PSYCH MIDTERMS

PSYCHOPHARMACOLOGY
CENTRAL NERVOUS SYSTEM • NOREPINEPHRINE (attention, learning, memory, sleep, wakefulness,
mood regulation)
• Brain − Norepinephrine (also called noradrenaline) increases blood
o Cerebrum pressure and heart rate. It’s most widely known for its effects on
o Cerebellum alertness, arousal, decision-making, attention and focus. Many
− Below cerebrum medications (stimulants and depression medications) aim to
− Center for coordination of movements and postural increase norepinephrine levels to improve focus or concentration to
adjustments treat ADHD or to modulate norepinephrine to improve depression
− Reception, integration of information from all body areas to symptoms.
coordinate movement and posture • EPINEPHRINE (flight-or-fight response)
o Brain stem − Epinephrine (also called adrenaline) and norepinephrine (see
− Midbrain: reticular activating system (motor activity, sleep, below) are responsible for your body’s so-called “fight-or-flight
consciousness, awareness) and extrapyramidal system response” to fear and stress. These neurotransmitters stimulate your
− Pons: primary motor pathway body’s response by increasing your heart rate, breathing, blood
− Medulla oblongata: vital centers for cardiac, respiratory pressure, blood sugar and blood flow to your muscles, as well as
function heighten attention and focus to allow you to act or react to
− Nuclei for cranial nerves III through XII different stressors. Too much epinephrine can lead to high blood
− Locus coeruleus: norepinephrine-producing neurons (stress, pressure, diabetes, heart disease and other health problems. As a
anxiety, impulsive behavior) drug, epinephrine is used to treat anaphylaxis, asthma attacks,
o Limbic system cardiac arrest and severe infections.
− Above brain stem • SEROTONIN (food intake, sleep, wakefulness, temperature regulation,
▪ Thalamus (activity, sensation, emotion) pain control, sexual behaviors, regulation of emotions)
▪ Hypothalamus (temperature regulation, appetite control, − Serotonin is an inhibitory neurotransmitter. Serotonin helps regulate
endocrine function, sexual drive, impulsive behavior) mood, sleep patterns, sexuality, anxiety, appetite and pain.
▪ Hippocampus and amygdala (emotional arousal, memory) Diseases associated with serotonin imbalance include seasonal
o Nerves that control voluntary acts (neurotransmitters) affective disorder, anxiety, depression, fibromyalgia and chronic
pain. Medications that regulate serotonin and treat these disorders
CEREBRUM include selective serotonin reuptake inhibitors (SSRIs) and serotonin-
norepinephrine reuptake inhibitors (SNRIs).
• Two hemispheres • HISTAMINE (alertness, control of gastric secretions, cardiac stimulation,
• FOUR LOBES: peripheral allergic responses)
o FRONTAL LOBE (thought, body movement, memories, emotions, − Histamine regulates body functions including wakefulness, feeding
moral behavior) behavior and motivation. Histamine plays a role in asthma,
o PARIETAL LOBE (taste, touch, spatial orientation) bronchospasm, mucosal edema and multiple sclerosis.
o TEMPORAL LOBE (smell, hearing, memory, emotional expression) • ACETYLCHOLINE (sleep and wakefulness cycle, signals muscles to
o OCCIPITAL LOBE (language, visual interpretation such as depth become alert)
perception) • GLUTAMATE (an excitatory amino acid)
− This is the most common excitatory neurotransmitter of your nervous
NEUROTRANSMITTERS system. It’s the most abundant neurotransmitter in your brain. It
plays a key role in cognitive functions like thinking, learning and
• Chemical substances manufactured in the neuron to aid in transmission
memory. Imbalances in glutamate levels are associated
of information
with Alzheimer’s disease, dementia, Parkinson’s
• Either inhibitory or excitatory
disease and seizures.
• Chemical substances to facilitate neurotransmission
• GAMMA-AMINOBUTRYIC ACID GABA (modulates other
• Important in right proportions to relay messages; studies showing
neurotransmitters)
differences in brains of people with some mental disorders
− GABA is the most common inhibitory neurotransmitter of your
• Play role in psychiatric illness and psychotropic medications, including
nervous system, particularly in your brain. It regulates brain activity
their actions and side effects
to prevent problems in the areas of anxiety, irritability,
• Neurotransmitter are chemical messenger that your body can’t
concentration, sleep, seizures and depression.
function without. Their job is to carry chemical signals (“messages”) from
one neuron (nerve cell) to the next target cell. • GLYCINE. Glycine is the most common inhibitory neurotransmitter in
• Your nervous system controls such functions as your: your spinal cord. Glycine is involved in controlling hearing processing,
o Heartbeat and blood pressure. pain transmission and metabolism.
o Breathing.
o Muscle movements. CAUSES OF MENTAL ILLNESS
o Thoughts, memory, learning and feelings.
o Sleep, healing and aging. • GENETICS AND HEREDITY: play a role but alone do not account for
o Stress response. development of mental illness
o Hormone regulation. • PSYCHOIMMUNOLOGY: a compromised immune system could
o Digestion, sense of hunger and thirst. contribute, especially in at-risk populations
o Senses (response to what you see, hear, feel, touch and taste). • INFECTIONS, particularly viruses, may play a role

NURSE’S ROLE IN RESEARCH AND EDUCATION

• Ensure all clients and families are well informed

• Help distinguish between facts and hypotheses
• Explain if or how new research may affect client’s treatment or
prognosis
• Provide information and answer questions

PSYCHOPHARMACOLOGY
• Psychotropic drugs
• Efficacy (maximal therapeutic effect)
NEUROTRANSMITTERS INCLUDE: • Potency (amount of drug needed for maximum effect)
• Half-life
• DOPAMINE (control of complex movements, motivation, cognition,
• Role of the FDA
regulation of emotional responses) • Off-label use (drug may be effective for treating a disease different
− Dopamine plays a role in your body’s reward system, which from one involved in original testing)
includes feeling pleasure, achieving heightened arousal and • Black box warning (serious or life-threatening side effects)
learning. Dopamine also helps with focus, concentration, memory,
sleep, mood and motivation. Diseases associated with dysfunctions
PRINCIPLES OF PSYCHOPHARMACOLOGY
of the dopamine system include Parkinson’s
disease, schizophrenia, bipolar disease, restless legs • Effect on target symptoms
syndrome and attention deficit hyperactivity disorder (ADHD). • Adequate dosage for sufficient time
Many highly addictive drugs (cocaine, methamphetamines, • Lowest effective dose
amphetamines) act directly on the dopamine system • Lower doses for older adults

1|RCJB
• Tapering rather than abrupt cessation to avoid rebound recurrence of TRICYCLIC ANTIDEPRESSANTS (TCA)
symptoms, or withdrawal
• Follow-up care EXAMPLES:
• Simple regimen to increase compliance
1. Imipramine (Tofranil)
MAJOR TRANQUILIZERS/ANTIPSYCHOTICS 2. Amitriptyline (Elavil)

EXAMPLES: DESIRED EFFECTS

prevents reuptake of norepinephrine; increased appetite; adequate
1. Haloperidol (Haldol) sleep
2. Chlorpromazine (Thorazine)
3. Clozapine (Clozaril) REPORTABLE SIGNS AND SYMPTOMS
4. Olanzapine (Zyprexa) Cardiac rhythm irregularities

DESIRED EFFECTS SIDE-EFFECTS

Decreased delusions, hallucinations, and looseness of association cardiac arrhythmias

REPORTABLE SIGNS AND SYMPTOMS NURSING CONSIDERATION

Report sore throat and avoid exposure to sunlight. Report elevated
temperature and muscle rigidity indicates NMS. • Therapeutic effects may become evident only after weeks of intake
• Check BP- hypotension
SIDE-EFFECTS • Check heart rate
Assess for akathisia, tardive dyskinesia. Torticollis, Opisthotonus.
MONOAMINE OXIDASE INHIBITORS (MAOI)
NURSING CONSIDERATION
Antidepressants
• Best taken after meals
• Check BP – hypotension EXAMPLES:
• Check CBC – leukopenia
• Parlodel/ Decanoate (antidote) 1. Tranylcypromine (Parnate)
2. Isocarboxazid (Marplan)
ANTI-PARKINSONIAN AGENTS 3. Phenelzine (Nardil)

Prevents pseudoparkinsonism DESIRED EFFECTS

Increased appetite; adequate sleep
PSEUDOPARKINSONISM is a reaction to medications that imitates the
symptoms and appearance of Parkinson's disease. The most recognizable REPORTABLE SIGNS AND SYMPTOMS
symptoms include slowed movements, muscle stiffness, and a shuffling Headache
walk. This condition is generally reversible and can be treated by stopping
the medication causing the reaction. SIDE-EFFECTS
Constipation, dizziness, drowsiness, diaphoresis
2 TYPES
NURSING CONSIDERATION
1. Dopaminergic Drugs
− Amatadine (Symmetrel) • after meals
− Levodopa-Carbidopa (Sinemet) • monitor BP
2. Anticholinergic Drugs • avoid tyramine rich foods
− Biperiden Hydrochloride (Akineton) • 2-3 weeks
− Benztropine Mesylate (Cogentin)
− Diphenhydramine Hydrochloride (Benadryl) SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRI)
DESIRED EFFECTS EXAMPLES:
muscles become less stiff; decreased pill-rolling tremors
1. Prozac
REPORTABLE SIGNS AND SYMPTOMS 2. Zoloft
Nausea, vomiting, anorexia 3. Paxil

SIDE-EFFECTS DESIRED EFFECTS

Leukopenia, agranulocytosis, hepatotoxicity, seizures Increased appetite; adequate sleep

NURSING CONSIDERATION REPORTABLE SIGNS AND SYMPTOMS

Seizures
• Best taken after meals
• Check BP- hypotension SIDE-EFFECTS
• Avoid use of Kava – increases parkinsonian symptoms Tremors
• Avoid driving
• Avoid Vit. B6 or protein rich foods (Bran, pistachios, garlic, liver, tuna) NURSING CONSIDERATION
“No to suicide patients”
MINOR TRANQUILIZERS/ ANXIOLYTICS
LITHIUM CARBONATE
anxiety disorders
Anti-Manic
EXAMPLES:
DESIRED EFFECTS
1. Diazepam (Valium)
decreased hyperactivity
2. Oxazepam (Serax)
3. Chlordiazepoxide (Librium)
REPORTABLE SIGNS AND SYMPTOMS
4. Aprazolam (Zanax)
Nausea, Anorexia, Vomiting, Diarrhea, Abdominal Cramps
DESIRED EFFECTS
SIDE-EFFECTS
Decreased anxiety, adequate sleep
Tremors

REPORTABLE SIGNS AND SYMPTOMS

NURSING CONSIDERATION
decreased respiratory rate
• after meals
SIDE-EFFECTS • Avoid activities that increase perspiration
drowsiness and physical or psychological dependence • 10 -14 days before it becomes therapeutic
• 0.5-1.5 mEq/L (Therapeutic Level)
NURSING CONSIDERATION • Mannitol (antidote)

• Administer valium separately

DISULFIRAM
• Before meals
Antabuse
• Avoid coffee

USES: Aversion therapy for treatment of alcoholism

2|RCJB
ACTION: Causes an adverse reaction when alcohol is ingested

SIDE EFFECTS

• Fatigue
• Drowsiness
• Halitosis
• Tremor
• Impotence

PATIENT TEACHING

• Avoiding alcohol (including products such as shaving cream,

aftershave, cologne, many OTC medications)
• Family should never administer without the person's knowledge

3|RCJB
PSYCH MIDTERMS
NURSE-PATIENT RELATIONSHIP
WHAT IS NURSE-PATIENT RELATIONSHIP?
Series of interaction between the nurse and the patient in which the nurse
assist the patient to attain positive behavioral change

WHAT ARE THE CHARACTERISTICS OF THE

NURSE-PATIENT RELATIONSHIP?

It is goal directed, focused on the needs of the patient, planned, time

limited and professional.

WHAT ARE THE BASIC ELEMENTS OF A THERAPEUTIC

NURSE-PATIENT RELATIONSHIP?

• Trust
• Rapport
• Unconditional positive regard
• Setting limits
• Therapeutic communication

PHASES OF NPR:

A. PRE-INTERACTION PHASE

• Begins when the nurse is assigned to a patient

• MAJOR TASK OF NURSE: to develop self-awareness
• Data gathering, planning for first interaction

B. ORIENTATION PHASE

• Begins when the nurse and the patient interacts for the first time
• Parameters of the relationship are laid
• MAJOR TASK OF THE NURSE: Establish rapport, develop trust,
assessment

C. WORKING PHASE

• The longest and most productive phase of the NPR

• MAJOR TASK: identification and resolution of the patient’s problems

D. TERMINATION PHASE

• MAJOR TASK: to assist the patient to review what he has learned

and transfer his learning to his relationship with others
• Evaluation

WHEN TO TERMINATE NPR?

• When goals have been accomplished

• When the patient is emotionally stable
• When the patient exhibits greater independence
• When the patient is able to cope with anxiety, separation, fear and loss

HOW TO TERMINATE?

• Gradually decrease interaction time

• Focus on future oriented topics
• Encourage expression of feelings
• Make the necessary referral

COMMON PROBLEMS AFFECTING NPR

TRANSFERENCE – the development of an emotional attitude of the

patient either positive or negative towards the nurse

COUNTERTRANFERENCE – transference as experienced by the nurse

RESISTANCE – development of ambivalent feelings towards self-

exploration

4|RCJB
PSYCH MIDTERMS
ANGER, HOSTILITY, AND AGGRESSION
ANGER, HOSTILITY, AND AGGRESSION INTERVENTION

Interventions are most effective and least restrictive when implemented

ANGER is a normal human emotion.
early in the cycle of aggression.

HOSTILITY AND AGGRESSION are inappropriate expressions of MANAGING THE MILIEU INCLUDES:
anger.
• Having planned activities; informal discussions
Hostility and Aggression are both rooted in anger. Aggression refers to • Scheduled one-to-one interactions; letting clients know what to
any word said or action taken with the purpose of being hurtful, harmful, expect
and with the intention of inflicting damage or other unpleasantness upon • Helping clients with conflicts to solve their problems, including
someone. Hostility, on the other hand, refers to a state of ill will and bad expression of angry feelings
feeling, where a person dislikes or hates someone or something else.
MANAGING AGGRESSIVE BEHAVIOR INCLUDES:
Hostility and Aggression are both rooted in anger, which is why they
are often confused as the same. However, that is not the case. In fact, • TRIGGERING PHASE:
hostility and aggression don’t even mean anger. The simplest way to − Approach in nonthreatening, calm manner
explain this is to understand that anger is a feeling, whereas hostility and − Convey empathy
aggression are behaviors that stem out of anger. Think of it this way, you − Listen
cry because you are sad. Similarly, you show hostility and aggression − Encourage verbal expression of feelings/deep breathing
because you are angry. Hostility and aggression are behaviors that are − Suggest going to a quieter area, or use of PRN medications
dictated by anger. − Physical activity such as walking

ANGER • ESCALATION PHASE:

− Take control
− Provide directions in firm, calm voice
ANGER is a strong, uncomfortable, emotional response to a − Direct client to room or quiet area for time out
provocation, either real or perceived. − Offer medication again
− Let client know aggression is unacceptable and nurse or staff will
Anger is a common feeling that everyone feels. It is normal, and it is even
help maintain/regain control if needed/ stand by staff
healthy to feel angry, as it helps one deal with whatever issues that need
− If ineffective to that point, obtain assistance from other staff
to be dealt with. However, how we react when we are angry is what
(show of force) to get client to take time out or take medication-
makes an impact. Some people deal with anger in an expectable
6 staff
manner by going over the issues and eventually letting them go, however,
others tend to react more violently or in a conflicting manner.
• CRISIS PHASE:
Everyone reacts differently when they are angry, some people scream, − Staff must take control of situation as determined by facility or
some turn red, some cry, some glare, etc. However, some people turn agency policy (trained in techniques for behavioral
violent. Aggression refers to any word said or action taken with the management)
purpose of being hurtful, harmful, and with the intention of inflicting − Use restraint or seclusion only if necessary- consent, 24, 15-30,
damage or other unpleasantness upon someone. In most cases,
aggression occurs in retaliation to something someone else said or did. • RECOVERY PHASE as client regains control:
− Talk about the situation or trigger
However, in some cases, the aggression can be unprovoked. This could − Help client relax or sleep
be due to repressed anger, or misplaced anger, i.e. taking the anger of − Explore alternatives to aggressive behavior
something else out on someone or something else. − Provide documentation of any injuries
− Staff debriefing

HOSTILITY AND AGGRESSION • POSTCRISIS PHASE:

− Client is removed from any restraint or seclusion and rejoins the
HOSTILITY IS AN EMOTION EXPRESSED BY: milieu
− Calm discussion of behavior; no lecturing or chastising; return to
• Verbal abuse activities, groups, and so forth
• Lack of cooperation − Focus is on appropriate expression of feelings, resolution of
• Violation of rules or norms problems or conflicts in nonaggressive manner
• Threatening behavior (verbal aggression)

Hostility, on the other hand, refers to a state of ill will and bad feeling, CULTURAL CONSIDERATIONS
where a person dislikes or hates someone or something else. For example:
if your colleague insulted you in front of your boss, chances are that you • Cultural views/values affect expression of anger.
are going to dislike or even hate him forever, or at least until the time you • Ethnic or minority status can play a role in diagnosis and treatment of
are working there. The colleague must also probably dislike or hate you, psychiatric illness.
which is why he insulted you in the first place. This feeling of usually mutual • Some culture-bound syndromes involving aggressive, agitated, or
dislike is called hostility. However, it need not be mutual, it could be one violent behavior.
sided. For example, if the colleague didn’t insult you on purpose and tries o Hwa-Byung
to apologize and you continue to hate him and refuse to accept his o Bouffée délirante
apology, then you are showing hostility towards him. o Amok

ETIOLOGY OF HOSTILITY AND AGGRESSION QUESTION #1

Is the following statement true or false?

NEUROBIOLOGIC THEORIES: decreased serotonin, increased
dopamine and norepinephrine; structural damage to limbic system, Hostility and aggression are terms that can be used interchangeably.
damage to frontal or temporal lobes
Answer to Question #1: False
PSYCHOSOCIAL THEORIES: failure to develop impulse control and
Rationale: Hostility and aggression are two different terms.
ability to delay gratification
Hostility means verbal aggression. Physical aggression involves attack on
or injury to another person or destruction of property.
APPLICATION OF THE NURSING PROCESS
TREATMENTS
DATA ANALYSIS
Focus on treating underlying/comorbid psychiatric diagnosis
COMMON NURSING DIAGNOSES:
LITHIUM: bipolar disorder, conduct disorders, intellectual disability
• Risk for Other-Directed Violence
CARBAMAZEPINE OR VALPROATE: dementia, psychosis, personality
• Ineffective Coping
disorders
ATYPICAL ANTIPSYCHOTICS: dementia, brain injury, intellectual
disability, personality disorders

5|RCJB
BENZODIAZEPINES: dementia Goal is to teach angry, hostile, potentially aggressive clients to express
HALOPERIDOL AND LORAZEPAM: decrease agitation or aggression feelings verbally and safely without threats or harm to others or
and psychotic symptoms destruction of property.

QUESTION #3
THE NURSING PROCESS
During which phase does staff debriefing occur?
ASSESSMENT
A. Escalation phase
• Be aware of factors influencing aggression in psychiatric B. Crisis phase
environment/unit milieu C. Recovery phase
• Individual clients D. Postcrisis phase
o History of violent or aggressive behavior in the past
o How client handles anger Answer to Question #3: C. RECOVERY PHASE
o Beliefs about anger
• Assess behavior to determine phase of aggression cycle (see Table RATIONALE: Staff debriefing occurs during the recovery phase to allow
11.1) for discussion of the event, how it was handled, what worked well or
needed improvement, and how the situation could have been defused
DATA ANALYSIS AND OUTCOME IDENTIFICATION more effectively.

• Data analysis WORKPLACE HOSTILITY

o Risk for other-directed violence
o Ineffective coping
• Sentinel event alert concerning intimidating and disruptive behaviors
• Outcome identification: Client will:
(The Joint Commission on Accreditation of Healthcare Organizations
o Not harm self or threaten others
[JCAHO], 2008)
o Refrain from intimidating/frightening behaviors
• Overt actions: verbal outbursts, physical threats
o Describe feelings and concerns without aggression
• Passive activities: refusing to perform assigned tasks, uncooperative
o Comply with treatment
attitude
• Occurrence of disruptive and intimidating behaviors
INTERVENTIONS • In 2016, the JCAHO added workplace bullying.
• New standards of leadership
• Most effective and least restrictive when implemented early in the
o Code of conduct defining acceptable and inappropriate,
aggression cycle
unacceptable behaviors
• MANAGING THE ENVIRONMENT o Process for managing disruptive/unacceptable behavior
o Planned activities o Education on expected professional behavior
o Scheduling one-to-one interactions o Zero tolerance = all are held accountable
o Offer opportunity for problem-solving or conflict resolution
o Consider safety of other patients
• Managing aggressive behavior: TRIGGERING PHASE COMMUNITY-BASED CARE
o Approach in a nonthreatening, calm manner
o Convey empathy • Effective management of comorbid conditions
o Encourage verbal expression of angry feelings o Regular follow-up appointments
o Use clear, simple, short statements o Compliance with prescribed medication
o Allow client time for self-expression o Participation in community support programs
o Suggest client go to a quieter area • Anger management groups help clients express their feelings and to
o Offer PRN medications if ordered learn problem-solving and conflict-resolution techniques.
o Suggest physical activity, such as walking • Studies on client assaults of staff in community
• Assaults by clients in community residences
QUESTION #2
SELF-AWARENESS ISSUES
Is the following statement true or false?

A client with a history of violent or aggressive behavior is more likely to
exhibit similar behavior in the future.
Answer to Question #2: TRUE
RATIONALE: A history of violent or aggressive behavior is one of the best
predictors of future aggression.
• Be aware of own management of anger.
• Practice and gain experience in restraint/seclusion before using.
• Be calm, nonjudgmental, and nonpunitive.
• Learn from watching experienced nurses to deal with hostile or
aggressive clients.

• Managing aggressive behavior: ESCALATION PHASE

o Take control
o Provide directions in a firm, calm voice
o Direct client to time-out in quiet room or area
o Communicate that aggressive behavior is not acceptable
o Offer medication if refused in triggering phase
o Show of force
• Management of aggressive behavior: CRISIS PHASE
o Take charge of situation for safety
o Restraint
− Only staff with training should participate in restraint.
− Four to six trained staff members are needed.
− Inform client that behavior is out of control and staff is taking
measures for safety.
• Management of aggressive behavior: RECOVERY PHASE
o Talk about situation or trigger
o Help client relax or sleep
o Help client explore alternatives to aggressive behavior
o Assess and document any injuries
o Debrief staff
o Encourage other clients to talk about feelings
− Do not discuss aggressive client in detail with other clients
• Management of aggressive behavior: POSTCRISIS PHASE
o Remove patient from restraint or seclusion as soon as criteria met
o Calmly discuss behavior (no lecturing or chastising)
o Give client feedback for regaining control
o Reintegrate client as soon as he or she is able to participate

EVALUATION

Care is most effective when anger defused in an earlier stage.

6|RCJB
PSYCH MIDTERMS
ABUSE AND VIOLENCE
CRISIS AND CRISIS INTERVENTION PHASES OF A CRISIS

CRISIS 1. DENIAL - initial reaction

2. INCREASED TENSION - the person recognizes the presence of a crisis
situation that occurs when an individual’s habitual coping ability and continues to do ADL
becomes ineffective to meet the demands of a situation
3. DISORGANIZATION - the person is preoccupied with the crisis and is
unable to do ADL
Crisis is a state of feeling; an internal experience of confusion and anxiety
to the degree that formerly successful coping mechanisms fail us and 4. ATTEMPTS TO REORGANIZE - the individual mobilizes previous coping
ineffective decisions and behaviors take their place. As a result, the mechanisms
person in crisis may feel confused, vulnerable, anxious, afraid, angry,
guilty, hopeless and helpless. FOUR STAGES OF CRISIS
CHARACTERISTICS OF A CRISIS STATE • Exposure to stressor
• Increased anxiety when customary coping is ineffective
• Individualized
• Increased efforts to cope
• lasts for 4-6 weeks
• Disequilibrium and significant distress
• person affective becomes passive and submissive

INTIMATE PARTNER VIOLENCE (IPV)

TYPES OF CRISES
Who are the persons protected by R.A. 9262 (Anti-
MATURATIONAL/DEVELOPMENTAL CRISIS
Violence Against Women and Their Children Act of 2004
MATURATIONAL CRISIS also called developmental crisis. These are (“VAWC”)?
predictable events in a person’s life which includes getting married,
having a baby and leaving home for the first time. The law recognizes the unequal relations between a man and a woman
in an abusive relationship where the woman is usually at a disadvantage.
• The result of normal processes of growth and development.
• Commonly occurs at specific developmental periods of life. BATTERED WIFE SYNDROME
• It is predictable in nature and normally occurs as a part of life.
• An individual is vulnerable based on their equilibrium. cycle of domestic violence characterized by wife beating by the
husband, humiliation and other forms of aggression
EXAMPLES:
LOW-SELF ESTEEM - most common trait of abusive men
• Birth DEPENDENCE - most common trait of abuse women
• Adolescence
• Marriage CHARACTERISTICS OF ABUSIVE HUSBANDS
• Death
1. They usually came from violent families
SITUATIONAL CRISIS 2. They are immature, dependent, non-assertive
3. They have strong feelings of inadequacy
SITUATIONAL CRISIS – unexpected or sudden events that imperils ones
integrity. Included in this type of crisis are: loss of a job, death of a loved PHASES OF BWS
one or relative and physical and emotional illness of a family member or
an individual. 1. TENSION BUILDING PHASE - involves minor battering incidents
2. ACUTE BATTERING INCIDENT - more serious form of battering
• An unexpected personal stressful event occurs with little advance
warning 3. AFTERMATH/HONEYMOON STAGE - the husband becomes loving
• It is less predictable in nature. and gives wife hope
• The event threatens an individual’s equilibrium.
In the tension-building phase, there is minor battering whereby the
woman allows herself to be abused for abuse which she considers minor.
EXAMPLES:
She thus tries to pacify the batterer through a kind and nurturing behavior
• Accident or by simply staying out of his way to prevent the escalation of violence.
• Illness or serious injury of self or family member This is a slippery slope because the woman harbors the belief that the
• Loss of a job man has the right to abuse her in the first place.
• Bankruptcy
The second phase acute battering incident is characterized by brutality
• Relocation/geographical move
and destructiveness whereby the woman has no control and it is only the
• Divorce
batterer that may put an end to the violence.

SOCIAL CRISIS The final phase of the cycle of violence begins when the acute battering
incident ends. During this tranquil period, the batterer may show a tender
ADVENTITIOUS CRISIS – also called social crisis. Included in this category and nurturing behavior towards his partner because he becomes
are: natural disasters like floods, earthquakes or hurricanes, war, terrorist conscious of his cruelty and therefore tries to compensate by asking for
attacks, riots and violent crimes such as rape and murder. the woman’s forgiveness and giving empty promises of never repeating
the assault. On the other hand, the battered woman falsely convinces
• An event that is uncommon or unanticipated.
herself that the battery will never happen again, that the batterer will
• The event often involves multiple losses or extensive losses.
change and that this “good and caring man” is the real person whom she
• It can occur due to a major natural or man-made event.
loves.
• It is unpredictable in nature.
• The event poses a severe threat to an individual’s equilibrium. In a twisted reality, a battered woman usually believes that she is the sole
anchor of the emotional stability of the batterer. She thus feels that she is
EXAMPLES: responsible for the batterer’s well-being. In addition, she believes that she
is the reason why the batterer commits his atrocious acts. Thinking that her
• Flood
acts are wrong, she feels that she has caused the unfortunate events to
• Fire
happen. This is the phase where the woman is tormented psychologically.
• Tornado
• Hurricane
PRIORITY IN THE CARE OF THE BATTERED WIFE
• Earthquake
• War
• PROVISION OF SHELTER
• Riot
• Violent crime
CHILD ABUSE
happens when an older adult takes advantage of his authority over a
younger child

7|RCJB
VIOLENCE: Refers to the use of force
INTIMATE PARTNER VIOLENCE
NEGLECT: Lack of provision of those things which are necessary for the
child's growth and development • Mistreatment or misuse of one person by another in context of
emotionally intimate relationship
PHYSICAL ABUSE: Abuse in the form of inflicting pain • Psychological abuse (emotional abuse) can be overt or subtle.
• Physical abuse: shoving, pushing, battering, choking
EMOTIONAL ABUSE: Abuse in the form of insults and undermining one's • Sexual: assaults during sexual relations, rape
confidence • Rates higher among women
• Increased rates during pregnancy
NEGLECT is the failure of a parent or other caregiver to provide for a • Domestic violence occurs in same-sex relationships with same statistical
child’s basic needs. Neglect generally includes the following categories: frequency.
o Victims have fewer protections.
PHYSICAL (e.g., failure to provide necessary food or shelter, lack of • Clinical picture
appropriate supervision) o Abuse often perpetrated by husband against wife
MEDICAL (e.g., failure to provide necessary medical or mental health o Abuser’s view of wife as belonging to him; strong feelings of
treatment, withholding medically indicated treatment from children with inadequacy, low self-esteem; poor problem-solving and social skills
life-threatening conditions) o Increasing violence, abuse with any signs of independence
EDUCATIONAL (e.g., failure to educate a child or attend to special o Dependency trait most commonly found in abused women who
education needs) stay with their husbands
EMOTIONAL (e.g., inattention to a child’s emotional needs, failure to • Cycle of abuse and violence
provide psychological care, permitting a child to use alcohol or other o Violent episode → honeymoon period → tension-building phase →
drugs) violent episode
• Assessment
PHYSICAL ABUSE is a nonaccidental physical injury to a child caused by o Victims do not commonly seek direct help for abuse.
a parent, caregiver, or other person responsible for a child and can − Some may be seeking treatment for other conditions.
include punching, beating, kicking, biting, shaking, throwing, stabbing, • Ask all clients if they feel safe
choking, hitting (with a hand, stick, strap, or other object), burning, or • Ask questions about safety (see Box 12.2)
otherwise causing physical harm. • Treatment and interventions
o Laws related to domestic violence; arrest
PHYSICAL DISCIPLINE, such as spanking or paddling, is not considered o Restraining order/protection order
abuse as long as it is reasonable and causes no bodily injury to the child. o Recognition of stalking
Injuries from physical abuse could range from minor bruises to severe o Shelters
fractures or death. o Individual psychotherapy/counseling, group therapy, support and
self-help groups
EMOTIONAL ABUSE (or psychological abuse) is a pattern of behavior o Treatment for PTSD
that impairs a child’s emotional development or sense of self-worth. This
may include constant criticism, threats, or rejection as well as withholding QUESTION #1
love, support, or guidance. Emotional abuse is often difficult to prove,
and, therefore, child protective services may not be able to intervene Is the following statement true or false?
without evidence of harm or mental injury to the child
The honeymoon period of violence often occurs before the first episode
of violence.
CHARACTERISTICS OF ABUSIVE PARENTS
1. They came from violent families Answer to Question #1: FALSE
2. They were also abused by their parents
3. They have inadequate parenting skills RATIONALE: The honeymoon period occurs after an episode of violence;
4. They are socially isolated because they don’t trust anyone this is the period in which the abuser expresses regret and then apologizes
5. They are emotionally immature and promises it will never happen again.
6. They have negative attitude towards the management of the abused
CHILD ABUSE
COMMON INDICATORS OF CHILD ABUSE
• Intentional injury of a child
1. Serious injuries in various stages of healing
o Physical abuse or injuries
2. Healthy hair in various length
o Neglect or failure to prevent harm
3. Apathy
o Failure to provide adequate physical or emotional care or
4. Depression
supervision
5. Excessive knowledge of sex
o Abandonment
6. Self-Esteem is low
o Sexual assault or intrusion
o Overt torture or maiming
WHAT IS THE PRIORITY IN A VICTIM OF CHILD ABUSE? • Clinical picture of parents
o Minimal parenting knowledge and skills
(R.A. 7610) - requires reporting of suspected cases to authorities within o Emotionally immature, needy, incapable of meeting own needs
48 hours o Frequently view children as property
o Cycle of family violence: adults raising children in same way they
were raised
CLINICAL PICTURE OF ABUSE AND VIOLENCE − Adults who were victims of abuse frequently abuse their own
children.
ABUSE: wrongful use and maltreatment of another • Detection and accurate identification are the first steps (see Box 12.3).
Perpetrator typically someone the person knows • Report suspected child abuse
o Nurse does not have to decide for certainty if abuse occurred.
Victims across life span: spouses, partners, children, elderly parents • Treatment and intervention
o Child’s safety and well-being is a priority.
TYPES OF INJURIES o Psychiatric evaluation
- Physical o Therapy may be indicated over significant period.
- Psychological Effect on survivors o Approach depends on the age of a child.
o Social services involvement
CHARACTERISTICS OF VIOLENT FAMILIES o Family therapy/requirements for parents

• FAMILY VIOLENCE: spouse battering; neglect and physical,

emotional, or sexual abuse of children; elder abuse; marital rape
ELDER ABUSE
• Common characteristics
o Social isolation • Maltreatment of older adults
o Abuse of power and control o Physical, sexual, psychological abuse
o Alcohol and other drug abuse o Neglect of self-neglect
o Intergenerational transmission process o Financial exploitation
o Denial of adequate medical treatment
• Estimated 10% of population over age 65 abused by caregivers.
CULTURAL CONSIDERATIONS
• 60% to 65% of victims are women.
• Domestic violence spanning families of all ages and from all ethnic, • People who abuse elders almost always in caretaker role or elders
racial, religious, socioeconomic, and sexual orientation backgrounds depend on them in some way.
• Battered immigrant women at particular risk • Most cases when one older spouse is taking care of another
o Face legal, social, and economic problems different from the U.S. • Bullying between residents in senior living facilities
citizens

8|RCJB
• Elders often reluctant to report abuse o Prophylactic treatment for STIs, pregnancy
o Want to protect family members o Counseling
o Fear losing support o Supportive therapy
• Clinical picture: variable depending on the type of abuse
• Assessment (possible indicators, see Box 12.4)
• Treatment and intervention
COMMUNITY VIOLENCE
o Caregiver stress relief
o Additional resources • School violence (homicides, suicides, theft, violent crimes)
o Possible removal of elder or caregiver • Bullying
o Ostracism
QUESTION #2 • Hazing
• Effects on children, young adults
Is the following statement true or false? • Violence on a larger scale (e.g., terrorism)
o PTSD and depression
Adults who were abused as children are more likely to abuse their own
children. QUESTION #3

Answer to Question #2: TRUE Which of the following statements about rape is most accurate?

RATIONALE: The tendency for adults to raise children in the same way A. It is a highly reported crime.
they were raised perpetrates the cycle of family violence. Adults who B. Most rapes are premeditated.
were victims of abuse as children frequently abuse their own children. C. Rape requires ejaculation.
D. Provocative dress invites rape.

RAPE Answer to Question #3: B. MOST RAPES ARE PREMEDITATED.

(R.A. 8353)- "The Anti-Rape Law of 1997. " Rape is committed: RATIONALE: Most rapes are premeditated.
By a man who shall have sexual intercourse with a woman under any of
Rape, an underreported crime, requires only slight penetration of the
the following circumstances: Through force, threat, or intimidation. When
vulva. Full erection or ejaculation is not necessary. Provocative dress
the victim is deprived of reason or is unconscious.
leading to rape is a myth.
it is generally considered as an act of hostility, anger or violence
SELF-AWARENESS ISSUES
WHAT ARE THE ESSENTIAL ELEMENTS NECESSARY TO DEFINE
AN ACT OF RAPE? • Be aware of own beliefs.
• Contain feelings of horror or revulsion, focus on client’s needs.
• Use of threat or force o Validate the client’s feelings.
• Lack of Consent of the victim • Ask all women about abuse.
• Actual penetration of penis into the vagina • Help client focus on the present.

RAPE-TRAUMA SYNDROME (RTS)

WHAT IS RAPE-TRAUMA SYNDROME (RTS)

It refers to a group of signs and symptoms experienced by a victim in

reaction to rape

WHAT ARE THE PHASES OF THE RAPE TRAUMA SYNDROME?

1. ACUTE PHASE - characterized by shock, numbness, and disbelief

2. DENIAL - characterized by the victim's refusal to talk about the event
3. HEIGHTENED ANXIETY - characterized by fear, tension and
nightmares
4. STAGE OF REORGANIZATION - the victim's life normalizes

WHAT IS THE PRIORITY IN THE CARE OF A RAPE VICTIM?

• PRESERVATION OF EVIDENCE

RAPE AND SEXUAL ASSAULT

• Perpetration of act of sexual intercourse with person against his or her
will and without consent
o Will overcome by force, fear of force, drugs, intoxicants
• Crime of violence and humiliation of victim expressed through sexual
means
• Also rape if victim cannot exercise rational judgment
• Only slight penetration necessary
• Committed by strangers (~28% of rapes), acquaintances, married
people, people of same sex
• Date rape (acquaintance rape)
• Highly underreported crime
• Most commonly occurs in victim’s neighborhood, often inside or near
home
• Most rapes are premeditated.
• Male rape is significantly underacknowledged and underreported.
• Dynamics of rape
o Generally accepted that rape is not sexual crime
o Exertion of power, control, infliction of pain or punishment.
o Feminist theory: women historically objects for aggression.
o Primary motivation of victim is to stay alive.
o Severe physical and psychological trauma
o Treatment has improved, but many still believe a woman provokes
rape with behavior.
o Common myths (see Box 12.5)
• Assessment
o Physical examination to preserve evidence
o Description of what happened
o Rape kits, rape protocols
• Treatment and intervention
o Immediate support
o Education (see Box 12.6)
o Give control back to victim

9|RCJB