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EBOOK Varcarolis Foundations of Psychiatric Mental Health Nursing A Clinical Ebook PDF Version Download Full Chapter PDF Kindle
EBOOK Varcarolis Foundations of Psychiatric Mental Health Nursing A Clinical Ebook PDF Version Download Full Chapter PDF Kindle
My ancestors were storytellers. Boxes of diaries, articles, news- my life goals, the profession, countless students, and recipients
paper clippings, and books in an unused closet detail many of of psychiatric mental health care. I wish for her all the best as
their moves and thoughts. The family tree includes a newspaper she enjoys retirement with her husband, Paul.
editor, a historian, a poet, and a nonfiction writer. One great My heartfelt appreciation also goes out to the talented group
aunt, Ella Chalfant, published a book titled A Goodly Heritage of writers who contributed to the seventh edition. This was an
in 1955 and was likely an early feminist. Her book centered on especially challenging version since the publication year was
inheritance laws in the 1800s and featured copies of wills that the same as for the Diagnostic and Statistical Manual’s fifth
demonstrated the disenfranchisement of women (e.g., a hus- edition. Clinical chapters were rearranged, and content was
band needed to leave a wife’s clothing to her on his death). As a added and deleted. My particular thanks go to those contribu-
registered nurse, I did have the opportunity to write some sto- tors who created new chapters and incorporated new content.
ries (in the form of nurses notes); as a tenure-track faculty I have a talented pool of veteran writers, and their knowl-
member, I was required to write some stories (in the form of edge and passion continue to influence psychiatric nursing
presentations and publications). in this edition. I have also welcomed a new cohort of writers
A 2004 phone call finally put me on the path to more fully whose expertise was both recognized and sought. It has truly
join these relatives in their vocation. I was in my office when been a joy working with each of you. Thanks for the countless
the phone rang. A pleasant voice with a slight New York accent hours you spent researching, writing, and rewriting!
says, “Peggy? Hi, this is Betsy Varcarolis.” I knew the name at A huge debt of gratitude goes to the many educators and
once. She went on, “The reason I’m calling is that I very much clinicians who reviewed the manuscript and offered valuable
enjoyed your article, “Stigma and help seeking related to suggestions, ideas, opinions, and criticisms. All comments were
depression: A study of nursing students.” I would like to feature appreciated and helped refine and strengthen the individual
it as an Evidence-Based Practice box in the fifth edition of my chapters.
book.” I was thrilled—what an honor! Throughout this project, a number of people at Elsevier
This was the beginning. After that call, my work progressed provided superb support. Sincere thanks go to Clay Broeker,
from chapter reviewer to chapter writer to textbook editor. I my gracious project manager, and to Karen Pauls, a talented
accomplished these milestones as an apprentice of Elizabeth and creative designer. Special gratitude goes to the team who
Varcarolis, the genius who conceived and published the first got this project off the ground and kept it airborne for nearly
edition of Foundations of Psychiatric Mental Health Nursing in 2 years. Yvonne Alexopoulos, senior content strategist, kept
1990 and went on to make this textbook a leader in the specialty me on a straight path; Lisa Newton, senior content develop-
of psychiatric nursing. Betsy has the rare gift of making the ment specialist, was my ever-optimistic team member who
complex understandable and of making impersonal learning a celebrated each milestone; and Kit Blanke (Mr. Kit Blanke),
joint process in which the experts talk with the students rather content coordinator, helped keep me organized and up to
than just providing information. speed on technological advances. My sincere thanks go out to
In this seventh edition of the book, Elizabeth Varcarolis is the whole Elsevier team.
honored with her name being added to the title. My sincere
thanks and gratitude go out to Betsy for what she has done for Peggy Halter
vii
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CONTRIBUTORS
Lois Angelo, APRN, BC Jodie Flynn, MSN, RN, SANE-A, SANE-P, Diane K. Kjervik, JD, RN, FAAN
Assistant Professor of Nursing D-ABMDI Professor Emeritus
Massachusetts College of Pharmacy Undergraduate Program Coordinator School of Nursing
and Health Sciences Dwight Schar College of Nursing and Health University of North Carolina at Chapel Hill
Boston, Massachusetts Sciences Chapel Hill, North Carolina
Chapter 17: Somatic Symptom Disorders Ashland University Chapter 6: Legal and Ethical Guidelines
Mansfield, Ohio for Safe Practice
Carolyn Baird, DNP, MBA, RN-BC, Chapter 29: Sexual Assault
CARN-AP, ICCDPD Mallie Kozy, PhD, PMHCNS-BC
Co-Occurring Disorders Therapist Kimberly Gregg, PhD(c), MS, Associate Professor, Chair
Counseling and Trauma Services PMHCNS-BC Undergraduate Nursing Studies, College of
Canonsburg, Pennsylvania Psychiatric Mental Health Clinical Nurse Nursing
Chapter 22: Substance-Related and Addictive Specialist Lourdes University
Disorders Hennepin County Medical Center Sylvania, Ohio
Minneapolis, Minnesota Chapter 14: Depressive Disorders
Leslie A. Briscoe, PMHNP-BC Clinical Assistant Professor, University of
Psychiatric Nurse Practitioner North Dakota Jerika T. Lam, PharmD, AAHIVE
U.S. Department of Veterans Affairs Grand Forks, North Dakota Assistant Director
Cleveland, Ohio Chapter 5: Cultural Implications for Inpatient Pharmacy Department
Chapter 30: Psychosocial Needs of the Older Psychiatric Mental Health Nursing Kaiser Moreno Valley Hospital
Adult Moreno Valley, California
Faye J. Grund, PhD(c), APRN, Chapter 3: Biological Basis for Understanding
Penny S. Brooke, APRN, MS, JD PMHNP-BC Psychiatric Disorders and Treatments
Professor Emeritus Interim Dean
University of Utah, Dwight Schar College of Nursing and Health Lorann Murphy, MSN, PMHCNS-BC
Salt Lake City, Utah Sciences Clinical Nurse Specialist
Chapter 6: Legal and Ethical Guidelines Ashland University Lutheran Hospital
for Safe Practice Mansfield, Ohio Cleveland, Ohio
Chapter 25: Suicide and Non-Suicidal Chapter 27: Anger, Aggression, and Violence
Claudia A. Cihlar, PhD, PMHCNS-BC Self-Injury
Coordinator of Behavioral Health Services Cindy Parsons, DNP, ARNP, PMHNP-BC,
Center for Psychiatry Mary A. Gutierrez, PharmD, BCPP FAANP
Akron General Medical Center Professor of Clinical Pharmacy and Associate Professor of Nursing
Akron, Ohio Psychiatry University of Tampa
Chapter 24: Personality Disorders Department of Pharmacotherapy and Tampa, Florida
Outcomes Science Chapter 11: Childhood and Neurodevelopmental
Alison M. Colbert, PhD, APRN, BC Loma Linda University School of Pharmacy Disorders
Assistant Professor Loma Linda, California
Duquesne University Chapter 3: Biological Basis for Understanding Donna Rolin-Kenny, PhD, APRN,
Pittsburgh, Pennsylvania Psychiatric Disorders and Treatments PMHCNS-BC
Chapter 32: Forensic Psychiatric Nursing Assistant Professor, School of Nursing
Monica J. Halter, APRN, PMHNP-BC University of Texas at Austin
Laura Cox Dzurec, PhD, PMHCNS, BC Psychiatric Nurse Practitioner Austin, Texas
Dean, College of Nursing Psychological and Behavioral Consultants Chapter 33: Therapeutic Groups
Kent State University Cleveland, Ohio
Chapter 34: Family Interventions Chapter 4: Settings for Psychiatric Care Judi Sateren, MS, RN
Chapter 35: Integrative Care Associate Professor Emerita
Edward A. Herzog, RN, BSN, MSN, CNS St. Olaf College
Carissa R. Enright, RN, MSN, PMHNP-BC Lecturer Northfield, Minnesota
Associate Clinical Professor College of Nursing Chapter 28: Child, Older Adult, and Intimate
Texas Woman’s University Kent State University Partner Violence
Psychiatric Consult Liaison Kent, Ohio
Presbyterian Hospital of Dallas Chapter 12: Schizophrenia and Schizophrenia
Dallas, Texas Spectrum Disorders
Chapter 18: Feeding, Eating, and Elimination Chapter 31: Serious Mental Illness
Disorders
ix
x Contributors
Mary Ann Schaepper, MD, MEd Elizabeth M. Varcarolis, RN, MA Patricia Clayburn, MSN, RN
Director of Psychiatry Residency Training Professor Emeritus and former Deputy Professional Instructor
Loma Linda University Medical Center Chairperson Dwight Schar College of Nursing
Associate Professor of Psychiatry Department of Nursing Ashland University
Loma Linda University School of Medicine Borough of Manhattan Community College Ashland, Ohio
Loma Linda, California Associate Fellow Chapter Review Questions
Chapter 3: Biological Basis for Understanding Albert Ellis Institute for Rational Emotional
Psychiatric Disorders and Treatments Behavioral Therapy (REBT) Marie Messier, MSN, RN
New York, New York Associate Professor of Nursing
L. Kathleen Sekula, PhD, APRN, FAAN Chapter 7: The Nursing Process and Standards of Germanna Community College
Associate Professor and Director Care for Psychiatric Mental Health Nursing Locust Grove, Virginia
Forensic Graduate Nursing Programs Chapter 8: Therapeutic Relationships Case Studies/Nursing Care Plans
Duquesne University Chapter 9: Communication and the Clinical
Pittsburgh, Pennsylvania Interview Kathleen Slyh, RN, MSN
Chapter 32: Forensic Psychiatric Nursing Chapter 10: Understanding and Managing Nursing Instructor
Responses to Stress Technical College of the Lowcountry
Jane Stein-Parbury, RN, BSN, MEd, PhD, Chapter 16: Anxiety and Obsessive-Compulsive Beaufort, South Carolina
FRCNA Related Disorders PowerPoint Presentations
Professor of Mental Health Nursing
Faculty of Health, University of Technology Kathleen Wheeler, PhD, APRN-BC, Linda Turchin, RN, MSN, CNE
Director PMHCNS, PMHNP, FAAN Assistant Professor of Nursing
Area Professorial Mental Health Nursing Unit Professor Fairmont State University
South East Sydney Local Health District Fairfield University School of Nursing Fairmont, West Virginia
Sydney, Australia Fairfield, Connecticut Test Bank Reviewer
Chapter 23: Neurocognitive Disorders Chapter 16: Trauma, Stressor-Related, Pre-Tests/Post-Tests
and Dissociative Disorders
Christine Tebaldi, MS, PMHNP-BC Linda Wendling, MS, MFA
Director of Psychiatric Emergency and Rick Zoucha, PhD, APRN-BC, CTN-A Learning Theory Consultant
Consultative Services Associate Professor, School of Nursing University of Missouri—St. Louis
Community Hospital Programs Duquesne University St. Louis, Missouri
McLean Hospital Pittsburgh, Pennsylvania TEACH for Nurses
Belmont, Massachusetts Chapter 5: Cultural Implications
Chapter 4: Settings for Psychiatric Care for Psychiatric Mental Health Nursing
Irma Aguilar, RN, PhD Susan Justice, MSN, RN, CNS Donna Rolin-Kenny, PhD, APRN,
Associate Professor Clinical Instructor PMHCNS-BC,
Tarrant County College District Psychiatric Nursing Lead Faculty Assistant Professor, School of Nursing
Fort Worth, Texas University of Texas College of Nursing University of Texas at Austin
Arlington, Texas Austin, Texas
Claudia Chiesa, PhD, RPh
Staff Pharmacist Marti Rickel, RN, MSN Judge Elinore Marsh Stormer
Catalina Pharmacy Management Services Instructor Summit County Probate Court
Tucson, Arizona North Seattle Community College Akron, Ohio
Seattle, Washington
Phyllis M. Jacobs, RN, MSN Sheila R. Webster, MA, RN, PMHCNS-BC
Assistant Professor Lecturer
Wichita State University Kent State University
Wichita, Kansas Kent, Ohio
xi
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TO THE INSTRUCTOR
The role of the health care provider continues to become more • Screenings and severity ratings are introduced in Chapter 1
challenging as our health care system is compromised by in- and included throughout most clinical chapters
creasing federal cuts, lack of trained personnel, and the dictates • Chapter 19 provides an in-depth look at both normal sleep
of health maintenance organizations (HMOs) and behavioral and also the cross-cutting problem of altered sleep that ac-
health maintenance organizations (BHMOs). We nurses and companies and/or exacerbates psychiatric disorders.
our patients are from increasingly diverse cultural and religious • A separate chapter focuses on impulse control disorders
backgrounds, bringing with us a wide spectrum of beliefs and (Chapter 20).
practices. An in-depth consideration and understanding of cul- • The terms substance abuse with substance dependence have
tural, religious/spiritual, and social practices is paramount in been consolidated into the single problem of substance use
the administration of appropriate and effective nursing care disorder (Chapter 22)
and is emphasized throughout this text. Refer to the To the Student section of this introduction on
We are living in an age of fast-paced research in neurobiol- pages xv-xvi for examples of thoroughly updated familiar fea-
ogy, genetics, and psychopharmacology, as well as research to tures with a fresh perspective, including Evidence-Based Prac-
find the most effective evidence-based approaches for patients tice boxes, Considering Culture boxes, Health Policy boxes, Key
and their families. Legal issues and ethical dilemmas faced by Points to Remember, Assessment Guidelines, and Vignettes,
the health care system are magnified accordingly. Given these among others.
myriad challenges, knowing how best to teach our students and
serve our patients can seem overwhelming. With contributions
from several knowledgeable and experienced nurse educators,
ORGANIZATION OF THE TEXT
our goal is to bring to you the most current and comprehensive Chapters are grouped in units to emphasize the clinical per-
trends and evidence-based practices in psychiatric mental spective and facilitate location of information. The order of the
health nursing. clinical chapters approximates those found in the DSM-5. All
clinical chapters are organized in a clear, logical, and consistent
format with the nursing process as the strong, visible frame-
CONTENT NEW TO THIS EDITION work. The basic outline for clinical chapters is:
The following topics are at the forefront of nursing practice and • Clinical Picture: Identifies disorders that fall under the
psychiatric-mental health care and are considered in detail in umbrella of the general chapter name. This section presents
this seventh edition: an overview of the disorder(s) and includes strong source
• Clinical disorders that are consistent with the DSM-5 are material.
presented along with corresponding nursing care. • Epidemiology: Helps the student to understand the extent of
• New and recombined DSM-5 disorders are presented, in- the problem and characteristics of those who would more
cluding hoarding disorder, disruptive mood dysregulation likely be affected. This section provides information related
disorder, premenstrual dysphoric disorder, binge eating dis- to prevalence, lifetime incidence, age of onset, and gender
order, and autism spectrum disorder. differences.
• Quality and Safety Education for Nurses (QSEN) content— • Comorbidity: Describes the most common conditions that
patient-centered care, teamwork and collaboration, evidence- are associated with the psychiatric disorder. Knowing that
based practice, quality improvement, safety, and informatics— comorbid disorders are often part of the clinical picture of
are integrated naturally in the application of the nursing specific disorders helps students as well as clinicians under-
process. stand how to better assess and treat their patients.
• The social influence of mental health care and the impor- • Etiology: Provides current views of causation along with
tance of legislation are stressed throughout and are high- formerly held theories. It is based on the biopsychosocial
lighted in Health Policy boxes. triad and includes biological, psychological, and environ-
• A complete update has been made on the biological basis mental factors.
for understanding psychiatric disorders and treatments • Assessment:
(Chapter 3). • General Assessment: Appropriate assessment for a spe-
• Settings for psychiatric care are presented along a contin- cific disorder, including assessment tools and rating scales.
uum of acuity and take into account the changing needs of The rating scales included help to highlight important
individuals seeking and/or requiring psychiatric services areas in the assessment of a variety of behaviors or mental
(Chapter 4). conditions. Because many of the answers are subjective in
• Trauma, stressor-related, and dissociative disorders are nature, experienced clinicians use these tools as a guide
given increased attention in a separate chapter to reflect the when planning care, in addition to their knowledge of
increasing recognition of these problems (Chapter 16). their patients.
xiii
xiv To the Instructor
• Self-Assessment: Discusses the nurse’s thoughts and feel- to enhance learning in the classroom or in Web-based course
ings that may need to be addressed to enhance self-growth modules. If you share them with students, they can use the
and provide the best possible and most appropriate care to note feature to help them with your lectures.
the patient. • Audience Response Questions for i.clicker and other
• Assessment Guidelines: Provides a summary of specific systems are provided with two to five multiple-answer ques-
areas to assess by disorder. tions per chapter to stimulate class discussion and assess
• Diagnosis: NANDA International–approved nursing diagno- student understanding of key concepts.
ses are used in all nursing process sections. • The Test Bank has more than 1800 test items, complete with
• Outcomes Identification: NIC classifications for interven- the correct answer, rationale, cognitive level of each ques-
tions and NOC classifications for outcomes are introduced in tion, corresponding step of the nursing process, appropriate
Chapter 8 and used throughout the text when appropriate. NCLEX Client Needs label, and text page reference(s).
• Planning • A DSM-5 Webinar explaining the changes in structure and
• Implementation: Interventions follow the Standards of disorders is available for reference.
Practice and Professional Performance set by Psychiatric-
Mental Health Nursing: Scope and Standards of Practice For Students
(2007), developed collaboratively by the American Nurses Student Resources on Evolve, available at http://evolve.elsevier.
Association, American Psychiatric Nurses Association, com/Varcarolis, provide a wealth of valuable learning resources.
and International Society of Psychiatric–Mental Health The Evolve Resources page near the front of the book gives login
Nurses. These standards are incorporated throughout instructions and a description of each resource.
the chapters and are listed on the inside back cover for • The Answer Key to Chapter Review Questions provides
easy reference. answers and rationales for the Chapter Review questions at
• Evaluation the end of each chapter.
• The Answer Key to Critical Thinking Guidelines provides
possible outcomes for the Critical Thinking questions at the
TEACHING AND LEARNING RESOURCES
end of each chapter.
For Instructors • Case Studies and Nursing Care Plans provide detailed case
Instructor Resources on Evolve, available at http://evolve. studies and care plans for specific psychiatric disorders to
elsevier.com/Varcarolis, provide a wealth of material to help supplement those found in the textbook.
you make your psychiatric nursing instruction a success. In • NCLEX® Review Questions, provided for each chapter, will
addition to all of the Student Resources, the following are help you prepare for course examinations and for your RN
provided for Faculty: licensure examination.
• TEACH for Nurses Lesson Plans, based on textbook chapter • Pre-Tests and Post-Tests provide interactive self-assess-
Learning Objectives, serve as ready-made, modifiable lesson ments for each chapter of the textbook, including instant
plans and a complete roadmap to link all parts of the educa- scoring and feedback at the click of a button.
tional package. These concise and straightforward lesson We are grateful to educators who send suggestions and pro-
plans can be modified or combined to meet your particular vide feedback and hope this seventh edition continues to help
scheduling and teaching needs. students learn and appreciate the scope of psychiatric mental
• PowerPoint Presentations are organized by chapter, with health nursing practice.
approximately 750 slides for in-class lectures. These are de-
tailed and include customizable text and image lecture slides Peggy Halter
TO THE STUDENT
CHAPTER FEATURES
❹ Vignettes describe the unique circumstances surrounding
individual patients with psychiatric disorders.
xv
xvi To The Student
16
profound lack of empathy, also known as callousness. This have found a higher prevalence rate of antisocial personality
callousness results in a lack of concern about the feelings of disorder in African Americans and in persons with co-occurring
others, the absence of remorse or guilt except when facing pun- substance dependence (McGilloway et al, 2010).
ishment, and a disregard for meeting school, family, and other
obligations.
Trauma, Stressor-Related, These individuals tend to exhibit a shallow, unexpressive, and
superficial affect; however, they may also be adept at portraying
VIGNETTE
Richard is a 25-year-old divorced cab driver who is referred to the ❹
hospital by the court for competency evaluation after an assault
and Dissociative Disorders themselves as concerned and caring if these attributes help them
to manipulate and exploit others. A person with antisocial per-
charge. He told the arresting officer that he has bipolar disorder.
He has a history of substance abuse and multiple arrests for
sonality disorder may be able to act witty and charming and be disorderly conduct or assault. During his intake interview, he is
Kathleen Wheeler good at flattery and manipulating the emotions of others. polite and even flirtatious with the female registered nurse. He
insists that he is not responsible for his behavior because he is
manic. The only symptom he describes is irritability. Richard
EPIDEMIOLOGY points out that he cannot tolerate any psychotropic medications
Antisocial personality disorder is the most researched person- because of the side effects. He also notes that he has dropped
ality disorder, probably due to its marked impact on society in out of three clinics after several visits because “the staff don’t
the form of criminal activity. The prevalence of antisocial per- understand me.”
❸ Visit the Evolve website for a pretest on the content in this chapter.
sonality disorder is about 1.1% in community studies (Skodol
et al., 2011). While the disorder is much more common in men
http://evolve.elsevier.com/Varcarolis (3% versus 1%), women may be underdiagnosed due to the APPLICATION OF THE NURSING PROCESS
traditional close association of this disorder with males.
ASSESSMENT
ETIOLOGY People with antisocial personality disorder do not enter the
❷ OBJECTIVES
1. Describe clinical manifestations of each disorder 8. Apply the nursing process to trauma-related disorders in Biological Factors
health care system for treatment of this disorder unless they
have been court-ordered to do so. Psychiatric admissions may
covered under the general umbrella of trauma-related adults. Antisocial personality disorder is genetically linked, and twin be initiated for anxiety and depression. Entering treatment may
and dissociative disorders. 9. Develop a teaching plan for a patient who suffers from studies indicate a predisposition to this disorder. Kendler and also be a way to avoid or address legal, financial, occupational,
2. Describe the symptoms, epidemiology, comorbidity, and posttraumatic stress disorder. colleagues (2012) note that the main two dimensions of genetic or other circumstances. Health care workers also encounter
etiology of trauma-related disorders in children. 10. Identify dissociative disorders, including depersonalization/ risk include the trait of aggressive-disregard (violent tendencies people with this disorder based on the physical consequences of
3. Discuss at least five of the neurobiological changes that oc- derealization disorder, dissociative amnesia, and dissociative without concern for others) and the trait of disinhibition (lack high-risk behaviors, such as acute injury and substance use.
cur with trauma. identity disorder of concern for consequences). Keep in mind that questions asked during the assessment phase
4. Apply the nursing process to the care of children who are 11. Create a nursing care plan incorporating evidence-based An alteration in serotonin transmission has also been impli- may not always result in accurate responses since the patient
experiencing trauma-related disorders. interventions for symptoms of dissociation, including cated with the aggression and impulsivity that frequently ac- may become defensive or simply not tell the truth.
5. Differentiate between the symptoms of posttraumatic flashbacks, amnesia, and impaired self-care. company this disorder. Levels of a metabolite of serotonin,
stress, acute stress, and adjustment disorders in adults.
6. Describe the symptoms, epidemiology, comorbidity, and
12. Role-play intervening with a patient who is experiencing a
flashback.
5-hydroxyindoleacetic acid, can be measured in urine and cere-
brospinal fluid. It has been found to be lower in individuals with
Self-Assessment
You may respond to a person with antisocial personality disor-
❺
etiology of trauma-related disorders in adults. antisocial personality disorder. Lower levels of serotonin along der in a variety of ways. Because these individuals have the
7. Discuss how to deal with common reactions the nurse may
with dopamine hyperfunction may contribute to aggression, capacity to be charming, you may want to defend the person as
experience while working with a patient who has
disinhibition, and comorbid substance abuse (Seo et al., 2008). someone who is being unfairly treated and misunderstood.
suffered trauma.
These feelings should be explored with your faculty or other
Environmental Factors experienced personnel. Conversely, if you are aware that your
❶ KEY TERMS AND CONCEPTS
acute stress disorder dissociative identity disorder
It is likely that a genetic predisposition for characteristics of anti-
social personality disorder such as a lack of empathy may be set
patient has a history of criminal acts, you may feel disdain or
personally threatened. Again, share your concerns with people
adjustment disorder eye movement desensitization and reprocessing into motion by a childhood environment of inconsistent parent- who are experienced in caring for this population. Awareness
alternate personality (alter) flashbacks ing and discipline, significant abuse, and extreme neglect. Chil- and monitoring of one’s own stress responses to patient behav-
debriefing hypervigilance dren reflect parental attitudes and behaviors in the absence of iors facilitate more effective and therapeutic intervention, re-
depersonalization neuroplasticity more prosocial influences. Virtually all individuals who eventually gardless of the specific approach to their care.
derealization posttraumatic stress disorder (PTSD) develop this disorder have a history of impulse control and con-
disinhibited social engagement disorder reactive attachment disorder duct problems as children and adolescents. Chapter 21 describes
dissociation
dissociative amnesia
resilience
trauma-informed care
impulse control and conduct disorders in greater detail. ASSESSMENT GUIDELINES
Antisocial Personality Disorder
❻
dissociative fugue window of tolerance Cultural Factors
Assigning a diagnosis of personality disorder cannot be 1. Assess current life stressors.
entirely separated from the cultural context of both the indi- 2. Assess for suicidal, violent, and/or homicidal thoughts.
3. Assess anxiety, aggression, and anger levels.
vidual and the person diagnosing. Cultural bias, including
304 4. Assess motivation for maintaining control.
race, ethnicity, ageism, religion, and gender expectations may 5. Assess for substance misuse (past and present).
unintentionally enter into the categorization. Some studies
CHAPTER 16 Trauma, Stressor-Related, and Dissociative Disorders 307 CHAPTER 12 Schizophrenia and Schizophrenia Spectrum Disorders 213
❼ EVIDENCE-BASED PRACTICE
Traumatic Stress Responses among Nurses
secure, avoidant, ambivalent, and disorganized attachment styles
(Ainsworth, 1967).
BOX 12-4 GUIDELINES FOR COMMUNICATION WITH PATIENTS EXPERIENCING DELUSIONS
• To build trust, be open, honest, genuine, and reliable. this obliquely can make it less confrontational: “I wonder if that
❽
Buurman, B. M., Mank, A.P.M., Beijer, H.J.M., & Olff, M. (2011). Environmental Factors • Respond to suspicion in a matter-of-fact, empathic, supportive, might be what is happening here, because what seems true to
Coping with serious events at work: A study of traumatic stress To a greater degree than adults, children are dependent on others. and calm manner. you does not seem true to others.”
among nurses. Journal of the American Psychiatric Nurses • Ask the patient to describe his beliefs. Example: “Tell me more • Once the patient has begun to question the delusion and/or
It is this dependency in tandem with the neuroplasticity (mallea-
Association, 17, 321-329. about someone trying to hurt you.” understand the concept of delusions, label subsequent delu-
bility) of the developing brain that can increase vulnerability to
• Avoid debating the delusional content, but interject doubt sions to help the patient recognize them as well.
adverse life experiences. External factors in the environment can where appropriate. Example: “It seems as if it would be hard • Do not dwell excessively on the delusion. Instead, refocus onto
Problem
Nurses frequently encounter traumatic events and experience
either support or put stress on children and adolescents and for a girl that small to hurt you.” reality-based topics. If the patient obsesses about delusions,
chronic stress in the workplace that can lead to PTSD and burnout. shape development. Young persons are vulnerable in an environ- • Validate if part of the delusion is real. Example: “Yes, there was a set limits on the amount of time you will talk about them, and
Events that are traumatic include aggression among themselves ment in which systems (e.g., schools, court systems) and adults man at the nurse’s station, but I did not hear him talk about you.” explain your reason.
as well as witnessing the pain, suffering, and death of others. (e.g., parents, counselors) have power and control. Parents model • Focus on the feelings or theme that underlie or flow from the delu- • Observe for events that trigger delusions. If possible, help the pa-
These serious events involve helplessness, fear, or horror that can behavior and provide the child with a view of the world. If par- sions. Example: “You seem to wish you could be more powerful” tient find ways to avoid such triggers or reduce associated anxiety.
lead to PTSD while chronic interpersonal stressors at work often ents are abusive, rejecting, or overly controlling, the child may or “It must feel frightening to believe others want to hurt you.” • Promote improved reality testing by guiding the patient to
lead to burnout. suffer detrimental effects during the period of development • Once trust has been established, acknowledge that, while the question his beliefs: “I wonder if there might be any other
when the trauma occurs. Most children, however, who suffer a belief seems very real to the patient, illnesses can sometimes explanation why others might be avoiding you? Instead of hating
Purpose of Study make things seem true even though they aren’t. Introducing you, might they simply be busy?”
traumatic and stressful event do develop normally.
The purpose of this study was to describe the nature and number
of serious events nurses encounter and their coping and reactions
Poverty, parental substance abuse, and exposure to violence Data from Farhall, J., Greenwood, K. M., & Jackson, H. J. (2007). Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies
and to investigate which factors were related to traumatic stress have received increasing attention and place minority children and therapeutic interventions. Clinical Psychology Review, 27, 476–493.
after a serious event. at greater risk for trauma and stress. Pervasive and persistent
economic, racial, and ethnic disparities are called the “millen-
Methods nial morbidities” (Shonkoff & Garner, 2012). A review of
Nurses (n 69) at a large university hospital in Amsterdam were
asked to complete two questionnaires, the Utrecht Coping List
and the List of Serious Events and Traumatic Stress in Nursing.
58 studies found that racial and ethnic disparities in children’s
health are worsening (Flores, 2010). Differences in cultural
expectations, presence of stresses, and lack of support by the
BOX 12-5 PATIENT AND FAMILY TEACHING: SCHIZOPHRENIA
Further information can be found in the Substance Abuse and Mental
Health Services Administration (SAMHSA) pamphlet Developing A
5. Have a plan, on paper, of what to do to cope with stressful
times.
❾
Key Findings dominant culture may have profound effects and increase the Recovery And Wellness Lifestyle: A Self-Help Guide, available at 6. Adhere to treatment. People who adhere to treatment that
• 98% of nurses reported traumatic stress with a mean of risk of mental, emotional, and academic problems. Family http://mentalhealth.samhsa.gov/publications/allpubs/SMA-3718 or via works for them are more likely to get better and stay better.
8 serious events experienced in the past 5 years. stability may provide cushioning effects in the face of poverty the Wellness Recovery Action Plan (WRAP) website (M. A. Copeland • Engaging in struggles over adherence does not help, but tying
• Active coping decreased the risk of experiencing traumatic and adversity. Working with children and adolescents from and staff): www.mentalhealthrecovery.com adherence to the patient’s own goals does. (“Staying in treat-
stress while comforting cognition and social support increased diverse backgrounds requires an increased awareness of one’s 1. Learn all you can about the illness. ment will help you keep your job and avoid trouble with the
the likelihood of appraising a serious event as traumatic. own biases and of the patient’s needs. • Attend educational and support groups. police.”)
• Join the National Alliance on Mental Illness (NAMI). • Share concerns about troubling side effects or concerns
The term resilience refers to positive adaptation, or the ability
Implications for Nursing Practice • Read books about mental illness such as Surviving Schizo- (e.g., sexual problems, weight gain, “feeling funny”) with
to maintain or regain mental health despite adversity. Studies have
Many nurses experience traumatic stress. Nurses need additional phrenia: A Manual for Families, Patients, and Providers by your nurse, case manager, doctor, or social worker; most
help particularly after events that threaten their physical integrity.
shown that factors that enhance resilience include the presence of E. Fuller Torrey. side effects can be helped.
More experienced nurses had more reactions after patients’ supportive relationships and attachments as well as the avoidance • Access trusted websites such as the National Institute of • Keeping side effects a secret or stopping medication can
deaths, perhaps because of cumulative trauma. Thus, experienced of frequent and prolonged stress (Herrman et al., 2011). Children Mental Health (www.nimh.nih.gov). prevent you from having the life you want.
nurses are particularly vulnerable for developing PTSD and burnout. brought up in a chaotic or non-nurturing environment suffer 2. Develop a relapse prevention plan. 7. Avoid alcohol and/or drugs; they can act on the brain and cause
Interventions should be initiated consistently after traumatic events, neurological consequences that are long-lasting and difficult to • Know the early warning signs of relapse (e.g., avoiding others, a relapse.
and future research is warranted in order to determine what inter- remediate (Shonkoff & Garner, 2012). Toxic stress and adverse trouble sleeping, troubling thoughts). 8. Keep in touch with supportive people.
ventions are most effective in preventing PTSD and burnout. childhood experiences have been found to result in lifelong con- • Make a list of whom to call, what to do, and where to go if 9. Keep healthy and stay in balance.
sequences for both psychological and physical health (Shonkoff, signs of relapse appear. Keep it with you. • Taking care of one’s diet, health, and hygiene helps prevent
2010). Trauma in early childhood also plays a role in the intergen- • Relapse is part of the illness, not a sign of failure. medical illnesses.
anxious state. This theory provides an explanation of why erational transmission of disparities in health outcomes. The 3. Participate in family, group, and individual therapy. • Maintain a regular sleep pattern.
4. Learn new ways to act and coping skills to help handle family, • Keep active (hobbies, friends, groups, sports, job, special
many people with PTSD also suffer from depression. nurse’s role is to identify and foster qualities to keep at-risk
work, and social stress. Get information from your nurse, case interests).
children from developing emotional problems.
manager, doctor, NAMI, community mental health groups, or a • Nurture yourself, and practice stress-reduction activities daily.
Psychological Factors Attachment at its most basic level ensures survival of the
hospital. Everyone needs a place to talk about fears and losses
Attachment Theory species. Lack of attachment is counter to such a basic drive. and to learn new ways of coping.
A psychological theory that has important implications for Tizard (1977) conducted one of the best-known early studies
trauma-related disorders is that of attachment theory. This theory related to attachment disorder. Children in this study were Data from Beyond symptom control: Moving towards positive patient outcomes. Paper presented at the American Psychiatric Association 55th
Institute on Psychiatric Services, October 29 to November 2, 2003, Boston, MA. Retrieved from www.medscape.com/viewprogram/2835_pnt.
describes the importance and dynamics of the early relationship abandoned by their parents and lived in an institutional set-
Further information can be found in the Substance Abuse and Mental Health Services Administration (SAMHSA) pamphlet Developing a recovery
between the infant and the caretaker based on the early work of ting. They were provided with play areas, books, and basic and wellness lifestyle: A self-help guide, available at http://mentalhealth.samhsa.gov/publications/allpubs/SMA-3718, or via the Wellness Recovery
Bowlby (1988). Attachment patterns or schemas are formed early needs. What they were not provided with was an adequate Action Plan (WRAP) website (M. A. Copeland and staff) at www.mentalhealthrecovery.com.
in life through interaction and experiences with caregivers, and ratio of caregivers to children, and caregivers were instructed
this relationship is embedded in implicit emotional and somatic not to form attachments with the children. After 4 years, eight
memories. Research has demonstrated that these templates of the 26 children managed to somehow form attachment
or patterns of attachment persist into adulthood. These schemas with caregivers, eight of the children became emotionally un-
were studied and classified for young children and include responsive, and 10 of the children became indiscriminately
CONTENTS
INTERACTIVE REVIEW—UNIT I
interactive review
CHAPTER
1
Mental Health and Mental Illness
Margaret Jordan Halter
Visit the Evolve website for a pretest on the content in this chapter:
http://evolve.elsevier.com/Varcarolis
OBJECTIVES
1. Describe the continuum of mental health and mental illness. 7. Identify how the Diagnostic and Statistical Manual, fifth edition
2. Explore the role of resilience in the prevention of and recov- (DSM-5) is used for diagnosing psychiatric conditions.
ery from mental illness and consider resilience in response 8. Describe the specialty of psychiatric mental health nursing
to stress. and list three phenomena of concern.
3. Identify how culture influences the view of mental illnesses 9. Compare and contrast a DSM-5 medical diagnosis with a
and behaviors associated with them. nursing diagnosis.
4. Discuss the nature/nurture origins of psychiatric disorders. 10. Discuss future challenges and opportunities for mental
5. Summarize the social influences of mental health care in health care in the United States.
the United States. 11. Describe direct and indirect advocacy opportunities for
6. Explain how epidemiological studies can improve medical psychiatric mental health nurses.
and nursing care.
1
2 UNIT I Foundations in Theory
If you are a fan of vintage films, you may have witnessed a scene skills, learning, emotional growth, resilience, and self-esteem
similar to this: A doctor, wearing a lab coat and an expression of (U.S. Department of Health and Human Services [USDHHS],
deep concern, enters a hospital waiting room and delivers the bad 1999). Some of the attributes of mentally healthy people are
news to an obviously distraught gentleman who is seated there. presented in Figure 1-1.
The doctor says “I’m afraid your wife has suffered a nervous break- Psychiatry’s definition of mental health evolves over time. It
down,” and from that point on, the woman’s condition is only is a definition shaped by the prevailing culture and societal
vaguely described. The husband dutifully visits her at a gated asy- values, and it reflects changes in cultural norms, society’s
lum, where the staff regard him with sad expressions. He may find expectations, political climates, and even reimbursement
his wife confined to her bed, or standing by the window and staring criteria by third-party payers. In the past, the term mental
vacantly into the middle distance, or sitting motionless in the hos- illness was applied to behaviors considered “strange” and
pital garden. The viewer can only speculate about the nature of the “different”—behaviors that occurred infrequently and devi-
problem but may assume she has had an emotional collapse. ated from an established norm. Such criteria are inadequate
because they suggest that mental health is based on confor-
CONTINUUM OF MENTAL HEALTH AND MENTAL mity, and if such definitions were used, nonconformists
and independent thinkers like Abraham Lincoln, Mahatma
ILLNESS Gandhi, and Socrates would be judged mentally ill. Although
We have come a long way in acknowledging psychiatric disor- the sacrifices of a Mother Teresa or the dedication of Martin
ders and increasing our understanding of them since the days Luther King Jr. are uncommon, virtually none of us would
of “nervous breakdowns.” In fact, the World Health Organiza- consider these much-admired behaviors to be signs of mental
tion (WHO) (2010) maintains that a person cannot be consid- illness.
ered healthy without taking into account mental health as well Mental illness refers to all mental disorders with definable
as physical health. diagnoses. These disorders are manifested in significant dys-
The WHO defines mental health as a state of well-being in function that may be related to developmental, biological, or
which each individual is able to realize his or her own potential, psychological disturbances in mental functioning. (APA, 2013).
cope with the normal stresses of life, work productively, and The cognition may be impaired—as in Alzheimer’s disease;
make a contribution to the community. Mental health provides emotions may be affected—as in major depression; and behav-
people with the capacity for rational thinking, communication ioral alterations may be apparent—as in schizophrenia; or the
Rational
thinking
Meaningful
relationships Effective coping
Developmentally
Self-care on task
patient may display some combination of the three. Behavior now that, when I was manic, it was a pressure-cooker feeling.
that deviates from socially accepted norms does not indicate a When I am happy now, or loving, it is more peaceful and
mental illness unless there is significant disturbance in mental real. I have to admit that I sometimes miss the intensity—the
functioning. sense of power and creativity—of those manic times. I never
You may be wondering if there is some middle ground be- miss anything about the depressed times, but of course the
tween mental health and mental illness. After all, it is a rare per- power and the creativity never bore fruit. Now I do get
son who does not have doubts as to his or her sanity at one time things done, some of the time, like most people. And people
or another. The answer is that there is a definite middle ground; treat me much better now. I guess I must seem more real to
in fact, mental health and mental illness can be conceptualized as them. I certainly seem more real to me (Altrocchi, 1980).
points along a mental health continuum (Figure 1-2).
Well-being is characterized by adequate to high-level function- Contributing Factors
ing in response to routine stress and resultant anxiety or distress. Many factors can affect the severity and progression of a mental
Nearly all of us experience emotional problems or concerns or illness as well as the mental health of a person who does not have
occasions when we are not at our best. We may feel lousy tempo- a mental illness (Figure 1-3). If possible, these influences need to
rarily, but signs and symptoms are not of sufficient duration or be evaluated and factored into an individual’s plan of care. In
intensity to warrant a psychiatric diagnosis. We may spend a day or fact, the Diagnostic and Statistical Manual of Mental Disorders, fifth
two in a gray cloud of self-doubt and recrimination over a failed edition (DSM-5), a 1.5-inch-thick manual that classifies 157 sepa-
exam, a sleepless night filled with worry and obsession about nor- rate disorders, states that there is evidence suggesting that the
mally trivial concerns, or months of genuine sadness and mourn- symptoms and causes of a number of disorders are influenced
ing after the death of a loved one. During those times, we are fully by cultural and ethnic factors (APA, 2013). The DSM-5 is dis-
or vaguely aware that we are not functioning optimally; however, cussed in further detail later in this chapter.
time, exercise, a balanced diet, rest, interaction with others, mental
reframing, or even early intervention and treatment may alleviate Resilience
these problems or concerns. It is not until we experience marked Researchers, clinicians, and consumers are all interested in
distress or suffer from impairment or inability to function in our actively facilitating mental health and reducing mental illness.
everyday lives that the line is crossed into mental illness. A characteristic of mental health, increasingly being promoted
People who have experienced mental illness can testify to the and essential to the recovery process, is resilience. Resilience is
existence of changes in functioning. The following comments closely associated with the process of adapting and helps people
of a 40-year-old woman illustrate the continuum between ill- facing tragedies, loss, trauma, and severe stress. It is the ability
ness and health as her condition ranged from (1) deep depres- and capacity for people to secure the resources they need to
sion to (2) mania to (3) health: support their well-being, such as children of poverty and abuse
1. It was horror and hell. I was at the bottom of the deepest and seeking out trusted adults who provide them with the psycho-
darkest pit there ever was. I was worthless and unforgivable. logical and physical resources that allow them to excel. This
I was as good as—no, worse than—dead. social support actually brings about chemical changes in the
2. I was incredibly alive. I could sense and feel everything. I was body through the release of oxytocin, which mutes the destruc-
sure I could do anything, accomplish any task, create what- tive stress-related chemicals (Southwick & Charney, 2012).
ever I wanted, if only other people wouldn’t get in my way. Disasters, such as the attack on the World Trade towers in
3. Yes, I am sometimes sad and sometimes happy and excited, 2001 and the devastation of Hurricane Sandy in 2012, in which
but nothing as extreme as before. I am much calmer. I realize people pulled together to help one another and carried on despite
Health Illness
Well-being Emotional problems Mental
or concerns illness
FIG 1-2 Mental Health–Mental Illness Continuum. (From University of Michigan, “Understanding U.”
[2007]. What is mental health? Retrieved from http://www.hr.umich.edu/mhealthy/programs/mental_
emotional/understandingu/learn/mental_health.html.)
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no related content on Scribd:
DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.