Module 3 Mental health psychiatric nursing practice

This module focuses on how mental illness occurs. The actual cause of mental illness is still
unknown but there were several theories that arise to explain possible reasons for mental illness. There
were two classifications of theories one based on biological perspective and the other one is on
psychosocial basis.

Learning Outcomes
1. Discuss how personality have been molded based on selected psychosocial theories.
2. Explain the possible causes of mental disorders utilizing selected psychosocial theories.
3. Discuss how to utilize the theories in the prevention and promotion of mental health.

Activities:
1. Study the Module
2. Supplement the module by reading e-book by Videbeck - Psychiatric-Mental Health Nursing.
3. Participate in classroom discussion.
4. Make a schematic diagram illustrating the occurrence of mental disorder utilizing a specific theory / or an
intervention in the prevention and promotion of health with simple explanation of 300 words. (formative
assessment no. 5)
5. Answer Module Assessment Self- Check No. 5.

Module Contents
Personality Theories and determinants of psychopathology: Implications to mental – health
psychiatric nursing practice.
Human behavior is the collection of activities performed by human beings and influenced by
culture, attitudes, emotions, values, ethics, authority, rapport, hypnosis, persuasion, and/or coercion.
Personality is the aggregate of the physical, mental qualities of the individual as these interact
characteristic fashion with his environment.

A. BIOLOGICAL FOUNDATIONS

The Nervous System - The neuron is the functional unit of the nervous system. Humans have about 100
billion neurons in their brain. While variable in size and shape, all neurons have three parts. Dendrites
receive information from another cell and transmit the message to the cell body. The cell body contains
the nucleus, mitochondria and other organelles typical of eukaryotic cells. The axon conducts messages
away from the cell body.
a. Brain Abnormalities
Central Nervous System is composed of:
Left Hemisphere
▪ controls the right side of the body
▪ Center for logical reasoning, analytical functioning such as reading, writing and
mathematical tasks
Right Hemisphere
▪ Center for creative thinking, intuition, and artistic abilities
Frontal lobe
▪ Control the organization of thought, body movement, memories, emotions and
moral behavior.
▪ Abnormalities are associated with Schizophrenia, Attention deficit / Hyperactivity
disorder and Dementia.
Limbic System
▪ Thalamus – regulates activity, sensation and emotion
▪ Hypothalamus – Temperature regulation, appetite control, endocrine function,
sexual drive and impulsive behavior.
▪ Hippocampus and amygdala – involved in emotional arousal and memory
▪ Memory loss in Dementia, poorly controlled emotions in Psychotic or Manic
behavior
b. Imaging Techniques
1) CT scan
▪ Some persons with schizophrenia have been shown to have enlarged ventricles;
this is associated with a poorer prognosis and marked negative symptoms.
2) MRI
▪ Solemon and Goldman Rakie (1995) found a 7% reduction in cortical thickness in
persons with schizophrenia.
3) PET / SPECT
▪ Persons with Alzheimer’s disease have decreased glucose metabolism in the brain
and decreased cerebral blood flow. Some persons with schizophrenia also
demonstrate decreased cerebral blood flow.

c. Neurotransmission Theories
Neurotransmitters
▪ chemical substances manufactured in the neuron that aid in the transmission of
information throughout the body.
▪ Are metabolized and inactivated by enzymes primarily Monoamine oxidase
(MAO)
1) Dopamine – involved in control of complex movements, motivation, cognition and
regulation of emotional responses; synthesized from tyrosine. ( Antipsychotic drugs
work by blocking dopamine receptors to reduce dopamine activity)
2) Norepinephrine – most prevalent neurotransmitter; plays a role in changes in
attention, learning & memory, sleep & wakefulness and mood regulation.
(Antidepressants blocks reuptake od Norepinephrine)
3) Serotonin – plays an important role in Anxiety, Mood disorders and schizophrenia;
plays a role in delusions, hallucinations and withdrawn behavior in schizophrenia;
synthesized from tryptorphan. (Antidepressants blocks serotonin reuptake)

d. Endocrine Theory – Decrease in TSH causes depression

e. CSF Metabolite Theory

– Decrease in HVA (Homo Vanillic acid) is present in schizophrenia
– Decrease in HIAA (Hydroxy Indole Acetic Acid) is present in schizophrenia

f. Vitamin D Deficiency Theory – Vitamin B1, B2, B6, folic acid, Ascorbic Acid, Vitamin D.
g. Genetics and heredity – Chromosome 14 and 21 are linked to Alzheimer’s Disease
h. Stress and Immune System – A compromised Immune system could contribute to the
development of a variety of illnesses.
i. Infection – Streptococcus is linked to OCD ( Obsessive compulsive Disorder)
B. PSYCHOSOCIAL THEORIES
SIGMUND FREUD (1856 – 1939) PSYCHOANALYTIC THEORY
1. Human behavior is motivated by repressed sexual impulses and desires.
THE Three STRUCTURE OF PERSONALITY

ID Unconscious part containing the uncultured, primitive drives and instincts/ impulses
of the individual. Sexual and aggressive drive
Born with it
Governed by pleasure principle (reduce tension by immediate gratification) –
tendency to seek pleasure and avoid pain
It is without sense of right and wrong
IRRATIONAL and NOT BASED ON REALITY
Functions of the ID
a. Responsible for image formation or wish fulfillment b. Reflex method
Drives of ID and instincts
a. sexual or libido
b. aggressive – destructive component
❖ If Id is not controlled individual is antisocial, lawless as his primitive drive are
expressed freely
EGO • CHIEF EXECUTIVE OFFICER
• Operates on REALITY PRINCIPLE
• An INTEGRATOR / MEDIATOR – its main function is to effect an acceptable compromise
between the crude pleasure seeking striving of the ID and the inhibitions of the
SUPEREGO.
• SECONDARY PROCESS OF THINKING(logical & oriented on time)
• Major personality mechanism that mediates between the person and environment
• Major functions: Adaptation to reality; modulation of anxiety; problem solving; control
and regulate instinctual drives; mediate ID drives and demands of reality; evaluate and
judge the external world; REALITY TESTING store of experiences in “memory”; direct
motor activities and action USE DEFENSE MECHANISM to protect self
• As the individual matures, the EGO becomes the rational, reasonable, conscious part of
personality and strives to integrate the total personality into a smoothly functioning
unified, coherent whole.
❖ Powerful EGO – mature, effective and stable adult life
SUPEREGO • The part of psyche that develops when the standards of the parents and of society are
incorporated.
• It incorporates the taboos, prohibitions, ideals, standards of the parents and significant
adults with whom the child associates.
• ANGEL / BLIND / MORALIST / PERFECTIONIST
• Operates in all levels of the mind but mostly carried in the subconscious mind.
• CONSCIENCE, punishes one for something wrong that was done
• EGO-IDEAL, rewards one for something good that was done
• SUPEREGO is fully developed at age 7 – age of reason.
❖ If SUPEREGO is so strong, the individual is inhibited, repressed, unhappy and guilt
ridden.
 1. Behavior is motivated by Subconscious thoughts and feelings:

“A Freudian slip (slips of the tongue) were not accidents or coincidence but rather were indicators of
subconscious feelings or thoughts that accidentally emerged in casual day to day conversation”.

3. Human Personality was believed to function at Three Levels of Awareness

Conscious Pre-conscious (Subconscious) Unconscious

- functions when the person is
awake, aware of himself, his
thoughts, feelings, perceptions
and what is going on in the
environment
- Ideas and reactions are stored - largest part of the mind
and partially forgotten - serves as storage or reservoir of
- acts as WATCHMAN – it painful memories & experiences
prevents unacceptable, which are difficult to recall
disturbing unconscious - realm of thoughts and feelings
memories from reaching the that motivate a person even he
conscious mind is totally unaware of them.
- brought into consciousness by - can be recalled by
recall psychoanalysis

4. Believed that a person’s dreams is reflected more of the subconscious and had significant meaning
(Gabbard, 2000)
Dream analysis is a primary method used in psychoanalysis. It involves discussing a client’s dreams
to discover their true meaning and significance.
Free association is another method used to gain access to subconscious thoughts and feelings. The
therapist tries to uncover the client’s true thoughts and feelings by saying a word and asking the client
to respond quickly with the first thing that comes to mind.

5. Believed that self or ego used ego defense mechanisms methods of attempting to protect the self
and cope with basic drives or emotionally painful thoughts, feelings and events. These mechanisms
operates at the unconscious level of awareness

Defense Mechanism Example (Clinical) Purpose

Co Compensation – Making up
for a perceived weakness or
over achievement in a more
comfortable way
P Projection – Attributing to
one’s own motive to
someone else, for
unacceptable desires
thoughts or any wrongful
acts
A college student academically weak To gain superiority or to overcome
becomes a beauty queen in her weaknesses and achieve success
school
A mother told that her child doesn’t Protects self image
know how to dance ballet. She
blame it on poor dance instructors.
R Rationalization – An act of
explaining or reasoning away
unacceptable data, that
sounds logical
I Identification – Projecting the
behavior of someone who is
respected, admired or afraid
of.
D Denial – An attempt to
screen or ignore
unacceptable realities by
refusing to acknowledge
them
D Displacement – Redirecting
emotional reaction from one
person to another
I Intellectualization – Act of
getting away painful incident
with the use of rational
explanation
S Sublimation – Unacceptable
behavior is replaced by a
socially acceptable impulse
or activities
I Introjections – Allows the
acceptance of behavior into
oneself
R Regression – Reversion of
thought or behavior to a
more desirable level
R Reaction Formation – When
a person feels opposite of
one’s true emotion ant aware
of it
U Undoing – Loosening of acts,
thoughts and feeling from
the past
S Substitution – Replacement
of unacceptable goal into a
more realistic or attainable
objects
A client’s inability to stop smoking
resulting to a bad marriage
A nurse, alone in her room,
delivering a lecture she imitates
from her mentor
A woman told her father she has
cancer but continues to plan a
family reunion 2 years in advance
A husband and wife are fighting, and
as the husband becomes more
angry, he hit his dog instead of his
wife
A woman tells her neighbor that she
loves her child so much but fails to
demonstrate her love to her child
A father who lost his child in a fire,
joined an organization that educates
the public on fire prevention
Without knowing it, a student
delivers a speech, acting like her
professor in a speech class
Terminally ill cancer patient allows
her doctor to visit her more often
A client is angry about the attention
and care he is receiving, but behaves
in a calm and collected manner
A father was very angry and hit his
child with a stick but the next day he
brought home a fried chicken
A mother to adopt a child looking
exactly like her dead son but ended
up having someone looking a little
bit like him
Cope with inability to meet certain
standards
To avoid self-devaluation
It isolate a person from the impact
of a traumatic experience
Allows feeling to be express from
less harmful objects or people
It shields a person from traumatic
stress or events
It shields a person from behaving in
irrational and impulsive ways
Helps person avoid social retaliation
and punishment
Allows a person to return to a point
in development when nurturing and
developing were needed and
accepted with comfort
It allows a person’s feelings to be
acted out in a more acceptable way
Helps a person to relieve his guilty
feelings
1. To hasten frustration in life
2. Aids in meeting goals
6. Freud theory of childhood development was based on the belief that sexual energy, termed libido,
was the driving force of human behavior. Children were thought to proigress through 5 stages of
Psychosexual Development.

PHASE AGE FOCUS

Oral Birth to 8 months Major site of tension and gratification is the mouth, lips and tongue, including
biting and sucking activities. ID present at birth and sucking activities, EGO
develops gradually from rudimentary structure present at birth
Anal 18-36 months Anus and surrounding area are major source of interest
Acquisition of voluntary sphincter control (toilet training)

Phallic/Oedipal 3-5 years Genital focus of interest , stimulation of excitement penis is organ of interest
for both sexes, Masturbation is common, penis envy (wish to possess penis)
seen in girls; oedipal complex (wish to marry opposite sex parent and be rid
of same sex parent) seen in boys and Electra complex in girls
Latency 5-11 or 13 years Resolution of oedipal complex, Sexual drive channeled into socially
appropriate activities such as school work and sports, formation of the
superego
Genital 11-13 years Final stages of psychosexual development, begins with puberty and the
biologic capacity for orgasm; involves the capacity for true intimacy

ERIK ERIKSON’S PSYCHOSOCIAL THEORY OF HUMAN DEVELOPMENT

Psychosocial Significant Psychosocial Psychosocial Maladaptations &

Stage (age)
crisis relations modalities virtues malignancies
to get, to give in sensory distortion --
I (0-1) Infant trust vs mistrust Mother hope, faith
return withdrawal
autonomy vs will, impulsivity --
II (2-3) Toddler Parents to hold on, to let go
shame and doubt determination compulsion
III (3-6) purpose, ruthlessness --
initiative vs guilt Family to go after, to play
Preschooler courage inhibition
IV (7-12 or so) -- industry vs neighborhood to complete, to make narrow virtuosity --
competence
School-age child inferiority and school things together inertia
V (12-18 or so) -- ego-identity vs peer groups, to be oneself, to fanaticism --
fidelity, loyalty
Adolescence role-confusion role models share oneself repudiation
to lose and find
VI (the 20’s) -- intimacy vs partners, promiscuity --
oneself in a love
Young adult isolation friends exclusivity
another
VII (late 20’s to generativity vs household, to make be, to take care overextension --
50’s) -- Middle self-absorption workmates care of rejectivity
adult
VIII (50’s and to be, through having
integrity vs mankind or presumption --
beyond) -- Old been, to face not wisdom
despair “my kind” despair
adult being
HARRY SULLIVAN STAGES OF HEALTHY INTERPERSONAL DEVELOPMENT

Infancy Birth to Primary need for bodily contact and tenderness

onset of Prototaxic mode dominates ( no relation between
language
experiences) Primary zones are oral and anal
If needs are met, infant has sense of well-being; unmet needs
lead to dread and anxiety

Childhood Language to Parents viewed as source of praise and acceptance

5 years Shift to parataxic mode (experiences are connected in sequence
to each other)
Primary zone is anal
Gratification leads to positive self-esteem
Moderate anxiety leads to uncertainty and insecurity; severe
anxiety results in self-defeating patterns of behaviors

Juvenile 5-8 years Shift to the syntaxic mode begins (thinking about self and others
based on anlysis of experiences in a variety of situations).
Opportunities for approval and acceptance of
others Learn to negotiate own needs
Severe anxiety may result in a need to control or
restrictive, prejudicial attitudes.

Preadolescenc 8-12 years Move to genuine intimacy with friend of the same sex
e Move away from family as source of satisfaction in
relationships Major shifts to syntaxic mode
Capacity for attachment, love, and collaboration emerges or fails
to develop.

Adolescence Puberty to Lust is added to interpersonal equation.

adulthood Need for special sharing relationship shifts to the opposite sex.
New opportunities for social experimentation lead to the
consolidation of self-esteem or self-ridicule.
If the self-esteem is intact, areas of concern expand to include
values, ideals, career decisions, and social concerns.
JEAN PIAGET THEORY OF COGNITIVE DEVELOPMENT

SENSORIMOTOR Development proceeds from reflex activity to representation and sensory

(0 - 2 years) motor solutions to problem
PRE-OPERATIONAL Problems solved through REPRESENTATION; language development ; (2 –
(2 - 7 years) 4 years) thoughts and language both EGOCENTRIC; cannot solve
conversation problems
CONCRETE REVERSIBILITY attained; can solve conversation problems; LOGICAL
OPERATIONAL OPERATION developed and applied to CONCRETE problems; cannot
(7 – 11 years) solve complex verbal problems
FORMAL OPERATION LOGICALLY SOLVES all types of problems; thinks SCIENTIFICALLY;
(11 years – adulthood) solves COMPLEX problems; COGNITIVE structures nature

LAWRENCE KOHLBERG DEVELOPMENT OF MORAL RESONING

LEVEL STAGE SOCIAL
ORIENTATION
Pre-conventional 1 Obedience Orientation and
Punishment Reflexes cause actions
“I must follow the rule otherwise I will be punished”

2 Instrumental Relativist Orientation (Individualism, Instrumentalism

and Exchange)
Conforms to obtain rewards or favors
“I must follow the rules for the reward and favor it gives”
Conventional 3 Good-boy-Nice girl Orientation
Seeks good relations and approval of family group; Orientation to
interpersonal relations of mutuality
“I must follow rules so I will be accepted”

4 Society-Maintaining Orientation
Obedience to Law and Order in society; maintenance of social order
shows respect to authority
“I must follow rules so there is order in the society”
Post- 5 Social Contract Reorientation
conventional Concerned with individual rights and legal contract; social contract;
utilitarian lawmaking perspective
“I must follow rules as there are reasonable laws for it”
Universal Ethical Principle Orientation (Principled
Conscience) Higher Law and Conscience Orientation
Orientation to internal decisions of conscience but without clear
6
rationale or universal; principles
‘I must follow rules because my conscience tells me”
HILDEGARD PEPLAU: THERAPEUTIC NURSE- PATIENT RELATIONSHIP

She Developed the concept of nurse-patient relationship which includes four phases;
orientation, identification, exploitation, and resolution. During these phases, the client
accomplishes tasks and the relationship changes, which helps the healing process (Peplau,
1952)

1. The orientation phase is directed by the nurse and involves engaging the client in
treatment, providing explanations and information, and answering questions.
2. The identification phase begins when the client works interdependently with the nurse,
expresses feelings, begins to feel stronger.
3. In the exploitation phase, the client makes full use of the services offered.
4. In the resolution phase, the patient no longer needs professional services and gives up
dependent behavior.

PEPLAU’S STAGES AND TASKS OF RELATIONSHIPS

STAGES TASKS
Orientation Clarification of patient’s problem and
needs Patient asks questions
Explanation of hospital routines and expectations
Patient harnesses energy toward meeting
problems Patient full participation is elicited
Identification Patient responds to persons he or she perceives as
helpful. Patient feels stronger.
Expression of feelings
Clarification of roles of both patient and nurse
Exploitation Patient makes full use of available services.
Goals such as going home and returning to work emerge.
Patient behaviors fluctuate between dependence and independence.
Resolution Patient gives up dependent
behavior Services no longer
needed by patient.
Patient assumes power to meet own needs, set new goals, and so
forth.
3. BEHAVIORAL THEORIES

Behaviorism is a school of psychology that focuses on observable behaviors and what one
can do externally to bring about behavior changes.
Behaviorist believe that behavior can be changed by a system or rewards and punishments.

IVAN PAVLOV: CLASSICAL CONDITIONING

Behavior can be changed by conditioning with external or environmental conditions or stimuli.

His experiment with dogs involved his observation that dogs naturally began to salivate
(response) when they saw or smelled food (stimulus). Pavlov set to change his salivating
response or behavior by conditioning. He would ring a bell (new stimulus) and then produce the
food, and the dogs would salivate ( the desired response). He repeated the ringing of the bell
along with the presentation of food many times. Eventually, he could ring the bell and the dogs
salivate without seeing or smelling the food. The dogs are “conditioned” or had learned a new
response – to salivate when they heard the bell.

B.F. SKINNER: OPERANT CONDITIONING

Behavior is learned from one’s history or past experiences that were repeatedly reinforced.
Principles of Operant Conditioning described by Skinner (1974) form the basis of
behavior techniques used today:
1. All behavior is learned.
1. There are consequences that result from behavior – reward and punishment.
2. Behavior that is rewarded with reinforcers tends to occur.
3. Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur.
4. Negative reinforcers that are removed after a behavior, increase the likelihood that the
behavior will recur.
5. Continuous reinforcement (a reward every time the behavior occurs is the fastest way to
increase that behavior, but the behavior will not last long after the reward ceases.
6. Random, intermittent reinforcement (a reward for the desired behavior once in a while) is
slower to produce an increase in behavior, but the behavior continues after the reward
ceases.
Behavior modification is a method of attempting to strengthen a desired behavior or
response by reinforcement, either positive or negative.
Positive reinforcement is applied in this situation. If the desired behavior is assertiveness,
whenever the client uses assertiveness skills in a communication group, the group leader
provides positive reinforcement by giving client attention and positive feedback.
Negative reinforcement involves removing a stimulus immediately after a behavior occurs so
that the behavior is more likely to occur again. If a client becomes anxious when waiting to talk
in a group, he may volunteer to speak first to avoid anxiety.
Systematic Desensitization can be used to help clients overcome irrational fears and
anxiety associated with phobia.
The client is asked to make a list of situations involving the phobic object, from the least
anxiety- provoking to the most anxiety – provoking. The client learns and practices relaxation
techniques to decrease and manage anxiety. The client is then exposed to the least anxiety-
provoking situation, using relaxation techniques to manage the resulting anxiety. The client is
gradually exposed to more and more anxiety provoking situation until he or she can manage the
most anxiety-provoking situation.
4. HUMANISTIC THEORIES
Humanism focuses on the positive qualities of the person, his or her capacity to change
(human potential) and the promotion of self-esteem.

MASLOW’S HEIRARCHY OF
NEEDS
COGNITIVE
NEEDS AESTETIC NEEDS
To know and Order, beauty, and
Understand, SELF- symmetry
ACTUALIZATION
explain, and analyze
Fulfillment of
unique potential
SELF ESTEEM
Self esteem & respect;prestige
LOVE & BELONGING
Giving & receiving affection;companionship;group
identification
SAFETY
Avoiding harm; security & order; & physical safety
PHYSIOLOGIC
Biological needs for oxygen, water, food, sleep, sex

5. Existential Theories
a. 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
RET attacks using ABC theory of personality
A - activating event B - belief about A
C – emotional reaction D – disputing & changing
philosophies A E – end result; effective new
A does not cause C; B causes C
b. Viktor Frankl - Logotherapy: life must have meaning and therapy is the search
for that meaning
c. Frederick “Fritz” Perls - Gestalt therapy emphasizes self-awareness and identifying
thoughts and feelings in the here and now
d. William Glasser - Reality therapy focuses on the person’s behavior and how that
behavior keeps the person from achieving life goals. Belief that patients &
delinquents share the
6. common characteristics of denying "the reality of the world around them” instead of fulfilling their
needs responsibly within the context of reality & society. The Goal is to help face reality and develop
responsible behavior patterns , needs for love & worth can be met effectively. Answer Module
 Assessment Self Check No 5

Matching type:

Test I : Structure of Personality

1. Operates on reality principle A. ID

2. It is without the sense of right and wrong B. EGO
3. Governed by the pleasure principle C. SUPEREGO
4. Acts as integrator / Mediator
5. Angel / Perfectionist
6. Rewards are for something good that is done
7. Use defense mechanism to protect self
8. Incorporates taboos, prohibitions, ideals of parents
9. Is fully developed at age 7
10. Responsible for image formation and wish fulfillment

Test II Level of consciousness

1. Can be recalled by psychoanalysis A. Conscious

2. Serves as a storage or reservoir of painful stimuli B. Subconscious
3. Acts as watchman – prevents unacceptable memories to C. Unconscious
comes to awareness
4. Functions when the person is fully awake
5. Ideas are stored and partially forgotten

Test III Biologic Theories

Causes :
1. Due to an excess in dopamine release A. Schizophrenia
2. Due to increase in Serotonin release B. Mood Disorders
3. Due to increase in Norepinephrine levels C. Obsessive-compulsive
4. Due to decrease in TSH behavior
5. Due to decrease level of Homo vanillic acid D. Alzheimer’s Disease
in the CSF E. Down Syndrome
6. Due to the presence of Streptococcus F. Anxiety disorders
7. Due to decrease in GABA
8. CT scan result reveals of enlarged ventricles
9. Pet scan results indicates a decreased in
glucose metabolism
10. Abnormality in chromosome 21
Assignment:
Make a schematic diagram illustrating the occurrence of mental disorder utilizing a specific theory / or an intervention
in the prevention and promotion of health with simple explanation of 300 words. (formative assessment no. 5)

Use a Hierarchical model to illustrate occurrence of mental disorder. You can add boxes to illustrate the occurrence;
State first the theory or intervention then illustrate.

Prepared by: Alma Trinidad R. Taragua