I.

CONCEPTS OF MENTAL HEALTH AND Mental Health

MENTAL ILLNESS Mental health is a state of emotional,
psychological, and social wellness evidenced by
INTRODUCTION
satisfying interpersonal relationships, effective
Psychiatric Nursing behavior and coping, positive self-concept, and
emotional stability (Videbeck, 2015).
“What you see is just the tip, what lies beneath is ● The ability to see oneself as others do
the truth about it.” and fit into the culture and society where
one lives.
Psychiatric nursing is a specialized area of
nursing practice, employing theories of human Characteristics of a Mentally Healthy
behavior as its science and purposeful use of self Person
as its art, in the diagnosis and treatments of
1. Positive attitude toward self
human response to actual or potential mental
2. Growth
health problems (ANA).
3. Development
4. Self-actualization
Focus of Mental Health 5. Integration
● Well client 6. Autonomy
● At risk individual 7. Reality perception
● Those with early symptoms of 8. Environmental mastery
maladjustments.
Factors Influencing Mental Health
● Individual - Person’s biological makeup,
autonomy and independence,
self-esteem, capacity for growth,
vitality, ability to find meaning in life,
emotional resilience, sense of
belonging, reality orientation and coping
or stress management abilities.
● Interpersonal - Or relationship, may
include effective communication, ability
to help others, intimacy, and a balance
of separateness and connectedness.
● Social/Cultural or Environmental -
Include a sense of community, access to
adequate resources, intolerance of
violence, support of diversity among
people, mastery of environment, and a
positive, yet realistic, view of one’s world.

Mental Health-Illness Continuum

 Mental Illness/Mental Disorder Diagnostic and Statistical Manual of Mental
Disorders
Mental illness is the inability to see oneself as
others do and not having the ability to conform The DSM-IV-TR describes all mental disorders,
to the norms of the culture and society. outlining specific diagnostic criteria for each
based on clinical experience and research.
Mental illness/disorder is a clinically
significant behavioral or psychological
THE STATE OF MENTAL HEALTH IN THE
syndrome or pattern that occurs in an individual PHILIPPINES
and that is associated with present distress or
disability or with significantly increased risk of The Mental Health Act and Universal Health
suffering death, pain, disability, or an important Care Law
loss of freedom. ● It was established to enhance the
services and to promote and protect the
Causes: rights of the Filipinos utilizing
● Genetics and hereditary psychiatric, neurologic, and
● Stress and immunes system psychosocial health services. However...
● Infection ○ Only 5% of the healthcare
expenditure is directed toward
mental health services.
General Criteria to Diagnose
○ 3.6 million Filipinos suffer from
Mental Disorder
at least 1 kind of mental,
1. Dissatisfaction with one’s neurological, or substance use
characteristics, abilities, disorder.
accomplishments. ● The Philippines has the third highest
2. Ineffective or unsatisfying relationship. rate of mental disorders in the Western
3. Dissatisfaction with one’s place in the
Pacific Region.
world. ● Stigma and Discrimination:
4. Ineffective coping with life’s events. ○ Toward mental health issues
5. Lack of personal growth. became part of the Filipino
culture, and this has greatly
Etiological Factors of Mental Illness affected the people and the
economy.
● Individual factors
○ Caused by heredity and ● The increasing prevalence of mental
biochemical factors. illnesses also made a huge impact in the
● Interpersonal factors country and to the human, social, and
● Social factors economic capital.
○ Loss of an effective support ○ The Philippines is a developing
system. country that struggles to obtain
economic stability because of
outdated ways that result in gaps
Links Between Stress and Illness
in mental health promotion,
Alarm Resistance Exhaustion which in turn bleed into the
economy.

Facts
● Mental illness is the third most
common disability in the Philippines.
● Six million Filipinos live with depression
and anxiety.
● The Philippines has the third highest
rate of mental disorders in the Western
Pacific (Martinez et al., 2020).
● Philippines World Health Organization
(WHO) Special Initiative for Mental
Health conducted in 2020 showed that >
3.6 million Filipins suffer from at least
one kind of mental, neurological, or
substance use disorder (Department of
Health, 2020).
● Suicide rates are reported to be at 3.2
per 100,000 population with higher
rates among males (4.3/100,000) than
females (2.0/100,000).
● The National Center for Mental Health
(NCMH) has revealed a significant
increase in monthly hotline calls
regarding depression, with numbers
rising from 80 calls pre-lockdown to
nearly 400.
Who is Affected?
● Between 17-20 percent of Filipino adults
experience psychiatric disorders, while
10-15 percent of Filipino children, aged
5-15 suffer from mental health
problems.
● According to the National Statistics
Office (NSO), mental health illnesses are
the third most common forms of
morbidity for Filipinos.
● In the Philippines, the major causes of
major obstacles are: poverty, leaks into
other parts of life in many ways.
Impoverished people with mental
illnesses are less likely to seek help
because it is unaffordable.
Current Information on Mental Health
Concern During the Pandemic
● The data from National Center for
Mental Health showed that from an
average of 13-15 daily calls before the
pandemic, mental health providers are
now receiving around 32-37 calls per
day.
● From around 300-400 calls in May 2019
to February 2020, it spiked to at least
1,000 calls from April to July.
● DOH - Mental health conditions
exacerbated by the pandemic:
○ Anxiety-related concerns.
○ Suicide-related calls peaked in
July 2020 with 115 calls.
● An article published in 2019 reports that
14% of Filipinos with disabilities have
identified mental disorders.
Variables That Discourage People From
Seeking Treatment
● Cultural beliefs emphasizing family and
community.
● Shame associated with mental illness
due to persistent stigma.
● People who need help often try to hide
their symptoms instead of discussing
them.
● Lack of mental health professionals in
the Philippines, it can be difficult to find
an affordable counselor, psychiatrist or
therapist.
● Poor families unable to afford the
privilege of therapy or medication.
● Underinvestment in mental health
resources along with underdeveloped
services.
State of Mental Health and Illness in the
Philippines (DOH, 2018)
1. In a 2004 WHO study, up to 60% of
people attending primary care clinics
daily in the country are estimated to have
one or more MNS disorders.
2. The 2000 Census of Population and
Housing showed that mental illness and
mental retardation rank 3rd and 4th
respectively among the types of
disabilities in the country (88/100,000).
3. Data from the Philippine General
Hospital 2014 show that epilepsy
accounts for 33.44% of adults and
66.20% of pediatric neurologic out-
patient visits per year.
4. Drug use prevalence among Filipinos
aged 10 to 69 years old is at 2.3%, or an
estimated 1.8 million users according to
the DDB 2015 Nationwide Survey on the
Nature and Extent of Drug Abuse in the
Philippines.
5. 2011 WHO Global School-Based Health
Survey has shown that in the Philippines,
16% of students between 13-15 years old
have ever seriously considered
attempting suicide while 13% have
actually attempted suicide one or more
times during the last year.
6. The incidence of suicide in males
increased from 0.23 to 3.59 per 100,000
in females (Redaniel, Dalida, and Gunnell,
2011).
7. Intentional self-harm is the 9th leading
cause of death among 20-24 years old
(DOH, 2003).
8. A study conducted among government
employees in Metro Manila revealed
that 32% out of 327 respondents have
experienced a mental health problem in
their lifetime (DOH, 2006).
9. Based on Global Epidemiology onKaplan
and Sadock’s Synopsis of Psychiatry,
2015 and Kaufman’s Clinical Neurology
for Psychiatrists, 7th Edition, 2013.
a. Schizophrenia - 1% (1 million)
b. Bipolar - 1% (1 million)
c. Major Depressive Disorder - 17%
(17 million)
d. Dementia - 5% (of older than 65)
e. Epilepsy - 0.06% (600,000)
State of Mental Health and Illness in the
World (WHO, 2020)
● Globally, the most vulnerable population
is those aged 15-29. Mental health-
related deaths are also the second
leading cause of fatalities in this age
group.
● Mental health and substance use
disorders affect 13% of the world’s
population.
● The mortality rate of those with mental
disorders is significantly higher than the
general population, with a media life
expectancy loss of 10.1 years (JAMA
Psychiatry, 2015).
● It is estimated mental disorders are
attributable to 14.3% of deaths
Mental Health Care Delivery System in the
worldwide, or approximately 8 million
deaths each year (JAMA Psychiatry,
2015).
● How Common is Mental Illness?
○ 970 million people worldwide
have a mental health or
substance abuse disorder.
○ Anxiety is the most common
mental illness in the world,
affecting 284 million people.
○ Globally, mental illness affects
more females (11.9%) than males
(9.3%).
○ Major depression, anxiety,
alcohol use disorders,
schizophrenia, bipolar disorder,
and dysrhythmia (persistent mild
depression), were identified as
leading causes of disability in the
U.S.
● The World Health Organization (WHO)
estimates that:
○ 154 million people suffer from
depression.
○ Million from schizophrenia.
○ 877,000 people die by suicide
every year.
○ 50 million people suffer from
epilepsy.
○ 24 million from Alzheimer’s
disease and other dementias.
○ 15.3 million persons with drug
use disorders.
● Mental health statistics worldwide (Our
World in Data, 2018):
○ Anxiety affects 284 million
people in the world.
○ Depression affects 264 million
people.
○ Alcohol use disorder affects 107
million people.
○ Drug use disorder affects 71
million people.
○ Bipolar disorder affects 46
million people.
○ Schizophrenia affects 20 million
people.
○ Eating disorders affect 16 million
people.
Philippines
● There is a scarcity of mental health
professionals in the Philippines, with
only a little over 500 practicing
psychiatrists.
● The ratio of 0.52 psychiatrists per
100,000 persons is lower than other
countries with similar income levels such
as Malaysia (1.27 per 100,00) and
Indonesia (0.3 per 100,000).
● Furthermore, access to mental health
services is not equally distributed
 across the country, as mostpsychiatrists
work in for-profit or private sectors in
larger urban cities such as Metro Manila.
● At present, resources are scarce: only 3
to 5 percent of the total health budget is
allocated to mental health, and there are
only around 1,400 psychologists and500
psychiatrists in the country.
● Feb 4, 2021 - There are 46 outpatient
mental health facilities available in the
country, of which 28% allocate units that
are for children and adolescents only.
These facilities treat 124.3 users per
100,000 general population.
● In Metro Manila, the cost of therapy per
session ranges from PHP 1,000 to PHP
4,500. Depending on the case, a patient
may visit once or twice a month.
● Consulting a private doctor can go up to
PHP 4,500 per session.
● June 21 2018 - President Rodrigo
Duterte signed the landmark Mental
Health Act, the first mental health act
legislation in the Philippines.
● It outlines a framework for the
integration and implementation of
optimal mental health conditions, their
family members, and industry
professionals.
RA 11036 is an act establishing a national
mental health policy for the purpose of
enhancing the delivery of integrated mental
health services, promoting, and protecting the
rights of persons utilizing psychiatric,
neurologic, and psychosocial health services,
appropriating funds therefore, and for other
purposes.
Impact of Philippine Mental Health Care
Delivery System in the Community
● Mental healthcare in the Philippines
faces continued challenges including
underinvestment, lack of mental health
professionals and underdeveloped
community mental health services.
● Although the recent Mental Health Act
legislation has for the first time provided
a legal framework for the delivery of
comprehensive mental healthcare,
economic restrictions preventing people
from accessing
mental healthcare should be considered
to enable the population to equitable
access appropriate care when required.
● Increased investment is urgently
needed to improve the training and
recruitment of psychiatrists, nurses,
psychologists, social workers, and the
multidisciplinary team members,
particularly as large numbers of skilled
professionals continue to emigrate.
Mental Health Staff Ratio
● There is 1 doctor for every 80,000 Filipinos
(WHO and Department of Health, 2012).
● There are a little over 500 psychiatrists
in practice. The ratio of mental health
workers per population in the
Philippines is low, at 2-3 per 100,000
population (WHO and Department of
Health, 2005).
● Together, these figures equate to a
severe shortage of mental health
specialists in the Philippines. This is
further illuminated when compared with
the World Health Organization(WHO) -
recommended global target of 10
psychiatrists per 100,000 population.
● The majority of psychiatrists work in
for-profit services or private practices
and are mainly based in the major urban
areas, particularly in the capital region
known as Metro Manila.
DOH Mental Crisis Hotline
0917-899-USAP (8727)
0917-989-8727
You can also reach out for help through:
Hopeline (02) 804-4673 (HOPE)
0917-558-4673 (HOPE)
2919 (Toll free for Globe
and TM subscribers
In Touch (02) 893-7603,
Community 0917-800-1123 (Globe
Services Crisis subscribers)
Lines
0922-893-8944 (Sun
subscribers)
Living Free 0917-322-7087
Foundation
 ○ Factors in every stage persist as
Manila Lifeline (02) 896-9191
a permanent part of the
Centre 0917-854-9191
personality.
Mood Harmony (02) 844-2941 ○ Resolution of the conflicts with
each stage is essential to the
PsychPros 0915-827-2415 development.
○ Unresolved conflicts remain in
THEORETICAL BASES OF PSYCHIATRIC the unconscious and may at times
NURSING result in maladaptive behavior.
○ Each stage has frustrations and
Psychoanalytic Theory traumas that must be outgrown.
Sigmund Freud (1856-1939) is the father of
psychoanalysis and modern psychiatry. Basic Needs in Development of Personality
Humanity has certain basic needs that must be
Psychodynamic of Human Behavior satisfied.
● Behavior has meaning and is not ● Need to communicate
determined by chance. ● Need for security
● All behavior is goal-directed. ● Need to move from dependence to
● The unconscious plays an active role in ● independence
determining behavior. ● Need to develop self concept
● The early years of life are extremely ● Need to find relief from organic
important to personal development. discomfort

Personality refers to the aggregate of the Factors Influencing Personality

physical and mental qualities as these interact in
characteristic fashion with his environment.
● Personality is expressed through
behavior. It is the sum total of one’s
behavior (John Watson).
Personality development refers to the sum of
all traits that differentiate one individual from
another.
● Total behavior patterns of an individual
through which the inner interests are
expressed.
● The individual’s unique and distinctive
ways of behaving and interacting with
others.
● Heredity
● Environment
● Training
Factors Involved in Personality Development
● Behavior is a learned response that
develops as a result of past experiences.
● To protect the individual’s emotional
well being, these experiences are
organized in the psyche on three levels:
○ Conscious
○ Subconscious
○ Unconscious
3 Components of Personality

Critical Periods in the Formation of Id ● Innate desires

Personality ↝ ● Pleasure seeking
behavior
● Personality of an individual develops in
● Aggression
overlapping stages that shade and merge
● Sexual Impulse
together.
● Certain goals must be accomplished Superego ● Moral and ethical
during each stage in the development concepts
from infancy to maturity. ● Values
● Parental and social
○ If goals are not accomplished at
expectations
specific periods, the basic
structure of personality will be Ego ● Mature adaptive
weakened. behavior
Johari Window
c. Concerned of thoughts, feelings and
Joseph Luft and Harry Ingham wereresearching
sensation, past experiences are
human personality at the University of
recalled without exerting efforts
California in the 1950s when they devised their
d. Corresponds to the “ego or self.”
Johari Window. They observed that there are
aspects of our personality that are: Subconscious/Preconscious
● Known to all
a. Composed of material that has been
● Known only by ourselves
● Unknown by ourselves but known by deliberately pushed out of
others consciousness but can be recalled
● Unknown by self and others with some effort.
Rather than measuring personality, the window b. Part of the mind in which ideas and
offers a way of looking at how personality is reactions are stored and partially
expressed. forgotten.
c. Acts as a watchman, it prevents
certain unacceptable disturbing
Open Blind unconscious memories from reaching
Contains things that Contains things that the conscious mind.
are openly known others observe that d. Thought and experiences can be
and talked about and we don’t know about. recalled at will.
They could be e. This is manifested during the tip of
which may be seen
positive or negative the tongue experience.
as strengths or behaviors and will
weaknesses. This is affect the way that Unconscious
the self that we others act towards
choose to share with us. a. Largest part of the mind which exerts
others. the greatest influence in one’s
personality.
Hidden Unknown b. The storehouse for all memories,
Contains aspects of Contains things that feelings, and responses experienced
ourself that we know nobody knows about by the individual during his entire life.
about and keep us including c. The memories cannot be recalled at
hidden from others. ourselves. This may will.
be because we’ve d. Contains the largest body of material,
never exposed those
greatly influencing behavior.
areas of our
personality or e. This can’t be deliberated brought
because they’re back into awareness, since it is:
buried deep in the i. Usually unaccepted and
subconscious. painful to the individual.
ii. If recalled, usually disguised or
Anxiety is a feeling of tension, distress and distorted, as in dreams but it
discomfort produced by a perceived or could create anxiety.
threatened loss of inner control.

Levels of Consciousness by Sigmund Freud

Conscious

a. Part of the mind which functions

when the person is awake that makes
a person a thinking being.
b. Focus on here and now.
 Defense Mechanisms man deals with a
business client in the
Defense mechanism is used to protect the ego same fashion his
against anxiety, feelings of inadequacy, and father deals with
worthlessness. They operate on an business clients.
unconscious level and distort reality.
Isolation Separation of an
unacceptable feeling,
Denial Unconscious failure to
acknowledge an event, idea, or impulse from
thought, feeling that is one’s thought process.
too painful for
Example: A nurse
conscious awareness.
working in an
Example: A woman emergency room is
diagnosed with cancer able to care for the
tells her family all the seriously injured by
tests were negative. isolating or separating
her feelings and
Displacement The transference of emotions related to
feelings to another the client’s pain,
person or object. injuries, or death.

Projection Attributing one’s own

Example: After being
scolded by his thoughts or impulses
to another person.
supervisor at work, a
man comes home and
Example: A student
kicks the dog for
who has sexual
barking.
feelings towards her
Identification Attempt to be like teeacher, tells her
someone or emulate friends that the
the personality, traits, teacher is coming
or behaviors of onto her.
another person.
Rationalization Offering an
Example: A teenage acceptable, logical
boy dresses and explanation to make
behaves like his unacceptable feelings
favorite singer. and behavior
acceptable.
Intellectualization Using reason to avoid
emotional conflict. Example: A student
who did not do well in
Example: A wife of a a course says it was
substance abuser poorly taught and the
describes, in detail, course content was
the dynamics of not important anyway.
enabling behavior, yet
Repression The involuntary
continues to call her
exclusion of a painful
husband’s work to
thought or memory
report his Monday
from awareness.
morning absences as
an illness.
Example: A young
Introjection Incorporation of man whose mother
values or qualities of died when he was 12
an admired person or cannot tell you how
group into one’s own old he was or the year
ego structure. she died.

Example: A young Sublimation Substitution of an

unacceptable feeling
 with a more socially
acceptable one.
Example: A student Months Old)
who feels too small to
play football becomes
a champion marathon
swimmer.
Suppression The
voluntary/intentional
exclusion of feelings
and ideas.
Example: When about
to lose, Tara Scarlet
O’Hara says. “I’ll think
about it tomorrow.”
Undoing Communication or
behavior done to
negate a previously
unacceptable act.
Example: A young
man who used to hunt
wild animals now
chairs a committee for
the protection of
animals.
(3-5 Years
Theory of Psychosexual Development by
Sigmund Freud
Anal Phase ● Primary source of
pleasure is elimination
(18-36 or retention.
● This is the critical
period for toilet
training.
● The anus is site of
tension and sexual
gratification.
● Greatest need: power
● First experience with
discipline and
authority.
● Retention and
expulsion (forcing out
are experienced as
pleasurable especially
because these
functions come under
child-control). Child
uses his new skill to
please or annoy
parenting adults.
Phallic or ● Genitals are the focus
Oedipal of interest,
stimulation, and
excitement.
Old)
● Masturbation is
common.

Oral Phase ● Greatest need: Latency ● Resolution of oedipal

Security. complex.
(Birth-18 ● Greatest fear: Anger, (5-11 or 13 ● Sexual drive is
Months Old) Years Old)
anxiety. channeled into socially
● Narcissistic: Pleasure appropriate activities
seeking is through such as school work
eating and sucking; and sports.
primary narcissism.
(self-love) Genital ● Final stage of
● Mouth: Erogenous (11-13 Years psychosexual
zone, area of Old) development.
satisfaction. ● Involves the capacity
● Insecurity in parting for true intimacy.
with breast or bottle
may cause fixation. Transference occurs when the client displaces
● Tension is relieved by onto the therapist attitudes and feelings thatthe
sucking and client originally experienced in other
swallowing. relationships.
● Sucking needs are Countertransference occurs when the
independent of hunger therapist displaces onto the client attitudes or
satisfaction. feelings from his or her past.
 Erikson’s Stages of Psychosocial Ego Integrity Wisdom Accepting
Development vs. Despair responsibilit
y for oneself
Stage Virtue Task (Maturity or and life.
45 Years Old
Trust vs. Hope Viewing the
and Above)
Mistrust world as safe
and reliable;
(Infant or relationships Cognitive Theory
Birth-18 as nurturing,
(Piaget, Aaron Beck, Albert Ellis)
Months Old) stable, and
dependable. ● Cognitive schemas as personal
controlling beliefs (Beck).
Autonomy vs. Will Achieving a
Shame and sense of ● Cognitive restructuring (Ellis).
Doubt control and ● These models use a cognitive
free will. approach based on an individual's
(Toddler or ability to think,analyze, judge, decide
1-3 Years Old) and do.
● According to the cognitive, replacing
Initiative vs. Purpose Beginning
Guilt development irrational beliefs with rational beliefs
of a can reduce stress and anxiety and self
(Preschool or conscience; defeating behavior.
3-6 Years Old) learning to
manage Cognitive Stages of Development
conflict and (Jean Piaget)
anxiety.
Sensorimotor The child develops a sense
Industry vs. Competence Emerging (Birth-2 Years of self as separate from the
Inferiority confidence Old) environment and the
in own
concept of object
(School Age or abilities;
6-12 Years taking permanence,that is
Old) pleasure in tangible objects do not
accomplishm cease to exist just because
ents. they are out of sight. He or
she begins to form mental
Identity vs. Fidelity Formulating
Role a sense of images.
Confusion self and
Preoperational The child develops the
belonging.
(Adolescence
(2-6 Years Old) ability to express himself
or 12-20 Years with language, and
Old) understands the meaning
of symbolic to classify
Intimacy vs. Love Forming
objects.
Isolation adults, loving
relationship,
Concrete The child begins to apply
(Young Adult and
Operations logic to thinking,
or 18-25 Years meaningful
(6-12 Years understands spatiality and
Old) attachments
Old)
to others. reversibility, and is
increasingly social and able
Generativity Care Being
to apply rules; however,
vs. Stagnation creative and
thinking is still concrete.
productive;
(Middle Adult establishing
Formal The child learns to think
or 24-45 the next
Years Old) generation.
Operations and reason in abstract
(12-15 Years terms, further develops
Old or Beyond)
logical thinking and
 reasoning, and achieves
cognitive maturity. Piaget’s
theory suggest that
individuals reach
Interpersonal Model (Sullivan, Peplau)
Human development results from IPR, and
that behavior is motivated by avoidance of
anxiety and attainment of satisfaction
(Sullivan).
3 Modes
Prototaxic Characteristics of infancy and
Mode childhood, involves brief,
unconnected experiences that
have no relationship to one
another.
Parataxic Begins in early childhood as
Mode the child begins to connect
experience in sequence.
Syntaxic Which begins to appear in
Mode school-aged children and
becomes more predominant in
preadolescence, the person
begins to perceive him or
herself and the world within
the context of environment
and can analyze experience in
a variety of settings. Maturity
may be defined as
predominance of syntaxic
mode.
Interpersonal Process (Peplau)
● Nurse-Patient relationship.
● Therapeutic use of self.
● Therapeutic relationship directed
toward meeting the patient’s needs.
Anxiety Levels
Mild
● Sharpened senses
● Increased motivation
● Alert
● Enlarged perceptual field
● Can solve problems
● Learning is effective
● Restless
● Gastrointestinal “butterflies”
● Sleepless
● Irritable
● Hypersensitive to noise
Moderate
● Selectively attentive
● Perceptual field limited to the
immediate task
● Can be redirected
● Cannot connect thoughts or events
independently
● Muscle tension
● Diaphoresis
● Pounding pulse
● Headache
● Dry mouth
● Higher voice pitch
● Increased rate of speech
● Gastrointestinal upset
● Frequent urination
● Increased automatisms (nervous
mannerisms)
Severe
● Perceptual field reduced to one detail
or scattered details
● Cannot complete tasks
● Cannot solve problems or learn
effectively
● Behavior geared toward anxiety relief
and is usually ineffective
● Feels awe, dread, or horror
● Doesn’t respond to redirection
● Severe headache
● Nausea, vomiting, diarrhea
● Trembling
● Rigid stance
● Vertigo
● Pale
● Tachycardia
● Chest pain
● Crying
● Ritualistic (purposeless, repetitive
behavior)
Panic
● Perceptual field reduced to focus on
self
● Cannot process environmental stimuli
● Distorted perceptions
● Loss of rational thought
● Personality disorganization
● Doesn’t recognize danger
● Possibly suicidal
● Delusions or hallucination possible
● Can’t communicate verbally
● Either cannot sit (may bolt and run)
or is totally mute and immobile
 Anxiety as a Response to Stress
● Stress is the wear and tear that life
causes on the body (Selye, 1956).
● It occurs when a person has difficulty
dealing with life situations, problems,
and goals.
● (+) or (-) occurrence
Hans Selye identified three stages of reaction
to stress:
Alarm Stress stimulates the body to
Reaction send messages from the
Stage hypothalamus to the glands
(such as adrenal gland, to send
out adrenaline and
norepinephrine for fuel) ans
orgas (such as the liver, to
reconvert glycogen stores to
glucose for food) to prepare for
potential defense needs.
Resistance The digestive reduces function
Stage to shunt blood to areas as
needed for defense. The lungs
take in more air, and the heart
beats faster and harder so that
it can circulate this highly
oxygenated and highly
nourished blood to the muscles
to defend the body to fight,
flight or freeze behaviors. If the
person adapts to the stress, the
body responses relax, and the
gland, organ and systemic
response abate.
Exhaustion Occurs when the person has
Stage responded negatively to
anxiety and stress: body is
depleted or emotional
components are not resolved,
resulting in continual arousal of
the physiological responses and
little reserve capacity.
Lazarus’ Interactional Model
Psychological stress is a relationship
between the person and the environment that
is appraised by the person as taxing or
exceeding his or her resources and
endangering his or her wellbeing.
3 Types of Appraisal
Primary The judgment that
Appraisal individuals make about a
particular event.
Secondary The individual’s evaluation of
Appraisal the way to respond to an
event. Possible strategies, or
solutions, as well as
resources and supports are
examined.
Reappraisal Further appraisal that is
made after new or additional
information has been
received.
Existential Model (Frankl, Perls, May)
● Centers on a person’s present
experiences rather than past ones.
● Holds that alienation from self causes
deviant behavior, and that people can
make free choices about which behavior
to display.
Nursing Model
(Rogers, Orem, Sister Roy, Peplau)
● Biopsychosocial being.
● Holistic approach focuses on caring
rather than curing.
● Establishes the nursing process.
Medical Model
● Disease is a result of deviant behavior.
● Identification of neurochemicals as
possible causes of deviant behavior.
● Socio-environmental influences.
Communication Models
(Berne, Bandler, Grindler)
All human behavior is a form of communication
and that the meaning of behavior depends on
the clarity of communication between sender
and receiver.
Behavioral Model (Skinner, Wolpe, Eysenck)
All behavior, including mental illness, is
learned. Desired behavior can be learned
through rewards, and negative behaviors can be
eliminated through punishment.
 Humanistic Model (Maslow)

Maslow (1954) formulated the hierarchy of

needs, in which he used a pyramid to arrange
and illustrate the basic drives or needs that
motivate people. The most basic needs—the
physiologic needs of food, water, sleep, shelter,
sexual expression, and freedom from pain—
must be met first. The second level involves
safety and security needs, which include
protection, security, and freedom from harm or
threatened deprivation. The third level is love Primary parts:
and belonging needs, which include enduring a. Cerebrum - Controls many things, including:
intimacy, friendship, and acceptance. The ● How we think
fourth level involves esteem needs, which ○ Left hemisphere: logical
include the need for self-respect and esteem reasoning and analytical
from others. The highest level is self- functions; right hemisphere:
actualization, the need for beauty, truth, and center for creative thinking,
justice. intuition, artistic abilities.
● What kind of personalities we have.
● Voluntary movement.
● The way we interpret sensations such as
sight, touch, and smell.

Frontal Lobe Temporal Lobe

● Thought ● Smell
● Body ● Hearing
movement ● Memory
● Memories ● Emotional
● Emotions expression
● Moral
Social Model (Caplan, Szasz) behavior

Deviant behavior is defined by the culture in Parietal Lobe Occipital Lobe

which a person lives.
● Taste ● Language
● Touch ● Visual
Biophysiological Theory and
● Spatial interpretation
Neurobiological Perspective
orientation
Genetic factors, neuroanatomy,
neurophysiology, and biological rhythms
related to the cause, course, and prognosis of b. Cerebellum - Overlies the pons and medulla.
mental disorders. ● It is mainly concerned with motor
functions that regulate muscle tone,
Central Nervous System coordination, and posture.
1. Brain - In the average adult human, the brain ● Lack of dopamine in this area is
weighs 1.3 to 1.4 kg (about 3 pounds). The brain associated with Parkinson’s and
contains about 100 billion nerve cells (neurons) Dementia.
and trillions of support cells called ‘glia.’ ● It controls the way we:
○ Walk (movement).
○ Maintain our posture.
○ Keep our sense of balance.
The diencephalon extends from the cerebrum 2. Spinal Cord
and sits above the brainstem.

c. Limbic System - Regulates emotional

responses.
● Thalamus - Receives and relays sensory
information and plays a role in memory
and in regulating mood. Activity,
sensation, and emotion.
● Amygdala - Emotional arousal and
memory.
● Hypothalamus - Controls the body
homeostasis. Temperature regulation,
appetite control, endocrine function,
sexual drive, and impulsive behavior.
d. Brain Stem - Is a major part of Corporate
Headquarters.
● The brainstem is a general term for the
area of the brain between the thalamus Neurobiological Theory
and spinal cord. It controls such vital Studies reveal that malfunction of certain CNS
functions as: neurons which excrete substances known as
○ Respiration rate/breathing neurotransmitters, appear to inhibit or trigger
○ Blood pressure impulses in other neurons and may be
○ Heartbeat/heart rate responsible for distortions of behavior
● Structures within the brainstem include associated with psychiatric disorders.
the medulla, pons, tectum, reticular
formation, and tegmentum. Neurotransmitters
● Are chemical substances manufactured
Midbrain 0.8 inches or 2 cm in in the neuron that aid in the
length. transmission of information throughout
the body.
Connects the pons and ● Necessary in just the right proportions
the cerebellum with the
to relay messages across the synapses.
cerebrum.
● Are the chemicals which account for the
Pons Primary motor pathway transmission of signals from one neuron
to the next across synapses.
Medulla Tail-like structure at the
Oblongata base of the brain that
connects the brain to the
spinal cord.

Reticulating Influences motor activity,

Activating sleep, consciousness and
System awareness.

Extrapyramidal Relays information about

System movements and
coordination from the
brain to the spinal nerves.
Locus Coeruleus Norepinephrine-producin
g neurons and is
associated with stress,
anxiety and impulsive
behavior.
Brain Imaging Technique
Computed Some people with
Tomography (CT) schizophrenia have
or Computed Axial been shown to have
Tomography enlarged ventricles;
this finding is
 CRISIS
associated with a
poorer prognosis and A crisis is any event or period that will lead, or
marked negative
may lead, to an unstable and dangerous
symptoms.
situation affecting an individual, group, or all of
Magnetic MRI produces more society.
Resonance Imaging tissue detail and ● In mental health terms, a crisis refers
(MRI) contrast than CT and not necessarily to a traumatic situation
can show blood flow
or event, but to a person's reaction to an
patterns and tissue
changes such as event.
edema. It can also be ● Occurs when the experience that is
used to measure the causing the anxiety is overwhelming
size and thickness of and the usual coping is no longer
brain structures; effective.
Persons with
Crisis is a state of disequilibrium resulting from
schizophrenia can have
the interaction of an event with the individual’s
as much as 7%
reduction in cortical or family’s coping mechanisms, which are
thickness. inadequate to meet the demands of the situation
combined with the individual’s or family’s
Positron Emission Positron emission perception of the meaning of the event (Taylor,
Tomography (PET) tomography (PET) and
1982).
single-photon emission
Single Photon computed tomography
Emission (SPECT) are used to Crisis is self-limiting. It does not last indefinitely
Computed examine the function but usually lasts for 4-6 wks. At the end of that
Tomography of the brain. PET and time the crisis is resolved in any of the 3 ways:
(SPECT) SPECT are used ● The person returns to his/her pre-crisis
primarily for research, level.
not for the diagnosis
● The person begins to function at a
and treatment of
clients with mental higher level.
disorders. ● The person functions at a lower level.

FDDNP with PET Recent breakthrough is

the use of the chemical Phases of Crisis
marker.

FDDNP with PET to

identify the amyloid
plaques and tangles of
Alzheimer's disease in
living clients.

These scans have

shown that clients with
Alzheimer disease have
decreased glucose
metabolism in the brain
and decreased cerebral Types of Crisis
blood flow. Some
Maturational ● Occurs during one's
persons with
Crisis stages of development.
schizophrenia also
● Anticipated or
demonstrate decreased
predictable events in
cerebral blood flow.
the normal course of
life.
Illness
Situational ● Unpredicted or sudden
● Genetic and hereditary
Crisis events that threaten the
● Stress and the immune system
● Infection as a possible cause

individual's integrity.
● Is a response to a
sudden and unavoidable
traumatic event that
largely affects a person’s
identity and roles.
Adventitious ● Is a social crisis that
Crisis affects a larger number
of people.
● Natural disasters such
as floods, typhoon,
earthquakes, war or
terrorism, riots, violent
crimes such as rape,
murder, and others.
Crisis Intervention
Crisis intervention are methods offered to help
people who are incapacitated or severely
distributed crisis. It refers to the methods used
to offer immediate, short term help to
individuals who experience an event that
produces emotional, mental, physical and
behavioral distress or problems.
Goals of Crisis Intervention
● To decrease emotional stress and protect
the crisis victim from additional stress.
● To assist the victim in organizing and
mobilizing resources or support systems
to meet unique needs and reach a
solution for the particular situation that
precipitated the crisis.
Requisites for the Effective Crisis
Intervention
● Ability to create trust via confidentiality
and honesty.
● Ability to listen in an attentive manner.
● Provide the individual with the
opportunity to communicate by talking
less.
● Being attentive to verbal and nonverbal
cues. Pleasant, interested, intonation of
voice. Maintaining good eye contact,
posture and appropriate social distance
if in a face to face situation.
● Pleasant, interested, intonation of voice.
Maintaining good eye contact, posture
and appropriate social distance if in a
face to face situation.
● Remaining undistracted, open, honest,
sincere.
● Asking open ended questions.
● Asking permission, never acting on
assumptions.
● Checking out sensitive cross-cultural
factors.
Length of Time for Crisis Intervention
● The length of time for crisis intervention
may range from one session to several
weeks, with the average being four
weeks.
● Crisis intervention is not sufficient for
individuals with long standing problems
and it may range from 20 minutes to 2or
more than 2 hours.
Key Element of Management
Management will depend on the severity and
causes of the crisis as well as the individual
circumstances of the patient.
● Many relatively minor crises can be
managed by providing friendly support
in primary care without referral.
● Severe crises will require referral to
counselors or the local mental health
team.
● Crisis therapy includes short term
behavior/cognitive therapy and
counseling.
● Involvement of family and other key
social networks is very important.
● Therapy should be relatively intense
over a short period and discontinued
before dependence on the therapist
develops.
● The risk of suicide and self harm must
be assesedat presentation and each
review.
● The aims of treatment are to:
○ Reduce distress.
○ Help to solve problems.
○ Avoid maladaptive coping
strategies such as self-harm.
○ Improve problem solving
strategies.
Interventions
Authoritative ● Designed to assess
Intervention the person’s health
status and promote
problem-solving
 such as: assessment and
○ Offering the service delivery and
person new averting a potential
information, state of crisis.
knowledge or ● Immediate crisis
meaning. intervention also
○ Raising the includes caring for
person’s self the medical,
awareness by physical, mental
providing health and personal
feedback needs of the victim
about his/her and providing
behavior. information to the
○ Directing the victim about local
person’s resources or
behavior by services.
offering
suggestions Second Phase ● The second phase of
or courses of crisis intervention
actions. involves an
assessment of needs
Facilitative ● Designed to meet to determine the
Intervention person’s need for service and
empathic resources required
understanding such by the victim in
as: order to provide
○ Encouraging emotional support
to identify to the victim.
and discuss
feelings. Third Phase ● Recovery
○ Serving as a intervention helps
sounding victims re-stabilize
board for the their lives and
person. become healthy
○ Affirming the again.
person’s self
worth.
Steps in Crisis Intervention (Aguilera, 1982)

Techniques of Crisis Intervention Assessment ● The assessment

● Catharsis: The release of feelings that process attempts to
takes place as the patient talks about answer questions
such as:
emotionally charged areas.
○ What has
● Clarification: Encouraging the patient
happened?
to express more clearly the relationship (Identification
between certain events. of problem)
● Reinforcement of behavior. ○ Who is
● Support of defenses. involved?
● Rising self esteem. ○ What is the
cause?
● Exploration of solution.
○ How serious
is the
Phases of Crisis Intervention problem?

Immediate ● It involves Planning ● The person should

Crisis establishing a Therapeutic be involved in the
Intervention or rapport with the Intervention choice of alternative
Psychological victim, gathering coping methods.
First Aid information for ● The needs and
short term reactions of
 significant other Phone: (632)8931 8101 to
must be considered. 07(632) 8932 2573

Therapeutic ● Therapeutic Women 24/7 Hotline: (63)2 8926

Intervention intervention Crisis 77447/F East Avenue, Medical
depends on Center Center, Quezon City
pre-listing skills, the (WCC)
creativity and
flexibility of the
crisis worker and THE NURSING PROCESS IN PSYCHIATRIC
rapidity of the MENTAL HEALTH CARE
person’s response.
● The crisis worker Assessment
helps the person to
Purpose
establish an
intellectual ● Construct a clear picture of the client's
understanding of the emotional state
crisis by noting the ● Mental capacity
relationship between ● Behavioral function
the precipitating
factors and the
Factors Influencing Assessment
crisis.
1. Patient’s participation/feedback.
Resolution and ● During the 2. Client’s health status.
Anticipatory evaluation phase or 3. Patient’s previous
Planning step of crisis experience/misconception regarding
intervention, health care.
reassessment must
4. Client’s ability to understand.
occur to ascertain
that the intervention 5. Nurse’s attitude and approach.
is reducing tension
and anxiety. General Guidelines
● Assistance is given 1. Ensure privacy.
to formulate realistic 2. Show support and sensitivity.
plans for the future,
3. Use reliable information sources.
and the person is
4. Consider the patient’s culture.
given the
opportunity to
discuss how present Interview Dos and Don’ts
experiences may
help in coping with ● Do set clear ● Don’t rush.
future crises. goals. ● Don’t make
● Do heed assumptions.
unspoken ● Don’t judge
Contact
signals. the patient.
National Landline: (02) 8893-7603 ● Do check
Suicide and Globe: 0917-8001123 yourself.
Crisis Lines Sun: 0917-8001123

Alcohol and Roads and Bridges to Beginning the Interview

Substance Recovery – Pasig City 1. Biographic Data
Abuse Phone: 02-8643-6006520 2. Socioeconomic Data
Ebden Bldg., Dr. Sixto Antonio 3. Cultural Beliefs
Avenue, Maybunga, Pasig City, 4. Chief Complaint
Philippines 5. Personal History (Ego function and
areas of strength).
Domestic Department of Social Welfare
6. Psychiatric History
and Sexual and Development The Social
7. Psychosocial History
Violence Protection Bureau
8. Family History
 9. Medication History
● Presence of any
10. Physical Illnesses
disturbance in
memory.
Components of a Psychosocial Assessment
● History
● General appearance and motor behavior Appearance Appearance
● Mood and affect and Behavior ● Type, condition and
● Thought process and content appropriateness of
● Sensorium and intellectual process clothing.
● Self concept ● Personal hygiene,
● Judgment and insight grooming, and
● Roles and relationship cleanliness.
● Physiologic and self care concerns
Behavior
General Appearance Assessment ● Behavior during
● Hygiene interview: degree of
● Grooming cooperation or
● Appropriate dress resistance.
● Gait ● Social skills:
● Posture friendly, shy,
● Activity withdrawn.
● Eye contact ● Amount and type of
● Use of cosmetics motor activity:
● Facial expressions psychomotor
● Unusual movements or mannerisms agitation or
retardation,
Mental Status Examination tremors, or
restlessness.
Judgment ● Presence of
● Correct interpretation of situation. disturbances in
● Make appropriate decision making. motor behavior.
● Soundness of problem solving.
Thinking Thought Content
Orientation ● Delusions,
● Recognize person, place and time. hallucinations.
● Level of consciousness. ● Helplessness,
hopelessness,
Intellectual ● Educational level: worthlessness.
Functioning cognitive functions. ● Suicidal or
● Attention: ability to homicidal thoughts.
concentrate. ● Suspiciousness,
● Retention: ability to obsessions, denial,
retain information. phobia.
● Abstract reasoning:
ability to interpret Thought Process
or associate ● Bizarre, impaired,
situations, proverbs logical, magical.
or comments. ● Ambivalence,
circumstantiality,
Memory ● Ability of the client tangentiality.
to recall distant and ● Thought blocking,
recent events or loose association,
short and long term flight of ideas.
memory.
 ● Perseveration, be corrected by
neologism and reasons.
other thought ● Persecutory
disturbances. Delusions
(Paranoid): False
Thought Clarity belief that
● Coherence, others are
confusion or against him or
vagueness. will harm him.
● Nihilistic
Speech Pattern ● Amount, rate,
Delusions
volume, tone,
(Cotard’s
pressure.
Syndrome):
● Mutism, stuttering,
False belief that
slurring.
one denies
existence of self
Common Signs and Symptoms of Mental or part of selfin
Disorders extreme cases,
the person
● Disturbances in affect.
believes that he
● Mood - Is an emotional state of an
is already dead.
individual.
● Alien Control:
○ The 6 Basic Emotions: Anger, joy,
False belief that
surprise, disgust, sadness, and
one's thoughts
fear
and actions are
● Affect - The person’s capacity to vary
controlled by an
the outward expression of mood (Joy,
external force.
acceptance, fear, surprise, sadness,
● Thought
disgust, anger, anticipation).
Broadcasting:
False belief that
Different Types of Affect one’s thought
can be read by
Inappropriate Disharmony between
Affect thought and emotional others.
response. ● Thought
Withdrawal:
Flat Affect No emotion attached to the
False belief that
content of speech.
one’s thought is
Blunted Affect Significantly reduced taken by others.
intensity of emotional ● Thought
expression. Insertion: False
belief that
Labile Affect Change of emotion from
happiness to tearfulness in a others inserted
very short span of time. thoughts/ideas
into his mind.
Exaggerated Overly dramatic expression ● Ideas of
Affect of emotion:
Reference: False
● Elated
belief that
● Depressed
● Angry situations or
● Anxious events in the
environment are
directly
Disturbances in Thought projected into
the client.
Delusions False belief that cannot
 ● Grandiosity: Tangentiality Verbal production is
False belief that not at all related to the
one is superior question
and powerful. Sudden stoppage of
Thought Blocking
● Self thought without
Depreciation: apparent reason.
False belief that
Neologism Creating new words
one feels
that only the client
unworthy, ugly,
understands.
or sinful.
● Somatic Example: “Chorvahin
Delusions: False ang mga echoserang
belief pertaining frog!”
to body image
Loose Association Patient’s verbal
or function. production is
● Word Salad: impossible to follow
Flow of due to lack of
unconnected organization and lack
words that of connection between
ideas.
convey no
meaning to the Word Salad Extreme form of loose
listener. association, wherein
there are no two words
Obsession A persistent and that connect together
irresistible thought that to form any logical
a person is driven to association.
think again and again.
Example: Colorless
Hypochondria A morbid belief that green ideas sleep
one is sick. furiously.
Perseveration A tendency to emit the Clang Association Patient speaks in
same verbal or motor rhymes.
response again and
again usually as a Example: Rock the boat
response to a stimulus. of a goat wearing coat.

Flight of Ideas Over productivity of

Circumstantiality Patient provides a lot of talk and verbal jumping
details before finally quickly from one idea
answering the to another. Sometimes,
question. ideas are superficially
associated.
Also known as
circumstantial thinking, Example: “I like the
or circumstantial color blue. Do you ever
speech, often include feel blue? Feelings can
excessive irrelevant change day to day. The
details in their speaking days are getting longer.”
or writing.
Poverty of Ideas Patient has few ideas
They maintain their and focuses only on
original train of negative aspects.
thought but provide a
lot of unnecessary Example:
details before circling Q. Do you have
back to their main children?
point. A. …
 Q. Do you have Disturbances of Motor Behavior
children?
A. … (mumbles) Yes.. Catatonic Is a motionless, apathetic
Stupor state in which one is
oblivious or does not react
Disturbances in Perception to external stimuli.
Illusions ● False The client is unresponsive to
Stupor
interpretation of
the surroundings but is
the external
conscious.
stimulus.
● Describes a Rigidity The client assumes position
misinterpretation and will not move when
of a true effort is made to change his
sensation. position.

Hallucination False sensory Waxy The client maintains his

perceptions that occur Flexibility position which he has been
in the absence of an originally placed in.
actual external stimuli
and it may involve any of Catatonic Is a state of constant
the senses.
Excitement purposeless agitation and
● Gustatory excitation.
Hallucination
Hyperactivity Presence of motor
(taste)
restlessness and extreme
● Olfactory
over activity.
Hallucination
● Impulsiveness:
(smell)
Unpredictable and
● Visual
sudden outburst of
Hallucination
activity.
(sight)
● Compulsion:
● Auditory
Unwanted urge to
Hallucination
perform repetitive
(hearing)
actions.
● Tactile
Hallucination Automatism Unconscious uncontrollable
(touch) undirected activity
● Echopraxia: Client
Depersonalization ● A feeling of
imitates actions of
detachment from
others.
the environment
● Echolalia: Client
and self.
repeats words or
● Going through
statements of others.
the motions of
life but not Pressured Unrelenting, rapid, often
experiencing it, Speech loud talking without pauses.
feeling as though
one is in a movie. Stereotype Repetitive persistent motor
activity or speech.
Derealization ● A feeling of ● Verbigeration:
altered reality. Repetition of words
● Dream-like state or phrases may not
of mind. have meaning to the
listener.
Mannerism Persistent motor behavior. Déjà vu Familiarity of events that
are unfamiliar.
Tics and Unconscious twitching or ● “Has seen.”
Spasm jerking of muscles usually
above the shoulder which Jamais Vu Unfamiliarity of events that
are involuntary. are familiar.
● “Hasn't seen.”

Disturbances in Memory Deja Entendu Familiarity of sounds that

are unfamiliar.
Amnesia Complete absence of
● “Has heard.”
memory.
Anterograde Amnesia Jamais Unfamiliarity of sounds that
(Goldfield’s Syndrome) Entendu are familiar.
● Forgetting recent ● “Hasn't heard.”
events.
● The client finds it
difficult to SCHIZOPHRENIA
remember things
Introduction
that occur after a
Schizophrenia is a group of disorders
traumatic event.
Retrograde Amnesia characterized by disturbance in thoughts,
● Forgetting further feelings, perception and behavior.
events. ● Severe impairment of mental and social
functioning with grossly impaired reality
● The client finds it
difficult to testing, sensory perception and with
deterioration and regression of
remember things
that occurred before psychosocial functioning.
a traumatic event.
Assessment of Schizophrenia
Paramnesia Incomplete absence of
Diagnostic Criteria
memory.
● Two or more of the following
● Confabulation:
characteristic symptoms present for
Fabricating stories
significant portion of during a 1-month
to fill up lapses of
period:
memory caused by
○ Delusions
anterograde
○ Hallucination
amnesia.
○ Disorganized speech
● Blackout: Amnesia
○ Grossly disorganized or
experienced by
catatonic behavior
alcoholics about
○ Negative symptoms
behavior during
● One or more major areas of social or
drinking bout.
occupational functioning markedly
● False Memory:
below previously achieved level such as:
Recollection of and
○ Work
belief in an event
○ Interpersonal relations
that did not actually
○ Self-care
occur.
● Continuous signs for at least 6 months.
● Lethologica:
Temporary inability
Symptoms of Schizophrenia
to remember a name
● Positive Symptoms - Reflect an excess
or proper noun.
distortion of normal functions
including:

○ Delusions - Fixed false beliefs
that have no basis in reality.
○ Hallucinations - False sensory
perceptions or perceptual
experiences that do not exist in
reality.
○ Ambivalence - Holding
seemingly contradictory beliefs
or feelings about the same person,
event, or situation.
○ Echopraxia - Imitation of the
movements and gestures of
another person whom the client
is observing.
○ Flight of ideas - Continuous flow
of verbalization in which the
person jumps rapidly from one
topic to another.
○ Perseveration - Persistent
adherence to a single idea or
topic; verbal repetition of a
sentence, word, or phrase;
resisting attempts to change the
topic.
○ Associative looseness
Fragmented or poorly related
thoughts and ideas.
○ Ideas of reference - False
impressions that external events
have special meaning for the
person.
○ Bizarre behavior - Outlandish
appearance or clothing;
repetitive or stereotyped,
seemingly purposeless
movements; unusual social or
sexual behavior.
● Negative Symptoms - Reflect
lessening or loss of normal function such
as:
○ Affective flattening and
blunting - Restriction of
flattening in the range and
intensity of emotions.
○ Alogia - Tendency to speak little
or to convey little substance of
meaning (poverty of content).
○ Avolition - Withdrawal and
inability to initiate and persist in
goal directed activity.
○ Anhedonia - Inability to
experience pleasure. Feeling no
joy or pleasure from life or any
activities or relationships.
○ Apathy - Feelings of indifference
toward people, activities, and
events.
○ Catatonia – Psychologically
induced immobility.
○ Blunted affect - Restricted range
of emotional feeling, tone, or
mood.
○ Avolition or lack of volition -
Absence of will, ambition, or
drive to take action or accomplish
tasks.
○ Asociality - Social withdrawal,
few or no relationships, lack of
closeness.
○ Blunted affect - Restricted range
of emotional feeling, tone, or
mood.
○ Flat affect - Absence of any facial
expression that would indicate
emotions or mood.
○ Inattention - Inability to
- concentrate or focus on a topic or
activity, regardless of its
importance.
● Disorganized Thinking
○ Echolalia - The client’s imitation
or repetition of what the nurse
says.
■ Example: Nurse: “Can you
tell me how you’re
feeling?”
○ Circumstantiality
○ Loose association
○ Tangentiality
○ Flight of ideas
a
○ Word salad - a combination of
jumbled words and phrases that
are disconnected or incoherent
and make no sense to the
listener.
■ Example: “Corn, potatoes,
jump up, play games,grass,
cupboard.”
○ Paranoia
○ Neologism - Words invented by
the client.
■ Example: “I’m afraid of
grittiz. If there are any
grittiz here, I will have to
leave. Are you a grittiz?”
 ○ Clang associations - Ideas that
are related to one another based
on sound or rhyming rather than
meaning.
■ Example: “I will take a pill
if I go up the hill but not if
my name is Jill, I don’t
want to kill.”
○ Referential thinking
○ Concrete thinking
○ Verbigeration - The stereotyped
repetition of words or phrases
that may or may not have
meaning to the listener.
■ Example: “I want to go
home, go home, go home,
go home.”
○ Stilted language - Use of words or
phrases that are flowery,
excessive, and pompous.
■ Example: “Would you be
so kind, as a
representative of Florence
Nightingale, as to do me
the honor of providing
just a wee bit of
refreshment, perhaps in
the form of some clear
spring water?”
○ Pressured speech
○ Hallucination
○ Delusion
○ Illusion
○ Autistic thinking
● Disorganized Behavior
○ Social Withdrawal - Aloof and
fails to encourage interpersonal
relationships.
○ Suspiciousness - Sees the world
as a hostile place.
○ Psychomotor Retardation - Slow
moving and slow speaking, and
waxy flexibility.
○ Hyperactivity - Loud rapid
speaking, inability to sit still.
■ Catatonic excitement
■ Hypervigilance
○ Regression - Inability to meet
basic survival needs.
■ Unable to feed oneself.
■ Poor personal hygiene.
■ Inappropriate dress for
the weather.
○ Aggression
○ Agitation
■ Stereotypy
■ Echopraxia
Bleuler’s Four A’s of Schizophrenia
1. Associative Looseness - Also known as
derailment, refers to a thought-process
disorder characterized by an absence or
lack of connection between thoughts or
ideas. The individual will frequently
jump from one idea to an unrelated one.
2. Autistic Behavior - Person’s thoughts
are excessively involved, and focused
outward.
3. Affect - Blunted affect, severe reduction
in emotional expressiveness.
4. Ambivalence - Presence of two equally
strong feelings coexisting and
neutralizing each other.
5. 5th A: Auditory Hallucinations - New
concept.
Etiological Theories
Current etiologic theories focus on biological
theories:
1. Genetic Factors - Genetic pattern
within the family system (50% chance for
the other identical twin, and 15% for
fraternal twins).
2. Neuroanatomic and Neurochemical
Factors - People with schizophrenia have
relatively less brain tissue and
cerebrospinal fluid, enlarged ventricles
in the brain and cortical atrophy. PET
studies suggest that glucose metabolism
and oxygen are diminished in the frontal
cortical structures of the brain.
3. Immunovirologic Factors - Exposure to
a virus of the body’s immune response to
a virus could alter the brain physiology.
Recent researchers have been focusing
on infections in pregnant women as a
possible origin for schizophrenia.
Psychodynamic Theory
● Poor care giving that leads to psychic
alteration (Freud and Blueler).
● Loss of ego boundaries.
● Double blind communications pattern
within a poor family relationship.
 Onset Characteristics: Inappropriate behavior, silly
● Abrupt or insidious. smiles and laughter, somatic delusions,
● Age of onset appears to be an important impaired ADL.
factor on how well the client fares. Nursing Diagnosis and Management:
● Those who develop the illness earlier ● Self-care deficit.
show worse outcomes than those who ● Promote self-care.
develop it later. ● Promote independence.
● Provide safe and relatively simple
activities.
Types of Schizophrenia
Impaired Socialization:
Paranoid Schizophrenia ● Active friendliness.
● Gain trust.
Behavioral Pattern: Suspicious ● Provide remotivation and
Defense Mechanism: Projection resocialization.
Characteristics: Extreme suspiciousness, ● Improve socialization skills.
ideas of reference, delusion of persecution,
auditory hallucination, and unpredictable Catatonic Schizophrenia
violence.
With stereotyped position (catatonia), waxy
4 P’s
flexibility, mutism, bizarre mannerisms.
1. Projection
Characteristics:
2. Proxemics
● Stupor – Slowed movement.
3. Passive Friendliness
● Posturing – Weird bizarre positions.
4. Persecutory Delusion - A person
● Rigidity - Cementation/stone-like
believes someone wants to hurt them.
position.
They firmly believe this is true, despite
● Negativism – resistance towards
the lack of proof.
flexion and extension
Considerations:
● Excitability - Hyperactivity.
● Consistency to build trust.
Onset: Any age group and usually acute and
● Food: packed or sealed food.
precipitated by an emotionally disturbing
● Social isolation
experience.
● Develop trust
Behavioral Pattern: Withdrawn
● Be reliable and consistent
Defense Mechanism: Repression
● Safety for other and client
Catatonic Stupor Characteristics: Sudden
○ Approach non-threatening
onset of mutism, bizarre mannerisms, waxy
manner.
flexibility, automatism.
○ Never whisper.
Catatonic Excitement Characteristics:
○ Never hold complicated
Dangerous periods of agitation, impulsive and
objects.
explosive behavior.
○ Provide solitary.
Nursing Diagnosis and Management:
○ Provide safe and relatively
● Provide a safe environment.
simple activities.
● Promote nutrition and hydration.
Hebephrenic Schizophrenia ● Prevent bowel and bladder problems.
● Minimize circulatory problems and
Characterized with inappropriate behavior, loss of muscle tone.
silly crying, laughing, regression, and Symptoms of more than one type of
transient hallucinations. schizophrenia. Has delusions and
disorganized behavior but DOES NOT meet
Disorganized Schizophrenia
the criteria for the above subtypes.
Onset: Early, usually below 18 years old and is
Undifferentiated Schizophrenia
insidious
Behavioral Pattern: Withdrawn Symptoms of more than one type of
Defense Mechanism: Regression schizophrenia.

● Affect is flat.
● Delusion and hallucination.
● Disorganized speech.
● Disorganized catatonic behavior.
● Social withdrawal.
● Does not meet the criteria for
paranoid; disorganized or catatonic.
Residual Schizophrenia
The patient no longer exhibits overt
symptoms, no more delusion but still has
negative symptoms or odd benefits or
unusual perceptions.
● People with residual schizophrenia
often neglect basic hygiene and need
help with everyday living activities.
● Absence of prominent delusion,
hallucinations, disorganized speech
and grossly disorganized or catatonic
behavior.
● Negative symptoms persist or two
more positive symptoms are presentin
attenuated form such as odd belief or
unusual perceptual experiences.
Treatment
● Psychopharmacology
○ Traditional medication (1950s)
■ Haloperidol
■ Chlorpromazine
■ Thiothixene
○ New medications (1990s)
■ Clozapine
■ Risperdal
■ Zyprexa
● Maintenance Therapy
Nursing Interventions for Clients with
Psychosocial
Schizophrenia
Psychotherapy
1. Promoting the safety of clients and
others and the right to privacy and
dignity.
a. Approach the client in a
nonthreatening manner.
b. Give ample personal space to
enhance a sense of security.
2. Establish therapeutic relationships.
a. Talk and provide explanations to
clients by being simple, direct and
easy to understand.
b. Call clients by their name
3. Using Therapeutic Communication
(clarifying feelings and statements when
speech and thought are disorganized).
a. Active listening.
b. Structure appropriate times for
rest and sleep; adjust work/rest
activity patterns as needed.
4. Enhance physiological stability/health
maintenance.
a. Provide quiet activities, soothing
music before bedtime, regular
hours for going to bed, drinking
warm milk.
5. Encourage family/significant other to
become involved in activities topromote
independent stratifying lives.
a. Refer to resources such as
occupational
therapist/movement
therapy/outdoor education
program and others.
6. Protect from erratic and inappropriate
behavior (delusions/hallucinations).
a. Communicate in a calm,
authoritative tone.
b. Address clients by their name.
c. Observe patients for early signs
of escalating behavior.
7. Administer antipsychotic medication as
indicated.
8. Accept client’s indifference (e.g., failure
to smile or greet nurse) and avoidance
behavior (e.g., hostility or sarcasm).
9. Explain staff changes, especially
vacations and absences.
a. Encourage the client's affect by
verbalizing what you observe e.g,
“you seem to think that I don’t
want to stay.”
Interventions and
● Counseling and Psychotherapy
○ Provides clients with
understanding of schizophrenia.
○ Helps clients learn to manage the
disease.
● Social Skills Education
○ Client’s ability to interact with
others may be altered.
○ Assist with vocational and career
education needs.
 Discharge Goals
Jealous Patient believes that his
1. Physiological well-being maintained spouse or lover is
with appropriate balance between rest unfaithful.
and activity.
Persecutory Patient believes that he is
a. Identify delusions and increase
being plotted against,
capacity to cope effectively with
spied on, maligned or
them by elimination of
harassed.
pathological thinking.
2. Demonstrate increasing/highest level of Somatic Patient believes that he
emotional responsiveness possible. has a physical deformity,
a. Establish intrapersonal odor or parasite.
relationships.
4. Brief Psychotic Disorder - Client
b. Display behavior congruent with
experiences the sudden onset of at least
verbalization of feelings.
one psychotic symptom, such as
3. Interact socially without
delusion, hallucination, or disorganized
decompensation.
speech or behavior which last from 1 day
a. Maintain reality orientation.
to 1 month.
4. Family displays effective coping skills
5. Shared Psychotic Disorder (Folie à
and appropriate use of resources.
Deux)
a. Demonstrate understanding of
a. Two people share a similar
and begin to use appropriate,
delusion.
constructive, effective methods
b. The person with this diagnosis
of coping.
develops delusion in the context
of a close relationship with
Related Disorders someone who has psychotic
1. Schizophreniform Disorder - The client delusions.
exhibits the symptoms of schizophrenia
but for less than 6 months. Social or Discharge Goals
occupational functioning may or may
1. Demonstrate increasing/highest level
not be impaired.
of emotional responsiveness possible.
2. Schizoaffective Disorder - The client
2. Establish intrapersonal relationships.
exhibits the symptoms of psychosis and
3. Display behavior congruent with
at the same time all the features of a
verbalization of feelings.
mood disorder either depression or
4. Maintain reality orientations.
mania.
5. Family displays effective coping skills
3. Delusional Disorder - The client has
and appropriate use of resources.
one or more bizarre delusions, the focus
6. Demonstrate understanding of self and
of delusion is believable.
begin to use appropriately.
a. Central Feature: Presence of 1 or
more false beliefs that persist for
at least 1 month. Current Trends in Schizophrenia Research
● Brain imaging and mapping.
Subtypes of Delusional Disorder ● Autoimmunity immune systems and
dysregulation model.
Erotomanic Patient believes that ● Ethical and legal considerations in high
another person is in love risk studies of schizophrenia.
with him. ● Pharmacogenetics and tailored drug
treatment.
Grandiose Patient believes that he
● The role of nurses and interdisciplinary
has great talent or has
team.
made an important
discovery.

Critical Thinking Questions
1. Clients who fail to take medications
regularly are often admitted to the
hospital repeatedly, and this can become
quite expensive. How do you reconcile
the client’s rights (to refuse treatment or
medications) with the need to curtail
avoidable health care costs?
2. What is the quality of life for the client
with schizophrenia who has a minimal
response to antipsychotic medications
and therefore poor treatment
outcomes?
3. If a client with schizophrenia who
experiences frequent relapses has a
young child, should the child remain
with the parent? What factors influence
this decision? Who should be able to
make such a decision?
4. How does the nurse maintain a positive
but honest relationship with a client’s
family if the client does not respond well
to antipsychotic medications?
5. Clients who take depot injections of
antipsychotic medications are
sometimes court ordered to comply with
this treatment when they are in the
community.
a. Does this violate the client’s right
to self-determination or
autonomy?
b. When should clients have the
ability to refuse such mediations?
MOOD DISORDERS AND SUICIDE
Current Issues Related to the Topic
● Euthanasia and assisted suicide are
hotly debated topic in our society.
○ Should either be legal?
○ Under what circumstances?
○ How should these issues be
decided?
● Some people struggle with the idea of
wether suicide can ever be the decision of
a rational person or whether being
suicidal is always a sign of mentalillness.
● Suicide rates remain high for
adolescents and the elderly (over the
age of 80).
● Is that a sign of despair and
hopelessness? What is society’s response
to these two populations?
Mood Disorders
Notable People with Mood Disorder
● Van Gogh
● Queen Victoria
● George Frederick Handel
● Abraham Lincoln
Categories
Major 2 or more weeks of sad mood,
Depression lack of interest in life activities,
and other symptoms.
MDD, also referred to as
clinical depression.
Bipolar Formerly called
Disorder ‘manic-depressive illness.’
Mood cycles of mania and/or
depression and normalcy and
other symptoms.
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 to a general
medical condition
● Seasonal Affective Disorder (SAD)
● Postpartum or maternity blues
● Postpartum depression
● Postpartum psychosis
Biological Theories
● Genetic Theories
● Neurochemical Theories
● Neuroendocrine Influences
○ Hormonal fluctuations.
● Theories of Cause of Depression:
Psychodynamic Theories
○ Aggression turned inward self
anger.
 ○ Response to separation of object
loss.
○ Genetic of neuro-biochemical
basis-impaired.
neurotransmission system,
especially serotonin regulation.
○ Self-approach to anger turned
inward.
○ Inability to achieve personal
ideas.
○ Powerless ego.
○ View manic episodes as a
“defense” against underlying
depression, with the ID taking
over the ego and acting as an
undisciplined hedonistic being
(child).
○ Reaction to a distressing life
experience.
○ Rejecting or unloving parents.
○ Depression is a result of specific
cognitive distortions in
susceptible people.
Cultural Considerations
● Other behaviors considered
age-appropriate can mask depression.
● Somatic complaints are a major
manifestation among cultures that avoid
verbalizing emotions.
○ Asians who are anxious or
depressed are more likely to have
somatic complaints of headache,
backache, or other symptoms.
○ Latin culture complains of
“nerves” or headaches.
○ Middle Eastern cultures
complain of heart problems.
Major Depressive Disorder
● Twice common in women and 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:
○ Changes in appetite or weight,
sleep, or psychomotor activity.
○ Decreased energy.
○ Feelings of worthlessness or
guilt.
○ Difficulty thinking,
concentrating, or making
decisions.
○ Recurrent thoughts of death or
suicidal ideation, plans, or
attempts.
● Untreated, can last 6 to 24 months;
recurs in 50%-60% of people.
● Symptoms range from mild to severe.
1. Bipolar Mixed - Cycles alternate
between periods of mania, normal
mood, depression, normal mood, mania,
and so forth.
2. Bipolar Type 1 - Manic episodes with at
least one depressive episode.
3. Bipolar Type II - Recurrent depressive
episodes with at least one hypomanic
episode.
Treatment
● Antidepressants
● SSRIs (Prozac, Zoloft, Paxil, Celexa)
prescribed for mild and moderate
depression.
● TCAs (Elavil, Tofranil, Norpramin,
Pamelor, Sinequan) used for moderate
and severe depression.
● Atypical antidepressants (Effexor,
Wellbutrin, Serzone)
● MAOIs (Marplan, Parnate, Nardil) are
used infrequently because interaction
with tyramine causes hypertensive
crises.
● Electroconvulsive Therapy (ECT) is used
when medications are ineffective or side
effects are intolerable.
○ 6-15 treatments scheduled three
times a week.
○ Preparation of clients 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 the most
 effective treatment; useful therapies
include behavioral, cognitive,
interpersonal therapy.
Application of the Nursing Process
Assessment
● History: The client’s perception of the
problem, behavioral changes, any
previous episodes of depression,
treatment, response to the treatment,
family history of mood disorders,
suicide, or attempted suicide.
● General Appearance and Motor
Behavior: Slouched posture, latency of
response, psychomotor retardation or
agitation.
● Mood and Affect: Hopelessness,
helpless, down, anxious, frustrated,
anhedonia, apathetic; affect is sad,
depressed, or flat.
● Thought Processes and Content:
Slowed thinking processes, negative and
pessimistic, ruminate, thoughts of dying
or committing suicide.
● Sensorium and Intellectual Processes:
Oriented, memory impairment,difficulty
concentrating.
● Judgment and Insight: Impaired
judgment, insight may be intact or
limited
● Self-Concept: Low self-esteem, guilty,
believe that others would be better off
without them.
● Roles and Relationships: Difficulty
fulfilling roles and responsibilities.
● Physiologic Considerations: Weight
loss, sleep disturbances, lose interest in
sexual activities, neglect personal
hygiene, constipation, dehydration.
● Depression Rating Scales: Zung Self-
Rating Depression Scale, Beck
Depression Inventory, the Hamilton
Rating Scale for Depression.
Diagnosis
Nursing diagnosis may include the following:
● Risk for suicide
● Imbalanced nutrition: Less than body
requirements
● Anxiety
● Ineffective coping
● Hopelessness
● Ineffective role performance
● Self-care deficit
● Chronic low self -esteem
● Disturbed sleep pattern
● Impaired social interaction
Planning/Outcomes
The client will:
● Not injure himself or herself.
● Independently carry out activities of
daily living (showering, changing
clothing, grooming).
● Establish a balance of rest,sleep, and
activity.
● Establish a balance of adequate
nutrition, hydration, and elimination.
● Evaluate self-attributes realistically.
● Socialize with staff, peers, and
family/friends.
● Return to occupation or school
activities.
● Comply with antidepressant regimen.
● Verbalize symptoms of a recurrence.
Intervention
● Providing for the client’s safety and
safety of others.
● Promoting a therapeutic relationship.
● Promoting activities of daily living and
physical care.
● Using therapeutic communication.
● Managing medications.
● Providing client and family teaching.
Evaluation
● Does the client feel safe?
● Is the client free of uncontrollable urges
to commit suicide?
● Is the client participating in therapy and
medication compliance?
● Can the client identify signs of relapse?
● Will the client agree to seek treatment
immediately upon relapse?
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 swing of depression
(same symptoms of major depressive
 disorder) and mania. Major symptoms of
mania include:
○ Inflated self-esteem or
grandiosity
○ Deceased need for sleep
○ Pressured speech
○ Flight of ideas
○ Distractibility
○ Increased involvement in goal-
directed activity or psychomotor
agitation.
○ Excessive involvement in
pleasure-seeking activities with a
high potential for painful
consequences.
Treatment and Prognosis
● Medication:
○ Lithium; regular monitoring of
serum lithium levels is needed.
○ Anticonvulsant drugs are used
for their mood-stabilizingeffects;
(carbamazepine)
Tegretol, (Valeric acid) Depakote,
Lamictal, Topamax, and
Neurontin, as is Klonopin (a
benzodiazepine)
● Psychotherapy:
○ Psychotherapy combined with
medication can reduce the risk of
suicide and injury.
○ Useful in mildly depressive or
normal portions of the bipolar
cycle. It is not useful during an
acute manic stage.
Application of the Nursing Process
Assessment
● General Appearance and Motor
Behavior: Psychomotor agitation;
flamboyant clothing or makeup; think,
move and talk fast; pressured speech.
● Mood and Affect: Euphoria, exuberant
activity, grandiosity, false sense of well
being, angry, verbally aggressive,
sarcastic, irritable.
● Thought Processes and Content: Flight
of ideas, circumstantiality, tangentiality,
possible grandiose delusions.
● Sensorium and Intellectual Process:
Oriented to person and place but rarely
to time, impaired ability to concentrate,
may experience hallucinations.
● Judgment and Insight: Judgment is
poor, insight is limited.
● Self-Concept: Exaggerated self-esteem.
● Roles and Relationships: Rarely can
fulfill role responsibilities, invade
intimate space and personal business of
others, can become hostile space and
personal business of others, can become
hostile to others, cannot postpone or
delay gratification.
● Physiologic and Self-Care
Considerations: Inattention to hygiene
and grooming, hunger or fatigue.
Diagnosis
Nursing diagnosis may include the following:
● Risk for other-directed violence
● Risk for injury
● Imbalanced nutrition: less than body
requirements
● Ineffective coping
● Noncompliance
● Ineffective role performance
● Self-care deficit
● Chronic low self-esteem
● Disturbed sleep pattern
Planning/Outcomes
The client will:
● Not injure himself or others.
● Establish a balance of rest, sleep and
activity.
● Establish adequate nutrition, hydration
and elimination.
● Participate in self-care activities.
● Evaluate personal qualities realistically.
● Engage in socially appropriate,
reality-based interaction.
● Verbalize knowledge of his or her illness
and treatment.
Intervention
● Provide for the safety of clients and
others.
● Meet physiological needs.
● Provide therapeutic communication.
● Promote appropriate behaviors.
● Manage medications.
● Provide client and family teaching.
● Set limits on client’s behavior when
needed.
● Remind the client to respect distances
between self and others.
 ● Protect the client’s dignity when
inappropriate behaviors occur.
● Channel client’s need for movement into
socially acceptable motor activities.
Evaluation
● Safety issues.
● Comparison of mood and affect
between start of treatment and present.
● Adherence to treatment regimen of
medication and psychotherapy.
● Changes in client’s perception of quality
of life.
● Achievement of specific goals of
treatment including new coping
methods.
Suicide
● Poor impulse control
● Poor judgment
● Immature coping skills
● Low self esteem, poor self integration,
and identity
● Depression
● Emotional isolation
● Dysfunctional family interactions
● Use of drugs or alcohol
● Social problems with peers/bullying
Theories on Suicide
1. Psychoanalytic Theory
a. Suicide is anger turnded inwards
b. Life (eros) and death (thanatos)
instinct.
c. Stressful life circumstances can
activate the death wish inherent
in each one of us.
2. Sociological Theory
a. Suicide and social conditions.
b. Suicide rates and poverty level,
unemployment, political and
economic instability.
3. Interpersonal Theory - Suicide is the
outcome of a failure to work or resolve
interpersonal conflicts.
4. Biological Theory - Usually attributed
to disturbances in neurotransmitters.
Application of the Nursing Process
Assessment
● Men commit suicide three times the rate
of women.
● Women are four times more likely than
men to attempt suicide.
● Popular at Risk:
○ Men, young women, adults older
than 65, and separated and
divorced people.
○ Clients with psychiatric
disorders.
● Environmental Factors:
○ Isolation
○ Recent loss
○ Lack of social support
○ Unemployment
○ Critical life events
○ Family history of depression or
suicide
● Behavioral Factors:
○ Impulsivity
○ Erratic or unexplained changes
from usual behavior
○ Unstable lifestyle
● Warnings of suicidal intent
● Risky Behaviors
● Lethality Assessment:
○ 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?
Planning/Outcomes
The client will:
● Not injure himself or others.
● Engage in a therapeutic relationship.
● Establish a no-suicide contract.
● Create a list of positive attributes.
● Generate, test, and evaluate realistic
plans to address underlying issues.
Intervention
● Use an authoritative role.
● Provide a safe environment.
● Initiate a no-suicide contract.
● Create a support system list.
Family’s Response
● Significant others may feel guilty, angry,
ashamed, and sad.
Nurse’s Response
● The nurse does not blame or act
judgmentally when asking about the
details of a planned suicide. Rather, the
nurse uses a non judgmental tone of
voice and monitors his or her body
language and facial expression to make
sure not to convey disgust or blame.
● Nurses must realize that no matter how
competent and caring intervention are,
a few clients will still commit suicide. A
client’s suicide can be devastating to the
staff members who treated the client.
● Oftentimes, nurses must care for
terminally ill or chronically ill people
with a poor quality of life.
● The nurse’s role is to provide supportive
care for clients and family.
● Depression is common among theelderly
and is markedly increased when elders
are medically ill.
● Elders tend to have psychotic features,
particularly delusions, more frequently
than younger people with depression.
● Suicide amoung people over the age of
65 is doubled compared to suicide rates
of persons younger than 65 years old.
● Elders are treated for depression with
ECT more frequently than younger
ones.
● Elder persons have decreased tolerance
of side effects of antidepressant
medications
● Education to address stressors
contributing to depressive illness.
● Promotions of factors reducing suicide
risk in adolescents (close parent-child
relationships, academic achievements,
family life stability, and connectedness
with peers and others outside the
family).
● Screening for early detection of risk
factors, such as family strife, parental
alcoholism or mental illness, history of
fighting, and access to weapons in the
home.
● Nurses and other staff members need to
deal with their own feelings about
suicide.
● Depressed or manic clients can be
frustrating and require a lot of energy to
care for.
● Keeping a written journal may help deal
with feelings; talking to colleagues is
often helpful.
ANXIETY AND STRESS RELATED ILLNESS
Anxiety in Everyday Life
● What are the objects of your worries?
● Are there personal worries stemming
from your societal role and duties?
● Do you have personal fear associated
with activities or objects?
Anxiety is a vague feeling of dread
apprehension; it is a response to external or
internal stimuli.
● Can have behavioral, emotional,
cognitive, and physical symptoms.
● Effective subjective response to an
imagined or real internal or external
threat.
Anxiety as a Response to Stress
● Stress is the wear and tear that life
causes on the body (Selye, 1956).
● It occurs when a person has difficulty
dealing with life situations, problems,
and goals.
● (+) or (-) occurrence
Hans Selye identified three stages of reaction
to stress:
Alarm Stress stimulates the body to
Reaction send messages from the
Stage hypothalamus to the glands
(such as adrenal gland, to send
out adrenaline and
norepinephrine for fuel) ans
orgas (such as the liver, to
reconvert glycogen stores to
glucose for food) to prepare for
potential defense needs.
Resistance The digestive reduces function
Stage to shunt blood to areas as
needed for defense. The lungs
take in more air, and the heart
beats faster and harder so that
it can circulate this highly
oxygenated and highly

nourished blood to the muscles
to defend the body to fight,
flight or freeze behaviors. If the
person adapts to the stress, the
body responses relax, and the
gland, organ and systemic
response abate.
Exhaustion Occurs when the person has
Stage responded negatively to
anxiety and stress: body is
depleted or emotional
components are not resolved,
resulting in continual arousal of
the physiological responses and
little reserve capacity.
Categories
Mild Sensation that something is
Anxiety different and warrants special
attention; sensory stimulation
increases; focus attention to
learn, solve problems, think,
act, feel, and protect self;
motivated.
Moderate Feeling that something is
Anxiety definitely wrong; nervous or
agitated; can still process
information, solve problems,
and learn new things with
assistance from others;
difficulty concentrating but
can be directed.
Severe Trouble thinking and
Anxiety reasoning; muscles tighten;
vital signs increase; pacing;
restless, irritable, and angry;
uses other
emotional-psychomotor means
to release tension.
Panic Fight, flight, or freeze
Anxiety responses; cognitive process
focuses on the person’s
defense.
When Working With Anxious Clients:
● Be aware of the 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
A group of conditions that share a key feature
of excessive anxiety with ensuing behavioral,
emotional, and physiologic responses.
● Agoraphobia with or without panic
disorder
● Panic Disorder
● Specific Phobia
● Social Phobia
● Obsessive-Compulsive Disorder (OCD)
● Generalized Anxiety Disorder (GAD)
● Post traumatic Stress Disorder (PTSD)
Incidence of Anxiety Disorders
● Anxiety disorders are the most common
psychiatric disorders affecting 25% of
adults.
● 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 courses are variable.
Related Disorders
● Anxiety disorder due to a general
medical condition.
● Substance-Induced Anxiety Disorder
● Separation Anxiety Disorder
● Adjustment Disorder
Etiologies
Biological Theories
Anxiety may have an inherited component;
neurotransmitters may be dysfunctional in
persons with anxiety disorders.
Psychodynamic Theories
Elder Considerations
Overuse of defense mechanisms; results from
Late-life anxiety disorders are often associated
problems in interpersonal relationships; as
with another condition, such as depression,
“learned” behavioral response.
dementia, physical illness, or medicationtoxicity
or withdrawal. Phobias, particularly
Neurochemical Theories
(GABA) is the amino acid neurotransmitter agoraphobia, and generalized anxiety disorders
(GAD) are the most common late-life anxiety
believed to be dysfunctional in anxiety
disorders.
disorders. GABA, an inhibitory
neurotransmitter, functions as the body’s
The treatment of choice for anxiety disorders in
natural anti-anxiety.
the elderly is SSRI antidepressants.
● Serotonin is believed to play a distinct
role in OCD, panic disorder, and
generalized anxiety disorder. An excess Mental Health Promotion
of norepinephrine is suspected in panic ● Goal is effective management, not total
disorder, generalized anxiety disorder, elimination of anxiety.
and posttraumatic stress disorder. ● Keep a positive attitude and believe in
yourself.
Interpersonal Theory ● Accept that there are events you cannot
Viewed anxiety as being generated from control.
problems in interpersonal relationships. ● Communicate assertively with others.
○ Talk about your feelings with
Behavioral Theory others.
Anxiety as being learned through experiences ○ Express your feelings through
and response. laughing, crying and so forth.
● Learn to relax.
Cultural Considerations ● Exercise regularly.
● Eat well-balanced meals.
Asian Cultures often express anxiety through
● Limit intake of caffeine and alcohol.
somatic symptoms such as headaches,
● Get enough rest and sleep.
backaches, fatigue, dizziness, and stomach
● Set realistic goals and expectations.
problems.
● Find an activity that is personally
meaningful.
Hispanics experience high anxiety as sadness,
● Learn stress management techniques.
agitation, weight loss, weakness, and heart rate
changes. The symptoms are believed to occur
because supernatural spirits or bad air from Panic Disorder
dangerous places and cemeteries invades the ● Involves 15- to 30-minute episodes of
body. intense, escalating anxiety with
emotional fear and physiologic
Treatment discomfort.
● Peaks in late adolescence and the
Treatments usually involve a combination of
mid-30s.
medication (anxiolytics and antidepressants)
● Can lead to avoidance behavior or
and therapy.
agoraphobia.
● Treated with cognitive-behavioral
Cognitive-Behavioral Therapy
techniques, deep breathing and
● Positive reframing - Turning negative
relaxation, and medications
messages into positive ones.
(benzodiazepines, SSRI antidepressants,
● Decatastrophizing - Making a more
tricyclic antidepressants, and
realistic appraisal of the situation.
antihypertensives).
● Assertiveness training - Learn to
● Symptoms persist for at least 1 month.
negotiate interpersonal situations and
● Attacks have a sudden onset of intense
foster self assurance.
anxiety.
 ● Profound fear or sense of imminent
danger.
● Women are 2-3 times more likely to
suffer from panic disorder than men.
Application of the Nursing Process
Assessment
● Reports of several panic attacks.
● May appear “normal” or may have signs
of anxiety.
● Anxious, worried, tense, depressed,
serious, or sad.
● Fears losing control or going insane.
● Confused and disoriented.
● Judgment is poor during an attack.
● Self-blaming statements.
● Alterations in his or her social
occupation, or family life.
● Problems sleeping and eating.
Diagnosis
Nursing diagnosis may include the following:
● Risk for injury
● Anxiety
Situational low self-esteem (panic
attacks)
● Ineffective coping
● Powerlessness
● Ineffective role performance
● Disturbed sleep pattern
Planning/Outcomes
The client will:
● Be free of injury.
● Verbalize feelings.
● Use effective coping techniques.
● Manage his own anxiety response.
● Verbalize a sense of personal control.
● Reestablish adequate nutritional intake.
● Sleep at least 6 hours per night.
Intervention
● Provide a safe environment and ensure
client’s privacy during a panic attack.
● Remain with the client during a panic
attack.
● Help the client to focus on deep
breathing.
● Talk to the client in a calm reassuring
voice.
● Teach the client to use relaxation
techniques.
● Help the client to use cognitive
restructuring techniques.
● Engage with the client to explore how
to decrease stressors and
anxiety-provoking situations.
Evaluation
● Does the client understand the
prescribed medication regimen, and is
he or she committed to adhering to it?
● Has the client’s episodes of anxiety
decreased in frequency or intensity?
● Does the client understand various
coping methods and when to use them?
● Does the client believe that his or her
quality of life is satisfactory?
Phobia
Phobia is a logical intense, persistent fear of a
specific object or social situation that causes
extreme distress and interferes with normal life
functioning.
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.
Types of Phobia
1. Agoraphobia - Fear of being outside.
2. Specific Phobia -An irrational fear of an
object or situation.
3. Social Phobia - Anxiety provoked by
certain social or performance situations.
Specific Phobia Fear of…
ABLUTOphobia Washing
ACHLUOphobia Darkness
AILUROphobia Cats
ARACHNOphobia Spiders
ASTRAPOphobia Lightning
BATHMOphobia Stairs
 BROMIDROSIphobia Body smells NOCTIphobia Night

CACOphobia Ugliness OCHLOphobia Crowds or mobs

CATAGELOphobia Being ridiculed OCHOphobia Vehicles

DEMOphobia Crowds OENOphobia Wines

DIDASKALEINOphobia Going to school PAGOphobia Ice or frost

DOMATOphobia Houses PANphobia Everything

EISOPTROphobia Mirrors PHALACROphobia Becoming bald

ENOCHLOphobia Crowds POTAMOphobia Rivers

FRIGOphobia Cold or cold PYROphobia Fire

things
RANIDAphobia Frogs
GAMOphobia Marriage
RHYPOphobia Defecation
GERASCOphobia Getting old
RHYTIphobia Getting wrinkles
GLOSSOphobia Speaking in public
RUPOphobia Dirt
GYNEphobia Women
SCIOphobia Shadows
HELIOphobia Sun
SCOLECIphobia Worms
HETEROphobia Opposite sex
SELACHOphobia Sharks
HIPPOphobia Horses
SIDERODROMOphobia Trains
HYPSIphobia Height
SYNGENESOphobia Relatives
IATROphobia Doctors
THANATOPhobia Death
ICHTHYOphobia Fish
THALASSOphobia Sea
IOphobia Poison
TRISKAIDEKAphobia Number 13
KAINOphobia Novelty
TRYPANOphobia Injections
KAKORRHAPHIOphobia Failure
VESTIphobia Clothing
LEVOphobia Objects to the left
XANTHOphobia Color yellow or
LILAPSOphobia Hurricanes the word ‘yellow’

MACROphobia Long waits XENOphobia Strangers

MAGEIROCOphobia Cooking XYROphobia Razors

MAIEUSIOphobia Childbirth ZELOphobia Jealousy

MEDOMALACUphobia Losing an erection ZOOphobia Animals

MYCTOphobia Darkness
Treatment and Prognosis
NEOPHOphobia Anything new ● Psychopharmacology
○ Anxiolytics, SSRI
NEPHOphobia Clouds antidepressants, beta blockers to
 slow heart rate and lower blood
pressure.
● Behavioral Therapies
○ Systematic desensitization -One
behavioral therapy often used to
treat phobias is systematic (serial)
desensitization in which the
therapist progressively exposes
the client to the threatening
object in a safe setting until the
client’s anxiety decreases.
○ Flooding - Is an abrupt exposure
to the feared object. It is a form
of rapid desensitization in which
a behavioral therapist confronts
the client with the phobic object
until it no longer produces
anxiety.
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.
Common Rituals
The person knows the rituals are unreasonable
but feels forced to continue them in an attempt
to relieve anxiety caused by obsessions.
● Checking rituals
● Counting rituals
● Washing and scrubbing until the skin is
raw
● Praying or chanting
● Touching, rubbing, or tapping
● Hoarding items
● Ordering (arranging and rearranging
items on a desk, shelf, or furniture, into a
prefect order; vacuuming the rug pile in
one direction).
Treatment and Prognosis
● Treatment is the most successful with
behavior therapy and medication.
○ SSRI antidepressants,
fluvoxamine, clomipramine,
buspirone, clonazepam
● Behavior Therapy Techniques:
○ Exposure (confronting
anxiety-provoking stimuli).
○ Response prevention (delaying or
avoiding ritual performance
Application of the Nursing Process
Assessment
● Yale-Brown Obsessive Compulsive Scale
● Reports of obsession becoming too
overwhelming, compulsions interfere
with daily life.
● Tense, anxious, worried, and fretful.
● Ongoing, overwhelming feelings of
anxiety.
● Intact intellectual functioning with
difficulty concentrating.
● Recognizes that the obsessions are
irrational, but he or she cannot stop
them.
● Powerlessness
● Relationships suffer.
● Trouble sleeping or loss of appetite.
Diagnosis
Nursing diagnosis may include the following:
● Anxiety
● Ineffective coping
● Fatigue
● Situational low self-esteem
● Impaired skin integrity (if scrubbing or
washing rituals).
Planning/Outcomes
The client will:
● Complete daily routine within a realistic
time frame.
● Demonstrate effective use of relaxation
techniques.
● Discuss feelings with others.
● Demonstrate effective use of behavior
therapy.
● Spend less time performing rituals.
Intervention
● Using therapeutic communication.
● Teaching relaxation and behavioral
techniques.
● Completing a daily routine.
● Providing client and family education.
Evaluation strangers ringing doorbells,
● Do the symptoms no longer interfere walking in crowds of people).
with the client's ability to carry out b. Note signs of increasing anxiety
responsibilities? (e.g., silence stuttering, inability
● When obsessions occur, does the client to sit still/pacing).
manage resulting anxiety without c. Develop a trusting relationship
engaging in complicated or time- with the client.
consuming rituals? 2. Assist the client to enhance self-esteem
● Does the client report regain control and regain a sense of control over
over his or her life? feelings/actions.
● Does the client report the ability to a. Identify whether the incident has
tolerate and manage anxiety with reactivated preexisting or
minimal disruption? coexisting situations
(physical/psychological).
b. Evaluate social aspects of
Generalized Anxiety Disorder (GAD)
trauma/incident (e.g.,
● Excessive worry and anxiety that is disfigurement, chronic
unwarranted more days than not. conditions, permanent
● Symptoms include uneasiness, disabilities).
irritability, muscle tension, fatigue, c. Encourage the client to keep a
difficulty thinking, and sleep alterations. journal about feelings,
● Seen most often by family physicians. precipitating factors, associated
● Treated with SSRI antidepressants and behaviors.
buspirone. d. Explore actions that can be used
during periods of stress (e.g.,
Post Traumatic Stress Disorder (PTSD) deep breathing, counting to 10,
reviewing the situation,
● An anxiety disorder resulting from
reframing).
exposure to a traumatic event in which
e. Stay with the client, maintaining
the individual has experienced,
a calm, confident manner. Speak
witnessed, or been confronted with an
in brief statements, using simple
event or events that involve actual or
words.
threatened death/serious injury or a
f. Provide a nonthreatening,
threat to the physical integrity of the self
consistent environment or
or others.
atmosphere.
● New behaviors develop related to the
trauma such as sleep difficulty,
hypervigilance, thinking difficulty, Acute Stress Disorder
severe startle response, and agitation. (Dissociative Disorder)
● A dissociative response develops
Application of the Nursing Process following the experience of a traumatic
Assessment situation.
● Sleep disturbances, recurrent intrusive ● The person has a sense that the event
dreams of the event, nightmares, was unreal, thinks he or she is unreal,
difficulty in falling or staying asleep; and forgets some aspects of the event
hypersomnia (intrusive thoughts, through amnesia, emotional
flashbacks, and/or nightmares are trial detachment, and muddled obliviousness
symptomatic of PTSD). to the environment.
● Blocks off part of his or her life from
Nursing Priorities consciousness during periods of
1. Provide safety for clients/others. intolerable stress. Stressful emotion
a. Identify development of phobic becomes a separate entity, as the
reactions to ordinary articles individual “splits” from it and mentally
(e.g., knives), situations (e.g., drifts into a fantasy state.

Dissociative Disorders
Disorders in which consciousness, behavior,
and identity are split or altered, typically
involve some degree of memory loss.
Dissociative Loss of memory for
Amnesia threatening or
The Advanced-Practice Psychiatric Nurse
anxiety-producing events
with no biological cause,
cannot be explained by
ordinary forgetfulness.
Dissociative Disorder in which a person
Fugue forgets identity and wanders
far from home, may take on a
new identity, may later regain
memory of original identity,
but have no memory of fugue
experiences.
● Stress and anxiety are common
experiences for all people.
● People with anxiety disorder often “look
well enough” to control their behavior.
● Avoid trying to “fix” the client’s
problems.
● Incorporates the role of the generalist
nurse.
● Applies advanced clinical skills.
● Determines differential diagnosis.
● Major interventions include:
○ Psychotherapy
○ Prescribing medications
○ Case management
○ Evaluation of outcomes
measures

Dissociative Disorder in which two or

Identity more identities exist within
Disorder the same person.
(Formerly
Multiple
Personality
Disorder or
MPD)

Nursing Priorities
1. Provide a safe environment; protect
clients/others from injury.
a. Provide a calm environment;
minimize external stimuli.
Identify individual
causes/precipitators of stress.
2. Assist clients to recognize anxiety.
a. Maintain a neutral approach
when confronted by an alternate
personality or dissociative state.
3. Promote insight into the relationship
between anxiety and development of
dissociative/other personalities.
a. Discuss relationship between
severe anxiety and
depersonalization behaviors.
b. Explore past experiences and
painful situations (e.g., trauma,
abuse) that may be repressed.
4. Support client/family in developing
effective coping skills and participating
in therapeutic activities.

Self-Awareness Issues