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PSYCHOLOGICAL THEORIES
FREUD’S PSYCHOANALYSIS
Personality
Id
Ego
Superego
Psychosexual Stages of Development
Oral (0-18 mos)
Anal (18mos.-3yrs)
Phallic (3-6yrs.)
Latency (6-12yrs)
Genital (12-
Defense Mechanisms
Defense Mechanisms- techniques used by the ego to keep threatening and unacceptable material out of
consciousness therefore reducing anxiety. Defense mechanisms are workings of the unconscious mind.
A number of phenomena are used to aid in the maintenance of repression. These are termed Ego Defense
Mechanisms (the terms “Mental Mechanisms” and “Defense Mechanisms” are essentially synonymous
with this). The primary functions of these mechanisms are:
1. to minimize anxiety
2. to protect the ego
3. to maintain repression
Denial Unconscious to admit an A man who has had a heart attack refuses to acknowledge illness and
unacceptable behavior or idea to follow prescribed therapy.
Displacement Discharging pent-up feelings to a A man who is angry at his boss comes home and yells at his wife.
less threatening object.
Dissociation Unconscious separation of painful A rape victim tells that she felt as if she were outside of her body
feelings from an unacceptable idea, watching what was happening.
situation, or object.
Some dissociation is helpful in
keeping one portion of one's life
from interfering with another (e.g.,
not bringing problems home from
the office). However, dissociation is
responsible for some symptoms of
mental illness; it occurs in "hysteria"
(certain somatoform and dissociative
disorders) and schizophrenia, The
dissociation of hysteria involves a
large segment of the consciousness
while that in schizophrenia is of
numerous small portions. The
apparent splitting of affect from
content often noted in schizophrenia
is usually spoken of as dissociation
of affect, though isolation might be a
better term.
Fantasy Gratifying frustrated desires by A man who fails to get a part in the play, imagines himself chosen
imaginary achievements. for the lead role.
Identification Imitating the behavior of someone A teenager dresses like that of her idolized movie star.
feared or respected.
Intellectualization Using only logical explanations A wife tells her husband that a dented car is better than a wrecked
without feeling or an affective car.
component.
Introjection Unconsciously incorporating other A young girl scolds her brother just like her mother would.
people’s norms and values as if they
were your own.
Projection Blaming someone else for one’s A husband forgets to pay the bill and blames his wife for not
difficulties. reminding him.
Rationalization Justification of behavior though A student fails an exam and says that the teacher did not clarify the
faulty logic. material sufficiently.
Reaction formation Acting oppositely to what the person A woman who dislikes her sister sends her gifts every holiday.
truly feels.
Regression Return to an earlier, more A 6 year old begins to wet his pants following the birth of his baby
comfortable level of functioning. sister.
Repression Involuntary and unconscious A accident victim becomes amnesic about the details of the accident,
forgetting of painful ideas, feelings but was aware at that time.
and events.
Restitution Attempting to restore unconscious A nurse who regrets not caring for her mother when she was dying
guilt feelings. because of anger chooses to work with terminal patients.
Sublimation Channeling instinctual drives into A man with excessive sexual drives becomes a successful nude
acceptable activities. painter.
Substitution Replacement of unacceptable objects A woman who wants to marry a man exactly like her dead father
or need with one that is more marries someone who looks a little bit like him.
acceptable.
Suppression Conscious exclusion of anxiety A woman says she is not ready to talk about her condition.
producing feelings or ideas from
awareness.
Symbolization An external object is made to A young woman gives flowers and chocolates to his girlfriend.
symbolize an internal feeling or idea.
Undoing Doing something to counteract or A mother spanks her child and brings home a gift for him the next
relieve guilt feelings. day.
THERAPEUTIC COMMUNICATION
Giving broad openings Clarifies that the lead is to be Where would you like to begin?
taken by the client What are you thinking about?
What would you like to discuss?
Offering general leads Using neutral expressions to Go on.
encourage the client to continue And then.
talking. Tell me about it.
Placing the events in Asking for relationships among What lead up to…?
time or sequence events. What happened before?
When did this happen?
Making observations Commenting on what is seen or You seem restless.
heard to encourage discussion of I noticed you’re biting of lips.
feelings and thoughts. Helpful You appear tense when you…
with withdrawn patients.
Encouraging Asking for client’s views of their What is happening to you right now?
descriptions of situation. What does the voice seem to be saying?
perceptions
Voicing doubt Expressing uncertainty about the That doesn’t sound like it.
reality of client’s perceptions Isn’t that unusual?
and conclusions, used when the
nurse wants to explore other
explanations.
Presenting reality Offering a view of what is real I know the voices are real to you, but I
and not, without arguing with don’t hear them.
the client. You are not in heaven, you are in the
hospital.
Encouraging Asking for similarities and Has this ever happened to you before?
comparison differences among feelings, Is this the way u felt when..?
behavior and events.
Restating Repeating the main idea Pt: I can’t sleep. I stay awake all night.
expressed Nurse: You have difficulty sleeping?
Testing Implies that the nurse feels that Do you know what this drug is for?
the patient needs help.
Defending Gives the impression that the Dr. Santos is a very good doctor.
client has no right to express The hospital staff is very competent to take
own opinions and feelings. care of you.
Minimizing feelings This technique fails to explore Patient: I wish I were dead.
the feelings of the patient. Nurse: Everyone gets down once in a while.
Making stereotypical Blocks off the communication It’s for your own good.
comments process since the patient is
encouraged to have empty
responses.
Changing the subject Fails to address the message of Let’s discuss that later.
the patient. The nurse maybe Let’s leave that and talk about…
threatened by an anxiety
provoking topic thus the
perceived need to change the
subject.
ERICKSON’S PSYCHOSOCIALTHEORY
Life stage Adult behaviors reflecting mastery Adult behaviors reflecting developmental problems
Trust vs. mistrust • Realistic trust of self and others • Suspiciousness/testing others
(0-18 mos.) • Confidence in others • Fear of criticism and affection
• Optimism and hope • Dissatisfaction and hostility
• Shares openly with others • Projection of blame and feelings
• Relates to others effectively • Withdrawal from others
Or
• Overly trusting of others
• Naïve and gullible
• Shares too quickly and easily
Autonomy vs. • Self control and willpower • Self doubt/self conscious
Shame and doubt • Realistic self concept and self- • Dependence on others for approval
(18 mos.- 3 yrs.) esteem • Feeling of being exposed/ attacked
• Pride and a sense of goodwill • Sense of being out of control of the self and one’s life
• Simple cooperativeness • Obsessive compulsive behaviors
• Generosity tempered by withholding Or
• Delayed gratification when • Excessive independence or defiance, grandiosity
necessary • Denial of problems
• Unwillingness to ask for help
• Impulsiveness
• Recklessness regarding safety for self and others
Initiative vs. Guilt • An adequate conscience • Excessive guilt/embarrassment
(3-5 yrs) • Initiative balance with restraint • Passivity and apathy
• Appropriate social behaviors • Avoidance of activities/pleasures
• Curiosity and exploration • Rumination and self pity
• Healthy competitiveness • Assuming a role as victim/self-punishment
• Sense of direction • Reluctance to show emotions
• Original and purposeful activities • Underachievement of potentials
Or
• Lack of follow-up on plans
• Little sense of guilt for actions
• Excessive expressions of emotion
• Labile emotions
• Excessive competitiveness/showing off
Industry vs. • Sense of competence • Feeling of unworthiness and inadequacy
inferiority (6-12 • Completion of projects • Poor work history (quitting, being fired, lack of
yrs.) • Pleasure in efforts and effectiveness promotions, absenteeism, lack of productivity)
• Ability to cooperate and • Inadequate problem solving skills
compromise • Manipulation of others/ violation of others’ rights
• Identification with admired others • Lack of friends of the same sex
• Joy of involvement in the world and Or
with others • Overly high achieving/ perfectionists
• Balance of work and play • Reluctance to try new things for fear of failing
• Feeling unable to gain love of affection unless totally
successful
• Being a workaholic
Identity vs. role • Confident of self • Feelings of confusion, indecision and alienation
confusion (12-18 • Emotionally stable • Vacillation between dependence or independence
yrs) • Commitment to career planning and • Superficial, short-term relationships with another person
realistic long-term goals Or
• Sense of having a place in society • Dramatic overconfidence
• Establishing an intimate relationship • Acting out behaviors (including alcohol and drug abuse)
• Fidelity to friends • Flamboyant display of sex role behaviors
• Development of personal values
• Testing out adults
Intimacy vs. • Ability to give and receive love • Persistent aloneness/isolation
isolation (18-25 or • Commitment and mutuality with • Emotional distance in all relationships
30 years) others • Prejudices against others
• Collaboration in work and affiliation • Lack of established vocation; many career changes
• Sacrificing for others • Seeking of intimacy through casual sexual encounters
• Responsible sexual behaviors Or
• Possessiveness and jealousy
• Dependency on parents and/or partner
• Abusiveness towards loved ones
• Inability to try new things socially or vocationally
(staying in routine/ mundane job/activities
Generativity vs. • Productive, constructive, creative • Self-centeredness/ self-indulgence
stagnation (30-65 activity • Exaggerated concern for appearance and possessions
years) • Personal and professional growth • Lack of interest in the welfare of others
• Parental and societal responsibilities • Lack of civic or professional activities/responsibilities
• Loss of interest in marriage and/or extramarital affairs
Or
• Too many professional or community activities to the
detriment of the family or self
Integrity vs. despair • Feelings of self-acceptance • Sense of helplessness, hopelessness, worthlessness,
(65 yrs. to death) • Sense of dignity, worth, and uselessness, and/or meaninglessness
importance • Withdrawal and loneliness
• Adaptation to life according to • Regression
limitations • Focusing on past mistakes, failures and dissatisfactions
• Valuing one’s life • Feeling too old to start over
• Sharing of wisdom • Suicidal ideas or apathy
• Exploration of philosophy of life • Inability to occupy self with satisfying activities (hobbies,
and death volunteer work, social events)
Or
• Inability to reduce activities
• Overtaxing strength and abilities
• Feeling indispensable
• Denial of death as inevitable
1. A mentally healthy person is free from internal conflicts. He is not at war with himself.
2. He is well adjusted. He is able to get along well with others. He is able to form effective
relationships. He is able to accept criticisms and is not upset easily.
3. He searches for an identity.
4. He has a strong sense of self-esteem.
5. He knows himself, his needs, problems and goals (self-actualization).
6. He has good control over his behavior.
7. He is productive.
8. He faces problems and tries to solve them intelligently.
1. When a person’s behavior is causing distress and suffering to the individual and/or others around
him
2. Abnormal changes in one’s thinking, feeling, memory, perceptions and judgment, resulting in
changes in talk and behavior.
3. Abnormal behavior causes disturbance in the person’s day-to-day activities, job and interpersonal
relationships.
Neurosis Psychosis
Frequently talks about his symptoms • Denies that there is something wrong with
Does not lose contact with reality him
Personality is intact • Loses contact with reality
• Personality is often disorganized and
Continue to function socially and at work deteriorates.
Hospitalization is usually not required • Cannot act normally in society and may
harm self and others.
• Often requires hospitalization
PREVENTION OF MENTAL ILLNESS
PRIMARY PREVENTION- involves the promotion of general mental health and protection against the
occurrence of specific diseases. Primary prevention aims to prevent the onset of a disease or a disorder,
thereby reducing the incidence (number of of new cases occurring in a specific period in time).
• Elimination of etiological agents
• Reducing risk factors
• Enhancing host resistance or interfering with disease transmission
• Reducing stress factors
• Counseling
o Student’s counseling
o Marriage counseling
o Sex counseling
o Genetic counseling
• Special centers
o Child guidance centers
o Crisis intervention center
o Geriatric center
• Mental health education
SECONDARY PREVENTION- early identification and effective treatment of an illness or disorder, with
the goal of reducing the prevalence (total number of existing cases in a year) is the aim of secondary
prevention.
• Population screening
• Crisis intervention services
• Mental health education
TERTIARY PREVENTION- aims to reduce the prevalence of residual defect or disability due to illness
or disorder. It involves rehabilitation after defect and disability have been fixed. Community reintegration
is also part of tertiary prevention.
CRISIS
• Refers to the state of the reacting individual who finds himself in a hazardous situation in which
the habitual problem solving activities are not adequate and do not lead to rapidly to the
previously achieved balance state.
CRISIS INTERVENTION- means of entering into the life situation of an individual, family or group to
alleviate the impact of a crisis including stress in order to help mobilize the resources of those directly
affected, as well as those who are in the significant “social orbit.”
CONCEPT OF LOSS
STAGES OF GRIEF
• Shock and disbelief
• Developing awareness
• Restitution and resolution of the loss
Nursing interventions:
Focus on parents
Assist parent to deal with their feelings
Encourage parents’ participation in child’s care
Nursing interventions
• Utilize play for expressing thoughts and feelings
• Explain what is death that it is final and not sleep
• Permit a choice of attending the funeral
Approaches:
• Accept regressive or protest behavior
• Encourage verbalization of feelings
• Adolescent (12-16)
• Mature understanding of death
• May have strong emotions about death, silent, withdrawn, angry
• Worry about physical changes
Approaches:
• Support maturational crisis
• Encourage verbalization of feelings
• Respect need for privacy and personal expression for anger , sadness or fear.
• Adult
• Death is disruption of the life cycle
• Death is viewed on terms of its effect on significant others.
• Older adult
• Emphasis is on religious beliefs for comfort. A time of reflection, rest and peace
SCHIZOPHRENIA
A group of mental disorders that feature withdrawal, affective problems and interrupted thought processes.
Subtypes:
Paranoid Type
• Dominant: hallucinations and delusions
• No disorganized speech, disorganized behavior, catatonia, or inappropriate affect present.
• Preoccupied with 1 or more systematized delusions or with frequent auditory hallucinations
related to a single theme.
Disorganized type
• Dominant: disorganized speech and disorganized behavior and inappropriate affect.
• Delusions and hallucinations, if present, are not prominent or fragmented.
• Associated features including grimacing, mannerisms and other oddities of behavior.
• Incoherence
• Looseness of associations
• Grossly disorganized behavior
• Flat or grossly inappropriate affect
Catatonic
• Motor immobility (waxy flexibility or stupor)
• Excessive purposeless motor activity (agitation)
• Extreme negativism or mutism
• Peculiar voluntary movements
o Posturing
o Stereotyped movements
o Prominent mannerisms
o Prominent grimaces
• Echolalia and echopraxia
Residual
o No longer has active phase symptoms (e.g. delusions, hallucinations, or disorganized speech and
behaviors)
o However, persistence of some symptoms is noted, e.g.
o Marked social isolation or withdrawal
o Marked impairment in role function (wage earner, student or home maker)
o Markedly eccentric behavior or odd beliefs
o Marked impairment in personal hygiene
o Marked lack of initiative, interest , or energy
o Blunted or inappropriate affect
Undifferentiated type
o Has active phase symptoms (does have hallucinations, delusions, and bizarre behaviors).
Prominent delusions, hallucinations, incoherence or grossly disorganized behavior.
o No clinical presentation dominates e.g.
o Paranoid
o Disorganized
o catatonic
TYPES OF DELUSIONS
1. Persecutory- suspicious of people and believes that others are trying to harm him, trying to kill
and poison him.
2. Grandiosity- suddenly the person starts to harbour a false belief that he is extraordinarily
powerful, wealthy and a very important person. He believes that he can achieve anything and
everything, and feels that all the world is under him.
3. Jealousy or infidelity- false belief that his spouse is unfaithful and is having extramarital affairs.
4. Control ( Passivity Phenomenon)- false belief that his thoughts , actions and feelings are all not
his own but are being controlled by some external agencies.
5. Nihilistic- false belief that the world is going to end or his body parts are missing.
6. Ideas of reference- the person has false idea that people around him talk about him and make fun
of him.
Pathoanatomy:
Hyperdopaminergic process
No structural changes
NEGATIVE SYMPTOMS
Alogia (poverty of speech)
Affective flattening
Anhedonia (lack of pleasure)
Attentional impairment
Avolition (poor motivation)
Asocial behavior
Anergia (lack of energy)
Pathoanatomy:
Nondopaminergic process
Structural changes
Increased ventricular brain ratio
Decreased cerebral blood flow
SCHIZOPHRENIC PROGNOSIS
Good Poor
Later Onset Younger Onset
Obvious precipitating factors No precipitating factors
Acute Onset Insiduous Onset
Good premorbid social, sexual and work Premorbid social and sexual and work
history history
Affective symptoms (esp. depression) Withdrawn, autistic behavior
Paranoid or catatonic features
Undifferentiated or disorganized features
Married Single, divorced or widowed
Family history of mood disorders Family history of schizophrenia
Good support systems Poor support systems
Undulating course Chronic course
Positive symptoms Negative symptoms
Neurological signs and symptoms
History of perinatal trauma
No remission in 3 years
Many relapses
Etiology:
BIOLOGICAL
Biochemical theories
Dopamine hypothesis
Excessive dopaminergic activity in cortical areas are responsible for the acute positive symptoms of
schizophrenia. This maybe due to increase in the synthesis of dopamine, increase release or turnover of
dopamine, or increase in number of dopamine receptors
NEUROSTRUCTURAL THEORIES
Negative symptoms are due to pathoanatomy: increased ventricular brain ratio, brain atrophy, and
decreased cerebral blood flow
GENETIC THEORIES
PSYCHODYNAMIC THEORIES
DEVELOPMENTAL THEORY
Freudian
Poor ego boundaries
Fragile ego
Inadequate ego development
Love-hate relationships
Arrested psychosexual development
Erikson and Sullivan
Absence of warm, nurturing attention during the early childhood years
Blocks the expression of those same affective responses during the later years
Disordered social interactions, avoid social interaction due to painful childhood experiences
FAMILY THEORIES
Lack of loving and nurturing primary caregiver
Inconsistent family behaviors
Faulty communication patterns
WITHDRAWN PATIENTS
Arrange nonthreatening activities that involve these patients in “doing something”.
Arrange furniture in a semicircle or around a table so that patients are forced to sit with someone.
Interactions are permitted in this situation, but should not be demanded. Sit in silence with patients
who are not ready to respond. Some will move the chair away despite the nurses’ efforts
Help patients to participate in decision making as appropriate.
Provide patients with opportunities for non-threatening socialization with the nurse on a one-to-one basis.
Reinforce appropriate grooming and hygiene (assist first if needed)
Provide remotivation and resocialization group experiences. Often students work with occupational or
recreational therapists to provide these experiences.
Provide psychosocial rehabilitation.
SUSPICIOUS PATIENTS
Be matter-of-fact when interacting with these patients.
Staff members should not laugh or whisper around patients unless the patients can hear what is said. The
nurse should clarify any misconceptions that patients have.
Do not touch suspicious patients without warning. Avoid close physical contact.
Patients who fear being poisoned should be allowed to open a can of food and serve themselves.
Obviously, this maybe difficult top arrange in some hospital settings.
Maintain eye contact.
Do not “slip” medications into juices or food without talking to patients. Catching the nurse in the act of
doing this will reinforce their suspicious.
DISORGANIZED PATIENTS
Remove disorganized patients to a less stimulating environment.
Provide a calm environment; the staff should appear calm.
Provide safe and relatively simple activities for these patients.
Provide information boards with schedules and refer to them often so patients can begin to use this as an
orienting function
Help protect each patient’s self esteem by intervening if a patient does something that is embarrassing.
Assist with grooming and hygiene.
HYPERACTIVITY
Allow patients to stand for a few minutes during group meetings.
Provide a safe environment and a place where patients can pace without inordinately bothering other
patients
Encourage participation in activities or games that do not require fine motor skills or intense concentration.
IMMOBILITY
Provide nursing care for catatonic or immobile patients in order to minimize
circulatory problems and loss of muscle tone.
Provide adequate diet, exercise, and rest.
Maintain bowel and bladder function, and intervene before problems arise.
Observe patients to prevent victimization (verbal or physical) by others.
DELUSIONAL DISORDER
SCHIZOPHRENIFORM
Typical signs of schizophrenia and at least one month but no longer that six months.
SCHIZOAFFECTIVE
Schizophrenic symptoms are dominant but are accompanied by major depressive or manic symptoms
MOOD DISORDERS
MAJOR DEPRESSION
Chronic Fatigue
Psychomotor retardation or pronounced reduced mental and physical activity
Psychomotor agitation or pronounced agitated mental and physical activity
Sleep disturbances
Disturbance in appetite
GI complaints
Impaired libido
Apathy
Sadness
Hopelessness
Helplessness/ ruminations of inadequacy
Thoughts of Death
Spontaneous crying without apparent cause
Dependency
Passiveness
Anhedonia
Lack of interest in self care
Deep sense or feeling of sadness
Anxiety
Unconscious anger or hostility directed inward
Guilt feelings
Indecisiveness
Lack of self-confidence
Alterations in activity
Psychomotor agitation
Unable to sit still
Pacing and engaging in hand wringing
Pulling or rubbing the hair, skin, clothing or other objects
Psychomotor retardation
Slowing of speech
Decreased frequency of speech
Increased pauses before answering
Soft or monotonous speech (dysprosody)
Muteness
General slowing of body movements
Change in sleeping patterns
Change in eating behaviors
Negligence of personal hygiene
Altered socialization
Easily distracted
Underachievement leading to lack of productivity on the job
Withdrawn
Subjective Signs:
Alterations in affect
Overall affective sense is one of low self-esteem
Guilt
Alterations in cognition
Ambivalence and indecision
Inability to concentrate
Confusion
Loss of interest and motivation
Pessimism, self blame, self depreciation
Self destructive thoughts and thoughts of death and dying
Alterations of a physical nature
Complaints of abdominal pain, anorexia, chest pain, dizziness, fatigue, headache
Preoccupation with the body
(+) panic attacks
Alterations of perceptions
(+) delusions (somatic and nihilistic)
(+) hallucinations
Etiology:
Biological theories
Due to a chemical imbalance or deficiency of certain neurotransmitters in the brain. These
neurotransmitters are norepinephrine, serotonin and dopamine
Psychodynamic Theories
Debilitating Early life experiences
Intrapsychic conflict
Reactions to life events
WITHDRAWN PATIENTS
Keep brief but frequent contacts.
Include these patients in group activities
ANOREXIC PATIENTS
Encourage to eat and spoon feed them if necessary
Allow patients to choose their food
Provide small frequent feedings and record intake.
Monitor and record bowel elimination. Since constipation is a side effect of anti-depressant, include high
fiber foods in the patient’s diet.
Allow patients to eat food from their home if he prefers it.
Suicide clusters
Mild intent- reflects action of the person who has thought of suicide and maybe trying to solve a problem
situation through suicide threat or gesture.
Has intense need for attention and recognition
Done to manipulate or blackmail another
Moderate intent
Serious to end life but ambivalent
Lethal intent
Fully expected to die
Method and timing are meant to be fatal
Physiological changes
Disturbance in sleep pattern
Fatigue
Anorexia with accompanying weight loss
Constipation or diarrhea
Shift in mood during the day
Somatic complaints
Psychomotor retardation
Agitation and restlessness
Behavioral
Loss of motivation
Lack of interest
Social withdrawal
Flat, sad affect
Decreased interest in sex
Suicidal talks and acts
Gives away personal things
Mental changes
Negative self concept
Negative expectations of the future
Impaired concentration
Exaggerated view of problems
Suicidal ideations and thoughts of death
Care strategies
Be available to the patients, have someone to stay with them. Provide structure and assistance
Take the patient seriously
Provide one-one supervision
Restrict to the ward
Supervise eating, toileting, smoking, sleeping
Make rounds at irregular times
Assess and evaluate for changes
Help patient to evaluate strengths and other ways to cope such as seeking interpersonal support or other
anxiety reducing activities
Provide a safe environment in which the patient is protected and cared for until the impulses are controlled
Maintain a safe unit
Remove potentially harmful objects and supervise use of razors, mirrors, pointed objects, lotions, drugs,
chemicals…
Use seclusion but ensure that patient is within sight and seconds away
Encourage the patient to verbalize feelings and plans
Obtain a “NO SUICIDE” contract
BIPOLAR DISORDERS
Psychomotor overexcitability or excitement
Insomnia with fatigue
Euphoria or elated mood
Distractability
Pressured speech
Flight of ideas
Manipulative or demanding behavior
Destructive or combative behavior
Delusions of grandeur
Impaired judgment
Objective behaviors
Disturbances of speech
Altered Social, interpersonal and occupational relationships
Manipulation of self esteem of others
Ability to find vulnerability in others
Ability to shift responsibility
Limit testing
Alienation of family
Alteration in activity and appearance
Hyperactive and agitated
Pacing
Flamboyant gestures
Colorful dresses
Lack of sleep and poor nutrition
Subjective behaviors:
Alterations in affect
Alterations of perception
Etiology:
Psychodynamic theories
Family dynamics
Mania as a defense
Biological theories
Imbalance between cholinergic and noradrenergic systems. Depression-increased cholinergic
activities; mania- increased noradrenergic activity.
Psychotherapeutic management:
Safety
Clear, concise directions and comments
Limit setting
Reinforcement of reality
Provide a homogenous group , if possible
MANIPULATIVE PATIENT
Manipulation refers to a coping strategy that a person employs to get one’s needs met without regard for
others
To cope with unmet needs for trust, security and control
Typical behaviors
Assuming instant intimacy
Using flattery
Claiming Entitlement
Splitting
Categorizes providers as ‘good’ or ‘bad’ based on whether the staff has done what the patient wants
Ignites power struggles
Care strategies
Limit setting
Establish boundaries
Put restrictions on problematic behaviors
Communicate constantly
Introduce shift nurses to illustrate shift-shift teamwork
Acknowledge grievances without defensiveness
Use clear, direct, specific approach when setting limits
Enforce limits consistently
Use clear, direct, specific approach when setting limits
Enforce limits consistently
Let the patient know that you are available and won’t abandon them
Firm kindness approach
Behavioral cues
Verbal- raising voice, shouting, speaking profanities, threatens, suspicious, makes demands.
Non-verbal- excessive psychomotor activity, pacing about, fist clenching, intensified facial expression,
threatening stances, violent gestures
Care strategies
Check for any history of violence
Observe current behavior
Observe physical distance in approaching the patient
Ensure space on both sides
Assume an oblique position instead of direct approach
Avoid aggressive posture
Utilize active listening
Utilize restraints or limit setting
Assess patients need for seclusion or physical restraints
Indications:
Prevent imminent harm to the patient or other person
Prevent serious disruption of the treatment program or serious damage to the physical environment
To provide control to psychotic symptoms that are severe and causing serious psychological pain
Decrease stimulation a patient receives.
Care strategies:
Initial action and objective is to talk down the patient and guide away from the extraneous stimulus
Give prn medication if ordered and set a contract
Form a four-man restraining team
Choose a restraint leader and designate the role of each member of the team
Present to the patient a “show of force” by gathering sufficient personnel.
Designate a seclusion marshal who would clear the are of other patients and any physical obstruction
State clearly the purpose and rationale of the procedure
Ensure correct team positioning
Ensure that when restraining the patient, care must be observed to avoid injury by holding on the patient’s
joints
Assume an oblique position in approaching the patient
Approach the patient calmly and promptly
Use proper body mechanics and maintain physical contact at all times. Use cross chest carry while other
members hold the extremities
Restrain the patient on 4 extremities using a double knot type, with a fingerbreadth allowance so as not to
impede blood circulation. Ensure proper body position is maintained
Isolate the patient with the head away from the door
Give tranquilizers or sedatives prescribed by the physician
Debrief family with regards to restraining and isolation. Ensure that the patient’s need for elimination, food
intake, comfort and safety are met
Assess if the patient’s behavior is under control and no longer possess a threat to self or others
SEXUAL DISORDERS
SEXUAL DYSFUNCTION
• Characterized by the inhibition of sexual appetite or psychophysiological changes that
compromise the sexual response cycle
Types:
• Sexual desire disorder
Have little or have no sexual desire or an aversion to sexual contact
• Sexual arousal disorders
Cannot attain the physiologic requirements for sexual intercourse
e.g.
Women-lubrication
Men- erection
• Orgasm disorder
Inability to achieve orgasm
• Sexual pain disorder
Suffer genital pain (dyspareunia) before, during and after intercourse
Vaginismus
PARAPHILIAS
• Sexual instinct is expressed in ways that are socially prohibited or unacceptable and are
biologically undesirable.
Types:
1. Pedophilia- victim: <13 y/o; pedophile: >_ 16 y/o or at least 5 years older
2. Incest
3. Exhibotionism
4. Fetishism- inanimate objects
5. Frotteurism- rubbing one’s genitals against an unconsenting individuals thighs or buttocks
6. Sexual masochism
a. hypoxyphilia-strangulation/oxygen deprivation
7. Sexual sadism
8. Voyeurism
ANXIETY-
ANXIETY- feeling of apprehension due to anticipation of danger
2 causes:
Threats of psychological integrity or well being
i.e. guilt, threats to self esteem, love and belongingness
Threats to physical integrity
i.e. illness, unmet needs, safety.
Selye’s GAS
Stages:
Alarm-
Alarm- adrenaline is released when threat is recognized
Resistance-
Resistance- fight or flight
Exhaustion-
Exhaustion- relaxation or death
Levels of Anxiety
Mild
Perception is more alert than usual
Moderate
Narrowed perception
Difficulty focusing
Selective inattention
Mild physical complaints such as stomachache
Severe
Very narrowed perception
Unable to focus on problem solving
Increased physical discomfort
Panic
Unable to see the whole situation or reality
Distortion of perception
Level Effects upon the ability to observe Effects upon the ability on what is
happening
Mild Person is alerted, sees, hears, and grasps Increased awareness and alertness
more than previously Attention is possible
• Level, that can motivate leaning Skill in seeing relations can be used.
and can produce growth and creativity
in the individual.
• Associated with the tension of
everyday life.
Moderate Person’s perceptual field is narrowed. Selected inattention, i.e. individuals fails to
Sees, hears, grasps less but can attend to notice what goes on in situations peripheral
more if asked to do so. to the immediate focus but can notice if
attention is pointed there by another
observer.
Severe Perceptual filed is greatly reduced. Dissociating tendencies operate to panic i.e.
HEARING IS NOT POSSIBLE the person does not notice what goes on in a
He tends to focus on a specific detail and situation ( specifically communication with
all his behavior aimed at getting relief. reference to the self). And there is inability
to do so even when attention is pointed to
this direction by another observer.
Panic Involves disorganization of the Person becomes immobilized (emotional
personality. paralysis)
Loss of control Increase motor activity
Unable to do things even with direction Decrease ability to relate to others.
Distorted perceptions
Loss of rational thought
ANXIETY DISORDERS
PHOBIC DISORDERS
Irrational, excessive fear of a condition or object
Degree of fear expressed is obviously unusual and out of proportion to the attending circumstances
e.g.
Claustrophobia (close space)
Agoraphobia (open space)
Acrophobia(heights)
Hydrophobia (water)
Xenophobia (strangers)
Arachnophobia (spiders)
Zoophobia (animals)
Allurophobia (cats)
Chromophobia (colors)
Mysophobia (dirt)
Bacillophobia (germs)
Etiology
Psychoanalytic view
Individual experiences severe diffused anxiety which is only incompletely resolved by repression and so
there is displacement of the anxiety to an external focus which the individual then tries to avoid
Definition:
Obsession- persistent thought that wont go away thru logical effort
Compulsion- uncontrollable impulse to repeatedly perform an act
Etiology:
Genetic predisposition
Decreased serotonin
Symptoms:
Ritualistic behavior
Constant doubting if he\she has performed the activity
Nursing Care:
Allow the patient to perform the ritual to decrease the anxiety and energy level
Provide structured activities to decrease the ritual to a degree that is comfortable to the patient
Note: The individual recognizes the unreasonableness and absurdity of the obsessions and compulsions but
is unable to control it.
Management:
Psychotherapy
Group therapy
Anxiolytics
Nursing Care:
Be nonjudgmental and honest; offer empathy and support; acknowledge any unfairness or injustices to the
trauma
Assure patient that what they are feeling are typical reactions to serious trauma
Help patient to recognize the connections between the trauma experience and their current feelings,
behaviors and problems.
Help patients to evaluate past behaviors in the context of the trauma, not in the context of current values
and standards
Encourage safe verbalizations of feelings, especially anger.
Encourage adaptive coping strategies and techniques
Encourage patients to establish or reestablish relationships
Symptoms:
Excessive worry and anxiety
Difficulty in controlling the worry
Anxiety and worry are evident in:
Restlessness
Fatigue and irritability
Decreased ability to concentrate
Muscle tension
Disturbed sleep
Nursing Care:
Provide a calm and quiet environment
Ask the patient to identify what and how they feel to increase awareness of what is happening to them
Encourage to describe and discuss their feelings with you to increase awareness of the connection between
feelings and behaviors
Help patients to identify possible causes of their feelings
Listen carefully for patients’ expressions of helplessness and hopelessness; assess for suicidality
Plan and involve patients in activities such as going for walks and playing recreational games
Discuss with patients their present and previous coping mechanisms
Discuss with patients the meaning of problems and conflicts to appraise stressors, explore their personal
values, and define the scope and seriousness of their problems
Use supportive confrontation and teaching.
Assist patients with exploring alternative solutions and behaviors
Encourage patients to test new adaptive coping behaviors through role playing or implementation.
Teach patients relaxation exercises
Promote use of hobbies and recreational activities.
SOMATOFORM DISORDERS
Have physical symptoms with no known organic or physiological cause
Defense mechanisms used
Repression
Denial
Displacement
HYPOCHONDRIASIS
Thought disorder
Characterized by persistent, severe, morbid preoccupation with one’s physical and emotional health and
accompanied by various somatic complaints without demonstrated organic cause
Individual is aware and exaggerates the intensity and importance of sensations that most others
disregard.
Characteristics:
No pathology
Doctor shopping
Symptoms are under unconscious control
CONVERSION DISORDER
Repression
Conversion
Characteristics:
Physical disability without pathology
Motor
Paralysis
paresthesia
Sensory
Hysterical Blindness
Mutism/deafness
Labelle indifference-
indifference- indifference with his/her condition
Treatment:
Psychotherapy
Hypnosis
Management:
Acknowledge complaints
Divert attention
Keep the patient busy
Discourage secondary gains
Encourage independence
MENTAL RETARDATION
Below average general intellectual functioning originating during the development period and
associated with impairment in adaptive behavior.
Levels IQ range
Mild Mental retardation 50-69
Moderate Mental retardation 35-49
Severe mental retardation 20-34
Profound mental retardation below 20
Normal Milestones
• 3 months- holding neck erect
• 6 months- sitting with support
• 9 months-1 year- walking
• 11/2 years- speaking few words or phrases
AUTISM
Withdrawal of the child into the self and into a fantasy world of his own creation. Course is chronic.
Symptoms:
• Failure to form interpersonal relationships
• Impairment in communication
• Bizarre responses to the environment
• Extreme fascination for objects that move (e.g. fans, trains)
• Fluctuating mood sudden crying or laughing
• Self mutilating behaviors
Symptoms:
• Easily distracted; not able to sit or do one thing for some time. Disorganized behavior
• Sustaining attention is very difficult. Hence is disruptive and overactive in the classroom.
• The child often has excessive gross motor activity (e.g. excessive running-climbing, difficulty in
sitting for long, restlessness)
CONDUCT DISORDERS
Disorders where the child’s behavor is against social norms and values. The behaviors are repetitive
and persistent. They violate rules. Their conduct is worse than ordinary mischief.
Common Problems:
• Truancy ( not attending school, spending time somewhere else)
• Lying, stealing, substance abuse, breaking things, setting fire, often running away from home,
gambling poor peer group relations, fights with others, thefts outside home.
• Does not accept responsibility and learn from past experiences and go on repeating the same
mischief again and again. They often get caught by the police.
COGNITIVE DISORDERS
DELIRIA
Characterized by a change in cognition and a disturbance of consciousness, which manifests as a reduced
ability to focus, sustain or shift attention. Delirium tends to develop over a short period of time and
tends to fluctuate during the course of the day.
Symptoms:
Reduced awareness of and attentiveness to the environment
Reduced stare of consciousness
Disorganized thinking
Rambling, irrelevant or incoherent speech,
Memory impairment
Disturbances in sleep
Disturbances in psychomotor activity and sensory misperceptions
Disorientation
Nursing Interventions:
Manipulation of the environment to provide familiarity and to decrease the fear of a strange place is also
beneficial
DEMENTIA
Characterized by the development of multiple cognitive deficits manifested by both memory impairment
and at least one of the cognitive disturbances of aphasia, apraxia, agnosia or disturbances in planning.
The course is gradual in onset with an unabated decline. Prognosis is usually poor.
Symptoms:
Cardinal symptoms: problems with orientation, judgement, attention, intellect and memory.
Alterations in memory ( short and long term, alterations in reasoning, language and personality)
Alterations in abstract thinking
Decreased capacity for generalization, differentiation, concept formation, and logical reasoning
Alterations in judgment
Alterations in perceptions
(+) visual and auditory hallucinations
(+) delusions arising out of a reaction to a cognitive deficit
(+) illusions
ALZHEIMER’S DISEASE
Age related, progressive disorder of the CNS, characterized by chronic cognitive dysfunction
Four A’s of Alzheimer’s disease
Amnesia
Agnosia
Aphasia
Apraxia
Delirium Dementia
• Acute onset Insidious onset
• Presence of disorientaion, anxiety, poor Disturbed memory, personality
attention deterioration
• Clouding of consciousness or drowsiness Clear consciousness
• Perceptual abnormalities are common Global impairment of cerebral function
(hallucinations and illusions) Progressive course
• Fluctuating course Mostly irreversible
• Reversible
Nursing Management:
Daily routine
Stress
Safety
Wandering
PERSONALITY DISORDERS
This involves lifelong, inflexible, and dysfunctional patterns of relating and behaving. These dysfunctional
patterns and behaviors usually cause distress to others. However, they do not find their behaviors
distressing to others.
Interventions: Consistency and firmness in confronting behaviors and enforcing rules and policies.
BORDERLINE PERSONALITY DISORDER- DISORDER- maybe due to neglect, over involvement or abusive
family. Defense mechanism: splitting (viewing things as all good or all bad)
Frantic avoidance of abandonment; real or imagined
Unstable and intense interpersonal relationships
Identity disturbances
Impulsivity
Self-mutilating behavior
Rapid mood shifts
Chronic feelings of emptiness
Problems with anger
Transient dissociative and paranoid symptoms
Interventions: Use of empathy. Recognize the reality of the patient’s pain, should offer support and
should empower and work with the patient to understand control and change dysfunctional behaviors.
Provide safe environment.
Interventions: supportive confrontation on what the patient sways and what exists. Limit setting and
consistency to decrease manipulation and entitlement behaviors.
HISTRIONIC PERSONALITY DISORDER- DISORDER- dramatizes all events and draws attention to self
Overly dramatic
Draws attention to self
Extroverted and thrives on being the center of attraction
Uses somatic complaints to avoid responsibility and support dependency
Dissociation
Interventions: Positive reinforcement in the form of attention, recognition or praise are given for
unselfish or other-centered behaviors.
Interventions: increase responsibility for self in day to day living; assertiveness training
CHEMICAL DEPENDENCE
DRUG ABUSE
Reasons for taking drugs:
• Search for euphoria
• Relief from psychological pain of diverse origins
• Wanting to feel better than they do
• To avoid withdrawal symptoms
DEPRESSANTS
ALCOHOL
Physiological effects
Disinhibition, impaired judgment and fuzzy thinking
Sedation and toxicity
Delirium Tremens-
Tremens- CNS irritability; the body not only invents sensory inputs but also has extreme
motor agitation; hallucinations may occur; seizures (grand mal) may also be present.
Nursing issues:
Overdose
Disulfiram (Antabuse)- intake of disulfiram with alcohol creates an ill feeling in the person ( sweating,
flushing of the face and neck, throbbing headache, nausea and vomiting, palpitation, dyspnea, tremors
and weakness
Interactions
Fetal alcohol Syndrome-
Syndrome- microencephaly, cleft palate, altered palmar creases, cardiac defects, anomalous
genitalia, mental retardation, and depressed sucking reflex
Management of alcoholism
• Assessment of the patient
o His drinking pattern
o Work spot
o Family
o Environment
• Physical methods
o Detoxification
o Disulfiram Therapy
• Psychological methods
o Counseling
o Individual and group psychotherapy
o Marital/family therapy
o Behavioral modification (Aversion therapy)
o Relapse prevention therapy
• Rehabilitation
• Alcoholic anonymous
Detoxification
• Administration of minor tranquilizers to control anxiety, insomnia, agitation and tremors
• Assess fluid and electrolyte imbalance
• Reestablish proper nutrition by giving high protein diet (if no liver damage).
• Supplementation- vitamin C to acidify urine to increase excretion of alcohol; B complex for liver
damage.
• Provide calm, safe environment
• Control nausea and vomiting
• Administer anticonvulsant (for seizures or rumfit)
3 element of detoxification:
secure environment
sedation
supplements
BARBITURATES
INHALANTS
STIMULANTS
COCAINE
PhysiologicEffects:
Euphoria
Increased mentalalertness
Increased strength
Anorexia
Increased sexual stimulation
Increased motor activity
Tachycardia
Increased blood pressure
Deeper respirations
Dilated pupils
Nasal septum perforation
AMPHETAMINES
Physiologic Effects:
Wakefulness
Alertness
Heightened concentration, energy
Improved mood to euphoria
Insomnia and amnesia
Amphetamine induced psychosis
HALLUCINOGENS
Natural hallucinogens
Mescaline
Psilocybin
Marijuana
Synthetic Hallucinogens
LSD
PCP
Psychotherapeutic Management:
Help patient understand positive motivators that will help in establishing new goals and direction for his
life
Trusting relationship; firm inimplementing rules
Expressing empathy and providing a safe environment
Group treatment
Assertion training
Lifestyle issues
ersonalresponsibilityConscience
ersonalresponsibilityConscience development
Milieu Management:
Drug free environment
Suicide prevention
Thwarting inappropriate sexual behaviors
Active, meaningful schedules
EATING DISORDERS
ANOREXIA NERVOSA
Symptoms:
Refusal to maintain body weight over a minimum normal weight for age and height
Intense fear of gaining weight or becoming fat, even though underweight
Disturbance in the way in which one’s bodyweight, shape or size is experienced
In females, absence of menses of at least 3 consecutive cycles
Objectives of Care:
Increasing self esteem
Increasing body weight to at least90% of average weight for age and height
Reestablishing good eating behavior
Nursing Interventions:
Monitor daily caloric intake
Observe signs of purging
Monitor activity level
Weigh daily
Provide accurate information on nutrition and discuss realistic and healthy diet
Regularly monitor electrolyte status
Convey warmth and sincerity
Listen empathically
Be honest
Set limits
Assist in identifying at least three positive characteristics
Involve patient in care
Teach patient about their illness
Avoid long silences
Behavior modification: reward increase in weight with meaningful privileges
Identify patient’s non weight related interests to reduce anxiety and refocus attention.
BULIMIA NERVOSA
Symptoms:
Recurrent episodes of binge eating
Feeling of lack of control over eating behaviors during the eating binges
Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self induced
vomiting
Binge eating and inappropriate eating behaviors
Persistent over concern with body shape and weight
Management:
Trust
Help patient identify feelings associated with binge-purge behaviors
Accept patient as worthwhile human beings because they are often ashamed of their behavior
Encourage patient to discuss positive qualities about themselves
Teach about bulimia nervosa
Encourage to explore interpersonal relationships
Encourage patients to adhere to meal and snack schedules
Encourage the patient to approach the staff if she feels like binging or purging
Encourage to attend group sessions
Encourage family therapy
Encourage participation in art, recreation and occupational therapy
Encourage the patient to describe their body image at different ages of their lives.
ABUSE
Definition:
• To take unfair or undue advantage of; to use or treat as to injure, hurt or damage.
• Misuse of power by one to inflict pain and injury to another who is less powerful.
• Abuse may involve omission or commission
• Sexuality abusive behavior- refers to some act as fondling of the genital area, oral-genital contact
or penetration of a bodily orifice.
• No consent of the victim.
General considerations:
• No population or socioeconomic group is immune to neglect or abuse.
• The less powerful a person is- the less likely she is to acknowledge abuse openly or seek
assistance of others.
• Lack of power or control over their own lives leads to distrust.
• Nurse should be comfortable with abuse and victimization behavior before they can become
therapeutic.
Categories of abuse:
• Spouse
• Rape
• Child physical abuse and neglect
• Child sexual abuse