as chlorpromazine (Thorazine), relieved many of
human body, the fraction seems disproportionate. Yet
the symptoms of psychosis, and iproniazid, a medica-
the drugs used to treat mental disorders often have pro-
tion for treating tuberculosis, improved depression,
found effects on behavior. To understand how this
there was renewed interest in biologic treatments.
occurs, one needs to understand both where and how
Recent scientific and technologic developments have
drugs work.
renewed awareness of the biologic basis of mental dis-
orders, leading to a proliferation of new medications
that act at the cellular level, producing major behavioral TARGETS OF DRUG ACTION:
and psychological change. These medications provide WHERE DRUGS ACT
relief from debilitating symptoms in millions of individ-
Psychopharmacologic drugs act at four sites: receptors,
uals with psychiatric disorders. They have become the
ion channels, enzymes, and carrier proteins. Drug mol-
dominant form of treatment and are the cornerstones of
ecules do not act on the entire cell surface, but rather at
all psychiatric treatment.
a specific receptor site.
Most psychiatricmental health nurses work with
individuals who are receiving psychopharmacologic
agents as part of their treatment. As awareness of the KEY CONCEPT Receptors are associated with
the work of German chemist Paul Erhlich, who in
prevalence of mental disorders increases, these medica-
1900 suggested that a receptive substance exists
tions are increasingly prescribed in primary care settings,
within the cell membrane. His work, along with that
and even nurses working in nonpsychiatric settings now of John Newport Langley, an English physiologist, is
need an in-depth knowledge of these medications to care the basis for the concept of a receptor regionor area
for their patients in any setting. on which a specific chemical may act. The biologic
action of a drug depends on how its structure inter-
KEY CONCEPT Psychopharmacology is a sub- acts with a specific receptor. The importance of recep-
specialty of pharmacology that studies medications tor sites is now firmly established and is a key to
that affect the brain and behaviors and that are used understanding how drugs work in the body.
to treat psychiatric disorders.
Several different types of proteins exist in the cell
This chapter reviews the major classes of psy- membrane, both presynaptically and postsynaptically.
chopharmacologic drugs used in treating mental disor- These proteins serve as receptors for both chemicals
ders, including antipsychotics, mood stabilizers, antide- found normally in the body and administered drugs.
pressants, antianxiety medications, and stimulants, and Normally occurring chemicals involved in neurotrans-
provides a basis for understanding the specific biologic mission, such as dopamine and serotonin, adhere to a
treatments of psychiatric disorders that are described specific group of receptors. Administered drugs may
more fully in later chapters. compete with neurotransmitters for these receptor
Psychiatric medications affect the central nervous sites, attempting to mimic or block the action of the
system (CNS) at the cellular, synaptic level. For this normally occurring neurotransmitter. Current medica-
reason, this chapter focuses on a basic understanding tions used in psychiatry primarily produce their actions
of synaptic physiology as it relates to the actions of at these four sites. Therefore, in this chapter, receptor
psychotropic medications. This basic understanding refers only to those sites to which a neurotransmitter
allows the psychiatricmental health nurse to accept can specifically adhere to produce a change in the cell
the role and responsibilities of administering medica- membrane, serving a physiologic regulatory function
tions, monitoring and treating side effects, and educat- (such as those discussed in Chapter 8). These include
ing the patient and family, which is crucial to success- the ligand-gated ion channel or the G-proteinlinked
ful psychopharmacologic therapy. In addition to receptor.
126 UNIT II Principles of Psychiatric Nursing

Receptors Affinity
Many drugs have been developed to act specifically at The second property is that of affinity, which is the
the receptor sites. Their chemical structure is similar to degree of attraction or strength of the bond between the
the neurotransmitter substance for that receptor. When drug and its receptor. Normally, these bonds are rela-
attached, these drugs act as agonistschemicals pro- tively weak chemical bonds. When a drug has more than
ducing the same biologic action as the neurotransmitter one type of chemical bond with a receptor, its affinity may
itselfor as antagonistschemicals blocking the bio- be increased. The number of specific receptors on the cell
logic response at a given receptor. Figure 9-1 illustrates membrane to which it might adhere may also increase a
the action of an agonist and an antagonist drug at a drugs affinity. However, these types of weak chemical
receptor site. bonds with a receptor allow a drugs effects to be easily
reversible when use of the drug is discontinued. Although
most drugs used in psychiatry adhere to receptors
through weak chemical bonds, some drugs, specifically
A drugs ability to interact with a given receptor type the monoamine oxidase inhibitors (discussed later), have
may be judged by three properties. The first property, a different type of bond, called a covalent bond. A covalent
called selectivity, is the ability of the drug to be specific bond is formed when two atoms share a pair of electrons.
for a particular receptor. If a drug is highly selective, it This type of bond is stronger and irreversible at normal
will interact only with its specific receptors in the areas temperatures. The effects of the drugs that form covalent
of the body where these receptors occur and, therefore, bonds are often called irreversible because they are
not affect tissues and organs where its receptors do not long lasting, taking several weeks to resolve.
occur. Using a lock-and-key analogy, only a specific,
highly selective key will fit a given lock. The more Intrinsic Activity
selective or structurally specific a drug is, the more
likely it will affect only the specific receptors for which The final property of a drugs ability to interact with a
it is meant. The more receptors for other neurochemi- given receptor is that of intrinsic activity, or the ability
cals are affected, the more unintended effects, or side of the drug to produce a biologic response once it
effects are produced. Selectivity is important to under- becomes attached to the receptor. Some drugs have
stand because it helps explain the concept of side effects selectivity and affinity but produce no biologic response;
caused by medications, a major cause of concern in therefore, an important measure of a drug is whether it
medication treatment. produces a change in the cell containing the receptor.
Drugs that act as agonists have all three properties: selec-
tivity, affinity, and intrinsic activity. However, antagonists
have only selectivity and affinity because they produce no
D biologic response by attaching to the receptor.
Some drugs are referred to as partial agonists. When a
R stronger agonist with high intrinsic activity is combined
with a weaker agonist (low intrinsic activity) that has high
affinity for a given receptor, the net effect is that the
weaker agonist will act as an antagonist to the stronger
agonist. Because it has some intrinsic activity (although
weak), it is referred to as a partial agonist. Because there
are no pure drugs, affecting only one neurotransmitter,
AR most drugs have multiple effects. A drug may act as an
agonist for one neurotransmitter and an antagonist for
another. Medications that have both agonist and antago-
nist effects are called mixed agonistantagonists.

FIGURE 9.1 Agonist and antagonist drug actions at a recep- Ion Channels
tor site. This schematic drawing represents drug-receptor
interactions. At top, drug D has the correct shape to fit recep- Some drugs directly block the ion channels of the nerve
tor R, forming a drugreceptor complex, which results in a cell membrane. For example, local anesthetics block the
conformational change in the receptor and the opening of a entry of sodium into the cell, preventing a nerve
pore in the adjacent membrane. Drug D is an agonist. At bottom,
impulse. In psychiatry, the utility of calcium-channel
drug A also has the correct shape to fit the receptor, forming
a drugreceptor complex, but in this case, there is no confor- blockers has been investigated for use with the symp-
mational change and, therefore, no response. Drug A is, there- toms of mania, a state of increased activity, euphoria, dif-
fore, an antagonist. ficulty sleeping, racing thoughts, and rapid and forced
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 127

speech (see Chapter 18). Operating on the hypothesis Serotonin reuptake blockade
that mania is related to too much neurotransmitter Storage vesicles
released into the synapse, researchers suggested that
modulating the influx of calcium (which stimulates the
vesicles to release neurotransmitter) might decrease the
symptoms of mania. Although this theory has yet to be
fully proved, it is an example of how neurotransmission
may be changed by different drug actions.
The benzodiazepine drugs, frequently used in psy-
chiatry, decrease the symptoms of anxiety and are an
example of drugs that affect the ion channels of the Presynaptic nerve Postsynaptic nerve
nerve cell membrane. The benzodiazepine molecule, in
FIGURE 9.2 Reuptake blockade of a carrier molecule for
such drugs as diazepam (Valium), works by binding to a serotonin by a selective serotonin reuptake inhibitor.
region of the gamma-aminobutyric acid (GABA)-
receptor chloride channel complex. They facilitate
GABA in opening the chloride ion channel, rather than A primary action of most of the antidepressants is to
replacing GABA, and have a modulatory effect in open- increase the amount of neurotransmitters in the synapse
ing the ion channel. by blocking their reuptake. Older antidepressants block
the reuptake of more than one neurotransmitter. The
newer antidepressants, such as fluoxetine (Prozac) and
sertraline (Zoloft), are more selective for serotonin, the
Enzymes are complex proteins that catalyze specific primary neurotransmitter thought to be involved in the
biochemical reactions within cells and are the targets development of depression. For this reason, these newer
for some drugs used to treat mental disorders. For medications are called selective serotonin reuptake
example, monoamine oxidase is the enzyme required to inhibitors (SSRIs). These medications have reduced the
break down most bioamine neurotransmitters, such as number of side effects experienced by the patients by
norepinephrine, serotonin, and dopamine, and can be acting more selectively on serotonin reuptake, rather
inhibited by medications from a group of antidepres- than norepinephrine or acetylcholine. Figure 9-2 illus-
sants called monoamine oxidase inhibitors (MAOIs). trates the reuptake blockade of serotonin by an SSRI.
Strong covalent bonds are formed between the medica-
tion and the enzyme, which inhibit the ability of the
enzyme to inactivate the bioamine neurotransmitters
after they have been used, resulting in increased
amounts of these neurotransmitters ready for release in Efficacy is another characteristic of medications to be
the nerve terminals. The inhibitory effect is greater for considered when selecting a drug for treatment of a par-
norepinephrine and serotonin than it is for dopamine. ticular set of symptoms. Efficacy is the ability of a drug
This increase in available norepinephrine and serotonin to produce a response that results from the receptor or
is thought to be the primary mechanism by which receptors being occupied. It is important to remember
MAOIs relieve the symptoms of depression. that the degree of receptor occupancy contributes to
efficacy, yet it is not the only variable. A drug may
occupy a large number of receptors but not produce a
Carrier Proteins: Uptake
response. Potency is also important when comparing
drug actions. This factor considers the dose required to
Neurotransmitters are small organic molecules, and a produce the desired biologic response. One drug may
carrier protein is usually required for these molecules to be able to achieve the same clinical effect as another
cross cell membranes. In much the same way as recep- drug but at a lower dose, making it more potent.
tors, these carrier proteins (also referred to as uptake Although the drug given at the lower dose is more
receptors) have recognition sites specific for the type of potent, because both drugs achieve similar effects, they
molecule to be transported. When a neurotransmitter may be considered to have equal efficacy.
such as serotonin needs to be removed from the
synapse, specific carrier molecules transport the sero-
Loss of Effect: Biologic Adaptation
tonin back into the presynaptic nerve, where most of it
is stored to be used again. Medications specific for this In some instances, the effects of medications diminish
site may block or inhibit this transport and, therefore, with time, especially when they are given repeatedly, as in
increase the amount of the neurotransmitter in the the treatment of chronic psychiatric disorders. This loss
synaptic space available for action on the receptors. of effect is most often a form of physiologic adaptation
128 UNIT II Principles of Psychiatric Nursing

that may develop as the cell attempts to regain homeo- Target Symptoms and Side Effects
static control to counteract the effects of the drug.
Psychiatric medications are indicated for specific symp-
Desensitization is a rapid decrease in drug effects that
toms, referred to as target symptoms. Target symp-
may develop in a few minutes of exposure to a drug. This
toms are those measurable specific symptoms expected
reaction is rare with most psychiatric medications but can
to improve with medication use. The target symptoms
occur with some medications used to treat serious side
for each class of medication are discussed more fully in
effects (e.g., physostigmine, sometimes used to relieve
later sections of this chapter. As yet, no drug has been
severe anticholinergic side effects). Tolerance is a grad-
developed that is so specific it affects only its target
ual decrease in the action of a drug at a given dose or con-
symptoms; instead, drugs act on target symptoms, as
centration in the blood. This decrease may take days or
well as a number of other organs and sites within the
weeks to develop and results in loss of therapeutic effect
body. Because most neurotransmitters have a number of
of a drug. This loss of effect is often called treatment
functions, even drugs with a high affinity and selectivity
for a specific neurotransmitter, such as serotonin, will
There are many reasons for decreased drug effec-
cause some responses in the body that are not related to
tiveness (Box 9-1). A rapid decrease can occur with
the target symptoms. These unwanted effects of med-
some drugs because of immediate transformation of the
ications are called side effects or untoward effects.
receptor when the drug molecule binds to the receptor.
Some unwanted effects may have serious physiologic
Other drugs cause a decrease in the number of recep-
consequences, referred to as adverse reactions.
tors. It is hypothesized that the receptors are taken into
Although technically different, these three terms are
the cell in a self-regulatory effort. In part, this may
often used interchangeably in the literature.
explain the development of some long-term side effects,
Knowledge of a medications affinity for receptors
such as tardive dyskinesia, a neuromuscular condition
and subtypes of receptors may give some indication of
resulting from long-term use of some medications used
the likelihood that specific target symptoms might
in treating psychosis.
improve and what side effects might be predicted. Table
Some drugs may exhaust the mediators of neuro-
9-1 provides a brief summation of possible physiologic
transmission. For example, amphetamines deplete the
effects from drug actions on specific neurotransmitters.
supplies of norepinephrine stored in the vesicles at the
For example, medications with a high affinity for acetyl-
terminals of the nerve cell. Drug tolerance is also
choline receptors of the muscarinic subtype, producing
caused by an increase in the metabolism (breakdown)
antagonism or blockage at the receptor site, will be
of the medication, such as with barbiturates, which trig-
more likely to cause anticholinergic side effects, includ-
ger an increase in some hepatic enzymes that increase
ing dry mouth, blurred vision, constipation, urinary
their own metabolism. This may add to the tolerance
hesitancy or retention, and nasal congestion. This
that develops to a given dose of barbiturate or may
information should serve only as a guide in predicting
cause a precipitant drop in the blood level of the anti-
side effects because many physical outcomes or behav-
convulsant carbamazepine (Tegretol).
iors resulting from neural transmission are controlled
Other forms of physiologic adaptation result in a
by multiple receptors and neurotransmitters. A psychi-
gradual tolerance that may be helpful when affecting
atricmental health nurse should use this information
unpleasant side effects, such as drowsiness or nausea.
to focus assessment on these areas. If the symptoms are
This information is important for the nurse to com-
mild, simple nursing interventions suggested in Table
municate to patients experiencing such side effects so
9-2 should be implemented. If symptoms persist or are
that they can be reassured that the effects will subside.
severe, the prescriber should be notified immediately.
The psychiatric nurse must also know when tolerance
will not occur and when a lack of tolerance to a sig-
nificant side effect warrants discontinuation of the
All drugs have the capacity to be harmful as well as help-
ful. Toxicity generally refers to the point at which con-
BOX 9.1 centrations of the drug in the bloodstream are high
Mechanisms Causing Decrease in enough to become harmful or poisonous to the body.
Medication Effects However, what is considered harmful? Side effects can be
harmful but not toxic, and individuals vary widely in their
Change in receptors responses to medications. Some patients experience
Loss of receptors adverse reactions more easily than others. Therapeutic
Exhaustion of neurotransmitter supply
Increased metabolism of the drug
index, a concept often used to discuss the toxicity of a
Physiologic adaptation drug, is a ratio of the maximum nontoxic dose to the
minimum effective dose. A high therapeutic index means
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 129

Drug Affinity for Specific Neurotransmitters and Receptors

Table 9.1
and Subsequent Effects

Neurotransmitter/ Example of Drugs That

Receptor Action Physiologic Effects Exhibit High Affinity

Receptor Blockade
Norepinephrine reuptake Antidepressant action Desipramine
inhibition Potentiation of pressor effects of norepinephrine Venlafaxine
Interaction with guanethidine
Side effects: tachycardia, tremors, insomnia, erectile and
ejaculation dysfunction
Serotonin reuptake Antidepressant action Fluoxetine
inhibition Antiobsessional effect Fluvoxamine
Increase or decrease in anxiety, dose dependent
Side effects: gastrointestinal distress, nausea, headache,
nervousness, motor restlessness and sexual side
effects, including anorgasmia
Dopamine reuptake Antidepressant action Buproprion
inhibition Antiparkinsonian effect
Side effects: increase in psychomotor activity, aggrava-
tion of psychosis

Reuptake Inhibition
Histamine receptor blockade Side effects: sedation, drowsiness, hypotension, and Quetiapine
(H1) weight gain Imipramine
Acetylcholine receptor Side effects: anticholinergic (dry mouth, blurred vision, Imipramine
blockade (muscarinic) constipation, urinary hesitancy and retention, memory Amitriptyline
dysfunction) and sinus tachycardia Thioridazine
Norepinephrine receptor Potentiation of antihypertensive effect of prazosin and Amitriptyline
blockade (1 receptor) terazosin
Side effects: postural hypotension, dizziness, reflex Clomipramine
tachycardia, sedation Clozapine
Norepinephrine receptor Increased sexual desire (yohimbine) Amitriptyline
blockade (2 receptor) Interactions with antihypertensive medications, blockade Clomipramine
of the antihypertensive effects of clonidine Clozapine
Side effect: priapism Trazodone
Norepinephrine receptor Antihypertensive action (propranolol) Propranolol
blockade (1 receptor) Side effects: orthostatic hypotension, sedation, depres-
sion, sexual dysfunction (including impotence and
decreased ejaculation)
Serotonin receptor blockade Antidepressant action Trazodone
(5-HT1a) Antianxiety effect Risperidone
Possible control of aggression Ziprasidone
Serotonin receptor blockade Antipsychotic action Risperidone
(5-HT2) Some antimigraine effect Clozapine
Decreased rhinitis Olanzapine
Side effects: hypotension, ejaculatory problems Ziprasidone
Dopamine receptor Antipsychotic action Haloperidol
blockade (D2) Side effects: extrapyramidal symptoms, such as tremor, Ziprasidone
rigidity (especially acute dystonia and parkinsonism);
endocrine changes, including elevated prolactin levels

that there is a large range between the dose at which the individuals increasing their dosages of barbiturates as
drug begins to take effect and a dose that would be toxic they became increasingly more tolerant to the effects and
to the body. Drugs with a low therapeutic index have a requiring larger doses to make them sleep have caused
narrow range. This concept has some limitations. The accidental suicides. The therapeutic index of a medica-
concept of toxicity is only vaguely defined. The range tion also may be greatly changed by the co-administra-
can also be affected by drug tolerance. For example, tion of other medications or drugs. For example, alcohol
130 UNIT II Principles of Psychiatric Nursing

Table 9.2 Managing Common Side Effects of Psychiatric Medications

Side Effect or Discomfort Intervention

Blurred vision Reassurance (generally subsides in 2 to 6 wk)

Dry eyes Warn ophthalmologist; no eye exam for new glasses for at least 3 wk after a
stable dose
Artificial tears may be required; increased use of wetting solutions for those
wearing contact lens
Dry mouth and lips Frequent rinsing of mouth, good oral hygiene, sucking sugarless candies,
lozenges, lip balm, lemon juice, and glycerin mouth swabs
Constipation High-fiber diet, encourage bran, fresh fruits and vegetables
Metamucil (must consume at least 16 oz of fluid with dose)
Increase hydration
Exercise, increase fluids
Mild laxative
Urinary hesitancy or retention Monitor frequently for difficulty with urination, changes in starting or stop-
ping stream
Notify prescriber if difficulty develops
A cholinergic agonist, such as bethanechol, may be required
Nasal congestion Nose drops, moisturizer, not nasal spray
Sinus tachycardia Assess for infections
Monitor pulse for rate and irregularities
Withhold medication and notify prescriber if resting rate exceeds 120 bpm
Decreased libido and Reassurance (reversible)
ejaculatory inhibition Consider change to less antiadrenergic drug
Postural hypotension Frequent monitoring of lying-to-standing blood pressure during dosage
adjustment period, immediate changes and accommodation, measure pulse
in both positions
Advise patient to get up slowly, sit for at least 1 min before standing
(dangling legs over side of bed), and stand for 1 min before walking or
until light-headedness subsides
Increase hydration, avoid caffeine
Elastic stockings if necessary
Notify prescriber if symptoms persist or significant blood pressure changes
are present, medication may have to be changed if patient does not have
impulse control to get up slowly
Photosensitivity Protective clothing
Dark glasses
Use of sun block, remember to cover all exposed areas
Dermatitis Stop medication usage
Consider medication change, may require a systemic antihistamine
Initiate comfort measures to decrease itching
Impaired psychomotor Advise patient to avoid dangerous tasks, such as driving
functions Avoid alcohol, which increases this impairment
Drowsiness or sedation Encourage activity during the day to increase accommodation
Avoid tasks that require mental alertness, such as driving
May need to adjust dosing schedule or, if possible, give single daily dose at
May need a cholinergic medication if sedation is the problem
Avoid driving or operating potentially dangerous equipment
May need change to less-sedating medication
Provide quiet and decreased stimulation when sedation is the desired effect
Weight gain Exercise and diet teaching
Caloric control
Edema Check fluid retention
May need a diuretic
Irregular menstruation Reassurance (reversible)
Amenorrhea May need to change class of drug
Reassurance and counseling (does not indicate lack of ovulation)
Instruct patient to continue birth control measures
Vaginal dryness Instruct in use of lubricants
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 131

consumed with most CNS-depressant drugs will have by a number of factors. Taking certain drugs orally
added depressant effects, greatly increasing the likeli- with food or antacids may slow the rate of absorption
hood of toxicity or death. or change the amount of the drug absorbed. For exam-
Despite the limitations of the therapeutic index, it is ple, the -receptor antagonist propranolol, a cardiac
a helpful guide for nurses, particularly when working medication that helps relieve symptoms of anxiety,
with potentially suicidal individuals. Psychiatricmental exhibits increased blood levels when taken with food.
health nurses must be aware of the potential for over- Antacids containing aluminum salts decrease the
dose and closely monitor the availability of drugs for absorption of most antipsychotic drugs; thus, antacids
these patients. In some cases, prescriptions may have to must be given at least 1 hour before administration or
be dispensed every few days or each week until a suici- 2 hours after.
dal crisis has passed to ensure that patients do not have Oral preparations absorbed from the gastrointestinal
a lethal dose available to them. The SSRIs such as flu- tract into the bloodstream first go to the liver through
oxetine have relatively few adverse reactions and have a the portal vein. There, they may be metabolized in such
high therapeutic index. Therefore, they are usually con- a way that most of the drug is inactivated before it
sidered the preferred, or first-line, antidepressants for reaches the rest of the body. Some drugs are also sub-
treatment of acutely suicidal individuals. jected to metabolism in the gastrointestinal wall, result-
ing in loss of available drug in the gastrointestinal sys-
tem or the liver, called the first-pass effect. The
Pharmacokinetics: first-pass effect happens when there is an organ that
How the Body Acts on affects excretion of the drug between the administration
point and systemic circulation. The consequence of
the Drugs first-pass effect is that the fraction of the drug reaching
The field of pharmacokinetics describes, often in math- systemic circulation is reduced, sometimes substantially.
ematic models, how biologic functions within the living Drugs that commonly undergo first-pass include nor-
organism act on a drug. The processes of absorption, triptyline, meperidine, and propranolol.
distribution, metabolism, and excretion are of central First-pass explains why the dose of propranolol given
importance. Overall, the goal in pharmacokinetics is to intravenously is so much less than the oral dose. How-
describe and predict the time course of drug concentra- ever, even drugs with first-pass effect reach the rest of
tions throughout the body and factors that may inter- the body, but other factors affecting absorption should be
fere with these processes. Together with the principles considered when administering drugs with known first-
of pharmacodynamics, this information can be helpful pass effect. It is extremely important for psychiatric
to the psychiatric nurse in such ways as facilitating or mental health nurses to attend conscientiously to drug
inhibiting drug effects and predicting behavioral administration times that meet the individual patients
response. needs, rather than adhere to all standardized adminis-
tration schedules.
Gastric motility also affects how the drug is absorbed.
Increasing age, many disease states, and concurrent
medications can reduce motility and slow absorption.
The first phase of drug disposition in the human body Other factors, such as blood flow in the gastrointestinal
is absorption, defined as the movement of the drug system, drug formulation, and chemical factors, may also
from the site of administration into the plasma. It is interfere with absorption. Nurses must be aware of a
important to consider the impact of routes by which a patients physical condition and use of medications or
drug is administered on the process of absorption. Not other substances that can interfere with drug absorption.
all potential routes of administration are available for In full strength, many liquid preparations, especially
medications used to treat psychiatric disorders. The antipsychotics, irritate the mucosal lining of the mouth,
primary routes available include oral (both tablet and esophagus, and stomach and must be adequately diluted.
liquid), intramuscular (short- and long-acting agents), Nurses must be careful when diluting liquid medications
and intravenous (rarely used for treatment of the pri- because some liquid concentrate preparations are incom-
mary psychiatric disorder, but instead for rapid treat- patible with certain juices or other liquids. If a drug is
ment of adverse reactions). The psychiatricmental mixed with an incompatible liquid, a white or grainy pre-
health nurse needs to know about the advantages and cipitant usually forms, indicating that some of the drug
disadvantages of each route and the subsequent effects has bound to the liquid and inactivated. Thus, the patient
on absorption (Table 9-3). actually receives a lower dose of the medication than
Drugs taken orally are usually the most convenient intended. Precipitants can also form from combining two
for the patient; however, this route is also the most liquid medications in one diluent, such as juice. Some-
variable because absorption can be slowed or enhanced times, precipitants may be difficult to see, such as in
132 UNIT II Principles of Psychiatric Nursing

Table 9.3 Selected Forms and Routes of Psychiatric Medications

Preparation and Route Examples Advantages Disadvantages

Oral tablet Basic preparation for most Usually most convenient Variable rate and extent of
psychopharmacologic absorption, depending
agents, including anti- on the drug
depressants, antipsy- May be affected by the
chotics, mood stabiliz- contents of the
ers, anxiolytics, etc. intestines
May show first-pass
metabolism effects
May not be easily swal-
lowed by some
Oral liquid Also known as Ease of incremental dosing More difficult to measure
concentrates Easily swallowed accurately
Many antipsychotics, such In some cases, more Depending on drug:
as haloperidol, chlorpro- quickly absorbed Possible interactions
mazine, thioridazine, with other liquids such
risperidone as juice, forming
The antidepressant precipitants
fluoxetine Possible irritation to
Antihistamines, such as mucosal lining of mouth
diphenhydramine if not properly diluted
Mood stabilizers, such as
lithium citrate
Rapid-dissolving tablet Atypical antipsychotics, Dissolves almost instanta- Patient needs to remember
such as olanzapine neously in mouth to have completely dry
Handy for people who hands and to place
have trouble swallowing tablet in mouth
or for patients who let immediately
medication linger in Tablet should not linger in
the cheek for later the hand
Can be taken when water
or other liquid is

Intramuscular Some antipsychotics, such More rapid acting than Injection-site pain and
as haloperidol, chlorpro- oral preparations irritation
mazine, and risperidone No first-pass metabolism Some medications may
Anxiolytics, such as have erratic absorption
lorazepam if heavy muscle tissue at
Anticholinergics, such as the site of injection is
diphenhydramine and not in use
benztropine mesylate High-potency antipsy-
No antidepressants chotics in this form may
No mood stabilizers be more prone to
adverse reactions, such
as neuroleptic malignant
Intramuscular depot Haloperidol decanoate, May be more convenient Significant pain at injec-
(or long-acting) fluphenazine decanoate, for some individuals tion site
risperidone who have difficulty fol-
lowing medication regi-
Intravenous Anticholinergics, such as Rapid and complete avail- Inflammation of tissue sur-
diphenhydramine, benz- ability to systemic rounding site
tropine mesylate circulation Often inconvenient
Anxiolytics, such as for patient and
diazepam, lorazepam, uncomfortable
and chlordiazepoxide Continuous dosage
The antipsychotic haloperi- requires use of a con-
dol (unlabeled use) stant-rate IV infusion
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 133

orange juice, so nurses must be aware of the compatibil- the drugs when generic forms of a drug are developed.
ities of liquid preparations. If a precipitant forms in a Although increased bioavailability of a drug may sound
medication cup, it will also form in the stomach, causing impressive, it is important to remember that this is not a
additional inactivation of the drugs. Therefore, some characteristic solely of the drug preparation. It may be
medications should be given at least an hour apart. With low if absorption is incomplete. Wide individual varia-
new technologies come novel administration routes and tions in the enzyme activity of the intestine or liver, gas-
drug forms, one of which is the rapid-dissolving oral pill. tric pH, and intestinal motility will all affect it. In prac-
Different manufacturers have different procedures for tice, bioavailability is difficult to quantify.
developing rapid-dissolving drugs, and the different Psychiatricmental health nurses must remember that
methods are patented and named differently. Common many factors on any particular occasion may affect the
forms include the DuraSolv and QuickTab technologies. absorption and bioavailability of the drug for an individual
Many drugs are currently available in rapid-dissolving patient.
form, including the atypical antipsychotic olanzapine
(Zyprexa, Zydis), risperidone (Risperdal M-Tab), and DISTRIBUTION
mirtazapine (Remeron SolTab). Nurses need to be aware
of the special administration and patient-teaching Even after a drug enters the bloodstream, several factors
requirements of the rapid-dissolving drug forms. affect how it is distributed in the body. Distribution of a
To take an orally disintegrating tablet, the nurse or drug is the amount of the drug found in various tissues,
patient should use dry hands to peel back the foil pack- particularly the target organ at the site of drug action for
aging, immediately take out the tablet, and place it into which it is intended. Factors that affect medication dis-
the mouth. The tablet will quickly dissolve and can be tribution to specific organs in the body include the size of
swallowed with saliva. No water is needed to swallow dis- the organ, amount of blood flow or perfusion within the
integrating tablets. This is advantageous when a patient organ, solubility of the drug, plasma protein binding
cannot swallow well or is unwilling to swallow pills, or (the degree to which the drug binds to plasma proteins),
when water is not readily available. and anatomic barriers, such as the bloodbrain barrier,
that the drug must cross. A drug may have rapid absorp-
tion and high bioavailability, but if it does not cross the
BIOAVAILABILITY bloodbrain barrier to reach the CNS, it is of little use in
Bioavailability describes the amount of the drug that psychiatry. Table 9-4 provides a summary of how some
actually reaches systemic circulation unchanged. The significant factors affect distribution. Two of these fac-
route by which a drug is administered significantly affects tors, solubility (ability of a drug to dissolve) and protein
bioavailability. With some oral drugs, the amount of drug binding, warrant additional discussion with regard to
entering the blood stream is decreased by first-pass how they relate to psychiatric medications.
metabolism and bioavailability is lower (Pandolfi et al.,
2003). On the other hand, some rapid-dissolving oral
medications have increased bioavailability.
Bioavailability is a concept often used to compare one Substances may cross a membrane in a number of ways,
drug with another, obviously implying that increased but passive diffusion is by far the simplest. To do this, the
bioavailability makes one drug better than another. The drug must dissolve in the structure of the cell membrane.
U.S. Food and Drug Administration (FDA) uses bioavail- Therefore, solubility of a drug is an important character-
ability as one measure for comparing the equivalency of istic. Drugs may be soluble in a number of substances,

Table 9.4 Factors Affecting Distribution of a Drug

Factor Effect on Drug Distribution

Size of the organ Larger organs require more drug to reach a concentration level equivalent to other
organs and tissues.
Blood flow to the organ The more blood flow to and within an organ (perfusion), the greater the drug concentra-
tion. The brain has high perfusion.
Solubility of the drug The greater the solubility of a drug within a tissue, the greater its concentration.
Plasma protein binding If a drug binds well to plasma proteins, particularly to albumin, it will stay in the body
longer but have a slower distribution.
Anatomic barriers Both the gastrointestinal tract and the brain are surrounded by layers of cells that control
the passage or uptake of substances. Lipid-soluble substances are usually readily
absorbed and pass the bloodbrain barrier.
134 UNIT II Principles of Psychiatric Nursing

but being soluble in lipids allows a drug to cross most of However, metabolism can also change a drug to an
the membranes in the body. The degree to which a drug active metabolite with potentially similar action as the
is lipid soluble varies somewhat, depending on the chem- parent compound. For instance, the antidepressant
ical structure of the drug, and may affect how readily the imipramine is metabolized to a pharmacologically active
medication reaches its primary site of action. The tissues substance, desipramine, which also has antidepressant
of the central nervous system (CNS) are less permeable effects. This becomes important when measuring the
to water-soluble drugs than are other areas of the body. therapeutic blood level of imipramine. It is more clini-
Most psychopharmacologic agents are lipid soluble to cally relevant and accurate to obtain both imipramine
easily cross the bloodbrain barrier. However, this char- and desipramine levels, even though the patient may be
acteristic means that psychopharmacologic agents also taking only the drug imipramine. Prozac (fluoxetine), an
cross the placenta. SSRI antidepressant, is metabolized in the liver and
forms an active metabolite, norfluoxetine, which has a
very long half-life. Metabolism may also change an inac-
Protein Binding
tive drug to an active one or an active drug to a toxic
Lipid-soluble drugs will also bind to other large mole- metabolite. For example, with an overdose of aceta-
cules in the body. Of considerable importance is the minophen, N-hydroxyacetaminophen is formed, which
degree to which the drug binds to plasma proteins. Only is further oxidized to a toxic chemical that can destroy
unbound or free drugs will be able to act at the recep- liver cells. Pharmacology textbooks provide a more
tor sites because drugprotein complexes are too large to complete review of drug metabolism.
cross cell membranes. High protein binding reduces the The hepatic microsomal drug-metabolizing enzymes
concentration of the drug at the receptor sites. However, that exist in the smooth endoplasmic reticulum carry
because the binding is reversible, as the unbound drug is out many of the processes of drug metabolism. The
metabolized, more drug is released from the protein popularity of the SSRIs has renewed attention to these
bonds. This process can prolong the duration of action of enzymes and the potential harmful effects of drugdrug
the drug. In addition, highly lipid-soluble drugs bind to interactions.
other sites in the body as well, particularly fat cells. As the Cytochrome P-450 is the major member of one class
concentration of unbound drug decreases, more drug is of enzymes that is localized in the liver and has a high
released from fat depots. This concept is important for affinity for lipid-soluble drugs. This class of enzyme is
medications that are highly lipid soluble. An example is involved in metabolizing most medications used in psy-
chlorpromazine, an antipsychotic medication. chiatric treatment. Each human P-450 enzyme is an
Patients who stop taking their medication often do expression of a unique gene. Most medications in psy-
not experience an immediate return of symptoms. This chiatry are metabolized by three distinct gene families
is because they are continuing to receive the drug as it (coded 1, 2, or 3) of enzymes within the cytochrome P-
is released from storage sites in the body. Medications 450 class, each of which may or may not be involved in
such as chlorpromazine may be found in the blood- the metabolism of a specific drug.
stream and urine for several weeks or months after dis- Additional research has delineated and coded for
continuation of their use. Knowing this can help nurses identification of subfamilies of enzymes within each of
help patients understand why their symptoms did not these gene families. Each subfamily can be induced, as
return, even though they had not been taking their well as inhibited, by a variety of drugs. For example, the
medication for several days or weeks. SSRIs are inhibitors of the P-4502D6 subfamily. When
the enzymes are inhibited, they decrease the clearance
of the drugs they metabolize and elevate the plasma lev-
els of other co-administered drugs metabolized by this
The extent of drug action depends to a large part on the same enzyme subfamily. Adverse reactions may occur
bodys ability to change or alter a drug chemically so that from the co-administration of such drugs as propranolol
it can be rendered inactive and removed from the body. (Inderal), codeine, carbamazepine, diphenhydramine
Metabolism, also called biotransformation, is the (Benadryl), and dextromethorphan (found in many
process by which the drug is altered and broken down nonprescription cough remedies). Not all SSRIs are
into smaller substances, known as metabolites. In most equal in their potency to inhibit P-4502D6. Paroxetine
cases, metabolites are pharmacologically inactive sub- (Paxil) is the most potent, producing more than 90%
stances. Through the processes of metabolism, lipid- inhibition of this enzyme subfamily, whereas sertraline
soluble drugs become more water soluble so that they exhibits mild effects, with only 20% to 50% inhibition
may be excreted more readily. (Dalfen & Stewart, 2001).
Most metabolism occurs in the liver, but it can also Because knowledge of the P-450 enzymatic pathway
occur in the kidneys, lungs, and intestines. The outcome is relatively new, and the technology that detects
of this process is most often an inactive metabolite. such effects was not available when many drugs were
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 135

developed, not all drugs are currently classified by which measure of the expected rate of clearance. Half-life refers
of these hepatic enzyme subfamilies act in their metabo- to the time required for plasma concentrations of the drug
lism. This information is available for only about 20% of to be reduced by 50%. For most drugs, the rate of excre-
commonly prescribed medications. tion slows while the half-life remains unchanged. It usu-
Research is continuing, and more information is con- ally takes four half-lives or more of a drug in total time for
stantly emerging. For now, it is important to note that more than 90% of the drug to be eliminated.
common substances such as cigarette smoke, chronic Only a few psychiatric medications are removed
alcohol consumption, coal tar in charcoal-broiled foods, predominantly by renal excretion. Lithium, a mood
and estrogens induce the P-450 enzyme system. Acute stabilizer, is a notable example of renal excretion. Any
alcohol ingestion and the antiulcer medication Tagamet impairment in renal function or renal disease may lead
(cimetidine), available over the counter, inhibit these to severe toxic symptoms. Drugs bound to plasma pro-
enzymes. teins do not cross the glomerular filter freely. These
Cytochrome P-450 enzymes help explain the enor- lipid-soluble drugs are passively reabsorbed by diffu-
mous differences in the reaction of individuals to med- sion across the renal tubule and thus are not rapidly
ications. More than 100,000 people die each year of excreted in the urine. Because many psychiatric med-
adverse reactions to medications that are safe and ben- ications are protein bound and lipid soluble, most of
eficial to others. Another 2.2 million experience serious their excretion occurs through the liver, where they are
side effects, whereas others experience no response to excreted in the bile and delivered into the intestine.
the same medications. Differences and changes in This is the process by which active metabolites may be
P-450 enzymatic activity among people alter how indi- reabsorbed in the intestine. In fact, as much as 20% of
viduals experience response to medications. These dif- the drug may recirculate, which may prolong the
ferences in the enzymes often are caused by genetic duration of action. The half-life of these metabolites
variations (Bachmann, 2002). DNA variants in the may also be calculated. Sometimes, the mean half-
cytochrome P-450 system and the enzymes encoded by life is provided to represent an average measure of the
these genes are the focus of much current research. excretion half-lives of both the parent drug and its
The science of pharmacogenomics blends pharma- metabolites.
cology with genetic knowledge and is concerned with Dosing refers to the administration of medication
understanding and determining an individuals specific over time, so that therapeutic levels may be achieved or
P-450 makeup, then individualizing medications to maintained without reaching toxic levels. In general, it
match the persons P-450 profile. Increasingly, psychi- is necessary to give a drug at intervals no greater than
atric medications are prescribed after testing to deter- the half-life of the medication to avoid excessive fluctu-
mine the patients P-450 genotype to guide treatment ation of concentration in the plasma between doses.
with the most effective drugs for the person, and to With repeated dosing, a certain amount of the drug is
drastically reduce adverse reactions. Within the next accumulated in the body. This accumulation slows as
decade, it is expected that scientists will begin to con- the dosing continues and plateaus when absorption
nect DNA variants with individual responses to medical equals excretion. This is called steady-state plasma con-
treatments, identify particular subgroups of patients, centration or simply steady state. The rate of accumula-
and develop drugs customized for those populations. tion is determined by the half-life of the drug. Drugs
Until more information is available, nurses should generally reach steady state in four to five times the
remain alert to the possibilities of drugdrug interactions elimination half-life. However, because elimination or
when patients are receiving more than one medication. excretion rates may vary significantly in any individual,
In addition, if an individual receiving a medication expe- fluctuations may still occur, and dose schedules may
riences an unusual reaction or suddenly loses effect from need to be modified.
a medication that had previously been working, the nurse The psychiatricmental health nurse should remem-
should carefully assess other substances that the person ber that these measures are subject to physiologic
has recently consumed, including prescription medica- processes and individual variation. They are guidelines;
tions, nonprescription remedies, dietary supplements or accurate assessment for indicators of treatment response
changes, and substances of abuse. or unwanted effects may be the better tool for individu-
alizing care.
Excretion refers to the removal of drugs from the body
either unchanged or as metabolites. Clearance refers to
the total volume of blood, serum, or plasma from which a Many factors affect drug absorption, distribution, metab-
drug is completely removed per unit of time to account olism, and excretion. These factors may vary among indi-
for the excretion. The half-life of a drug provides a viduals, depending on their age, genetics, and ethnicity.
136 UNIT II Principles of Psychiatric Nursing

Nurses must be aware of and consider these individual Ethnicity and Genetic Makeup
variations in the effects of medications.
Although only a small amount of information is available
at this time, it is clear that genetics plays a significant role
Age in the metabolism of medications. Studies of identical
and nonidentical twins show that much of the individual
Pharmacokinetics are significantly altered at the extremes
variability in elimination half-life of a given drug is
of the life cycle. Gastric absorption changes as individuals
genetically determined. Individuals of Asian descent may
age because of increased gastric pH, decreased gastric
metabolize ethanol to produce higher concentrations of
emptying, slowed gastric motility, and reduced splanchnic
acetaldehyde than do Caucasian individuals, resulting in
circulation. Normally, these changes do not significantly
a higher incidence of adverse symptoms, such as flushing
impair oral absorption of a medication, but addition of
and palpitations, with alcohol use. Asian research subjects
common conditions, such as diarrhea, may significantly
have been found to be more susceptible to the effects of
alter and reduce absorption.
drugs such as propranolol than are Caucasian individuals,
Renal function is also altered in both very young and
whereas individuals of African descent were less sensitive
elderly patients. Infants who are exposed in utero to
(Bachmann, 2002). Early indications are that differences
medications that are excreted through the kidneys may
in rates of side effects and therapeutic effects may also
experience toxic reactions to these medications because
exist with other medications used in psychiatry. Several
renal function in the newborn is only about 20% that
reports indicate that Asians require one half to one third
of an adult. In less than a week, renal function develops
the dose of antipsychotic medications that Caucasian
to adult levels, but in premature infants, the process
may take longer. Renal function also declines with age.
Creatinine clearance in a young adult is normally 100
to 120 mL/min, but after age 40 years, this rate declines FAME AND FORTUNE
by about 10% per decade. Medical illnesses, such as dia- Abraham Lincoln (18191865)
betes and hypertension, may further the loss of renal Civil War President
function. When creatinine clearance falls below 30
mL/min, the excretion of drugs by the kidneys is sig- Public Personna
nificantly impaired, and potentially toxic levels may The 16th President of the United States led a nation
through turbulent times during a civil war. Ulti-
accumulate. mately his leadership preserved the United States as
Metabolism changes across the life span. In new- the republic we know today, despite periods of
borns, many of the liver enzymes take as long as 8 weeks "melancholy" or depression throughout his life. At
to become fully functional. Drugs metabolized by these times, he had strong thoughts of committing sui-
enzymes will accumulate, exhibiting very long half- cide. Yet he had an enormous ability to cope with
depression, especially in later life. He generally
lives. With age, blood flow to the liver and the mass of coped with the depression through his work, humor,
liver tissue both decrease. The activity of hepatic fatalistic resignation, and even religious feelings.
enzymes also slows with age. As a result, the ability of He generally did not let his depression interfere with
the liver to metabolize medications may show as much his work as President. In 1841, he wrote of his
as a fourfold decrease between the ages of 20 and 70 ongoing depression, A tendency to melancholy . . . .
let it be observed, is a misfortune, not a fault.
years. (Letter to Mary Speed, September 27, 1841)
Most psychiatric medications are bound to proteins.
Albumin is one of the primary circulating proteins to Personal Realities
Lincolns depression began in early childhood and
which drugs bind. Production of albumin by the liver
can be traced to multiple causes. There is evidence
generally declines with age. In addition, a number of that there was a genetic basis because both of his
medical conditions change the ability of medications to parents suffered from depression. Lincoln was par-
bind to albumin. Malnutrition, cancer, and liver disease tially isolated from his peers because of his unique
decrease the production of albumin, which means that interests in politics and reading. Additionally, he
suffered through the deaths of his younger brother,
more free drug is acting in the system, producing
mother, and older sister. There is speculation that
higher blood levels of the medication and potentially Lincolns depression may have dated to Thomas
toxic effects. Lincolns cold treatment of his son. There is also
Less information is known about pharmacodynamic evidence that Abraham Lincoln took a commonly
changes of age, but changes in the sites of medication prescribed medication called blue mass, which
contained mercury. Consequently, some speculate
actions may make older individuals more sensitive to
that he suffered from mercury poisoning.
certain side effects. Changes in the parasympathetic
nervous system produce a greater sensitivity in elderly SOURCE: Hirschhorn, N., Feldman, RG & Greaves, IA (2001). Abraham
Lincolns Blue Pills: Did Our 16th President Suffer from Mercury
patients to anticholinergic side effects, which are more Poisoning? Perspectives in Biology and Medicine, 44 (3), 315322.
severe with this age group.
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 137

require and that they may be more sensitive to side diagnosis and determine target symptoms for med-
effects because of higher blood levels (Zhou, 2003). ication use.
Lower doses of antidepressant medications are also often Physical examination and indicated laboratory
required for individuals of Asian descent. Although many tests, often including baseline determinations such
of these variations appear to be related to the P-450 as a complete blood count (CBC), liver and kidney
genetic differences discussed earlier, more research is function tests, electrolyte levels, and urinalysis,
needed to understand fully the underlying mechanisms and possibly thyroid function tests and electrocar-
and to identify groups that may require different diogram (ECG), will help determine whether a
approaches to medication treatment. physical condition may be causing the symptoms
and establish that it is safe to initiate use of a par-
ticular medication.
Nurses must be aware of the outcomes of these eval-
Concurrent medication use is a common factor for indi- uations and determine what aspects of treatment may
vidual variations in drug response. Both prescription need to be more closely monitored.
and nonprescription medications may alter other drugs Psychiatricmental health nurses should perform
when they are present in the body. Medications may their own premedication evaluations, including physical
compete for the same sites of action in target organs or assessments that focus on pre-existing symptoms, such
at the sites of unwanted effects. Drugs may compete for as gastrointestinal distress, or restrictions in range of
the same mechanisms of metabolism or alter another motion that may later be confused with side effects.
drugs route of metabolism. Each of these factors must Side effects are difficult to assess if baseline status has
be carefully explored when considering individual not been evaluated. A pharmacologic history should be
responses and side effects to all medications, as well as obtained to determine prescription and nonprescription
psychopharmacologic agents. medications and substances of abuse that the individual
Working closely with individuals receiving these med- may be taking concurrently with psychiatric medica-
ications and their families, psychiatricmental health tions. An assessment of cognitive functioning will assist
nurses may be instrumental in uncovering the source of the nurse in assessing whether memory aids or other
individual variations in medication response and in plan- supports are necessary to assist the individual in accu-
ning for optimizing response to psychopharmacologic rately completing the medication regimen.
drugs. Psychosocial factors, such as level of patients health
knowledge, support networks, financial health resources,
occupation, family history of psychiatric disorders, and
Phases of Drug Treatment beliefs about psychiatric disorders, should be addressed
The psychiatricmental health nurse is involved in all of with special attention to factors that may interfere with
the phases of medication treatment. Considerations treatment. This information should be reviewed in con-
in terms of assessment, treatment issues such as sultation with the prescriber and other members of the
adherence (compliance with the therapeutic regimen), multidisciplinary team to develop a plan that is accept-
predominance of side effects, and expected symptom able to the patient and that will improve the individuals
relief vary across the phases of treatment, but all involve functioning, minimize side effects, and improve quality
potential nursing actions. (In this text, the terms adher- of life.
ence and compliance will be used interchangeably.) These In all situations, recommendations and treatment
phases include initiation, stabilization, maintenance, and alternatives should be developed and reviewed with
discontinuation of the medication. Psychiatricmental input from the individual seeking treatment. Doing so
health nurses must be concerned with treatment phases will allow the patient to ask questions, receive complete
as a guide for what may be expected as they administer information, and give informed consent to the selected
medications and monitor individuals receiving medica- approach. Patients are often overwhelmed during the
tions across each of these phases. The following subsec- initial phases of treatment and may have symptoms that
tions discuss some of the knowledge required and the make it difficult for them to participate fully in treat-
assessments and interventions to be performed by the ment planning. Information is often forgotten or may
psychiatricmental health nurse within each phase. need to be repeated. Nurses must be fully knowledge-
able of the indications, target symptoms, actions, phar-
macokinetics, and side effects of each medication to be
able to answer questions and provide ongoing education.
Before beginning to take medications, patients must When use of the medication is initiated, psychiatric
undergo several assessments. mental health nurses should treat the first dose as if it
A psychiatric evaluation, including past history and were a test dose. They should observe the patient
previous medication treatment response, will clarify closely for sensitivity to the medication, such as changes
138 UNIT II Principles of Psychiatric Nursing

in blood pressure, pulse, or temperature; changes in At times, an individual may show only partial
mental status; allergic reactions; dizziness; ataxia; or improvement from a medication, and the prescriber may
gastric distress. Other common side effects that may try an augmentation strategy. Augmentation adds another
occur with even one dose of medication should also be medication to enhance or potentiate the effects of the
closely monitored. If any of these symptoms develop, first medication. For example, a prescriber may add a
they should be reported to the prescriber. mood stabilizer, such as lithium, to an antidepressant to
improve the effects of the antidepressant. These strate-
gies are often used with so-called treatment-resistant sit-
uations. Treatment resistance has various definitions, but
During stabilization, the medication dosage is often most often it means that after several medication trials,
being adjusted and increased to achieve the maximum the individual has received, at best, only partial improve-
amount of improvement with a minimum of side ment. Treatment-resistant symptoms often require com-
effects. This process is sometimes referred to as titration. binations of medications to affect more than one neuro-
Psychiatricmental health nurses must continue to transmitter group. Polypharmacy, using more than one
assess target symptoms, looking for change or improve- group from a class of medications, is increasingly being
ment and side effects. If medications are being used as an acceptable strategy with most psychopharma-
increased rapidly, such as in a hospital setting, nurses cologic agents to match the drug action to the neuro-
must closely monitor temperature, blood pressure, chemical needs of the patient. Nurses must be familiar
pulse, mental status, common side effects, and unusual with the potential effects, side effects, drug interactions,
adverse reactions. and rationale for the treatment regimen.
On an outpatient basis, nurses must educate individu-
als who are receiving the medication as to the expected
outcome and potential side effects. This education
should include factors that may influence the effective- Once the individuals target symptoms have improved,
ness of the medication, such as whether to take the med- medications may be continued to prevent relapse.
ication with food, common interventions that may mini- Relapse means that the symptoms of the disorder
mize side effects if they develop, and what side effects return. In some cases, this may occur despite the
require immediate attention. A plan should be developed patients continued use of the medication. Some med-
for patients and their families to clearly identify what to ications lose their efficacy with time. Other medications
do if adverse reactions develop. The plan, which should activate or speed up their own metabolism, causing a
include emergency telephone numbers or available precipitant drop in the therapeutic blood level of the
emergency treatment, should be reviewed frequently. drug. Other factors, such as medical illness, psychoso-
Therapeutic drug monitoring is most important in cial stressors, or concurrent use of prescription or non-
this phase of treatment. Many medications used in psy- prescription medications, may cause the medications to
chiatry improve target symptoms only when a thera- lose their effect. Whatever the reason, patients must be
peutic level of medication has been obtained in the indi- educated about their target symptoms and have a plan
viduals blood. Some medications, such as lithium, have of action if the symptoms return. The psychiatric
a narrow therapeutic range and must be monitored fre- mental health nurse has a central role in assisting indi-
quently and accurately. Nurses must be aware of when viduals to monitor their own symptoms, manage psy-
and how these levels are to be determined and assist chosocial stressors, and avoid other factors that may
patients in learning these procedures. Because of pro- cause the medications to lose effect.
tein binding and lipid solubility, most medications do Some side effects or adverse reactions emerge only
not have obtainable plasma levels that are clinically rel- after the individual has been receiving the medication
evant. However, plasma levels of these medications may for an extended period. Psychiatricmental health
still be requested to evaluate further such issues as nurses must be familiar with standardized assessment
absorption and adverse reactions. tools to monitor the development of these unwanted
Sometimes the first medication chosen does not ade- effects. Some of these tools are discussed more fully
quately improve the patients target symptoms. In such throughout the book. In addition, medications may
cases, use of the medication will be discontinued and alter the function of other body organs, such as the
treatment with a new medication will be started. Medica- liver or thyroid, or cause blood dyscrasias (abnormalities),
tions may also be changed when adverse reactions or such as leukopenia or agranulocytosis. Nurses need to
seriously uncomfortable side effects occur or these effects monitor for symptoms of adverse events and be famil-
substantially interfere with the individuals quality of life. iar with the laboratory tests that detect these abnor-
Nurses should be familiar with the pharmacokinetics of malities. They should also ensure that patients under-
both drugs to be able to monitor side effects and possible stand the need to schedule these tests at appropriate
drugdrug interactions during this change. intervals.
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 139

DISCONTINUATION PHASE certain side effects. These medications treat the symp-
toms of psychosis, such as hallucinations, delusions,
Many psychiatric medications require a tapered discon-
bizarre behavior, disorganized thinking, and agitation.
tinuation. Tapering involves slowly reducing dosage
while monitoring closely for re-emergence of the symp-
toms. Some psychiatric disorders, such as mild depres- TYPICAL AND ATYPICAL
sion, may respond to several months of treatment and ANTIPSYCHOTICS
not recur. Other disorders, such as schizophrenia, usu-
Initially, the term major tranquilizer was applied to this
ally require continued medication treatment for a life-
group of medications. Later major tranquilizers were
time. Discontinuance of some medications, such as con-
known as neuroleptics, which more accurately describes
trolled substances, produces withdrawal symptoms;
the action of drugs such as chlorpromazine and
discontinuance of others does not.
haloperidol. Neuroleptic means to clasp the neuron.
Nurses must be aware of the potential for these
The term reflects the common and often significant
symptoms, monitor them closely, and implement mea-
neurologic side effects produced by these types of
sures to minimize their effects. Psychiatricmental
drugs. The development of newer antipsychotic drugs
health nurses should support individuals throughout
that have less significant neurologic side effects has led
this process, whether they can successfully stop taking
to these older agents being used as secondary, not first-
the medication or must continue the treatment. Even if
line drugs, referred to as typical antipsychotic, and the
patients can successfully discontinue use of the medica-
new drugs as atypical antipsychotics. The term typical
tion without a return of symptoms, nurses may help
antipsychotic now identifies the older antipsychotic drugs
implement preventive measures to avoid recurrence of
with many common neurologic side effects, and atypical
the psychiatric disorder. In the roles of advocate, patient
antipsychotic identifies the newer generation of antipsy-
educator, and provider of interpersonal support, psychi-
chotic drugs with fewer adverse neurologic effects.
atricmental health nurses often have a central role in
relapse prevention.
Indications and Mechanism
of Action
Antipsychotic Medications Antipsychotic medications generally are indicated for
It is hard to image how psychiatric illnesses were treated treating psychosis. Possible target symptoms for the
before the development of psychopharmacological med- antipsychotics include hallucinations, delusions, para-
ications. Antipsychotic medications were among the noia, agitation, assaultive behavior, bizarre ideation,
very first drugs ever used to treat psychiatric disorders. disorientation, social withdrawal, catatonia, blunted
First synthesized by Paul Charpentier in 1950, chlor- affect, thought blocking, insomnia, and anorexia, when
promazine became the interest of Henri Lorit, a French these symptoms are the result of a psychotic process.
surgeon, who was attempting to develop medications (These symptoms are described more fully in later
that controlled preoperative anxiety. Administered in chapters.)
intravenous doses of 50 to 100 mg, chlorpromazine pro- In general, the older, typical antipsychotics, such as
duced drowsiness and indifference to surgical procedures. haloperidol (Haldol), chlorpromazine, and thioridazine
At Lorits suggestion, a number of psychiatrists began to (Mellaril) are equally effective in relieving hallucina-
administer chlorpromazine to agitated psychotic patients. tions, delusions, and bizarre ideation, considered the
In 1952, Jean Delay and Pierre Deniker, two French psy- positive symptoms of schizophrenia. The negative
chiatrists, published the first report of chlorpromazines symptomsblunted affect, social withdrawal, lack of
calming effects with psychiatric patients. They soon dis- interest in usual activities, lack of motivation, poverty of
covered it was especially effective in relieving hallucina- speech, thought blocking, and inattentionrespond
tions and delusions associated with schizophrenia. As less well to the typical antipsychotics and in some cases
more psychiatrists began to prescribe the medication, the may even be worsened by such agents.
use of restraints and seclusion in psychiatric hospitals Newer atypical antipsychotics, such as clozapine,
dropped sharply, ushering in a revolution in psychiatric risperidone (Risperdal), olanzapine (Zyprexa), quetiap-
treatment. ine (Seroquel), and ziprasidone (Geodon), are more
Since that time, numerous antipsychotic medications effective at improving negative symptoms. Therefore,
have been developed. Older, typical antipsychotic med- these additional symptoms may now be considered tar-
ications, available since 1954, are equally effective, inex- get symptoms for atypical antipsychotic drugs.
pensive drugs that vary in the degree to which they Although antipsychotic medications are the primary
cause certain groups of side effects. Table 9-5 provides treatment for schizophrenia and related illnesses, such
a list of selected antipsychotics grouped by the nature of as schizoaffective disorder, schizophreniform disorder,
their chemical structure and indicating the likelihood of and brief psychotic disorder, they are increasingly being
140 UNIT II Principles of Psychiatric Nursing

Table 9.5 Side-Effect Comparison of Selected Antipsychotic Medications

Drug Category Orthostatic

Drug Name Sedation Extrapyramidal Anticholinergic Hypotension

Standard (Typical) Antipsychotics

Chlorpromazine (Thorazine) 4 2 3 4
Thioridazine (Mellaril) 3 1 4 4
Mesoridazine (Serentil) 3 1 4 3
Fluphenazine (Prolixin) 1 4 1 1
Perphenazine (Trilafon) 2 3 2 2
Trifluoperazine (Stelazine) 1 3 1 1
Thiothixene (Navane) 1 4 1 1
Loxapine (Loxitane) 2 3 2 3
Haloperidol (Haldol) 1 4 1 1
Molindone (Moban) 2 3 2 1
Atypical Antipsychotics
Clozapine (Clozaril) 4 /0 4 4
Risperidone (Risperdal) 1 /0 /0 2
Olanzapine (Zyprexa) 4 /0 2 1
Quetiapine fumarate (Seroquel) 4 /0 /0 3
Ziprasidone HCL (Geodon) 1 /0 1 2
Aripiprazole (Abilify) 1 /0 /0 1

used to treat other psychiatric and medical illnesses. elderly patients who have dementia by reducing symp-
Psychotic symptoms that occur during a major depres- toms of agitation, hyperactivity, hallucinations, suspi-
sive episode, anxiety, or bipolar affective disorder can be ciousness, and hostility. Antipsychotic medications may
treated with antipsychotics, primarily on a short-term also be useful in treating migraine headaches, Hunting-
basis. Olanzapine (Zyprexa) is now approved by the tons chorea, and some other neurologic disorders.
FDA for the short-term treatment of acute mania, and The typical antipsychotic drugs generally are effective
some manufacturers of atypical antipsychotics are seek- in decreasing the so-called positive target symptoms
ing FDA approval for their use in depression without because they are potent postsynaptic dopamine antago-
psychosis. These medications reduce agitation, aggres- nists. Chapter 16 discusses the link between dopamine
siveness, and inappropriate behavior in pervasive devel- and disorders such as schizophrenia and provides addi-
opmental disorders, such as autism or severe mental tional detail about how lowering dopamine levels helps
retardation. Within the typical antipsychotics, haloperi- reduce target symptoms. The atypical antipsychotic
dol and pimozide are approved for treating Tourettes medications differ from the typical antipsychotics in that
syndrome, reducing the frequency and severity of vocal they block serotonin receptors as well as dopamine
tics. Some of the typical antipsychotics, particularly receptors. The differences between the mechanism of
chlorpromazine, are used as antiemetics or for postop- action of the typical and atypical antipsychotic helps to
erative intractable hiccoughs. explain their differences in terms of effect on target
Off-label uses of the drug have also been effective. symptoms and in the degree of side effects they produce.
Chlorpromazine and haloperidol are both effective in It also helps to explain why the atypical antipsychotic
treating drug-related psychosis, such as that caused by drugs are, in general, more effective than the typical ones
phencyclidine. Atypical antipsychotics have been effec- in addressing the negative target symptoms of disorders
tive and safe in controlling behavioral disturbances in such as schizophrenia and possibly depressive disorders.
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 141

Pharmacokinetics especially with use. The nurse must also remember that
plastic syringes may absorb some medications. This is
Antipsychotic medications administered orally have a
true of the antipsychotics, and injectable medications
variable rate of absorption complicated by the presence
should never be allowed to remain in the syringe longer
of food, antacids, smoking, and even the co-administra-
than 15 minutes.
tion of anticholinergics, which slow gastric motility.
Metabolism of these drugs occurs almost entirely in
Clinical effects begin to appear in about 30 to 60 min-
the liver, where hepatic microsomal enzymes convert
utes. Absorption after intramuscular (IM) administra-
these highly lipid-soluble substances into water-soluble
tion is less variable because this method avoids the first-
metabolites that can be excreted through the kidneys.
pass effects. Therefore, IM administration produces
Therefore, these medications are subjected to the
greater bioavailability. It is important to remember that
effects of other drugs that induce or inhibit the
IM medications are absorbed more slowly when
cytochrome P-450 system described earlier. Table 9-6
patients are immobile because erratic absorption may
summarizes many of the possible medication interac-
occur when muscles are not in use, which is especially
tions with antipsychotics, including those resulting
important to remember when administering IM
from changes in hepatic enzymes. Careful observance
antipsychotic medication to patients who are restrained.
of concurrent medication use, including prescribed,
For example, the patients arm may be more mobile
over-the-counter, and substances of abuse, is required
than the buttocks. The deltoid has better blood perfu-
to avoid drugdrug interactions.
sion, and the medication will be more readily absorbed,

Table 9.6 Chemical Interactions With Antipsychotic Medications

Agent Effect

Alcohol Phenothiazines potentiate CNS depressant effects

Extrapyramidal reactions may occur
Barbiturates Speed action of liver microsomal enzymes so antipsychotic is metabolized
more quickly, reducing phenothiazine and haloperidol plasma levels; barbi-
turate levels may also be reduced by phenothiazines; potentiate CNS
depressant effect
Tricyclic antidepressants Can lead to severe anticholinergic side effects; some antipsychotics
(especially phenothiazines or haloperidol) can raise the plasma level of the
antidepressant, probably by inhibiting metabolism of the antidepressant
Hydrochlorothiazide and hydralazine Can produce severe hypotension
Guanethidine Antihypertensive effect is blocked by phenothiazines, haloperidol, and possi-
bly thiothixene
Aluminum salts (antacids) Impair gastrointestinal absorption of the phenothiazines, possibly reducing
therapeutic effect
Administer antacid at least 1 h before or 2 h after the phenothiazine
Nicotine Heavy consumption requires larger doses of antipsychotic because of hepatic
microsomal enzyme induction
Charcoal (and charbroiled food) Decreases absorption of phenothiazines
Anticholinergics May reduce the therapeutic actions of the phenothiazines, increase anticholin-
ergic side effects, lower serum haloperidol levels, worsen symptoms of
schizophrenia, increase symptoms of tardive dyskinesia
Meperidine May result in excessive sedation and hypotension when coadministered with
Fluoxetine Case report of serious extrapyramidal symptoms when used in combination
with haloperidol
Lithium May induce disorientation, unconsciousness, extrapyramidal symptoms, or
possibly the risk for neuroleptic malignant syndrome when combined with
phenothiazines or haloperidol
Carbamazepine Decreases haloperidol serum levels, decreasing its therapeutic effects
Phenytoin Increase or decrease in phenytoin serum levels; thioridazine and haloperidol
serum levels may be decreased
Methyldopa May potentiate the antipsychotic effects of haloperidol or may produce
Serious elevations in blood pressure may occur with methyldopa and
General anesthesia (barbiturates) Antipsychotic may potentiate effect of anesthetic; may increase the neuro-
muscular excitation or hypotension
142 UNIT II Principles of Psychiatric Nursing

Excretion of these substances tends to be slow. As elimination time does allow the medication to be given
highly lipid-soluble drugs, antipsychotics easily pass the in once-daily dosing. This schedule increases adherence
bloodbrain barrier but accumulate in the fatty tissues and reduces the impact of the peak occurrence of some
of the body. Most antipsychotics have a half-life of 24 side effects, such as sedation during the day.
hours or longer, but many also have active metabolites High lipid solubility, accumulation in the body, and
with longer half-lives. These two effects make it diffi- other factors have also made it difficult to correlate
cult to predict elimination time, and metabolites of blood levels with therapeutic effects. Doseresponse
some of these agents may be found in the urine months curves have not been established, and the dose required
later. Psychiatric nurses must remember that just for an individual to experience treatment effects varies
because use of a medication was discontinued today, it widely. Plasma levels of these medications are only par-
does not mean that the effects of the drug will be gone tially helpful. Although these can be measured for a
tomorrow. If a patient experiences side effects from a number of antipsychotics, their correlation with thera-
medication severe enough to discontinue use of the peutic response has been inconsistent. Haloperidol and
drug and begin use of a new one, the adverse effects of clozapine correlate well and may be helpful in deter-
the first drug may not necessarily immediately subside. mining whether an adequate blood level has been
The patient may continue to experience and sometimes reached and maintained during a trial of medication.
need treatment for the adverse effects for several days. Table 9-7 shows the therapeutic ranges available for
Similarly, patients who have discontinued use of some of the antipsychotic medications. Plasma levels
antipsychotic drugs may still derive therapeutic benefit may also be helpful in identifying absorption problems,
for several days to weeks after drug discontinuation. determining whether the patient is taking the medica-
Typical antipsychotics are best administered in tion as prescribed, and identifying adverse reactions
divided doses to minimize side effects, but the long from drugdrug interactions.

Table 9.7 Antipsychotic Medications

Generic (Trade) Usual Dosage Therapeutic Equivalent
Drug Name Range (mg/d) Half-Life (h) Blood Level Dosage (mg)

Standard (Typical) Antipsychotics

Chlorpromazine (Thorazine) 501200 230 30100 mg/mL 100
Thioridazine (Mellaril) 50600 1020 11.5 ng/mL 100
Mesoridazine (Serentil) 50400 2448 Not available 50
Fluphenazine (Prolixin) 220 4.515.3 0.20.3 ng/mL 2
Perphenazine (Trilafon) 1264 Unknown 0.812.0 ng/mL 10
Trifluoperazine (Stelazine) 540 47100 12.3 ng/mL 5
Thiothixene (Navane) 560 34 220 ng/mL 4
Loxapine (Loxitane) 20250 19 Not available 15
Haloperidol (Haldol) 260 2124 515 ng/mL 2
Molindone (Moban) 50400 1.5 Not available 10
Atypical Antipsychotics
Clozapine (Clozaril) 300900 412 141204 ng/mL 50
Risperidone (Risperdal) 28 20 Not available 1
Olanzapine (Zyprexa) 510 2154 Not available Not available
Quetiapine fumarate (Seroquel) 150750 7 Not available Not available
Ziprasidone HCl (Geodon) 40160 7 Not available Not available
Aripiprazole (Abilify) 1030 7594 Not available Not available
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 143

Potency of the antipsychotics also varies widely and is gradual basis after the patient is fully informed and
of specific concern when considering typical antipsy- consents and has taken several oral doses to ensure no
chotic drugs. As Table 9-7 indicates, 100 mg chlorpro- significant immediate adverse reactions are likely to
mazine is roughly equivalent to 2 mg haloperidol and 5 occur.
mg trifluoperazine. Although drugs that are more potent Recently, an atypical antipsychotic, risperidone, has
are not inherently better than less potent drugs, differ- become available in a long-acting formulation. It differs
entiating low-potency versus high-potency antipsy- from the conventional depot form in that it is aqueous
chotics may be somewhat helpful in predicting side based and thereby better tolerated. Long-acting risperi-
effects. Roughly speaking, high-potency medications, done is unique in that microspheres (encapsulated poly-
such as haloperidol and fluphenazine, produce a greater mers containing the medication) gradually break down,
frequency of extrapyramidal symptoms, and low- releasing the active form of the medication. This med-
potency antipsychotics, such as chlorpromazine and ication is administered intramuscularly every 2 weeks.
thioridazine, produce more sedation and hypotension. Initiation of this medication regimen requires that an
Ultimately, selection of medication from the group oral antipsychotic be given during the first 3 weeks to
of typical antipsychotics depends predominately on pre- reach a therapeutic blood level.
dicted side effects, prior history of treatment response,
whether or not a depot preparation will be needed dur-
Side Effects, Adverse Reactions,
ing maintenance, concurrent medications, and other
and Toxicity
medical conditions.
Various side effects and interactions can occur with
antipsychotics (see Tables 9-6 and 9-7), with the typical
Drug Formulations: Long-Acting
drugs producing more significant side effects than the
atypical antipsychotics. The side effects vary largely
Currently, in the United States, two typical antipsy- based on their degree of attraction to different neuro-
chotic drugs, haloperidol and fluphenazine, are available transmitter receptors and their subtypes.
in long-acting, depot forms. These two antipsychotics
may be administered by injection once every 2 to 4
Cardiovascular Side Effects
weeks. After administration, the drug is slowly
released from the injection site; therefore, these forms Cardiovascular side effects, such as orthostatic hypoten-
of the drugs are referred to as depot preparations. Long- sion, depend on the degree of blockade of -adrenergic
acting injectable medications maintain a fairly con- receptors. Low-potency typical antipsychotics, such as
stant blood level between injections. Because they chlorpromazine and thioridazine, and the atypical
bypass problems with gastrointestinal absorption and antipsychotic clozapine have a high degree of affinity
first-pass metabolism, this method may enhance ther- for -adrenergic receptors and therefore produce con-
apeutic outcomes for the patient. Lower rates of siderable orthostatic hypotension. Other cardiovascular
relapse have been reported for patients receiving long- side effects from typical antipsychotics have been rare,
acting injectable medication compared with those tak- but occasionally they cause ECG changes that have a
ing oral medications. Depot preparations are used benign or undetermined clinical effect. Thioridazine
when individuals have difficulty remembering to take (Mellaril) and ziprasidone (Geodon) have both been
their oral medications and are able to keep appoint- associated with prolonged QTc intervals and should be
ments reliably or attend a program regularly where the used cautiously in patients who have increased Q-T
injection may be administered. Fluphenazine intervals or are taking other medications that may pro-
decanoate and haloperidol decanoate are equally effec- long the Q-T interval (Taylor, 2003).
tive in treating the symptoms of psychosis. Long-act-
ing forms of fluphenazine are available as fluphenazine
Anticholinergic Side Effects
decanoate and fluphenazine enanthate. The latter has
a markedly increased risk for extrapyramidal side Anticholinergic side effects resulting from blockade of
effects and is rarely used. Nurses should be aware that acetylcholine are another common concern with typi-
the injection site may become sore and inflamed if cer- cal and with some of the atypical antipsychotic drugs.
tain precautions are not taken. The liquids are viscous, Dry mouth, slowed gastric motility, constipation, uri-
and a large-gauge needle (at least 21 gauge) should be nary hesitancy or retention, vaginal dryness, blurred
used. Because the medication is meant to remain in vision, dry eyes, nasal congestion, and confusion or
the injection site, the needle should be dry, and a deep decreased memory are examples of these side effects.
IM injection should be given by the Z-track method. Interventions for decreasing the impact of these side
(Note: Do not massage the injection site. Rotate sites effects are outlined in Table 9-2. This group of side
and document in the patients record.) A change to effects occurs with many of the medications used for psy-
depot preparation from oral antipsychotic is done on a chiatric treatment. Sometimes, a cholinergic medication,
144 UNIT II Principles of Psychiatric Nursing

such as bethanechol, may reduce the peripheral effects Blood Disorders

but not the CNS effects. Using more than one medica-
Blood dyscrasias are rare but have received renewed
tion with anticholinergic effects often increases the
attention since the introduction of clozapine. Agranulo-
symptoms. Elderly patients are often most susceptible
cytosis is an acute reaction that causes the individuals
to a potential toxicity that results from high blockade
white blood cell count to drop to very low levels, and
of acetylcholine. This toxicity is called an anticholinergic
concurrent neutropenia, a drop in neutrophils in the
crisis and is described more fully, along with its
blood, develops. In the case of the antipsychotics, the
treatment, in Chapter 16. The likelihood of anticholin-
medication suppresses the bone marrow precursors to
ergic side effects, along with sedation and extrapyrami-
blood factors. The exact mechanism by which the drugs
dal side effects, from antipsychotics, is explored in
produce this effect is unknown. The most notable
Table 9-5.
symptoms of this disorder include high fever, sore
throat, and mouth sores. Although benign elevations in
Weight Gain temperature have been reported in individuals taking
clozapine, no fever should go uninvestigated. Untreated
Other clinically important effects also occur with the
agranulocytosis can be life threatening. Although
antipsychotic medications. Weight gain from increased
agranulocytosis can occur with any of the antipsy-
appetite is common with the low-potency antipsy-
chotics, the risk with clozapine is 10 to 20 times greater
chotics but occurs in highest proportion with clozapine
than with the other antipsychotics (Bilici, Tekelioglu,
and olanzapine. Weight gain has been associated with
Efendioglu, Ovali, & Ulgen, 2003). Therefore, pre-
antipsychotic drugs since chlorpromazine was devel-
scription of clozapine requires weekly blood samples for
oped and is of increasing concern with the increased use
the first 6 months of treatment, and then every 2 weeks
of atypical drugs such as clozapine and olanzapine. The
after that for as long as the drug is taken. Drawing of
weight gain related to antipsychotic medications is
these samples must continue for 4 weeks after clozapine
linked to an increased risk for diabetes, heart disease,
use has been discontinued. If sore throat or fever devel-
and hyperlipidemia. Awareness of these risks empha-
ops, medications should be withheld until a leukocyte
sizes the need for early, preventive intervention with
count can be obtained. Hospitalization, including
diet and exercise. The chronic health problems of dia-
reverse isolation to prevent infections, is usually
betes and cardiovascular illness occur much more often
required. Agranulocytosis is more likely to develop dur-
in individuals with mental illness than in the general
ing the first 18 weeks of treatment. Some research indi-
population, making it essential for nurses to assist
cates that it is more common in women.
patients in dealing effectively with issues of weight gain.
Ziprasidone (Geodon) and quetiapine (Seroquel) are
two atypical antipsychotics associated with little to no
weight gain during clinical trials. Photosensitivity reactions to antipsychotics, including
severe sunburns or rash, most commonly develop with
the use of low-potency typical medications. Sun block
Endocrine and Sexual Side Effects
must be worn on all areas of exposed skin when taking
Endocrine and sexual side effects result primarily from these drugs. In addition, sun exposure may cause pig-
the blockade of dopamine in the tuberoinfundibular mentary deposits to develop, resulting in discoloration
pathways of the hypothalamus. As a result, blood levels of of exposed areas, especially the neck and face. This dis-
prolactin may increase with almost all of the typical coloration may progress from a deep orange color to a
antipsychotics but less commonly with the atypical blue gray. Skin exposure should be limited and skin tone
antipsychotics. Increased prolactin causes breast enlarge- changes reported to the prescriber. Pigmentary deposits
ment and rare but potential galactorrhea (milk produc- may also develop on the retina of the eye, especially
tion and flow), decreased sexual drive, amenorrhea, men- with high doses of thioridazine, even for a few days.
strual irregularities, and increased risk for growth in This condition is called retinitis pigmentosa and can lead
pre-existing breast cancers. Bromocriptine, a dopamine to significant visual impairment. Therefore, thiori-
agonist, may be helpful, but more likely these symptoms dazine should never be administered in doses greater
necessitate a change in medication. The prescriber than 800 mg/d.
should be notified immediately. Endocrine side effects Antipsychotics may also lower the seizure threshold.
can occur in males as well. Retrograde ejaculation (back- Patients with an undetected seizure disorder may expe-
ward flow of semen) is rare, but it may be painful and can rience seizures early in treatment. Those who have a
occur with all of the antipsychotics. A more common side pre-existing condition should be monitored closely.
effect is erectile dysfunction, including difficulty achiev- Neuroleptic malignant syndrome (NMS) and water
ing and maintaining an erection. Anorgasmia, or the intoxication are two serious complications that may
inability to achieve orgasm, may develop in women. result from antipsychotic medications. Characterized
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 145

by rigidity and high fever, NMS is a rare condition that complain of a thick tongue, tight jaw, or stiff neck. The
may occur abruptly with even one dose of medication. syndrome can progress to a protruding tongue, oculo-
Temperature must always be monitored when adminis- gyric crisis (eyes rolled up in the head), torticollis (mus-
tering antipsychotics, especially high-potency medica- cle stiffness in the neck, which draws the head to one
tions. Water intoxication may develop gradually with side with chin pointing to the other), and laryngopha-
long-term use. This condition is characterized by the ryngeal constriction. Abnormal postures of the upper
patients consumption of large quantities of fluid (poly- limbs and torso may be held briefly or sustained. In
dipsia) and the resulting effects of sodium depletion severe cases, the spasms may progress to the intercostal
(hyponatremia). Both of these conditions are discussed muscles, producing more significant breathing diffi-
more fully in Chapter 16. culty for patients who already have respiratory impair-
ment from asthma or emphysema.
Drug-induced parkinsonism is sometimes referred to
Medication-Related Movement
as pseudoparkinsonism because its presentation is
identical to Parkinsons disease without the same
Medication-related movement disorders are a group of destruction of dopaminergic cells. These symptoms
side effects or adverse reactions that are commonly include the classic triad of rigidity, slowed movements
caused by typical antipsychotic medications but less com- (akinesia), and tremor. The rigid muscle stiffness is usu-
monly with atypical antipsychotic drugs. These disorders ally seen in the arms. Akinesia can be observed by the
of abnormal motor movements can be divided into two loss of spontaneous movements, such as the absence of
groups: acute extrapyramidal syndromes (EPS), which the usual relaxed swing of the arms while walking. In
are acute abnormal movements developing early in the addition, mask-like facies or loss of facial expression and
course of treatment (sometimes after just one dose); and a decrease in the ability to initiate movements also are
chronic syndromes, which develop from longer exposure present. Usually, tremor is more pronounced at rest, but
to antipsychotic drugs. The atypical antipsychotic drugs it can also be observed with intentional movements,
are most likely to cause movement disorders. such as eating. If the tremor becomes severe, it may
interfere with the patients ability to eat or maintain ade-
quate fluid intake. Hypersalivation is possible as well.
Acute Extrapyramidal Syndromes
Pseudoparkinsonism symptoms may occur on one or
Acute extrapyramidal syndromes occur in as many as both sides of the body and develop abruptly or subtly
90% (Glazer, 2000) of all patients receiving typical but usually within the first 30 days of treatment.
antipsychotic medications. These syndromes include Akathisia, is characterized by the inability to sit still.
dystonia, parkinsonism, and akathisia (an involuntary The person will pace, rock while sitting or standing,
movement disorder). They develop early in treatment, march in place, or cross and uncross the legs. All of
sometimes from as little as one dose. Although the these repetitive motions have an intensity that is fre-
abnormal movements are treatable, they are at times quently beyond the explanation of the individual. In
dramatic and frightening, causing physical and emo- addition, akathisia may be present as a primarily subjec-
tional impairments that often prompt patients to stop tive experience without obvious motor behavior. This
taking their medication. Some milder forms of EPS subjective experience includes feelings of anxiety, jitter-
may occur with classes of medication other than iness, or the inability to relax, which the individual may
antipsychotics, including the SSRIs. The acute or may not be able to communicate. It is extremely
extrapyramidal syndromes often are mistaken for uncomfortable for a person experiencing akathisia to be
aspects of anxiety, rather than medication side effects. forced to sit still or be confined. These symptoms are
Nurses play a vital role in the early recognition and sometimes misdiagnosed as agitation or an increase in
treatment of these syndromes. Early recognition can psychotic symptoms, but if the nurse administers an
save the patient considerable discomfort, fear, and antipsychotic medication (PRN, as needed), the symp-
impairment. All nurses must be aware of these symp- toms will not abate and will often worsen. Differentiat-
toms, notifying the prescriber as soon as possible and ing akathisia from agitation may be aided by knowing
implementing selected medication changes and other the persons symptoms before the introduction of med-
interventions. Several medications can control these ication. Psychotic agitation does not usually begin
acute extrapyramidal symptoms (Table 9-8). abruptly after antipsychotic medication use has been
Dystonia, sometimes referred to as an acute dystonic started, whereas akathisia may occur after administra-
reaction, is impaired muscle tone that generally is the tion. In addition, the nurse may ask the patient if the
first extrapyramidal symptom to occur, usually within a experience is felt primarily in the muscles (akathisia) or
few days of initiating use of an antipsychotic. Dystonia in the mind or emotions (agitation).
is characterized by involuntary muscle spasms, especially Akathisia is the most difficult acute medication-
of the head and neck muscles. Patients usually first related movement disorder to relieve. It does not usually
146 UNIT II Principles of Psychiatric Nursing

Table 9.8 Drug Therapies for Acute Medication-Related Movement Disorders

Agents Typical Dosage Ranges Routes Available Common Side Effects

Benztropine (Cogentin) 26 mg/d PO, lM, lV Dry mouth, blurred vision, slowed
gastric motility causing constipa-
tion, urinary retention, increased
intraocular pressure; overdose
produces toxic psychosis
Trihexyphenidyl (Artane) 415mg/d PO Same as benztropine, plus gastroin-
testinal distress
Elderly people are most prone to
mental confusion and delirium
Biperiden (Akineton) 28 mg/d PO Fewer peripheral anticholinergic
Euphoria and increased tremor may
Diphenhydramine 2550 mg qid to PO, lM, lV Sedation and confusion, especially
(Benadryl) 400 mg daily in elderly people
Dopamine Agonists
Amantadine (Symmetrel) 100400 mg daily PO Indigestion, decreased concentration,
dizziness, anxiety, ataxia, insom-
nia, lethargy, tremors, and slurred
speech may occur on higher
Tolerance may develop on fixed dose
Propranolol (Inderal) 10 mg tid to 120 mg PO Hypotension and bradycardia
daily Must monitor pulse and blood
Do not stop abruptly as may cause
rebound tachycardia
Lorazepam (Ativan) 12 mg IM PO, IM All may cause drowsiness, lethargy,
0.52 mg PO and general sedation or paradoxi-
cal agitation
Confusion and disorientation in
elderly people
Diazepam (Valium) 25 mg tid PO, IV Most side effects are rare and will
disappear if dose is decreased
Clonazepam (Klonopin) 14 mg/d PO Tolerance and withdrawal are poten-
tial problems

respond well to anticholinergic medications and is blockers, such as propranolol (Inderal), given in doses of
uncommon in patients receiving atypical antipsychotics. 30 to 120 mg/d, have been most successful. Nurses must
It is thought that the pathology of akathisia may involve monitor the patients pulse and blood pressure because
more than just the extrapyramidal motor system. It may propranolol can cause hypotension and bradycardia. If
include serotonin changes that also affect the dopamine the patients pulse falls below 60 bpm, propranolol
system (Kulkarni & Naidu, 2003). A number of medica- should be withheld and the prescriber notified. Normal
tions have been used to reduce symptoms, including - signs of hypoglycemia may be blocked by propranolol;
adrenergic blockers, anticholinergics, antihistamines, therefore, patients with diabetes must monitor their
and low-dose antianxiety agents (Sajatovic, 2000). The blood or urine glucose levels carefully, especially because
usual approach to treatment is to change to an atypical they are under physical stress from the disorder.
antipsychotic if possible. If not, reducing the dose of A number of nursing interventions may reduce the
typical antipsychotic medication can be tried. During impact of these syndromes. Individuals with acute
this time, psychiatricmental health nurses must closely extrapyramidal symptoms need frequent reassurance that
assess for worsening of symptoms. Then, -adrenergic this is not a worsening of their psychiatric condition but
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 147

instead is a treatable side effect of the medication. They BOX 9.2

also need validation that what they are experiencing is
Risk Factors for Tardive Dyskinesia
real and that the nurse is concerned and will be respon-
sive to changes in these symptoms. Physical and psycho- Age more than 50 years
logical stress appears to increase the symptoms and fur- Female
ther frighten the patient; therefore, decreasing stressful Affective disorders, particularly depression
situations becomes important. These symptoms are often Brain damage or dysfunction
Increased duration of treatment
physically exhausting for the patient, and nurses should Standard antipsychotic medication
ensure that the patient receives adequate rest and hydra- Possiblehigher doses of antipsychotic medication
tion. Because tremors, muscle rigidity, and motor rest-
lessness may interfere with the individuals ability to eat,
the nurse may need to assist the patient with eating and ing. Abnormal finger movements are common as well.
drinking fluids to maintain nutrition and hydration. In some individuals, the trunk and extremities are also
Risk factors for acute EPS syndromes include previous involved, and in rare cases, irregular breathing and swal-
episodes of extrapyramidal symptoms. Listen closely lowing lead to belching and grunting noises. These
when patients say they are allergic or have had bad symptoms usually begin no earlier than after 6 months
reactions to antipsychotic medications. Often, they are of treatment or when the medication is reduced or with-
describing one of the medication-related movement dis- drawn. Once thought to be irreversible, considerable
orders, particularly dystonia, rather than a rash or other controversy now exists as to whether or not this is true.
allergic symptoms. About 90% of the individuals who Part of the difficulty in determining the irreversibil-
have experienced extrapyramidal symptoms in the past ity of tardive dyskinesia is that any movement disorder
will again have these symptoms if use of an antipsychotic that persists after discontinuation of antipsychotic med-
medication is restarted (Arana, 2000; Nasrallah, 2002). ication has been described as tardive dyskinesia. Atypi-
High-potency medications, such as haloperidol and cal forms are now receiving more attention because
fluphenazine, are more likely to cause extrapyramidal some researchers believe they may have different
symptoms. Age and gender appear to be risk factors for underlying mechanisms of causation. Some of these
specific syndromes. Acute dystonia occurs most often in forms of the disorder appear to remit spontaneously.
young men, adolescents, and children; akathisia is more Symptoms of what is now called withdrawal tardive dys-
common in middle-aged women. Elderly patients are at kinesia appear when use of an antipsychotic medication
the greatest risk for experiencing pseudoparkinsonism is reduced or discontinued and remit spontaneously in 1
(OHara et al., 2002). Although the occurrence of EPS is to 3 months. Tardive dystonia and tardive akathisia have
decreasing as atypical medications are more commonly also been described. Both appear in a manner similar to
used, acute EPS remains a serious clinical concern. Risk the acute syndromes but continue after the antipsy-
factors may be helpful in identifying individuals who need chotic medication has been withdrawn. More research
closer assessment of acute extrapyramidal syndromes. is needed to determine whether these syndromes are
distinctly different in origin and outcome.
The risk for experiencing tardive dyskinesia
Chronic Syndromes
increases with age. Although the prevalence of tardive
Chronic syndromes develop from long-term use of dyskinesia averages 15% to 20%, the rate rises to 50%
antipsychotics. They are serious and afflict about 20% to 70% in elderly patients receiving antipsychotic med-
of the patients who receive typical antipsychotics for an ications (OHara et al., 2002; Yeung et al., 2000).
extended period. These conditions are typically irre- Cumulative incidence of tardive dyskinesia appears to
versible and cause significant impairment in self-image, increase 5% per year of continued exposure to antipsy-
social interactions, and occupational functioning. Early chotic medications (Levy et al., 2002). Women are at
symptoms and mild forms may go unnoticed by the higher risk than men. Individuals with affective disor-
person experiencing them because they frequently ders, particularly depression, are at higher risk than are
remain beyond the individuals awareness. Therefore, those who have schizophrenia. Any individual receiving
psychiatricmental health nurses in contact with indi- antipsychotic medication may experience tardive dyski-
viduals who are taking antipsychotic medications for nesia; therefore, nurses must be particularly alert to
months or years must be vigilant for symptoms of these individuals at higher risk. Risk factors are summarized
typical chronic conditions. in Box 9-2. The causes of tardive dyskinesia remain
First identified in 1957, tardive dyskinesia is the most unclear. Lack of a consistent theory of etiology for the
well-known of the chronic syndromes. It involves irreg- chronic medication-related movement disorder syn-
ular, repetitive involuntary movements of the mouth, dromes has led to inconsistent and disappointing treat-
face, and tongue, including chewing, tongue protrusion, ment approaches. No one medication relieves the
lip smacking, puckering of the lips, and rapid eye blink- symptoms. Dopamine agonists, such as bromocriptine,
148 UNIT II Principles of Psychiatric Nursing

and many other drugs have been tried. Even dietary LITHIUM
precursors of acetylcholine, such as lethicin, and nutri-
Lithium, a naturally occurring element, was first discov-
tional therapies, such as vitamin E supplements, may
ered in the early 1800s. It has been in medical use in a
prove to be beneficial.
variety of forms, including tonics and elixirs, since that
The best approach to treatment remains avoiding the
time. As an element that acts as a salt substitute, the
development of the chronic syndromes. Preventive mea-
unregulated use of lithium produced a number of cases of
sures include use of atypical antipsychotics, using the
toxicity and, as a result, lost favor in the 1940s. Rediscov-
lowest possible dose of typical medication, minimizing
ered in 1949 by the Australian John Cade, lithium was
use of PRN medication, and closely monitoring individ-
found to reduce agitation in some patients experiencing
uals in high-risk groups for development of the symp-
psychosis, and in the 1950s, Mogens Schou published
toms of tardive dyskinesia. All members of the mental
reports that lithium controlled and prevented the symp-
health treatment team who have contact with individu-
toms of mania. In 1970, the FDA approved lithium for
als taking antipsychotics for longer than 3 months must
use in treating manic episodes in bipolar affective disor-
be alert to the risk factors and earliest possible signs of
der. Since then, it has become a mainstay in psychophar-
chronic medication-related movement disorders.
macology. Lithium is effective in only about 40% of
Monitoring tools, such as the Abnormal Involuntary
patients with bipolar disorder, and patients who do expe-
Movement Scale (AIMS), should be used routinely to
rience response often have limited clinical improvement.
standardize assessment and provide the earliest possible
Although lithium is not a perfect drug, a great deal is
recognition of the symptoms. Standardized assessments
known regarding its useit is inexpensive, it has restored
should be preformed at a minimum of 3- to 6-month
stability to the lives of thousands of people, and it remains
intervals. The earlier the symptoms are recognized, the
the gold standard of bipolar pharmacologic treatment.
more likely they will resolve if the medication can be
changed or its use discontinued. Newer, atypical antipsy-
chotic medications have a much lower risk of causing tar-
Indications and Mechanisms of
dive dyskinesia and are increasingly being considered
Action of Lithium
first-line medications for treating schizophrenia. Other
medications are under development to provide alterna- The target symptoms for lithium are the symptoms of
tives that limit the risk for tardive dyskinesia. mania, such as rapid speech, jumping from topic to
topic (flight of ideas), irritability, grandiose thinking,
impulsiveness, and agitation. Other psychiatric indica-
Mood Stabilizers tions include using lithium for its mild antidepressant
effects in treating depressive episodes of bipolar illness
(Antimania Medications) and in patients experiencing major depression that has
Mood stabilizers, or antimania medications, are psy- only partially responded to antidepressants alone. Used
chopharmacologic agents used primarily for stabilizing in patients who have experienced only partial response,
mood swings, particularly those of mania in bipolar affec- lithium has been used in augmentation as a potentiator
tive disorders. For a number of years, lithium was the (enhancing the effects) of antidepressant medications. It
only drug known to stabilize the symptoms of mania. also has been shown to be helpful in reducing impulsiv-
Although it remains the gold standard of treatment for ity and aggression in certain psychiatric patients.
acute mania and maintenance of bipolar affective disor- Lithium has been effective in treating several nonpsy-
ders, not all individuals experience response to lithium, chiatric disorders, such as cluster headaches. Because
and increasingly other drugs are being used as first-line lithium stimulates leukocytosis, it often improves the
agents. In the 1970s, carbamazepine (Tegretol) and later neutrophil counts of patients who are undergoing
valproate, both anticonvulsants approved for treating chemotherapy or who have other conditions that cause
epilepsy, were found to have mood-stabilizing effects. neutropenia. In addition, lithium has been investigated
Other medications, such as calcium-channel blockers, as an antiviral agent because it appears to inhibit the
have been used as adjunctive treatment for the symptoms replication of several DNA viruses, including herpes
of mania. At present, three drugs have FDA approval for virus. Additional research is needed to fully understand
the short-term treatment of acute mania. They include the mechanisms of these effects.
lithium, olanzapine (Zyprexa), and valproic acid The exact action by which lithium improves the
(Depakote). Lithium is the only drug with approved symptoms of mania is unknown. Lithium is thought to
FDA indication for the prevention and treatment of both exert multiple neurotransmitter effects, including
manic and depressive episodes. Many other drugs, enhancing serotonergic transmission, increasing synthe-
including other anticonvulsants, atypical antipsychotics, sis of norepinephrine, and blocking postsynaptic
adrenergic blocking agents, and calcium channel block- dopamine (Bschor et al., 2003). Lithium is actively trans-
ers are frequently used to treat bipolar disorder. ported across cell membranes, altering sodium transport
CHAPTER 9 Psychopharmacology and Other Biologic Treatments 149

in both nerve and muscle cells. It replaces sodium in the itored 12 hours after the last dose of medication. In the
sodiumpotassium pump and is retained more readily hospital setting, nurses should withhold the morning
than sodium inside the cell. Conditions that alter sodium dose of lithium until the serum sample is drawn to avoid
content in the body, such as vomiting, diuresis, and falsely elevated levels. Individuals who are at home
diaphoresis, also alter lithium retention. The results of should be instructed to have their blood drawn in the
lithium influx into the nerve cell lead to increased storage morning about 12 hours after their last dose and before
of catecholamines within the cell, reduced dopamine they take their first dose of medication. During the
neurotransmission, increased norepinephrine reuptake, acute phases of mania, blood levels of 0.8 to 1.4 mEq/L
increased GABA activity, and increased serotonin recep- are usually attained and maintained until symptoms are
tor sensitivity (Solomon et al., 2000). Lithium also alters under control. The therapeutic range for lithium is nar-
the distribution of calcium and magnesium ions and row, and patients in the higher end of that range usually
inhibits second messenger systems within the neuron. experience more uncomfortable side effects. During
Most likely, the mechanisms by which lithium improves maintenance, the dosage is reduced, and dosages are
the symptoms of mania are complex, involving the sum adjusted to maintain blood levels of 0