08/06/2018 (First Day)  INTRODUCTION TO MENTAL HEALTH PSYCHIATRIC 

FOUR TYPES OF TEMPERAMENTS  NURSING 
1. Sanguine   Mental Health 
● Symbol: dolphin ● Mental health, according to the American psychiatric
● Cheerful, sociable, confident, friendly personality association, is defined as “as state of being that is
● Skilled conversationalist relative rather than absolute.
● Strengths: talkative, optimistic, volunteer, forgives ● It is the successful performance of mental functions
easily shown by productive activities, fulfilling relationships
● Weakness: excitable, disorganized, late for with other people and the ability to adapt change and
appointments, lack discipline, vanity, maybe to cope with adversity
self-centered, good starter but bad finisher, easily ● This is further supported by Townsend’s (2009)
forgets that they volunteer definition of mental health which describes it as “the
successful adaptation to stressors from the internal or
2. Choleric   external environment, evidenced by thoughts, feelings
● Symbol: shark and behaviors that are age-appropriate and
● Ambitious, all the raw materials to become a leader congruent with local and cultural norms
● Takes charge in a situation ● WHO - mental health is defined as a state of
● Strengths: self-motivated, goal oriented, heroic, well-being in which every individual realizes his or her
optimistic, must correct wrong, strong willed, decisive, own potential, can cope with the normal stresses of
thrives on opposition life, can work productively and fruitfully, and is able to
● Most evil dictators make a contribution to her or his community (2004)
● Weaknesses: temper, arrogance, abrasive, ● Basic skills must be retained to the patient so that
argumentative, stubborn, hypocrisy, cold and they can give contribution to the family and to the
heartless community
● Mental Health Law – passed last May 2017
3. ​Melancholic   ● Phils: 17% adults have mental health issues, 16%
● Symbol: oyster – Introverted but they have a beautiful have mental health issues
and precious pearl inside ● 3rd common form of disability
● Sculptors and painters, accountants  
● Strengths: deep thinker, good planner, hardworking, HISTORICAL PERSPECTIVES OF MENTAL 
sensitive to others, loyal, consistent, high standards ILLNESS 
● Depressed, sees cruel face of the world Historical perspectives of mental illness  
● Weaknesses: pessimists, skeptical, perfectionist ● Mental illness, as with any other illnesses,
(oneself, others, based on one’s standard), too was perceived by the people of ancient times
cautious, criticizes others, easily gets depressed, lack as punishment for the gods for the sins and
courage because of fear of change wrongdoings of members of the society
● People with mental disorders were viewed
4. ​Phlegmatic   as being possessed by demons and were
● Symbol: turtle – relaxed person with a big heart ostracized, punished, and burned at the
● Avoids conflicts, perfect mediator stake
● Strength: self-content, low key, patient, finds easy ● Later on, the understanding on mental illness
way, avoid conflicts, works with anyone has evolved, as the Greeks, Romans, and
● So slow, non-reactive Arabs then believe that these disorders
● Weaknesses: shy, unemotional, indecisive, easily emerge as a result of an ​organic dysfunction
abused and manipulated by others, may lack of the brain and the body.
ambition, sluggish, hazy

UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019

 ● Specifically, Aristotle developed a theory that
correlated the imbalance of the amount of
blood, yellow and black bile
● Age of Christianity - blamed it on demons
● Age of Renaissance - people with mental
illness were distinguished from criminal.
However, those deemed “dangerous
lunatics” were imprisoned, chained and
starved (Videbeck, 2014)
 
POWER TOOLS IN MENTAL HEALTH NURSING  Crisis intervention services
● All people go through series of stages in their
development from infancy to old age
● The meaning of particular events and relationships is
influenced by the stage in the life cycle they occur.
● Nurses draw on relevant theories, personality and
development as a basis for assessment, planning,
intervention and evaluation.
- Important: behavior modification (reward,
punishment)
● Sociocultural theories 
- Forces in the environment that affects a
person’s behavior
- Identified stressors that precipitated
behavioral changes
- Therapy: Milieu therapy (you structure the
environment which aids patient coping),
II. THEORIES OF GROWTH AND DEVELOPMENT 
● Freud’s Developmental Stages

I. PERSONALITY THEORIES 
● Biological theory 
- Behavior is determined by biochemical
events in the brain
● Erik Erikson’s Stages of Psychosocial Development
- There are some mental disorders which
have genetic predisposition
- Therapy: ECT, pharmacotherapy

● Intra-psychic theories 
- Psychoanalytic models (e.g. Freud, Erikson)
- Based on the premise that childhood
experiences determine behavior as adults.
- According to Sullivan, a person who never
experiences a secured, comforting
relationship with other human beings is at
risk of developing mental disorder. ● Sullivan’s Life Stages (not sure if tama yung ages
- Therapy: one-to-one interaction, nito)
psychotherapy

● Behavioral theories 
- Pavlov, Watson, etc.
- Mental disorder caused by lack of adequate
reinforcements in the environment
- Based on learned pathological patterns
(maladaptive behaviors)
- Therapy: conditioning, desensitization

UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019

1. Pre-adolescence
2. Adolescence
III. COMMUNICATION  distance between family and friends while talking;
● Giving and receiving of information
● Three (3) elements: Sender, Message, Receiver
● Psychiatric Nursing: Goal is not only to be understood
by the patient, but also to teach patients more
effective communication skills for interaction with
mainstream society
● Factors affecting communication between nurse and
client
○ Attitude
○ Sociocultural background past experiences
○ Knowledge of subject matter
○ Ability to relate to others
○ Interpersonal perceptions
○ Environmental factors
● Verbal communication
○ Communicate our beliefs and values
○ Communicate perceptions and meanings
○ Convey interest and understanding or insult
and judgment
○ Convey messages clearly or convey
conflicting or implied messages
○ Convey clear, honest feelings or disguised,
distorted feelings
○ To verify/validate
● Nonverbal communication
○ Body behaviors
○ Facial expressions
○ Eye contact
○ Voice-related behaviors
○ Observable automatic physiological
responses
○ General appearance
○ Physical characteristics
○ Touch
○ Paralanguage – refers to the way in which
the voice is used (modulation of voice)
○ Proxemics- use of space
● Four-distance zones
1. Intimate zone (0” to 18”) - this amount of
space is comfortable for people with mutual desire
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
for physical contact. Invasion of this intimate zone
can be threatening and can produce anxiety.
2. Personal zone (18” to 3 feet) – comfortable
therapeutic communication occurs in this zone
3. Social zone (4-12 feet) – acceptable
distance for communication in social, work and
business settings
4. Public zone (12-25 ft) – no physical contact;
minimal eye contact and people remain strangers.
● Implications of nonverbal communication
○ Respond to nonverbal behavior by
confirming and clarifying its meaning and
significance to the client
○ Assess level of client’s spatial tolerance by
observing the distance the patient maintains
with other people
○ Use touch judiciously
○ Clearly communicate explanations before
and during procedures requiring physical
contact
○ Recognize your own nonverbal cues that
communicate interest, respect and
genuineness - equally important is
recognizing negative nonverbal cues that
communicate more than judgment, anger,
etc.
○ Identify cultural differences in nonverbal
communication for interventions.
● Top 10 tips for effective communication
1. Know yourself.
2. Be honest with your feelings.
3. Be secure with your ability to relate to
people.
4. Be sensitive to the needs of others.
5. Be consistent.
6. Recognize symptoms of anxiety.
7. Watch your non-verbal reactions.
8. Use words carefully.
9. Recognize differences
10. Recognize and evaluate your own actions
and response
● 9 things that may result to ineffective communication
1. Failure to listen
 2. Conflicting verbal and nonverbal messages
3. A judgmental attitude
4. Misunderstanding because of multiple meanings
of words
5. False reassurance
6. Giving advice rather than encouraging client to
make decisions
7. Disagreeing with and criticizing person who is
seeking support
8. Inability to receive information due to
preoccupation of impaired thought processes
9. Changing the subject if one becomes
uncomfortable with the topic being discussed
● Therapeutic communication
- Interpersonal interaction between the
healthcare provider and client during which
the focus is on the specific needs of the
client to promote an effective exchange of
information
- The relationship in which therapeutic
communication takes place must be warm,
positive and helps diminish anxiety and
offers the patient connection.
○ Goals in therapeutic communication
■ Establish a therapeutic relationship
■ Identify the most important client
concern that moment in time
■ Assess the client’s perception of the
problem
■ Recognize client’s underlying needs
● Therapeutic communication techniques (Review from
the book)
○ Using silence
○ Accepting
○ Giving recognition
○ Offering self
○ Asking open-ended information
○ Giving information
● Techniques that hinder communication
○ Reassuring
○ Giving approval
○ Rejecting
○ Disapproving
○ Agreeing
○ Disagreeing
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
○ Advising
○ Probing
○ Testing
○ Defending
○ Requesting
○ Minimizing feelings
○ Making stereotypical comments
○ Using denial
○ Changing the subject
IV. THE NURSE AS A THERAPEUTIC PERSON 
● Understanding of another begins with understanding
of self
● Nursing takes place in an interpersonal setting and
builds relationships and interactions concerning the
self.
● Therapeutic use of self
- During therapeutic communication,
healthcare provider use themselves as
therapeutic tool to establish therapeutic
relationship with a client
- This is using one’s humanity – personality,
experiences, values, feelings, intelligence,
coping skills and perceptions to help the
client grow and change
● ​Self​​ – describes own person as distinguished from
others in the environment
○ Self represents each person’s unique pattern
of values, attitudes, feelings, ideas
● Self-concept ​– sum total perceptions, feelings and
beliefs about oneself
○ includes characteristics and personality traits
and an evaluation of worth or desirability of
these traits
● Self-awareness​​ – recognition of one’s own
uniqueness
○ encompasses self-knowledge about one’s
behavior and its impact on self and others,
feelings towards self and the others, one’s
need and wishes, and one’s sense of life
purpose
JOHARI WINDOW  meanings underlying a client’s
(OPEN, BLIND, HIDDEN, UNKNOWN)  communications
 
  
● Self-assessment​​ – an essential ingredient of
therapeutic use of self and integral part of therapeutic
relationships
○ example of self-assessment questions
■ who am i?
■ do I behave in a particular way with
people I like? Dislike?
■ how do I express anxiety? what
types of client frighten me?
■ what emotions are stirred in me
when I interact with this client?
■ ■ process whereby a person
● Therapeutic relationship
○ relationship between nurse and client which
is different from social or intimate
relationship
○ nurse maximizes inner communication skills,
understanding of human behaviors and
personal strengths
○ Focuses on the client’s ideas, experiences,
feelings and personal ideas
● CORE DIMENSIONS IN THERAPEUTIC 
RELATIONSHIP  ●
○ empathy – temporary experiencing of naothe
rind feelings
■ expressions that convey the nurse’s
understanding and accurate
recognition of feelings, motives, and
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
■ it is the ability “to get inside
another’s skin” and subjectively feel
with a client while objectively
observing behavior.
○ respect – communication of acceptance of
the client’s ideas, feelings, and experiences
recognition of client’s potential for
self-actualization
○ confidentiality – respecting client’s right to
keep info only to those who are dealing with
client’s care
○ genuineness – awareness of one’s own
feelings as they arise within the relationship,
and the ability to communicate them when
appropriate; ability to puse therapeutic
communication
○ Concreteness - clear, direct expression of
personally relevant perceptions, values and
feelings a they exist in the present
relationship
■ used to help clients focus specific
problems and significant details
○ Immediacy - a dimension of communication
that
● ESTABLISHING BOUNDARIES 
○ Transference
unconsciously and inappropriately
displaces onto individuals in his
current life those patterns of
behavior and emotional reactions
that originated with significant
figures from childhood
○ Counter-transference
■ tendency of the therapist to
displace onto the client’s feelings
caused by people
PHASES OF A THERAPEUTIC RELATIONSHIPS 
1. ORIENTATION
2. WORKING
3. TERMINATION
● mutually accepted goals resulting in the termination of
therapeutic relationship including client’s ability to:
 ○ summarizing goals and obj achieved In the
relationship is part of the process
○ it is important for the nurse to work with the
client to bring into awareness any feelings
and rxns the client may be experiencing
related to separation

   

UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019


08/07/2018  ■
(Second Day)   ○
 
ASSESSMENT IN MENTAL HEALTH AND PSYCHIATRIC  plan of care
NURSING  ■ Helping the patient relax
 
I. The Psychiatric Nursing Interview
● Purpose: To gather information necessary to
treat and understand the patient.
● Includes an evaluation of the patient’s
physical and mental health and social
well-being.
● It is the quality and not the quantity of the
assessment data that matters narrow the
range of data collection to information most
relevant to present condition.
● Content and process vary according to the
state of the patient and the context in which
the interview takes place.
● The content of the initial interview should
focus on eliciting information to help the staff
ensure safety for the patient and others.
● Data gathered should be validated with the
family or significant others, especially for
psychiatric patients.
● The therapeutic nurse-patient relationship as
a prerequisite to a comprehensive mental
health assessment.
○ Establishing trust and rapport
○ Observation of verbal and
non-verbal cues
○ Attention to words and process of
communication
○ Broad knowledge on mental health
problems and maladaptive
behaviors
● Phases
○ Initial Phase
■ Establishing rapport
■ Orientation and contract
setting
■ Confidentiality
○ Middle
■ Data are collected and
processes
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
Obtains and provides
information to patient
Termination
■ Summarize
■ Tentative diagnosis and
from an often emotional
interaction
● Tips
○ Active listening and attention to the
patient’s responses
○ Convey interest, attentiveness and
acceptance
○ Avoid bombarding the patient with
questions
○ Paraphrase or summarize the
content and feelings to let the
patient know you understand what
was said​ (“Ibig sabihin ba na
nagagalit ka sa mga magulang mo
kasi dinala ka dito sa ospital”)
○ Always clarify and avoid jumping
into conclusions
○ Manage the flow of the interaction
without offending the patient
(“Napapansin ko na lumalayo na
tayo sa usapan, eto muna pag
usapan natin”)
○ Be sensitive to transference,
resistance or manipulation from the
patient
II. Components of a Psychiatric Assessment
● Biopsychosocial History (and anamnesis)
● Family Assessment (include genogram)
● Physical Assessment (include laboratory and
diagnostic findings)
● Mental Examination
III. Physical Assessment
● Physical examination as an integral part of the
psychiatric assessment often not given much
attention in psychiatric patients
● Must be performed upon admission
● A way to rule out an organic source for the behavioral
problems
● A basis for treatment and medications
 ● Psychiatric symptoms may have impact on patient’s
physical health
● Physical Health as priority Maslow’s Hierarchy of
Needs
● Be sensitive to patient who would refuse to be
touched or have their bodies examined.
● Document refusal of patient
● Maintain privacy and dignity when performing PE
● Significant laboratory/diagnostics tests
○ Cranial CT Scan and other neurologic test
○ Urine drug tests
○ Blood chemistry tests – liver, kidney and
thyroid function tests, electrolytes
○ Pregnancy test
○ Valproic Acid Assay/Lithium Assay
IV. Biopsychosocial History
1. Identifying data
➢ Summary of the patient’s demographics
2. Chief complaint
➢ Result for consult/admission
➢ As stated by the patient and by the family
(document both!)
3. History of present illness  religiosity
➢ Chronologic account of events leading to
consult
➢ Onset, duration and change of symptoms
over time
➢ Alleviating/exacerbating factors, stressful
events, changes in social functioning
4. Psychiatric History
➢ Information about past psychiatric illness
5. Alcohol/Substance Use History
➢ High comorbidity between mental illness and
substance use
➢ Addiction as a mental health problem
➢ Substance use as a form of coping
6. Medical History
➢ Psychiatric symptoms secondary to another
medical condition
➢ Presence of any illness predisposes a
patient to a mental health problem (e.g.
cancer depression)
7. Family History
➢ Genetic predisposition
➢ Genogram
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
8. Developmental History
➢ Developmental adaptation that are required
in each stage
➢ Psychodynamic, psychosocial, cognitive and
moral stage of development
➢ Parenting, interpersonal relationships and
childhood experiences
9. Social History
➢ Ability to make and sustain relationships
➢ Type of relationships
➢ Family dynamics- presence of support
system
➢ Ability to accomplish social milestones
10. Occupational/Educational History
➢ Level of function in work and school
➢ Work or school-related stress
11. Culture, Spirituality, Values
➢ Cultural beliefs and practices that impact
health management
➢ Spirituality as sources of motivation and
strength; finding meaning in the presence of
illness
➢ Spirituality as much broader concept than
12. Coping skills
➢ Coping behaviors, adaptive and maladaptive
coping mechanisms
➢ How the patient coped with the presence of
illness
V. Mental Status Examination
● Includes a structured assessment of the patient’s
behavioral and cognitive functioning.
● Focuses on the patient’s current state in terms of
thoughts, feelings and behaviors
● Expert observation of verbal and non-verbal cues
● Usually limited to what is observed during the time of
interview
● (BESTPICK)
● Behavior and General Appearance
○ Type, condition and appropriateness of
clothing
■ Appropriate/inappropriate for age
and sex
■ Properly worn
■ Layered or seductive clothes
■ Seductive clothes
 ○ Grooming, cleanliness ■ Hypoproductive/Hyperproductive
■ Kempt, Unkempt ■ Verbose/Repetitive
■ Poorly groomed, disheveled ■ Dramatic, Slurred, Incoherent
■ Excessive make-up ■ Speaks in English
○ Posture ■ Perseveration/Echolalia
■ Slouched or relaxed or stiff ● Thought Content and Thought Process 
■ Frequent change of posture ○ Assess for delusions and flow of thoughts
○ Motor activity (“Ano ang naiisip mo ngayon?)
■ Hyperactive/slow/agitated ○ Always assess for suicidal and homicidal
■ Psychomotor retardation thought
■ Abnormal movements like ○ Thought Process/Form
mannerisms, fidgeting, echopraxia, ■ Normal
ritualistic behaviors, nail biting, etc. ■ Tangential (Going away)
○ Attitude/behavior towards the interview ■ Circumstantiality
■ Cooperative/passive/aggressive ■ Flight of ideas (Frequently changing
■ Manipulative/hostile topics)
■ Attention span ■ Loosening of association ​(walang
■ Eye contact- poor/good/piercing connect)
● Emotions: Mood and Affect  ■ Clang association (rhyming words)
○ Mood: pervasive subjective emotional state ■ Word salad (Jumbled words)
○ (Ask the patients directly about how they ■ Neologism ​(nag iimbento ng words)
feel) ■ Thought blocking ​(biglang tumigil
■ Euthymic (Calm) tapos nagsalita ulit)
■ Depressed ■ Verbigeration (​paulit-ulit)
■ Elated ○ Thought Content
■ Irritable ■ Delusions
■ Expansive ● Grandiose
■ Anxious ● Persecutory
■ Labile (shifting mood) ● Infidelity
○ Affect: visible expression of emotional state; ● Religious
type, range and congruency of affect ● Somatic
■ Constricted​ (kulang) ● Ideas of reference
■ Blunted​ (sobrang kulang) ● Thought insertion
■ Flat ​(walang affect) ● Thought broadcasting
■ Normal ​(appropriate) ● Perceptual Disturbances
■ Inappropriate ​(e.g. depressed but ■ Five senses!
looks happy) ■ Auditory
■ Broad ■ Visual
● Speech Pattern  ■ Tactile
○ Rate ■ Olfactory
■ Increased/pressured speech ■ Gustatory
(masyadong mabilis na matigas) ○ Ask the patient directly about presence of
■ Decreased/Monosyllabic hallucinations
■ Prodded to respond ■ Example: ​“May naririnig ka bang
○ Volume mga boses / may nakikita ka ba?”
■ Loud/Soft/Mute/Whispered ■ If yes, probe: ​“Ano ang sinasabi ng
○ Quality/Quantity mga boses?”
■ Spontaneous/Non-spontaneous ■ If no, then stop asking/exploring.
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
 ○ Do not ask about the delusions again, just ○ (Risk Assessment)
observe ■ Danger to Self
○ If the patient denies, observe for ■ History
hallucinatory gestures ■ Stated intent
○ Assess for command hallucinations Patient ■ Psychosocial risk factors
safety! ■ Specific suicide inquiry
○ Illusion: with trigger or stimuli, but ■ Depressed mood
misinterpreted ■ Isolation and lack of social support
● Impulse Control ■ Hopelessness
○ The ability to delay, modulate or inhibit the ■ Worthlessness
expression of behaviors and feelings ○ Assess the specificity, lethality, availability,
○ Look at ways the patient has handled proximity of the suicide plan.
stressful situations in the past -- drug use, ○ Danger to Others
uncontrolled aggressive behavior, frustration ■ History
tolerance ■ Stated intent
○ An important part of determining potential for ■ Substance Use
acting on suicidal and violent thoughts ■ Aggression, dangerous or
■ Good/Bad threatening actions
● Cognition and Sensorium ■ Refusal to cooperate
○ Level of consciousness, orientation, ■ Anger, hostility, irritability
concentration ■ Suspiciousness
○ Disturbances of memory: short term and ■ Low mood or elevated mood
long term ■ Persecutory delusions
○ Intellectual functioning, concrete and ■ Command hallucinations
abstract thinking dementia, intellectual ■ Thoughts of deliberate harm
disability VI. Anamnesis
○ Observe! ​Wag paulit ulit a. Family History
● Knowledge, Insight and Judgment  b. Personal History- from infancy to present
○ Insight: Assess if the patient is aware of developmental stage
his/her illness and maladaptive behaviors c. Previous Attacks of Mental Disorders
■ Level 1: Complete denial d. Onset and Symptoms of the Psychiatric Disorder
■ Level 2: Slight awareness, but e. Survey of the Presenting Features of the Personality
denying
■ Level 3: Aware but blaming it to VII. Family Assessment 
others ● Family Genogram and Family Dynamics
■ Level 4: Illness is something ○ Include narrative explanation
unknown to client ○ Legends:
■ Level 5: Intellectual insight ■ Male
■ Level 6: True emotional insight ■ Female
○ Judgment: Assess if the patient is able to ■ Deceased
understand the potential consequences in ■ Close Relationship
his/her behavior. ■ Conflicting Relationship
■ Ask the patient about how /she ■ Circle: same household
would react to hypothetical ● Knowledge, attitude and beliefs regarding the illness
situations. ○ Insight and acceptance of the family
■ Poor/impaired judgment or good members
judgment ○ Presence of stigma within the family

UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019

 Cultural beliefs about maladaptive behaviors
○
and symptoms
 
○ Educate the family!  
● Effects of illness to the family
○ Effects of illness to family functioning-  
economic, socialization, emotional functions
○ Family reactions to the illness may be similar
 
to those experienced by the patients  
○ What adaptations, adjustments, and role
changes were made  
● Coping Strategies of the family  
○ Mental health problems and maladaptive
behaviors are harder to deal with for family  
members
○ Assess for family support, strength, and  
resiliency  
○ Assess for presence of burden/caregiver role
strain  
VIII. Nursing Diagnoses
 
➢ Acute Confusion (hallucinations and delusions)  
➢ Labile Emotional Control (pag paiba iba ang mood)
➢ Impaired Mood Regulation  
➢ Chronic Low Self Esteem
➢ Disturbed Body Image
 
➢ Dysfunctional Family Processes  
➢ Impaired Social Interaction
➢ Ineffective Coping  
➢ Ineffective Denial
➢ Compromised Family Coping
 
➢ Risk for Other-direction Violence  
➢ Risk for Suicide
➢ Wala nang altered thought processes/disturbed  
thought content
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
 ASSESSMENT OF EGO FUNCTIONS  give reasons for their actions and will give
 
● Id: Pleasure
● Ego: Rational
● Superego: Moral
○ ego defense mechanisms - to balance the
ego functions
● Tools of mental functioning that a person uses to
accomplish ego strength
● Some ego functions deal primarily with our
relationship to the world around us and protect us
from being overwhelmed by external stimuli
● Others deal primarily with the internal environment
and protect us from being overwhelmed by internal
stimuli
What are the individual ego functions?   innate equipment to connect different
● Capacity for play
○ also called as regression in the service of the
ego
○ this refers to the ability to relax, to dream into
fantasies and daydreams, and to experience
unconscious feelings and urges without
feeling anxious or overstimulated
○ people with the capacity for play are able to
channel their fantasies and daydreams into
productive creativity
○ e.g. when stressed, people resort to
things/activities that make them happy
○ it also helps them to connect to
deeply-seated emotions
○ also important both to patient and therapist;
it allows patient to experience and retrieve
unconscious thoughts and feelings and
facilitates empathy in the therapist
○ if people feel confused on overwhelmed or
disabled by fantasies, or if they regress
easily but have trouble reversing the
process, this can be disorganizing
● Self-awareness/psychological mindedness
○ Having the ability to recognize and identify
one’s feelings appropriately
○ Have the capacity to reflect on what is
happening inside of you
○ people who lack self-awareness show little
interest in exploring their behavior, cannot
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
lots of “I don’t know” answers and have little
awareness of feelings
● Self-esteem regulation/accurate self-appraisal
○ Self-esteem: one’s ability to regulate oneself
in response to a blow to the ego
○ Accurate Self-appraisal: reflects the degree
to which one’s subjective sense of one’s
capacity correlates with one’s actual or
objective capacities
○ related to one’s ability to believe in one’s
capacity and sense of self-reliance
● Cognitive functions
○ Refers to the built-in cognitive apparatus a
person is equipped with (intelligence,
memory, attention, linear thinking)
○ It also encompasses the ability to use this
aspects of experience and to recognize
patterns and to reconcile inconsistent
attitudes and feelings to solve problems and
to think abstractly
● Defenses
○ Unconscious and automatic ways the mind
responds to internal and external stress and
emotional conflict
○ Coping mechanisms that make a person’s
awareness of painful affects such as anxiety,
depression and envy, and resolve internal
emotional conflict.
○ More adaptive defenses are generally based
on repression
○ Less adaptive defenses are generally based
on splitting
○ Object constancy - knowing that bad and
good can exist in the same person
● Reality testing and sense of reality
○ differentiate what is real and what is not
● Judgment
○ aware of the appropriateness and likely
consequences of an intended behavior and
behaves in a way that reflects this
awareness
● ​Relationships with others
○ quality of life in pattern of relationships and
ability to sustain them
 ○ ​stable,intimate, loving, sharing person is
whole and separate
● Sensory stimulus regulation
○ ​in order to function effectively in the world,
people need to be able to actively ward off
excessive sensory stimulation
○ Stimuli: both external (e.g. noise) and
internal (e.g. body pain)
○ with intact stimulus regulation, insignificant
stimuli are automatically diverted from
attention from other important stimulus from
the environment
○ External stimuli should not divert attention
from other stimuli
○ You can focus
● Affect/anxiety tolerance
○ Ability to tolerate and regulate anxiety and
other intense positive and negative emotions
○ people with poor anxiety/affect tolerance feel
easily disorganized
● Impulse control
○ good impulse control refers to the ability to
act on or channel feelings or urges in
controlled way
○ ​poor – act on feelings/urges in maladaptive
way (temper tantrums, overusing alcohol,
impulsive sexual activities)
○ Common with risky behaviors
○ Frustration tolerance – frustrated
immediately if wants are not followed
○ Capacity to delay gratification
 
Defense Mechanisms: Less adaptive (book)  ● Identification - ‘‘if you can’t beat ’em, join ’em’’
● Splitting - ego preserves good feelings and avoids
bad feelings by separating them into different people
● Projection - ego protects itself by perceiving
unacceptable thoughts, feelings, and fantasies as
originating outside of the self
● Projective Identification - Projective identification
occurs when one person (A) projects a thought or
feeling into another person (B) and then interacts with
B to make B experience the projected feeling. We say
that in this way, person A maintains an identification
with the projected feeling
● Pathological idealization and devaluation -
Idealization and devaluation are natural
results of splitting.
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
● Denial - ego protects itself from unacceptable feelings
by disavowing their existence.
● Dissociation - allows the ego to avoid unacceptable
thoughts and affects by disconnecting the self from
aspects of one’s current reality. This can involve
losing one’s consistent sense of identity, memory, and
ability to perceive sensations or current sense of
reality
● Acting Out - One way to avoid a painful or
uncomfortable feeling is to do something that enacts
the feeling without becoming consciously aware of it.
● Regression - they go back to an earlier way of
functioning in order to avoid the anxiety-provoking
feelings prompted by a later developmental period
Defense Mechanisms: More adaptive 
● Isolation of affect - ego represses the affect but the
thought remains conscious
● Intellectualization - uses substitution of excessive
thinking to take the place of painful or uncomfortable
feelings
● Rationalization - ego deals with unacceptable feelings
by coming up with good reasons or justifications for
problematic situations/feelings.
● Displacement - object of a wish or feeling is
exchanged for one that feels more comfortable
● Somatization - thought or affect is repressed and is
experienced as a bodily sensation
● Undoing - ego’s chance at a ‘‘do-over’’ – the ego gets
to reverse something it feels is unacceptable or
uncomfortable
● Reaction formation - unacceptable affect is reversed
and experienced consciously only as its opposite
defense. Feelings such as jealousy and
competitiveness are dealt with by internalizing
aspects of the other person
● Excessive emotionality - thought content is repressed
while affect remains conscious
● Externalization - people perceive internal conflicts as
if they were external conflicts
● Sexualization - When people sexualize, they take
issues that are not sexual and make them sexual to
avoid deeper uncomfortable feelings
● Repression - hides thoughts, feelings, and fantasies
from consciousness, leading to forgetting, denial, and
inhibited sexuality
● Turning against self - substitutes the self for the
object, particularly when it comes to negative affects
Defense Mechanisms: Most adaptive  PSYCHODYNAMIC FORMULATION
● Humor - to allay uncomfortable thoughts or  
affect.When this is conscious, it is quite adaptive,
however the chronic use of humor to avoid painful
affects can be problematic.
● Altruism - doing things for others as a way of dealing
with painful affects
● Sublimation - when an uncomfortable thought or
affect goes straight from the unconscious to
consciousness in a useful form – without having to be
transformed. Thus, when a person can discharge
his/her feelings of rage by writing a poem about anger
or going to the gym to punch a punching bag, the
affect is completely discharged without having to
launch a frank ‘‘defense.’’ Sublimation often implies
that the result is something that is useful or positive.
● Suppression - suppression involves a conscious
decision to put a thought or affect out of one’s mind
 
 
 
 
 
 
 
 
 
 
 
 
  How to make Psychodynamic Formulation:
  1.
  ● Self
 
 
 
 
 
 
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
 
● A hypothesis about the way a person’s unconscious
thoughts and feelings may be causing the difficulties
that have led him/her to treatment
● Also about understanding how and why those
unconscious thoughts and feelings developed.
● At other times, we use this understanding to help
patients develop capacities that were not fully formed
during their earlier years.
● Finally, we can help support patients’ functioning that
is impaired by acute or chronic problems. Needs to
include:
○ Ideas about how unconscious thoughts and
feelings might affect out patients’ problems
○ Ideas about how those unconscious
thoughts and feelings might have developed
● Just a hypothesis
● Earlier in the history of psychoanalysis, the
psychodynamic formulation was thought to be a
definitive explanation of a person’s development. Now
we understand that is it better conceptualized as a
tool to improve our treatment methods and
understanding of our patients.
● It guides every aspect of the treatment
● Enables us to:
○ Make treatment recommendation and set
goals
○ Understand what patients need
developmentally
○ Develop therapeutic strategies and predict
the way patients will react in treatment
(transference)
○ Construct meaningful interventions
○ Help our patients create cohesive life
narratives
 
Describe:
○ Self-perception
■ Identity (sense of who we are;
ability to know out likes and dislikes
as well as our talents and
limitations)
■ Fantasies about the self
 ○ Self-esteem
■ Vulnerability to self-esteem threats
(fragile self-esteem)
■ Internal response to self-esteem
threats
-Less adaptive: Grandiosity
(inflating one’s sense of self) and
self-depreciation & masochism
(deflating one’s sense of self)
-More adaptive: becoming more or
less competitive
● Use of others to regulate
self-esteem
-People requiring constant
attention, praise and validation from
others to manage their self-esteem.
-People with more adaptive
self-esteem regulation strategies
are able to take advice,
metabolize it, and make their own
decisions.
● Relationships
-are the interactions the we have with people in our
lives (e.g. parent-child, peer friendships, romantic and
sexual relationships)
○ Trust
-allows people to count on one another, to
believe that they will be taken care of, and to
have confidence in the consistency of their
relationships.
-Lack of trust leads to constant fear of
aggression from others, a sense of being
neglected, and a perennial feeling of
aloneness.
-Trust in others develops during the earliest
years and depends on both temperament
and early relationships with caregivers.
○ Sense of self and other
-the person can think about himself/herself
and others as having (1) both bad and good
qualities, (2) separate and unique feelings,
beliefs, needs, or motivations and (3)
generally consistent feelings about self and
others from past to present
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
○ Security
-feeling safe with another person
-being able to feel that the relationship will
persist even if there are (1) physical
separations, (2) disagreements, and (3)
other negative feelings. In development, this
is often called having a secure attachment.
-People with more secure relationships are
generally able to (1) tolerate a range of
ambivalent feelings about other people, (2)
have a variety of long-lasting relationships,
and (3) form relationships more slowly,
taking time to get to know others.
○ Intimacy
-Refers to closeness and familiarity.
-People are intimate with one another if they
share things about themselves, such as
feelings, experiences, wishes, and
disappointments.
-Without at least some intimacy,
relationships are superficial.
-However, because intimacy involves
sharing private thoughts and feelings, it
makes many people feel anxious and
vulnerable.
○ Mutuality
-Relationships are mutual when both people
involved are able to give and take. It’s a
two-way street.
● Adapting
-Each person has his/her own (1) thresholds for
tolerating internal and external stimulation and (2)
ways of adapting to internal and external stimulation.
-Adapting means adjusting
-Internal stimulation includes: (1) thoughts and
fantasies, (2) feelings and anxiety, (3) pain and other
physical sensations
-External stimulation includes: (1) relationship with
others, (2) economic and work-related pressures, (3)
trauma and other environmental events
○ Defenses
-unconscious ways of adapting to stress
-(Refer to the ego functions)
 ○ Managing emotions
○ Impulse control
-Impulses come in many forms. People with
difficulty controlling impulses can have
trouble with (1) managing appetites
(substances, food, sex), (2) gambling, (3)
controlling aggression/violence, (4) stealing
○ Stimulus regulation
● Cognition
○ General cognitive abilities
■ Intelligence
■ Memory
■ Attention
■ Speech and Language
○ Decision making and problem solving
-Some people are very detail oriented, while
others are more impressionistic; some
people make decisions based on research,
while others are guided by ‘‘hunches.’’ Some
people are planners, and some ‘‘take things
as they come.’’ Still others have
considerable creative talents that help them
not only with solving problems but also with
everything from inventing new recipes to
making scientific discoveries.
-Problem solving requires the ability to
organize thinking, plan ahead, and think
creatively.
-Problem solving abilities:
■ Decision making
■ Problem solving
■ Organizing thoughts
■ Planning
■ Creative thinking
○ Self-reflection and reality testing
-Self-reflection is the capacity to examine
one’s own thoughts and behaviors. It is the
ability to step back, sometimes just a little bit,
from one’s experience in order to try to
understand it.
-Psychological mindedness: ability to think
about possible unconscious motivations for
one’s thoughts, feelings, and behavior.
-Reality testing is the ability to differentiate
reality from fantasy.
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
○ Mentalization
-Capacity to understand that other people
have thoughts and feelings that are different
from one’s own. The ability to mentalize is
central to the ability to empathize with
others.
○ Judgment
-Capacity to consider the consequences of
behavior.
-Involves not only being aware of the
appropriateness and likely consequences of
an intended behavior but also behaving in a
way that reflects this awareness.
-Can wax and wane in different
circumstances.
● Work and Play
○ Variables for describing work and play
■ Well matched to developmental
level/talents/limitations
■ Comfortable/satisfying/pleasurable
■ Adequate for care of self and
dependents
■ Culturally sanctioned
○ Work
■ For money or not for money
■ Consistent or sporadic
■ In the home or out of the home
■ Skilled or unskilled
○ Play
■ How much time it occupies in the
person’s life
■ Whether they play alone or with
others
■ Depth and breadth of their
involvement
■ Sex as play
■ Absence of play
2. Review: Developmental History
● Genetics and Prenatal Development
● Earliest Years (0-3 years)
● Middle Childhood (3-6 years)
● Later Childhood, Adolescence and Adulthood
3. Link: Problems and Patterns to History
● Trauma
 ● Early Cognitive and Emotional Difficulties
● Conflict and Defense
● Relationships with Others
● Development of the Self
● Attachment
  
PSYCHODYNAMIC PARADIGM 
 
● All assessment findings are reviewed
● Identify the factors affecting the illness/maladaptive
behaviors
● Write them in a scholarly manner
● Organize data by showing the course of events that
took place
● Discuss its theoretical background; may include
theories of personality
● Items must not be repetitive
  
  
  
  
  
  
  
  
  
 
 
 
   

UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019


08/08/2018  developmental period
Third Day  Possible Nursing Interventions
 
Neurodevelopmental and Neurocognitive Disorders  environment
Neurodevelopmental Disorders​​ – group of conditions with
onset in the developmental period
- typically manifest early in development, often before
the child enters grade school
- characterized by developmental deficits that produce
impairments of personal, social, academic, or
occupational functioning
● Regressed – returning to an earlier developmental
stage to express an impulse to deal with reality
● Repetitive Behaviors – specific types of unusual
voluntary behaviors, also sometimes referred to as
self-stimulating behavior or stimming
● Inattention – lack of attention or a reduced attention
span
● Impulsive – to act on a whim, displaying behavior
characterized by little or no forethought, reflection or
consideration of the consequences
● Hyperactive – constant activity, being easily
distracted, impulsiveness, inability to concentrate,
aggressiveness
Possible Nursing Diagnoses  routines, or ritualized patterns of verbal or nonverbal behavior
● Impaired Social Interaction
● Risk for Injury
● Risk for Caregiver Role Strain
Intellectual Disabilities​​ – disorder with onset during the
developmental period that includes both intellectual and
adaptive functioning deficits in conceptual, social, and practical
domains
- Deficits in general mental abilities
Reasoning
Problem solving
Planning
Abstract thinking
Judgement
Academic learning
Learning from experience
Diagnostic Criteria
1. Deficits in intellectual functions (same as above)
2. Deficits in adaptive functioning that result in failure to
meet developmental and sociocultural standards for
personal independence and social responsibility
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
3. Onset of intellectual and adaptive deficits during the
 
● Enhancing effective communication
● Maintaining safe, accessible, and comfortable
● Reducing challenging behaviors
● Decreasing caregiver role strain
Autism Spectrum Disorder ​– a developmental disorder that
affects communication and behavior
- Generally appears in the first two years of life
- Children are often restricted, rigid, and even
obsessive in their behaviors
Diagnostic Criteria
1. Persistent deficits in social communication and social
interaction across multiple contexts, which include:
- Deficits in social reciprocity
- Nonverbal communicative behaviors used for social
interaction
- Skills in developing, maintaining, and understanding
relationships
Restricted, repetitive patterns of behavior, interests,
or activities which include:
- Stereotyped or repetitive motor movements, use of
objects or speech
- Insistence on sameness, inflexible adherence to
- Highly restricted, fixated interests that are abnormal in
intensity or focus
- Hyper- or hypo-reactivity to sensory input or unusual
interest in sensory aspects of the environment
2. Symptoms may be present in the early developmental
period
3. Symptoms cause clinically significant impairment in social,
occupational, or other important areas of current functioning
4. These disturbances are not better explained by intellectual
disability or global developmental delay.
**Intellectual disability and autism spectrum disorder frequently
co-occur; to make comorbid diagnoses of it, social
communication should be below that expected for general
developmental level
Assessment Parameters
Social
- Abnormal or lack of comfort-seeking behaviors
- Abnormal or lack of social play
- Impairment in peer relationships
- Lack of awareness of the existence or feelings of
others
 - Abnormal or lack of imitation of others
Communication
- Lack of, impaired, or abnormal speech such as
producing a monotone voice or echolalia
- Abnormal nonverbal communication (does not use
gestures to communicate)
- Lack of imaginative play
Behavior
- Persistent preoccupation or attachment to objects;
range of interests restricted
- Self-injurious behaviors
- Must maintain routine; any environmental change
produces marked distress
- Produces repetitive body movements such as rocking
or head banging
Possible Nursing Interventions  (mood disorder, anxiety disorder, substance
● Determine the child’s routines, habits, and
preferences; maintain consistency as much as
possible
● Determine the specific ways the child communicates;
use these methods
● Avoid placing demands on the child
● Evaluate the child for safety
● Implement safety precautions as necessary for
self-injurious behaviors
● Initiate referrals to special programs as required
● Provide support to parents
Attention Deficit/Hyperactivity Disorder ​– a brain disorder
marked by an ongoing pattern of inattention and/or
hyperactivity-impulsivity that interferes with functioning or
development
● Inattention – a person wanders off task, lacks
persistence, has difficulty sustaining focus, and is
disorganized all of which are not due to defiance or
lack of comprehension
● Hyperactivity – a person seems to move about
constantly, including in situations in which it is not
appropriate; excessively fidgets, taps; or talks; adults
may have extreme restlessness of wearing others out
with constant activity
● Impulsivity – a person makes hasty actions that occur
in the moment without first thinking about them and
that may have high potential for harm; a desire for
immediate rewards or inability to delay gratification;
may be socially intrusive and excessively interrupt
others or make important decisions without
considering the long-term consequences
Diagnostic Criteria
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
1. Persistent pattern of inattention, disorganization,
and/or hyperactivity-impulsivity that interferes with
functioning or development as characterized by
inattention and/or hyperactivity and impulsivity
2. Several inattentive or hyper-impulsive symptoms were
present prior to age 12
3. Several inattentive or hyperactive-impulsive
symptoms are present in two or more settings (home,
school, work, with friends or relatives, in other
activities)
4. There is a clear evidence that the symptoms interfere
with, or reduce the quality of, social, academic, or
occupational functioning
5. The symptoms do not occur exclusively during the
course of schizophrenia or another psychotic disorder
intoxication or withdrawal)
Assessment Parameters
● Fidgets with hands or feet or squirms in the seat
● Easily distracted with external or internal stimuli
● Difficulty with following through on instructions
● Poor attention span
● Shifts from one uncompleted activity to another
● Talks excessively
● Interrupts or intrudes on others
● Engages in physically dangerous activities without
considering the possible consequences
Possible Nursing Interventions 
● Provide parents with information and treatment plan;
encourage support groups for parents
● Maintain a consistent home and classroom
environment; provide safety measures
● Promote self-esteem
● Instruct the child and the parents about medication
administration and the need for regular follow-up
Neurocognitive Disorders​​ – characterized by impaired
cognition which has not been present since birth or very early
life
- Represents a decline from a previously attained level
of functioning
● Angry/Hostile – persistent angry feelings, irritability in
response to minor slights and insults
● Passive-Aggressive – indirect resistance to the
demands of others and an avoidance of direct
confrontation
● Assaultive – extremely aggressive or forcefully
assertive
Causes  5. There is evidence from the history, PE, or laboratory
● Alzheimer’s disease
● Lewy body disease
● Vascular disease
● Prion disease
● Parkinson’s disease
● Huntington’s disease
● HIV infection
● Frontotemporal lobar degeneration
● Traumatic brain injury
● Strongest risk factor for major and mild NCDs: old age
Possible Nursing Interventions  ● Validation Therapy: technique tries to find the reason
● Do not allow the client to assume responsibility for
decisions or actions if he/she is unsafe
● Explain limits and reasons clearly and within the
client’s ability to understand
● Involve the client in making plans or decisions as
much as he/she is able to participate
● Assess the client daily or more often for his/her level
of functioning
● Allow client to make decisions as much as he/she is
able
● Assist the client to establish a daily routine including
hygiene, activities, etc.
Delirium ​– a disturbance of attention or awareness that is
accompanied by a change in baseline cognition that cannot be
better explained by a preexisting or evolving neurocognitive
disorder (NCD)
- Often associated with a disturbance in the sleep-wake
cycle
- May exhibit emotional disturbances
- Rapid, unpredictable shifts from one emotional state
to another evident in calling out, screaming, cursing,
muttering, moaning, or making other sounds
- Behaviors are prevalent at night and under conditions
in which stimulation and environmental cues are
lacking
Diagnostic Criteria
1. Disturbance in attention or awareness
2. The disturbance develops over a short period of time,
represents a change from baseline attention and
awareness, and tends to fluctuate in severity during
the day
3. Disturbance in cognition
4. Disturbances 1 and 3 are not better explained by
another preexisting, established, or evolving NCD,
and do not occur in the context of a severely reduced
level of arousal
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
findings that the disturbance is a direct physiological
consequence of another medical condition, substance
intoxication or withdrawal or exposure to a toxin, or is
due to multiple etiologies
Nursing Interventions 
● Ensure safety of the patient and others
● Meet physiological needs (nutrition, sleep, etc.)
● Use short, simple sentences; speak slowly and
clearly’ use a low-toned voice to be heard; do not act
rushed; do not shot; allow adequate time for response
behind the expressed feeling
● Resolute Therapy: attempts to understand and
acknowledge the confused client’s feelings
● Educate the family and the client about the condition
● Reality Orientation: offer orienting information as a
normal part of daily care and activities; repeat
information as necessary for the confused person
● Use consistency in routines, caregiver, primary nurse
● Use familiar items
● Avoid room changes, especially at night; put delirious,
disruptive clients in a private room if at all possible
● Keep the environment calm and quiet with adequate
but soft indirect light; limit noise levels
● Consider the use of night lights to combat nighttime
confusion
● Divide activities into smaller steps in order to simplify
them and decrease likelihood of causing disruptive
behaviors
Nursing Interventions ​(for episodes of acute confusion)
● Ensure safety
● One to one supervision
● Pay attention to clients
● Removal of client from the situation; time out;
seclusion/isolation; reposition
● Positive reinforcement of desired behaviors; removal
of reinforce of undesired behavior
● Restrict activities
● Physical or chemical restraint as a last resort
● Diversions can be used to distract the client from the
disruptive behaviors that she/he is currently engaging
in
Major Neurocognitive Disorder​​ – previously known as
dementia
- there is significant cognitive decline
Symptoms
 ● Significant cognitive decline compared to a previous
level of performance in one or more areas
● Memory loss, difficulty remembering new information
● Difficulties with abstract thinking
● Forgets names of everyday objects or familiar people
● Loss of communication skills
● Disorientation relating to time and place
● Problems with physical movement and balance
● Extreme behavioral changes (dresses inappropriately,
speaks about topics that are controversial or offensive
without regard for others’ feelings, makes decisions
without regard for personal safety)
● Interfere with the independence of the individual with
relation to everyday activities
Diagnostic Criteria
● Evidence of significant cognitive decline from a
previous level of performance in one or more
cognitive domains based on:
○ Concern of the individual, a knowledgeable
informant, or the clinician that there has
been a significant decline in cognitive
function
○ A substantial impairment in cognitive
performance, preferably documented by
standardized neuropsychological testing or,
in its absence, another quantifies clinical
assessment
● The cognitive deficits interfere with independence in
everyday activities
● The cognitive deficits do not occur exclusively in the
context of a delirium
● The cognitive deficits are not better explained by
another mental disorder
Mild Neurocognitive Disorder​​ – have similar symptoms to
major NCD but the cognitive decline is modest rather than
severe
Common Symptoms
● Modest cognitive decline compared to a previous
level of performance
● Difficulty in multitasking or handling more than one
task at a time
● Everyday tasks take longer than normal to complete
● Difficulty recalling recent events
● Difficulty in recalling recent events
● May need to rely on maps or other people for
directions
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
● Subtle changes in personality, for example,
decreased empathy, decreased inhibition,
restlessness, increased extraversion or introversion
● Has difficulty remembering correct words and names
● The cognitive decline does not interfere with the
independence of the individual with relation to
everyday activities
Diagnostic Criteria
● Evidence of modest cognitive decline from a previous
level of performance in one or more cognitive
domains
● The cognitive deficits do not interfere with capacity for
independence in everyday activities
● The cognitive deficits do not occur exclusively in the
context of a delirium
● The cognitive deficits are not better explained by
another mental disorder
Note:
● NCDs and NdDs differ in age of onset (older persons
and children, respectively)
● It is important to educate the caregivers, especially in
children with Neurodevelopmental Disorders, in order
for structured environment, consistency, and setting
limits, and other Nursing Interventions to be
maintained and practiced
● Confusion and disorientation cause hostility, anger,
etc. It is not intentional that these patients want to
harm.
● Those with intellectual disabilities have an IQ of 70
and below
● Intellectual disabilities was known as mental
retardation and Major NCD as dementia
Schizophrenia Spectrum and Psychotic disorders 
Behavioral Focus:
● Projective​ - defense mechanism; patient’s own
unacceptable attributes are projected to someone
else
● Delusional ​– fixed beliefs not amenable to change
despite conflicting evidence
● Hallucinating ​– perception-like experience that occur
without external stimulus
● Suspicious/Paranoid ​– intense anxious or fearful
feelings and thoughts often related to persecution,
threat, or conspiracy
5 Domains of Psychotic Disorders
● Delusions ​- fixed beliefs not amenable to change in
light of conflicting evidence
 ○ Types:
1. Persecutory - one is to be harmed,
harassed
2. On reference - certain gestures,
comments, environmental cues, etc. are
directed at oneself
3. Bizarre - phenomenon regarded as
physically impossible
4. Delusional Jealousy - one’s sexual
partner is unfaithful
5. Erotomanic - person of higher status is
in love with the individual
6. Grandiose - inflated worth, power,
knowledge
7. Of Being Controlled - person is not in
control of own actions
8. Somatic - pertains to appearance or
functioning of one’s body
9. Thought Broadcasting - thoughts are
being broadcasted and can be
perceived by others
10. Thought Insertion - certain of one’s
thoughts are not one’s own
● Hallucinations ​- perception-like experience that
occur without external stimulus
○ Types:
1. Visual Hallucinations
2. Auditory Hallucinations
● Command- ​instruct a
patient to act in specific
ways
● Commentary
3. Tactile Hallucinations
4. Olfactory Hallucinations
○ Must occur in context of clear conscience
○ Learn whether patient follows what
hallucinations instruct them to do
● Disorganized Thinking (Speech)
○ Patients tend to switch from one topic to
another (derailment or loose associations)
○ Answer questions that may be obliquely
related or completely unrelated (tangential)
○ Rarely, resembles receptive aphasia in its
linguistic disorganization (incoherence or
word salad)
● Grossly Disorganized or Abnormal Motor  ■ Hallucinations (critical
Behavior  voices)
○ Can lead to difficulty in performing ADLs
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
○ Catatonic behavior - decrease in reactivity to
the environment
■ Resistance to instructions (negativism)
■ Maintaining rigid/bizarre posture, to a
complete lack of verbal and motor
responses (mutism, stupor)
■ Can include purposeless and excessive
motor activity w/o obvious cause
(catatonic excitement)
● Negative Symptoms ​- prominent in schizophrenia;
less prominent in other psychotic disorders
○ Diminished emotional expression - flat affect,
face, eye contact, speech intonation
(prosody), hand gestures, head and facial
movement
○ Avolition - decrease in motivated
self-initiated purposeful activities
○ Alogia - diminished speech output
○ Anhedonia - decreased ability to experience
pleasure
○ Asociality - apparent lack of interest in social
interactions
 
Psychotic Disorders
1. Schizophrenia
● Diagnosis I
○ At least 2 of the ff for a significant
time during a 1 month period
■ Delusions
■ Hallucinations
■ Disorganized speech
(frequent derailment or
incoherence)
■ Grossly disorganized/
catatonic behavior
■ Negative symptom
○ 1 month period of psychosis
○ Symptoms persist for at least 6
months
■ Psychotic features emerge
typically between late
teens and the mid-30s
● Diagnosis II
○ Positive symptoms are excesses in
behavior:
 ■ Delusions: unrealistic
beliefs
■ Disorganized speech,
inability to maintain
conversation
■ disorganized/ catatonic
behavior can be bizarre
○ Negative symptoms are deficits in
behavior (reduced functions):
■ Reduced emotional
expression
■ Lacks motivation/energy
■ Loss of enjoyment in
activities (social
interaction)
■ Negative symptoms tend
to be the most persistent
○ Common delusions:
■ Grandeur, Persecution,
Reference, Somatic,
Control
○ 4 A’s
■ Inappropriate Affect
■ Loosening of Associations
■ Autistic thoughts
■ Ambivalence
2. Brief Psychotic Disorder
● 1-30 days
● Often in response to a very stressful event
(e.g. death of loved one)
● No mood disorder
● No negative symptoms
● Presence of at least one of the ff:
○ Delusions
○ Hallucinations
○ Disorganized speech
○ Grossly disorganized or catatonic
behavior
3. Schizophreniform
● At least 2 of the ff during 1 month period:
○ Delusions
○ Hallucinations
○ disorganized / catatonic behavior
○ Negative symptoms
○ Symptoms similar to Schizophrenia
but less duration
UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019
● 1-6 months
4. Schizoaffective Disorder
● Symptoms of both schizophrenia and a
mood disorder
○ Uninterrupted period of illness
where there is a major mood
episode (major depressive/manic)
concurrent with Schizophrenic
symptoms, alternating
■ Delusions or hallucinations
for at least 2 weeks in the
absence of major mood
episode (depressive or
manic) during the lifetime
duration of illness
■ Major mood symptoms are
mostly present
● Types:
○ Bipolar
○ Depressive
5. Delusional Disorder
● Delusion only
● Long lasting, held strongly
● Specifiers
○ Erotomanic
○ Grandiose
○ Jealous
○ Persecutory
○ Somatic
○ Mixed
○ Unspecified
6. Psychotic Disorder ​Due to Another Medical Condition
● Prominent hallucinations or delusions
● Direct pathophysiological consequence of
another medical condition
○ Not better explained by another
mental disorder
○ Not occurring exclusively during the
course of a delirium
○ Specify with delusions or
hallucinations
NURSING MANAGEMENT 
1. Establish trust and rapport.
- This is important in order for the patient to
share details with you. It is because patients
with Psychosis can have hallucinations
ordering them to do a specific action.
2. Maximize level of functioning.
3. Ensure safety and minimize environment stimulation.
4. Deal with hallucinations by presenting reality.
5. Use distraction techniques/ diversional activities
- Listening to music
- Art Therapy
- Exercise
- Counting objects
6. Promote compliance and monitor drug therapy.
7. Encourage family involvement.
8. Collaborate with the healthcare team in resolving
medical conditions (Psychotic disorder due to another
medical condition)

UPCN Batch 2019 N109.2 Batch 1 AY 2018-2019