NCM 117 – PSYCHIATRIC NURSING
 Significant weight loss when not dieting or
Lesson One: Depression
DEFINITION:
MOOD – is a pervasive and sustained emotion
that may have a major influence on a person’s
perception of the world. (E.g.: depression, joy,
elation, anger and anxiety)
 ang perception
AFFECT – is describes as the emotional
reaction associated with an experience
(Taber’s, 2005)
 inappropriate affect – sad inside, but happy
outside.
DEPRESSION
 Otherwise known as major depressive
disorder or clinical depression.
 → If e check ang DSM V, major depressive
disorder, is only a type of depression.
 Those who suffer from depression
experience persistent feelings of sadness
and hopelessness and lose interest in
activities they once enjoyed
 Aside from the emotional problems caused
by depression, Individuals can also present
with a physical symptom such as chronic
pain or digestive issues.
 To be diagnosed with depression,
symptoms must be present for at least
two weeks.
 Signs and Symptoms of depression should
last for two weeks.
 You can say it is depression if it impairs
your day to day living
CRITERIA
 The DSM-5 outlines the following criterion
to make a diagnosis of depression. The
individual must be experiencing five or
more symptoms during the same 2-week
period and at least one of the symptoms
should be either (1) depressed mood or
(2) loss of Interest or pleasure.
 To receive a diagnosis of depression, these
symptoms must cause the Individual
clinically significant distress or
impairment in social, occupational, or other
important areas of functioning. The
symptoms must also not be a result of
substance abuse or another medical
condition.
 Depressed mood most of the day, nearly
every day.
 Markedly diminished interest or pleasure in
all, or almost all, activities most of the day,
nearly every day.
weight gain or decrease or increase in
appetite nearly every day.
 Weight gain or weight loss
 A slowing down of thought and a reduction
of physical movement (observable by
others, not merely subjective feelings of
restlessness or being slowed down).
 2 week to 3 week before makakita ang
therapeutic effects of antidepressants.
 Monitor for suicide when the patient is able
to do normal things again. So, after 2-3
weeks after giving antidepressants.
 Fatigue or loss of energy nearly every day.
 Tamaran ang mga may depression, they
can still do their activities of daily living, but
may depression na sila.
 Feelings of worthlessness or excessive or
inappropriate guilt nearly every day.
 Diminished ability to think or concentrate, or
indecisiveness, nearly every day.
 Recurrent thoughts of death, recurrent
suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for
committing suicide
 Easily bored/short attention span if may
problem
 During what time of the day may suicide:
Morning, and afternoon (rush hour).
EPIDEMIOLOGY
 Age and Gender - higher in women than it
is in men by almost 2 to 1.
 Women experience more depression than
men beginning at about age 10 and
continuing through midlife.
 Social Class - both depression and
personality disorders have most commonly
been found to be outcomes of low
socioeconomic status. (Hudson 2005).
 Leading cause of depression.
 Race and Culture - socioeconomic class of
the race being investigated.
 Clinicians tend to underdiagnose mood
disorders and to over diagnose
schizophrenia.
 Depression Is more prevalent in whites than
it is in blacks, but that depression tends to
be more severe, persistent, and disabling In
blacks, and they are less likely to be
treated.
 Marital Status - being single was a
significant predictor of depression in the 37-
to 49-year-old age group but was not a
significant predictor of depression in any of
the other age groups (18-25, 26-36, 50+).
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(LaPierre 2004) Married had a protective
effect against major depression (George
1992
 18-25 (mga wala kapasar board exam, na
stress sa school)
 26-36 (partner probs)
 50+ (menopause)
 Seasonality → suicide - Spring (March to
May); Fall (September to November) -
(Davidson 2005)
 Wala sun, therefore, gloomy, sun stimulates
the production of serotonin. It increases
serotonin in the brain. (Exposure to sun for
at least 30 minutes).
TYPES OF DEPRESSIVE
DISORDERS
1. MAJOR DEPRESSIVE DISORDER (MDD)
- is characterized by depressed mood or
loss of interest or pleasure in usual
activities.
 impaired social and occupational
functioning that has existed for at least 2
weeks, no history of manic behavior.
 symptoms that cannot be attributed to use
of substances or a general medical
condition.
 the diagnosis of MDD is specified according
to whether it is a single (the individual's first
encounter) or recurrent episode (the
individual has a history of previous
episodes)
 Symptoms last for two weeks.
2. PERSISTENT DEPRESSIVE DISORDER
(DYSTHYMIA) - similar to, if somewhat
milder than, those ascribed to MDD.
Individuals with this mood disturbance
describe their mood as sad or "down in the
dumps" (American Psychiatric Association
(APA), 2000).
 There is no evidence of psychotic
symptoms, The essential feature is a
chronically depressed mood (or possibly an
irritable mood in children or adolescents) for
most of the day, more days than not, for at
least 2 years (1 year for children and
adolescents).
 The diagnosis is identified as early onset
(occurring before age 21 years) or late
onset (occurring at age 21 years or older).
 Anorexia Nervosa – the type of mental
disorder that is the leading cause of death
because the patient does not eat, and they
induce vomiting, therefore the patient
losses electrolytes (potassium: 3.5 -5.5
mEq/L, sodium: 135 – 145 mEq/L). If
potassium is lost, there is a decrease in the
contraction of smooth muscles (lungs & h)
3. PREMENSTRUAL DYSPHORIC
DISORDER - depressed mood, excessive
anxiety, mood swings, and decreased
Interest in activities during the week prior to
menses, improving shortly after the onset of
menstruation and becoming minimal or
absent in the week post menses (APA
2013)
4. SUBSTANCE / MEDICATION - Induced
Depressive Disorder - direct result of
physiologic effects of substance (drug
abuse, medication or toxin exposure). The
depressed mood is associated with
intoxication or withdrawal from substances
such as alcohol, amphetamines, cocaine,
etc.
5. DEPRESSIVE DISORDER DUE TO
ANOTHER MEDICAL CONDITION –
Characterized by symptoms associated
with major depressive episodes that are
direct physiological consequence of another
medical condition. (APA 2013).
PRESIDPOSING FACTORS
I. BIOLOGICAL THEORIES
1. GENETICS
A. Twin Studies - monozygotic twins indicate
that recurrent major depression is
heritability approximately 37 percent.
B. Family Studies - major depression is 1.5 to
3 times more common among first-degree
biological relatives of people with the
disorder than among the long the general
population (APA, 2000).
C. Adoption Studies - biological children of
parents with mood disorders are at
increased risk of developing a mood
disorder, even when they are reared by
adoptive parents who do not have the
disorder (Dubovsky, Davies, & Dubovsky,
2003)
2. BIOCHEMICAL INFLUENCES
A. Biogenic Amines - deficiency of the
neurotransmitters, serotonin and dopamine
at functionally important receptor sites in
the brain.
3. NEUROENDOCRINE DISTURBANCES
A. Hypothalamic-Pituitary- Adrenocortical
Axis – Hypersecretion of cortisol. This
elevated serum cortisol is the basis for the
dexamethasone suppression test that is
sometimes used to determine if an
individual has somatically treatable
depression.
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4. PHYSIOLOGICAL INFLUENCES
A. Medication Side Effects - drugs with direct
to CNS (anxiolytics, antipsychotics,
sedatives)
B. Neurological Disorders - CVA, Brain
Tumors, Alzheimer's disease, Parkinson's
disease, and Huntington's disease
C. Electrolyte Disturbances - Excessive
levels of sodium bicarbonate or calcium can
produce symptoms of depression, as can
deficits in magnesium and sodium.
Potassium is also Implicated in the
syndrome of depression. Symptoms have
been observed with excesses of potassium
in the body, as well as in instances of
potassium depletion.
D. Hormonal Disturbances - Depression is
associated with dysfunction of the adrenal
cortex and is commonly observed in both
Addison's disease and Cushing's
syndrome. Other endocrine conditions
include hypoparathyroidism,
hyperparathyroidism, hypothyroidism, and
hyperthyroidism.
E. Nutritional Deficiencies - Deficiencies in
vitamin B1 (thiamine), vitamin B6
(pyridoxine), vitamin B12, niacin, vitamin C,
iron, folic acid, zinc, calcium, and potassium
may produce symptoms of depression
(Schimelpfening, 2009).
F. Other Physiological Conditions - SLE,
cardiomyopathy, congestive heart failure,
myocardial infarction, and cerebrovascular
accident (stroke); infections, such as
encephalitis, hepatitis, mononucleosis,
pneumonia, and syphilis; and metabolic
disorders, such as diabetes mellitus.
II. PSYCHOSOCIAL THEORIES
A. Psychoanalytical Theory - Freud
observed that melancholia occurs after the
loss of a loved object, either actually by
death or emotionally by rejection, or the
loss of some other abstraction of value to
the Individual.
B. Learning Theory - Seligman theorized that
learned helplessness predisposes.
Individuals to depression by Imposing a
feeling of lack of control over their life
situation. They become depressed because
they feel helpless; they have learned that
whatever they do is futile.
C. Object Loss Theory - The theory of object
loss suggests that depressive illness occurs
as a result of having been abandoned by or
otherwise separated from a significant other
during the first 6 months of life.
D. Cognitive Theory - Beck and colleagues
(1979) proposed a theory suggesting that
the primary disturbance in depression is
cognitive `rather than affective.
SIGNS AND SYMPTOMS
 Sleep (insomnia or hypersomnia)
 Interest (diminished interest or pleasure
from activities)
 Guilt (excessive or inappropriate; feelings of
worthlessness)
 Energy (loss of energy or fatigue)
 Concentration (diminished or
indecisiveness)
 Appetite (decrease or increase; weight loss,
weight gain)
 Psychomotor retardation/ agitation
 Suicide (recurrent: thoughts of death,
suicidal ideation, suicide attempt.
TREATMENT MODALITIES
FOR DEPRESSION
 Individual Psychotherapy
 Group Therapy
 Family Therapy
 Cognitive Therapy
 Cognitive rather than affective. (Depression
is all in the mind, does not affect the
feelings)
 Introjection – most common coping
mechanism of patients with depression
(signs and symptoms slide)
 Electroconvulsive Therapy
 ECT – is no longer being used in NCMH.
One of the most effective treatment for
depression.
 When do you submit yourself for ECT: once
the patient is no longer responsive to
medication. (last resort)
 ECT – Action is not well understood but
works well with severe depression.
 Light Therapy
 Transcranial Magnetic Stimulation
 Psychopharmacology
 → Psychopharmatherapy –antidepressants,
SSRI, MAOI. Affects 2-3 weeks after.
ELECTROCONVULSIVE
THERAPY
 is the induction of a grand mal (generalized)
seizure through the application of electrical
current to the brain.
 Action: Application of Electric Current(70-
110 volts) → alteration (temporary) of
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brain's electrochemical processes →
decreased depression.
Note: Action of ECT is not well understood
INDICATIONS:
1. Primarily used with clients with depression
2. Used as adjunct therapy for patients no
longer responding to antidepressants
CONTRAINDICATIONS:
1. Brain tumor
2. Respiratory diseases (PTB, etc)
3. Pregnant women (specially with PIH)
ALWAYS REMEMBER
 Duration of administration: 0.5 to 1 second
 70 to 110 v used for patients who undergo
ECT. (.5 to 1 seconds: in book) (3-5
seconds: actual)
 Frequency of treatment: 2-3 times weekly
 Total number of treatments: 6-12 therapies.
 Side effect: Seizure (tonic-clonic seizure)
 Usual side effect – pt may suffer
anterograde amnesia. So dapat e reorient
the patient.
 Priority: Safety.
 Position: Post ECT – side lying.
 Asses vital signs, LOC (s/e), presence of
gag reflex.
NURSING MANAGEMENT:
 Informed consent
 Pre-ECT Medications:
 Anectine (muscle relaxant)
 Brevital (anesthetic agent)
 Atropine sulfate (anticholinergic)
o Atropine sulfate – give to decrease
salivation of patient post ECT. Put patient
in side lying position.
 NPO
 Assisting in ECT: hold patients arm (it does
not shock you. Patient only experiences
grand mal seizure, not electrocuted)
 ECT – can also be given to catatonic type
of schizophrenia. Not only depressive
patients.
 Catatonic schizophrenia – mag assume one
position and does not move for how many
hours or days. (Ting)
 Ngaa gina tagaan ECT ang catatonic schiz
pts? Kay pwede nila ma pugnga nila
breathing, not only their movements.
 ECT- given to emergency cases.
 In ECT – after exposure, pwede mabalik
imo patient to normal.
 Bipolar patients can also be given ECT,
since they are prone to committing suicide.
Lesson two: Schizophrenia
and other Psychoses
 Patients have a flattened affect and
undergo hoarding (this serves as their
security blanket; these things are significant
to them)
SCHIZOPHRENIA
 The word schizophrenia comes from the
Greek words “schizo” meaning split, and
“phrene” meaning mind, to describe
fragmented thinking.
 Is genetically passed on.
THREE INESCAPABLE
FACTS ABOUT
SCHIZOPHRENIA
1. Age at onset: late adolescence and early
adulthood.
 More common in males, and have worst
manifestations; because they suppress
their emotions, genetics, wala estrogen ang
boys, estrogen plays a role in the
decreasing of dopamine in the body.
2. Role of Stress: onset and relapse always
related to stress.
 Stress triggers schizophrenia.
 Advise to change the environment after
discharge to prevent relapse.
 Despite the maintenance meds, stress can
cause relapse.
3. Efficacy of Dopamine Antagonist: Drugs
that block dopamine receptors are
therapeutic.
Psychosis
 is a disruptive mental state in which in
individual struggles to distinguish the
external world from internally generated
perception.
 They are not in touch of reality. If you ask
about their disease condition, they are not
aware about their illness, that is why they
do not submit to the treatment.
DIFFERENTIATE NEUROSIS
FROM PSYCHOSIS AS TO:
PERSONALIT Neurosis: Present
Y Psychosis: Absent
REALITY Neurosis: in touch with
reality, they are aware that
they have a disease
condition
Psychosis: not in touch
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with reality  Inappropriate affect – laughing mskin subo.

INSIGHT Neurosis: Present
(Panan-awan; Psychosis: Absent; not
not the same intact 5. BEHAVIOR (SOCIAL WITHDRAWAL)
as judgement, Judgement vs Insight:  Patients prefer to be alone.
If the patient Judgement – ga shades 6. ATTENTION
knows what while night, ga jacket while  Inability to concentrate
they will do in a init 7. MOTIVATION
situation)
 cannot initiate or persist in goal directed
DELUSION Delusion: false belief. May activities – abolition: Absence of motivation.
gina claim pero ndi mo SCHIZOPHRENIA
makita or may paniniwala  Formerly known as Dementia Pracox (Emil
na ndi makita. Ex Ga claim
Kraeplin).
sya na sya pinaka gwapa,
pro ndi  It was known as a manifestation of
Illusion: with stimulus. Ex. possession.
May kurtina na puti, pero  Age of onset in men is typically 4 to 6 yrs.
panan-awan sa patient is earlier than in women.
white lady  Men have more severe course.
Hallucination: without  → because of hormones: Estrogen:
stimulus, may makita na ndi Dopamine
naton makita. Patient has  Women have more positive symptoms.
alteration with the 5
 Estrogen modulates dopamine function.
senses
CAUSES Neurosis: No organic  Women are more compliant with
cause medications.
Psychosis: There is  Women tend to have lower blood levels and
organic cause (genes) longer half-lives of medications.
EPIDIMEOLOGY OF
SCHIZOPHRENIA SCHIZOPHRENIA
 − Is a diagnostic term used to describe a
 1% of the population develops
major disorder characterized by
schizophrenia. (1 out of 100)
disturbances of the following:
1. PERCEPTION (HALLUCINATIONS)  95% suffer lifetime.
 If patient has visual hallucinations,  50% experience serious side effects from
therapeutic communication should be to medications.
acknowledge the feelings of the patient,  10% kill themselves
after that present reality, and lastly, divert  Pt w/ schizophrenia are prone to suicide:
the attention of the patient. TRUE. Because they are having auditory
 Example: “Na iintindihan ko na baka miss hallucinations. (maka bati mga tingug).
mo ang tatay mo, pero patay na itong tao  What are the gestures of patient who are
na ito. Halika, manood tayo ng TV.” hallucinating?
 Tactile Hallucination: Patient refuses to lie  Auditory Hallucination: Ga balikid
down on the bed because he claims that FOUR A’S OF
there are ants. Therefore, the nurse should
acknowledge the feelings, present reality, SCHIZOPHRENIA
and provide diversion. A – ffective Disturbance – inappropriate, or
2. THOUGH PROCESS (THOUGHT flattened affect.
DERAILMENT) A – utism – preoccupation with the self, with
 Kung gina ask ang patient, lain ang iya gina little concern for external reality.
answer. A – ssociative looseness – the stringing
 Kung ma ask ka “Saan ka nanggaling”, pt together of unrelated topics.
answers “Ang nakaon ko…” A – mbivalence – simultaneous opposite
3. REALITY TESTUNG (DELUSIONS) feelings.
4. FEELING (FLAT OR INAPOPRIATE
AFFECT)

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COURSE OF ILLNESS  They have a feeling that they are dead.

 They have a feeling that they do not exist.
(OVERLAPPING PHASES)  Feeling that an organ is absent. (ex. Ndi
ACUTE PHASE – the patient experience mag kaon ang patient, kay wala siya kuno
severe psychotic symptoms bituka)
 There are manifestations.  If a patient looks at themselves in the
STABILIZING PHASE – the patient is getting mirror, it is a good sign because it shows
better. that they know and are aware of their
 Ga dula na slight ang manifestations. appearance and body, and that they still
STABLE PHASE - the patient might still have a face, and still exist.
experience hallucinations and delusions but  Delusion of Influence
not as severe or disabling as they were during  Belief that they are in control.
the acute phase.  Delusion of Reference.
 Ga dula na ang manifestations. Gamay  Ideas of reference: belief that they are
nlng bilin being talked about, with evidence. People
DSM V CRITERIA are pointing and looking.
A. Characteristics Symptoms (at least 2 of  Delusion of reference: belief that they are
the following) being talked about. But there are no
 Delusions physical evidence. Ex: Belief that TV
 Hallucinations anchors who does not know him are
 Disorganized Speech “talking” about him
 Grossly disorganized (sagay giho) or B. Social-Occupational dysfunction: work,
catatonic behavior (ndi mag giho)(either of interpersonal, and self-care functioning
the two with schizophrenia) below the level achieved before onset.
C. Duration: continuous signs of disturbance
 Negative symptoms
for at least 6 months.
TYPES OF DELUSION D. Schizoaffective and mood disorders not
 Erotomatic present and not responsible for the signs
 They have a false belief that somebody is in and symptoms.
love with him/her.  Schizoaffective – combination between
 Eros = love schizophrenia and affective disorder.
 Grandiose E. Not caused by substance abuse or a
 Delusion of grandeur. general medical disorder.
 Delusion of grandiosity. POSITIVE VS NEGATIVE
 Feeling niya siya ang PINAKA sa tanan.
 Ndi mag pa perde.
SCHIZOPHRENIA
TYPE 1: POSITIVE SYMPTOMS
 Jealous
 Hallucinations
 Belief that their partner/spouse is unfaithful
 There are five types of hallucination,
or having an affair.
because this depends on the five senses.
 Persecutory
 Visual, tactile, olfactory, gustatory,,
 Paranoia
auditory.
 Feeling nila may CCTV where gina monitor
 Delusion
sila.
 There are several types of delusion.
 Feeling niya may stalker siya
 Incoherence
 Somatic
 Ang mga patients na lain ang gina ask from
 False belief that one has an illness /
them, lain ang ila gina answer.
medical condition.
 There is alteration of thoughts. Patient
 Mixed or Unspecified
cannot answer the right answers.
 Delusion with two or more delusions.
o include Paranoia in 2013.
 Combination of 2 or more
TYPE 2 NEGATIVE SYMPTOMS
 Religious
 Alogia
 Feeling nila naka istroya sila kay mama
 Absence of speech (ndi ka hambal).
mary.
 Can also be mutism (which is a diagnosis,
 Nihilistic
wherein the patient cannot talk. But in
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alogia absence of speech because nag ka

schizophrenia.)
 Sang una ga hambal ang patient, pagka
diagnose nya schizophrenia, na dula.
 Anergia
 Lack/Absence of energy.
 Wala ga giho ang patient kay wala siya WHAT DIFFERS FROM
energy to move.
 Asocial behavior
POSITIVE TO NEGATIVE
 Patient wala ga mingle, wala naki POSITIVE NEGATIVE
associate, staying away from the crowd. Patient no symptoms May ara isa ka trait
 Attention deficits until nag ka but after na diagnose
 Avolition schizophrenia. siya, na dula ang
 Absence of motivation. Patient was normal amo to na trait. Ex.
before diagnosis, no Before, patient is
 Gusto sila mag kaon pero wala sila gana
delusions and talkative, after
mag giho. Not motivated to move. hallucinations. diagnosis of
 Blunted affect Happens after schizophrenia,
 Can be blunted, inappropriate affect. diagnosis; these are patient manifests
 A problem in the affect. manifestations added alogia, poverty of
 Communication difficulties (+) to the patient. speech, and
 Pwede ang patient ndi ka hambal becos of communication
the disease condition. problems.
 Because of the disease patient develops
alogia. OBJECTIVE SIGNS
 Patients find it hard to communicate.  Alterations in Personal Relationships
 Can sometimes be caused by the  Nurse notices that there are alternations in
medications that the patient is taking. Ex. personal relationships related to:
Facial paralysis can occur. Dystonia can 1. Decreased attention to appearance and
affect the speech of the patient = social amenities related to introspect rum
communication difficulties. and autism.
 Difficulty with Abstraction o Ndi maki mingle si patient.
 The patient has difficulty analyzing and o Ang patient may sariling mundo.
interpreting. o There is problem in making social
 Passive social withdrawal interaction with other people.
 Active social withdrawal – if you are part of 2. Inadequate or inappropriate communication
the one group, the patient walks out and o If ang patient wala ga sabat/ga hambal.
wants to be by himself, has initiative to be o If the patient is not answering properly to
alone. (Same as schizoid personality the questions.
disorder) o You cannot establish a relationship with
 → Passive social withdrawal – one group other people if you don’t communicate.
ga updanay lakat, ang patient nabilin. 3. Hostility
Patient refused to mingle, but the initiative o If the patient is angry, violent.
does not come from the patient, it comes o Patient will not be able to mingle with other
from the people around the patient. people because they are hostile.
 Poor grooming and hygiene 4. Withdrawal
 Such as disorganized schizophrenia  Alterations of Activity
 Best example of a negative symptom. 1. Psychomotor agitation
 Poor rapport o Patient is restless, agitated or si patient
 Poverty of speech wala ga giho (Ex. Catatonic Schizophrenia)
 Alogia VS poverty of speech: o Patient cannot perform regular activities,
 (1) Poverty of speech: there is 2. Catatonic rigidity
communication but limited ang answers and o Acute stupor
way of communication. o Patients resists changes done to their
 (2) Alogia: if ma ask ka, wala gd ga sabat. posture.
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 NCM 117 – PSYCHIATRIC NURSING
3. Echopraxia
o Copying or imitating one’s actions –
echopraxia.
o Copying or imitating one’s speech -
echolalia.
 Stereotypy
o Patients tend to be do an action repeatedly.
o It differs from mannerisms: because with
mannerisms, they do it unconsciously.
In Catatonic patients, if e change mo ila
position after nag freeze sila, balikon nila
original position? Mabalik. (negativism -one
of the manifestations of patients with
catatonic schizophrenia.)
Prominent Manifestations of patients with
schizophrenia:
 Waxy flexibility
 Acute stupor (ndi ka giho)
 Negativism (resists to changes)
Paralytic Agent – gapa paralyze, therefore,
ma rest/relax ang patient. (Succinylcholine)
*In patients with schizophrenia, muscle
contraction is not the problem. The problem
is in the neurotransmitters, which can result
in paralytic agents having no effect in
patients with catatonic schizophrenia. This
further gives importance in the need for
ECT.
Patients with catatonic schizophrenia can
hold their breath = need for ECT.
SUBJECTIVE SIGNS
 ALTERED PERCEPTION
 Hallucination
o No stimulus. Making things up.
o Best nursing diagnosis: Altered perception
 Illusion
o With stimulus, misinterpretation of stimulus.
o Paranoid drinking/thinking
 ALTERATION OF THOUGHT
 Loose association
o There is a speech problem.
o Patient has word salads, if e ask ang
patient layo and ila answers to the
questions.
o Patients can have acoherence.
 Retardation (slowing of mental activity)
o Loading si patient.
o Patient takes too much time to think
 Blocking (interruption of thought and
inability to recall it)
o Ex. Tuon ka mayo at home, and na
memorize mo tanan, pero pag abot ka
exam, ga dula tanan.
o Patient sagay hambal, gulpi lang nag untant
kay nalipat siya sa iya gna hambal.
 Autism (Introspective/ own world)
 Ambivalence (love-hate)
 Delusions (fixed, false beliefs)
o Altered thoughts
 Poverty of speech
o Inability to formulate and articulate
thoughts, vocabulary is limited.
 Ideas of reference
o Paranoid patients usually have this.
o Si patient ga suspect na siya ang gina
storyahan.
o Kung ang patient paranoid: patient can
have delusion of persecution.
 Mutism
 Concrete thinking (inability to conceptualize
the meaning of words0
o Ndi ma express ang gusto e hambal.
 ALTERED CONSCIOUSNESS (IS
PATIENT AWARE AND ORIENTED)
 Confusion
o Tulala si patient
 Incoherent speech (difficult to understand)
 Clouding (mental fog)
o Dumduman mo na nakita mo siya, pero
nalipatan mo ang iban na details. Likeano
ila color of shirt. Nasugata mo sila pero ndi
ka maka klaro sa ila chura.
 Sense of “going crazy” (loss of control)
o Daw mabuang na ang patient – hambal ya.
o Patient has panic anxiety.
 ALTERATIONS OF AFFECT
 Inappropriate, blunted, flattened, or labile
affect.
o Inappropriate Affect – patient says he is
happy, but ga hibi siya.
o Blunted Affect – hapaw. No emotion, but
happy iya gina hambal. [A decreased ability
to express emotion through your facial
expressions, tone of voice, and physical
movement.]
o Flattened Affect – no expression at all.
o Labile Affect – ga ilis2, massive change /
shifts in mood.
 Apathy
o Lack/ Absence of concern
 Ambivalence
 Overreaction
 Anhedonia
o Loss of pleasure in usual activities.
ETIOLOGY
1. BIOCHEMICAL THEORIES
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 NCM 117 – PSYCHIATRIC NURSING
 talks about neurotransmitters.
 Dopamine – increased in schizophrenia.
 Norepinephrine is also increased.Increase
taan with schizophrenia.
 There are changes in the patient behavior
because of the increasing of
neurotransmitters.
2. NEUROSTRUCTURAL THEORIES ((brain
atrophy, cerebral blood flow)
 Patient with schizophrenia do not have
normal size of brain – gamay.
 There are problems in the oxygenation of
the brain [cerebral blood flow]. If there is
deficiency in oxygen, it can be one reason
why there is schizophrenia.
3. GENETIC THEORIES
 If may genes ka na schizophrenia, most
likely mag ka schizophrenia ka.
 This just proves the schizophrenia is the
same as other illness, it can be passed
down through genetics.
4. PERINATAL RISK FACTORS
 If may mga issues of the mother before nag
pregnant.
 Ex. Unwanted pregnancies.
 That is why it is very important to know the
background of the patient. Ex. Pag bata ya,
palangga siya sa iya ginikanan?
5. FAMILY THEORIES
 Same as genetic, runs in the blood.
6. VULNERABILITY – STRESS MODEL
 Biologic and psychodynamic
predispositions coupled with stress.
 if ang schizophrenia ara daan sagenes sa
patient, but if ndi siya stress, pwede ndi ma
trigger.
 Two factors can trigger schizophrenia:
Nature (genes) and environment/nurture
(how the patient is/was brought up which
can cause stress)
 This model emphasized na ndi lang sa
blood ang schizophrenia but can be
triggered by stress.
7. DEVELOPMENTAL THEORIES OD
SCHIZOPHRENIA
 Sigmund Freud - patients with
schizophrenia has poor ego boundaries,
superego dominance.
 ID – pleasure.
 EGO – in between, balancebetween ego
and superego.
 SUPEREGO – Superego is governed by
conscience. In schizophrenia, there is an
increase in SUPEREGO. Puro tanan bawal,
which makes it very hard for the self to
cope, which is why there are defense
mechanism.
 Erik Erikson – trust vs mistrust (0–1-year-
old)
 Gamay palang sila, wala nila nabatyagan
nga gina care for sila by their parents.
 Since mother/father ang pinaka important
person during this developmental stage.
 The best communication for a child in this
stage is crying. If wrong ang pag deal sa iya
pag cry, this can lead to the child to feel
unwanted and can be the start of the
development of schizophrenia.
 Sullivan - absence of warm, nurturing
attention can result disordered social
interactions
 If you are not welcome in the real world,
you make your own fantasy world.
 That is why we should create a better place
for our patients to prevent them going to
their fantasy world.
TYPES OF SCHIZOPHRENIA
I. PARANOID
 Used to be the most common form of
schizophrenia. In 2013, the American
Psychiatric Association determined that
paranoia was a positive symptom of the
disorder, so paranoid schizophrenia wasn’t
a separate condition. Hence, it was then
just changed to schizophrenia.
 Paranoia is still under positive symptoms
 The subtype description is still used
through, because of how common it is.
 Patients with this type of schizophrenia, do
not have a problem in their grooming.
 Ang problem lang sa ila is ang ila
paminsaron.
SYMPTOMS:
 Delusion
 Type of delusion common in patients who
are paranoid: Delusion of persecution /
persecutory delusion.
 Hallucinations
 Prominent hallucination in patients who are
paranoid: hearing / auditory. May ga hutik
sa ila.
 Disorganized speech (world salad,
echolalia)
 Trouble concentrating
 Behavioral impairment (impulse control,
emotional lability)
 Patient has Poor Impulse Control: ang
patient ndi maka pugong sa ila mga actions
 Flay affect
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 NCM 117 – PSYCHIATRIC NURSING
II. CATATONIC
 Rare severe mental disorder characterized
by striking motor behavior, typically
involving either significant reductions in
voluntary movement or hyperactivity and
agitation.
 Wala ga giho si patient for several hours.
(ting)
 In some cases, the patient may remain in a
state of almost complete immobility, often
assuming statuesque positions. Patients
may remain motionless in a rigid posture for
hours or even days.
III. DISORGANIZED / HEBEPHRENIC
 The individual doesn’t have hallucinations
or delusions. Instead, they experience
disorganized behavior and speech. This
can include:
 Flat affect
 Speech disturbances
 Disorganized thinking
 Inappropriate emotions or facial reactions.
 Trouble with daily activities.
 The type of schizophrenia that we always
see sa plaza.
 Wala ga pa ligo.
 These types of patients have a silly
behavior (bastos). Patients are also
hyperactive, incoherence, may mga
mannerisms.
IV. UNDIFFRENTIATED SCHIZOPHRENIA
 The term used to describe when an
individual displaced behaviors that were
applicable to more than one type of
schizophrenia. For instance, an individual
who had catatonic behavior but also had
delusion or hallucinations, with world salad,
might have been diagnosed with
undifferentiated schizophrenia.
 A combination of two types of
schizophrenia.
 There are a manifestation of different types
of schizophrenia.
V. RESIDUAL
 When a person has a previous diagnosis of
schizophrenia but no longer has any
prominent symptoms of the disorder. The
symptoms have generally lessened in
intensity.
 As if the patient is normal. Their symptoms
are more on the negative signs.
 Since these negative symptoms can also
be seen in normal people like us.
 No positive symptoms.
 Patients with residual schizophrenia, even
though they act and look normal, they still
need to take medications.
 It could be because of the medications na si
patient wala na positive symptoms. If mag
stop siya take medications, positive
symptoms could come back.
 Residual schizophrenia usually includes
more “negative” symptoms, such as:
 Flattened affect
 Psychomotor difficulties
 Slowed speech & Poor Hygiene
DEPRESSION AND SUICIDE IN
SCHIZOPHRENIA
 Mood Disorders: Depression and Bipolar
(bipolar - patient has mania[being
hyperactive], patient is depressed but is
actually happy. Patients who are manic,
they experience euphoria. Patients who are
bipolar are originally depressed, but they
only have episodes of being happy. Mas
taas ang ila possibility of committing
suicide, compared to patients with
depression.)
 In bipolar, patients experience a euphoric
stage – a stage wherein they cannot
explain their happiness.
1. Depression is a natural part of
schizophrenia.
 If ang patient may schizophrenia, it is only
natural na may depression sila.
 They may have the same type of
medications. (ex. Antipsychotic, lithium
carbonate - given to patients with manic
disorder. Since patients with schizophrenia
could also have manic episodes.)
2. Depression is a reaction to
schizophrenia.
 Patient is depressed because
schizophrenic siya.
 In schizophrenia, they have episodes of
lucid interval wherein the patient may
appear to be okay, and free of symptoms.
During this, patients learn they are
diagnosed with schizophrenia, that is when
they are diagnosed with depression.
3. The biologic nature of the disorder and
the drugs used to treat it.
 Schizophrenia can be linked to depression
through the neurotransmitters.
 In schizophrenia: ↑dopamine, ↑norepi, ↑
serotonin.
 Very evident in patients with depression:
↓norepinephrine
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 NCM 117 – PSYCHIATRIC NURSING

PSYCHOTHERAPEUTIC embarrass
patients.
NURSE-PATIENT- For withdrawn  If the patient is withdrawn,
patients, start provide INDIVIDUAL
INTERACTION: with one to-one therapy.
EXAMPLE OF THE PRINCIPLES interactions  Patient would feel left out
Be calm when  Should not show patient in group therapy
talking to the that we are disturbed Allow and
patients because they can sense it encourage
Accept patients  Dapat as a psychiatric verbalization of
as they are, but patient, we accept them, feelings.
do not accept all but not their behaviors.
behaviors.  We do not agree with their
hallucinations
PSYCHOTHERAPEUTIC
Keep promises  Be careful of patients who PRINCIPLES
are manipulative. If asked what the patient needs in order to
 If you promise, you must heal: (1) therapeutic communication –NPR
keep your promise. Principles, (2) Medications, (3) Manipulation
Because these patients of environment – Milieu therapy
are victims of failed  NPR PRINCIPLES
relationships.
 Focus on behavior
Be consistent  If naka mention na until
Friday 11:30 ka lang,  A long-term relationship is most
dapat you should follow it, therapeutic.
because patients are very  Accept patient but not all behaviors.
particular.  Be consistent,
 Consistency helps in  Do not reinforce hallucinations and
establishing trust. delusions.
Be honest  Because patients are very  Avoid whispering or laughing if patient
particular and observant cannot hear all of the conversation.
Do not reinforce  Do not encourage the  PSYCHOTROPIC DRUGS (also known as
hallucinations patients’ hallucinations major tranquilizer)
and delusions and delusion A. TRADITIONAL ANTIPSYCHOTICS OR
Orient patients  Every time we talk to the TYPICAL
to time, person, patient, we have a pattern.
 Haloperidol (Haldol)
and place, if  Introduce name, from what
indicated o The only drug that can solve manifestations
school, and until when,
everyday of positive symptoms.
Do not touch the  Most especially if the  Fluphenazine Decanoate (Fluxim)
patient without patient is paranoid, which  Chlorpromazine (Thorazine)
warning them / is why you should know if o Traditional Antipsychotics: the firstones
without their your patient is sensitive or made, have been introduced first.
consent not. o These drugs have more side effects
Avoid  Patients may have ideas compared to therapeutic effect.
whispering or of reference. Avoid o Still given to patients because they are the
laughing whispering to avoid
only drugs that can address certain
misinterpretation.
manifestations by the patient.
Reinforce  Because some may have
positive o Should be given to the patient with caution.
poor self-esteem
behaviors. B. ATYPICAL ANTIPSYCHOTICS
Avoid  Okay lang maki play  Clozapine (Leponex)
competitive competitive games with  Risperedone (Risperdal)
activity with some patients, but it  Olanzapine (Zyprexa)
some patients depends if paano ka  Quetiapine (Seroquel)
severe ang schizophrenia  Aripiprazole (Abilify)
sa patient.
o Mas mahal, but lesser or no side effects
 If mag hatag ka prizes,
because these are new medications.
give prizes to everybody.
Do not MECHANISM ACTION OF DRUGS

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 NCM 117 – PSYCHIATRIC NURSING
Nerve endings carry dopamine to the brain →
you need medication to block the nerve cells
para ndi kasulod si dopamine sa brain kay if
mag increase si dopamine, patient can have
manifestations of schizophrenia. → with
medications that block dopamine from entering
the brain → it prevents the development of
schizophrenia / lessens the signs and
symptoms.
MAJOR SIDE EFFECTS OF ANTI-
PSYCHOTIC DRUGS
1. PSEUDO-PARKINSONISM
 Is false parkinsonism → may tremors at
rest but they are caused by the
medications.
 Parkinsonism: Tremors do not stop even if
may gina hold na siya.
 Tremors with alcoholism: may tremors but
ga stop ang tremors if may gina hold na
sya.
 Patient can stop taking the drug, but the
side effect it still there.
 Stooped posture
 Shuffling gait
 Rigidity
 Tremors at rest
 Pill-rolling motion of the hand.
2. ACUTE DYSTONIA
 Facial grimacing / facial paralysis.
 Involuntary upward eye movement
 Muscle spasms of tongue, face, neck, and
back (back muscle spasms cause trunk to
arch forward)
 Laryngeal spasms
3. AKATHISIA (ants in the pants)
 Restless
 Trouble holding still.
 Paces the floor.
 Feet in constant motion, rocking back and
forth.
4. TARDIVE DYSKINESIA
 Protrusion and rolling the tongue.
 Sucking and smacking movements of the
lips.
 Chewing motion
 Facial Dyskinesis.
 Involuntary movements of the body and
extremities.
 A.P.A.T → These are extrapyramidal
syndrome manifestations.
 Anticholinergic medications are given to
deal with the side effects.
5. PISA SYNDROME
 A reversible lateral bending of the trunk with
a tendency to lean on one side.
 Name taken from the Leaning Tower of
Pisa.
6. ANTICHOLINERGIC EFFECTS:
 Anticholinergic Drugs
 Akineton – an antiparkinsonian drug.
 Benadryl
 Cogentin – an antiparkinsonian drug.
 Dopaminergic – levodopa
 They are given along with antipsychotics.
 ↑ these meds are given to address the side
effects ↓ They are given along with
antipsychotics.
 Dry mouth
 Blurred vision
 Constipation
 Urinary hesitation
 Tachycardia
 Nursing Considerations for patient taking
anticholinergic: MIO, Increase fluid intake,
safety.
7. TARDIVE DYSKINESIA
8. ELEVATED PROLACTIN (amenorrhea,
galactorrhea, impotence, decreased
libido)
 Mag dako ang ila boobs, even in males,
and could produce milk. Since mag taas
ang levels of prolactin.
9. SEDATION
 Antipsychotic can also serve as sedation for
patients in the OR.
10. ORTHOSTATIC HYPOTENSION.
 If patient is with orthostatichypotension,
assist the patient during getting up,
dangling of feet before standing.
NEUROLEPTIC MALIGNANCY SYDROME
 Major side effect of antipsychotic drug, it is
lethal, meaning thepatient can die.
 If you see signs NMS (increasedtemp after
taking antipsychotic meds, and there is
muscle rigidity) (1) stop medication → (2)
provide cooling measure (TSB, give
paracetamol), and (3) notify the physician.
 MILIEU MANAGEMENT PRINCIPLES
 Milieu – therapeutic manipulation of the
environment.
o Lessen the stimulus because the more the
stimulus, the more gaka panic ang patient.
o Ex. If ang patient depressed, dapat ipa siga
ang suga sa room. Kay if dulom ang room,
the more na ma depress si patient.
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 NCM 117 – PSYCHIATRIC NURSING
o Dapat gina expose ang patient to light if
they are depressed.
o This can also include attitude therapies (Ex.
Matter of fact, passive friendliness).
 Modify environment to decrease stimulation
and for safety.
 Staff consistency is crucial.
 Arrange environment to reduce withdrawn
behavior.
 Monitor television watching.
 Protect patients’ self-esteem.
ADDRESS THE
ENVIRONMENT OF
SCHIZOPHRENIC PATIENTS
BY:
For patients with impaired communication:
 Be patient, do not pressure the patient to
make sense.
 Do not place the patient in group activities
that would frustrate them.
 Provide opportunities for purposeful
psychomotor activities.
For patients with hallucinations:
 Acknowledge feelings, present reality,
divert attention.
 Provide distracting activities.
 Monitor television selections.
For disorganized patients:
 Limit stimulus
 Provide a calm environment.
 Provide safe and simple activities.
OTHER PSYCHOTIC
DISORDERS
Schizophrenia spectrum: There are other
illnesses that have the same manifestations
as schizophrenia, but it is
schizophrenia.
Schizophrenia: manifestations should be
present for 6 months.
1. SCHIZOAFFECTIVE DISORDER
 Is a psychosis characterized by both
affective (mood disorder) and schizophrenic
(thought disorder) symptoms
substantial loss of occupational and social
functioning.
 Schizophrenic symptoms are dominant but
are accompanied by major depressive or
manic symptoms.
 Prognosis is better than schizophrenia.
 Combination of affective/mood disorder and
schizophrenia.
 There is manic episodes
2. DELUSION DISORDER
 Display symptoms similar to those seen in
patients with schizophrenia. However,
substantial differences exist and
necessitate a diagnostic differentiation. The
following symptoms differentiate delusional
disorders from schizophrenic disorders:
 Delusions have basis in reality.
 The patients have not met the criteria for
schizophrenia.
 The behavior is relatively normal except in
relation to their delusions.
 If mood episodes have occurred
concurrently with delusions, their total
durations have been relatively brief.
 The symptoms are NOT the direct result of
a substance-induced or medical condition.
o Delusions in schizophrenia: they are other
people. If student siya, ang delusion ya is
siya si dean.
o Delusional Disorder: Delusions consist of
being the best. They have a basis in reality;
If student siya, siya nag pinaka the best and
bright na student.
3. BRIEF PSYCHOTIC DISORDER
 Includes all psychotic disturbances that last
less than one month and are not related to
mood disorder, a general medication
condition, or a substance induced disorder.
 At least one of the following disturbances
must be present: delusions, hallucinations,
disorganized speech, or grossly
disorganized or catatonic behavior.
 Manifestation of schizophrenia (positive and
negative symptoms) but experiences it only
for a brief period of time / 1 month
4. SCHIZOPHRENIFORM DISORDER
 Displays symptoms that are typical of
not
schizophrenia and last at least one month
but no longer than six months.
 This cautious approach spares the
individual the lifelong diagnosis of
schizophrenia until professionals are sure
of the diagnosis.
 2-5 months signs and symptoms of
with
schizophrenia. But not more than 6 months.
These types of schizophrenia need different
labels/names because of the existence of
court cases with people claiming to be
mentally ill. This helps with the identification
of mental disorders present and can help
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 NCM 117 – PSYCHIATRIC NURSING

put them into a mental health facility rather

than prison.

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