o Example: music therapy,
INTRODUCTION:
Study of Behaviors
➢ Your actions—the way you talk,
the way you move, emotions, etc.
➢ 2 Types of Actions:
o Verbal Behavior
o Non-verbal Behavior
*Noted: ALL Behavior have meaning – be
OBSERVANT/ AWARE!
*Noted: ALL NURSES should have Clinical
Eye
➢ In term of psychiatric nursing,
“Observant of the behavior”— due
to paranoia (always looking for
your own SAFETY and the client’s
safety! (NCLEX EXAM).
➢ Nurses should learn the
Therapeutic Communication.
Psychotherapeutic Management:
➢ Reading, singing, dancing,
watching a movie.. anything
activity events.
PSYCHIATRIC NURSING
Psychiatric Mental Health Nursing
Psychiatric Nursing
➢ Is an interpersonal process that
promotes and maintains behaviors
that contribute to integrated
functioning the patient maybe an
individual, family, group,
organization or community.
➢ Is a specialized area of nursing
practice, employing the wide
range of explanatory theories of
human behavior as it’s science
and purposeful use of self as it’s
art.
o Is also as a science and
art—aspect of therapists’
doing.
counseling, yoga.. etc.
➢ Psychiatric Nursing began to
emerge as a profession on the late
19th century and by the 20th
century it had evolved into a
specialty with unique roles and
functions.
LINDA RICHARDS
➢ Is the first American’s psychiatric
nurse. Graduated 1873 from New
England Hospital for women and
children in Boston.
HILDEGARDE PEPLAU
➢ Is the Mother of Psychiatric
Nursing.
➢ Interpersonal Theory
➢ Identified 4 Levels of Anxiety
1. Mild
2. Moderate
3. Severe
4. Panic
➢ Identified the different roles of the
nurse.
Mentally ill
➢ Was no better than wild animals
“Ship of Fools” – where boat leads
of mentally disordered cast out to
sea to find their “right minds”.
➢ Mentally ill were thought to be
immune to normal biologic
stressors such as heat, cold, and
hunger → Barbaric.
➢ Patients were placed on display for
amusement of the paying public.
5 PERIODS OR DECADES OF PSYCHIATRIC
NURSING HISTORY:
1. Period of Enlightenment
o Asylum (means safety or
protection).
2. Period of Scientific Study
1
 o Classification of mental
illness; Bleuler → coined
the word
“SCHIZOPHRENIA”
(psychosis).
o 3 Classification of Mental
Illness:
i. Psychosis
ii. Depression
iii. Manic disorder
3. Period of Psychotropic Drugs
o Antidepressant
o Antipsychotic
o Antimanic
4. Period of Community Mental
Health
o Deinstitutionalization
(meaning bringing out from
the institution and
bringing in the community).
5. Decade of the Brain
o Brain research, brings
psychiatric nursing in the
mainstream of psychiatric
care.
Schizophrenia → cancer of mental illness.
Mental illness is contagious? YES!
Behavioral symptoms→ assess in nursing
plan.
Boracay Ward → term for “habitually
naked or pavilion eleven”.
Collaborative Team:
1. Psychiatrist
2. Nurses
3. Occupational therapist
4. Physical therapist
5. Nutritionist
6. Social Worker, etc.
THEORETICAL FRAMEWORK’S
INFLUENCING THE DEVELOPMENT OF
PSYCHIATRIC NURSING THEORY
SIGMUND FREUD
➢ Psychoanalytic Theory
➢ Human Behavior – “id, ego, super
ego”
➢ Early stages of sexual
development.
➢ Used of maladaptive defense
mechanism.
HARRY STACK SULLIVAN
➢ Interpersonal Theory (Originated
before Peplau)
➢ Humans as Social Beings
➢ Development interpersonal
relationship.
B.F. SKINNER
➢ Behavior Theory
➢ Nurses recognized that
interventions can be used to bring
about changes in thoughts,
feelings and observed behavior.
o ADPIRE
ERIC ERIKSON
➢ Development Theory
➢ Nurses recognized that personality
development begins at birth and
continues across the lifespan.
o Behavior can be learn
o Growth lifespan
According to Freud
➢ You can develop and can still
change the behavior at 6 years old.
But, after 6 years old is difficult to
change the behavior.
NURSING PROCESS
➢ Is a 6 STEP problem solving
approach to nursing that also
serves as an organizational
2
 framework for the practice of
nursing: ADOPIE
1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Assessment (focused, comprehensive and
screened).
➢ Most common → Comprehensive
– means complete.
Collection of Data:
• Appearance – physical
characteristics
• Affect or Emotional State –
observable manifestation of one’s
emotion or feelings.
Types of Affective Process:
1. Blunted
o Severe reduction or
limitations in responses to
a certain situations.
o Example: limited/ delayed
laughed – Slow.
2. Flat → absence or near absence of
affective response.
o Did not understand
o Very observable patient.
3. Inappropriate
o Lack of harmony between
verbal and non-verbal.
4. Labile
o Abnormal fluctuation or
variability of one’s
expression.
o Bipolar/ manic disorder.
5. Restricted or Constricted
o A reduction in one’s
expressive range ang
intensity of effective
response.
o Similar to blunted.
6. Behavior, Attitude and Coping
Patterns
o Strange, threatening,
suicidal, self-injuries,
violent, aggressive
behaviors.
7. Unusual mannerism or motor
activity
o Tremors
o Psychomotor retardation
(slow action)
o Agitation
8. Friendly, embarrassed, evasive,
resentful, negativistic
9. Overreactive or Underactive
behavior
FOCUS on Nonverbal Behavior.
Coping → are used when you are stress,
anxious, and can get strength coping from
family or friends in a positive way.
Affect—meaning feelings.
Most common affect – flat affect.
Festive situation – means “happy”
First Role of a Nurse → “stranger” –
meaning you are stranger to a patient
(distance, wall)
Aggression → is a severe anger.
*Note: If your patient is a threat, violent
and aggressive—maintain a certain
distance.
➢ SAFETY.
COMMUNICATION AND SOCIAL SKILLS
Impaired Communication Skills:
1. Blocking
o Sudden stoppage in the
spontaneous flow or
stream of thinking or
speaking.
3
 ▪ Not quite ready to
open-up—patient
needs time to think
and expressed
feelings/thoughts.
▪ RESPECT the
silence.
2. Circumstantiality
o Unnecessary details that
delays stating a point.
o Example: patient stating a
lengthy story not related to
the topic.
3. Tangentiality
o Responds to a question
that is appropriate to a
general question but does
not specifically answer the
question.
o Example: limited similarity
but not answering the
question directly --- almost
the same as
circumstantiality.
4. Clang association
o Rhyming of words
o Example: rap music sound
like.
5. Echolalia
o Parrotlike repetition of
words or phrases.
o Example: Nurse said, what
is your name. Then patient
answered, what is your
name?—repeating the
word but not the entire
sentence.
6. Flight of ideas
o Over productivity of talk
and verbal skipping from
one idea to another.
o Example: conversation
changed of topic but still
connected to the topic.
7. Looseness of association
o Fragmented thoughts, no
relationship between
sentences.
o Example: topic is not
connected
8. Mutism
o Refusal to speak.
o Quite person.
o In nursing intervention—
used a WRITING Method to
communicate (using a
marker and a white board).
o NOT ALLOWED— sharp
pointed objects such as
pen, fork or knifes.
9. Neologism
o Coining of words or words
invented by the client.
o Example: Brusca means
nurse
o Clarify Brusca? Wearing
white means nurses—
“meeting by the nurse and
clients in terms of
understanding”.
10. Perseveration
o Repetitive verbal or motor
response to various stimuli.
o Example: there is a
repetitive words.
11. Verbigeration
o Meaningless repetition of
specific words.
o Example: there is shout or
clapping in every
conversation.
12. Word Salad
o Mixture of words and
phrases that has no
meaning.
THOUGHT CONTENT:
➢ Delusions → meaning “fixed, false
belief”.
4
Types of Delusions:
1. Ideas of Reference
o “Silent beliefs while
watching TV Patrol, thinks
he was being talk”.
2. Delusions of Alien
o The client believe that the
alien is talking to him.
3. Nihilistic Delusion
o The client believe that he is
already dead.
4. Delusion of Poverty
o The client believe he is
poor. He believe that
everyone in the room is
poor.
5. Delusion of Grandiosity
o The client believe that his
father is the President of
the Philippines.
6. Somatic Delusion
o The client believe he is sick.
o Somatic means sickness.
*Note: You cannot negate with the client.
Otherwise, the patient is going to be
angry.
➢ What is the nursing priority?
CORRECT interpretation with
PRESENT REALITY.
Hallucination → false sensory perception:
1. Auditory
2. Visual
3. Olfactory
4. Tactile
5. Gustatory
Command Hallucination
➢ False perception of orders that a
person may feel obligated to obey
or unable to resist.
Illusion
➢ Misperception of a real external
stimuli.
➢ Example: he thinks that the wire is
a snake.
Visual Hallucination—the client see’s
something that we could not see.
Tactile Hallucination— the client believe
that he was being poisoned.
Delusion of Alien control—similar to
command hallucination.
Hallucination—has NO STIMULI. Example:
he may see plenty of butterflies in the
room.
Depersonalization
➢ Feeling of unreality or strangeness
concerning self.
➢ A mental state in which a person
feels detached or disconnected
from his or her personal identity or
self. This may include the sense
that one is "outside" oneself, or is
observing one's own actions,
thoughts or body.
Obsessions
➢ Insistent thoughts arising from the
self (through thoughts).
Compulsions
➢ Insistent, repetitive, intrusive and
unwanted urges to perform an act
(through action).
Orientation
➢ Place, person and time.
➢ Always check status in MSE
(mental status examination).
o Appropriate answer should
always be valid/ correct.
o Orientation of time:
morning, lunch, dinner, or
evening.
5
Anxiety Disorder
➢ Under of OCD (obsessive- Nightmare Disorder
compulsive disorder). ➢ Repeated awakenings from major
sleep due to extremely frightening
Memory dreams.
➢ Ability to recall past experiences. ➢ Can cause from psychiatric
unresolved problems and can lead
Hyper amnesia to sleep terror disorder.
➢ Abnormally pronounces memory.
➢ Example: dementia; most recent Restless Legs Syndrome
event. ➢ Insomnia associated with crawling
sensation frequently associated
Amnesia with arthritis.
➢ Loss of memory.
Sleep Apnea
Para amnesia ➢ Breathing related sleep disorder
➢ Falsification of memory. due to disrupted ventilation or
airway obstruction—FATAL!
Intellectual Ability
➢ Person’s ability to use facts Sleep Terror Disorder
comprehensively. ➢ Recurrent abrupt awakening
Insight to Illness accompanied by panicky scream,
➢ Self-understanding to illness intense fear and tachycardia.
➢ Example: he knows he is sick
➢ Poor insight of illness—patient
stated, “ they put me in a rehab CHAPTER 1: MENTAL HEALTH
because I’m drinking a lot”.
FOUNDATIONS OF PSYCHIATRIC MENTAL
Spirituality HEALTH NURSING
➢ Client beliefs, values and religious ➢ WHO definition—state of
culture. complete physical, mental, and
➢ Example: transcultural; Muslim social wellness, not merely
don’t eat pork. absence of disease or infirmity.
➢ State of emotional, psychological,
Sleep Patterns and social wellness evidenced by:
➢ Common sleep disorders. 1. Satisfying interpersonal
relationships
Insomnia 2. Effective behavior and
➢ Difficulty initiality or maintaining coping
sleep. 3. A positive self-concept →
“convert negative person
Jet Lag to a positive person”.
➢ Sleepiness after repeated travel. 4. Emotional stability →
especially when it comes to
Narcolepsy death situation—must
➢ Irresistible attack of sleepiness or practice/ control your
sleep paralysis. emotions.

6

Factors Influencing a Person’s Mental
Health:
1. Individual Factors
o Biologic makeup,
autonomy and
independence, self-esteem
capacity for growth,
vitality, ability to find
meaning in life, emotional
resilience or hardiness, a
sense of belonging
(Abraham Maslow), reality
orientation, and coping or
stress management
abilities.
2. Interpersonal Factors
o Effective communication
ability to help others,
intimacy, and a balance of
separateness and
connectedness.
3. Social/ Cultural Factors
o A sense of community,
access to adequate
resources, intolerance of
violence, support of
diversity among people,
mastery of the
environment
(active/attentive), and a
positive yet realistic, view
of one’s world.
Mental Illness
➢ Historically viewed as possession
by demons (wild animals),
punishment for religious or social
transgressions, weakness of will or
spirit, and violation of social
norms.
➢ Today seen as medical problem,
although some stigma from
previous beliefs remains.
Mental Disorder
➢ Is a “clinically significant
behavioral or psychological
syndrome or pattern” that occurs
in an individual and that is
associated with distress or
disability or with a significantly
increased risk of suffering.
Student Concerns:
1. Saying the wrong thing
2. What student will be doing
3. Fear of no one talking to student
4. Bizarre or inappropriate behavior
5. Physical safety
6. Seeing someone known to the
student
*Note: NEVER use WHY? Make it
Therapeutic Question using WHAT.
➢ Using WHY can mislead to
mistrusting issues.
Self-awareness Issues
➢ Everyone values, beliefs, ideas;
nurses need to know what theirs
are not to change them, but to
prevent unknown or undue
influence on their nursing practice.
➢ “you cannot give what you don’t
have”
Hints to Increase Self-awareness:
1. Keep a journal
2. Talk to trusted coworkers
3. Examine points of view other than
one’s own.
CHAPTER 2: NEUROLOGIC THEORIES AND
PSYCHOPHARMACOLOGY
NEUROBIOLOGIC THEORIES
➢ Great strides are being made in
understanding the brain and
mental illness, but much is still
unknown; nurses need to keep
7
 abreast of developments to
promote effective teaching.
SCHIZOPHRENIA
➢ Is NOT CURABLE; but is treatable.
➢ Recovery can be made after 20
years; still psychosis remains.
➢ NOTE: when you stop taking the
medication—you will restart again
from the beginning to correct the
dosage and prevent drug tolerance
to treat correctly.
“Delusion of Grandiosity”
➢ You can talk anything under the
sun—there is no measure of
intelligence. But rather knowledge
from what you learn.
Individualized approach to manifest and
deal the patient central nervous system
consist of:
1. Brain
o Cerebrum
o Cerebellum
o Brain stem
o Limbic system
2. Spinal cord
3. Nerves that control voluntary acts.
Cerebrum
➢ Divided into 2 hemisphere’s with 4
lobes each:
1. Frontal lobe – thought, body
movement, memories, emotions,
moral behaviors.
2. Parietal lobes—taste, touch,
spatial orientation
3. Temporal lobes—smell, hearing,
memory, emotional expressions
(types of affective process)
4. Occipital lobe – language, visual
interpretation.
Cerebellum
➢ Receives and integrates
information from all body areas to
coordinate movement and
posture.
Neurotransmitters
➢ Chemical substances
manufactured in the neuron to aid
in transmission of information.
➢ Most common serotonin and
dopamine.
Neurotransmitters include:
❖ Dopamine – control of complex
movements, motivation, cognition,
regulation of emotional responses.
❖ Norepinephrine – attention,
learning, memory, sleep,
wakefulness, mood regulation.
❖ Epinephrine – (flight-or-flight
response)
❖ Serotonin – food intake, sleep,
wakefulness, temperature
regulation, pain control, sexual
behaviors, regulation of emotions.
❖ Histamine – alertness, control of
gastric secretion, cardiac
stimulation, peripheral allergic
reactiveness.
❖ Acetylcholine – sleep and
wakefulness cycle, signal muscles
to become alert (muscle jerking/
muscle twitching).
❖ Glutamate – excitatory, results in
neurotoxicity effects.
❖ GABA – modulates
neurotransmitters (inhibitory) –
example, induced sleep.
Depressed → can either be overweight/
underweight; or over-eating/ under-
eating.
Brain Imaging Techniques Include:
❖ Computer Tomography (CT)
❖ MRI
❖ PET
❖ SPECT (Single Photon Emission
Computed Tomography)
8
Causes of Mental Illness: ANTIPSYCHOTIC DRUGS
1. Genetic and Heredity (NEUROLEPTIC DRUGS)
o Play a role but alone do not ❖ Conventional
account for development ❖ Atypical
of mental illness. ❖ New generation
2. Psychoimmunology
o A compromised immune Uses: Schizophrenia, acute mania,
system could contribute, psychotic depression, drug-induced
especially in at-risk psychosis, other psychotic symptoms
populations (example: dementia with psychosis).
o Example: HIV/AIDS
3. Infectious, particularly viruses, ACTIONS: treatment of psychotic
may play a role symptoms, such as delusions and
o #1 symptom: FEVER → hallucinations.
convulsion →
Hallucinations (as a result Conventional Antipsychotic Drugs
of a high grade fever). ❖ Phenothiazines (Throrazines,
Proloxin, Mellaril, Stelazine)
❖ Navane
>> PSYCHOPHARMACOLOGY << ❖ Haldol
❖ Lexitane
Psychopharmacology and medication ❖ Moban
management are important in the
treatment of many mental illnesses. Side Effects:
➢ “A good research is about the o Extrapyramidal side effects (EPSs)
good effect in the intervention” – o Pseudo parkinsonism
example: 1 nurse with 50 patient’s o Dystonia
doesn’t have an effect in o Akathisia
psychiatric nursing. o Anticholinergic effects
o Tardive dyskinesia (TD)
Principles that guide the use of o Neuroleptic Malignant syndrome
medications include: (MNS)→ FEVER – major FATAL
1. Effect on target symptom symptom!
2. Adequate dosage for sufficient
time Patient Teaching:
3. Lowest dose needed for o Adhering to medication
maintenance o Managing side effects:
4. Lower doses for the elderly ▪ Excessive thirst
5. Tapering rather than abrupt ▪ Constipation
cessation to avoid rebound or ▪ Sedation
withdrawal.
6. Follow-up care Atypical Antipsychotic Drugs
7. Simplify the regimen for increased ❖ Clorazil
compliance. ❖ Rispedal
o TID antipsychotic drugs and ❖ Zyprexa
28 days one single shot. ❖ Seroquel

9
 ❖ Geodon
Side Effects:
o Fewer EPSs
o Weight gain – due to increased
sugar level
o Agranulocytosis (Clorazil) –
increased WBC
Patient Teaching:
o Adhering to medication regimen
o Reducing sugar and caloric intake
o Clorazil
▪ Weekly WBC monitoring
▪ Discontinue medication
and seek care at first sign
of infection.
New Generation Antipsychotic Drugs
❖ Aripiprazole (Abilify)
Side Effects:
❖ Headache, anxiety, nausea
Patient Teaching:
• Adhering to medication regimen
Antidepressant Drugs
❖ SSRIs
❖ TCAs
❖ MAOIs
Uses:
o Major depression
o Panic disorder and other anxiety
disorder
o Bipolar depression
o Psychotic depression
ACTION: interact with monoamine
neurotransmitter systems in the brain,
particularly the neurotransmitters
norepinephrine and serotonin.
SSRIs Antidepressant Drugs
❖ Fluoxetine (Prozac)
❖ Paroxetine (Paxil)
❖ Sertraline (Zoloft)
❖ Citalopram (Celexa)
❖ Escitalopram (Lexapro)
Side Effects:
o Anxiety
o Agitation
o Akathisia
o Nausea
o Insomnia
o Sexual dysfunction (anorgasmia/
impotence)
Patient Teaching:
o Take in the morning.
o Take with food
o Propranolol given for akathisia.
TCAs Antidepressant Drugs
❖ Imipramine (Tofranil)
❖ Desipramine (Elavil)
❖ Doxepin (Sine Quan)
❖ Clomipramine (Anafranil)
Side effect:
o Anticholinergic (blurred vision,
urinary retention, dry mouth,
constipation)
o Orthostatic hypotension
o Sedation
o Weight gain
o Tachycardia
o Sexual dysfunction
Patient teaching:
o Take in the evening
o Using caution in driving
MAOIs Antidepressant Drugs
❖ Phenelzine (Nardil)
❖ Tranylcypromine (Parnate)
❖ Isocarboxazid (Marplan)
Side effects:
o Sedation
o Insomnia
10
 o Weight gain o OCD
o Dry mouth o Depression
o Orthostatic hypotension o PTSD
o Sexual dysfunction o Alcohol withdrawal
o Hypertensive crisis with excessive
tyramine or sympathomimetic Side effects:
drugs. o Tolerance and dependence
o Drowsiness
Patient Teaching: o Sedation
o Following tyramine free diet (avoid o Poor concentration
aged cheeses, aged meats, beer o Impaired memory
and wine, sauerkraut, soy) o Clouded sensorium
o Avoiding sympathomimetic drugs
o Using caution when driving Patient Teaching:
o Using caution during driving due to
MOOD Stabilizing Drugs slower reflexes and responses
❖ Lithium time.
❖ Anticonvulsant medications – o Never discontinuing abruptly as
Carbamazepine (Tegretol), withdrawal can be FATAL.
Valproic Acid (Depakote), o Avoid Alcohol.
Lamotrigine (Lamictal),
Gabapentin STIMULANT Drugs
❖ Methylphenidate (Ritalin)
Side effect (Lithium): ❖ Pemoline (Cylert)
o Nausea ❖ Dextroamphetamine
o Diarrhea
o Anorexia Uses: ADD, ADHD, etc
o Fine hand tremor
o Polydipsia Patient Teaching:
o Polyuria ❖ AVOID (caffeine, sugar, chocolate)
o Fatigue ❖ Take after meals
o Weight gain ❖ Long-term use can cause
o Acne dependency

Patient Teaching: DISULFIRAM (Antabuse)

o Take with food Uses: Aversion therapy for treatment of
o Having monthly blood levels alcoholism
drawn every 12 hours after last
dose. ACTION: causes an adverse reaction when
alcohol is ingested.
Anti-anxiety Drugs
❖ Benzodiazepines Side effect:
❖ Buspirone (Buspar) o Fatigue
o Drowsiness
Uses: o Halitosis
o Anxiety disorder o Tremor
o Insomnia o Impotence

11
Patient teaching:
o Avoiding alcohol (including
products such as shaving cream,
after shave, cologne, many OTC
medication)
o Family should never administer
without a person’s knowledge.
Cultural Considerations:
• Ethnic backgrounds influence
responses to some psychotropic
medications
• African Americans responds more
rapidly to antipsychotic and TCAs
medication than do whites and
have greater risk of side effects.
• Asians metabolize antipsychotic
and TCAs more slowly, required
using lower doses to produce the
same effects.
• Hispanic required lower doses of
antidepressant than white people
to achieve.
•
Chapter 3
Psychosocial Theories and Therapy
Psychoanalytic Theories
Pioneered by Sigmund Freud
(1856–1939) in Vienna
Psychoanalytic Theories
 All human behavior is caused and
can be explained
 Personality components
conceptualized as id, ego, and
superego
 Ego defense mechanisms
 Psychosexual stages of
development
 Transference and
countertransference
Psychoanalysis focuses on discovering the
causes of the client’s unconscious and
repressed thoughts, feelings, and conflicts
believed to cause anxiety and helping the
client to gain insight into and resolve
these conflicts and anxieties.
Psychoanalysis is lengthy, expensive, and
practiced on a limited basis today;
however, Freud’s defense mechanisms
remain current.
Developmental Theories
Erik Erikson (1902–1994)
Described eight stages of
psychosocial development
Trust vs. Mistrust….
Interpersonal Theories
Harry Stack Sullivan (1892–1949)
 Established five life stages of
personality development that
included the significance of
interpersonal relationships
 Believed that unsatisfying
relationships were the basis for all
emotional problems
 Described the concept of
therapeutic milieu or community
Hildegard Peplau (1909–1999)
 Leading nursing theorist and
clinician: developed the nurse–
patient relationship with phases
and tasks
 Identified roles of the nurse:
stranger, resource person,
teacher, leader, surrogate,
counselor
12
  Described four levels of anxiety
(mild, moderate, severe, panic)
still widely used today
Humanistic Theories
Abraham Maslow (1921–1970)
 Hierarchy of needs: basic
physiologic needs, safety and
security needs, love and belonging
needs, esteem needs, self-
actualization
Carl Rogers (1902–1987)
 Client-centered therapy
 Concepts of unconditional positive
regard, genuineness, and
empathetic understanding
Behavioral Theories
Ivan Pavlov (1849–1936)
B. F. Skinner (1904–1990)
 Behaviorism focuses on behaviors
and behavior changes rather than
on explaining how the mind works
 All behavior is learned
 Behavior has consequences
(reward or punishment)
 Rewarded behavior tends to recur
 Positive reinforcement increases
the frequency of behavior
 Removal of negative reinforcers
increases the frequency of
behavior
 Continuous reinforcement is the
fastest way to increase behavior;
random intermittent
reinforcement increases behavior
more slowly but with longer-
lasting effect
 Treatment modalities based on
behaviorism include behavior
modification, token economy, and
systematic desensitization
Existential Theories
 Cognitive therapy focuses on
immediate thought processing and
is used by most existential
therapists
Albert Ellis
 Rational emotive therapy: people
make themselves unhappy
through “irrational beliefs and
automatic thinking”—the basis for
the technique of changing or
stopping thoughts
Viktor Frankl
 Logotherapy: life must have
meaning and therapy is the search
for that meaning
William Glasser
 Reality therapy focuses on the
person’s behavior and how that
behavior keeps the person from
achieving life goals
Existential theorists believe that
deviations occur when the person is out
of touch with self or environment; thus,
the goal of therapy is to return the person
to an authentic sense of self.
Treatment Modalities
Community (outpatient) mental health
treatment
 The client can often continue to
work and can stay connected with
family, friends, and other support
systems while participating in
therapy
13
  Personality or behavior patterns  Self-help groups
gradually develop over the course
Group Therapy
of a lifetime and cannot be
changed in a relatively short  Stages of group development
inpatient course of treatment
 Pregroup stage
Hospital (inpatient) treatment
 Initial stage
 Severely depressed and suicidal
 Working stage
 Severely psychotic
 Termination stage
 Experiencing alcohol or drug
 Group leadership
withdrawal
 Therapy groups and
 Exhibiting behaviors that require
education groups: formal
close supervision in a safe,
leader
supportive environment
 Support groups and self-
Individual psychotherapy
help groups: no formal
 A method of bringing about leader
change in a person by exploring his
Effective group leaders focus on group
or her feelings, attitudes, thinking,
process as well as group content
and behavior
 Group roles
 It involves a one-to-one
relationship between the therapist  Growth-producing roles:
and the client information-seeker,
opinion-seeker,
 The therapist’s theoretical beliefs
information-giver,
strongly influence his or her style
energizer, coordinator,
of therapy
harmonizer, encourager,
 Group therapy involves a therapist and elaborator
or leader and a group of clients
 Growth-inhibiting roles:
sharing a common purpose;
monopolizer, aggressor,
members contribute to the group
dominator, critic,
and expect to benefit from it.
recognition-seeker, and
Types of groups include: passive follower
 Psychotherapy groups The therapeutic results of group therapy
(Yalom, 1995) include the following:
 Family therapy
 Gaining new information or
 Family education
learning
 Education groups
 Gaining inspiration or hope
 Support groups
 Interacting with others

14
  Feeling acceptance and belonging Chapter 4
Treatment Settings and Rehabilitation
 Becoming aware that one is not
Programs
alone and that others share the
same problems Inpatient Hospital Treatment
 Gaining insight into one’s In the 1990s, managed care
problems and behaviors and how shortened hospital stays; people were
they affect others sicker when admitted and were
discharged sooner, rendering milieu
Giving of oneself for the benefit of others
therapy and “talk” therapy ineffective.
(altruism
Provide rapid assessment, stabilization,
 Psychiatric Rehabilitation
and discharge planning
Involves providing services to clients with
A client-centered, multidisciplinary
persistent and severe mental illness in the
approach
community
Clinicians help clients recognize symptoms
May involve medication management,
and identify coping skills
transportation, shopping, food
preparation, hygiene, finances, social As the client is safe and stable, the
support, vocational referral clinicians and the client identify long-term
issues for the client to pursue in
 Psychosocial Interventions
outpatient therapy.
Psychosocial interventions are nursing
• Scheduled intermittent hospital
activities that enhance the client’s social
stays
and psychological functioning and
promote social skills, interpersonal • Long-stay patients
relationships, and communication.
• Case management
These interventions are used in mental
• Discharge planning
health and other practice areas.
Long-Stay Patients
Self-Awareness Issues
Clients with severe and persistent mental
 No one theory or treatment
illness may still require acute care despite
approach is effective for all clients.
the current emphasis on decreased
 Using a variety of psychosocial hospital stays.
approaches increases nurse
Case Management
effectiveness.
Liaison between the client and community
 The client’s feelings and
resources, home care, and third-party
perceptions are most influential in
payers
determining his or her response.

15
Discharge Planning
Effective discharge planning is crucial. The
better the discharge plan is, the longer
the client remains in the community.
Impediments to effective discharge
planning include:
• Alcohol and drug abuse
• Criminal or violent behavior
• Noncompliance with medications
• Suicidal ideation
Successful discharge planning occurs
when:
• Inpatient staff communicate with
outpatient clinicians prior to
discharge
• Clients are able to start or visit the
outpatient program prior to
discharge
• Family members are involved in
the client’s care during
hospitalization
• Social services, day treatment, and
housing programs are geared
toward survival in the community,
compliance with treatment
recommendations, rehabilitation,
and independent living
Partial Hospitalization Programs
Designed to help clients make a
successful, gradual transition to
independent community living by:
• Focusing on stabilizing psychiatric
symptoms
• Monitoring drug effectiveness
• Stabilizing living environment
• Improving activities of daily living
• Learning to structure time
• Developing social skills
• Obtaining meaningful work
• Providing follow-up for health
concerns
Residential Settings
Vary according to the level of
supervision, structure, and services
provided as well as the intent of the
services. Types of residential services
include:
• Board and care homes
• Adult foster homes
• Halfway houses
• Group homes
• Supervised apartment living
Rehabilitation Programs
Clubhouse Model offers:
• A place to come to
• Meaningful work
• Meaningful relationships
• A place to return to (lifetime
membership)
Members are given opportunities
to participate in the work of maintaining
the clubhouse, leisure activities, and
employment and housing opportunities
and are encouraged to use local
psychiatric services.
Assertive Community Treatment (ACT)
One of the most successful types
of community-based treatment, ACT
offers outreach services (going to the
16
client instead of waiting for the client to
come to the services). ACT programs
involve:
• A problem-solving orientation; no
problem is too small
• Direct provision of service rather
than referral
• Intensity (three or more face-to-
face contacts per week)
• A team approach rather than
having one assigned case manager
• A long-term commitment for as
long as the client needs services
Special Populations
Homeless
When compared with homeless persons
who are not mentally ill, the homeless
mentally ill:
• Spend more time in jail
• Are homeless longer
• Spend more time in shelters
• Have less family contact
• Face greater barriers to
employment
Prisoners
Up to 15% of persons in jail
or prison have severe mental
illness.
Criminalization of mental illness refers to
prosecuting mentally ill offenders, even
for misdemeanors, at a rate four times
that of the general population in an effort
to contain them in some type of
institution.
This practice is fueled by:
• Increasing public concern that
mentally ill persons are violent
• More stringent commitment laws
• Lack of community support
• Deinstitutionalization
Interdisciplinary Team
A multidisciplinary or
interdisciplinary team involves the
collaboration of a variety of disciplines to
provide the most comprehensive,
effective services for clients. Each
member makes a unique contribution:
• Psychiatrist—diagnosis and
prescription of treatment
• Psychologist—therapy, research,
interpretation of psychological
tests
• Interdisciplinary Team
• Psychiatric nurse—holistic view of
client, interventions, evaluate
care/treatment effectiveness
• Psychiatric social worker—working
with families, community support,
referrals
• Occupational therapist—improving
functional abilities through arts
and crafts
• Recreational therapist—
constructive use of leisure or
unstructured time
• Vocational rehabilitation
specialist—pursuit of school or
job, job seeking and retention
skills
17
Psychosocial Nursing
Psychosocial nursing in public
health is concerned with issues such as:
• Stress management education
• Early identification of mental
health problems
• Monitoring and coordinating
psychiatric rehabilitation services
In clinical practice, public health
and home care nurses encounter
substance abuse, domestic violence, child
abuse, grief, depression, and more.
Chapter 5
Therapeutic Relationships
The ability to establish therapeutic
relationships with clients is one of the
most important skills a nurse can develop.
Components include:
• Trust (nurse is friendly, caring,
understanding, consistent; keeps
promises; listens; is honest)
• Genuine interest
• Empathy (not sympathy)
• Acceptance of person, not
necessarily his or her behavior
• Positive regard (unconditional,
nonjudgmental attitude)
Self-Awareness and Therapeutic Use of
Self
Self-awareness is a process of
understanding one’s own values, beliefs,
thoughts, feelings, attitudes, motivations,
strengths, and limitations and how one’s
thoughts and behaviors affect others.
Therapeutic use of self is when the nurse
uses aspects of his or her personality,
experience, values, feelings, intelligence,
needs, coping skills, and perceptions to
establish relationships with clients that
are beneficial to clients.
Self-Awareness and Therapeutic Use of
Self
The Johari window is a self-awareness
tool; categorizes qualities of self as:
• open/public
• blind/unaware
• hidden/private
• unknown
Patterns of Knowing
There are several patterns of
knowing (ways of observing and
understanding client interactions):
• Empirical (from nursing science)
• Personal (from life experiences)
• Ethical (from moral nursing
knowledge)
• Aesthetic (from art of nursing)
• Unknowing is when the nurse
admits he or she does not know
the client or understand the
client’s subjective world
Establishing the Therapeutic Relationship
Therapeutic relationships are focused on
the needs, experiences,
feelings, and ideas of
the client, not the nurse.
18
The therapeutic relationship consists of
three phases.
In the orientation phase, the nurse and
client meet, roles are established, the
purposes and parameters of future
meetings are discussed, expectations are
clarified, and the client’s problems are
identified.
The working phase involves
problem identification, where the client
identifies issues or concerns causing
problems, and exploitation, when the
nurse guides the client to examine his or
her feelings and responses, develop
better coping skills and a more positive
self-image, change behavior, and develop
independence.
In the working phase the nurse must be
acutely aware that two common elements
can arise:
• Transference is when clients
unconsciously transfer feelings
they have for significant persons in
their life onto the nurse
• Countertransference is when the
nurse responds to the client based
on his or her own unconscious
needs and conflicts
The termination or resolution phase
begins when the client’s problems are
resolved and ends when the relationship
is ended. It is important to deal with
feelings of anger or abandonment that
may occur.
Behaviors That Diminish Therapeutic
Relationships
• Inappropriate boundaries
(relationship becomes social or
intimate)
• Feelings of sympathy and
encouraging client dependency
rather than promoting
independence
• Nonacceptance of client as a
person because of his or her
behaviors, leading to avoidance of
the client
Nurse self-awareness is the way to avoid
such problems.
Therapeutic Roles of the Nurse in a
Relationship
• Teacher
• Caregiver
• Advocate
• Parent surrogate
Self-Awareness Issues
Self-awareness on the nurse’s part is
crucial to developing therapeutic
relationships.
Values clarification, journaling, group
discussions, and reading will assist with
this process.
Developing self-awareness is a continual,
ongoing process; the nurse needs to plan
for self-growth.
Chapter 6
Therapeutic Communication
Communication is the process people use
to exchange information:
• Verbal (what is said, or content)
• Nonverbal (behavior such as facial
expression, tone of voice,
hesitancy, distance from speaker,
or process)
19
 • Context (environment or situation,
including culture)
• Congruency (when content and
process agree)
• Incongruency (when content and
process do not agree; nonverbal is
more accurate)
Therapeutic communication involves
interpersonal interactions between the
nurse and the client. It focuses on the
client’s specific needs and is used to:
• Establish the therapeutic
relationship
• Identify the client’s most
important concerns
• Assess the client’s perceptions
Verbal Communication Skills
• Recognize the client’s needs
Use concrete messages
• Guide the client toward
satisfactory and acceptable
solutions
Essential Components of Therapeutic
Communication
• Privacy and respect for boundaries:
therapeutic communication is
most comfortable at 3 to 6 feet;
should not be less than 18 inches
• Touching a client may be
comforting and supportive if it is
permitted and welcome; nurse
must evaluate whether the client
perceives touch as positive or
threatening and unwanted and
should never assume that touching
a client is acceptable
• Active listening (concentrating
exclusively on what client is
saying) can be promoted by:
– Facing the client
– Using moderate eye
contact
– Removing physical
barriers
– Maintaining open
body posture
– Leaning forward
• Active listening means refraining
from other internal mental
activities and concentrating
exclusively on what the client says
• Active observation means
watching the speaker’s nonverbal
actions as he or she communicates
• Concrete messages are specific
and clear; abstract messages are
unclear and vague and require
interpretation
• Concrete messages elicit more
accurate responses and avoid the
need to go back and rephrase
unclear questions, which
interrupts the flow of a
therapeutic interaction
• Therapeutic communication
techniques facilitate interaction
and enhance communication
between client and nurse.
Techniques that encourage the
client to discuss his or her feelings
or concerns in more depth include:
– Exploring
– Focusing
– Restating
20
 – Reflecting • The nurse must first assess his or
her own spiritual beliefs-self
– Interpreting signals or cues
awareness
Cues are verbal or nonverbal messages
• The nurse must remain objective
that signal key words or issues for the
and nonjudgmental regarding the
client. Finding cues is a function of active
client’s beliefs and must not allow
listening.
them to alter nursing care
Nonverbal Communication Skills
• The nurse must assess the client’s
• Facial expression spiritual needs and guard against
imposing his or her own on the
• Body language
client
• Vocal cues
Cultural Considerations
• Eye contact
The nurse must be aware of cultural
• Silence differences in:

Understanding the Meaning of • Speech patterns and habits

Communication
• Styles of speech and expression
• Messages often contain more
• Eye contact
meaning than just the spoken
words • Touch

• The nurse must try to discover all • Concept of time

the meaning in the client’s
• Health and health care
communication, not only the
literal meaning of the words Goals of a Therapeutic Communication
Session
Understanding Context
• Establishing rapport
• Understanding the context of a
situation gives the nurse more • Identifying issues of concern
information and reduces the risk
• Being empathetic, genuine, caring,
of assumptions
and unconditionally accepting of
• To clarify context, the nurse must the person
gather information from verbal
• Understanding the client’s
and nonverbal sources and
perception
validate findings with the client
• Exploring the client’s thoughts and
Understanding Spirituality
feelings
• Spirituality is a client’s belief
• Developing problem-solving skills
about life, health, illness, death,
and one’s relationship to the • Promoting the client’s evaluation
universe of solutions

21
 Beginning Therapeutic
Communication
• Introduction and establishing a
contract (outlines the care being
provided and parameters of the
relationship)
• Finding client-centered goals
(maintains the focus on the client
and provides parameters for
evaluation of effectiveness)
– Using directive or
nondirective role
appropriately, based on
client behaviors
• Phrasing questions appropriately
– Asking for clarification
• Response to drugs
• Self-efficacy (belief that personal
abilities and efforts affect life
events)
• Hardiness (ability to resist illness
when under stress)
• Resilience (healthy response
despite stressful or risky
situations) and resourcefulness
(problem solving and faith in
ability to deal with new or adverse
situations)
• Spirituality (essence of being and
beliefs about purpose/meaning of
life)
Interpersonal Factors

– Managing client’s • Sense of belonging

avoidance of the anxiety-
• Social networks (groups of people
producing topic
one knows and feels connected to)
• Guiding the client in problem-
• Social support (emotional
solving and empowering the client
sustenance from family, friends,
to change
others)
Self-Awareness Issues
• Family support
• Know that nonverbal (93%)
Cultural Factors
communication is as important as
verbal(7%) • Beliefs about causes of illness
• Ask colleagues for feedback • Factors in cultural assessment:
• Examine your communication skills – Communication
Chapter 7 – Physical space or distance
Client’s Response to Illness
– Social organization
Individual Factors
– Time orientation
• Age, stage of growth and
– Environmental control
development
– Biologic variations
• Genetics and biologic factors
• Socioeconomic status and social
• Physical health and health
class
practices

22
Cultural Patterns and Differences
Knowledge of expected cultural
patterns provides a starting place for the
nurse to begin to relate to persons from
different ethnic backgrounds.
Nurse’s Role in Working With Clients
From Various Cultures
Nurse must learn about the client’s
cultural values, beliefs, and health
practices.
Best source of information is the client.
General knowledge about culture can
guide nurse in initial meetings with client
and deciding what questions to ask, but
this general knowledge cannot replace
client assessment.
Self-Awareness Issues
• Maintain a genuine, caring
attitude
• Recognize own feelings and
possible prejudices
• Remember that the client’s
response to illness is complex and
unique
Chapter 8
Assessment
Purposes of Psychosocial Assessment
• To construct picture of client’s
current emotional state, mental
capacity, and behavioral function
• To form basis for
plan of care
• To establish clinical
baseline to evaluate
effectiveness of
treatment and
interventions
Factors Influencing Assessment
• Client participation/feedback
• Client’s health status
• Client’s previous experiences/
misconceptions about health care
• Client’s ability to understand
• Nurse’s attitude and approach
How to Conduct the Interview
• Provide a comfortable, private,
safe environment
• Obtain input from family and
friends (with client’s permission)
• Ask questions that are open-ended
or closed-ended as needed
Content of the Assessment
• History
• General appearance and motor
behavior
• Mood and affect
• Thought process and content
– Assessment of suicide or
harm toward others; if the
client is having suicidal
ideas, then assessment of
lethality should follow
• Sensorium and intellectual
processes
– Orientation, memory,
concentration, ability to
think abstractly
• Sensory-perceptual alterations
• Judgment and insight
• Self-concept
23
 • Roles and relationships
• Physiologic and self-care concerns
Data Analysis
• Data analysis follows assessment
• Nursing diagnoses are formulated
for the nursing care plan
• The assessment data can be
analyzed to form an
interdisciplinary treatment plan or
a plan for home care
Psychological Tests
Psychological tests are another source of
data to use in planning care.
• Intelligence tests—cognitive
abilities and intellectual
functioning
• Personality tests—self-concept,
impulse control, reality testing,
and major defense mechanisms
Psychiatric Diagnoses
Based on the DSM-IV-TR multiaxial
system:
• Axis I: clinical disorders, other
conditions that may be a focus of
clinical attention
• Axis II: personality disorders,
mental retardation
• Axis III: general medical conditions
• Axis IV: psychosocial and
environmental problems
• Axis V: Global Assessment of
Functioning (GAF)
Mental Status Exam
Focuses on the client’s cognitive abilities:
• Orientation to person, time, place,
date, season, day of the week
• Ability to interpret proverbs
• Ability to perform math
calculations
• Memorization and short-term
recall
Self-Awareness Issues
• Self-awareness is important for the
nurse so that personal beliefs,
attitudes, or feelings do not
interfere with the objective
assessment of clients
• It may be uncomfortable to discuss
areas such as suicidal ideas or
sexuality issues, but it is important
for the nurse to do so
• Being open, clear, direct, and
nonjudgmental are essential nurse
behaviors; it may be helpful to
discuss feelings with a colleague if
difficult issues are encountered in
the assessment process
Chapter 9
Legal and Ethical Issues
Legal Considerations
Rights of Clients
Mental health clients retain all civil
rights afforded to all people except the
right to leave the hospital in the case of
involuntary commitment.
24
Involuntary Hospitalization
• Laws are determined by each
state. Know the laws of the state
where you practice
• Persons detained in this way lose
only the right to freedom; all other
rights are intact
• Persons held without their consent
must present an imminent danger
to themselves or others; this must
be proven at a hearing if the
person is to be committed
Release From the Hospital
• Clients hospitalized voluntarily
have the right to request discharge
at any time and must be released
unless they represent a danger to
themselves or others; if such a
danger is present, then
commitment proceedings must be
instituted to keep them in the
hospital
• Clients who are no longer
dangerous must be discharged
from the hospital
Conservatorship
• Legal guardianship is separate
from civil commitment for
hospitalization
• A hearing can be held to
determine whether the person is
competent. An incompetent client
cannot provide his or her own
shelter, food, and clothing; cannot
act in his or her own best
interests; and cannot run his or
her own business and financial
affairs. If found incompetent, a
guardian is appointed to speak for
the client
An incompetent client can no longer:
• Enter into legal contracts with a
signature
• Sign checks
• Use a credit card
• Make a will
• Open bank accounts
• Sell property
• Get married
• Give consent for surgery
Least Restrictive Environment
• Treatment must be provided in the
least restrictive environment
appropriate to meet the client’s
needs
• This philosophy is central to the
deinstitutionalization of large state
hospitals and the move to
community-based care and
services
• Physical restraint or seclusion in a
locked room can be used only
when the person is imminently
aggressive or threatening to harm
self
• Restraint and seclusion, if used,
must be in place for the shortest
time necessary. Many regulations
govern the monitoring of clients in
seclusion or restraint for their
safety
• Restraint and seclusion standards
are being revised frequently
• Legal Considerations
25
Confidentiality
• Regulated by the Health Insurance
Portability and Accountability Act
(HIPPA) of 1996
• Both civil (fines) and criminal
(prison sentences) penalties exist
for violation of patient privacy
Duty to Warn Third Parties
• Duty to warn a third party is an
exception to client confidentiality.
Clinicians must warn identifiable
third parties of threats made by a
client
Insanity Defense
Insanity is a legal term (not medical) that
means the person could not control his or
her actions or understand the difference
between right and wrong at the time of
the crime (M’Naghten rule). If insane, the
person can be found not guilty of the
crime in most states.
Thirteen states have provisions for a
“guilty, but insane” verdict, which holds
the person responsible for the crime while
ensuring that he or she receives
treatment.
Nursing Liability
Nurses are responsible for providing safe,
competent, legal, and ethical care to
clients and families. Nurses are expected
to meet standards of care, meaning care
provided meets set expectations and is
what any nurse would do in a similar
situation.
A tort is a wrongful act that results in
injury, loss, or damage, and may be
intentional or unintentional.
Unintentional Torts
• Negligence is an unintentional tort
that involves harm caused by
failure to do what is reasonable
and prudent
• Malpractice is a type of negligence
specifically applied to health care
professionals; a successful
malpractice suit must prove duty
to the client; breach of that duty;
injury or damage to the client;
breach of duty was the direct
cause of the injury or loss
Intentional Torts
• Assault (causes person to fear
being touched in an offensive
manner)
• Battery (harmful or unwanted
actual contact)
• False imprisonment (unjustifiable
detention)
Nurses can minimize the risk of lawsuits
through safe, competent nursing care and
descriptive, accurate documentation.
Ethical Issues
• Ethics: a branch of philosophy that
deals with values of human
conduct (rightness and wrongness
of actions) and the goodness or
badness of the motives and ends
of such actions
• Utilitarianism: a theory that bases
decisions on “the greatest good for
the greatest number”
• Deontology: decisions should be
based on whether an action is
26
 morally right or wrong, with no
regard for the consequences
• Deontologic principles include:
– Autonomy—right to self-
determination and
independence
– Beneficence—duty to
benefit others or promote
good
– Nonmaleficence—do no
harm
– Justice—fairness
– Veracity—honesty, truthful
– Fidelity—honor
commitments and
contracts
Ethical Dilemmas in Mental Health
• Ethical dilemma—a situation in
which ethical principles conflict or
there is no one clear course of
action
• Many dilemmas in mental health
involve the client’s right to self-
determination and independence
(autonomy) and concern for the
“public good” (utilitarianism)
Ethical Decision Making
Models for ethical decision making
include gathering information, clarifying
values, identifying options, identifying
legal considerations and practical
restraints, building consensus for the
decision reached, and reviewing and
analyzing the decision to determine what
was learned.
Self-Awareness Issues
Self-awareness for nurses is essential so
that nurses’ own values do not interfere
with care to clients and families, including
the ability to be an advocate for the client.
• Naming common objects in the
environment
• Ability to follow multistep
commands
• Ability to write or copy a simple
drawing
Chapter 10
Anger, Hostility, and Aggression
Anger is a normal human emotion.
Hostility and aggression are inappropriate
expressions of anger.
Anger
Anger is a strong, uncomfortable,
emotional response to a provocation,
either real or perceived.
It results when one is frustrated,
hurt, or afraid and energizes the body for
defense (fight or flight).
• Denying or suppressing angry
feelings can lead to physical or
emotional problems
• Anger that is expressed
inappropriately can lead to
hostility and aggression
• Appropriate expression of anger
involves assertive communication
skills that lead to problem solving
or conflict resolution
• Venting angry feelings by engaging
in safe but aggressive activities
(punching bag, yelling) is called
catharsis. However, research has
27
 shown that catharsis may increase
rather than alleviate angry feelings
• Clients with depression may have
anger attacks when they feel
emotionally trapped
Hostility and Aggression
Hostile and aggressive behavior may occur
suddenly without warning, but often
stages or phases can be identified:
• Triggering
• Escalation
• Crisis
• Recovery
• Postcrisis
Hostility is an emotion expressed by:
• Verbal abuse
• Lack of cooperation
• Violation of rules or
norms
• Threatening behavior
(verbal aggression)
Related Disorders
Most psychiatric clients are not
aggressive, but some exhibit angry,
hostile, or aggressive behavior caused by:
• Paranoid delusions
• Auditory (command)
hallucinations
• Dementia, delirium
• Head injury
• Intoxication with alcohol or drugs
• Antisocial and borderline
personality disorders
Intermittent Explosive Disorder:
• Rare psychiatric diagnosis
involving discrete episodes of
aggressive impulses resulting in
serious injury or property damage
• Episodes are out of
proportion to any provocation,
and the person is remorseful and
embarrassed afterward.
Acting Out
• An immature defense
mechanism in which the person
deals with emotional conflict or
stress by actions rather than
reflection or feelings; the person is
trying to feel less powerless or
helpless by acting out.
Etiology of Hostility and Aggression
• Neurobiologic theories: decreased
serotonin, increased dopamine
and norepinephrine; structural
damage to limbic system, damage
to frontal or temporal lobes
• Psychosocial theories: failure to
develop impulse control and ability
to delay gratification
Cultural Considerations
In certain cultures, expressing
anger may be seen as rude or
disrespectful; some culture-bound
syndromes involve aggressive, agitated, or
violent behavior.
Treatments and Medications
Treatment often focuses on
treating the underlying or comorbid
psychiatric diagnosis such as
schizophrenia or bipolar disorder.
28
Aggressive Clients
• Lithium for bipolar disorder,
conduct disorder, or mental
retardation
• Carbamazepine for dementia,
psychosis, or personality disorders
• Atypical antipsychotics such as
clozapine for dementia, brain
injury, mental retardation, and
personality disorders
• Benzodiazepines for older adults
with dementia
• Haloperidol and lorazepam for
clients with psychoses
Application of the Nursing Process
Assessment
• Early assessment and intervention
needed when clients are angry or
hostile to avoid physically
aggressive episodes
• Nurse must assess both individual
clients and the therapeutic milieu
or environment
• Assessment and intervention are
based on five phases of aggression
Intervention
Interventions are most effective and least
restrictive when implemented early in the
cycle of aggression.
• Managing the milieu includes:
– Having planned activities;
informal discussions
– Scheduled one-to-one
interactions; letting clients
know what to expect
– Helping clients with
conflicts to solve their
problems, including
expression of angry
feelings
Self-Awareness Issues
• How nurse handles own angry
feelings
• Comfort with expression of anger
from others
• Ability to be calm, nonjudgmental
• Nurse must have assertive
communication skills, conflict
resolution skills, ability to see that
client’s behavior/anger is not
personal or a sign of nurse’s
failure, and ability to deal with
own fear when clients are
aggressive or threatening
Chapter 11
Abuse and Violence
Clinical Picture of Abuse and Violence
Abuse is the wrongful use and
maltreatment of another person…
…can be child, spouse, partner, or
elder parent
Victims of abuse and trauma can have
both physical and psychological injuries,
including:
• Agitation anxiety, silence
• Suppressed anger or resentment
• Shame and guilt
• Feelings of being degraded or
dehumanized; low self-esteem
• Relationship problems; mistrust of
authority figures
29
Characteristics of Violent Families
• Social isolation
• Power and control by abusive
person
• Alcohol and other drug abuse
• Intergenerational transmission
process
Cultural Considerations
• Domestic violence occurs in
families of all ages and from all
ethnic, racial, religious,
socioeconomic, and sexual
orientation backgrounds
• Battered immigrant women face
increased legal, social, and
economic barriers
Spouse or Partner Abuse
• Involves the mistreatment of one
person by another in the context
of an intimate relationship
• 90% to 95% of domestic violence
victims are women
• Pregnancy escalates domestic
violence
• Abuse can occur in same-sex
relationships
Cycle of Abuse and Violence
• Initial episode of violence
• Honeymoon period: abuser
promises it will never happen
again, gives gifts and flowers,
affectionate
• Tensions begins to build with
arguments, silence, complaints
• Violence occurs again
• This cycle repeats over and over
Assessment
• It is necessary to identify victims of
abuse in all settings, since they
often do not seek treatment
directly
• SAFE questions can be used to
assess:
• Stress/Safety
• Afraid/Abused
• Friends/Family
• Emergency plan
Treatment and Intervention
• Domestic violence laws vary
among states and are not always
followed
• Women may stay in abusive
relationships
for fear of violence to children,
fear of increased violence or
death, financial dependence
• Identifying women in violent
situations is a priority. More health
care agencies are beginning to ask
routine screening questions of all
women
Treatment and Intervention (cont’d)
• Providing women with information
about shelters, services, and so
forth is essential
• The nurse must never indicate that
is
he or she thinks the woman should
leave the relationship; need to
keep the door open for further
communication
30
Child Abuse • Urinary tract infections; red,
swollen, or bruised genitalia; tears
Child abuse is intentional injury of a child,
of vagina or rectum
including:
• Old injuries that were not treated
– Physical abuse or injuries
• Multiple, unexplained bruises
– Sexual assault or intrusion
Treatment and Intervention
– Neglect or failure to
prevent harm (failure to • Getting the child to a safe place
provide adequate physical once abuse is identified
or emotional care or
• Family therapy
supervision; abandonment)
• Individual therapy for the child
– Psychological abuse
• Intensive involvement of social
All states have mandatory child abuse
service agencies
reporting laws that include nurses.
• Treatment for parents for any
Parents who abuse children:
substance abuse or psychiatric
• Have minimal parenting issues
knowledge and skills
Elder Abuse
• Are emotionally immature and
Elder abuse is maltreatment of older
needy
adults by family members or caretakers,
• Are incapable of meeting their including:
own needs, much less those of a
– Physical, sexual, or
child
psychological abuse or
• Often raise their children the way neglect
they were raised, including
– Self-neglect
corporal punishment and abuse
– Financial exploitation
• Expect the child to meet all their
needs for love and affection – Denial of adequate medical
treatment
Assessment
• 60% of perpetrators are spouses,
Suspect child abuse when there are:
20% adult children, 20% others
• Unusual injuries such as scalding
• People who abuse elders are
and cigarette burns
almost always in a caretaker role
• Delays in seeking treatment,
• Elders are reluctant to report
inconsistent history, or illogical
abuse because they fear the
explanation for the injuries
alternative (nursing home)

• Not all states have mandatory

elder abuse reporting laws

31
Assessment
Possible indicators of physical abuse:
• Malnourished, dehydrated
• Rashes, sores, lice
• Smell of urine, feces, dirt
• Failure to keep needed medical
appointments
• Untreated medical condition
Possible indicators of emotional or
psychological abuse:
• Reluctance to talk openly
• Helplessness
• Withdrawal or depression
• Anger or agitation
Possible indicators of self-neglect:
• Inability to manage own finances
• Inability to perform activities of
daily living
• Inadequate clothing
• Signs of malnutrition or
dehydration
• Rashes and sores
Possible indicators of financial
exploitation:
• Inability to manage money
• Unusual activity in bank accounts
• Different signatures on checks
• Recent changes in will that client
could not make
• Missing valuables
Possible indicators of abuse by
caregiver:
• Caregiver speaks for the elderly
person
• Caregiver shows indifference or
anger
• Caregiver blames elderly person
for physical problems
• Caregiver shows defensiveness
• Caregiver and client give
conflicting accounts
Treatment and Intervention
Treatment and intervention may
involve:
• Providing adequate support and
respite for the caregivers
• Changing caregiving arrangements
• Moving the elderly person to a
safe environment
Rape
Rape is a crime of violence and aggression
expressed through sexual means. The act
is against the victim’s will or against
someone who cannot give consent.
• The victim can be any age
• Half of rapes are committed by
someone known to the victim
• Rape is underreported to the
police
• Same-sex rape can occur between
partners but is most common in
institutions
Male rapists have been categorized as:
• Sexual sadists aroused by pain of
victim
• Exploitative predators
32
 • Inadequate men and children and conflict
management in the home
• Those who rape as a displaced
expression of anger and rage • Mentoring programs for young
people
Physical and psychological trauma to rape
victims is severe: A history of violence, victimization, and
witnessing of violence can lead to
• Medical problems: victims are
problems with aggression, depression,
significantly less healthy;
relationships, achievement, and abuse of
pregnancy, STDs, HIV are concerns
drugs and alcohol.
• Victims may feel frightened,
Psychiatric Disorders Related to Abuse
helpless, guilty, humiliated, and
and Violence
embarrassed; may avoid
previously pleasurable activities Two psychiatric disorders are associated
with histories of violence and abuse:
• Relationship problems may occur
1. Posttraumatic stress disorder
Treatment and Intervention
(PTSD)
• Immediate support to ventilate
2. Dissociative disorders
fear and rage
PTSD
• Care by persons who believe that
the rape happened Disturbing behavior resulting after a
traumatic event at least 3 months after
• Coordination of all needed services
the trauma occurred
in one location
Up to 60% of persons at risk (combat
• Giving the victim control over
veterans, victims of violence and natural
choices whenever possible
disasters) develop PTSD.
• Prophylactic treatment for STDs
Symptoms of PTSD include:
• Referral to therapy services;
• Persistent nightmares
counseling; and groups for longer-
term help • Memories
Community Violence • Flashbacks
Of great concern are homicides and • Emotional numbness
suicides associated with schools.
• Insomnia
Solutions emphasize:
• Irritability
• Problem-solving skills, anger
• Hypervigilance
management, and social skills
development • Angry outbursts
• Parenting programs that promote
strong bonding between parents

33
Dissociative Disorders
Dissociation is a subconscious defense
mechanism that helps a person protect
the emotional self from recognizing the
full impact of some horrific or traumatic
event by allowing the mind to forget or
remove itself from the painful situation or
memory.
Dissociation can occur both during and
after the event and becomes easier with
repeated use.
Dissociative disorders include:
• Amnesia
• Fugue
• Dissociative identity disorder
(formerly multiple personality
disorder)
• Depersonalization disorder
Treatment and Interventions
• Involvement in group and/or
individual therapy in the
community
• Clients with dissociative disorder
or PTSD are seen in the acute
setting for brief periods when
symptoms are severe or there is
concern for their safety
Application of the Nursing Process
Assessment
• Includes history of trauma or
abuse
• Client often appears hyperalert,
anxious, or agitated
• Mood and affect: client is fearful
and anxious; needs large personal
space; has a wide range of
emotions
• Thought processes and content:
nightmares, flashbacks,
destructive thoughts or impulses
• Sensorium and intellectual
processes: disorientation (during
flashbacks), memory gaps
• Judgment and insight: impaired
decision-making and problem-
solving abilities
• Self-concept: client has low self-
esteem
• Roles and relationships: problems
with relationships, work, authority
figures
• Physiologic considerations:
difficulty sleeping, under- or
overeating, use of alcohol or drugs
for self-medication
Data Analysis
Nursing diagnoses include:
• Risk for Self-Mutilation
• Ineffective Coping
• Post-Trauma Response
• Chronic Low Self-Esteem
• Powerlessness
Outcome Identification
The client will:
• Be physically safe
• Distinguish between self-harm
ideas and taking action on those
ideas
• Learn healthy ways to deal with
stress
34
 • Express emotions nondestructively Grieving, also known as bereavement, is
the process of experiencing grief.
• Establish social support network in
the community Anticipatory grief is facing an imminent
loss.
Intervention
Mourning is the outward sign of grief.
• Promoting the client’s safety
Experiences of grief and loss are essential
• Helping the client cope with stress
and normal in the course of life; letting
and emotions using grounding
go, relinquishing, and moving on happen
techniques
as we grow and develop.
• Helping to promote the client’s
Grief and loss are uncomfortable.
self-esteem
Types of Losses
• Establishing social support
Losses may be planned, expected,
Evaluation
or sudden. Loss of a loved one is probably
Is the patient: the most devastating type of loss, but
there are many other types of losses:
• Learning to protecting him- or
herself? • Physiologic (loss of limb, ability to
breathe)
• Learning to manage stress and
emotions? • Safety (domestic violence,
posttraumatic stress disorder,
• Able to function in their daily
breach of confidentiality)
lives?
• Security/sense of belonging
Self-Awareness Issues
(relationship loss [death, divorce])
• Becoming comfortable asking all
• Self-esteem (ability to work,
women about abuse (SAFE
children leaving home)
questions)
• Self-actualization (loss of personal
• Listening to accounts of abuse
goals, such as not going to college,
from clients and families
never becoming an artist or
• Recognizing client’s strengths, not dancer)
just problems
The Grieving Process
• Working with perpetrators of
Nurses must recognize the signs of
abuse; dealing with own feelings
grieving to understand and support the
about abuse and violence
client through the grieving process.
Chapter 12
The therapeutic relationship and
Grief and Loss
therapeutic communication skills are
Grief refers to the subjective emotions paramount when assisting grieving clients.
and affect that are a normal response to Using these skills, nurses may promote
loss.

35
the expression and release of emotional
as well as physical pain during grieving.
Theories of the Grieving Process
Kubler-Ross’s stages of grieving:
• Denial (shock and disbelief)
• Anger (toward God, relatives,
health care providers)
• Bargaining (trying to get more
time, prolonging the inevitable
loss)
• Depression (awareness of the loss
becomes acute)
• Acceptance (person comes to
terms with impending death or
loss)
• Theories of the Grieving Process
(cont’d)
Bowlby’s phases of grieving:
• Numbness and denial of the loss
• Emotional yearning for lost loved
one and protesting permanence of
loss
• Cognitive disorganization and
emotional despair
• Reorganizing and reintegrating
sense of self
John Harvey’s phases of grieving:
• Shock, outcry, and denial
• Intrusion of thoughts, distractions,
and obsessive reviewing of loss
• Confiding in others to emote and
cognitively restructure
Rodebaugh’s stages of grieving:
• Reeling
• Feelings
• Dealing
• Healing
There are many similarities among
theorists about grief. Not all clients follow
predictable steps or make steady
progress.
Tasks of the Grieving Process
• Undoing psychosocial bonds to
loved one and eventually creating
new ties
• Adding new roles, skills, and
behaviors
• Pursuing a healthy lifestyle
• Integrating the loss into life
Dimensions of Grieving
• Cognitive responses to grief
– Questioning and trying to
make sense of the loss
– Attempting to keep the lost
one present
• Emotional responses to grief
• Spiritual responses to grief
• Behavioral responses to grief
• Physiologic responses to grief
Cultural Considerations
All cultures grieve for lost loved ones, but
the rituals and habits surrounding death
vary among cultures, for instance, how
shock and sadness are expressed, how
long mourning should last, and so forth.
36
Many cultural bereavement rituals have
their roots in a major religion.
Nurses should be sensitive to cultural
differences and ask how the mourners can
be assisted.
African Americans
• Typically view the body in church
before burial
• Hymns, poetry, eulogies common
• Mourning may be expressed by
public prayer, wearing black
clothing, and decreasing social
activities for a few weeks to
several years
Muslim Americans
• Muslims do not permit cremation
• Important to follow the five steps
of the burial procedure
Filipino Americans
• Often Catholic
• Wear armbands or black clothing
• Place wreaths on casket
• Drape a black banner on the
deceased’s home
• Ask for prayers and blessings for
the soul of the deceased
Haitian Americans
• May practice vodun or calling on
spirits to make peace
Chinese Americans
• Strict norms for announcing death,
preparing the body, arranging the
funeral and burial, mourning
• Burning incense and reading
scripture assist the spirit of the
deceased on his or her journey
Japanese Americans
• Japanese Americans who are
Buddhists view death as a life
passage
• Bathing and purification rites are
performed
• Friends and family visit, bringing
gifts or money
• Prayers are said
• Incense is burned
Vietnamese Americans
• Predominately Buddhist
• Deceased is bathed and dressed in
black clothes
• Rice and money may be sent with
the deceased on the journey to
the afterlife
• Viewing the body before burial
occurs at home
Hispanic Americans
• Predominately Catholic
• Pray for the soul during a novena
and rosary
• Mourning may involve wearing
black and decreasing social
activities
• A wake in the home may be held
Native Americans
• Variety of practices depending on
religious beliefs and practices of
different tribes
37
 • Death may be seen as a state of
unconditional love
• Many believe the deceased is
going on another journey
• Celebrations may include a ghost
meal
• Mourners may be encouraged to
be happy for the person
Orthodox Jewish Americans
• Leaving a dying person alone is a
sign of disrespect
• Burial must occur within 24 hours
unless delayed by the Sabbath
• Body should be untouched until
rites can be performed by family,
rabbi, or Jewish undertaker
Nurse’s Role
The nurse must encourage clients to
discover and use effective and meaningful
grieving behaviors:
• Praying
• Staying with the body
• Performing rituals
• Attending memorials and public
services
Disenfranchised Grief or
Complicated Grieving
Disenfranchised grief is grief over a loss
that is not or cannot be openly
acknowledged, mourned publicly, or
supported socially:
• A relationship has no legitimacy
• The loss itself is not recognized
• The griever is not recognized
Complicated grieving is a response that
lies outside the norm of grieving in terms
of extended periods of grieving: responses
that seem out of proportion or responses
that are void of emotion
Disenfranchised Grief
People who are vulnerable to
disenfranchised grieving:
• Relationships that may be viewed
as having no legitimacy: lovers,
friends, neighbors, foster parents,
colleagues, caregivers, same-sex
relationships, cohabitation without
marriage, and extramarital affairs
• Losses that may not be recognized:
prenatal death, abortion,
relinquishing a child for adoption,
death of a pet, or other losses not
involving death such as job loss,
separation, divorce, and children
leaving home
• Grievers who may not be
recognized: older adults, children,
nurses
Complicated Grieving
People who are vulnerable to complicated
grieving include
those with:
• Low self-esteem
• Low trust in others
• A previous psychiatric disorder
• Previous suicide threats or
attempts
• Absent or unhelpful family
members
38
 • An ambivalent, dependent, or
insecure attachment to the
deceased person
Experiences increasing the risk for
complicated grieving include:
• Death of a spouse or child
• Death of a parent (particularly in
early childhood or adolescence)
• Sudden, unexpected, and untimely
death
• Multiple deaths
• Death by suicide or murder
Complicated Grieving as a Unique and
Varied Experience
• Physical reactions can include:
– Impaired immune system
– Increased adrenocortical
activity
– Increased levels of serum
prolactin and growth
hormone
– Psychosomatic disorders
– Increased mortality from
heart disease
• Emotional responses can include:
– Depression
– Anxiety or panic disorders
– Delayed or inhibited grief
– Chronic grief
Application of the Nursing Process
Assessment
• Does the client have adequate
perception regarding the loss?
– What does the client think
and feel about the loss?
– How is the loss going to
affect the client’s life?
– What information does the
nurse need to clarify or
share with the client?
• Does the client have
adequate support?
• Does the client have
adequate coping
behaviors?
Data Analysis and Planning
Possible nursing diagnoses:
• Grieving
• Anticipatory Grieving
• Dysfunctional Grieving
Outcome Identification Grieving
The client will:
• Identify the effects of his or her
loss
• Seek adequate support
• Apply effective coping strategies
while expressing and assimilating
all dimensions of human response
to loss in his or her life
Anticipatory Grieving
The client will:
• Identify the meaning of the
expected loss in his or her life
• Seek adequate support while
expressing grief
• Develop a plan for coping with the
loss as it becomes a reality
39
 • Application of the Nursing Process
(cont’d)
Dysfunctional Grieving
The client will:
• Identify the meaning of his or her
loss
• Recognize the negative effects of
the loss on his or her life
• Seek or accept professional
assistance to promote the grieving
process
Intervention
• Regarding perception of the loss
– Explore perception and
meaning of the loss
• Regarding adequate support
– Help the client reach out
and accept what others
want to give
• Regarding adequate coping
behaviors
– Shift from an unconscious
defense mechanism to
conscious coping
– Compare and contrast past
coping
– Encourage the client to
care for self
Essential communication and
interpersonal skills to assist grieving:
• Use simple, nonjudgmental
statements
• Refer to a loved one or object of
loss by name (if acceptable in the
client’s culture)
• Appropriate use of touch indicates
caring
• Respect the client’s unique process
of grieving
• Respect the client’s personal
beliefs
• Be honest, dependable, consistent,
and worthy of the client’s trust
• Offer a welcoming smile and eye
contact
Evaluation
• Evaluation of progress is
based on the goals established for
the client.
• Make an evaluation of the
client’s status based on the
theoretical tasks and phases of
grieving.
Self-Awareness Issues
• Examining one’s own experiences
with grief and loss
• Taking a self-awareness inventory
and reflecting on the results may
be helpful.
Chapter 13
Anxiety and Stress-Related Illness
Anxiety is a vague feeling of dread or
apprehension in response to external
or internal stimuli. Anxiety is
unavoidable in life and can serve
many positive functions.
Stress is the wear and tear that life causes
on the body. It occurs when a person
has difficulty dealing with life
situations, problems, and goals.
40
Stages of Reaction to Stress
• Alarm reaction stage
• Resistance stage
• Exhaustion stage
Anxiety as a Stress Response
• Mild anxiety: sensation that
something is different and
warrants special attention; sensory
stimulation increases; focus
attention to learn, solve problems,
think, act, feel, and protect self;
motivated
• Moderate anxiety: feeling that
something is definitely wrong;
nervous or agitated; can still
process information, solve
problems, and learn new things
with assistance from others;
difficulty concentrating but can be
redirected
• Severe anxiety: trouble thinking
and reasoning; muscles tighten;
vital signs increase; pacing;
restless, irritable, and angry; uses
other emotional-psychomotor
means to release tension
• Panic anxiety: fight, flight, or
freeze responses; cognitive
process focuses on the person’s
defense
Working With Anxious Clients
• Be aware of nurse’s own anxiety
level
• Assess the person’s anxiety level
• Speaking in short, simple, and
easy-to-understand sentences
• Lower the person’s anxiety level to
moderate or mild before
proceeding with anything else
• Talk to the client in a low, calm,
and soothing voice
• Walk while talking if the patient
cannot sit still
• Ensure safety during panic-level
anxiety
• Remain with the client until the
panic recedes
• Short-term use of anxiolytics
Anxiety Disorders
• Agoraphobia with or without panic
disorder
• Panic disorder
• Specific phobia
• Social phobia
• Obsessive-compulsive disorder
(OCD)
• Generalized anxiety disorder
• Acute stress disorder
• Posttraumatic stress disorder
Incidence of Anxiety Disorders
• More prevalent in women
• Prevalent in people younger than
45 years
• More common in divorced and
separated persons
• More common in persons of lower
socioeconomic status
• Onset and clinical course are
variable
Related Disorders
• Anxiety disorder due to a general
medical condition
• Substance-induced anxiety
disorder
• Separation anxiety disorder
• Adjustment disorder
Etiologies
• Biologic theories: anxiety may
have an inherited component;
neurotransmitters may be
dysfunctional in persons with
anxiety disorders
• Psychodynamic theories: overuse
of defense mechanisms; results
from problems in interpersonal
relationships; as “learned”
behavioral response
Cultural Considerations
• Asian cultures often express
anxiety through somatic
symptoms such as headaches,
backaches, fatigue, dizziness, and
stomach problems
• Hispanics experience high anxiety
as sadness, agitation, weight loss,
weakness, and heart rate changes.
The symptoms are believed to
occur because supernatural spirits
or bad air from dangerous places
and cemeteries invades the body
41

Treatment
Usually involves a combination of
medication (anxiolytics and
antidepressants) and therapy
• Cognitive-behavioral therapy:
– Positive reframing (turning
negative messages into
positive ones)
– Decatastrophizing (making
a more realistic appraisal of
the situation)
– Assertiveness training
(learn to negotiate
interpersonal situations)
Elder Considerations
• Late-life anxiety disorders are
often associated with another
condition, such as depression,
dementia, physical illness, or
medication toxicity or withdrawal.
Phobias, particularly agoraphobia,
and generalized anxiety disorders
(GAD) are the most common late-
life anxiety disorders
• The treatment of choice for
anxiety disorders in the elderly is
SSRI antidepressants
Mental Health Promotion
Goal is effective management, not total
elimination of anxiety.
• Keep a positive attitude and
believe in yourself
• Accept that there are events you
cannot control
• Communicate assertively with
others
• Talk about your
feelings with others
• Express your
feelings through
laughing, crying,
and so forth
• Learn to relax
• Exercise regularly
• Eat well-balanced meals
• Limit intake of caffeine and alcohol
• Get enough rest and sleep
• Set realistic goals and expectations
• Find an activity that is personally
meaningful
• Learn stress management
techniques
Panic Disorder
Involves 15- to 30-minute episodes of
intense, escalating anxiety with emotional
fear and physiologic discomfort
Peaks in late adolescence and the mid-30s
Can lead to avoidance behavior or
agoraphobia
Treated with cognitive-behavioral
techniques, deep breathing and
relaxation, and medications
(benzodiazepines, SSRI
antidepressants, tricyclic
antidepressants, and
antihypertensives)
Panic Disorder
Intervention
• Promoting safety and comfort
• Using therapeutic communication
• Managing anxiety
• Client and family teaching
Phobias
A phobia is an illogical, intense, persistent
fear of a specific object or social situation
that causes extreme distress and
interferes with normal life functioning.
• Agoraphobia, or fear of being
outside
• Specific phobia, an irrational fear
of an object or situation
42
 • Social phobia, anxiety provoked by
certain social or performance
situations
Obsessive-Compulsive Disorder
Obsessions are recurrent, persistent,
intrusive, and unwanted thoughts,
images, or impulses that cause
marked anxiety and interfere with
interpersonal, social, or occupational
functioning.
Compulsions are ritualistic or
repetitive behaviors or mental acts
that a person carries out continuously
in an attempt to neutralize anxiety.
The person knows the rituals are
unreasonable but feels forced to
continue them in an attempt to
relieve anxiety caused by obsessions.
Onset and Clinical Course
Specific phobias usually occur in
childhood or adolescence. In some
cases, merely thinking about or
handling a plastic model of the
dreaded object can create fear.
Specific phobias that persist into
adulthood are lifelong 80% of the
time.
Treatment and Prognosis
Psychopharmacology: anxiolytics; SSRI
antidepressants; beta blockers to
slow heart rate and lower blood
pressure
Behavioral therapies:
– Systematic desensitization
Intervention
• Using therapeutic communication
• Teaching relaxation and behavioral
techniques
• Completing a daily routine
• Providing client and family
education
Generalized Anxiety Disorder
• Excessive worry and anxiety that is
unwarranted more days than not
• Symptoms include uneasiness,
irritability, muscle tension, fatigue,
difficulty thinking, and sleep
alterations
• Seen most often by family
physicians
• Treated with SSRI antidepressants
and buspirone
Posttraumatic Stress Disorder
• Following witnessing a terrifying
and potentially deadly event, the
person re-experiences all or some
of it through dreams or waking
recollections and responds
defensively to these flashbacks
• New behaviors develop related to
the trauma such as sleep
difficulties, hypervigilance,
thinking difficulties, severe startle
response, and agitation
Acute Stress Disorder
• A dissociative response develops
following the experience of a
traumatic situation
• The person has a sense that the
event was unreal, thinks he or she
is unreal, and forgets some aspects
of the event through amnesia,
emotional detachment, and
muddled obliviousness to the
environment
Self-Awareness Issues
• Stress and anxiety are common
experiences for all people
43
 • Persons with anxiety disorders
often “look well enough” to
control their behavior
• Avoid trying to “fix” client’s
problems
Chapter 14
Schizophrenia
Schizophrenia is a syndrome or
disease process of the brain causing
distorted and bizarre thoughts,
perceptions, emotions, movements,
and behavior.
It is usually diagnosed in late
adolescence and early adulthood.
Prevalence is 1% of total population,
or 3 million in U.S.; same prevalence
throughout world.
Hard or positive symptoms include:
• Delusions
• Hallucinations
• Grossly disorganized
thinking, speech, and
behavior
Soft or negative symptoms include:
• Flat affect
• Avolition
• Social withdrawal or discomfort
• Apathy
• Alogia
Types of Schizophrenia
1. Paranoid type: persecutory or
grandiose delusions and
hallucinations; sometimes
excessive religiosity; hostile and
aggressive behavior
2. Disorganized type: grossly
inappropriate or flat affect,
incoherence, loose associations,
extremely disorganized behavior
3. Catatonic type: marked
psychomotor disturbance,
motionless or excessive motor
activity, extreme negativism,
mutism, peculiarities of voluntary
movement (echolalia, echopraxia)
4. Undifferentiated type: mixed
schizophrenic symptoms along
with disturbances of thought,
affect, behavior
5. Residual: at least one previous
psychotic episode but not
currently; social withdrawal, flat
affect, loose associations
Clinical Course
• Most clients experience a slow and
gradual onset of symptoms
• Younger age of onset associated
with poorer outcomes
• In first years after diagnosis, client
may have relatively symptom-free
periods between psychotic
episode or fairly continuous
psychosis with some shift in
severity of symptoms
• Over the long term, psychotic
symptoms diminish for most
clients and are managed more
easily
• Many years of dysfunction are
rarely overcome
Related Disorders
• Schizophreniform disorder:
symptoms of schizophrenia are
experienced for less than the 6
months required for a diagnosis of
schizophrenia
• Schizoaffective disorder: symptoms
of psychosis and thought disorder
along with all the features of a
mood disorder
• Delusional disorder: one or more
non-bizarre delusions with no
impairment in psychosocial
functioning
• Brief psychotic disorder: one
psychotic symptoms lasting 1 day
to 1 month; may or may not have
44
 an identifiable stressor, such as
childbirth
• Shared psychotic disorder (folie à
deux): similar delusion shared by
two people, one of whom has
psychotic delusions
Etiology
Current etiologic theories focus on
biologic theories:
• Genetic factors
• Neuroanatomic theories
• Neurochemical theories
• Immunovirologic factors
Cultural Considerations
• Ideas that are considered
delusional in one culture may be
commonly accepted by other
cultures
• Auditory or visual hallucinations
may be a normal part of religious
experiences in some cultures
• Ethnicity may be a factor in the
way a person responds to
psychotropic medications:
– African Americans,
Caucasian Americans, and
Hispanic Americans appear
to require comparable
therapeutic doses of
antipsychotic medications
– Asian clients need lower
doses of drugs such as
haloperidol (Haldol) to
obtain the same effects
Treatment
• Conventional antipsychotics target
the positive signs:
– Delusions
– Hallucinations
– Disturbed thinking
– Other psychotic symptoms
but have no observable effect on
the negative signs
• Atypical antipsychotics diminish
positive symptoms, and they
lessen the negative signs:
– Avolition
– Social withdrawal
– Anhedonia
Maintenance Therapy
• Two antipsychotics are available in
depot injection forms for
maintenance therapy:
– Fluphenazine (Prolixin) in
decanoate and enanthate
preparations
– Haloperidol (Haldol) in
decanoate
• The effects of the medications last
2 to 4 weeks, eliminating the need
for daily oral antipsychotic
medication
Side Effects of Antipsychotic Medications
• Neurologic side effects:
– Extrapyramidal side effects
(acute dystonic reactions,
akathisia, and parkinsonism)
– Tardive dyskinesia
– Seizures
– Neuroleptic malignant
syndrome
• Nonneurologic side effects:
– Weight gain
– Sedation
– Photosensitivity
– Anticholinergic symptoms (dry
mouth, blurred vision,
constipation, urinary
retention)
– Orthostatic hypotension
– Agranulocytosis (Clozapine)
Treatment
Adjunctive Treatment
• Individual, group, and family
therapy
• Structured milieu therapy
• Community support programs
45
 • Client/family education and
support
Intervention
• Promote safety of clients and
others
• Establish a therapeutic
relationship
• Use therapeutic communication
• Interventions for delusional
thoughts
• Interventions for hallucinations
• Protect the client who has socially
inappropriate behaviors
• Client and family teaching
Elder Considerations
• Psychotic symptoms that appear in
later life are usually associated
with depression or dementia, not
schizophrenia
• Elderly people with schizophrenia
experience a variety of long-term
outcomes:
– 20% to 30% of clients
experience dementia,
resulting in a steady,
deteriorating decline in
health
– 20% to 30% experience a
reduction in positive
symptoms, somewhat like
a remission
– 40% to 60% remain mostly
unchanged
Mental Health Promotion
• Psychiatric rehabilitation has the
goal of recovery for client, more
than just symptom control and
medication management
• Early identification and aggressive
treatment of psychotic symptoms
maximizes recovery and quality of
life
• Future research on prophylactic
drug treatment to treat genetically
vulnerable relatives with beginning
negative signs of schizophrenia
Self-Awareness Issues
• May be challenging if client is
suspicious or mistrustful or nurse
is frightened
• Nurse may become frustrated if
client is noncompliant
• Nurse must not take client’s
success or failure personally. The
client’s remarks and behavior or
noncompliance are not personal
toward the nurse; part of the
illness
• Nurse should focus on client’s
strengths and time out of the
hospital, not just on symptoms
and need for acute care
• No nurse has all the answers
Chapter 15
Mood Disorders
Pervasive alterations in emotions that
are manifested by depression, mania,
or both, and interfere with the
person’s ability to live life
Categories
• Major depression: 2 or more
weeks of sad mood, lack of
interest in life activities, and other
symptoms
• Bipolar disorder (formerly called
“manic-depressive illness”): mood
cycles of mania and/or depression
and normalcy and other symptoms
46
Related Disorders
• Dysthymia: sadness, low energy,
but not severe enough to be
diagnosed as major depression
disorder
• Cyclothymia: mood swings not
severe enough to be diagnosed as
bipolar disorder
• Substance-induced mood disorder
• Mood disorder due to a general
medical condition
• Seasonal affective disorder (SAD)
• Postpartum or “maternity” blues
• Postpartum depression
• Postpartum psychosis
Etiology
Biologic theories
• Genetics
• Neurochemical theories
• Neuroendocrine or hormonal
fluctuations
Major Depressive Disorder
• Twice as common in women and
more common in single or
divorced people
• Involves 2 or more weeks of sad
mood, lack of interest in life
activities, and at least four other
symptoms:
• o Distractibility
o Changes in appetite or
weight, sleep, or
psychomotor activity
o Decreased energy
o Feelings of worthlessness
or guilt
o Difficulty thinking,
concentrating, or making
decisions
o Recurrent thoughts of
death or suicidal ideation,
plans, or attempts
• Untreated, can last 6 to 24
months; recurs in 50% to 60% of
people
• Symptoms range from mild to
severe
• Electroconvulsive therapy
(ECT) is used when
medications are ineffective or
side effects are intolerable.
– 6 to 15 treatments
scheduled three times a
week
– Preparation of a client
for ECT is similar to
preparation for any
outpatient minor
surgical procedure
– The client will have
some short-term
memory impairment
• Psychotherapy in conjunction
with medication is considered
most effective treatment;
useful therapies include
behavioral, cognitive,
interpersonal therapy
Bipolar Disorder
• Occurs almost equally among men
and women
• It is more common in highly
educated people
• The mean age for a first manic
episode is the early 20s
• Involves mood swings of
depression (same symptoms of
major depressive disorder) and
mania. Major symptoms of mania
include:
o Inflated self-esteem or
grandiosity
o Decreased need for sleep
o Pressured speech
o Flight of ideas
Treatment and Prognosis
Medication
• Lithium; regular monitoring of
serum lithium levels is needed
• Anticonvulsant drugs are used
for their mood-stabilizing
effects: Tegretol, Depakote,
Lamictal, Topamax, and
Neurontin, as is Klonopin (a
benzodiazepine)
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Nursing Intervention
• Providing for safety of client
and others
• Meeting physiologic needs
• Managing medications
Suicide
Assessment
• Men commit suicide three times
the rate of women
• Women are four times more likely
than men to attempt suicide
Populations at risk
• Men, young women, Caucasians,
adults older than 65, and
separated and divorced people
• Clients with psychiatric disorders
• Environmental factors include
isolation, recent loss, lack of social
support, unemployment, critical
life events, and family history of
depression or suicide
• Behavioral factors include:
impulsivity, erratic or unexplained
changes from usual behavior, and
unstable lifestyle
• Warnings of suicidal intent
• Risky behaviors
• Lethality assessmentu
– Does the client have a
specific plan?
– Are the means available to
carry out this plan?
– If the client carries out the
plan, is it likely to be lethal?
– Has the client made
preparations for death?
– Where and when does the
client intend to carry out the
plan?
– Is the intended time a special
date or anniversary that has
meaning for the client?
Intervention
• Using an authoritative role
• Providing a safe environment
• Initiating a no-suicide contract
• Creating a support system list
Chapter 16
Personality Disorders
Personality: an ingrained, enduring
pattern of behaving and relating to self,
others, and the environment; behaviors
and characteristics are consistent across a
broad range of situations and do not
change easily
Personality disorders: when personality
traits become inflexible and
maladaptive and significantly
interfere with how a person functions
in society or cause the person
emotional distress; usually not
diagnosed until adulthood;
maladaptive behavior can be traced
to early childhood or adolescence
DSM-IV-TR Categories
• Cluster A: people whose behavior
is odd or eccentric (paranoid,
schizoid, schizotypal)
• Cluster B: people who appear
dramatic, emotional, or erratic
(antisocial, borderline, histrionic,
narcissistic)
• Cluster C: people who are anxious
or fearful (avoidant, dependent,
obsessive-compulsive)
• Disorders being considered for
inclusion are depressive and
passive-aggressive
Onset and Clinical Course
• Personality disorders occur in 10%
to 13% of the general population
• Incidence is even higher in lower
socioeconomic groups
• 40% to 45% of people with a
primary diagnosis of major mental
illness also have a coexisting
personality disorder that
significantly complicates treatment
• Clients with personality disorders
have:
48
 – Higher death rates,
especially as a result of
suicide
– Higher rates of suicide
attempts, accidents, and
emergency department
visits
– Increased rates of
separation, divorce, and
involvement in legal
proceedings regarding child
custody
– Increased rates of criminal
behavior, alcoholism, and
drug abuse
Treatment
• Many people with personality
disorders do not seek treatment
because they don’t believe they
have a problem
• Individual and group therapy may
be helpful to those desiring
change, but any changes are slow
• Improvement in relationships,
improved basic living skills, relief
of anxiety may be goals of therapy
• Cognitive-behavioral techniques
such as thought-stopping, positive
self-talk, and decatastrophizing
can be effective
Pharmacologic treatment is based on the
type and severity of symptoms rather
than the particular personality
disorder itself.
Four symptom categories include:
• Cognitive-perceptual distortions
including psychotic symptoms
• Affective symptoms and mood
dysregulation
• Aggression and behavioral
dysfunction
• Anxiety
Pharmacologic Treatment for Symptoms
• Cognitive-perceptual disturbances
(magical thinking, odd beliefs,
illusions, suspiciousness, ideas of
reference, and low-grade
psychotic symptoms)
– Low-dose antipsychotic
medications
• Mood dysregulation (emotional
instability, emotional detachment,
depression, and dysphoria)
– Lithium, carbamazepine
(Tegretol), valproate
(Depakote), low-dose
neuroleptics, SSRIs, MAOIs,
atypical antipsychotics
• Aggression (predatory or cruel
behavior, impulsivity, poor social
judgment, and emotional lability)
– Lithium, anticonvulsant
mood stabilizers,
benzodiazepines, and low-
dose neuroleptics
• Anxiety
– SSRIs, MAOIs, or low-dose
antipsychotics
Individual and Group Psychotherapy
Focus is on building trust, teaching basic
living skills, providing support,
decreasing distressing symptoms, and
improving interpersonal
relationships.
• Cognitive-behavioral therapy
• Basic living skills for people with
cluster A personality disorders
• Inpatient hospitalization to
provide safety for people with
borderline personality disorder
• Assertiveness training groups for
people with cluster C personality
disorders
• Relaxation or meditation
techniques for people with cluster
C personality disorders
Cluster A Personality Disorders
1. Paranoid personality disorder
2. Schizoid personality disorder
3. Schizotypal personality disorder
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 1. Paranoid Personality
Disorder
Clinical Picture
• Mistrust and suspiciousness, aloof
and withdrawn, guarded or
hypervigilant, restricted affect, use
the defense mechanism of
projection
Nursing Interventions
• Approach in a formal, business-like
manner, keep commitments, be
straightforward, involve them in
formulating their care plans, help
them learn to validate ideas before
taking action
2. Schizoid Personality
Disorder
Clinical Picture
• Detached from social
relationships, restricted affect,
aloof and indifferent, no leisure or
pleasurable activities, do not
report feeling distressed about
lack of emotion, intellectual and
accomplished with solitary
interests, indifferent to praise or
criticism, dissociate from or no
bodily or sensory pleasures
Nursing Interventions
• Improve functioning in the
community, make referrals to
social services, provide care that
accommodates the desire for
solitude
3. Schizotypal Personality
Disorder
Clinical Picture
• Acute discomfort in relationships,
cognitive or perceptual distortions,
eccentric behavior, bizarre speech,
affect flat and sometimes
inappropriate
Nursing Interventions
• Promote self-care, social skills, and
improved functioning in the
community
Cluster B Personality Disorders
1. Antisocial
2. Borderline
3. Narcissistic
4. Histrionic
1. Antisocial Personality Disorder
Clinical Picture
• Pervasive pattern of disregard for
and violation of rights of others,
deceit and manipulation
Intervention
• Forming therapeutic
relationship
– Limit setting
– Confrontation
• Promoting responsible
behavior
• Helping client solve problems
and control emotions
• Enhancing role
performance
2. Borderline Personality Disorder
Clinical Picture
• Pervasive pattern of unstable
interpersonal relationships, self-
image, affect, and marked
impulsivity
Intervention
Long-term therapy to resolve family
dysfunction and abuse
Hospitalization when client is
exhibiting self-harm behaviors or
having intense symptoms
Brief hospitalizations to stabilize
condition
50

• Promoting the client’s safety
– No-self-harm contract
• Promoting the therapeutic
relationship
• Establishing boundaries in
relationships
• Teaching effective
communication skills
• Helping the client to cope and
control emotions
• Reshaping thinking patterns
– Cognitive restructuring
– Thought stopping
– Positive self-talk
– Decatastrophizing
• Structuring daily activities
3. Histrionic Personality Disorder
Clinical Picture
• Excessive emotionality and
attention seeking; colorful and
theatrical speech; overly
concerned with impressing others;
emotionally expressive,
gregarious, and effusive; emotions
are insincere and shallow; self-
absorbed; uncomfortable when
they are not the center of
attention and go to great lengths
to gain that status
Nursing Interventions
• Give feedback about social
interactions; teach social skills
through role playing
4. Narcissistic Personality Disorder
Clinical Picture
• Grandiose; lack of empathy; need
for admiration; arrogant or
haughty attitude; disparage,
belittle, or discount the feelings of
others; view their problems as the
fault of others; hypersensitive to
criticism and need constant
attention and admiration
Nursing Interventions
• Use self-awareness skills to avoid
anger and frustration; use matter-
of-fact manner; set limits on rude
or verbally abusive behavior
Cluster C Personality Disorders
1. Avoidant personality disorder
2. Dependent personality disorder
3. Obsessive-compulsive personality
disorder
1. Avoidant Personality Disorder
Clinical Picture
• Social inhibitions; feelings of
inadequacy; hypersensitivity to
negative evaluation; avoid
situations or relationships that
may result in rejection, criticism,
shame, or disapproval; strongly
desire closeness and intimacy but
fear possible rejection and
humiliation
Nursing Interventions
• Explore positive self-aspects and
reasons for self-criticism; practice
self-affirmations and positive self-
talk; cognitive restructuring
techniques, such as reframing and
decatastrophizing; teach social
skills
2. Dependent Personality Disorder
Clinical Picture
• Submissive and clinging behavior;
excessive need to be taken care of;
pessimistic and self-critical; other
people hurt their feelings easily;
report feeling unhappy or
depressed; difficulty making
decisions; seek advice and
repeated reassurances
Nursing Interventions
• Help identify strengths and needs;
use cognitive restructuring; assist
in daily functioning; teach problem
solving and decision making;
refrain from giving advice
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 3. Obsessive-Compulsive Personality
Disorder
Clinical Picture
• Preoccupation with orderliness,
perfectionism, and control; formal
and serious demeanor; constricted
emotions; stubborn; preoccupied
with details, rules, lists, and
schedules; believe they are right;
problems with judgment and decision
making
Nursing Interventions
• Help accept or tolerate less-than-
perfect work; use cognitive
restructuring techniques;
encourage to take risks; practice
negotiation
Related Disorders
1. Depressive personality disorder
2. Passive-aggressive personality
disorder
1. Depressive Personality Disorder
Clinical Picture
• Sad, gloomy, or dejected affect;
persistent unhappiness,
cheerlessness, and hopelessness;
inability to experience joy or
pleasure in any activity; cannot
relax; do not display a sense of
humor; brood and worry over all
aspects of daily life; thinking is
negative and pessimistic
Nursing Interventions
• Assess risk for self-harm;
encourage to become involved in
activities; give factual feedback;
use cognitive restructuring
techniques; teach effective social
skills
2. Passive-Aggressive Personality
Disorder
Clinical Picture
• Negative attitudes; resent,
oppose, and resist demands
expected by others; express
resistance through
procrastination, forgetfulness,
stubbornness, and intentional
inefficiency
Nursing Interventions
• Help examine the relationship
between feelings and subsequent
actions; teach appropriate ways to
express feelings directly
Elder Considerations
• Personality disorders from Clusters
A and C are more prevalent in
older age and are closely
correlated with depression
Community-Based Care
• Caring for clients with personality
disorders occurs primarily in
community-based settings
• Acute psychiatric settings such as
the hospital are useful for safety
concerns for short periods
• Often the personality disorder is
not the focus of attention; rather,
the client may be seeking
treatment for a physical condition
• Most people with personality
disorders are treated in group or
individual therapy settings,
community support programs, or
self-help groups
Mental Health Promotion
• Identify behaviors in children and
adolescents that correlate with the
development of personality
disorders as adults
– Adolescents exhibiting
Cluster A and Cluster B
traits are more likely to
commit violent acts in
adulthood
– Children at risk for Cluster
B personality disorders
demonstrate dramatic
emotional responses to
other people while
paradoxically showing self-
centeredness and utter
disregard for the feelings of
others
52
 • Employ prevention strategies
– Activities that are
structured, met regularly,
involve skill mastery, and
led by one or more adults

Self-Awareness Issues
• Avoiding client attempts to
manipulate
• Engaging in clear communication
• Setting limits and boundaries
• Dealing with frustration: clients
change slowly yet “look” like they
are capable of better behavior
• Working effectively as part of the
team; consistency is essential

53