NCMB317 LECTURE:
06
BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
Bachelor of Science in Nursing 3YB
Professor: Donato Mirador MAN, RN & Vilma Miguel MAN, RN
Prelim Topics:
• Psychiatric Mental Health Nursing
• Concepts Mental Health and Mental Illness Practice
• Therapeutic Theories in Psychiatric Nursing Practice
• Schizophrenia
• Mental Health Care Delivery in the Philippines
• Johari Window & Self Awareness
• Therapeutic Communication and Relationships
• Treatment modalities
• Psychopharmacology
PSYCHIATRIC MENTAL HEALTH NURSING
Mental Health and Mental Illness
- WHO a state of complete physical, mental and social
wellness and not merely the absence of disease or infirmity.
- Mental health a state of emotional, psychological, and
social wellness evidenced by satisfying interpersonal
relationships, effective behavior and coping, positive self
concept, and emotional stability.
Components of mental health
1) Individual or personal factors
• Biologic make up
• Autonomy and independence
• Self esteem
• Capacity for growth
• Vitality
• Ability to find meaning in life
• Emotional resilience or hardness
• Sense of belonging
• Reality orientation
• Coping or stress management abilities
2) Interpersonal or relationship factors
• Effective communication
• Ability to help others
• Intimacy
• Balance of separateness and connectedness
• Social cultural and environmental factors
• Sense of community
• Access to adequate resources
• Intolerance of violence
• Support of diversity among people
• Mastery of environment
• Positive yet realistic view of one’s world
Mental illness
- Mental disorder a clinically significant behavior or
psychological syndrome, or pattern that occurs in an
individual and is associated with present distress.
Factors contributing to mental illness
1) Individual factors
• Biologic make up
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Exam Week
• Intolerable or unrealistic worries or fear
• Inability to distinguish reality from fantasy
• Intolerance of life uncertainties
• A sense of disharmony in life
• A loss of meaning in one’s life
2) Interpersonal factors
• Ineffective communication
• Excessive dependency
• Withdrawal from relationships
• No sense of belonging
• Inadequate support
• Loss of emotional control
3) Social cultural factors
• Lack of resources
• Violence
• Homelessness
• Poverty
• Unwanted negative view of the world discrimination
Diagnostic and Statistical Manual of Mental Disorders
1) Provide a standardized nomenclature and language for all
mental health professionals.
2) To present defining characteristics or symptoms that
differentiate specific diagnosis.
3) To assist in identifying the underlying cause of disorders.
Multi Axial Classification System
• AXIS I for identifying all major psychiatric disorders except
mental retardation and personality disorders.
• AXIS II for reporting mental retardation and personality
disorders as well as prominent maladaptive personality
features and defense mechanism.
• AXIS III for reporting current medical conditions that are
potentially relevant to understanding or managing person’s
mental disorder as well as medical conditions that may
contribute to understanding the person.
• AXIS IV for reporting psychosocial and environmental
problems that may affect the diagnosis treatment and
prognosis of mental disorders. Ex problems with primary
support grp, social environment, education, occupation,
housing, economic access to health care and legal system.
• AXIS V this represents the clinicians assessment of the
persons current level of functioning. Ex the Global
Assessment of Functioning
Historical Perspectives
Ancient times
- The illness indicate the displeasure of the gods and
punishment for sins and wrong doings.
- Aristotle (382-322 BC) attempt to relate mental disorders
to physical disorders and developed the theory that the
amount of blood water and yellow and black bile in the
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
body control the emotions. Imbalance of the four humors
were believed to cause mental disorders.
- Early Christian times (1-1000 AD) all diseases were blamed
on demons and the mentally ill were possessed
- Renaissance (1300-1600) mental illness were
distinguished from criminals, harmless are allowed to
wander to country side and lived in rural communities, the
dangerous were thrown into prison chained and starved.
- 1547 St Mary of Bethlehem Hospital was officially declared
a hospital for insane.
- 1775 visitors at the institution were charged of fees for the
privilege of viewing and ridiculing the insane viewed as
animals less than human.
- 1790 Phillippe Pinel, Wlliam Tukes formulate the concelts
of assylum as safe refuge or haven for the mentally ill in the
institution from being whipped beaten and starved.
- Dorothea Dix ( 1802-1887) began a crusade to reform the
treatment of mental illness after a visit to Tuke’s institution.
Sigmund Freud and Emil Kraeplin
• Freud (1856-1939)
• Kraeplin (1856-1926)
• Eugin Bleuler (1857-1939)
Psychopharmacology
- 1950 development of psychotropic drugs, drugs used to
treat mental illness.
• Chlorpromazine (thorazine) anti-psychotic drug
• Haldol anti-psychotic
• Lithium anti manic agent
• MAO inhibitor anti-depressant
• Tricyclic antidepressant
• Benzodiazepines anti-anxiety agents
Neurobiological Theories and Psychopharmacology
Cerebrum
- Divided into two lobes, all lobes and structures are found
in both halves except for the pineal body, or gland which is
located between the hemispheres.
- Pineal body is an endocrine gland which affects the activity
of the pituitary, islets of Langerhans, parathyroid, adrenal
and gonads.
- The frontal lobe controls the organization of thoughts, body
movement, memories, emotions, and moral behavior. The
integration of all the information regulates arousal, focuses
attention, enables problem solving and decision making.
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- Abnormalities is associated with schizophrenia ADHD and
dementia
Cerebellum
- CENTER FOR COORDINATION MOVEMENT AND
POSTURAL JUDGEMENTS.
- Inhibited transmission of dopamine in this area is
associated with the lack of smooth coordinated
movements such in Parkinson’s disease and Dementia.
Brain stem
- Includes the midbrain, pons, medulla oblongata and the
nuclei for cranial nerve III and XII
- Medulla contains the vital centers for respiration and
cardio vascular functions.
- Pons bridges the gaps both structurally and functionally,
serving as a primary motor pathway
- Midbrain connects the pons and cerebellum with the
cerebrum (0.8 inches) 2cm long includes mostly the RAS
and the EPS.
- Extra pyramidal system (EPS) relays information about
movement and coordination from brain to the spinal nerve
- Locus Ceruleus nor epinephrine producing neuron in the
brain stem, associated with stress, anxiety and impulsive
behavior.
Limbic System
- Located above the brain stem, includes the thalamus,
hypothalamus, hippocampus, and amygdala.
- Thalamus regulates activity, sensation and emotion.
- Hypothalamus temp regulation, appetite control,
endocrine function, sexual drive, and impulsive behavior,
such as anger, rage and excitement.
- Hippocampus and Amygdala involve in emotional arousal
and memory.
- Disturbances in the limbic system have been implicated in
a variety of mental illness memory loss, poorly controlled
emotions, impulses seen in psychotic and manic behavior.
Neurotransmitter
- Neurotransmission the process of sending electrochemical
messages from neuron to neuron.
- Neurotransmitter chemical substances manufactured in
the neuron that aid in the transmission of information
throughout the body
A.) Synapses and neurotransmitters
• Information in the nervous system is transferred
across the synaptic cleft (i.e., the space between the
axon terminal of the presynaptic neuron and the
dendrite of the postsynaptic neuron).
• When the presynaptic neuron is stimulated, a
neurotransmitter is released, travels across the
synaptic cleft, and acts on receptors on the
postsynaptic neuron. Neurotransmitters are
excitatory if they increase the chances that a neuron
will fire and inhibitory if they decrease these
chances.
B.) Presynaptic and postsynaptic receptors are proteins
present in the membrane of the neuron that can
recognize specific neurotransmitters.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• The changeability of number or affinity of receptors
for specific neurotransmitters (neuronal plasticity)
can regulate the responsiveness of neurons.
• Second messengers. When stimulated by
neurotransmitters, postsynaptic receptors may alter
the metabolism of neurons by the use of second
messengers, which include cyclic adenosine
monophosphate (cAMP), lipids (e.g., diacylglycerol),
Ca2+, and nitric oxides.
C.) Classification of neurotransmitters. Biogenic
amines (monoamines), amino acids, and peptides
are the three major classes of neurotransmitters.
D.) Regulation of neurotransmitter activity
• The concentration of neurotransmitters in the
synaptic cleft is closely related to mood and
behavior. A number of mechanisms affect this
concentration.
• After release by the presynaptic neuron,
neurotransmitters are removed from the synaptic
cleft by mechanisms including:
o Reuptake by the presynaptic neuron.
o Degradation by enzymes such as monoamine
oxidase (MAO).
- Depression Norepinephrine (↓), serotonin (↓), dopamine (↓)
- Mania Dopamine (↑), g-aminobutyric acid (GABA) (↓)
- Schizophrenia Dopamine (↑), serotonin (↑), glutamate (↑or
↓)
- Anxiety GABA (↓), serotonin (↓), norepinephrine (↑)
- Alzheimer disease Acetylcholine (↓), glutamate (↑)
• Availability of specific neurotransmitters is associated
with common psychiatric conditions (Table 4.4).
Normalization of neurotransmitter availability by
pharmacological agents is associated with symptom
improvement in some of these disorders
Biogenic Amine
Overview
- The biogenic amines, or monoamines, include
catecholamines, indolamines, ethyl amines, and
quaternary amines.
- The monoamine theory of mood disorder hypothesizes that
lowered monoamine activity results in depression and
elevated levels in mania.
- Metabolites of the monoamines are often measured in
psychiatric research and diagnosis because they are more
easily measured in body fluids than the actual
monoamines
- Distribution of dopaminergic, noradrenergic and
serotonergic tracts in the CNS
Dopamine
- Dopamine, a catecholamine, is involved in the
pathophysiology of schizophrenia and other psychotic
disorders, Parkinson disease, mood disorders, the
conditioned fear response and the “rewarding” nature of
drugs of abuse
- Synthesis. The amino acid tyrosine is converted to the
precursor for dopamine by the enzyme tyrosine
hydroxylase.
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- Receptor subtypes. At least five dopamine receptor
subtypes (D1–D5) have been identified; the major site of
action is D2 for traditional antipsychotic agents and D1 and
D4 as well as D2 for the newer “atypical” antipsychotic
agents
Dopaminergic tract
1) The nigrostriatal tract is involved in the regulation of
muscle tone and movement.
a) This tract degenerates in Parkinson disease.
b) Treatment with antipsychotic drugs, which block
postsynaptic dopamine receptors receiving input from
the nigrostriatal tract, can result in Parkinson-like
symptoms.
2) Dopamine acts on the tuberoinfundibular tract to inhibit
the secretion of prolactin from the anterior pituitary.
a) Blockade of dopamine receptors by antipsychotic drugs
prevents the inhibition of prolactin release and results
in elevated prolactin levels.
b) This elevation in turn results in symptoms such as
breast enlargement, galactor- rhea, and sexual
dysfunction.
3) The mesolimbic–mesocortical tract is associated with
psychotic disorders.
a) This tract may have a role in the expression of emotions
since it projects into the limbic system and prefrontal
cortex.
b) Hyperactivity of the mesolimbic tract is associated with
the positive symptoms (e.g., hallucinations) of
schizophrenia; hypoactivity of the mesocortical tract is
associated with the negative symptoms (e.g., apathy) of
schizophrenia
Norepinephrine, a catecholamine, plays a role in mood,
anxiety, arousal, learning, and memory.
1) Synthesis
a) Like dopaminergic neurons, noradrenergic neurons
synthesize dopamine.
b) Dopamine b-hydroxylase, present in noradrenergic
neurons, converts this dopamine to norepinephrine.
2) Localization. Most noradrenergic neurons (approximately
10,000 per hemisphere in the brain) are located in the
locus ceruleus
Serotonin, an indolamine, plays a role in mood, sleep,
sexuality, and impulse control. Elevation of serotonin is
associated with improved mood and sleep but decreased
sexual function (particularly delayed orgasm). Very high
levels are associated with psychotic symptoms
Decreased serotonin is associated with poor impulse control,
depression, and poor sleep.
1) Synthesis. The amino acid tryptophan is converted to
serotonin (also known as 5-hydroxy- tryptamine [5-HT]) by
the enzyme tryptophan hydroxylase as well as by an amino
acid decarboxylase.
2) Localization. Most serotonergic cell bodies in the brain are
contained in the dorsal raphe nucleus in the upper pons
and lower midbrain
3) Antidepressants and serotonin. Heterocyclic
antidepressants (HCAs), selective serotonin reuptake
inhibitors (SSRIs), and monoamine oxidase inhibitors
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
(MAOIs) ultimately increase the presence of serotonin and
norepinephrine in the synaptic cleft
a) HCAs block reuptake of serotonin and norepinephrine,
and SSRIs such as fluoxetine (Prozac) selectively block
reuptake of serotonin by the presynaptic neuron.
b) MAOIs prevent the degradation of serotonin and
norepinephrine by MAO.
Histamine
1) Histamine, an ethylamine, is affected by psychoactive
drugs.
2) Histamine receptor blockade with drugs such as
antipsychotics and tricyclic antidepressants is associated
with common side effects of these drugs such as sedation
and increased appetite leading to weight gain.
Acetylcholine (Ach), a quaternary amine, is the transmitter
used by nerve–skeleton–muscle junctions.
1) Degeneration of cholinergic neurons is associated with
Alzheimer disease, Down’s syndrome, and movement and
sleep disorders (e.g., decreased REM sleep.
2) Cholinergic neurons synthesize Ach from acetyl coenzyme
A and choline using the enzyme choline acetyltransferase.
3) The nucleus basalis of Meynert is a brain area involved in
production of Ach.
4) Acetylcholinesterase (AchE) breaks Ach down into choline
and acetate.
5) Blocking the action of AchE with drugs such as donepezil
(Aricept), rivastigmine (Exelon), and galantamine (Reminyl)
may delay the progression of Alzheimer disease but cannot
reverse the function already lost.
6) Blockade of muscarinic Ach receptors with drugs such as
antipsychotics and tricyclic antidepressants results in the
classic “anticholinergic” adverse effects seen with the use
othese drugs, including dry mouth, blurred vision, urinary
hesitancy, and constipation. Use of these agents can also
result in central anticholinergic effects such as confusion
and memory problems.
7) Anticholinergic agents are commonly used to treat the
Parkinson-like symptoms caused by antipsychotic agents
(see section IV.B.4.a. above).
Amino Acid Neurotransmitter
These neurotransmitters are involved in most synapses in the
brain and include glutamate, g-aminobutyric acid (GABA), and
glycine.
Glutamate
- Glutamate is an excitatory neurotransmitter that
contributes to the pathophysiology of neurodegenerative
illnesses such as Alzheimer disease and schizophrenia.
• The mechanism of this association involves activation
of the glutamate receptor N-methyl-d-aspartate
(NMDA) by sustained elevation of glutamate.
• Such activation results in calcium ions entering
neurons leading to nerve cell degen- eration and death
through excitotoxicity.
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• Memantine (Namenda), an NMDA receptor antagonist,
ultimately blocks this influx of calcium and is indicated
for patients with moderate to severe Alzheimer disease.
GABA
- GABA is the principal inhibitory neurotransmitter in the
CNS. It is synthesized from glutamate by the enzyme
glutamic acid decarboxylase, which needs vitamin B6
(pyridoxine) as a cofactor.
- GABA is closely involved in the action of antianxiety agents
such as benzodiazepines (e.g., diazepam [ Valium]) and
barbiturates (e.g., secobarbital [Seconal]).
Benzodiazepines and barbiturates increase the affinity of
GABA for its GABAA-binding site, allowing more chloride to
enter the neuron. The chloride-laden neurons become
hyperpolarized and inhibited, decreasing neuronal firing
and ultimately decreasing anxiety. Anticonvulsants also
potentiate the activity of GABA.
Glycine
- an inhibitory neurotransmitter found primarily in the spinal
cord. Glycine works on its own and as a regulator of
glutamate activity.
Neuropeptides
- Endogenous opioids such as enkephalins, endorphins,
dynorphins, and endomorphins are produced by the brain
itself. They act to decrease pain and anxiety and have a
role in addiction and mood.
- Placebo effects may be mediated by the endogenous
opioid system. For example, prior treatment with an opioid
receptor blocker such as naloxone can block placebo
effects
- Types of neurotransmitter:
1) Excitatory excites or stimulates an action in the cell
• Dopamine
• Nor epinephrine
• Epinephrine
• Acetylcholine
• Glutamate
2) Inhibitory inhibit or stop an action in the cell
• Serotonin
• Acetylcholine
• GABA
Synapse
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
Neuromodulators enhances both the excitatory or inhibitory
function of a neurotransmitter
• Histamine
• Neuropeptide
Dopamine
- Located primarily in the brainstem found to involve in the
control of complex movement, motivation, cognition, and
regulation of emotional response, it is synthesize from
tyrosine. Implicated in schizophrenia as well as psychoses
and other movement disorders.
Nor epinephrine and epinephrine
- Nor epinephrine located primarily in the brain stem play a
role in changes in attention, learning and memory, sleep
and wakefulness and mood regulation.
- Excess is implicated in several anxiety disorders
- Deficit contribute to memory loss, social withdrawal and
depression.
- Antidepressant block the reuptake of norepinephrine
- MAO inhibit the metabolism or NE
- Epinephrine has limited distribution in the brain but control
the fight or flight response in the PNS
Serotonin
- Found only in the brain derived from tryptophan
- Involved in the control of food intake, sleep and
wakefulness, temp regulation, pain control, sexual
behavior, and regulation of emotion.
- Plays important role in anxiety, mood disorders and
schizophrenia.
- Some Antidepressant block serotonin reuptake, leaving it
available longer in the synapse thus improving the mood.
Histamine
- Involves in peripheral allergic responses, control of gastric
secretions, cardiac stimulation and alertness.
- Some psychotropic drugs block histamine, resulting in
weight gain, sedation and hypotension.
Acetylcholine
- Found in the brain spinal cord and peripheral nervous
system at the neuromuscular jucntion of skeletal muscle.
Synthesize from dietary choline found in red meat and
vegetables and found to affect the sleep and wake cycle
and to signal muscle to become active
- Study shows people with alzheimer’s disease have
decrease acetylcholine secreting neurons, and people with
myasthenia gravis (impulses fail to pass myoneural
junctio )
Glutamate
- At high level can have major neurotoxic effect, implicate in
brain damage caused by stroke, hypoglycemia, sustained
hypoxia, ischemia and some degenerative diseases such
as huntington’s and alzheimer’s
GABA
- Major inhibitory neurotransmitter in the brain, found to
modulate other neurotransmitter system than to provide a
direct stimulus.
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CONCEPTS OF MENTAL HEALTH AND MENTAL ILLNESS
Mental Health Care Delivery System in the Philippines
Three Levels of care in the Health Care System
1) Primary - The primary health care tier serves as a patient's
first point of contact with a health professional who can
provide outpatient medical care
2) Secondary - The secondary health care includes referrals
to psychologists and psychiatrists where short hospital
visits and consultation-liaison services to other medical
departments are made. Services includes assessment,
counselling, and/or prescription drugs
3) Tertiary - The tertiary health care includes referrals to
psychiatric institutions if the mental illness needs
specialized care and more severe mental illness would
require more rehabilitation. In the Philippines, most
psychiatrists are in private practice, although some work in
government institutions such as in the National Center for
Mental Health.
Institutions and other mental health services in the
Philippines
- Both private and public groups maintain mental health
facilities and institutions in the Philippines but access to
them remains uneven throughout the country.
- Most facilities are located in the National Capital
Region (NCR) and other major cities in the country, thus
favoring individuals who live near these urban areas.
National Center for Mental Health (NCMH)
- National Center for Mental Health originally named Insular
Psychopathic Hospital, was established in 1925 under the
Public Works Act 3258. At the time, the City Sanitarium and
San Lazaro Hospital were the only primary institutions that
catered for the needs of the mentally ill, however, due to
the large volume of patients pouring in; there was a need to
build another institution that could provide for the needs of
mentally ill patients. It is located in Mandaluyong City in a
64-hectare site.
- The institution officially opened on December 17, 1928,
accepting 379 patients who were all crowding in San
Lazaro Hospital. In 1930, the bed capacity was increased
to 800, although the total number of patients was over
836. Two pavilions were added to increase the bed
capacity to 1,600. By 1935, the City Sanitarium closed, and
leaving NCMH with 1,646 patients to serve.
- Aside from being a hospital, NCMH is authorized by the
Department of Health as a Special Research Training
Center. According to the NCMH website, the hospital is
"mandated to render a comprehensive (preventive,
promotive, curative and rehabilitative) range of quality
mental health services nationwide". Aside from this, NCMH
also offers a 4-year psychiatric residency-training program
for doctors and a 2-year psychiatric nursing program for
nurses specializing in psychiatric care. There are also
affiliation programs that cater to students from the fields of
psychology, pharmacy, and nursing, among others.
- NCMH currently occupies 46.7 hectares of land, with 35
pavilions/cottages, and 52 wards, as well as facilities such
as medical infirmary, library, chapel, conference rooms,
tennis court, basketball court, multi-purpose hall and
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
dormitories. NCMH has a bed capacity of 4,600 and serves
an average of 3,000 in-patients on a daily basis, in addition
to 56, 000 outpatients per year. Most patients come from
Metro Manila and nearby regions III and IV. They also serve
patients from other regions, often-forensic cases referred
by the courts. Subsidy for treatments is given to 87% of the
inpatients, which belong to classes C and D. The institution
received its ISO 9001:2008 certification on December 2,
2015
Philippine Mental Health Association, Inc.
- The Philippine Mental Health Association, or PMHA, is "a
private, non-stock, non-profit organization dedicated to the
promotion of mental health and prevention of mental
disorders. Its headquarters is located in Quezon City with
nine chapters all over the Philippines:
• PMHA Bacolod-Negros Occidental,
• PMHA Baguio-Benguet,
• PMHA Cabanatuan-Nueva Ecija
• PMHA Cagayan de Oro-Misamis Oriental
• PMHA Cebu,
• PMHA Dagupan-Pangasinan
• PMHA Davao
• PMHA Dumaguete-Negros Oriental
• PMHA Lipa-Batangas.
- It was established on January 15, 1950 with Dr. Manuel
Arguelles as president due to the call for assessment of
mental health problems induced by WW II. At present, their
programs range from Education and Information Services
(EIS), Clinical and Diagnostic Services (CDS), and
Intervention Services (IS).
- The PMHA provides guidance and educational programs for
the youth through collaborating with various private and
public schools and colleges in the country. They also
organize seminars and workshops for youth mental health
through their EIS arm.
- The Association officially expanded its services to the adult
population in 1960. They now provide psychiatric,
psychological, and counseling services to all sectors of
society under CDS.[19] They also launched Rehabilitation
Care Services in 1962 to assist in the recovery and
reintegration of patients into the community.
- The Association's IS arm has two centers: the Center for
Children and Youth (CCY) and the Adult Work Center
(AWC). The CCY provides various kinds of therapy sessions
and counseling along with special education for those with
learning disorders and mental retardation. The AWC
provides life skills training and family programs to assist
mental health patients in their recovery and therapy.
Other Institutions
- Most major hospitals (both public and private) In
the National Capital Region (NCR), have a psychiatric
department which caters to the need of people with mental
illness.
a) The Medical City
b) Philippine General Hospital (PGH)
c) Manila Doctors Hospital (MDH)
d) University of the East Ramon Magsaysay Memorial
Medical Center (UERMMMC)
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Note: Webbline provides a list of mental health care facilities
that can be found in the provinces and in NCR.
Suicide Prevention Hotlines in the Philippines
- Those who are in need of immediate assistance may opt to
call a suicide hotline:
• Natasha Goulbourn Foundation (NGF). The NGF
suicide hotline can be reached at (02) 804-HOPE (4673),
0917 558 HOPE (4673) or 2919 (toll-free for GLOBE and
TM subscribers).
• Manila Lifeline Centre (MLC). The MLC can be
reached at (02) 8969191 or 0917 854 9191.
Importance of Mental Health in the community
1) Belonging. Community provides a sense of belonging — a
group that one can identify as being a part of. A true sense
of belonging includes the ability to feel that one is a part of
the community that will embrace and appreciate a
person’s unique qualities.
2) Support. Community provide support in times of difficult
situations. Knowing there are people, GO’s or NGO’s in the
community who support you can help one feel safe and
cared for, safe resulting to a positive outlook on life.
3) Purpose. In community, people fill different roles. These
roles can give one a sense of purpose through bettering
other people’s lives. Having purpose, and helping others,
helps give meaning to life.
Global & Regional Perspective on Mental Health
Mental Health Act (Republic Act No. 11036)
- The Law proposes a mental health policy that aims to:
a) Enhance the delivery of mental health services
b) Promote mental health services
c) Provide accessible mental health care – Mental health
services are proposed to be accessible from large-scale
hospitals down to the barangay level.
d) Promote and protect the rights of the individuals
utilizing psychiatric, neurologic and psychosocial health
services
Mental Health Gap Action Programmed (mhGAP) training
- MhGAP is a WHO program, launched in 2008, to scale up
care for MNS disorders
• Mental disorders
• Neurological disorders
• Substance abuse disorders
- The program asserts that, with proper care, psychosocial
assistance and medications, millions of people around the
world could be treated for psychoses, epilepsy,
depression, and suicide can be prevented, thus they may
live a normal life.
- To meet this goal is to train non-specialist care to address
the unmet needs of people with priority MNS conditions.
- The mhGAP training is a collaboration between the World
Health Organization, the Department of Health, and local
government units to strengthen the mental health services
in local communities in the Philippines. Over a few years,
non-specialized health workers in all 18 regions in the
country have participated in the training, empowering them
to make decisions and manage mental health patients
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
close to where it is most needed. Leon is one of the first
municipalities to have a comprehensive community-based
mental health program in the country.
Psychobiologic Bases of Behavior
Biology and Behavior
- Behavior is determined by biology. There is a genetic basis
to all behaviors. Most behavior has an adaptive or
evolutionary function. Behaviors have their origins in
specific locations of the brain.
- In order to understand human behavior, it is necessary to
include animal studies.
- Biology is 100% involved in all the variance in what we think,
what we feel, and how we behave
Concepts and Patterns of Human Behavior
Family Dynamics
- Family dynamics are all about the functioning of a family in
a good and bad situation. It also includes the ways of
decision-making, problem solving, or even sharing their
feelings. Thus, it helps individuals to judge themselves as
well as the outside world.
- Types of Family Structures & Family Dynamics
1) Nuclear family
2) Single Parents
3) Extended Family
4) Childless Family
5) Grandparent Family
6) Stepfamily
Concepts of Human behavior
Needs and Behavior
- Needs are internal motives that energize, direct and
sustain behavior. They generate strivings necessary for the
maintenance of life as in physiological needs and for the
promotion of growth and wellbeing as in psychological and
implicit needs.
- According to humanist psychologist Abraham Maslow, to
our actions are motivated in order to achieve certain needs.
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Conflicts and Frustrations
- Conflict is a painful emotional state that results from a
tension between opposed and contradictory wishes as
defined by Douglas and Holland.
- Conflict is a state of tension brought by the presence in the
individual of two or more opposing desires as defined by
Barney and Lehner.
- Sources of Conflict at home environment
a) Faulty upbringing at home,
b) Unhealthy relationships,
c) Overprotection.
- Sources of Conflict in the school environment
a) Unpleasant school or college environment,
b) role of teachers,
c) faulty method of teaching,
d) denial of opportunities for self-expression
e) Classmates are some of the sources of conflict.
- Sources of Conflict in occupational environment
a) Improper working environment
b) dissatisfaction with the working conditions
c) unsatisfactory relationships
- Frustration means emotional tension resulting from the
blocking of a desire or need (Good, 1959). According to
Barney and Lehner (1953), frustration refers to failure to
satisfy a basic need because of either condition in the
individual or external obstacles.
- Causes of Frustration
1) External factors
- Physical factors: Natural calamities,
floods, droughts, earthquakes, fire and accidents
cause frustration in an individual.
- Social and societal factors: Societal norms and
values impose certain obstacle in meeting the
individual needs, which leads to frustration
- Economic and financial factors: Unemployment and
lack of money causes frustration in an individual.
2) Internal factors
- Physical abnormality or defects.
- Conflicting desires or aims: When a person has
conflicting desires, he develops frustration.
- Individual’s morality and high ideals: An individual’s
moral standards, code of ethics and high ideals may
become a source of frustration.
- Level of aspirations: Conflict between one’s
aspirations to one’s capability to achieve it may lead
to frustration
Anxiety & anxiety responses
- Anxiety - A vague unpleasant feeling of apprehension. An
emotional response to unknown and non-specific danger
or threat. Anxiety motivates a person to take action, to
solve a problem or to resolve a crisis.
- Anxiety is considered normal when it is appropriate to the
situation
- Anxiety becomes abnormal when it is excessive, chronic
and results to impairment in the individual’s major
functioning. Individual usually shows unusual behaviors.
- Examples:
• Panic without reason
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

• Irrational fear of objects 4) Panic anxiety

• Uncontrollable repetitive actions - Perception: Disorganized
Types of Anxiety - Behavioral:
1) Mild anxiety • Immobilized
- Perception – increased/widens • Hysterical or mute
- Behavioral changes: Alert/ aware, energetic, attention • Disorganized thinking
increased • Irrational reasoning
- Physiological changes: Slight discomfort, restlessness, • Feeling overwhelmed and out of control - Suicidal
GI butterflies and difficulty Sleeping. • Maybe out of contact with reality
- Coping: Adaptive Tasked or defense oriented (Hallucination/Delusion)
- Nursing management - Physiological
• Listen • Same w/ severe anxiety
• Focus on problem solving • SOB
• Engage in goal directed activities • Hyperventilation
2) Moderate anxiety - Coping: Dysfunctional: use of defense mechanisms fail
- Perception: Decreased / narrowed and Selective - Nursing Management
inattention • Provide safety
- Behavioral Changes: Difficulty in concentration, easily • Reduce environmental stimuli
distracted, attention span decreased and pacing • Continuously talk with the person
- Physiological Changes: Clammy hands, diaphoresis, • Use touch judiciously
muscle tension, GI distress, headache, dry mouth and • Remain with the person (Panic can last from 5 – 30
frequent urination minutes)
- Coping: Palliative - use of any defense mechanism Adaptation and Coping Mechanisms
available
1) Adaptation
- Nursing Management:
- The physical or behavioral characteristic of an organism
• Refocus attention that helps an organism to survive better in the
• Supervise client in solving problems and learning surrounding environment.
new things. - Levels of Adaptation:
• Speak in short, simple and easy to understand a) Adaptive - Facing and finding solution to the
sentence. situation
• Administer oral anxiolytic b) Less Adaptive - Use defense mechanisms
3) Severe anxiety temporarily
- Perception: distorted perception c) Maladaptive - Use defense mechanisms excessively
- Behavioral d) Dysfunctional - Defense mechanism is ineffective.
• Inability to reason abstractly ADL and social functions are affected
• In ability to make decision 2) Coping
• Inability to solve a problem - Involves any effort to decrease the stress response
• Impaired judgment - Coping mechanism can be constructive or destructive
• Confused and disoriented - Constructive coping mechanism when it is:
• Difficulty focusing even with assistance a) Tasked oriented (direct problem solving)
- Signs and symptoms becomes the focus of attention b) Defense oriented (regulate response to stress
• Increased BP, RR, CR through the use of defense mechanism)
• Chest pain 3) Defense Mechanisms
• Severe headache - Also called ego defense mechanism /protective
• Nausea/ Vomiting defense. It is defined as patterns of behaving or thinking
• Diarrhea used by an individual to protect himself from
• Tremors threatening aspects of his own environment or from his
own feeling of anxiety.
• Dilated pupils
- Purposes:
• Coping: Maladaptive - Excessive use of defense
a) Maintain a sense of being in control of the situation
mechanisms
b) Lessen discomfort
- Nursing Management:
c) Deal with stress
• Decrease anxiety
d) Decrease anxiety
• Relaxation technique - Types of Defense Mechanisms
• Reduce environmental stimuli a) Normal and adaptive mechanism
• Stay or walk with person who is upset - Persons who use these mechanisms are viewed
• Attentive listening as having virtues
• Administer intramuscular anxiolytics

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- Enhances the user a feeling of mastery and
pleasure.
• Anticipation – planning ahead for a realistic
expectation
• Compensation – making up for imagined
handicapped or deficiency
• Compromise – reciprocal give and take
necessary in many relationships
• Sublimation – most constructive mechanism
– rechanneling socially unacceptable
behavior to a socially acceptable one
• Humor - seeing the lighter side of the situation
b) Narcissistic Defense Mechanisms
- Most primitive mechanism
- Usually used by children
- Person who uses these defenses eliminate the need to
cope with reality
• Denial – refusal to accept reality
• Projection – blaming others for unacceptable deeds
or thoughts
• Fantasy – gratification of wishes through imagination
c) Immature Defense Mechanism
- Seen in adolescence and some non-psychotic
individual.
- Lessen distress and anxiety provoking situations
- People who excessively use these defenses are seen as
socially undesirable in that they are immature, difficult
to deal with, and seriously out of touch to reality
• Conversion – transferring emotional conflict into
physical symptoms
• Malingering - Fabrication of an ailments
• Fixation – psychosocial development ceased to
advance
• Regression – returning to an earlier developmental
stage
• Identification – unconscious attempt to change
oneself to resemble admired person
• Introjection – a type of identification in which the
individual incorporates the traits or values of
another to self.
• Intellectualization – Excessive reasoning to obscure
real feeling
• Suppression – Conscious or voluntary forgetting of
unacceptable or painful Ideas, thoughts or feelings
• Isolation – Person blocks feelings associated with
unpleasant experience
o Physical isolation - Physical withdrawal from
people to prevent further hurt or damage to one’s
security
o Emotional isolation - The process of separating
an unacceptable feelings, ideas or impulses from
one’s thought
d) Neurotic Defense Mechanisms
- Seen in obsessive-compulsive, hysterical individual,
and adults under stress.
- Have short-term advantage in coping
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- When used as one’s primary style of coping the world, it
can cause long term problems in relationships and in
enjoying life.
• Displacement – releasing anger in a less threatening
way
• Dissociation – blocking off anxiety provoking event
from the conscious mind. Example amnesia
• Substitution – taking something in place of the
original goal
• Rationalization - justifying one’s behavior to make
unacceptable feelings and behavior acceptable
• Reaction formation - acting out behaviors opposite
to what one really feels
• Repression – involuntary or unconscious forgetting
unacceptable thoughts from conscious mind
• Undoing – engaging in a behavior that is considered
to be opposite of a previous unacceptable
behavior
- Underlying Causes of Anxiety
1) Interpersonal Factor
• Fear of interpersonal rejection
• Traumatic or dysfunctional relationship
2) Behavioral Factor
• Exposure to early negative life circumstances
• Learned response to frustration
3) Psychoanalytic Factor
• Conflict between the ID and the Superego
Crisis
- Occurs when the EVENT that is causing the ANXIETY is
overwhelming and the usual coping patterns are
suspended.
- Many life’s events can evoke a crisis such as:
• Man-made disasters
• Interpersonal events
• Natural disasters
• Traumatic experience
- Types of Crisis
1) Maturational crisis
- Normal part of growth and development
- Ex: leaving home for the first time, completing
school, getting married, having a baby, beginning a
career, accepting adult responsibility
- Successful resolution of a crisis allows a person to
develop positive characteristics
2) Situational crisis
- Unpredicted or sudden events that threaten the
individual’s integrity
- Ex. death of a loved one, loss of a job/job promotion,
illness of a member of the family, migration, high
school/college graduation
3) Adventitious crisis
- Unexpected unusual events that can affect an
individual or a multitude of people
- a social crisis, which includes:
• Natural disasters such as floods, typhoon,
earthquakes, forest fires, hurricane, tsunami
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• national disasters such as racial discriminations,
kidnapping, riots, war or terrorism
• violent crimes such as rape, murder and assault
and battery
- Stages of Crisis
1) Denial - initial reaction (shock & disbelief)
2) Increased tension - the person recognizes the
presence of a crisis, still functional
3) Disorganization - the person is preoccupied with the
crisis, and functioning is affected.
4) Attempts to reorganize - the individual mobilizes
previous coping mechanisms or acquire new ways of
coping
Mental Health and Mental Illness
- Mental health and mental illness are difficult to define
precisely. People who can carry out their roles in society
and whose behavior is appropriate and adaptive are viewed
as healthy.
- Conversely, those who fail to fulfill roles and carry out
responsibilities or whose behavior is inappropriate are
viewed as ill.
- The culture of any society strongly influences its values and
beliefs, and this in turn affects how that society defines
health and illness. What one society may view as
acceptable and appropriate, another society may see as
maladaptive and inappropriate.
Mental health
- The World Health Organization defines mental health as a
state of well-being in which every individual realizes his or
her potential, can cope with the normal stresses of life, can
work productively and fruitfully and can contribute to his or
her community
- Criteria of a Mental Health
• P – Positive attitude toward self – you have a strong
sense of identity and believe you're capable of rising to
whatever challenges that comes your way. Negative
self-concept – you have an inaccurate perceptions of
yourself and believe you’re incapable of doing things as
others do and uncertain of achieving your goal.
• R – Reality perception – The ability to view the world not
being too pessimistic or optimistic
• A – Autonomous behavior – the ability to function
independently.
• I – Integrative capacity – ability to handle of manage
any adverse or difficult situations.
o Resilience ability to adjust in a healthy manner in
any difficult situations
o Hardiness ability to resist illness even under stress/
ability
o Self-efficacy ability to succeed in specific situations
or accomplish a task.
o Resourceful ability to problem solved and believing
that you can cope in any adverse or difficult
situations
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• S – Self-actualization and personal growth – ability to be
motivated to realize one's full potential and make use of
these potentials to achieve goals.
• E – Environmental mastery – ability to meet the
demands of any situations and being able to adapt to
changing circumstances.
Mental illness
- Mental Illness is a health conditions marked by alterations
in thinking, mood or behavior that causes distress and/or
impair individual’s major functioning:
a) Occupational functioning
- unable to perform ADL,
- role performance
- unable to work or go to school
b) Emotional functioning
- unable to express feelings effectively and
assertively
• project/suppress feelings
• aggressively express feelings
• destroying things/properties
• yelling or hurting others
c) Psychological functioning
- unable to think abstractly
- unable to think rationally (committing suicide)
- unable to cope with stress
- unable to solve problems effectively
d) Social functioning
- unable to develop a satisfying relationship with
others
- unable to involve self in community activities or
organizations.
e) Spiritual functioning
- Spirituality involves the essence of person’s being
and his/her beliefs about the meaning of life and
the purpose of life
- faith in God is a primary source of comfort and
help in times of stress and difficult situations and
serve as a primary coping device
- Criteria of Mental Illness
• L – Lack of personal growth
• I – Ineffective coping with one’s life events
– Ineffective or non-satisfying relationship
– Inability to meet own needs
• D – Dissatisfaction with one’s characteristics, abilities,
and accomplishments. Dissatisfaction with one’s place
in the world.
Factors Contributing to Mental Illness
- Mental illness is common. About one in five adults has a
mental illness in any given year. Mental illness can begin at
any age, from childhood through later adult years, but most
cases begin earlier in life.
- The effects of mental illness can be temporary or long
lasting. A person can have more than one mental health
disorder at the same time. For example, one can have
depression and a substance use disorder simultaneously.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- There are many factors that influences the development of
mental illness which includes the following
Biologic Factors
1) Genetic Factor. Mental illnesses sometimes run in families,
suggesting that people who have a family member with a
mental illness may be somewhat more likely to develop one
themselves.
2) Neurostructural Factor. Infections: Certain infections have
been linked to brain damage and the development of mental
illness or the worsening of its symptoms. For example, a
condition known as pediatric autoimmune neuropsychiatric
disorder (PANDA) associated with
the Streptococcus bacteria has been linked to the
development of obsessive-compulsive disorder and other
mental illnesses in children.
3) Brain defects or injury: Defects in or injury to certain areas
of the brain have also been linked to some mental illnesses.
4) Prenatal damage: Some evidence suggests that a disruption
of early fetal brain development or trauma that occurs at the
time of birth -- for example, loss of oxygen to the brain -- may
be a factor in the development of certain conditions, such
as autism spectrum disorder.
5) Brain chemistry. Neurotransmitters are naturally
occurring brain chemicals that carry signals to other parts
of the brain and body. When the neural networks involving
these chemicals are impaired, the function of nerve
receptors and nerve systems change, leading to
depression and other emotional disorders.
Individual Factors (PAIN)
• P- Poor physical health
• A – Any kind of loss (loss of meaning in one’s life)
• I – Ineffective coping and inability to distinguish reality from
fantasy
• N - Negative view of self
Interpersonal Factor (FAIL)
• F- Faulty family interaction & nurturing during childhood
• Absence of sense of belongingness
• Ineffective communication & interaction (withdrawal from
relationship)
• L-Loss of emotional control
Environmental Factor (PAIN)
• P- Poverty, homelessness and presence of discrimination
• A - Abuse and violence
• I – Inability to make use of support and community
resources
• N -Negative view of the world
Risk factors
Certain factors may increase the risk of developing a mental
illness, which includes the following:
1) A history of mental illness in a blood relative, such as a
parent or sibling
2) Stressful life situations, such as financial problems, a
loved one's death or a divorce
3) An ongoing (chronic) medical condition, such as diabetes
4) Brain damage as a result of a serious injury (traumatic
brain injury), such as a violent blow to the head
5) Traumatic experiences, such as military combat or assault
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6) Use of alcohol or recreational drugs
7) A childhood history of abuse or neglect
8) Few friends or few healthy relationships
9) A previous mental illness
Complications of Mental Illness
- Mental illness is a leading cause of disability. Untreated
mental illness can cause severe emotional, behavioral and
physical health problems.
- Complications sometimes linked to mental illness
includes:
1) Unhappiness and decreased enjoyment of life
2) Family conflicts
3) Relationship difficulties
4) Social isolation
5) Problems with tobacco, alcohol and other drugs
6) Missed work or school, or other problems related to
work or school
7) Legal and financial problems
8) Poverty and homelessness
9) Self-harm and harm to others, including suicide or
homicide
10) Weakened immune system, so your body has a hard
time resisting infections
11) Heart disease and other medical conditions
Classification of Mental Illness
1) Psychosis. It is characterized by loss of reality testing,
altered thought process ad presence of psychotic
manifestation such as hallucination and delusions
2) Neurosis. It is refers to a class of functional mental
disorder involving distress but not delusion or hallucination,
where behavior is not outside socially acceptable norms. It
is also known as psychoneurosis or neurotic disorder. No
loss of reality testing
3) Functional. It is characterized by unknown underlying
cause or has no clear-cut etiologic factor to account for
the impairment because it is difficult to investigate brain
function during life.
4) Organic. It is a disturbance caused by injury or disease
affecting brain tissues as well as by chemical or hormonal
abnormalities. Exposure to toxic materials, neurological
impairment, or abnormal changes associated with aging
can also cause these disorders
The Diagnostic Statistical Manual of Mental Disorders 5th
Edition (DSM-5)
Purposes
1) To enable physicians or other clinicians to reliably
diagnose patients who present a mental disorder
2) To outline treatment pathways for the diagnosis and the
likely outcome
The following list describes the main types (often-called
classes or categories) of psychiatric disorders according
to the DSM 5:
1) Bipolar and Related Disorders. This group includes
disorders in which episodes of mania (periods of excessive
excitement, activity, and energy) alternate with periods of
depression
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2) Depressive Disorders. These include disorders 13) Sexual Dysfunctions. These disorders of sexual response
characterized by feelings of extreme sadness and include such diagnoses as premature ejaculation, erectile
worthlessness, along with reduced interest in previously disorder, and female orgasmic disorder.
enjoyable activities. Examples include major depressive 14) Paraphilic Disorders. Many sexual-interest disorders are
disorder and premenstrual dysphoric disorder (PMDD), included in this group. Examples include sexual sadism
which is more severe than the more widely known disorder, voyeuristic disorder, and pedophilic disorder.
premenstrual syndrome (PMS). PMS is not classified as a 15) Gender Dysphoria. These disorders stem from the distress
psychiatric disorder. that goes with a person's stated desire to be a different
3) Schizophrenia Spectrum and Other Psychotic gender. The diagnostic criteria in this group differ
Disorders. Psychotic disorders cause detachment from somewhat among children, adolescents, and adults.
reality. People with these diagnoses experience delusions, 16) Neurocognitive Disorders. These psychiatric disorders
hallucinations, and disorganized thinking and affect people’s ability to think and reason. The disorders in
speech. Schizophrenia is probably the best known of these this group include delirium as well as disorders of thinking
illnesses, although detachment from reality can and reasoning caused by such conditions or diseases as
sometimes affect people with other psychiatric disorders. traumatic brain injury or Alzheimer's disease.
4) Anxiety Disorders. Anxiety involves focusing on bad or 17) Neurodevelopmental Disorders. The many psychiatric
dangerous things that could happen and worrying fearfully disorders in this group usually begin in infancy or
and excessively about them. Anxiety disorders childhood, often before a child starts school. Examples
include generalized anxiety disorder (GAD), panic disorder, include attention-deficit/hyperactivity disorder (ADHD),
and phobias (extreme or irrational fears of specific things, autism spectrum disorder, and learning disorders.
such as heights). 18) Substance-Related and Addictive Disorders. People with
5) Obsessive-Compulsive and Related Disorders. People with these diagnoses have problems associated with excessive
these disorders experience repeated and unwanted urges, use of alcohol, opioids (for example, oxycodone and
thoughts, or images (obsessions) and feel driven to taking morphine), recreational drugs, hallucinogens, and six other
repeated actions in response to them (compulsions). types of drugs. This group also includes gambling disorder
Examples include obsessive-compulsive disorder (OCD), 19) Disruptive, Impulse-Control, and Conduct Disorders
hoarding disorder, and hair-pulling People with these disorders show symptoms of difficulty
disorder (trichotillomania). with emotional and behavioral self-control. Examples
6) Trauma- and Stressor-Related Disorders. These psychiatric include kleptomania (repeated stealing) and intermittent
disorders develop during or after stressful or traumatic life explosive disorder
events. Examples include posttraumatic stress 20) Other Mental Disorders. This group includes psychiatric
disorder (PTSD) and acute stress disorder. disorders that are due to other medical conditions or that
7) Dissociative Disorders. These are disorders in which a don't meet all the requirements for any of the other
person’s sense of self is disrupted, such as dissociative psychiatric disorder groups
identity disorder and dissociative amnesia.
8) Somatic Symptom and Related Disorders. A person with Mental Health versus Mental Illness
one of these disorders may have distressing and Signs of Mental Health Signs of Mental Illness
incapacitating physical symptoms with no clear medical Happiness Major Depressive Episode
cause. (“Somatic” means “of the body.”) Examples include • Finds life enjoyable • Losses interest or
illness anxiety disorder, somatic symptom disorder • Can see in objects, pleasure in all or almost
(previously known as hypochondriasis), and factitious people, and activities all usual activities and
disorder. their responsibilities for pastimes
9) Personality Disorders. A personality disorder involves a meeting his or her needs • Describes mood as
lasting pattern of emotional instability and unhealthy depressed, sad,
behaviors that seriously disrupt daily living and hopeless, discouraged
relationships. Examples include borderline, antisocial, or “down in the dumps”
and narcissistic personality disorders. Control over behavior Impulse control disorder
10) Eating and Feeding Disorders. These psychiatric disorders • Can recognize and act on & aggressive behavior
are disturbances related to eating, such as anorexia cues to existing limits • Shows repetitive and
nervosa, bulimia nervosa, and binge eating disorder. • Can respond to the rules, persistent pattern of
11) Elimination Disorders. Psychiatric disorders in this group routines, and customs of aggressive conduct in
relate to the inappropriate elimination (release) of urine or any group to which he or which the basic rights of
stool by accident or on purpose. Bedwetting (enuresis) is she belongs others are violated
an example. Appraisal of reality Schizophrenia &
12) Sleep-Wake Disorders. These are severe sleep disorders,
• Accurate picture of what psychotic disorders
including insomnia disorder, nightmare disorder, sleep
is happening around the • Shows bizarre
apnea, and restless legs syndrome.
individual delusions, such as
• Good sense of the delusion of being

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consequences, both controlled may, in times of severe emotional stress, use many of the
good and bad, that will • Has auditory behaviors listed below, it is the repetitive use of these
follow his or her acts hallucinations behaviors in most situations that is indicative of problems.
• Can see the difference • Manifests delusions with - Defenses mechanisms are used as:
between the “as if” and persecutory or jealous 1) Protection of self-security
“for real” in situations content 2) Promotion of self-esteem
Effectiveness in work Adjustment disorder with 3) Resolve mental conflict
• Within limits set by work (or Academic) 4) Reduce anxiety
abilities, can do well in Inhibition Types of Defense Mechanisms
tasks attempted • Shows inhibition in work 1) Commonly Used Normal Defense Mechanisms that
• When meeting mild or academic functioning may help an individual deal with reality.
failure, persist until whereas previously a) Compensation – making up for imagined handicapped
determines whether or there was adequate or deficiency
not he or she can do the performance b) Compromise – reciprocal give and take necessary in
job many relationships
A healthy self-concept Dependent personality c) Identification – unconscious attempt to change oneself
• Sees self as approaching disorder to resemble an admired person
individual ideas, as • Passively allows others d) Sublimation – re-channeling socially unacceptable
capable of meeting to assume responsibility behavior to a socially acceptable one
demands for major areas of life e) Substitution – taking something in place of the original
• Has reasonable degree because of inability to goal or desire
of self-confidence that function independently 2) Compensatory Defense Mechanisms
helps in being • Lacks self-confidence a) Conversion – transferring emotional conflict into
resourceful under stress (e.g. sees self as physical symptoms
helpless or stupid) b) Denial– unacceptance of reality
Satisfying relationships Borderline personality c) Displacement – releasing anger in a least threatening
• Experiences satisfaction disorder way
and stability in • Shows pattern of d) Dissociation – blocking off of an anxiety provoking event
relationships unstable and intense from the conscious mind
• Socially integrated and interpersonal e) Fantasy – gratification by imaginary achievements and
can rely on social relationships wishful thinking
supports • Has chronic feeling of f) Fixation – psychosocial development ceased to
emptiness advance
Effective coping strategies Substance dependents g) Intellectualization – excessive reasoning to avoid real
feeling
• Uses stress reduction • Repeatedly self-
h) Introjection – a type of identification in which the
strategies that address administered
individual incorporates the traits or values of another to
the problem issue, threat substances despite
self
(e.g. problem solving, significant substance-
i) Isolation – person blocks feelings associated with
cognitive restructuring) related problems (e.g.
unpleasant experience
• Using coping strategies threat to job, family and
j) Projection – transferring one’s internal feelings,
in a healthy way that social relationships)
thoughts, and unacceptable ideas and traits to
does not cause harm to
someone else
self and others
k) Rationalization – justifying one’s behavior to make
unacceptable feelings and behavior acceptable
Coping and Defense Mechanisms
• Sour Graping - implies that what is sincerely wanted
Coping Mechanisms
is not worth trying after all
- involves any effort to decrease the stress response. Coping
mechanism can be constructive or destructive • Sweet Lemon - implies that a person tries to
convince himself/herself that what he/she has is
1) Constructive coping mechanism when it is tasked
exactly what he want
oriented (direct problem solving) or defense oriented
l) Reaction Formation – acting out behaviors opposite to
(regulate response to protect oneself)
what one really feels.
2) Destructive coping mechanisms often cause a mental
m) Regression – returning to an earlier developmental
health disorder because the person avoids the problem.
stage
Defense Mechanism
n) Repression – involuntary or unconscious forgetting
- It is a pattern of behaving or thinking use d by individual to
unacceptable thoughts from conscious mind
protect self from threatening aspect s of the environment
o) Suppression – conscious or voluntary forgetting of
and from her/his own feeling of anxiety. It serve as a coping
unacceptable or painful ideas, thoughts or feelings
mechanism or protective defense. Although all individuals

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p) Symbolism – conscious use of idea or object to Major

Theorists Overview Applicability
represent another actual event or Object Concepts
q) Undoing – engaging in a behavior that is considered to Psychoanal Founder of - Id, ego, Individual
be opposite of a previous unacceptable behavior, ytic Models psychoanalysi superego therapy
thought or feeling 1.Sigmund s. Believed - approach
Freud that the Psychosexual used for
THERAPEUTIC THEORIES IN PSYCHIATRIC NURSING (1856- unconscious stages of enhancemen
PRACTICE 1939) could be development t of personal
Terminologies accessed - Anxiety & maturity and
• Cognitive theory. An approach to psychology that through defense personal
attempts to explain human behavior by understanding your dreams and mechanism growth
thought processes free - Free
• Developmental theories. Explain normal human growth association. associations,
and development and focus on change over time. Many Developed a transference
developmental theories are presented in terms of stages personality and
based on the assumption that normal development theory and countertransf
proceeds longitudinally from the beginning to the ending theory of erence
stage infantile
• Psychoneuroimmunology. The study of interaction sexuality
between behavior, neural and endocrine function, and 2. Anna Application of Refinement Individual
immune processes (Ader et al, 1995) Freud ego of concepts therapy
• Needs’ Theory. Explained that needs can create internal (1895- psychology to of anxiety Childhood
pressures that can influence a person's behavior. 1982) psychoanalyti and defense analysis
• Neurobiological theories. An essentially physiological c treatment mechanisms
approach to psychology that attempts to relate human and child
behavior to electrical and chemical activities taking place analysis with
in the brain and central nervous system emphasis on
• Psychoanalytic theory is the theory of personality the adaptive
organization and the dynamics of personality functions of
development that guides psychoanalysis, a clinical method defense
for treating psychopathology mechanisms
• Psychodynamic theories. Explained the mental and Neo- First defected Inferiority Added to the
emotional forces or developing processes, especially in the Freudian from Freud. understandin
early childhood and their effects on behavior and mental Models Founded the g of human
states. 1.Alfred school of motivation
• Role theories. A conceptual framework that defines how Adler individual
individuals behave in social situations and how these (1870- psychology
behaviors are perceived by external observers 1937)
• Social theories. Analytical frameworks, or paradigms, that 2.Carl After Redefined Personalities
are used to study and interpret social phenomena Gustav separating libido are often
Jung (1875- from Freud, Introversion assessed on
Relevant theories in the psychiatric nursing practice 1961)` founded the Extroversion the
Psychodynamic Theories school of Persona introversion
- Psychodynamic theories explained the mental and psychoanalyti and
emotional forces or developing processes, especially in the c psychology. extroversion
early childhood and their effects on behavior and mental Developed dimensions
states. The study f the unconscious is art of the dynamic new
theory, and many models that are important in psychiatric therapeutic
nursing began with the Austrian physician Sigmund Freud approaches.
(1856-1939). 3 Otto Introduced Birth trauma Recognized
- Since his time Freud’s theories has been enhanced by the Rank idea of primary Will the
interpersonal and humanist models. Psychodynamic (1884- trauma of importance
theories initially attempted to explain the causes of mental 1939) birth. Active of feelings
illness but etiologic explanations were not supported by technique of within
controlled research. However, these theories proved to be therapy psychoanalys
especially important in the development of therapeutic including more is
relationships, techniques and interventions nurturing than
Freud.

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Emphasized - Ego. Functions in all level but primarily on the conscious

feeling aspect level of awareness and concerns with reality principles
of analytic - Superego. Functions in all level but primarily on the
process subconscious level of awareness and in moral principles. It
4. Erich Emphasized Individual Individual has 2 portions: 1) Conscience and 2) ego ideal
Fromm the and society desires are Psychosexual Stages of Development by Sigmund Freud
(1900- relationship of are not form by 1) Oral Phase (1-11/2 year old)
1980) the individual separate society - Erogenous zone: Mouth
to society - Source of satisfaction: sucking, biting, and crying
Interperson Impulses and Participant Provided the - Greatest need: sense of security
al Relation striving need observer framework - Insecurity in parting with breast or bottle may cause
Models to be Parataxic for the fixation
1.Harry understood in distortion introduction - Greatest fear: separation anxiety
Stack terms f Consensual of the - Tension is relieved by sucking.
Sullivan interpersonal validation interpersonal 2) Anal phase (1 ½ -3 years old) a
(1892- situations theories in - Erogenous zone: Anus
1949) nursing - Source of satisfaction: defecation
Humanist Concerned Needs Used as a - This is the critical period for toilet training: letting go or
Theories himself with Motivation model to holding on
1. Abraham healthy rather understand • Bladder control: 18 months
Maslow than sick how people • Daytime bladder control: 2 ½ year old
(1921- people. are • Night time bladder control: 3 year old
1970) Approached motivated 3) Phallic phase (3 -6 years old)
individuals and needs - Erogenous zone: Genital
from a holistic that should - Source of satisfaction: Playing sex organ (masturbation)
dynamic be met • Sexual curiosity
viewpoint • Consensual validation
2.Frederick Awareness of Reality Used as a • Castration anxiety/Penis envy
S. Perl’s emotion, Here and therapeutic • Oedipal / electra complex
(1893- physical state, now approach to 4) Latency phase ( 6 - 12 years old)
1970) and repressed resolve - Erogenous zone: Genital (dormant/inactive)
needs would current life - Source of satisfaction:
enhanced the problems • Focus in acquiring knowledge, and social skills
ability to deal that • Focus in the development of competence in school
with emotional influenced by activities and school achievements
problems old, 5) Genital phase ( 12 - 18 years old and above)
unresolved - Erogenous zone: Genital
emotional - Source of satisfaction: Genital
problems - Development of heterosexual relationship
3. Carl Based theory Empathy Individual - Final stage
Rogers on the view of Positive therapy
(1902- human regard approach Interpersonal Stages of Development by Harry Stack
1987) potential for that involves Sullivan
goodness. never giving - Sullivan believed that the health or sickness of one’s
Used the term advice and personality was determined by the characteristic ways in
client rather always which one dealt with other people.
than patient. clarifying Significant
Stressed the client’s Stages Ages
Relationships
relationship feelings
Infancy 0-1 ½ years mother
between
therapist and 1 ½ -3
Toddler Parents
client years
Siblings, relatives,
Pre-school age 3-6 years
Psychodynamic Theory by Sigmund Freud playmates, teachers,
Personality Components by Sigmund Freud Juvenile era 6-9 years Friends (gang formation)
- Id. Functions in the unconscious level of awareness and Special friend (chum
Pre adolescence 10-12 years
concerns with pleasure principles formation)
Adolescence 12-21 years Peers

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Partner, Loved ones, Cognitive Theory

Late adolescence 21-above
colleagues There are three important cognitive theories. The three
- Sullivan also believed that childhood experiences cognitive theories are Piaget’s developmental theory, Lev
determine, to a large degree, the adult personality. He Vygotsky’s social cultural cognitive theory, and the
called the stages in his developmental information process theory.
theory "epochs" Sullivan suggested that many adulthood Cognitive Development Theory by Jean Piaget
problems arise from the confusions of adolescence. - Piaget believed that children go through four stages of
Sullivan believed that childhood experiences determine, to cognitive development in order to be able to understand
a large degree, the adult personality. the world. Organization and adaptation are the two
processes that allow us to make sense of our world. He
Hildegard Peplau Interpersonal relationships in nursing also states that we go through four stages that allow us to
practice understand the world. For each stage, the child views the
- Peplau's theory is one of the early Nursing theories, world differently.
published in 1952. The nurse-patient relationship consists a) Sensorimotor stage, (0-2 years old). In this stage, the
of four steps (orientation, identification, development and child is only aware of what is in front of them.
conclusion). In these steps nurse could have the role of b) Preoperational stage (2-7 years of age. In this stage, the
foreign, reliable person, teacher, and guide in nursing care, child go beyond sensory perception and he/she is able
substitute and consultant. Nurse-patient relationship is to think symbolically.
influenced by psychobiological experiences (needs, c) Concrete operational stage (7 to 11 years of age). In this
frustrations, conflicts and anxiety) which need dynamism. stage the child becomes aware of their surroundings.
Peplau thinks that nursing care is an important opportunity They are less self-centered.
for nurse because she can help patient to complete the d) Formal operational stage (11 to 15 years of age). In this
infancy psychological tasks (learning to rely on other stage allows the child to think in abstract and logical
people, learning to show satisfaction, self-identifying, and ways.
developing ability in sharing) if these are not completed. Lev Vygotsky’s theory
For these reasons, Nursing, by Peplau, is a maturation - focuses on how culture and social interaction lead
strength of civilization. cognitive development.
- He believed that social interaction plays an important role
Developmental theories in the way we develop cognitively.
- The developmental theories explain normal human growth Information-Processing Theory
and development and focus on change over time. Many - views the mind as a system that processes information.
developmental theories are presented in terms of stages
based on the assumption that normal development UNDERSTANDING STRESS
proceeds longitudinally from the beginning to the ending - Stress - Stress is a process whereby an individual
stage perceives and responds to events appraised as
overwhelming or threatening to one’s well-being.
Psychosocial Stages of Development by Erik Erikson (Eight Hans Selye’s Response to Stress
Ages of Man) 1) Alarm stage
Stages Ages Tasks Virtues - stress stimulate/signal hypothalamus to send
INFANCY 0-1 ½ Trust vs. Hope & Faith messages to the glands (adrenal gland) to send out
years Mistrust adrenaline and norepinephrine for fuel and organs
TDLER 1 ½-3 Autonomy Will & (liver) to convert glycogen to glucose for body’s
years vs. Shame Determination defenses
and Doubt 2) Resistance
PRE-SCHOOL 3-6 Initiative Purpose & - Digestive system reduces function to shunt blood to
years vs. Guilt Courage areas needed for defense
SCHOOL 6-12 Industry Competence - Lungs to take in more oxygen
years vs. Inferiority - Heart beats faster and harder so that it can circulate
ADOLESCENCE 12-21 Identity Fidelity & this highly oxygenated blood to the muscles to defend
years vs. Role Loyalty the body by fight, flight or freeze
confusion - If the person adapts to the stress, the body responses
YOUNG ADULT 21-35 Intimacy Love relax and the body gland, organ and systemic response
years vs. Isolation abate
ADULT 35-60 Generativity Care 3) Exhaustion stage
years vs. - if the person has responded negatively to anxiety and
Stagnation stress; body sores are depleted or the emotional
ELDERLY 60- Integrity Wisdom components are not resolved, resulting in continual
above vs. Despair arousal of the physiologic responses and little reserve
capacity

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- Anatomic nervous system responses to fear and anxiety
generate the involuntary activities of the body that are
involved in self-preservation
• Sympathetic nerve fibers increases
• Parasympathetic nerve fibers decreases
Lazarus’ Theory of Stress
- Stress as defined by Lazarus is a "particular relationship
between the person and environment that is appraised by
the person as taxing or exceeding his or her resources and
endangering his or her wellbeing"
- Lazarus states that stress is experienced when a person
perceives that the “demands exceed the personal and
social resources the individual is able to mobilize." this is
called the 'transactional model of stress and coping
- According to Lazarus, the effects that stress has on a
person is based more on the person’s feelings of threat,
vulnerability and ability to cope than on the stressful event
itself.
1) Primary Appraisal - When we decide if a situation is
threatening or positive, relevant or irrelevant to our
situation. There are three things needing to be
evaluated:
• Is the threat significant to that person?
• Is it a positive encounter?
• Is it threatening/harmful/challenging?
If an individual decides that the situation is
threatening the following may occur: injury, illness,
angry, disgust, disappointment, worry, anxiety, a
fear response, a challenge or anticipation.
2) Secondary Appraisal - When we assess what resources
are available to us to help combat or cope with the
stressor. An individual may choose to use:
• Internal Options: will-power, inner strength
• External Options: peers, professional help.
3) Problem-Based Coping - Used when we feel we have
control over the situation, thus can manage the source
of the problem. There are four steps to manage this
stress:
• Define the problem,
• Generate alternative solutions,
• Learn new skills to dealing with stressors,
• Reappraise and find new standards of behavior.
GAS Theory of Stress
- GAS is the three-stage process that describes the body’s
response to stress. According to Selye’s theory, the stress
response is the body’s “non-specific reaction to demands
made to its internal equilibrium.” The stress damage
results from prolonged exposure to the stressor and
happens in 3 stages
Psychoneuroimmunology
- It is the study of interaction between behavior, neural and
endocrine function, and immune processes (Ader et al,
1995)
- Early life stress, both psychological and physiological,
affects PNI function.
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PSYCHOPATHOLOGY, ETIOLOGY AND PSYCHODYNAMICS
OF SCHIZOPHRENIA, MOOD AND ANXIETY DISORDERS
Terminologies
• Alogia: Tendency to speak very little or to convey little
substance of meaning (poverty of content)
• Ambivalence: Holding seemingly contradictory beliefs or
feelings about the same person, event, or situation
• Anhedonia: Feeling no joy or pleasure from life or any
activities or relationships
• Anxiety. A vague unpleasant feeling of apprehension
• Apathy: Feelings of indifference toward people, activities,
and events
• Asocial. Loss of interest in social relationships Associative
looseness: Fragmented or poorly related thoughts and
ideas
• Attitude therapy. An orientation organized through
experiences, which respond consistently to an object,
person, or situation. It aimed to modify a patient's patterns
of behavior, which is viewed as a group of symptoms,
rather than one specific symptom.
• Avolition. Lack of volition: Absence of will, ambition, or
drive to take action or accomplish task
• Behavioral therapy. A form of therapy that seeks to
identify and help change potentially self-destructive or
unhealthy behaviors of patient. The focus of treatment is
often on current problems and how to change them
• Bipolar I disorder. The patient may had at least one manic
episode that may be preceded or followed by hypomanic or
major depressive episodes. In some cases, mania may
trigger a break from reality (psychosis). Bipolar I disorder
can be severe and dangerous
• Bipolar II disorder. The patient had at least one major
depressive episode and at least one hypomanic episode,
but never had a manic episode.
• Blunted affect: Restricted range of emotional feeling, tone,
or mood
• Catatonia: Psychologically induced immobility
occasionally marked by periods of agitation or excitement;
the client seems motionless, as if in a trance
• Cognitive-behavioral therapy: This form of psychotherapy
focuses on changing harmful thinking patterns, feelings,
and behaviors.
• Commitment therapy. A method of psychotherapy that
promotes the use of mindfulness to accept the traumatic
event
• Creative therapies. Therapies that allow patients to
explore and express their thoughts, feelings, and
experiences in a safe and creative environment
• Cyclothymic disorder. The patient had at least two years
for adult or one year in children and teenagers of many
periods of hypomania symptoms and periods of depressive
symptoms (though less severe than major depression).
• Delusions: Fixed false beliefs that have no basis in reality
• Depersonalization. Feeling of being detached from one’s
thoughts, feelings, and body
• Derealization. Feeling of disconnected from one’s
surrounding environment
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Dialectic-behavior therapy: This form of psychotherapy is
for people with severe personality disturbances (which can
include dissociative symptoms), and often takes place
after the person has suffered abuse or trauma..
• Dissociation. A disconnection between a person’s
thoughts, memories, feelings, actions or sense of who he
or she is.
• Dissociative disorders. A mental illness in which there is
a breakdown of mental functions that normally operate
smoothly, such as memory, consciousness or awareness,
and identity and/or perception.
• Distraction techniques. Any activity that you engage in to
redirect your mind off your current emotions. Instead of
putting all your energy into the upsetting emotion, you
reset your attention to something else.
• Echopraxia: Imitation of the movements and gestures of
another person whom the client is observing
• Eye movement desensitization and reprocessing: This
technique is designed to treat people who have continuing
nightmares, flashbacks, and other symptoms of post-
traumatic stress disorder (PTSD).
• Family therapy: This helps teach the family about the
disorder and helps family members recognize if the
patient’s symptoms come back
• Fear. An unpleasant often strong emotion caused by
expectation or awareness of danger
• Flashbacks. A sudden and disturbing vivid memory of an
event in the past, typically as the result of psychological
trauma or taking mind altering drugs
• Flat affect: Absence of any facial expression that would
indicate emotions or mood
• Flight of ideas: Continuous flow of verbalization in which
the person jumps rapidly from one topic to another
• Grounding techniques strategies that can help a person
manage their traumatic memories or strong emotions by
focusing at present situation,.
• Hallucinations: False sensory perceptions or perceptual
experiences that do not exist in reality Ideas of reference:
False impressions that external events have special
meaning for the person
• Hoarding disorder. A mental disorder in which the
individual excessively save items and the idea of discarding
items causes extreme stress
• Hypomania. A mild form of mania, marked by elation and
hyperactivity
• Hypnosis. Also called hypnotherapy. Uses guided
relaxation, intense concentration, and focused attention to
achieve a heightened state of awareness that is sometimes
called a trance. The person's attention is so focused while
in this state that anything going on around the person is
temporarily blocked out or ignored.
• Malingering Disorder. Refers to producing false medical
symptoms or exaggerating existing symptoms in hopes of
being rewarded in some way.
• Mindfulness. The act of living in the present moment to
keep the victim’s thoughts and feelings at present
circumstances or future possibilities than in the moment of
the trauma.
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• Mania. A mental illness marked by periods of great
excitement or euphoria, delusions, and overactivity
• Panic Disorder. A mental health condition characterized
by sudden onset of intense apprehension or terror that last
for 15-30 min
• Perseveration: Persistent adherence to a single idea or
topic; verbal repetition of a sentence, word, or phrase;
resisting attempts to change the topic
• Phobia. An extreme or irrational fear of or aversion to
something.
• Post-traumatic stress disorder (PTSD). A mental health
condition that's triggered by a terrifying event - either
experiencing it or witnessing it
• Pseudocyesis: A false belief of being pregnant that is
associated with objective signs and reported symptoms of
pregnancy.
• Psychoeducation. A humanistic approach to changing the
behavior patterns, values, interpretation of events, and life
outlook of individuals who are not adjusting well to their
environment(s) (e.g. home, school, and workplace).
• Psychotherapy: Psychotherapy, sometimes called “talk
therapy,” that includes several forms of therapy.
• Schizophrenia. A group of disorder characterized by
disturbance in thinking, feelings, perceptions and behavior
• Somatic symptom disorders. Mental health disorders
characterized by an intense focus on physical (somatic)
symptoms that causes significant distress and/or
interferes with daily functioning.
• Suicide. The act or an instance of taking one's own life
voluntarily and intentionally
• Trichotillomania. A chronic condition characterized by
pulling, picking, scraping or biting the hair, nails or skin,
that often cause self-damage.
Schizophrenia
- A brain disorder that comprises multiple etiologies.
- The hallmark symptom of schizophrenia is psychosis, such
as experiencing auditory hallucinations (voices) and
delusions (fixed false beliefs) and impaired cognition or a
disturbance in information processing that interferes with
day-to-day life.
- People with schizophrenia have lower rates of employment,
marriage, and independent living compared with other
people.
Characteristic symptoms
1) Delusions
2) Hallucinations
3) Disorganized speech (e.g., frequent derailment or
incoherence)
4) grossly disorganized or catatonic behavior
5) Negative symptoms (i.e., diminished emotional expression
or avolition)
Social/occupational dysfunction
- For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major
areas, such as work, interpersonal relations, or self-care, is
markedly below the level achieved prior to the onset (or
when the onset is in childhood or adolescence, there is
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
failure to achieve expected level of interpersonal,
academic, or occupational functioning).
Duration
- Continuous signs of the disturbance persist for at least 6
months.
- This 6-month period must include at least 1 month of
symptoms (or less if successfully treated) that meet
Criterion A (i.e., active-phase symptoms) and may include
periods of prodromal or residual symptoms.
- During these prodromal or residual periods, only negative
symptoms or two may manifest the signs of the
disturbance or more symptoms listed in Criterion A maybe
present in an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).
Theories of Etiology
Biologic factors
1) Genetic predisposition
2) Neuroanatomic and Neurochemical factors
3) Immunovirologic factors
Psychological factors
S - Self-concept changes
A - Affective blunting
D - Difficulties in relating
- Difficulties with decision-making
- Difficulty with stress coping
- Difficulty with financial resources
- Discriminated, rejected or unwanted
Phases of Schizophrenia
Acute Illness phase
- Sudden change of behavior
- S - Staying up all night for several nights (sleepless nights)
- A - Aggressive acts against self and others
- I - Increase dependency, Incoherent conversation
- D - Disruptive and bizarre behavior that are uncontrollable
Stabilization Phase where initial treatment is initiated to:
- Alleviation of symptoms
- Decreasing risk of suicide
- Normalizing sleep
- Reducing substance use when using prohibited
substances
Maintenance and recovery period (FHM)
- Focus on regaining the client previous level of functioning
- Family support
- Health education on medication, psychosocial treatment
and prevention of relapse
- Maintenance of medication
Relapse
- Identify reasons for relapse and further management
Nursing Intervention for patient with Schizophrenia and
other Psychotic Disorders
Biologic Domain
1) Self-care deficit
- Promotion of self-care and personal hygiene
2) Disturbed sleep pattern
- Promotion of sleep hygiene strategies
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3) Imbalance nutrition
- Promotion of healthy nutrition
4) Constipation
- Prevention of constipation
5) Activity, and exercise intervention
- Encourage activity and exercise to maintain a healthy
lifestyle and to counteract the side effect of psychiatric
medications
6) Thermoregulation intervention
- Protect client from extremes in temperature because
they have disturbed body temperature regulation
- Promotion of normal fluid balance and prevention of
water intoxication
- Fluid and weight gain should be monitored to control
fluid intoxication
- Teach and assist client to develop self-monitoring skills.
Psychological Domain
1) Disturbed thought process ex delusion
2) Disturbed sensory perception ex: hallucination
- Validate the client experience
- Identify the meaning of client’s feeling and experience
- Decrease the frequency of intensity of hallucinations
and delusions
• Provide diversional activities like drawing, dancing,
singing, exercise, etc.
• Help cope up with experience
- Enhance cognitive functioning
• Identify deficits in cognitive functions (problem with
memory, focusing, problem solving, etc.)
• Improve motivation and organize routine daily
activities
- Develop effective stress coping skills
• Establish regular counseling sessions to support the
development of positive coping skills
Social Domain
1) Impaired social interaction
2) Ineffective role performance
3) Interrupted family processes
- Develop social interaction skills
- Provide therapeutic environment for the client and
helping client who are unable to live with family
members to live harmoniously with others/strangers
4) Convening support groups
- Focus on daily problems and the stress dealing with
mental illness. (Reduce the risk of suicide, sharing
experience of living with a mental illness)
5) Developing psychiatric rehabilitation strategies
- Rehabilitation strategies are used to support the
individuals’ recovery and integration in the societies: ex:
Occupational training, job placement and social skills
training
Other Psychotic Disorders
Delusional Disorder
- previously called paranoid disorder, is a type of
serious mental illness called a psychotic disorder. People
who have it cannot tell what is real from what is imagined.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- Delusions are the main symptom of delusional disorder. It
involves delusions that are not bizarre, having to do with
situations that could happen in real life, like being
followed, poisoned, deceived, conspired against, or loved
from a distance.
- These delusions usually involve mistaken perceptions or
experiences. However, in reality, the situations are either
not true at all or highly exaggerated.
- A bizarre delusion, by contrast, is something that could
never happen in real life, such as being cloned by aliens or
having your thoughts broadcast on TV. A person who has
such thoughts might be considered delusional with bizarre-
type delusions.
- People with delusional disorder often can continue to
socialize and function normally, apart from the subject of
their delusion, and generally do not behave in an obviously
odd or bizarre manner. This is unlike people with
other psychotic disorders, who also might have delusions
as a symptom of their disorder. Nevertheless, in some
cases, people with delusional disorder might become so
preoccupied with their delusions that their lives are
disrupted.
- Although delusions might be a symptom of more common
disorders, such as schizophrenia, delusional disorder itself
is rather rare. Delusional disorder most often happens in
middle to late life and is slightly more common in women
than in men.
- The types are based on the main theme of the delusion:
1) Erotomanic: The person believes someone is
in love with them and might try to contact that person.
Often it is someone important or famous. This can lead
to stalking behavior.
2) Grandiose: This person has an over-inflated sense of
worth, power, knowledge, or identity. They could believe
they have a great talent or made an important
discovery.
3) Jealous: A person with this type believes their spouse or
sexual partner is unfaithful.
4) Persecutory: Someone who has this believes he or she
(or someone close to him or her) are being mistreated,
or that someone is spying on him or her or planning to
harm him or her. They might make repeated complaints
to legal authorities.
5) Somatic: They believe they have a physical defect or
medical problem.
6) Mixed: These people have two or more of the types of
delusions listed above.
Brief Psychotic Disorders
- an uncommon psychiatric condition characterized by
sudden and temporary periods of psychotic behavior, such
as delusions, hallucinations, and confusion.
- Symptoms can endure for only one day or for as long as
one month, but may be severe enough to put the person at
increased risk of violent behavior or suicide.
- A majority of cases present for the first time when an
individual is in their 20s or 30s, although onset can occur
at any age.
- Brief psychotic disorder is differentiated from other
disorders in which psychosis occurs by its limited duration,
J.A.K.E 20 of 62
and it is not triggered by drugs or alcohol abuse. In most
cases, brief psychotic disorder does not indicate the
presence of a chronic mental health condition.
- According to the DSM-5, symptoms of brief psychotic
disorder may include:
• Delusions and hallucinations
• Sudden and extreme mood changes
• Nonsensical or disordered speech
• Disorganized behavior
• Catatonia
Risk factors
• Women are more likely than men to develop brief
psychotic disorder, especially postpartum. The DSM-5
classifies one subtype of brief psychotic disorder as
psychosis with onset within one month of giving birth. Most
people who develop brief psychotic disorder experience
only one episode and are able to resume all activities with
no permanent symptoms or impairment.
• People with certain personality disorders have an elevated
risk of experiencing a brief psychotic episode, as are those
who have experienced trauma or severe stress.
• NOTE: It is important to understand that the prognosis for
brief psychotic disorder is generally good. However, an
initial psychotic episode may be the first sign of a chronic
mental health condition such as schizoaffective disorder,
schizophrenia, or a mood disorder with psychotic
symptoms. The diagnosis of brief psychotic disorder is
generally reevaluated if symptoms persist for more than
one month.
Causes
• The cause of brief psychotic disorder is unclear, but major
stress or trauma — such as the death of a loved one,
assault, or natural disaster — can trigger an episode.
• As with other disorders on the psychotic spectrum, there
may be a genetic, biologic, environmental, or neurological
basis for this episode.
• Neurological abnormalities have been found in people with
psychotic disorders; some appear to be present before
symptoms first appear, while other abnormalities have
been recorded after the onset of symptoms. Brief
psychotic disorder tends to run in families.
Treatment and management
• Antipsychotic medications and, if
necessary, antidepressants may be prescribed to help
manage symptoms.
• Short-term psychotherapy can help a person understand
and recover from brief psychotic disorder, manage their
medications, and learn to cope with stress.
• Supervised at all times to ensure they don’t harm
themselves or others
• Health education. Those who fail to seek treatment after
a first psychotic episode are more likely to see a future
recurrence of brief psychotic disorder or to subsequently
be diagnosed with a chronic disorder on the psychotic
spectrum.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
Schizophreniform
- A psychotic condition similar in its symptoms to
schizophrenia, but developing rapidly and present for a
shorter period.
- Like the other entities in the schizophrenia spectrum,
schizophreniform disorder is a serious and often disabling
mental illness with both positive and negative thought and
behavioral symptoms.
- According to the DSM-5, symptoms of brief psychotic
disorder may include:
1) Positive
• Hallucinations
• Delusions
• thought disorder
• disorganized speech
• behavioral disorganization or catatonia
2) Negative symptoms
• inability to feel emotions with flattening of affect,
• inability to experience pleasure or anhedonia
• loss of interest in social relationships
• lack of motivation
• reduction of impairment of speech
Treatment and Management
Medications
a) Antipsychotic
- Risperidone (Risperdal), quetiapine (Seroquel),
olanzapine (Zyprexa) and ziprasidone (Geodon) are
the most commonly-used atypical neuroleptics, so
called because they do not work solely by blockade
of the D2 dopamine receptors as the first-generation
or typical neuroleptics like chlorpromazine or
haloperidol do
- A new generation of neuroleptics is effective for
resistant psychotic symptoms: Aripiprazole (Abilify),
which is a partial agonist rather than blocker of
dopamine receptors and can be given by injection;
Paliperidone (Invega),
b) Antidepressant
- If depressive symptoms usually is treated with an
SSRI or SNRI antidepressant
- If manic symptoms accompany the psychosis,
mood stabilizers (Lithium carbonate,
carbamazepine, Valproic acid, lamotrigine or
Topiramate) can be added.
Supportive psychotherapy
• Insight-oriented therapy but of limited value because of
frequent denial and limited insight.
• Group therapy
Schizoaffective Disorders
- characterized by mood and psychotic symptoms
(American Psychiatric Association, 2013). Hallmarks of
schizoaffective disorder include depression and mood
disorders, hallucination, and delusion.
- To be diagnosed as schizoaffective, it must be
characterized by a bout of illness during which a significant
mood episode is manifested. Hallucinations and delusions
must also be present in a time span of 2 week and drugs or
J.A.K.E 21 of 62
medications must not be the cause of these mood
symptoms, hallucinations, and delusions.
- Furthermore, difficulty in an occupational setting is often
seen in schizoaffective disorder, but it is not a requisite
condition for a diagnosis of schizoaffective disorder.
- Symptoms of schizoaffective disorder according to the
DSM-5
• Night eating syndrome, wherein the individual
recurrently indulges in late-night episodes of binge
eating, (Palmese et al., 2013).
• Insomnia.
• lack of organized speech and thought patterns,
• suicide ideation
• Paranoia
• Neglect of hygiene and personal appearance.
• difficulties in concentrating
• Mood swings, range from one of melancholy to one of
exuberance.
• Tendency to speak rapidly, such that one’s peers are
unable to interrupt.
• Isolation in social settings may occur when one has
schizoaffective disorder.
Treatment of Schizoaffective Disorder
• Cognitive behavioral therapy to reduce “auditory verbal
hallucinations
• Psychotherapy has been used – with some success – in
treating the psychotic
• Group psychotherapy – wherein patients could interact
with individuals with the same disorder in a safe context –
provided the patients with a deeper understanding of their
own nature.
Catatonia
- A neuropsychiatric condition that affects both behavior
and motor function, and results in unresponsiveness in
someone who otherwise appears to be awake.
- For the purpose of diagnosis, there are three types of
catatonia, including catatonia associated with another
mental disorder, catatonia disorder due to another medical
condition, and unspecified catatonia. Although often
associated with schizophrenia and other affective
disorders, catatonia may be a result of, or due to, any
number of psychotic disorders, mood disorders or general
medical conditions.
- Catatonia is sometimes referred to as catatonic syndrome,
because there is not just one identifying sign or symptom
associated with this condition or symptoms that appear
separately from one another, but rather a collection of
several symptoms that appear together at the same time.
- According to the DSM-5, at least three out of twelve
symptoms must be present for a diagnosis of catatonia.
These symptoms include:
• Stupor (oblivious inability to move or respond to stimuli),
catalepsy (rigid body posture)
• Mutism (little to no verbal communication)
• Waxy flexibility (body remains in whatever position it is
placed by another)
• Negativism (lack of verbal response)
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Posturing (holding a posture or position that goes
against gravity)
• Mannerisms (extreme or odd movements and
mannerisms)
• Stereotypy (frequent repetitive movements for no
reason)Agitation (for no reason), grimacing (distorted
facial expressions)
• Echolalia (repeating others’ words)
• Echopraxia (repeating others’ movements)
• Rigidity and automatic obedience.
- When catatonia is associated with schizophrenia, stupor
may continue for long periods as compared to
schizophrenia associated with other psychiatric conditions,
where there are likely to be long remissions.
Treatment
1) Psychopharmacology
• benzodiazepines (tranquilizers),
• antidepressants,
• muscle relaxers
• Antipsychotic medications.
2) Brain stimulation therapy
• electroconvulsive therapy
• NMDA antagonists (anesthetic pain medications)
Attenuated Psychosis Syndrome
- A new and somewhat controversial diagnosis in DSM-5. It
is a set of symptoms that cause clinically significant
distress or impairment in social, occupational, or other life
areas (American Psychiatric Association, 2013).
- These symptoms are very similar to the symptoms seen in
schizophrenia, but do not reach the clinical level of severity
to be considered to fit any of the disorders in the
schizophrenia spectrum or other psychotic disorder.
- The symptoms are less severe, are more likely to come and
go to an extent, and reality is maintained at least partially.
Although the symptoms are present, the patient’s reality
testing appears to be relatively intact. This likely leads to
the distress felt by the patient. Being aware of the unusual
nature of the symptoms being experienced is distressing.
• Hallucinations
• Delusions
• disorganized speech
• Isolation. The tendency to withdraw for short periods of
time or a desire to isolate oneself.
• Low level of suspiciousness
• Difficulty in thinking or concentrating
Treatment
• Cognitive therapies, like Cognitive Behavioral Therapy
(CBT), lessened the likelihood of early symptoms
converting to psychosis in young adults.
• Supportive therapy and CBT improving depression, anxiety,
and positive psychotic symptoms.
• Risperidone combined with CBT showed promise as a
treatment approach compared to a need-based group
Shared Psychotic Disorders
- (Folie a deux) is an unusual mental disorder characterized
by sharing a delusion among two or more people who are in
a close relationship.
J.A.K.E 22 of 62
- The (inducer, primary) who has a psychotic disorder with
delusions influences another individual or more (induced,
secondary) with a specific belief. It commonly presents
among two individuals, but in rare cases can include larger
groups, i.e., family and called folie a famille
- The types are the following:
1) Folie imposee (imposed psychosis) - Described by
Lasegue and Falret in 1877. The delusions were
transferred from one individual to another with the
existence of an intimate relationship. These soon
disappear once the two were separated.
2) Folie simultanee (simultaneous psychosis) - Described
by Regis in 1880. Both partners shared the psychoses
simultaneously. They both have risk factors through
long social interactions that predispose to develop this
condition. There are reports of sharing genetically risk
factors among siblings.
3) Folie communiquée (communicated psychosis) -
Described by Marandon de Montyel in 1881. This type is
similar to type (1) however; more resistance is applied
to the delusions by the second partner. Finally, the
second partner will adopt it even after separation.
4) Folie induite (induced psychosis) - Described by
Lehmann in 1885. In this type, additional new delusions
induced to the second partner by the first partner.
Researchers noticed that an expansion of the delusions
exists. This type would be present among two mentally
ill individuals.
- Treatment should be tailored case by case
• Medication for both partners whether alone
(antipsychotics-antidepressant)
• Combination (mood stabilizers/antipsychotics)
• Combination (antidepressants/antipsychotics)
• Psychotherapy could be offered to both partners either
individually or as conjoined
• ECT has also been an option
Bipolar disorder
- formerly called manic depression, is a mental health
condition that causes extreme mood swings that include
emotional highs (mania or hypomania) and lows
(depression).
- When a person become depressed, he or she may feel sad
or hopeless and lose interest or pleasure in most activities.
When his or her mood shifts to mania or hypomania (less
extreme than mania), he or she may feel euphoric, full of
energy or unusually irritable.
- These mood swings can affect sleep, energy, activity,
judgment, behavior and the ability to think clearly.
- Episodes of mood swings may occur rarely or multiple
times a year. While most people will experience some
emotional symptoms between episodes, some may not
experience any. Although bipolar disorder is a lifelong
condition, mood swings and other symptoms can be
manage by medications and psychological counseling
(psychotherapy).
- There are several types of bipolar and related disorders.
They may include mania or hypomania and depression.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

Symptoms can cause unpredictable changes in mood and
behavior, resulting in significant distress and difficulty in
life.
Types of Bipolar Disorders
1) Bipolar I disorder
- The patient may had at least one manic episode that
may be preceded or followed by hypomanic or major
depressive episodes. In some cases, mania may trigger
a break from reality (psychosis).
- Bipolar I disorder can be severe and dangerous
2) Bipolar II disorder
- The patient had at least one major depressive episode
and at least one hypomanic episode, but never had a
manic episode.
- Bipolar II disorder is not a milder form of bipolar I
disorder, but a separate diagnosis. An individual with
bipolar II disorder can be depressed for longer periods,
which can cause significant impairment
3) Cyclothymic disorder.
- The patient had at least two years for adult or one year
in children and teenagers of many periods of
hypomania symptoms and periods of depressive
symptoms (though less severe than major depression).
4) Other types.
- These include, for example, bipolar and related
disorders induced by certain drugs or alcohol or due to
a medical condition, such as Cushing's disease,
multiple sclerosis or stroke.
Although bipolar disorder can occur at any age, typically it's
diagnosed in the teenage years or early 20s. Symptoms can
vary from person to person, and symptoms may vary over
time.
Diagnostic Criteria
• Mania and hypomania are two distinct types of episodes,
but they have the same symptoms. Mania is more severe
than hypomania and causes more noticeable problems at
work, school and social activities, as well as relationship
difficulties. Mania may also trigger a break from reality
(psychosis) and require hospitalization.
• Both a manic and a hypomanic episode include three or
more of these symptoms:
- Abnormally upbeat, jumpy or wired
- Increased activity, energy or agitation
- Exaggerated sense of well-being and self-confidence
(euphoria)
- Decreased need for sleep
- Unusual talkativeness
- Racing thoughts
- Distractibility
- Poor decision-making — for example, going on buying
sprees, taking sexual risks or making foolish
investments
- An episode includes five or more of these symptoms:
• Depressed mood, such as feeling sad, empty, hopeless
or tearful (in children and teens, depressed mood can
appear as irritability)
• Marked loss of interest or feeling no pleasure in all — or
almost all — activities
• Significant weight loss when not dieting, weight gain, or
decrease or increase in appetite (in children, failure to
gain weight as expected can be a sign of depression)
• Either insomnia or sleeping too much
• Either restlessness or slowed behavior
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or inappropriate
guilt
• Decreased ability to think or concentrate, or
indecisiveness
• Thinking about, planning or attempting suicide
Other features of bipolar disorder
• Signs and symptoms of bipolar II disorders and I may
include other features, such as anxious distress,
melancholy, psychosis or others. The timing of symptoms
may include diagnostic labels such as mixed or rapid
cycling. In addition, bipolar symptoms may occur during
pregnancy or change with the seasons.
• Symptoms in children and teens. Symptoms of bipolar
disorder can be difficult to identify in children and teens. It
is often hard to tell whether these are normal ups and
downs, the results of stress or trauma, or signs of a mental
health problem other than bipolar disorder.
• Children and teens may have distinct major depressive,
manic, or hypomanic episodes, but the pattern can vary
from that of adults with bipolar disorder. And moods can
rapidly shift during episodes. Some children may have
periods without mood symptoms between episodes. The
most prominent signs of bipolar disorder in children and
teenagers may include severe mood swings that are
different from their usual mood swings.
• Despite the mood extremes, people with bipolar disorder
often don't recognize how much their emotional instability
disrupts their lives and the lives of their loved ones and
don't get the treatment they need.
Behaviors considered appropriate can mask depression
1) Children – cranky, school phobia, hyperactivity, learning
disorders, failing grades, antisocial behaviors
2) Adolescence – substance abusers, joining gangs, engage
in risky behavior, under achiever, drop outs
3) Adults – substance abuse, eating disorders, compulsive
behavior (gambling, workaholic), hypochondriasis
4) Older adult – argumentative, cranky, somatic ailments

Major depressive episode

- A major depressive episode includes symptoms that are
severe enough to cause noticeable difficulty in day-to-day
activities, such as work, school, social activities or
relationships.

J.A.K.E 23 of 62
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

Psychopathology, Etiology and Psychodynamic of Mood • Specific Phobia is persistent irrational fear other than
Disorders mentioned above
Factors Depression Bipolar (Mania) Types of Specific Phobia
Genetic Factor Higher incidence Higher incidence Acrophobia- height Microphobia - germs
among family with among family Ailurophobia- cats Mysophobia - contamination or
depressive disorder with manic or Algophobia- pain germs
than in general mood disorder Androphobia- man Nyctophobia - nights/ dark
population than in general Astraphobia- storms places
population Belonophobia- needles Ochlophobia - crowds
Neurochemical Decreased serotonin Brontophobia - thunder Opidiophobia - snakes
Factor and norepinephrine Claustrophobia- enclosed Pathophobia - disease
Neurostructural Ex: Limbic system Ex: Limbic places Phonophobia - loud noises
factor hypometabolism system Cynophobia- dogs Photophobia - light
dysfunction Entomophobia- insects Pyrophobia- fire
Individual Imagined or real loss Mask for Genophobia - dirt Taphophobia- being buried
Factor of loved person or depression Hematophobia- blood alive
object Kakorrhaphobia - failure Topophobia- stage fright
Psychosocial Faulty family and Faulty family and Xenophobia- fear of strangers
Factor social interaction social Zoophobia- animals
interaction
Generalized Anxiety Disorder
Treatment and management - Generalized Anxiety Disorder is characterized by non-
1) Biological therapy specific, excessive and uncontrollable which may last over
• Psychopharmacology days for 6 months.
• ECT - Individual w/ GAD typically anticipate disasters and overly
2) Interpersonal therapy concern about everyday matters such as:
• Help client establish a successful relationship • Health issues
• Help client learn to trust others • Death
3) Behavioral therapy • Money
• Reinforcing behavioral change through positive • Family problem
feedback and decreasing negative interactions • Work difficulties
• Focus on improving social & coping skills and
4) Cognitive Therapy Treatment and Management for Panic Disorder, Phobia
• Changing negative thinking into positive thinking and Generalized Anxiety Disorders
5) Attitude therapy Biological Domain
1) Relaxation techniques
Anxiety disorders across the lifespan • Isometric exercise
Panic Disorder • Progressive muscle relaxation
- characterized by sudden onset of intense apprehension or 2) Divert attention by increasing physical activities to
terror that last for 15 - 30 min. release energy
- After the attack, it is followed by 1 month of one or more of • Stationary bicycling.
the ff. symptoms. • Avoid situations that will provoke anxiety
• Persistent concern of having another attack 3) Teach client about medications as part of the
• Feeling of “Going crazy”, losing control, or having heart treatment plan.
attack • Panic
• Significant change in behavior - SSRI (Prozac and Zoloft)
- Types of Panic Disorder - SNRI (Effexor )
a) Panic disorder with agoraphobia - Benzodiazepine (Xanax, Klonopin and Valium)
b) Panic disorder without agoraphobia • GAD
Phobias - Non-benzodiazepine (BusPar)
- characterized by specific or irrational fear. Defense - Antidepressants
mechanisms used by patient with phobia are displacement, - SNRI (Effexor-Venlafaxine)
repression and projection - SSRI (Paxil-Paroxetine)
• Agoraphobia is fear of open spaces, fear of being alone - TCA (Tofranil (Imipramine)
in public places • Phobia
• Social Phobia is avoidance of social situations because - Benzodiazepine (Xanax)
of fear of being humiliated or embarrassed - Non-benzodiazepine (BuSpar)
- SSRI (Paxil & Zoloft

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 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Psychological Domain
- Distraction techniques
o Performing simple repetitive activities
o Rubber band, counting objects, counting
backward from 100 by threes.
- Positive self-talk
- Exposure therapy
o Systemic desensitization
o Gradual exposure to the feared object
o Implosive therapy/Flooding technique
o Abrupt exposure to the feared object. The goal is
to rid the client’s phobia in one or two sessions
- Cognitive behavioral therapy
o Cognitive restructuring
o Breathing training
o Psychoeducation
Selective Mutism
- Selective Mutism is failure to be able to speak in particular
situations, such as the classroom, where he is expected to
speak but is unable to do so. However, he may be able to
talk while at home.
- Diagnostic criteria for Selective mutism may include:
• Talkative at home with his family, but changes his
speaking to words with one syllable and utters or
gestures in order to communicate.
• A health professional must eliminate the possibility that
the child is unable to speak the Language or does not
have the knowledge about something he’s asked about.
• The condition must be present for a minimum of a
month.
• A determination will be made if the condition is causing
a negative impact on school and other activities.
• The health professional must rule out other disorders,
including stuttering or the lack of verbal communication
during a psychotic disorder.
• He is extremely attached to parents.
• He is extremely shy.
• The child does not have contact with other individuals
(social isolation).
Treatment
• Cognitive Behavioral Therapy may help the child identify
the thoughts that make him anxious as they relate to the
behavior.
• Medication: antidepressants and antianxiety medications
Obsessive-Compulsive and Related Disorders
Obsessive-Compulsive Disorders
- characterized by repetitive thoughts (obsession) and
actions (compulsion)
- Common obsession: Violence, power, Wealth, sex,
Cleanliness, contaminations
- Common compulsion: Checking, counting, Handwashing,
touching, Arranging, cleaning
- Nursing Management:
• Teach client about medications as part of the treatment
plan.
J.A.K.E 25 of 62
• P - Psychopharmacology: Benzodiazepine (Xanax), Non-
benzodiazepine (BuSpar), TCA (Anafranil and Klonopin),
SSRI (Paxil- Prozac/Zoloft – Luvox)
A - Allow client time to perform rituals
C - Convey acceptance of the client, despite ritualistic
behavior
E - Encourage expression of feelings.
D - Diversional therapy - Encourage limit setting on
ritualistic behaviors as part of the treatment plan
• Keep a journal – Assist client in listing all of the objects
and places that triggers anxiety as part of exposure-
response prevention program
Body Dysmorphic Disorder
- Body dysmorphic disorder is a mental health disorder in
which an individual can't stop thinking about one or more
perceived defects or flaws in his/her appearance - a flaw
that appears minor or can't be seen by others. However,
he/she may feel so embarrassed, ashamed and anxious
that he/she may avoid many social situations.
- Symptoms
• Intensely focus on appearance and body image
• Repeatedly checking the mirror, grooming or seeking
reassurance from others sometimes for many hours
each day.
• Significant distress and impaired the individual’s ability
to function in his/her daily life.
• Seek out numerous cosmetic procedures to try to "fix"
the perceived flaw. Afterward, you may feel temporary
satisfaction or a reduction in your distress, but often the
anxiety returns and you may resume searching for other
ways to fix your perceived flaw.
- Treatment of body dysmorphic disorder may include
• Cognitive behavioral therapy
• Medication to reduce level of anxiety
Hoarding Disorder
- Hoarding disorder is a mental disorder characterized by
excessively save items and the idea of discarding items
causes extreme stress.
- Hoarders cannot bear to depart from any of their
belongings, which results in excessive clutter to an extent
that impairs functioning and may create health and safety
risks.
- Hoarding disorder is more than collecting a little clutter.
People with Hoarding Disorder have rooms that are
stacked full with items; hallways are difficult to pass
through because of the amount of clutter, and sinks and
tables unusable.
- They may come to the attention of authorities because of
health and safety concerns of their homes. Hoarders are
not comfortable inviting guests over and guests do not feel
comfortable in the hoarder’s chaos.
- Symptoms of hoarding include the following;
• Unable to discard possessions.
• Severe anxiety over the idea of discarding possessions.
• Limited living space in the home
• Floor and counter space within common areas of the
home (such as the kitchen and living room) are seen as
storage space.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Isolation
• Loneliness
• Depression
• Fear or embarrassment of having visitors in the home
• Withdrawn
• Disorganized
• Indecisive about where to put things
- Treatment for Hoarding
• People with hoarding disorder are not always aware of
the seriousness of their problems and only go for
treatment when pressured by family or are at risk of
being convicted from their home. Since hoarding can
create safety and health risks, harm reduction may be a
focus of treatment.
• Psychotherapy
- Group cognitive-behavioral therapy has shown to
decrease hoarding symptoms
- Talk therapy address the cognitive and emotional
challenges with hoarding behaviors
• Medications are used to relieve symptoms of
depression and anxiety
Trichotillomania
- Trichotillomania is an impulse control psychiatric disorder
within the group of conditions known as body-focused
repetitive behaviors (BFRBs). Such conditions are
characterized by self-grooming through pulling, picking,
scraping or biting the hair, nails or skin, often causing self-
damage. (The TLC Foundation for Body-Focused Repetitive
Behaviors 2018)
- Symptoms. If someone is suffering from trichotillomania,
they will usually display various symptoms, including
• Constant pulling or twisting hair
• Bald patches or hair loss
• Uneven hair appearance
• Denial of the hair pulling
• Obstructed bowels if the hair is consumed
• Tension before hair is pulled and relief or gratification
after
• Other self-injury behaviors
• Poor self-image
• Feeling sad, depressed or anxious
Treatment for trichotillomania focus on managing and
relieving the symptoms.
1) Psychotherapy – Cognitive-behavioral therapy helps
patient to develop techniques to reverse the habit and
substitute unhelpful behaviors.
• Using a fidget toy or squeezing a stress ball
• Relieving stress by taking a hot bath
• Breathing deeply until the urge has subsided
• Tensing the arm to form a fist
• Keeping hair cut short or wearing a tightly-fitting hat
• Exercising
• Repeating a phrase out loud until the urge has passed
2) Medication may help provide relief from trichotillomania,
treating depressive and obsessive-compulsive symptoms.
• Fluoxetine (Prozac)
• Sertraline (Zoloft)
J.A.K.E 26 of 62
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Clomipramine (Anafranil)
• Valproate (Depakote)
• Lithium (Lithobid, Eskalith)
Excoriation Disorder
- also known as dermatillomania, is a disorder of impulse
control characterized by the urge to pick at the skin, even
to the extent that damage is caused.
- It is analogous to trichotillomania, the urge to pull one’s
own hair, but has now been anglicized to hair-pulling
disorder.
- Both are classified with the obsessive-compulsive
disorders, but some analogies have been suggested to
substance use disorders.
Treatment and management
• Behavioral treatments are helpful to patients with and
without psychological disabilities.
• Habit reversal training is coupled with awareness training
to focus attention on the picking behavior
• Competing response training teaches patients to execute a
different motor response Example: making a fist, in
situations that usually trigger skin-picking (Lang et al.,
2010).
• Acceptance and commitment therapy
• Cognitive behavioral therapy
• Use of protective clothing that covers picked-at areas of
skin for developmentally
Traumatic and Stressor Related Disorders
Post-traumatic Stress Disorder
- Post-traumatic Stress Disorder is a mental health
condition characterized by re-experiencing extreme
traumatic events / stressors through flashbacks and
nightmare causing extreme level of anxiety. Patients with
PTSD usually use voidance or dissociation as defense
mechanisms.
- Symptoms
1) Persistently re-experiencing the events:
• Thoughts/perceptions
• Flashbacks
• Illusions/hallucinations
• Nightmares
2) Increased arousal:
• Startling behavior
• Difficulty falling/staying asleep
3) Avoidance of stimuli associated with trauma:
• Avoidance of thoughts, feelings, conversations
• Avoidance of people, places, activities
• Dissociation
• Depersonalization/derealization
Categories that may cause PTSD
• Natural disasters (e.g. earthquake, flood, hurricane,
tornadoes,
• Accidental man-made disasters (e.g., car crashes,
industrial accidents, airplane Crashes, nuclear plant
accidents)
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Intentional man-made disasters (e.g. war, rape, smuggling,
robbery, assault military Combat, physical abuse, bullying)
Nursing Interventions to patients with PTSD and ASD
includes the following:
• Promote client safety
• Discuss self-harm thoughts
• Help client to cope with stress and emotions
• Use grounding techniques to help client who is dissociating
or experiencing flashbacks
• Distraction techniques
- Physical exercise
- Listening to music
- Talking with others
- Engaging in a hobby
• Make a list of activities and provide materials close at hand
- Books/Listen to a tape/Draw a picture
• Help client promote self esteem
- Refer client as “survivor” and not a “victim”
• Make a list of people and activities in the community for
client to contact when he/she needs help
- Local crisis hotline
- Local support group (Ex: DSWD, NGO)
Acute Stress Disorder
- Acute stress disorder as the development of specific fear
behaviors that last from 3 days to 1 month after a
traumatic event.
- These symptoms always occur after the patient has
experienced or witnessed death or threat of death, serious
injury or sexual assault.
- Contributing factors resulting to ASD:
• Physical attack,
• Physical abuse,
• Mugging,
• Active combat,
• Sexual violence,
• Natural disaster
• Serious accidents.
• Hearing or witnessing a violent or accidental trauma of
a loved one,
• Repeated exposure to traumatic events
- Symptoms of Acute Stress Disorder:
• Experience intrusive thoughts or memories of the
traumatic event.
• Distressing dreams about the trauma
• General sleep disturbances are also common.
• Flashbacks or distress when exposed to triggers of the
traumatic event.
• “Block out” or be unable to remember parts or the
entire traumatic event.
• Avoidance of external reminders, such as places or
people related to the traumatic
• Event.
• Negative mood. They may feel depressed, anxious,
angry or guilty and unable to feel happy.
• Unrealistic feelings or beliefs about the event. (E.g.
believing that a plane crash could have been prevented
had the patient done something differently).
J.A.K.E 27 of 62
• Hypervigilance,
• Problems with concentration
• Exaggerated startle response are also common.
• Physical symptoms, such as headaches, dizziness and
sensitivity to light or sound may occur, even without
injury
Treatment of Acute Stress Disorder
The primary treatment goal of acute stress disorder is to
prevent the disorder from developing into PSTD, which is
chronic and involves long-term social and occupational
impairment.
1) Debriefing or crisis therapy to promote a sense of safety
after a trauma
• Calm the victim,
• Promote a sense of self-efficacy,
• Encourage community or victim connectedness
• Instill a sense of hope. Debriefing can be done in a
variety of ways. When an entire community is affected
by a catastrophe, such as a school shooting or natural
disaster,
2) Group therapy is helpful. During
3) Individual therapy to help victims of trauma share their
personal narrative related To the traumatic event and
quickly develop coping skills (Foa, 2009).
4) Acceptance and commitment therapy to promote the use
of mindfulness to accept the traumatic event.
5) Stress management and reduction techniques to prevent
PTSD from developing at a later time.
• thought stopping,
• Relaxation breathing,
• Assertiveness training
• Behavior rehearsal
• Psycho-education (Simpson and Moriarty, 2013).
Adjustment Disorder
- When stressful times in life from expected or unexpected
events cause an individual to be confused, lost
(disoriented), and prevents him from going on with normal,
everyday life.
- Some of the instances that may cause an individual stress
include losing a job and not knowing how to pay the
mortgage on the house, having been cheated on by a
spouse or being the victim of a sexual assault.
Stressors That May Cause Adjustment Disorders
• Stressors can be a single event, such as:
- Divorce or break-up of a relationship.
- Being fired from a job.
• There may be multiple stressors, including:
- Difficulties with a business and marital problems.
• Stressors may be recurrent, such as:
- Business crises that occur in the “off-season.”
- Unfulfilling sexual relationships.
• Continuous stressors can include:
- Continuous painful illness that increases disability.
- Residing in a crime-filled community.
• Some stressors can affect an entire family or community,
such as:
- A natural disaster.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- Terrorism.
• Some of the stressors can accompany specific
developmental events, such as:
- Getting married.
- Going to school.
- Becoming a parent.
- Leaving the parents’ home.
- Re-entering the parents’ home after being away (such
as having been at college, after a marriage or
relationship breakup, or loss of a job).
- Failure to succeed in a career.
- Retirement.
Symptoms of Adjustment Disorder
• Worry
• Angry or disruptive behavior
• Insomnia
• Loss of self-esteem
• Sadness
• Difficulty concentrating
• Anxiety
• Feeling as if trapped and have no other options
• Hopelessness
• Feeling isolated
Children and adolescents typically show the following
symptoms in Adjustment Disorder:
• Irritable
• Depressed
• Poor sleep
• Poor grades and performance in school
Treatment for Adjustment Disorder.
Adjustment Disorder rarely extends beyond six months, there
may be some lasting feeling that happens beyond that time
frame. Those are normal and are usually not serious enough to
require additional treatment.
• Psychotherapy is usually the best choice. for Adjustment
Disorder, because the disorder is seen as temporary and a
somewhat normal reaction to a stressful event. The
therapist works with the individual to find new behaviors
and ideas and helps him to be able to deal more effectively
with the problem. In addition, the therapist helps the
individual find a clearer understanding of the issue/s. The
treatment will often stress the significance of
• Social support in the individual’s life. If there’s an issue
with stress, therapy may also include
• Relaxation training techniques.
• Family therapy for a child and adolescent patients
- Family is used a family as a scapegoat (blaming that
individual).
- Family education about the disorder and gain
knowledge of its seriousness of the condition
• Couples therapy is used when the disorder is negatively
affecting a marriage or romantic relationship
Attachment Disorders
1) Reactive Attachment Disorder (RAD)
- An attachment disorder describes a problematic
pattern of developmentally inappropriate moods, social
behaviors, and relationships due to a failure in forming
J.A.K.E 28 of 62
normal healthy attachments with primary care givers in
early childhood.
- A child who experiences neglect, abuse, or separation
during the critical stages of development of first three
years of life is at risk of developing an attachment
disorder.
2) Disinhibited Social Engagement Disorder (DSED)
- The absence of normal fear or discretion when
approaching strangers. The child is unusually
comfortable talking to, touching, and leaving a location
with an adult stranger.
- These behaviors are not the result of attention problems
or other issues that might be associated with impulsive
behavior.
- The DSM-5 explains that a background of severe social
neglect is a diagnostic requirement (American
Psychiatric Association, 2013). Because young infants
are unable to form selective attachments, disinhibited
social engagement disorder is not diagnosed in children
younger than nine months old.
- Development of disinhibited social engagement
disorder usually occurs during the first two years of life
(American Psychiatric Association, 2013).
Diagnosing RAD and DSED
• RAD is diagnosed when a child’s social relations are
inhibited and, as a result, he/she fails to engage in social
interactions in a manner appropriate to his/her
developmental age. The child may exercise avoidance,
hyper-vigilance or resistance to social contact. The child
may also avoid social reciprocity, fail to seek comfort when
upset, become overly attached to one adult, and refuse to
acknowledge a caregiver. Links have been shown between
RAD, future behavioral, and relationship problems.
• DSED is diagnosed when a child is excessively social with
strangers and does not engage in selective attachments. A
child with DSED will indiscriminately engage in social
behavior.
Symptoms of RAD according to the DSM-5 classification of
disorders
The first indications of RAD or DSED are a child’s abnormal
social interactions. The child may avoid initiating social
interaction or responding to social stimuli even from family
members and other intimates. Alternatively, under DSED
he/she may indiscriminately seek excessive social interaction
with strangers. The symptoms according to the DSM-V are as
follows (American Psychiatric Association, 2013):
• Failure to develop normally
• Poor hygiene
• Underdevelopment of motor coordination and a pattern of
muscular hypertonicity
• Bewildered, unfocused, and under-stimulated appearance
• Blank expression, with eyes lacking the usual luster and joy
• Fails to respond appropriately to interpersonal exchanges
Symptoms of Disinhibited Social Engagement Disorder
(DSED):
• Excessive social interaction with unknown persons
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Readiness to give hugs to anyone who approaches and to
go with that person if asked
• Willingness to approach a complete stranger for comfort or
food, to be picked up, or to receive a toy
• The disorder must be present for 12 months. Under DSM-V,
if the symptoms of both RAD and
• DSED are present at high levels, the disorder is specified as
severe
Reactive Attachment Disorder Therapy
1) Behavioral therapies to identify the triggers underlying the
disassociation, as well as model and reinforce healthy
adaptive behavior.
2) Trauma-focused cognitive behavioral therapy (TF-CBT)
to treat underlying attachment disruptions and promotes
emotion regulation, producing positive therapeutic
outcomes (Michelson, 2010).
3) Emotion regulation to ensure a safe and supportive
environment to teach, model and regulate emotion.
4) Integrative play therapy (IPT) and social learning provide
creative channels through which children can learn social
behavior and explore the underlying causes of their
detachment disorder.
5) Cognitive-behavioral therapy (CBT) is often applied
simultaneously with IPT.
Disinhibited Social Engagement Disorder Therapy and
Treatment
1) Play therapy offers an opportunity to create attachments
that did not occur during early infancy
2) Creative arts therapy uses painting, drawing, dance,
music and theatrical activities as a means of carrying out
interactive and experiential activities. (Malchiodi &
Crenshaw, 2013). Both play therapy and creative arts
therapy is that both approaches can be done non-verbally.
This is important because young children are not always
willing to able to verbally discuss trauma, thoughts, and
feelings (Malchiodi & Crenshaw, 2013
3) Social Therapy. Children, teens, and adults experience
relationships through hugging, touching, storytelling, and
eating together
Somatic Symptoms Disorder and Related Disorders
Somatic symptoms disorder
- Somatic symptom disorders are mental health disorders
characterized by an intense focus on physical (somatic)
symptoms that causes significant distress and/or
interferes with daily functioning.
- The diagnostic criteria for Somatic Symptom Disorder
noted in DSM 5 are:
1) One or more somatic symptoms that are distressing or
result in significant disruption of daily life.
2) Excessive thoughts, feelings, or behaviors related to the
somatic symptoms or associated health concerns as
manifested by at least one of the following:
• Disproportionate and persistent thoughts about the
seriousness of one’s symptoms.
• Persistently high level of anxiety about health or
symptoms.
J.A.K.E 29 of 62
• Excessive time and energy devoted to these
symptoms or health concerns.
3) Although any one somatic symptom may not be
continuously present, the state of being symptomatic is
persistent (typically more than 6 months).
Treatment for Somatic symptom disorders
• Cognitive behavior therapy
• Mindfulness-based therapy are effective for the treatment
of somatic symptom disorder.
• Medicines: Amitriptyline, Selective serotonin reuptake
inhibitors,
Malingering disorder
- Refers to producing false medical symptoms or
exaggerating existing symptoms in hopes of being
rewarded in some way.
- It is a medical diagnosis, but not a psychological condition.
- For example, someone might pretend to be injured so they
can collect an insurance settlement or obtain prescription
medication. Others may exaggerate mental health
symptoms to avoid criminal convictions.
- More specific examples of malingering include:
• Putting makeup on his/her face to create a black eye
• Adding contaminants to a urine sample to change its
chemistry
• Placing a thermometer near a lamp or in hot water to
increase its temperature
Symptoms of Malingering Disorder
• Malingering does not have any specific symptoms. Instead,
it’s usually suspected when someone suddenly starts
having physical or psychological symptoms while:
• Being involved with a civil or criminal legal action
• Facing the possibility of military combat duty
• Not cooperating with a doctor’s examination or
recommendations
• Describing symptoms as being much more intense than
what a doctor’s exam reveals
Causes of Malingering Disorder
• Malingering is not caused by any physical factors. Rather,
it’s the result of someone’s desire to gain a reward or avoid
something. It is often accompanied by real mood and
personality disorders, such as antisocial personality
disorder or major depressive disorder.
Management:
1) Cognitive Behavioral Therapy
2) Assertiveness training
3) Therapist-Patient Relationship.
- Confrontation. Indirectly confront the client that
objective findings do not meet the physician's objective
criteria for diagnosis. Allow the person the opportunity
to her save face
Conversion disorder
- Conversion disorder, also known as functional
neurological symptom disorder, occurs when a person
experiences neurological symptoms (symptoms of the
nervous system) not attributable to any medical condition.
The symptoms are real and not imaginary, and they can
affect motor functions and senses.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- A person may be at increased risk of developing the
condition if they have a neurological disease, a movement
disorder, or a mental health condition. They are also at
increased risk if a family member has a functional
neurologic disorder or if they have experienced physical or
sexual abuse as a child or any other trauma in life. Women
are also two to three times more likely to receive a
diagnosis of conversion disorder than men are.
Symptoms Conversion disorder.
It is possible that the symptoms are triggered by physically or
psychologically traumatic events or by stress, but not
necessarily. Symptoms can include:
• Difficulty walking
• Loss of balance
• Body tremors
• Weakness or paralysis
• Hearing difficulty
• Vision problems or blindness
• Loss of sensation
• Trouble swallowing
• Seizures or shaking episodes
• Unresponsiveness
The diagnostic criteria for Conversion Disorder noted in
DSM 5 are:
• One or more symptoms of altered voluntary motor or
sensory function\
• Clinical findings provide evidence of incompatibility
between the symptom and recognized neurological or
medical conditions.
• The symptom or deficit is not better explained by another
medical or mental disorder.
• The symptom or deficit causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning or warrants medical
evaluation.
Factitious disorder
- A mental disorder in which a person acts as if he or she has
a physical or mental illness. People with factitious disorder
deliberately create or exaggerate symptoms of an illness. T
- hey have an inner need to be seen as ill or injured. It is
considered a mental illness because it is associated with
severe emotional difficulties and stressful situations.
- Most patients with factitious disorder have histories of
abuse, trauma, family dysfunction, social isolation, early
chronic medical illness, or professional experience in
healthcare (training in nursing, health aid work, etc.).
Types of factitious disorder
• Factitious disorder imposed on self includes the falsifying
of psychological or physical signs or symptoms, as
described above. Example: Mimicking behavior that is
typical of a mental illness, such as schizophrenia. The
person may appear confused, make absurd statements,
and report hallucinations (the experience of sensing things
that are not there; for example, hearing voices).
• Factitious disorder imposed on another: People with this
disorder produce or fabricate symptoms of illness in others
under their care: children, elderly adults, disabled persons,
J.A.K.E 30 of 62
or pets. It most often occurs in mothers (although it can
occur in fathers) who intentionally harm their children in
order to receive attention. The diagnosis is not given to the
victim, but rather to the perpetrator.
Warning signs of factitious disorder
• Dramatic but inconsistent medical history
• Unclear symptoms that are not controllable, become more
severe, or change once treatment has begun
• Predictable relapses following improvement in the
condition
• Extensive knowledge of hospitals and/or medical
terminology, as well as the textbook descriptions of illness
• Presence of many surgical scars
• Appearance of new or additional symptoms following
negative test results
• Presence of symptoms only when the patient is alone or
not being observed
• Willingness or eagerness to have medical tests, operations,
or other procedures
• History of seeking treatment at many hospitals, clinics, and
doctors’ offices, possibly even in different cities
• Reluctance by the patient to allow healthcare
professionals to meet with or talk to family members,
friends, and prior healthcare providers
• Refusal of psychiatric or psychological evaluation
• Forecasting negative medical outcomes despite no
evidence of this
• Sabotaging discharge plans or suddenly becoming more ill
as one is about to be discharged from the hospital setting
Symptoms of factitious disorder
• People with factitious disorder may:
• Lie about or mimic symptoms
• Hurt themselves to bring on symptoms
• Alter diagnostic tests (such as contaminating a urine
sample or tampering with a wound to prevent healing)
• Be willing to undergo painful or risky tests and operations
in order to obtain the sympathy and special attention given
to people who are truly medically ill
The diagnostic criteria for Factitious Disorder noted in
DSM 5 are:
1) Factitious Disorder Imposed on Self
• Falsification of physical or psychological signs or
symptoms, or induction of injury or disease, associated
with identified deception.
• The individual presents himself or herself to others as ill,
impaired, or injured.
• The deceptive behavior is evident even in the absence
of obvious external rewards.
• The behavior is not better explained by another mental
disorder, such as delusional disorder or another
psychotic disorder.
2) Factitious Disorder Imposed on another (Previously
Factitious Disorder by Proxy)
• Falsification of physical or psychological signs or
symptoms, or induction of injury or disease, in another,
associated with identified deception.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• The individual presents another individual (victim) to
others as ill, impaired, or injured.
• The deceptive behavior is evident even in the absence
of obvious external rewards.
• The behavior is not better explained by another mental
disorder, such as delusional disorder or another
psychotic disorder.
Illness Anxiety disorder
- Illness anxiety disorder (previously called hypochondriasis,
a term that has been abandoned because of its pejorative
connotation) most commonly begins during early
adulthood and appears to occur equally among men and
women.
- The patient's fears may derive from misinterpreting non-
pathologic physical symptoms or normal bodily functions
(e.g., borborygmi, abdominal bloating and crampy
discomfort, awareness of heartbeat, sweating).
- The course of the disorder is often chronic, fluctuating in
some, steady in others and some patients recover.
- Symptoms:
5.1. Preoccupied with the idea that they are or might become
ill
5.2. Preoccupied that their illness anxiety impairs social and
occupational functioning or causes significant distress.
5.3. May or may not have physical symptoms, but if they do,
their concern is more about the possible implications of the
symptoms than the symptoms themselves.
5.4. Repeatedly examine themselves (e.g., looking at their
throat in a mirror, checking their skin for lesions).
5.5. Easily alarmed by new somatic sensations.
5.6. Visit physicians frequently (care-seeking type); others
rarely seek medical care (care-avoidant type).
The diagnosis of illness anxiety disorder
• The patient is preoccupied with having or acquiring a
serious illness.
• The patient has no or minimal somatic symptoms.
• The patient is highly anxious about health and easily
alarmed about personal health issues.
• The patient repeatedly checks health status or maladaptive
avoids doctor appointments and hospitals.
• The patient has been preoccupied with illness for ≥ 6
months, although the specific illness feared may change
during that period.
• Symptoms are not better accounted for by depression or
another mental disorder.
• Patients who have significant somatic symptoms and are
primarily concerned about the symptoms themselves are
diagnosed with somatic symptom disorder.
Treatment for Illness Anxiety disorder
1) Serotonin reuptake inhibitors
2) Cognitive-behavioral therapy
Pseudocyesis
- A false belief of being pregnant that is associated with
objective signs and reported symptoms of pregnancy. It is a
rare, but debilitating somatic disorder in which a woman
presents with outward signs of pregnancy, although she is
not truly gravid.
J.A.K.E 31 of 62
- Commonly, women of lower socioeconomic status, limited
access to health care, and feeling under significant stress
to conceive are most at risk for this disorder.
- Although depression is a frequent comorbidity alongside
pseudocyesis, endocrinologic disorders have been
documented that mimic signs of polycystic ovary
syndrome.
- This complex array of concerns requires an understanding
of similar differentials and treatment options
- Treatment
1) Psychotherapy
2) Medication if co-morbid with depression or anxiety
Dissociative Disorders
- Involve problems with memory, identity, emotion,
perception, behavior and sense of self.
- Dissociative symptoms can potentially disrupt every area
of mental functioning.
- Examples of dissociative symptoms include the experience
of detachment or feeling as if one is outside one’s body,
and loss of memory or amnesia. Dissociative disorders are
frequently associated with previous experience of trauma.
- There are three types of dissociative disorders:
1) Dissociative identity disorder
2) Dissociative amnesia
3) Depersonalization/derealization disorder
- Dissociation is a disconnection between a person’s
thoughts, memories, feelings, actions or sense of who he
or she is. Everyone has experienced this normal process.
- Examples of mild, common dissociation include
daydreaming, highway hypnosis or “getting lost” in a book
or movie, all of which involve “losing touch” with
awareness of one’s immediate surroundings. During a
traumatic experience such as an accident, disaster or
crime victimization, dissociation can help a person tolerate
what might otherwise be too difficult to bear. In situations
like these, a person may dissociate the memory of the
place, circumstances or feelings about of the
overwhelming event, mentally escaping from the fear, pain
and horror. This may make it difficult to later remember the
details of the experience, as reported by many disaster and
accident survivors.
Dissociative identity disorder
- Associated with overwhelming experiences, traumatic
events and/or abuse that occurred in childhood.
- Dissociative identity disorder was previously referred to as
multiple personality disorder.
- Symptoms of dissociative identity disorder (criteria for
diagnosis) include:
• The existence of two or more distinct identities (or
“personality states”). The distinct identities are
accompanied by changes in behavior, memory and
thinking. The signs and symptoms may be observed by
others or reported by the individual.
• Ongoing gaps in memory about everyday events,
personal information and/or past traumatic events.
• The symptoms cause significant distress or problems in
social, occupational or other areas of functioning.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• The disturbance must not be a normal part of a broadly
accepted cultural or religious practice. As noted in the
DSM-51, in many cultures around the world,
experiences of being possessed are a normal part of
spiritual practice and are not dissociative disorders.
Treatment
• Psychotherapy. Therapy can help people gain control over
the dissociative process and symptoms.
• Cognitive behavioral therapy
• Dialectical behavioral therapy.
• Hypnosis
• Medication may be helpful in treating related conditions or
symptoms, such as the use of antidepressants to treat
symptoms of depression
Dissociative amnesia
- A condition in which a person cannot remember important
information about his or her life.
- This forgetting may be limited to certain specific areas
(thematic), or may include much of the person’s life history
and/or identity (general). In some rare cases called
dissociative fugue, the person may forget most or all of his
personal information (name, personal history, friends), and
may sometimes even travel to a different location and
adopt a completely new identity.
- In all cases of dissociative amnesia, the person has a
much greater memory loss than would be expected in the
course of normal forgetting.
There are three types, or patterns, of dissociative
amnesia:
1) Localized: Memory loss affects specific areas of
knowledge or parts of a person’s life, such as a certain
period during childhood, or anything about a friend or
coworker. Often the memory loss focuses on a specific
trauma. For example, a crime victim may have no memory
of being robbed at gunpoint but can recall details from the
rest of that day.
2) Generalized: Memory loss affects major parts of a
person’s life and/or identity, such as a young woman being
unable to recognize her name, job, family, and friends.
3) Fugue: With dissociative fugue, the person has generalized
amnesia and adopts a new identity. For example, one
middle manager was passed over for promotion. He did not
come home from work and was reported as missing by his
family. He was found a week later, 600 miles away, living
under a different name, working as a short-order cook.
When found by the police, he could not recognize any
family member, friend, or coworker, and he could not say
who he was or explain his lack of identification.
Treatment
1) Psychotherapy: Psychotherapy, sometimes called “talk
therapy,” is the main treatment for dissociative disorders.
This is a broad term that includes several forms of therapy.
2) Cognitive-behavioral therapy: This form of psychotherapy
focuses on changing harmful thinking patterns, feelings,
and behaviors.
3) Eye movement desensitization and reprocessing: This
technique is designed to treat people who have continuing
J.A.K.E 32 of 62
nightmares, flashbacks, and other symptoms of post-
traumatic stress disorder (PTSD).
4) Dialectic-behavior therapy: This form of psychotherapy is
for people with severe personality disturbances (which can
include dissociative symptoms), and often takes place
after the person has suffered abuse or trauma.
5) Family therapy: This helps teach the family about the
disorder and helps family members recognize if the
patient’s symptoms come back.
6) Creative therapies (for example, art therapy, and music
therapy): These therapies allow patients to explore and
express their thoughts, feelings, and experiences in a safe
and creative environment.
7) Meditation and relaxation techniques: These help people
better handle their dissociative symptoms and become
more aware of their internal states.
8) Clinical hypnosis: This is a treatment that uses intense
relaxation, concentration, and focused attention to achieve
a different state of consciousness, and allows people to
explore thoughts, feelings, and memories they may have
hidden from their conscious minds.
9) Medication: There is no medication to treat dissociative
disorders. However, people with dissociative disorders,
especially those with depression and/or anxiety, may
benefit from treatment with antidepressant or anti-anxiety
medications.
Depersonalization/Derealization disorder
- Depersonalization/derealization disorder is the feeling of
being detached from one’s thoughts, feelings, and body
(depersonalization), and/or disconnected from one’s
surrounding environment (derealization).
- It involves disruptions or breakdowns of memory,
consciousness or awareness, identity and/or perception—
mental functions that normally work smoothly. When one
or more of these functions is disrupted, dissociative
symptoms can result. These symptoms can interfere with a
person’s general functioning, both in their personal life and
at work.
- People with this disorder do not lose contact with reality.
They realize that their odd perceptions are not real.
Depersonalization and/or derealization also might be
symptoms of other disorders, including brain diseases and
seizure disorders.
- The goal of treatment is to address all stressors
associated with the onset of the disorder. The best
treatment approach depends on the individual, the nature
of any identifiable triggers, and the severity of the
symptoms.
- Most likely treatment will include some combination of
the following methods:
• Psychotherapy: Psychotherapy,
• Cognitive-behavioral therapy:
• Eye movement desensitization and reprocessing
(EMDR):
• Dialectic-behavior therapy (DBT):
• Family therapy:
• Creative therapies
• Meditation and relaxation techniques:
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

• Clinical hypnosis includes assessment, counselling, and/or prescription

• Antidepressant or anti-anxiety medications. drugs
- includes specialists such as neurologists, OB/GYNs,
MENTAL HEALTH CARE DELIVERY SYSTEM IN THE oncologists, etc.
PHILIPPINES - consists of specialized care requiring more sophisticated
Three Levels of care in the Health Care System and complicated diagnosis and treatment than is provided
Primary Health Care at the primary health care level. Normally involves
- provided at the community level hospitalization. (ex. patient ward in general hospital)
- serves as a patient's first point of contact with a health Goals of Care
professional who can provide outpatient medical care - Provide measures to curtail the disease process.
- the first point of contact. GPs, nurses, dentists work in 1) Early detection of cases
primary care. 2) Case finding/surveying
- Elements: health education, MCH care, prevention of 3) Early recognition of symptoms of mental illness
illness, prevention of control of endemic diseases, 4) Immediate implementation of treatment to manage
treatment of minor injuries and illnesses, sanitation > the disorders
adequate and safe water supply, promotion of mental Identifying available resources
health, adequate nutrition, providing essential drugs, - Ex: community mental health services, health care
immunization. organizations, crisis intervention services, support
Goals Of Care group, rehabilitation, etc.
- Provide measures to prevent mental illness and promote Case management
mental health - Ex: services to provide continuous care of clients with
1) Information dissemination mental health problems in the community
2) Health education Community Mental Health Program
3) Early consultation
Goals:
4) Alleviation of early symptoms
• To promote positive mental health though life style
Youth Seminars/Classes
education
1) Substance abuse and alcoholism
2) Sex education in adolescent group • To reduce prevalence of mental disorders through
3) Stress management screening and intervention
4) Anger management • To facilitate independent functioning of mentally ill
5) Problem solving and conflict resolution skills • To provide continuing care in the community
6) Social skills for children and teens Tertiary Health Care
7) Environmental sanitation - provided at hospitals
8) Proper personal hygiene - includes referrals to psychiatric institutions if the mental
Prenatal And Perinatal Seminars/Classes illness needs specialized care and more severe mental
1) Prenatal and parenting classes illness would require more rehabilitation.
2) Proper nutrition for pregnant and lactating mother - Hospitalized patients and those undergoing operations are
3) Newborn care in tertiary care.
4) Importance of immunization - Consists of highly specialized diagnostic and therapeutic
services which can usually only be provided in centers
Parental Seminars/Classes
specifically designed staffed and equipped for this purpose.
1) Normal growth and development
(ex. neonatal intensive care unit)
2) Child rearing practices (Do’s and Don'ts)
Rehabilitation
3) Proper nutrition & hygiene for children
- includes measures to minimize relapse and chronic
4) Father role in the child development
disability, and restore client’s optimal level of
5) Family planning
functioning
Community Seminars/Classes - Recovery from mental illness
1) Healthy lifestyle - Continuous treatment
2) Good hygiene habits - Reduced hospital admission
3) Environmental sanitation & waste management - Promote personal growth and independency
4) Communicable & non-communicable diseases - Promote social function
5) Crisis intervention - Promote vocational/occupational functioning
6) Disaster preparedness - Reintegration to the community
Secondary Heath Care
- provided at PHC, CHC, DH etc. Types of Admission
- includes referrals to psychologists and psychiatrists 1) Voluntary Admission
where short hospital visits and consultation-liaison - Client or guardian voluntarily seek and sign consent
services to other medical departments are made. Services for the treatment

J.A.K.E 33 of 62
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- Client complies and participate with the treatment
plan, however, he/she has the right to “leave the
hospital even against the advice of the physician”
(AMA)
2) Involuntary Admission
- Client is confined in the hospital without consent but
with a court order
- Reasons for involuntary admission
1) Dangerous to self and others
2) Gravely disabled
3) Mentally disordered
Types
Emergency commitment
- 48-72 hours, authorized by health care provider but
without court order
Extended Commitment
- treatment is renewed for a period of 90 days – 6
months
National Center for Mental Health
- It is the first hospital exclusively dedicated for the
treatment of patients afflicted with mental and nervous
disorders.
- It is located at Nueve de Febrero, Brgy. Mauway
Mandaluyong City in a 46.7 hectares with a bed capacity
of 4,600 and serves an average of 3,000 in-patients on a
daily basis, in addition to 56,000 outpatients per year
- 1925: NCMH was established under the Public Works Act
3258
- 1928: Insular Psychopathic Hospital was opened and
inaugurated December 27, 1928
- 1953: The National Psychopathic Hospital was renamed
National Mental Hospital (NMH)
- 1986’s: National Center for Mental Health.
Spanish Regime
HOSPICIO DE SAN JOSE
• The first institution to care for mentally ill patients in
the 19th century (1810)
• It is the first Roman Catholic social welfare institution
in the country founded in 1782 which fosters
abandoned, surrendered and neglected children and
those with special needs, and the elderly
AMERICAN REGIME
SAN LAZARO HOSPITAL
• INSANE DEPARTMENT was established as the
country’s first hospital unit to care for mentally ill
patients in 1904.
J.A.K.E 34 of 62
• Through the years, supplementary units were even
added to accommodate the increasing demand for
ward space.
• 1918: The CITY SANITARIUM was established at San
Juan del Monte because of unprecedented upsurge
of the mentally ill population.
• 1935: The CITY SANITARIUM was closed prompting
all of its existing patients to be transferred to the
Insular Psychopathic Hospital and exaggerating the
already overfilled hospital wards. In response to the
said predicament, additional pavilions were put up
subsequently expanding its total bed capacity from
400 to 1,600.
Philippine Mental Health Associationn
- It is a private, non-stock, non-profit organization dedicated
to the promotion of mental health and prevention of
mental illness. It was established on January 15, 1950 with
Dr. Manuel Arguelles as president
- Its headquarters is located in Quezon City with nine
chapters all over the Philippines:
• PMPMHA Bacolod-Negros Occidental,
• PMHA Cabanatuan-Nueva Ecija,
• PMHA Cebu,
• PMHA Baguio-Benguet ,
• PMHA Cagayan de Oro-Misamis Oriental,
• PMHA Davao,
• PMHA Dumaguete-Negros Oriental
• PMHA Lipa-Batangas
• PMHA Dagupan-Pangasinan
- PMHA programs: 1). Education and Information Services
(EIS), 2). Clinical and Diagnostic Services (CDS), and 3).
Intervention Services (IS).
Other Institutions & Services
Webbline
• provides a list of mental health care facilities that
can be found in the provinces and in NCR.
Suicide Prevention Hotlines in the Philippines
1) Natasha Goulbourn Foundation (NGF).
• The NGF suicide hotline can be reached at (02) 804-
HOPE (4673), 0917 558 HOPE (4673) or 2919 (toll-
free for GLOBE and TM subscribers).
2) Manila Lifeline Centre (MLC).
• The MLC can be reached at (02) 8969191 or 0917 854
9191.
Global & Regional Perspective on Mental Health
MENTAL HEALTH LAW (REPUBLIC ACT 11036)
- It provides a rights-based mental health bill and a
comprehensive framework for the implementation of
optimal mental healthcare in the Philippines
Purpose:
1) Enhance the delivery of integrated mental health
2) Services. Mental health services are proposed to be
accessible from large-scale hospitals down to the
barangay level.
3) Promote and protect the rights of the individuals
utilizing psychiatric, neurologic and psychosocial
health services
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

World Health Organization (WHO)

- The World Health Organization (WHO) based in the
Philippines has been training local health workers in
psychological first aid community- based mental health
care for addressing mental health needs.
1) Victims of natural disasters
2) Filipina migrant workers who were victims of abuse
3) Displaced populations
• Amerasians
• Mindanao Refugees
• Filipino Children

MENTAL HEALTH GAP (MHGAP) ACTION PROGRAMME

- MhGAP is a WHO programme, launched in 2008, to scale
up care for MNS disorders
• Mental disorders Healthy Family Dynamics
• Neurological disorders - Everyone has a voice and is treated with respect
• Substance abuse disorders - The parent-child attachments are secure (if there is a
- The programme asserts that, with proper care, child or children)
psychosocial assistance and medications, tens of millions - Everyone feels loved, safe, and connected
of people could be treated for depression, psychoses and - If there are children, the parenting style provides structure
epilepsy, prevented from suicide, thus they may live a and rules, but is flexible, understanding, and loving (vs.
normal lives overly rigid or totally non-structured)
- Its focus is to increase non-specialist care, including non- Types of Family Structures
specialized health care, to address the unmet needs of
1) Nuclear Family
people with priority MNS conditions.
- is made up of parents and one or more children living
- Mental, neurological and substance use (MNS) conditions
together.
account for 13% of the global burden of disease. Yet
- Advantages
between 75–90% of individuals with MNS conditions do
• Financial stability
not receive the treatment they require although effective
• Stable parenting
treatment exists. This represents the mental health
treatment gap. • Education, health, upbringing, is a top-notch
priority
• Emphasis on efficient communication
Psychobiologic Bases of Behavior
2) Single-Parent Family
THE BIOLOGICAL BASIS OF HUMAN BEHAVIOR
- is one where there is one parent and one or more
- The three main elements biology contributes to human
children.
behavior are:
- Advantages
1) Self-preservation;
• Sharing of household duties with kids
2) Reason for self-preservation
3) Method to enhance self-preservation • Family and relative’s support
MASLOW’S HIERARCHY OF NEEDS • Children and the parent become strong to face
any situation
- Disadvantages
• Financial instability
• Limitation on job opportunities and income
• Finding childcare becomes difficult
3) Extended Family or Joint Families
- means father, mother, daughters, sons,
grandparents,uncles, aunts, cousins, nieces and
nephews
- Advantages
• Constant support especially in case of
emergencies
• Financial, mental, and social support
• Division of chores and income
- Disadvantages
• Lack of privacy

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• Financial burden or instability of income (if want to grow up more quickly and make big plans that may
members aren’t contributing) never come true.
• Interference in other relationships • MIDDLE CHILD: Because the oldest receives
4) Childless Family responsibility and the youngest can be spoiled, children in
- Advantages the middle can feel like they don’t receive any attention at
• No dependency all. They fight for significance and privilege. This causes
• Abundant income the child to develop an attitude that is very black-and-
• Couples get more time to spend with each other white. They tend to be even-tempered and fight to protect
• Cherish other activities like adventure, travel, etc. the social justice of others, but can also feel very lonely.
- Disadvantages • TWINS: One twin is usually stronger than the other twin.
• Sometimes feel isolated One may be more active. Some families may see the older
• If they love kids, then they feel like something is twin as being the oldest child. Because they are born
missing together, there isn’t the same transition issues from an
5) Grandparent Family only child, but there can also be some identity problems.
- Advantages One twin tends to become the “leader” and the other is
• Grandparents form a strong family while the “follower.”
maintaining a healthy relationship with children • GHOST CHILD: Some children are born into families
• Children raised in affection and care where a first child may have died before they were born.
This causes parents, especially mothers, to become over-
• Secured feeling and a way to learn moral values
protective of all their children, but especially their oldest.
- Disadvantages
Children in this position often become rebellious or may
• Grandparents have to find a source of income
attempt to exploit their parent’s feelings for personal
• Owing to health, their energy levels to do not
• ADOPTED CHILD: Many adopted children receive the
match with kids
same levels of attention that an only child receives.
• Generation gap may lead to conflict in thinking
Parents who adopt tend to try to compensate the child for
• Compassion may lead to indiscipline mannerism
the loss of their biological parents. This causes the child
6) Stepfamily
to become demanding, lack in self-confidence, and even
- Advantages
resent their family over time.
• Children have a big family and siblings from both
Birth order
their parents
Alder’s five psyhologucal positions:
• Both the parents are always around
• Odest child – receives more attention, spoiled, center
• Children form strong bonding with both families
of attention.
• There is financial security from both families
• Second of only two - behaves as if in a race, often
- Disadvantages
opposite to first child
• It might get tough for children to adjust • Middle – often feels squeezed out
• Parents might have fights over their respective • Youngest – the baby
kids • Only – does not learn to share or cooperate with other
• Children may become undisciplined children, learns to deal with adults.
7) Foster Families
- are families where a child lives with and is cared for
by people who are not his or her parents.
Adler’s Birth Order Theory
• ONLY CHILD: An only child tends to receive the full
attention of both parents. They can be over-protected, but
they can also be spoiled. This causes the child to like
being the center of attention, prefer adult company, and
have difficulty sharing with others.
• OLDEST CHILD: The eldest child in a family goes from
being an only child to the oldest child. That requires the
child to learn how to share. Expectations are usually very
high, which includes the need for the child to set an
example for other siblings. This causes the child to trend
toward authoritarian and strict approaches. They feel
powerful and often require encouragement to be helpful.
• YOUNGEST CHILD: The youngest child in a family often
sees every sibling as a potential “mother” and “father.”
Just about everyone tells them what to do and when to do
it. Their role is never removed. This causes the child to

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JOHARI WINDOW & SELF AWARENESS - The Words to Use in JOHARI WINDOW
The Johari Window
- The Johari window is a model of interpersonal awareness.
It’s a useful tool for improving self awareness and,
through it, our abilities to work well with others. It works
by helping us understand the differences between how we
see ourselves and how others see us.
- The four quadrants of the window are:

- Your Window

Discover Your Johari Window

- Discovering what your Johari Window looks like requires
some honesty, a group of peers and some trust. To
complete the activity, you need to choose words that you
think describe you from a set list and get your peers to do
the same. You then explore at the differences between the
words you and they chose. Once you understand where
the differences are you can create a plan to help you
bridge the gap.
- The following steps will help you do this:
1. Choose your peers: Identify people who you trust
and who you think know you, or members of your
team if you’re completing a team activity.
2. Select your words: Review the list of 56 words and
circle 5-10 words that you think best describe you.
3. Get your feedback: Ask your chosen peers to - Next Steps
complete the same exercise, choosing the 5-10 words • Once you’ve completed The Johari Window activity
they think best describe you. and have a clear view of what your window looks like,
4. Plot your words: Place words both you and others you can start to work towards changing your window.
selected in “Open” pane. Place words that only you
• Most people aim to increase the size of their “open”
selected in the “Hidden” pane.
window and shrink the size of their other windows.
5. Plot your feedback: Place words your peers selected
1. One should try being more open and transparent
but that you didn’t in the “Blind” pane. Place the
with others about how they think and feel.
remaining words in the “unknown” pane. Alternatively,
2. They seek more feedback from others, which
you can choose to leave the “Blind” pane empty.
reduces the size of their “blind” window. Some
6. Review your Window: Review the words in the four people also look to reduce the size of their
panes of the window. How aligned is your view of who
“unknown” window, though this can be more
you are with how others see you? How open are you
difficult.
as a person?
- Planning
• Once you know your window, it’s good to plan to
change it over time.
1. Plan for your hidden pane: Consider if there is
more you would like to share about yourself, and
how you could disclose it.

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2. Plan for your blind pane: Consider if there is
more you would like to learn about how others
perceive you and how to get more feedback.
3. Share your window and plans: Share your
completed window with the peers that provided
your feedback and let them know your plans to
grow your open pane and shrink your other panes.
Self-awareness
- “Understanding of another human being begins with
understanding of self” (Jones & Learning, 2005). Everyone
has different strategies to know their inner feelings,
thoughts and realities. Understanding of self can help
people to differentiate their own values, beliefs and
personal boundaries. Thus, the process of understanding
and accepting one’s own believes, feelings, state of mind,
standards, different approaches, inspirations, biases,
strengths and boundaries and recognizing how they affect
others.
- Ongoing process of becoming aware of self, allows a
nurse to admit the values and beliefs of others that may
vary from his/her own (Videbeck, 2004). According to
Mount Royal University (2011), self-awareness represents
the ability of pointing one’s own strengths and
weaknesses. This is a state in which people willingly
identify, process, and store information about themselves.
Furthermore, the main function of self-awareness
consists of self-evaluation, get away from the self, and
strengthening of one’s individual experience, improves
self-knowledge, self-regulation, and inferences about
others’ mental states (Mount Royal University, 2011).
- Without self-awareness, nurses will find it impossible to
establish and maintain therapeutic relationships with
patients. Know thyself' is a basic tenet of psychiatric-
mental health nursing (Boyd, 2011).
- Self-awareness is a psychological state in which people
are aware of their traits, feelings and behavior.
- Self-awareness is being aware of both our mood and our
feelings about mood. Dubrin (2007) defined self
awareness as, “insightfully processing feedback about
oneself to improve one’s effectiveness”. Self-awareness
is tremendously essential for nurses. Nurses need to
know themselves so that their individual emotional state,
attitudes and desires do not confine quality care provided
to clients (White, Duncan, & Baumle, 2010).
- Dealing with mentally ill patient is very challenging for a
nurse and it has also a significant impact on mental status
of psychiatric nurses (Ahmed & Elmasri, 2011). Engin &
Cam (2009) explained that it is very important for
psychiatric clinics, to have professional values, self-
awareness and self-sufficiency to accomplish a concrete
nursing practice.
The importance of self-awareness
1. Self-awareness is considered an important quality for a
mental health professional. Mental health professionals
deal with people from varied cultures, religions, languages,
lifestyles, and value systems.
• Being self-aware can enable the counselor to mark
their ‘ego boundaries,’ and successfully discriminate
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between what belongs to them and what belongs to
their clients.
• Secondly, self-awareness enables the counselor to
make a ‘conscious use of the self’. Being self-aware
can make the counselor feel empowered in delivering
therapeutic interventions, as they will feel more
conscious and thought of, rather than spontaneous
and awkward.
2. Being aware of yourself also helps in identifying what your
stressors are, so you can utilize the information to build
effective coping mechanisms.
The importance of self-awareness in General:
- It can make us more proactive, boost our acceptance, and
encourage positive self-development (Sutton, 2016).
- Self-awareness allows us to see things from the
perspective of others, practice SELF-CONTROL, work
creatively and productively, and experience pride in
ourselves and our work as well as general self-esteem
(Silvia & O’Brien, 2004).
- It leads to better decision making (Ridley, Schutz, Glanz, &
Weinstein, 1992).
- It can make us better at our jobs, better communicators in
the workplace, and enhance our SELF-CONFIDENCE and
job-related wellbeing (Sutton, Williams, & Allinson, 2015).
KEYPOINTS in doing the SELF-AWARENESS ACTIVITY
1. Create a list of moral and ethical values, attitudes,
feelings, strengths and weaknesses, behaviors,
requirements, wishes, and judgments.
2. Uncover hidden positive and negative qualities of self by
asking others for what they see in me as a student nurse.
The remarks mentioned above must be true and honest.
There must not be strict prohibitions for those who are
enlisting negative qualities.
3. Put the list side by side and allocate qualities to the
suitable quadrant. If the size of the open quadrant is large,
it indicates that the people are open to others while a
smaller quadrant implies that people are sharing less
about themselves. If the open and hidden quadrants both
are small, it implies a little insight.
SELF AWARENESS Techniques:
- Journaling - where one reflects on one’s experiences by
writing about them outside the therapy session. Such
insights can make therapy more effective.
- Bibliotherapy - including self-help books, especially
those recommended by one’s therapist because they are
particularly insightful and based on sound research.
- Write a personal manifesto - A personal manifesto
describes your core values and beliefs, the specific ideas
and priorities that you stand for, and how you plan to live
your life. This acts as both a statement of personal
principles and a call to action.
- Create a bucket list - Having a bucket list will help you
identify your personal and professional goals. When the
daily routines of your life begin to set in, you are likely to
let the days pass by without thinking too much about your
long-term goals and desires.
- Know and understand your personality type - Knowing
your personality type will help you understand why you're
different or similar to other people, help you manage your
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time and energy better, and help you recognize your - Common terms used to describe appearance are healthy,
emotions. sickly, ill at ease, looks older/younger than stated age,
- Record your personal narrative AUTOBIOGRAPHY disheveled, childlike, and bizarre.
• How would you tell the story of your life to - Signs of anxiety are noted: moist hands, perspiring
yourself? forehead, tense posture and wide eyes.
• What would your autobiography look like? - Appearance Example
Some guided questions to get you started: • The pt. is a 23 y.o male who appears his age. There is
- What are your strengths and weaknesses? List three of poor grooming and personal hygiene evidenced by
each. foul body odor and long unkempt hair. The pt. is
- What do you value most? wearing a worn T-Shirt with an odd symbol looking
- Differentiate between what one can or cannot do by like a shield. This appears to be related to his
themselves. delusions that he needs ‘antivirus’ protection from
- What feelings are you more aware of experiencing, as people who can access his mind.
compared to others? • Attitude towards the Examiner
- What are your triggers (people and situations most likely o Cooperative, friendly, attentive, interested, frank,
to trigger negative or uncomfortable emotions)? seductive, defensive, contemptuous, perplexed,
- How do you respond under stress? apathetic, hostile, playful, ingratiating, evasive,
- How do the different roles you play in your life make you or guarded; any number of other adjectives can
feel (eg.student, sister, brother, father, mother, best friend, be used.
employee, athlete, breadwinner, husband, housewife, o Record the level of rapport established.
etc.)? o Note an apathetic, non-cooperative, attitude
towards examiner
MENTAL STATUS EXAMINATION • Speech Characteristics:
- The mental status examination describes the sum total of o Speech can be described in terms of its quantity,
the examiner’s observations and impressions of the rate of production, and quality.
psychiatric patient at the time of the interview. o Such as: talkative, garrulous, voluble, taciturn,
- Whereas the patient's history remains stable, the unspontaneous, or normally responsive to cues
patient's mental status can change from day to day or from the interviewer. There is alogia or poverty of
hour to hour. speech in Schizophrenia
- Even when a patient is mute, is incoherent, or refuses to o Speech can be rapid or slow, pressured (hard to
answer questions, the clinician can obtain a wealth of interrupt the pt), hesitant, emotional, dramatic,
information through careful observation. monotonous, loud, whispered, slurred, staccato,
Component of the Mental Status Examination or mumbled.
Appearance o Speech impairments, such as stuttering, are
• Overt behavior included in this section.
• Attitude o Any unusual rhythms (termed dysprosody) or
• Speech accent should be noted.
• Mood and affect • Behavior and Psychomotor Activity
Thinking o Mannerisms, tics, gestures, twitches, stereotyped
a. Form behavior, echopraxia, hyperactivity, agitation,
b. Content combativeness, flexibility, rigidity, gait, and agility.
c. Perceptions o Take note of movements which can result due to
Sensorium drug side effects eg. TD or EPS or tremors
a. Alertness o Describe restlessness, wringing of hands, pacing,
b. Orientation (person, place, time) and other physical manifestations.
c. Concentration o Note psychomotor retardation or generalized
d. Memory (immediate, recent, long term) slowing of body movements.
e. Calculations o Describe any aimless, purposeless activity.
f. Fund of knowledge Psychomotor Agitation
g. Abstract reasoning - Mood
Insight/Intellect • Mood is defined as a pervasive and sustained emotion
• Judgment that colors the person's perception of the world.
• Cognition • Usually means patient’s self-reported mood
Appearance • Does the patient remark voluntarily about feelings or
- Examples of items in the appearance category include whether it is necessary to ask the patient how he or
body type, posture, poise, clothes, grooming, hair, and she feels?
nails. • Statements about the patient's mood should include
depth, intensity, duration, and fluctuations.

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• Common adjectives used to describe mood include
depressed, despairing, irritable, anxious, angry,
expansive, euphoric, empty, guilty, hopeless, futile,
self-contemptuous, frightened, and perplexed.
• Mood can be labile, fluctuating or alternating rapidly
between extremes (e.g., laughing loudly and
expansively one moment, tearful and despairing the
next).
- Affect
• Patient's present emotional responsiveness, inferred
from the patient's facial expression, including the
amount and the range of expressive behavior.
• Quality: Dysphoric in depression, Euthymic (normal)
or Elevated/Euphoric in mania, Flat in Schizophrenia
or labile (all over the place), or irritable
• Congruency: Affect may or may not be congruent
with mood.
• Range: Affect can be described as within normal
range, constricted, blunted, or flat.
• In the normal range of affect can be variation in facial
expression, tone of
• voice, use of hands, and body movements.
• When affect is constricted, the range and intensity of
expression are reduced. In blunted affect, emotional
expression is further reduced.
• To diagnose flat affect, virtually no signs of affective
expression should be present; the patient's voice
should be monotonous and the face should be
immobile. Note the patient's difficulty in initiating,
sustaining, or terminating an emotional response.
- Dysphoric Affect
- Anxious Affect
- Elevated Affect
- Labile affect - Observe how at first the affect is elevated
then becomes more irritable later on, therefore a labile
affect
- Flat Affect
- Appropriateness of Affect
• This means appropriateness of the patient's
emotional responses in the context of the subject the
patient is discussing.
• Delusional patients who are describing a delusion of
persecution should be angry or frightened about the
experiences they believe are happening to them.
• Inappropriate affect for a quality of response found in
some schizophrenia patients, in which the patient's
affect is incongruent with what the patient is saying
(e.g., flattened affect when speaking about murderous
impulses).
- Perception
• Perceptual disturbances, such as hallucinations and
illusions, can be experienced in reference to the self
or the environment.
• This can be sometimes inferred also when the patient
clearly responds to internal stimuli (and can be
described as such)
• The sensory system involved (e.g., auditory, visual,
taste, olfactory, or tactile) and the content of the
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illusion or the hallucinatory experience should be
described.
• Feelings of depersonalization and derealization
(extreme feelings of detachment from the self or the
environment) are also part of this section.
- Thought
• Thought can be divided into process (or form) and
content.
• Process refers to the way in which a person puts
together ideas and associations, the form in which a
person thinks.
• Process or form of thought can be logical and
coherent or completely illogical and even
incomprehensible.
• Content refers to what a person is actually thinking
about: ideas, beliefs, preoccupations, obsessions
- Thought Process
• The patient may have either an overabundance or a
poverty of ideas.
• There may be rapid thinking, which, if carried to the
extreme, is called a flight of ideas.
• A patient may exhibit slow or hesitant thinking.
• Thought can be vague or empty.
o Do the patient's replies really answer the
questions asked?
o Does the patient have the capacity for goal-
directed thinking?
o Are the responses relevant or irrelevant?
o Is there a clear cause-and effect relation in the
patient's explanations?
o Does the patient have loose associations (e.g., do
the ideas expressed seem unrelated and
idiosyncratically connected)?
• Disturbances of thought continuity include
statements that are:
o tangential, circumstantial, rambling, evasive, or
perseverative
- Formal Thought Disorders
• Circumstantiality: Overinclusion of trivial or irrelevant
details that impede the sense of getting to the point.
• Tangentiality: In response to a question, the patient
gives a reply that is appropriate to the general topic
without actually answering the question. Example:
o Doctor: “Have you had any trouble sleeping
lately?”
o Patient: “I usually sleep in my bed, but now I'm
sleeping on the sofa.”
• Derailment: (Synonymous with loose associations) A
breakdown in both the logical connection between
ideas and the overall sense of goal-directedness. The
words make sentences, but the sentences do not
make sense.
• Word Salad: Incoherent or incomprehensible
connections of thoughts (most severe thought
disorganization)
• Flight of ideas: A succession of multiple associations
so that thoughts seem to move abruptly from idea to
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
idea; often (but not invariably) expressed through
rapid, pressured speech.
• Clang associations: Thoughts are associated by the
sound of words rather than by their meaning (e.g.,
through rhyming, or assonance).
• Neologism: The invention of new words or phrases or
the use of conventional words in idiosyncratic ways.
• Perseveration: Repetition of out of context of words,
phrases, or ideas.
• Thought blocking : interruption of the train of thought
before an idea has been completed; the patient may
indicate an inability to recall what was being said or
intended to be said
- Thought Content
• Disturbances in content of thought include delusions,
preoccupations (which may involve the patient's
illness), obsessions, compulsions, phobias, plans,
intentions, hypochondriacal symptoms, and specific
antisocial urges.
• Does the patient have thoughts of doing self-harm? Is
there a plan?
• Note homicidal ideation, intent or plan
• Delusions—fixed, false beliefs out of keeping with the
patient's cultural background— may be mood
congruent (thoughts that are in keeping with a
depressed or elated mood, e.g., a depressed patient
thinks he is dying or an elated patient thinks she is
the Virgin Mary) or mood incongruent (e.g., an elated
patient thinks he has a brain tumor).
• Describe the content of any delusional system and
attempt to evaluate its organization and the patient's
conviction about its validity.
• Delusions can be bizarre and may involve beliefs
about external control (Thought insertion, withdrawal
or broadcasting)
• Delusions can have themes that are persecutory or
paranoid, grandiose, jealous, somatic, guilty, nihilistic,
or erotic.
• Ideas of reference include a person's belief that the
television or radio is speaking to or about him or her.
• Examples of ideas of influence are beliefs about
another person or force controlling some aspect of
one’s behavior.
- Orientation & Level of Alertness
• Some terms used to describe the patient's level of
consciousness are clouding, somnolence, stupor,
coma, lethargy, or alert.
• Orientation to time, place and person
- Levels of Memory
Immediate Recall of perceived material within seconds
to minutes
Recent Recall of events over the past few days
Recent past Recall of events over the past few moths
Remote Recall of events in the distant past
- Insight
• Insight is a patient's degree of awareness and
understanding about being ill.
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• Patients may exhibit complete denial of their illness
or may show some awareness that they are ill but
place the blame on others, on external factors, or
even on organic factors.
• They may acknowledge that they have an illness but
ascribe it to something unknown or mysterious in
themselves.
• Level of Insight:
1. Complete denial of illness
2. Slight awareness of being sick and needing help,
but denying it at the same time
3. Awareness of being sick but blaming it on others,
on external factors, or on organic factors
4. Awareness that illness is caused by something
unknown in the patient
5. Intellectual insight: admission that the patient is
ill and that symptoms or failures in social
adjustment are caused by the patient's own
particular irrational feelings or disturbances
without applying this knowledge to future
experiences
6. True emotional insight: emotional awareness of
the motives and feelings within the patient and
the important persons in his or her life, which can
lead to basic changes in behavior.
- Cognition
• Usually not extensively reported and can be inferred
from the interview or reported as ‘intact’
• If indicated a miniCog can be done
o Orientation
o 3 word recall
o Concentration – spell EVOLVE backwards or
serial 7s
• If impairment is suspected a MMSE is more
appropriate
o These and other bedside tests will test Memory
(immediate, recent, long term), Calculations,
Fund of knowledge, Abstract reasoning
- Judgment
• During interview one can assess/infer many aspects
of the patient’s capability for social judgment.
• Does the patient understand the likely outcome of his
or her behavior, and is he or she influenced by this
understanding?
• Can the patient predict what he or she would do in
imaginary situations (e.g., smelling smoke in a
crowded movie theater)?
• If impaired, then it is a safety issue and therefore it
makes this an important aspect of MSE
Sample MSE
- Mania - Ms. Joanna Doe is a 34 yo female who appears her
stated age. Appearance is remarkable for wearing
revealing and likely designer clothes with excessive
makeup. Behavior is hyperactive and agitated at times.
Speech is pressured and with an increased rate, often
loud. Mood is described as ‘happy and on top of the world’
and affect is elevated and euphoric. Not appropriate to
situation. It is also irritable in parts and quite labile.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
Thought process is disorganized with apparent flight of
ideas connected to grandiose delusional themes. There is
no suicidal or homicidal ideation. Thought content has
grandiose delusions. Perception appears normal. Insight
is poor and Judgment is quite poor – wants to fly to Milan
in this state which can lead to unfortunate outcomes. Also,
client is exercising poor judgment with finances.
- APPEARANCE/BEHAVIOUR
• The patient is an 18-year old male, 163 cm tall,
wearing a plain black shirt coupled with shorts and
slippers. He patient has black hair and dark brown
eyes. His eyes are sunken and appear drowsy. He
has noticeable bruises on the knuckles, arms, and
presence of scar on the face. The client has
difficulty communicating and did not maintain eye
contact during NPI. He has a blunt affect and
manifested poverty of speech. He also showed signs
of aggressive and impulsive behavior.
- THINKING
• The patient only talked minimally and showed signs of
poverty of speech saying “ewan” or “wala lang” in
most questions. He was not able to maintain a
linear train of thought with apparent disorganization
or irrational connections when expressing himself.
He keeps blaming those people around him for not
providing him a support. He denied any thoughts of
suicide and hallucinations. He has impaired thought
content of what is right and wrong as he thinks
that there is nothing wrong with stealing from
grocery stores if will yield positive effect (e.g. stealing
food will not make him hungry)
- ORIENTATION
• The patient is oriented to the three spheres: place,
person, and time/situation. He was able to say
that he is actually incarcerated in a psychiatric
facility. He was aware of whom heinteracted with as
he was able to recall the name of the student nurse
who looked after him but did not remember all of
them. He was also time-oriented, as he was able to
tell the time and date of the day.
- MEMORY
• The patient can remember recent events. He was
able to report on his activities from the previous day
but with minimal use of words. His long term memory
is intact and he can recall the day that they
transferred here in Manila. During my interview, he
was able to remember the day that his father was
arrested. He was also able to remember his
experiences at the warzone in Isabela, Basilan.
However, he refused to talk about it. The patient
can mostly recall traumatic experiences caused by
his father. He is having a hard time remembering the
names of other nursing students except the nursing
student assigned to him. (Short term memory)
- INTELLECT/INSIGHTS
• During NPI, when the client was asked to solve a
simple mathematical problem, (5x3), he answered 2.
But when asked to repeat his answer, he counted
J.A.K.E 42 of 62
using his finger and changed his answer to 15.The
patient was able to solve basic math problems;
however he needs sufficient time to respond to
provide an answer. The patient can count numbers.
When he was asked to count by 3 backwards starting
from 20 the patient was able to do it but required
ample time to respond. About his condition, he
denied that he is sick and its normal to steal, stating
“konting konti lang ninakaw ko”.
- COGNITION
• Due to mental incapacity or neurological disorder, the
patient's cognitive ability may be impaired. However,
during the therapeutic activities, the client was
participative but at times was stubborn. The client
was able to understand and follow instructions in
our therapeutic activities. He needed sufficient
time to provide answers to my questions. He has
little to no difficulty remembering previous
therapeutic activities.
THERAPEUTIC COMMUNICATION AND RELATIONSHIPS
- “Communication is the exchange of information, ideas,
thoughts or feelings between two or among people. “
- Verbal Communication – Comprises all words a person
speaks. It uses methods such as talking and listening.
- Written Communication – Communication could also be
in the form of writing or reading
- Content
• is the literal words that a person speaks.
• The patient stated “I feel calm today”
- Process
• denotes all the nonverbal messages that the speaker
uses to give meaning and context to the message.
• The patient speaks in a high pitch voice and perspiring
profusely while continuously wringing his finger and
tapping his foot on the floor
- Congruent Message
• Is conveyed when content and process agree.
• Example, a client says, “I know I haven’t been myself. I
need help.” She has a sad facial expression and a
genuine and sincere voice tone. The process validates
the content as being true.
- Incongruent Message
• When the content and process disagree
• When what the speaker says and what he or she does
do not agree
• The process or observed behavior invalidates what the
speaker says (content).
Non-Verbal Communication
- Comprises all behaviors displayed by an individual
- EXAMPLES
1) Kinesics – body behaviors, facial expressions, eye
contact, eye cast
2) Paralanguage – voice related behavior Ex: Tone, pitch,
intensity, stuttering, pauses, silence
3) Proxemics – space that people feel deem necessary to
set between themselves and others.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
4) OTHERS
1) Observable autonomic physiologic responses - Ex:
increase respiration, diaphoresis, pupil dilation,
blushing, paleness
2) General appearance. Ex: hygiene, grooming,
dressing
3) Physical characteristics. Ex: height, weight,
physique, apparent age, complexion
Factors that Influence the Communication Process
1) Proxemics
- Intimate – 0 to 1 ½ feet
- Personal – 1 ½ to 4 feet (It is the distance people prefer
when interacting with others)
- Social – 4 to 12 feet
- Public – 12 – 25 feet and beyond
2) Gender
- Man and woman communicate differently and that they
may interpret the same communication differently.
3) Values and Perception
- Each person has unique personality traits, values, and
life experiences, each one of us will perceive and
interpret messaged and experiences differently.
4) Interpersonal Attitude
- Attitudes such as caring, warmth, respectful, and
accepting facilitate communication, and coldness
inhibit communication
5) Attentive Listening
- Is listening actively and with mindfulness and using all
the senses, and paying attention to what the client is
saying, doing, and feeling
Behavioral Attitude When Attentively Listening
SOLER:
S: Squarely face the patient
O: Open posture
L: Lean forward
E: Eye contact
R: Relaxed attending attitude
Factors That Influences The Communication Process
• Congruence
- When the verbal and nonverbal aspects of the message
match.
- Clients more readily trust the nurse when they perceive
the nurse’s communication as congruent.
• Touch
- Touching a client can be comforting and supportive
when it is welcome and permitted
J.A.K.E 43 of 62
- Touch can be an invasion of intimate and personal
space.
- The nurse should observe the client for cues that show
whether touch is desired or indicated.
“Effective communication provide the best care and patient
outcomes possible.”
Communicating is an integral part of a helping relationship.
Nurses who communicate effectively are better able to:
• Collect assessment data
• Initiate interventions
• Evaluate outcomes of interventions
• Initiate change that promotes physical and mental health
Therapeutic Communication in Nursing
- An interpersonal interaction between the nurse and the
client during which the nurse focuses on the client’s
specific needs to promote an effective exchange of
information
- Skilled use helps the nurse understands and emphatize
with the client’s experience
Therapeutic communication can help nurses to
accomplish many goals
• Establish a therapeutic nurse–client relationship.
• Building trust
• Identify the most important current client’s concern
(client-centered goal).
• Assess the client’s perception of the problem. • Facilitate
the client’s expression of emotions. • Recognize the
client’s needs.
• Implement interventions designed to address the client’s
needs.
• Guide the client toward identifying a plan of action to a
satisfying and socially acceptable resolution of needs.
• Facilitating personal growth and behavioral change
• Teach the client and family necessary selfcare skills.
Therapeutic Communication Techniques
Open Ended
– invites client to share their personal experience
– Giving Broad Openings
• Allowing the client to take the initiative in introducing
the topic.
• “Is there something you’d like to talk about today?”
• “Where would you like to begin?”
• “How will you approach your father?”
• “What would you like to discuss?”
• “What are your plans for the future?”
• Broad opening may stimulate client who is hesitant to
talk.
- Gentle Command /Encouraging Description Of
Perceptions
• “Tell me something about your home life”
• “Share with me some of your hopes about the therapy”
• “Describe for me the problems with your boss”
• “Tell me when you feel anxious.”
• “What happened?”
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

• “What does the voice seem to be saying?” Facilitatory Statements

Focused • Accepting
– used with a resistant clients or those client who jump from - Indicates that the nurse has heard and is interested in
one topic to another what the client is saying
– Focusing - Facial expression, tone of voice, and so forth also must
• Concentrating on a single point convey acceptance.
• “Of all the concerns you’ve mentioned, which is most o “Yes .”
troublesome?” o “I’m Nodding head
- Exploring • Offering General Lead
• Examining an issue more fully by asking further. - Indicate that the nurse is listening and following what
• Can you describe your feelings? the client is saying without taking away the initiative for
• Can you tell me about your boss? the interaction.
• Can you tell me what the voices are saying? o “Go on”
- Qualitative Questions o “And then?”
• How’s your appetite? o “Tell me about it”
• How's your job going? Closed Ended
• How’s your mood been? • Help obtain important facts or ask for specific details and
give information or explanations
• How are you feeling right now?
• Aim to discover meaning or gain an understanding of • Help focusing a wandering client.
the patients experience of a certain situations or • Closed Ended Questions (Seeking Information)
circumstances - “How long have you been hearing
- Quantitative Questions - “What medication are you
• Aim to discover cause and effect relationships, often - “Are you feeling angry?”
through comparison. - “I read in your chart that you tried suicide once before”
Other Useful Techniques
• “How may hours did you sleep last night”
• Presenting Reality
• “How many times you were visited this week”
- Indicating what is real.
Statement of Inquiry
o “I see no one else in the room.”
• Reflecting/ Paraphrasing
o “That sound was a car backfiring.”
- Directing client actions, thoughts, and feelings back to
o “Your mother is not here; i am a nurse.”
client
- The nurse calmly and quietly express his/her
- You say you were second in your class? “Can you tell
perceptions or the facts
me more about it”
o P --“eggs are flying
- You seem to be saying that you are viewed as the bad
o N --“eggs are food to be eaten
guy in the family?
• Encouraging Expression of Feelings
- Give me an example of being ‘no good’
- P ––“I want to kill
• Reflecting on the Feelings Expressed
- N ––“tell me of you’re feeling of wanting to kill yourself”
- P ––“No one wants
• Offering Self
- N --“You mean you feel rejected?”
- Making oneself available
• Clarifying Client’s Statement
- ’ll sit with you for awhile
- P --“I’m crazy”
• Consensual Validation
- N --“What do you mean you are crazy”
- Searching for mutual understanding on the meaning of
• Validate Client’s Statement
the words
- P ––“I can’t sleep. I stay awake all night”
- “Tell me whether my understanding of it agrees with
- N ––“You mean you have difficulty sleeping?”
yours.”
• Restate Or Feedback on What The Client Has Said
- “Are you using this word to convey that…?”
- P --“do you think I should tell my husband what
- Sometimes, words, phrases, or slang terms have
happened?”
different meanings and can be easily misunderstood.
- N ––“Do you think you should tell your husband?”
• Encouraging Comparison
- P ––“Nurse am I crazy
- Asking that similarities and differences of a situations or
- N ––“Do you think you’re
circumstances
Empathetic Statements
- “Was it something like…?”
• Sharing Perceptions
- “Have you had similar experiences?”
- It sounds like a troubling time for you”
- “Which do think is better. When you were with your
- “It looks like you’re feeling
mother or with your father?”
- It’s difficult to end a marriage after 10 years
• Giving Information
- RESPOND IN SUCH A WAY THAT CLIENT FEEL WORTHY
AND IMPORTAN T

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 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- Informing the client increases his/her knowledge about
a topic or allows the client know what to expect. Giving
information also builds trust with the client.
- “My name is….”
- “Visiting hours
- “My purpose in being here is….”
• Giving Recognition
- Greeting the client by name, indicating awareness of
change, or noting efforts the client has made all show
that the nurse recognizes the client as a person, as an
individual.
- “Good morning, M r. S.….”
- “You’ve finished your list of things to do.”
- “I notice that you’ve combed your hair today.”
• Formulating a Plan of Action
- Making definite plans increases the likelihood that the
client will cope more effectively in a future similar
situations.
- “what could you do to let your anger out harmlessly?”
- “Next time this comes up, what might you do to handle
it?”
• Making Observation
- Verbalizing what the nurse perceive. May encourage the
patient to talk and share feelings.
- “You appear
- “I noticed that you’re biting your
- “Are you uncomfortable
• Silence
- Absence of verbal communication, which provides time
for the client to put his/her thoughts or feelings into
words, to regain composure, or when to talk. The nurse
says nothing but continues to maintain eye contact and
conveys interest.
- Much nonverbal behavior takes place during silence,
and the nurse needs to be aware of the client and
his/her own nonverbal behavior.
• Summarization
- Reviewing main points and conclusions
- “Let’s see, so far you have said ……”
- It allows the client and nurse to have same ideas and
provides a sense of closure at the completion of each
discussion.
• Translating Into Feelings
- Seeking to verbalize client’s feelings that he/she
expresses indirectly
- P: “I'm dead.”
- N: “Are you suggesting that you feel lifeless?”
- P: “I'm way out in the ocean.”
- N: “You seem to feel lonely or deserted2.”
- Often the client’s statements are meaningless or far
from reality. T he nurse must understand what the client
might want to express or is feeling
• Voicing Doubt
- Expressing uncertainty about the reality of the client’s
perceptions
- Isn’t that unusual?”
- “That’s hard to
J.A.K.E 45 of 62
These permits the client to become aware that others
do not perceive events in the same way. This may the
client to reconsider or reevaluate his/her perception.
Non Therapeutic Communication Techniques
The Don’t’s (COWARD)
1) C Changing topic, challenging, testing, defending
2) O Opinion, advises , value judgment, false reassurance,
3) W --“Why” questions
4) A Asking questions with “yes” or “no” response
5) R Refuse to listen or not paying attention
6) D Disapproving or approving
-Disagreeing or agreeing
-Disregarding patient's statement and feelings
-Devaluating patient's feelings expressed
Changing Topic, Challenging, Testing, Defending
7) Changing the Subject
- Introducing an unrelated topic
- P: “I'd like to die.”
- N: “Did you have visitors last evening?”
- This usually happens because the nurse is
uncomfortable, doesn’t know how to respond, or has a
topic he/she would rather discuss .
• Challenging
- Demanding proof from the
- N --“But how can you be president of the united states?”
- N --“If you’re dead, why is your heart beating?”
- Challenging causes the client to defend the delusions
or misperceptions more strongly than before.
• Defending
- Attempting to protect someone or something from
verbal attack?
- “This hospital has a fine reputation.”
- “I’m sure your doctor has your best interests in mind.”
- Defending what the client has criticized implies that he
or she has no right to express impressions, opinions, or
feelings. This further block communication.
• Testing
- Appraising the client’s degree of insight
- “Do you know what kind of hospital this is?”
- “Do you still have the idea that…?”
- The client’s acknowledgment that he or she doesn’t
know these things is not helpful for the client.
Opinion, Advises, False Reassurance
• Opinion and Value Judgment
- Limit patient’s decision making, think, analyze and
independence
- “That’s unfair” “ That’s not right
• Advising
- Telling the client what to do
- “I think you should….”
- “Why don’t you….”
- Giving advice implies that only the nurse knows what is
best for the client.
• Reassuring
- Indicating there is no reason for anxiety or other
feelings of discomfort
- “I wouldn’t worry about that.”
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- “Everything will be all right.”
- “You’re coming along just fine.”
- Attempts to dispel the client’s anxiety by implying that
there is not sufficient reason for concern
“Why” Questions
• Requesting An Explanation
- Asking the client to provide reasons for thoughts,
feelings, behaviors, events
- “Why do you think that?”
- “Why do you feel that way?”
- A “why” question is intimidating. T he client is unlikely
to know “why” and may become defensive trying to
explain himself/herself.
- There is a difference between asking the client to
describe what is occurring or has taken place and
asking him to explain why.
Asking Probing Questions and Questions Answerable By
“Yes” Or “No” Response Except When Clarifying
• Probing
- Persistent questioning of the client
- “Now tell me about this problem. You know I have to
find out.”
- “Tell me your psychiatric history.”
- “How come you are the president of the universe”
- Probing tends to make the client feel used or invaded.
Clients have the right not to talk about issues or
concerns if they choose. Pushing and probing by the
nurse will not encourage the client to talk.
• Yes/ No Response
- Patient may not give accurate information of his/her
ideas, thoughts or feelings.
Refuse To Empathize
• Interpreting
- Asking to make conscious that which is unconscious;
telling the client the meaning of his or her experience
- “What you really mean is….”
- “Unconsciously you’re saying….”
- The client’s thoughts and feelings are his or her own,
not to be interpreted by the nurse for hidden meaning.
Only the client can identify or confirm the presence of
feelings.
• Making Stereotyped Comments
- Offering meaningless clichés or trite comments
- “it’s for your own good.”
- “Keep your chin up.”
“Just have a positive attitude and you’ll be better in no
time.”
Social conversation contains many clichés and much
meaningless chitchat. Such comments are of no
value in the nurse client relationship. Any automatic
responses lack the nurse’s consideration or
thoughtfulness.
Disapproving or Approving
8) Disapproving
- Denouncing the client’s behavior or ideas
- That’s bad.”
- “I’d rather you wouldn’t….”
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- Disapproval implies that the nurse has the right to give
judgment on the client’s thoughts or actions. It further
implies that the client is expected to please the nurse.
• Giving Approval
- Sanctioning the client’s behavior or ideas
- “That’s good”
- “I’m glad that….”
- Approval tends to limit the client’s freedom to think,
speak, or act in a certain way. This can lead to the
client’s acting in a particular way just to please the
nurse.
Disagreeing or Agreeing
• Disagreeing
- Opposing the client’s ideas
- “That’s wrong.”
- “I definitely disagree with….”
- “I don’t believe that.”
- Disagreeing implies the client is “wrong.” Consequently,
the client feels defensive about his or her point of view
or ideas.
• Agreeing
- Indicating accord with the client
- “that’s right.”
- “I agree”
- When the nurse agrees with the client, there is no
opportunity for the client to change his or her mind
without being “wrong.” Opinions and conclusions
should be exclusively the client’s.
Disregarding Patient's Statement
• Rejecting
- Refusing to consider or showing contempt for the
client’s ideas or behaviors
- “Let’s not discuss….”
- “I don’t want to hear
- Rejecting any topic blocks exploration because the
client may feel personally rejected along with his/her
ideas.
• Using Denial
- Refusing to admit that a problem exists
- P: “I'm nothing.”
- N: “Of course you’re something everybody’s something.”
- P: “I'm dead.”
- N: “Don’t be silly.”
- The nurse denies the client’s feelings or the seriousness
of the situation by dismissing his or her comments
without attempting to discover the feelings or meaning
behind them .
Devaluating Feelings Expressed
• Belittling Feelings Expressed
- Misjudging the degree of the client’s discomfort
- Client: “I have nothing to live for… I wish I was dead.”
- Nurse: “I've felt that way myself.”
- T he nurse implies that the discomfort is temporary,
mild, self limiting, or not very important.
• Giving Literal Responses
- Responding to a figurative comment as though it were a
statement of fact
- P : “They’re looking in my head with a television camera.”
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

- N: “Try not to watch television” process to provide a more comprehensive nursing

- N --“What channel?” assessment of the patient.
- Often the client is at a loss to describe his or her - She identified 11 areas to assessed through questions
feelings, so such comments are the best he or she can asked by the nurse and medical examinations to provide an
do. Usually, it is helpful for the nurse to focus on the overview of the individual's health status and health
client’s feelings in response to such statements. practices that are used to reach the current level of health
or wellness.
Process recording
- a method in which a nurse and student nurses record all
the communication, both verbal and non verbal, spoken
and observed during his or her interview with the patient.
- Purposes of a Process Recording
• To provide means for self evaluation of verbal and non
verbal communication pattern and its effect on the
client.
• To improve the quality of therapeutic nurse patient
relationship
• To asses the nurse to plan, structure and evaluate the
interaction on a conscious rather than intuitive level
• To help the nurse identify the thoughts and feelings in
relation to self and others
• To help increase the ability to identify problems and
gain skills in solving them
Process Recording Sample Form
Name of student: _______Group no.: __Agency: NCMH Area of
assignment: Pav . 14
Name of client (initial only): _______Age: _____Sex: _____Race:
______
Phase of interaction: Orientation Phase Date of NPI: Feb. 14,
2021 Medical diagnosis:
Bipolar Disorder Type 1, manic episode
Objectives of the interaction:
1) To establish rapport and gain patient’s trust
2) To gather patient’s medical and psychiatric history
3) To assess patient’s psychosocial problems and mental
health status
General Description of the Client: (Guided By MSE)
• Patient is male, is of regular body built, has an average
height, stands about 160cm and weighs 76kg. He was clad
in clean blue hospital suit, wearing a green cleanrubber
slipper which he claimed it was given by her mother and
the color green is his favorite. He was also observed to
have just taken a bath because his short hair was wet but
was well comb. In general, the client is observed o have a
good personal hygiene.

GORDON Health Assessment Functioning

- Gordon’s functional health patterns is a method devised by
Marjory Gordon to be used by nurses in the nursing

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Therapeutic Relationship Nurse Patient Relationship (NPR)

- Establishing a therapeutic relationship is one of the most - Using oneself as a tool in the development of nurse patient
important responsibilities of the nurse when working with relationship (NPR) to meet clients’ emotional needs and
clients. resolve client’s health needs
- Communication is the means by which a therapeutic - It requires: EARS
relationship is initiated, maintained, and terminated. • E empathy
Nurse Patient Relationship • A awareness of self
- A therapeutic nurse patient relationship is defined as a • R respect
helping relationship that is based on mutual trust, respect, • S self disclosure
nurturing, being sensitive to self and others and assisting Developing Helping Relationships
with gratification of your patient’s physical, emotional and 1) Listen attentively.
spiritual needs through your knowledge and skills. 2) Help to identify what the patient is feeling
Therapeutic Relationship 3) Put yourself in the patient’s shoes
- A helping relationship between the nurse and a client 4) Be honest, genuine and credible
focusing on meeting the needs the of client. 5) Use your ingenuity.
• Patient centered 6) Maintain client confidentiality.
• Professional relationship 7) Know your role and your limitations
• Goal directed 8) Be aware of cultural differences
• Time bounded Phases of Nurse Patient Relationship
• Structured – planned and follows a sequence Pre Orientation Phase
o Establishing - It begins before the client first contact with the patient. T
o Maintaining, he nurse gathers information. Such information may
o Terminating include the client’s name, address, age, medical and
Roles of the Nurse in a Therapeutic Relationship social history.
• Teacher The nurse teaches the client new methods of - The nurse should consider her personal strength and
coping and solving problems. He or she may instruct about limitation when working with the client and in any area that
the medication regimen and available community might signal difficulty because of past experiences
resources 1) Self awareness.
• Caregiver The nurse implements therapeutic relationship 2) Data gathering
to build trust, explore feelings, assist the client in problem Orientation (Establishing)
solving, and help the client meet psychosocial needs. - The nurse establishes a relationship , develop trust and
• Advocate The nurse informs the client and then supports respect , setting goals, and security within the nurse client
him or her in whatever decision he or she makes and acting relationship
on the client’s behalf when he or she cannot do so. 1) Establish trust consistent, congruent, honest, keeping
• Parent Surrogate The nurse p rovides personal care such promises, show genuine interest and respect
as feeding or bathing 2) Establish contract
Components of Nurse-client relationship - time, place and length of session
• Trust – Key factor in establishing a therapeutic relationship - Duration
towards recovery process - Purpose of the meeting
• Genuine interest – when the nurse is comfortable with - Client responsibilities
himself or herself, aware of his or her strengths and - Nurse responsibilities
limitations, and clearly focused, the client perceives a 3) Set boundaries of the relationship
genuine person showing genuie interest. The nurse should - Nurse responsibilities
be open and honest and display congruent behavior. • Arrive on time
• Empathy • End on time
• Acceptance – A caring action on the client’s well being • Maintain confidentiality
such as, sensitivity, comforting, attentive listening , • -Document sessions (recording
honesty and non judgmental acceptance • process)
• Positive regard – the nurse who apreatiaes the client as a • Assess client level of anxiety
unique worthwhile human being can respect the client • Prepare client for terminationand separation of
regardless of his or her behavior, background or style. the relationship
• Therapeutic use of self – ability to use one’s personality 4) Beginning assessment and identify problems to work
consciously and in full awareness in an attempt to with the patient
establish relatedness and to structure nursing Working (Maintaining)
interventions. Nurses must posses self-awareness, self- 1) The nurse works with the client on the resolution of his
understanding, and a philosophical belief about life, death, identified problem while maintaining the nurse patient
and overall human condition. relationship
2) Identifies issues or concerns causing problems

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3) Facilitate behavioral changes
• Examine feelings and responses
• Develop a better coping skills
• Promote a positive self concept
• Develop independency
• Exploring perception of reality
4) Evaluation and redefining goals as Appropriate
Termination (Terminating / Separating)
- The nurse summarizes with the clients his progress of the
relationship and assessing the client’s ability to handle
situations independently
1) Assess client emotional stability
2) Identify and deal with separation issues
3) Encourage client to discuss feelings about the
termination
4) Do not promise the client that the relationship will be
continued
5) Refer and transfer client to other support system
Barriers to Therapeutic Relationship (Candy TRIES)
• C – Countertransference – Nurse transfers feelings to
client of a significant person in her life
• T – Transference – Client transfers feelings to nurse of a
significant person in her life
• R – Resistance and Avoidance – Development of
ambivalent feelings for self exploration or self disclosure
• I – Inappropriate Boundaries – Relationship should be
maintained within the NPR
• E – Encourage Dependency – Encourage independency
• S – Sympathy – Empathize
 conditions
TREATENT MODALITIES IN PSYCHIATRIC NURSING
PRACTICE
Terminologies
• Art Therapy. The therapeutic use of art making such as
drawing, painting, clay art, and others
• Attitude Therapy. Treatment that emphasizes the
evaluation of current attitudes in terms of the origins of the
attitudes, the purpose these attitudes serve, and their
possible distortions.
• Behavioral therapy. A strategy that help patients change
behavior:
• Behavioral modification. A psychotherapeutic
intervention primarily used to eliminate or reduce
maladaptive behavior in children or adults.
• Client-centered therapy. Also known as person-centered
therapy or Rogerian therapy, is a non-directive form of talk
therapy developed by humanist psychologist Carl Rogers
during the 1940s and 1950s
• Cognitive-behavioral therapy. It used to restructure how
a person perceives self or events in his or her life to
facilitate behavioral and emotional change
• Cognitive Restructuring. Use to monitor automatic
thoughts, then to recognize the connection between
thoughts, emotional response and behavior
• Dance therapy. Also known as, movement therapy or
dance movement therapy (DMT) is a type of therapy that
J.A.K.E 49 of 62
uses movement to help individuals achieve emotional,
cognitive, physical, and social integration.
• Family therapy. A group therapy in which the client and his
family members participat.
• Gestalt therapy. A psychotherapeutic approach
developed by Fritz Perls (1893–1970). It focuses on insight
into gestalts in patients and their relations to the world,
and often uses role-playing to aid the resolution of past
conflicts.
• Group therapy. Compose of number of persons who
gather in a face-to-face setting to accomplish tasks that
requires cooperation, collaboration, or working together.
• Individual psychotherapy. A method of bringing about
change in a person by exploring his/her feelings, attitudes,
thinking and behavior
• Milieu Therapy. The purposeful use of the environment to
enhance mental health of psychiatric patients
• Music Therapy. A technique of complementary medication
that uses music to help patient overcome physical,
emotional, intellectual and social challenges.
• Occupational therapy. A discipline that aims to promote
health by enabling people to perform meaningful and
purposeful activities.
• Play therapy. A form of counselling or psychotherapy in
which play is used as a means of helping children express
or communicate their feelings.
• Positive feedback – Recreational therapy. Also referred to
as recreation therapy and therapeutic recreation, is a
treatment service that provides treatment and recreation
activities to individuals with illnesses or disabling
• Remotivation technique. A very simple group therapy of
an objective nature used in an effort to reach the
unwounded areas of patient’s personality & get them
moving back into the reality
• Somatic therapy. A form of body-centered therapy that
looks at the connection of mind and body and uses both
psychotherapy and physical therapies for holistic healing
• Thought Reframing. Treatment method used to change
client’s negative thoughts to a positive one
• Thought stopping. Used with patients who have
obsessional thoughts such as OCD, panic attack,
borderline personality disorder and aggressive behavior.
• Token economy. A positive reinforcement strategy to
encourage and maintain appropriate performance and
behavior, be it at home or in a classroom setting
Somatic Therapy
- Somatic therapy is a form of body-centered therapy that
looks at the connection of mind and body and uses both
psychotherapy and physical therapies for holistic healing.
Somatic therapy can help people who suffer from stress,
anxiety, depression, grief, addiction, problems with
relationships, and sexual function, as well as issues
related to trauma and abuse.
- Those for whom traditional remedies have not been helpful
for chronic physical pain, digestive disorders and other
medical issues may also benefit from somatic therapy.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

- Somatic therapy techniques can be used in both individual 3) Post-ECT

and group therapy settings.
Electroconvulsive Therapy
- ECT is use treat severe depression. Sometimes, they also
use it to treat other mental illnesses such as schizophrenia.
- ECT is one of the fastest and most effective ways to relieve
symptoms in severely depressed or suicidal people or
those who have mania or other mental illnesses.
- It involves introduction of electrical current to the brain
through an electrode attached to client’s temporal region.
In addition, it produces grandmal seizures.
- Clients are usually given series of 6 – 15 treatments 3 x a
week. Maximum benefit is achieved in 12 – 15 treatments
- Two Forms of ECT
1) Unilateral - Electrode is attached to either sides -
Results in less memory loss but more treatments may
be needed
2) Bilateral - Electrodes are attached to both sides -
Results in more rapid improvement but with increased
short memory loss
- Indications
1) Clients who are severely depressed
2) Clients who are actively suicidal
3) Clients who does not respond to antidepressant
4) Clients who experience intolerable side effects of
antidepressants
5) Use to prevent relapse of depression
- Position client in a lateral position
- Assess any injury
- Take vital signs
- Stay with the client and orient him as the client will
experience confusion and short-term memory
impairment
- Offer food if client is fully awake and when gag reflex
returns
Deep Brain Stimulation Deep brain stimulation (DBS)
- A surgery to implant a device that sends electrical signals
to brain areas responsible for body movement.
- Electrodes are placed deep in the brain and are connected
to a stimulator device. Similar to a heart pacemaker, a
neurostimulator uses electric pulses to regulate brain
activity.
Supportive Therapy
1) Individual Therapy
- Individual psychotherapy is a method of bringing about
change in a person by exploring his/her feelings,
attitudes, thinking and behavior.
- It involves a one on one relationship between the
therapist and the client and it proceeds through similar
stages similar with the NPR.
1) Introduction
2) Working
3) Termination

- Contraindications - Purposes of Individual Psychotherapy:

1) Hypertension and other cardiovascular diseases 1) To understand themselves and their behavior
2) Brain tumor 2) To make personal changes
3) Pulmonary diseases (COPD) 3) To improve interpersonal relationships
4) Fracture 4) To get relief from emotional pain or unhappiness
5) Fever of any kind 2) Family Therapy
6) Glaucoma - Family therapy is a group therapy in which the client
- Preparation before ECT and his family members participate.
1) Inform client - Goals includes:
2) Secure consent 1) Understanding how family dynamics contribute to
3) Complete physical exam the client’s psychopathology,
4) Cardiopulmonary exam 2) Mobilizing the family’s inherent strengths and
5) Dental records functional resources,
Nursing Responsibilities 3) Restructuring maladaptive family behavioral styles
1) Pre-ECT 4) Strengthening family problem-solving behaviors.
- NPO 6 – 8 hours/ post-midnight - Family education focuses on the client’s disorder
- -Take vital signs - Remove jewelries • Example of disorders where family education can be
- Remove dentures - Loosen clothings used are schizophrenia, bipolar disorder, clinical
- Dry client - Empty the bladder depression, panic disorder, and OCD.
- Remove nail polish - Move bowel • The course discusses the clinical treatment of these
- Place client in a supine position comfortably in bed w/ illnesses and teaches the knowledge and skills that
firm mattress family members need to cope more effectively.
- Administer pre-medication as prescribed by the • It includes emphasis on emotional understanding
physician: and healing.
- Ex: muscle relaxant (succinylcholine – Anectine), short 3) Group Therapy
acting anesthesia. - Group therapy compose of number of persons who
2) During ECT gather in a face to face setting to accomplish tasks that
- Stay with the client requires cooperation, collaboration, or working together.
- Provide emotional support
- Assess any complications

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 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- Members share a common purpose and are expected to
contribute to the group to benefit others (altruism) and
receive benefit from others in return.
- Therapeutic results of Group Therapy includes:
1) Feeling of acceptance and belonging
2) Becoming aware that one is not alone and that
others share same problems
3) Gaining new information, or learning
4) Gaining inspiration or hope
5) Gaining insight into one’s problems and behaviors
and how they affect others
6) Giving of oneself for the benefit of others
7) Interacting with others
- Psychoeducation Group. Education group is to provide
information to members on specific issues such as:
• Stress management,
• Medication management,
• Assertiveness training
• Conflict resolution
• Anger management
• Problem solving
- Self-help groups are concern about coping with a
specific problem or life crisis
• Alcoholic anonymous – alcoholics
• Al- Anon – wives of alcoholics
• Ala-teen – children of alcoholics
• Overeaters Anonymous
• One Day at a Time (a grief group)
- Support groups are organized to help members who
shares a common problem to cope with it. It often
provide a safe place for group members to express their
feelings of frustration, boredom, or unhappiness and to
discuss common problems and potential solutions.
Common support groups includes:
• Those for cancer or stroke victims,
• Person with aids,
• Family members of someone who has committed
suicide,
• Mothers Against Drunk driving (MADD), Role
Reversion
4) Psychotherapy groups focus in managing the individuals’
emotional problem. This includes the application of the
different theories:
Cognitive theory – Aaron T. Beck
Behavioral theory – Skinner
Psychoanalytic theory – Sigmund Freud
Psychosocial theory – Erik Erikson
• Cognitive behavioral therapy was first developed and
implemented by Albert Ellis in 1950’s. It used to
restructure how a person perceives self or events in his
or her life to facilitate behavioral and emotional change
o Cognitive Restructuring – use to monitor automatic
thoughts, then to recognize the connection between
thoughts, emotional response and behavior
o Thought stopping – used with patients who have
obsessional thoughts
- Obsession - Borderline
- Panic – Aggression
J.A.K.E 51 of 62
Cue cards – used to help patient restructure
thought patterns
o Thought Reframing – changing negative thoughts to a
positive one
• Behavioral therapy is a strategy that help patients
change behavior:
o Positive feedback
o Behavioral modification
o Token economy
Milieu Therapy
- The purposeful use of the environment to enhance mental
health of psychiatric patients
- Elements of Therapeutic Environment includes:
1) Unit structure includes:
• Activity groups
• Social skills groups
• Physical exercise program
• Community meetings
• Psycho-educational program
2) Unit norms
• Related to unit rules and policies
• This includes rules concerning dressing, appearance,
group meetings, medications, visiting hour,
telephone use, etc
• This also includes norms of nonviolence, physical &
emotional security, respect, privacy, acceptance,
independence and individual responsibility
3) Limit setting
• Is the art of clearly identifying acceptable and
unacceptable behaviors
• This includes self-destructive acts, physical
aggressions, noncompliance, inappropriate sexual
behaviors
4) Unit modification
• Purposeful arrangement of the environment
• This includes physical arrangement of furniture, safety
issues and orientation strategies
Therapeutic Activities as Adjunct Therapies to Patient
Recovery
Remotivation Technique
- Founded in 1956 by Dorothy Hoskins Smith, a gifted
English teacher; it actually started in 1949 at North
Hampton, Massachusetts where she works as a volunteer.
The therapy can be used in a ward situation regardless of
the length of hospitalization, nature of illness, and age of
the patient. It is something done expertly and well that
helps in the patient’s recovery and be back in pre-
hospitalization state
- Remotivaton technique is a very simple group therapy of an
objective nature used in an effort to reach the unwounded
areas of patient’s personality & get them moving back into
the reality
- Objectives:
• Develop the patient ability to communicate and share
ideas and experience with other
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
• Stimulate patient to think about something and talk
about himself
• Stimulate patient to be fellow explorer of the real world
• Enhance feeling of recognition and acceptance to
increase self-respect and self-esteem
• Stimulate the patient’s interest in reality situation
• Take the patient out of the dullness of the ward and
from the “vegetative state”
• Develop group harmony
- Duration: 45 – 60 minutes for once or twice per week. The
therapy consists of 12 series of sessions.
- Subjects to be considered:
1) Nature
2) Sports
3) Literature
4) Industry
5) Science
6) Geography
7) History
8) Hobbies
- Subjects to be avoided:
1) Family problem
2) Religion
3) Sex
4) Politics
5) Love
- Steps of Remotivation Techniques:
1) Climate of Acceptance
• The leader opens the discussion by greeting the
group in general and expressing appreciation of the
group’s attendance.
• The leader gives his/her name and must ask
participants to introduce themselves.
• After the introduction, the leader may comment on
the weather, the patient’s appearance or may give a
pleasant compliment.
• The general objective is to create a relaxed and
comfortable atmosphere in which the patients feel
accepted
2) Bridge to reality (15min)
• The leader attempts to stimulate or help the patient
get interested in the reality-oriented topic.
• Ask bouncing questions that are short and easy to
answer and may lead to the topic for discussion.
• You may ask anybody who knows a poem about the
topic of discussion
• A poem appropriate for the topic may be used by
reading the stanzas and use them as focus of
discussion until everyone has participated. The
poem and picture or visual aids will serve as a bridge
between topics of discussion of reality.
3) Sharing the world we live in (15min)
• Stimulating question leading to the topic
• Leader should try to explore the topic under
discussion
4) Appreciation of the work of the world (15min)
J.A.K.E 52 of 62
• The step is blended with step 3 4.2. Be sure to relate
the patient so he will be able to think of himself in
relation into certain job
5) Climate of appreciation (15min)
• Leader should try to ask a summary about the topic
w/c has discussed
• Explore with the patient topic to be discussed in the
next session
• Express your appreciation to the patient for coming
to the sessions and participating in the activity
Music and Art Therapy
- A technique of complementary medication that uses music
to help patient overcome physical, emotional, intellectual
and social challenges.
- It is use in many setting including schools, rehabilitation
centers, hospitals, hospice, nursing homes, and
community and even at home.
- Purposes:
1) To promote participation and social interaction
2) To improve reality orientation
3) To develop coping skills
4) To reduce stress
5) To help express feeling through music
- Art Therapy – is the therapeutic use of art making such as
drawing, painting, clay art, and others
- Purposes:
1) To increase self-awareness
2) To cope with stress and traumatic experiences
3) To enhance cognitive abilities
4) To promote self-esteem
5) To promote self-discovery and personal fulfillment
6) To help express feeling through art
- Steps in music appreciation through art:
1) Select appropriate music depending on your objective.
2) Prepare necessary materials needed such as crayons,
bond paper, music player, speaker and extension
3) Gather clients in a U-shape, seated in a bench with a
table.
4) Greet the group in general and express appreciation of
the group’s attendance.
5) The leader gives his/her name and must ask
participants to introduce themselves.
6) Introduce the activity. You may introduce the activity by
asking client about their favorite music, the importance
of music to them, types of music they know, etc.
7) Explain procedure of the activities.
8) Play the music. During the session, play the same
music until all clients are done with their drawing
9) Ask clients to comment and explain their drawing while
student nurses listen and analyze the explanation of
their assigned client.
10) Collect clients drawing.
11) End the activity by thanking the participants and give
brief explanation of what to expect in the next session.
Occupational therapy
- A discipline that aims to promote health by enabling
people to perform meaningful and purposeful activities.
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
- Occupational therapists work with individuals who suffer
from a mentally, physically, developmentally, and/or
emotionally disabling condition by utilizing treatments that
develop, recover, or maintain clients' activities of daily
living.
- The therapist helps clients not only to improve their basic
motor functions and reasoning abilities, but also to
compensate for permanent loss of function.
- Any activity, mental or physical, prescribed and guided to
aid individual’s recovery from diseases or injury. Patient
may enjoy the activity because they exclude competition
and pressure.
- Objectives:
1) To develop the patient’s ability to grasp reality through
activities of daily living
2) To provide opportunity for creativeness and produce
something tangible out of patent’s own thinking and
imagination
3) To promote self-confidence and personal achievements.
4) To prepare client before discharge from the institution
to have independent, productive, and satisfying lives.
Occupational therapy process
Fearing, Law, and Clark suggested a 6 stage process which
includes:
1) Identify occupational performance issues
2) Assess factors contributing the identified occupational
performance issue(s)
3) Consider the strengths and resources of both client and
therapist
4) Negotiate targeted outcomes and develop an action
plan
5) Implement the plan through occupation
6) Evaluate outcomes
Activity analysis
- Activity analysis has been defined as a process of
dissecting an activity into its component parts and task
sequence in order to identify its inherent properties and the
skills required for its performance, thus allowing the
therapist to evaluate its therapeutic potential
- Activities suggested:
1) Painting sketching ceramics cooking
2) Basketry weaving toy making picture frame
3) Sewing knitting flower making and many more
- Areas of practice in occupational therapy
1) Mental health
• Facilitates maximum independence in activities of
daily living (dressing, grooming, etc.)
• Activities of daily living (medication management,
grocery shopping, keeping a schedule, employment,
education, livelihood, etc.).
• Increasing community participation, community
access (grocery store, library, bank, etc.), money
management skills, engaging in productive activities
to fill the day, coping skills, routine building, building
social skills, and childcare (Cara & MacRae, 2005).
2) Physical health
• Schools, Community, inpatient hospital based child
OT:
J.A.K.E 53 of 62
• Acute care hospitals:
• Inpatient acute care hospital setting for individuals
with a serious medical condition(s) usually due to a
traumatic event, such as a traumatic brain injury,
spinal cord injury, etc.
• Inpatient rehabilitation (e.g., Spinal Cord Injuries)
• Rehabilitation centers (e.g., Traumatic Brain Injury
(TBI),[29] Stroke (CVA), Spinal Cord Injuries, Head
Injuries)
• Home Health: geriatric population who have one or
more of the following diagnoses: Alzheimer’s
disease, arthritis, depression, CVA, generalized
weakness, COPD, or Parkinson’s disease.
• Outpatient clinics (e.g., Hand Therapy, orthopedics)
Diagnoses seen by this practice area include:
fractures of the hand or arm, lacerations and
amputations, burns, and surgical repairs of tendons
and nerves, tendonitis, rheumatoid arthritis and
osteoarthritis, and carpal tunnel syndrome
• Productive Aging
3) Community.
• Community based practice involves working with
people in their own environment rather than in a
hospital setting. It often combines the knowledge
and skills related to physical and mental health
Recreational therapy
- Also referred to as recreation therapy and therapeutic
recreation, is a treatment service that provides treatment
and recreation activities to individuals with illnesses or
disabling conditions.
- Treatment may incorporate arts and crafts, animals, sports,
games, dance and movement, drama, music and
community outings.
- Purposes:
1) Helps patient recover basic motor functioning,
reasoning abilities, build confidence, and socialize
more effectively.
2) Improve or maintain physical, mental and emotional
well-being
3) Help patients educe depression, stress and anxiety
- Process: The recreational therapy process begins with an
individual assessment of their:
1) Strengths, interest, and values
2) Previous leisure activities and expectations
3) Available resources in your home and community
4) Social needs and relationships
5) Economic and other potential problem areas
6) Lifestyle adjustments necessary for healthy leisure
functioning
- Activity and treatment ideas for Recreational Therapy
includes
1) Arts/ Crafts/ Cooking
2) Leisure/ Education/ Academics
3) Dance/ Drama/ Music/ Writing
4) Social activities
5) Experiential
6) Warm up activities
7) Holiday and special events
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

8) Wellness and fitness patient approaches her at any time, shows an interest
9) Humor and fun but allows, indeed encourages, the patient to make the
Dance/ Movement therapy initial overtures.
- Usually referred to simply as dance therapy or DMT, is a - This is often use for people who are frightened by active
type of therapy that uses movement to help individuals friendly attentions who recognize some of their own
achieve emotional, cognitive, physical, and social emotional reactions and who will seek the friendship
integration. attention, or
- Beneficial for both physical and mental health, dance - companionship of the nurse when they need it but will
therapy can be used for stress reduction, disease be dismayed or angered of the nurse interacts the
prevention, and mood management. In addition, DMT's attention.
physical component offers increased muscular strength, 3) Indulgence and Permissiveness
coordination, mobility, and decreased muscular tension. - Some patients are so frightened of reality, even the
- Dance/movement therapy can be used with all populations reality of a protective place like the psychiatric hospital,
and with individuals, couples, families, or groups. In that it is necessary for us to accept behavior normally
general, dance therapy promotes self-awareness, self- unacceptable in most groups. It means that the nurse
esteem, and a safe space for the expression of feelings. accepts without punishing minor infractions of the ward
- The creative expression of dance therapy can bolster rules; she may even instigate such infractions for
communication skills and inspire dynamic relationships. It example, by allowing the patient to sit by her desk and
is commonly used to treat physical, psychological, read after “lights outs” at night.
cognitive, and social issues such as: 4) Watchfullness
- Physical Issues: - Use for patient who are suicidal
• Chronic pain - It implies more than watching the patient alone; the
• Childhood obesity personnel must be aware of the many tools of daily
• Cancer hospital life which can prove dangerous to the life of
• Arthritis such persons and frequent inspection should be made
• Hypertension of the patients’ belongings as well as the hospital ward
• Cardiovascular disease itself, for any article secreted to aid the patient to
- Mental Health Issues: escape, harm other or commit suicide
• Anxiety 5) Matter of fact
- Patients for whom this attitude is necessary are often
• Depression
nagging and co plaintive and may make frequent bids
• Disordered eating
for sympathy whether because of physical pain or of
• Poor self-esteem
some annoying hospital routine.
• Posttraumatic stress - The nurse should ignore all such bids, go on about her
- Cognitive Issues:
routines and be friendly toward the patient. She should
• Dementia avoid falling into the trap of arguing or defending the
• Communication issues hospital, the diet, kitchen or the doctor’s orders. “This
- Social Issues: is the way it is, so we accept it” should be implied of her
• Autism calm manner in carrying out the daily routines.
• Aggression/violence 6) Kind firmness
• Domestic violence trauma - Some patients are usually self-punitive, suicidal
• Social interaction persons cannot accept overt friendliness. They feel
• Family conflict unworthy, guilty or fearful and active or even passive
friendliness adds to rather than lessens the burden of
Nurses attitudes in psychiatric nursing care their guilt.
Nursing care involves the use of attitudes in giving patients the - It implies a near sternness in the care of such patients
greatest opportunity to regain their health and to learn good but the nurse must be careful not to use this attitude to
health habits. express some of her own hostility. Firmness is a tool for
1) Active friendliness the care of the patient only not a release for the nurses’
- Means an attitude of interest in the immediate own tensions.
wellbeing of the patient, despite the attitude the patient
himself maybe presenting.
- It is giving attention before the patient requests it. It
means common sense and a genuine interest in the
patient as a person will guide the nurse in its use.
2) Passive friendliness
- Implies an attitude of interest in the patients’ welfare
but one, which does not seek him out to reassure him of
that friendliness. Rather, the nurse is friendly when the

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 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023
PSYCHOPHARMACOLOGY & COMPLEMENTARY AND
ALTERNATIVE THERAPY
Terminologies
• Alternative Therapy - uses alternative medicine in place of
common Western medicine.
• Anticholinergic drugs. Inhibit the transmission of
parasympathetic nerve impulses, thereby reducing spasms
of smooth muscles (for example, muscles in the bladder
• Antidepressants are medications used to treat major
depressive disorder, some anxiety disorders, some chronic
pain conditions, and to help manage some addictions
• Antimanic drug. Any drug that stabilizes mood by
controlling symptoms of mania, the abnormal
psychological state of excitement.
• Antipsychotic drugs. A classification of psychotropic
drugs used to treat psychosis and other mental and
emotional conditions.
• Complementary therapy - uses complementary medicine,
in conjunction with common Western medicine.
• Neurobiological theories. An essentially physiological
approach to psychology that attempts to relate human
behavior to electrical and chemical activities taking place
in the brain and central nervous system
• Psychopharmacology. The study of the use of
medications in treating mental disorders
• Psychotropic drugs. These medications directly affect the
CNS and affect behavior, perceptions, thinking and
behavior
• Side effects. Unwanted or unexpected reactions to a drug.
Mostly foreseen by the physician and the patient is told to
be aware of the effects that could happen while on the
therapy
• Tobacco products. Include cigarettes, cigars, pipes,
hookah, smokeless tobacco, and others. Tolerance. The
need to increase amount of a substance to obtain the
desired effect
• Western medicine. A term used to describe the treatment
of medical conditions with medications, by doctors, nurses
and other conventional healthcare providers who employ
methods developed according to Western medical and
scientific traditions.
Psychopharmacology
- The study of the use of medications in treating mental
disorders
- Psychotropic drugs are the drug’s use in treating mental
disorders, which directly affect the CNS and affect
behavior, perceptions, thinking and behavior.
- The classes (types) of psychotropic medications are:
1) Antipsychotics.
2) Antidepressants.
3) Mood stabilizers.
4) Antianxiety agents
5) Anticholinergic drugs
- Pharmacokinetics
J.A.K.E 55 of 62
• Derived from the Greek word Pharmacon’ means ‘Drug’
and ‘Kinesis’ means ‘
• What the body does to thedrug
- Pharmacodynamics
• Derived from the Greek word Pharmacon ’ means ‘Drug’
and Dynamis ’ means ‘
• What the drug do to the body
Definition of terms
• Efficacy. The maximal therapeutic effect drug can achieve.
• Half Life – how long the medication stays in the body.
• Potency. The amount of drug needed to achieve its
maximum effect.
• Drug-to-drug interactions – how medications affect one
another.
• Off-Label use. The use of drugs other than what is
originally intended to.
• Target symptoms. Specific symptoms expected to
improve with treatment.
• Tolerance – the need to increase amount of a substance to
obtain the desired effect
• Rebound. The recurrence of original symptoms resulting to
abrupt discontinuation of the drug
• Withdrawal. The occurrence of new symptoms resulting
from discontinuation of the drug
• Toxicity – Refers to the point at which concentration of the
blood in the bloodstream are high enough to become
harmful or poisonous to the body
• Physical dependence. The repeated use of substance to
avoid physical symptoms of withdrawal
• Psychological dependence. The repeated use of drugs to
give relief from tension and emotional discomfort despite
the (-) effect.
• Common Side Effects – Are adverse drug reactions that
can occur with all medications. Symptoms are unpleasant
yet benign. (Ex: drowsiness, sedation, nausea, vomiting,
weight gain, etc)
• Adverse Side Effects – Are those that could potentially
cause damage over the long term, severe enough to make
the patient stop taking the medication. (Ex: kidney failure,
liver damage, an increase in blood pressure or cholesterol,
etc.)
• Black box warning. Gives information that the drug has
serious or life-threatening side effect
Major Categories of Psychotropic Drugs
1) Antipsychotic drugs
2) Antidepressants
3) Antimanic or mood stabilizing agents
4) Antianxiety
5) Antiepileptic
Nurses should understand the following before administering
medications:
1) Categories of drugs
2) Mechanism of actions
3) Indications and drug rationale
4) Contraindications
5) Side effects
6) Nurse responsibilities
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

7) Health teaching - Avolition

- Apathy
Neurons - Affective disturbance
• Neurons (Nerve Cells) Are electrically excitable cell that - Anergia
communicates with other cells through a synapse - Asocial anhedonia
• Neurotransmission – the process of transmitting electrical • Weak blocker of D2 receptor
impulses from one neuron to another through a chemical • Lower incidents of EPS
signals. Example of Typical Antipsychotic drugs
• Neurotransmitters – are chemical messengers in the body. 1) Phenothiazine’s (ToP MaSS)
They transmit signals from nerve cells to target cells. T- Thorazine (Chlorpromazine)
o Adrenaline - fight flight - Trilafon (Perphenazine)
o Epinephrine- fight flight P- Prolixin (Fluphenazine)
o Noradrenaline -concentration M- Mellaril (Thioridazine)
o Norepinephrine -concentration S.- Serentil (Mesoridazine)
o Dopamine -pleasure S- Stelazine (Trifluphenazine)
o Serotonin -mood 2) Thioxantene
o GABA (gamma amino butyric acid) -calming Navane (Thiothixine)
o Acetylcholine -learning 3) Butyrophenones
o Glutamate -memory H - Haldol (Haloperidol)
o Endorphins -euphoria I - Inapsine (Droperidol)
Neurotransmitters have different types of action: 4) Dibenzazepine
• Excitatory – neurotransmitters encourage a target cell to Loxitane (Loxapine)
take action. Ex: Dopamine, norepinephrine 5) Dihydroindolne
• Inhibitory – neurotransmitters decrease the chances of the Moban (Molindone)
target cell taking action. In some cases, these Examples of Atypical Antipsychoic Drugs (Car of SuZy and
neurotransmitters have a relaxation like effect. Ex: Geo)
Serotonin, GABA C - Clozaril (Clozapine)
• Modulatory – neurotransmitters can send messages to R - Risperdal (Risperidone)
many neurons at the same time. They also communicate S - Seroquel (Quetiapine)
with other neurotransmitters. Ex: Histamine, Z - Zyprexa (Olanzapine)
neuropeptides G - Geodon (Ziprasidone)
Dopamine System Stabilizer (DSS)
Antipsychotic Drugs 1) Aripiprazole (Abilify)
- Also called neuroleptics or major tranquilizers - Atypical antipsychotic
- Indications: - Use to stabilize dopamine output
• Schizophrenia - Approved by the FDA in November 2002
• Psychotic episode of mania 1) Paliperidone ( Invega)
• Psychotic depression - Atypical antipsychotic
- Approved by the FDA in September 2007
• Drug induced psychosis
Side Effects of Antipsychotic Drugs
• Dementia with psychotic symptoms
Extrapyramidal Side Effects
- Mechanism of action: Blocks dopamine receptors in the
1) Akinesia – The word originates from the Greek word
post synaptic membrane thus reduce dopamine activity
‘kinesis’ which means movement of the body. The prefix ‘A’
Antipsychotics are divided into two groups
stands for absence.
1) Typical (or first generation) antipsychotics were first
a) Akinesia or Pseudoparkinsonism
developed in 1950
- Motor retardation - Salivation
• Conventional/ traditional drug
- Decreased arm swing - Tremors
• Tx positive Sx of Schizophrenia - Shuffling festinating ga - Bradycardia
- Delusions
- Mask-like face
- Hallucinations
- Drug of Choice: Amantadine (Symmetryl) 100mg BID
- Disorganized thinking and behavior
(Anticholinergic/Dopamine agonist)
• Potent blocker of D2 receptor b) Akathisia
• Produces many extrapyramidal syndrome (EPS) - Motor restlessness - Pacing
• Higher incidence of tardive dyskinesia - Inability to sit still - hand tremors
2) Atypical (or second generation) antipsychotics, were - Rigid posture and gait
first developed in 1994 - Types of Akathisia:
• New generations of neuroleptic drug • Acute akathisia shows up soon after you start a
• Treat positive & negative symptoms of Schizophrenia medication. It lasts for less than 6 months.
- Alogia

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• Chronic akathisia lasts for 6 months or more. 1) Anticholinergic side effects:

• Tardive akathisia may not show up until months or • Dry mouth
years after you take a medicine. • Urinary retention
• Withdrawal akathisia usually sets in within 6 weeks • Constipation
after you switch or stop an antipsychotic drug. • Blurred vision
c) Acute Dystonia - Nursing responsibilities:
- Torticollis - twisted head and neck • Offer sugarless candies or ice chips
- Opisthotonus - rigidity at the back of the neck, arched • Measure I and O, assess for bladder distention,
neck sensation of bladder fullness
- Oculogyric crisis - eyes rolled upward in a locked • Increase fluid, fiber foods and exercise
position • Provide well-lighted environment
- Dystonia is most likely to occur: 2) Endocrine side effects:
• first week of treatment • Gynecomastia
• in clients younger than 40 year old • Sexual dysfunction
• in males • Amenorrhea
• those receiving high potency antipsychotic drug • Increased Risk for breast cancer
• Severe cases of Dystonia: Laryngospasm, - Nursing responsibilities:
Respiratory distress • Breast examination
• Treatment: • Encourage client to discuss effect on body image
1) Cogentin Mesylate (Benztropine) 1-2mg IM • Report any changes on sexual desire or functioning
(Anticholinergic) 3) Cardiovascular adverse effects
2) Benadryl (Diphenhydramine) 25-50mg IM • Tachycardia, Arrhythmias, Dysrhythmias –
(Antihistamine) Dangerous and life threatening side effects
d) Tardive Dyskinesia S – Serentil (Mesoridazine)
- Eye blinking - Tongue protruding I – Inapsine (Droperidol)
- Lip smacking - Cheek puffing M – Mellaril (Thioridazine)
- Teeth grinding - Body rocking
• Orthostatic hypotension
- Tics and spasm
- Nursing responsibilities:
- It is involuntary, repetitive body movements of the face,
• Assess radial and apical pulse
lips, tongue, trunk, and extremities that occur in patient
• Report feeling of lightheadedness and dizziness
treated with antipsychotics.
- Prevention of TARDIVE DYSKINESIA • Take a baseline blood pressure
• Monitor blood pressure in different position
• Maintain dosage as low as possible
• Instruct patient to change position gradually
• Changing medications as necessary
4) Central Nervous System Effects:
• Monitor client periodically for initial signs of TD using
• Headache
the Abnormal Involuntary Movement Scale (AIMS)
- Treatment of TARDIVE DYSKINESIA • Dizziness/Sedation
• Reevaluating and adjusting the medications • Decreased mental alertness
- Nursing responsibilities
• Medications
o Clonazepam Klonopin • Headache may be temporary until client will be
o Valbenazine Ingrezza accustomed to medications
o Levodopa • May take medication at bedtime as advised by
Prevention and Management of EPS physician
1) Preventive Interventions • Caution client on activities that needs mental
• Select prescribing of apms , alertness
• Close monitoring of uncharacteristic 5) Dermatologic Effect:
• movements through the use of • Photosensitivity
• screening instruments, • Dermatitis
- Nursing responsibilities
• Prompt management of symptoms,
• Avoid exposure to sunlight to prevent skin burning
• Thorough client education.
2) Management Strategies • Offer sunscreen lotion before exposure to sunlight
• Giving diphenhydramine for acute dystonia; • Supervise personal hygiene to prevent skin
infections
• Stopping or reducing the dose of antipsychotic;
• Wear clothing to cover their skin when out in the sun
• Switching to a second generation;
• Using a lower risk second generation antipsychotic
Serious side effects
such as quetiapine.
1) Agranulocytosis
Other side effects
- SX:

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• Fever 1) Tricyclic Antidepressant drugs (TCA): SAVE mr. TAN (2 – 6

• Sore throat weeks)
• Sore mouth S - Sinequan (Doxepin)
• Body malaise A - Anafranil (Clomiframin)
• WBC level < 2,000 V - Vivactil (Protriptylline)
- TX: E - Elavil (Amitriptylline)
• Monitor results of WBC T - Tofranil (Imipramine)
• Notify physician A - Ascendin (Amoxapine)
N - Norpramin (Desipramine)
• Withhold further medication
- TCA Overdose Symptoms
• Reverse isolation – Protects the patient from the
• Sedation
other people, usually because they have a
weakened immune system and can't fight against • Ataxia
the bacteria and other infections that live on and • Convulsion
around us all the time. • Agitation
2) Hepatotoxicity • Respiratory depression
- SX: • Stupor
• Fever • Coma
• Nausea - Treatment for TCA Overdose
• Jaundice • Monitor vital signs and ECG tracing
• abdominal pain • Maintain patent airway
• abnormal liver function test (elevated enzymes) • Cathartics or gastric lavage
- TX: • Medications that has cholinergic stimulants such as
• Monitor results of liver function test Antilirium (Physostigmine)
• Notify physician 2) Selective Serotonin Reuptake Inhibitor (SSRIs)
• Withhold any further medication - The most commonly prescribed antidepressants coz
• Ensure adequate rest, nutrition and fluids they are highly effective and generally cause fewer side
3) Neuroleptic Malignant Syndrome effects than the other antidepressants.
D - Diaphoresis - SSRIs help to alleviate symptoms of depression by
C - Change in mental alertness (stupor – coma) blocking the reabsorption or reuptake of serotonin in
H - Hyperthermia (102-105F) the brain.
- Hypertension/Hypotension (BP lability) - Therapeutic effect may occur 2 – 3 weeks
A - Agitation, Tachycardia (> 130 bpm) P - Prozac (Fluoxetine)
Tachypnea (> 25 rpm) P - Paxil (Paroxetine)
M - Muscle-rigidity (arm/abdomen like a board) Z - Zoloft (Sertraline)
P - Pallor L - Luvox (Fluvoxamine)
- Treatment for Neuroleptic Malgnant sysndrome 3) Monoamine Oxidase Inhibitor
- Inhibits the activity of monoamine oxidase, thus
• Pharmacology:
preventing the breakdown of monoamine
o Dopamine receptor agonist > Parlodel
neurotransmitters and thereby increasing their
(Bromocriptin)
availability.
o Beta blocker >L-dopa (Levodopa)
- Monoamine Oxidase – An enzyme that breaks down
o Benzodiazepam >Ativan (Lorazepam)
neurotransmitters serotonin, norepinephrine and
• Withhold medication and notify physician
dopamine.
• Admit client to ICU
- Therapeutic effect may occur 2 – 4 weeks
• Administer IV fluids and anti-arrythmia, maintain
M - Marplan (Isocarboxazid)
stable body temperature
N - Nardil (Phenelzine)
P - Parnate (Tranylcypromine)
Antidepressant drugs
S Selegiline (EMSAN
- Indicated to clients with major depressive disorder, bipolar
What to avoid?
type II, depression secondary to other mental disorders
- Instruct patient taking monoamine oxidase inhibitor to void
such as those seen in OCD, panic attacks, phobia, etc
foods rich in tyramine content to avoid hypertensive crisis
- Use across the lifespan:
- Foods rich in tyramine contents
1) Prescribed for adults and elderly
• Aged cheese: cheddar cheese, Swiss cheese, Bleu
2) Used for children and adolescence
cheese
3) Not recommended during pregnancy and lactation
• Aged or fermented meats, fish or poultry
- Blocks the reuptake of serotonin and norepinephrine into
the pre-synaptic membrane • Smoked/pickled meat, fish or poultry: salmon
Classification of Antidepressant Drugs • Chicken and beef liver pate
• Brewer’s yeast

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• Red wines: Chianti, burgundy • Weight gain

• Herring: Sausage, beef, salami, pepperoni • Polyuria
Contraindication of Antidepressant Drugs: • Metallic taste
1) Cardiovascular disease • Tremors
2) Benign prostatic hypertrophy - Serious Side Effects:
3) Glaucoma • Thyroid impairment. Thyroid function studies are
4) Liver and renal diseases monitored every 3-6 months for clients on long-term
Common Side effects of Antidepressant Drugs: lithium therapy.
1) Anticholinergic effects • Renal impairment
2) Cardiovascular effects - Toxic Side Effects (MaN s SAVeD)
3) Photosensitivity M - Muscle weakness
4) GIT effect (anorexia and nausea) N - Nausea
5) CNS effect (sedation and fatigue) S - Slurred speech
Serious Side effects of Antidepressant drugs: A - Agitation, Ataxia
1) Agranulocytosis V - Vomiting
2) Seizures D - Diarrhea, Drowsiness
3) Serotonin Syndrome - Severe Toxic Effects (CASHieR)
D - Diaphoresis C - Coma
C - Change in mental status (confusion, restlessness, A - Altered level of consciousness, Arrhythmia
agitation) S - Seizure, Stupor, spasticity of muscle
H - Hypertension, rigor H - Hypotension
A - Acidosis, respiratory failure R - Renal failure
M - Myoclonus (muscle twitching), tremors Nursing responsibilities
Treatment for Serotonin Syndrome 1) Check Lithium level in the blood every 2-3 days during the
1) Pharmacology (Serotonin receptor antagonist) first month of therapy, then weekly and monthly or less
• Sansert (Methysergide) when stable.
• Periactin (Cyproheptadine) • Toxicity is closely related to serum lithium levels and
2) Stop medication and notify physician can occur at therapeutic level
3) Admit client to ICU • Therapeutic level – 0.6 – 1.2 mEq/L
4) Administer IV fluid and antiarrythmic drug, hyperthermic 2) Thyroid function test done as baseline and every 6 months
measures, during treatment of lithium
• Use of lithium may alter thyroid functions usually 6 18
Antimanic Drugs/ Mood Stabilizing Agents months of treatment
- LITHIUM: most established mood stabilizer • Increase level of thyroid stimulating hormone – anxiety,
- Mechanism of action: labile emotions, sleeping difficulties
• Normalizes the reuptake of serotonin, NE, dopamine • Decrease level of thyroid stimulating hormone – fatigue
and acethylcholine. & depression
• Stabilize client moods, preventing or minimizing the 3) Assess symptoms of hypothyroidism
highs and lows of bipolar disorders. • Dry skin
- Other drugs used as mood stabilizers: • Hair loss
• Carbamazepine ( Tegretol ), • Bradycardia
• Valproic acid (Depakote), • Cold intolerance
• Gabapentin (Neurotin), • Constipation
• Topiramate (Topamax) 4) Assess symptoms of hypoparathyroidism
- Indications: • Muscle aches & cramps
• Manic cycle of bipolar disorder • Tingling sensation
• Prevention of recurrent episodes of mania & depression • Fatigue/weakness
• Schizo-affective disorders • Twitching or spasm of muscles
• Episodes of acute hyperactivity associated with other 5) Increase parathyroid hormone increases calcium level that
mental disorder. may cause mood changes, anxiety, lethargy and sleep
- Contraindications: disturbance
• Hypersensitivity response to lithium 6) Lithium should not be given to pregnant women
• Renal disease Treatment of Lithium toxicity:
• Thyroid disease • Withhold any further doses.
• Obtain immediate serum lithium level
- Common Side Effects: • Monitor vital signs, electrolyte levels, BUN & creatinine
• GIT effect (nausea, anorexia, diarrhea) • Hemodialysis is indicated for severe toxicity
• Fatigue and lethargy

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Prevention of Lithium Toxicity •OCD

• Maintain adequate H2O intake •Post-traumatic disorders
• Maintain adequate sodium intake 2g/day •Alcohol withdrawal
• Cautious use in clients with diarrhea, polyuria, vomiting, •Depression
profuse sweating, and low salt diet as it may increase Classification of Antianxiety Drugs
incident of lithium toxicity 1) Non-benzodiazepines
• Drink fluids with necessary electrolytes when exercising - acts a partial agonist at serotonin receptors which
• Report symptoms indicating toxicity should they occur. decreases serotonin turnover
• Maintain appointments to monitor blood levels as - Example:
prescribed. • BusPar (Buspirone)
• Restrict caffeine intake • Ambien (Zolpidem)
Other Mood Stabilizing Agents - Side effects (SHiNeD)
DIVALPROEX, VALPROIC ACID OR VALPROATE S – Sedation
- The differing names for this anticonvulsant medication H - Headache
reflect the various ways it is formulated. N - Nausea
- Divalproex (and its various forms) is used for acute manic D - Dizziness
episodes. Brand names include Depakene and Epival 2) Benzodiazepines
- Common side effects of divalproex include drowsiness, - mediate the actions of GABA (gamma amino butyric
dizziness, nausea and blurred vision. acid)
- Less common side effects are vomiting or mild cramps, - Example: (D LAST VIVE of Kim, Hannah, & ReX)
muscle tremor, mild hair loss, weight gain, bruising or D – Dalmane (Flurazepam)
bleeding, liver problems and, for women, changes in the L – Librium (Chlordiazepoxide)
menstrual cycle. A –Ativan (Lorazepam)
CARBAMAZEPINE (TEGRETOL) S – Serax (Oxazepam)
- Carbamazepine ( Tegretol ) is another anticonvulsant. It is T – Tranxene (Chlorazepate)
used for mania and mixed states that do not respond to V – Valium (Diazepam)
lithium or when the person is irritable or aggressive. I – Inderal (Propanolol)
- Common side effects of carbamazepine include dizziness, V – Vistaril (Hyroxyzine)
drowsiness, blurred vision, confusion, muscle tremor, E – Equanil (Propanolol)
nausea, vomiting or mild cramps, increased sensitivity to K – Klonopin (Clonazepam)
sun, skin sensitivity and rashes, and poor co ordination H – Halcion (Triazolam)
- A rare but dangerous side effect of carbamazepine is R – Restoril (Temazepam)
reduced blood cell counts. X – Xanax (Akprazolam)
- People who take this drug should have their blood - Side Effects of Benzodiazepines
monitored regularly for this effect. Soreness of the mouth, D – Drowsiness
gums or throat, mouth ulcers or sores, and fever or flu like I – Impaired memory
symptoms can be a sign of this effect and should be P – Poor motor coordination
reported immediately to your doctor. S – Sedation
- If carbamazepine is the cause of these symptoms, they will - Remember the 5 D’s in the administration of antianxiety
go away when the medication is stopped. drugs
LAMOTRIGINE D – Dependence
- Lamotrigine Lamictal ) may be the most effective mood D – Driving and other hazardous activities should be
stabilizer for depression in bipolar disorder, but is not as avoided
helpful for mania. D – Drowsiness and sedation decreases with time
- The starting dose of lamotrigine should be very low and D – Don’t stop benzodiazepine abruptly
increased very slowly over four weeks or more. This D – Don’t drink alcohol beverages with antianxiety
approach decreases the risk of a severe rash a potentially drugs.
dangerous side effect of this drug
- Common side effects of lamotrigine include fever, Tobacco control and basic interventions
dizziness, drowsiness, blurred vision, nausea, vomiting or - Tobacco products include cigarettes, cigars, pipes, hookah,
mild cramps, headache and skin rash. smokeless tobacco, and others.
- Although it is rare, a severe skin rash can occur with - Programs combine and integrate multiple evidence-based
lamotrigine. Any rashes that begin in the first few weeks of strategies, including educational, regulatory, economic,
treatment should be reported to the doctor. and social strategies at local, state, or national levels.
- Evidence-based interventions that are key components of a
Antianxiety Drugs comprehensive tobacco prevention and control effort
- Indication include:
• Anxiety/ anxiety disorders

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1) Mass-reach health communications campaigns that
use multiple-media formats;
• include hard-hitting or graphic images; are intended
to change knowledge, beliefs, attitudes, and
behaviors affecting tobacco use
• RA. 10643: An act to effectively instill health
consciousness through graphic health warnings on
tobacco products,
• Provide tobacco users with information on
resources on how to quit.
2) Increases in the unit price for tobacco products, which
will decrease the number of people using tobacco,
reduce the amount of tobacco consumed, and prevent
young people from starting to use tobacco, prohibiting
the sale of tobacco products to minors.
• Republic Act 9211 (Tobacco Regulation Act of 2003)
on June 23, 2003 as the first comprehensive national
legislation on tobacco control.
3) Comprehensive smoke-free policies that prohibit
smoking in all indoor areas of workplaces and public
places, including restaurants and bars, to prevent
involuntary exposure to secondhand smoke.
Epidemiology
- The World Health Organization (WHO) estimates that about
4 million people die every year of tobacco related diseases.
If current global trends continue, it is estimated that
tobacco will kill more than eight million people annually by
2030, and three quarters of these deaths will be in low and
middle income countries.
Complementary and Alternative Therapy
- Complementary therapy – uses complementary medicine,
in conjunction with common Western medicine.
- Alternative Therapy – uses alternative medicine in place
of common Western medicine. Western medicine is a term
used to describe the treatment of medical conditions with
medications, by doctors, nurses and other conventional
healthcare providers who employ methods developed
according to Western medical and scientific traditions.
- According to Baxter, there are eight most commonly used
CAM therapies in health care:
• acupuncture,
• aromatherapy,
• hypnosis,
• massage therapy,
• meditation,
• Tai Chi,
• therapeutic touch,
• Vitamins/herbal supplements.
- Western medicine is a term used to describe the treatment
of medical conditions with medications by doctors, nurses
and other conventional healthcare providers who employ
methods developed according to Western medical and
scientific traditions
- Non Western alternative medicine includes the
approaches and techniques of healers working outside
traditional Western medicine, and include ancient healing
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traditions, mind body interventions, herbs, diet and
nutrition, acupuncture and manual healing
Study on CAM
- There are 82 psychiatric inpatients hospitalized for acute
care were interviewed about their use of complementary
and alternative medicine (CAM) modalities.
- The clinical diagnoses of respondents included Depressive
Disorder (61%), Substance Abuse (26%), Schizophrenia
(9%), and Anxiety Disorders (5%). Analysis indicated that
63% used at least one CAM modality within the previous 12
months.
- The most frequently used modality was herbal therapies
(44%), followed by mind-body therapies such as relaxation
or mental imagery, hypnosis, meditation, biofeedback
(30%), and spiritual healing by another (30%). Physical
modalities such as massage, chiropractic treatment,
acupuncture, and yoga were used by 21% of respondents.
- CAM therapies were used for a variety of reasons ranging
from treatment of anxiety and depression to weight loss.
However, most respondents indicated they did not discuss
such use with their psychiatrist or psychotherapist.
CAM therapies
1) Mind body therapies
- These combine mental focus, breathing, and body
movements to help relax the body and mind.
- Meditation: Focused breathing or repetition of words or
phrases to quiet the mind.
- Biofeedback: Using simple machines, the patient learns
how to affect certain body functions that are normally
out of one's awareness (such as heart rate
- Hypnosis: A state of relaxed and focused attention in
which a person concentrates on a certain feeling, idea,
or suggestion to aid in healing.
- Yoga: Systems of stretches and poses, with special
attention given to breathing.
- Tai Chi: Involves slow, gentle movements with a focus
on the breath and concentration.
- Imagery: Imagining scenes, pictures, or experiences to
help the body heal.
- Creative outlets: Interests such as art, music, or dance.
2) Biologically based practices
- This type of CAM uses things found in nature.
- Vitamins and dietary supplements
- Botanicals uses plants or parts of plants. Ex: cannabis
- Herbs and spices such as turmeric or cinnamon.
- Special foods or diets
3) Manipulative and body based
- Manipulative and body based therapies – therapies
which involve direct contact between the professional
and the patient . Wherein the patient's body is moved,
adjusted, or manipulated in a certain way that intends
to heal, or relieve pain.
- Massage: The soft tissues of the body are kneaded,
rubbed, tapped, and stroked.
- Chiropractic therapy: A type of manipulation of the
spine, joints, and skeletal system.
- Reflexology: Using pressure points in the hands or feet
to affect other parts of the body.
4) Biofield therapy
 PSYCHIATRIC NURSING LECTURE: BSN 3RD YEAR 2ND SEMESTER PRELIM 2023

-Biofield therapy, sometimes called energy medicine,
involves the belief that the body has energy fields that
can be used for healing and wellness. Therapists use
pressure or move the body by placing their hands in or
through these fields.
- Reiki: Balancing energy either from a distance or by
placing hands on or near the patient
- Therapeutic touch: Moving hands over energy fields of
the body
5) Whole Medical system
- These are healing systems and beliefs that have evolved
over time in different cultures and parts of the world.
- Ayurvedic medicine: A system from India in which the
goal is to cleanse the body and restore balance to the
body, mind, and spirit.
- Traditional Chinese medicine: Based on the belief that
health is a balance in the body of two forces called yin
and yang.
- Acupuncture is a common practice in Chinese
medicine that involves stimulating certain points on the
body to promote health, or to lessen disease symptoms
and treatment side effects
- Homeopathy: Uses very small doses of substances to
trigger the body to heal itself.
- Naturopathic medicine: Uses various methods that help
the body naturally heal itself (ex: herbal treatments).
6) Nutrition and Dietary Therapy
this lower incidence rate has proven to be a direct result
of omega-3 fatty acid intake.
- One to two grams of omega-3 fatty acids taken daily is
the generally accepted dose for healthy individuals, but
for patients with mental disorders, up to 9.6 g has been
shown to be safe and efficacious.
- Western diets are usually also lacking in fruits and
vegetables, which further contributes to vitamin and
mineral deficiencies (Lakhan & Vieira, 2008)
- Omega 3 fatty acids, also known as fish oil, may help
address mood concerns and depression. Some also
believe fish oil helps enhance the effectiveness of
antidepressants
- Research has shown that young adults who begin taking
omega 3 fatty acids after experiencing their first
psychotic episode may be less likely to develop a more
serious condition.
- Folate, otherwise known as folic acid and vitamin B9,
may also be used to supplement traditional mental
health treatment for people with depression and
schizophrenia.
- One specific form of folate, I-methylfolate , has been
approved for this use by the FDA.
GO FUTURE NURSES!! U CAN DO THISSS!!

Nutrition and Dietary Therapy

- Mental neurological and substance-use disorders
presently represent the greatest global burden of disease.
- Likewise, depression and other psychopathologies are
elevated risk comorbidities of other health hazards, such
as obesity.
- Nutrition has been implicated in behavior, mood and in the
pathology and treatment of mental illness. (Owen & Corfe,
2017)
Study on Nutrition and Dietary Therapy
1) Diet and nutrition are not only critical for human physiology
and body composition, but also have significant effects on
mood and mental wellbeing. While the determining factors
of mental health are complex, increasing evidence
indicates a strong association between a poor diet and the
exacerbation of mood disorders, including anxiety and
depression, as well as other neuropsychiatric conditions.
- There are common beliefs about the health effects of
certain foods that are not supported by solid evidence
and the scientific evidence demonstrating the
unequivocal link between nutrition and mental health is
only beginning to emerge (Adan, et al., 2016).
2) Research has shown that nutritional deficiencies correlate
with some mental disorders.
- The most common nutritional deficiencies seen in
mental disorder patients are of omega-3 fatty acids, B
vitamins, minerals, and amino acids that are precursors
to neurotransmitters.
- Compelling population studies link high fish
consumption to a low incidence of mental disorders;

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