PSYCHIATRIC NURSING

SEMINAR ON ::-

PSYCHOANALYTICAL THEORY
Adarsh.s 13th batch MSc nursing Govt. college of nursing calicut

Psychoanalytical theory is a branch of psychology developed in the late 1800s and early 1900s by Austrian psychologist Sigmund Freud. Psychoanalysis expanded, criticized and developed in different directions, mostly by Freud's students (Alfred Adler and Carl G. Jung, and later the neoFreudians as Erich Fromm, Karen Horney and H. S. Sullivan).

PERSONALITY
 Derived from the Greek word persona

The DSM IV-TR (2000)defines personality traits as enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts  It is the pattern developed by the integrated functioning of all the traits and characteristics of an individual. (Cruze)


SIGMUND FREUD THE FATHER FREUD: OF PSYCHOANALYSIS

 Born on May 6, 1856, in Freiburg, a small town in

Moravia, which is now part of the Czech Republic  At 4 years old, his father moved the family to Vienna, where Freud spent most of his life  After his education in France, he returned to Vienna and began clinical work with hysterical patients.  Between 1887 and 1897, his work with these patients led him to develop psychoanalysis.  He died in London in 1939.

FREUD'S PSYCHOANALYTIC THEORY OF PERSONALITY DEVELOPMENT Freud's theory of personality development describes three major categories:  The development of personality  The organization or structure of personality  The dynamics of personality

THE DEVELOPMENT OF PERSONALITYTOPOGRAPHIC MIND THE TOPOGRAPHIC THEORY OF MIND

 This concept was advanced by Freud in the year 1900,

in the book called the interpretation of dreams.  Freud explains the development of the personality by describing three levels of consciousness: -The conscious -Preconscious (subconscious) -Unconscious

The Conscious


The conscious system in Freud's topographical model is the part of the mind in which perceptions coming from the outside world or from within the body or mind are brought into awareness.  Consciousness is a subjective phenomenon whose content can be communicated only by means of language or behavior.  Freud assumed that consciousness used a form of neutralized psychic energy that he referred to as attention cathexis, whereby persons were aware of a particular idea or feeling as a result of investing a discrete amount of psychic energy in the idea or feeling.

The Preconscious
 The preconscious system is composed of those mental

events, processes, and contents that can be brought into conscious awareness by the act of focusing attention.  The preconscious interfaces with both unconscious and conscious regions of the mind. To reach conscious awareness, contents of the unconscious must become linked with words and thus become preconscious.  The preconscious system also serves to maintain the repressive barrier and to censor unacceptable wishes and desires.

The Unconscious
 The unconscious system is dynamic. Its mental contents and

processes are kept from conscious awareness through the force of censorship or repression and it is closely related to instinctual drives.  The unconscious system is characterized by primary process thinking, which is principally aimed at facilitating wish fulfilment and instinctual discharge. It is governed by the pleasure principle and, therefore, disregards logical connections.  Memories in the unconscious have been divorced from their connection with verbal symbols.

THE ORGANIZATION OR STRUCTURE OF PERSONALITY- THE STRUCTURAL THEORY OF MIND

 The organization or structure of the personality (Freud,

1960) consists of the id, the ego and the superego  In 1923, in The Ego and The Id, Freud divided the mental apparatus into three dynamic structures: The id, ego, and superego
Reality Id Pleasure principle Ego Reality principle Super Ego Morality principle

The Id
 The Id is the original state of human mental apparatus with

which a new born baby is born.  it is totally unconscious .  It is the part of ones nature that reflects basic or innate desires such as pleasure-seeking behavior, aggression, and sexual impulses.  The id seeks instant gratification; causes impulsive, unthinking behavior; and has no regard for rules or social convention.  It is characterised by primary process thinking and is based on pleasure principle, lacking any direct link with reality

The superego
 The superego is the part of a persons nature that reflects

moral and ethical concepts, values, and parental and social expectations; therefore, it is in direct opposition to the id.  The superego establishes and maintains an individual's moral conscience on the basis of a complex system of ideals and values internalized from parents. (5 or 6 years)  Freud viewed the superego as the heir to the Oedipus complex.  The superego then serves as an agency that provides ongoing scrutiny of a person's behavior, thoughts, and feelings; it makes comparisons. It is based on morality principle/ perfection principles

The ego
 The ego, is the balancing or mediating force between the id

and the superego.  The ego represents mature and adaptive behavior that allows a person to function successfully in the world.  Freud believed that anxiety resulted from the egos attempts to balance the impulsive instincts of the id with the stringent rules of the superego.  Ego is also called the rational self or the reality principles, begins to develop between the ages of 4 and 6 months.  The ego experiences the reality of the external world, adapts to it, and responds to it.

Freuds components of personality

THE DYNAMICS OF PERSONALITY

 According to Freud's explanation of the dynamics of the

personality, each person has a certain amount of psychic energy to cope with the problems of everyday living.  The id's energy is used to reduce tension and may be exhibited, for example, by frequency of urination, daydreaming, or eating.  The ego's energy controls the impulsive actions of the id and the moralistic and idealistic actions of the superego.  One whose energy is controlled primarily by the superego generally behaves in an overly moralistic manner because the structure of the personality (eg, superego) monopolizes the psychic energy that governs the person's behavior

EGO DEFENSE MECHANISMS

 Freud believed the self or ego used ego defense

mechanisms, which are methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events.  For example, a person who has been diagnosed with cancer and told he has 6 months to live but refuses to talk about his illness is using the defense mechanism of denial, or refusal to accept the reality of the situation.

EGO DEFENSE MECHANISMS

 Compensation :Overachievement in one area to offset real

or perceived deficiencies in another area Napoleon complex: diminutive man becoming emperor Nurse with low self-esteem works double shifts so her supervisor will like her.  Conversion: Expression of an emotional conflict through the development of a physical symptom, usually sensorimotor in nature A teenager forbidden to see X-rated movies is tempted to do so by friends and develops blindness, and the teenager is unconcerned about the loss of sight

EGO DEFENSE MECHANISMS

 Denial: Failure to acknowledge an unbearable condition;

failure to admit the reality of a situation, or how one enables the problem to continue Diabetic eating chocolate candy Spending money freely when broke Waiting 3 days to seek help for severe abdominal pain  Displacement: Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings A person who is mad at the boss yells at his or her spouse. A child who is harassed by a bully at school mistreats a younger sibling

EGO DEFENSE MECHANISMS

 Dissociation: Dealing with emotional conflict by a

temporary alteration in consciousness or identity Amnesia that prevents recall of yesterdays auto accident An adult remembers nothing of childhood sexual abuse  Fixation: Immobilization of a portion of the personality resulting from unsuccessful completion of tasks in a developmental stage. Never learning to delay gratification Lack of a clear sense of identity as an adult

EGO DEFENSE MECHANISMS

 Identification: Modelling actions and opinions of

influential others while searching for identity, or aspiring to reach a personal, social, or occupational goal Nursing student becoming a critical care nurse because this is the specialty of an instructor she admires.  Intellectualization: Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions Person shows no emotional expression when discussing serious car accident.

EGO DEFENSE MECHANISMS

 Introjection: Accepting another persons attitudes, beliefs,

and values as ones own A person who dislikes guns becomes an avid hunter, just like a best friend  Projection: Unconscious blaming of unacceptable inclinations or thoughts on an external object Man who has thought about same-gender sexualrelationship but never had one, beats a man who is gay. A person with many prejudices loudly identifies others as bigots

EGO DEFENSE MECHANISMS

 Rationalization: Excusing own behavior to avoid guilt,

responsibility, conflict, anxiety, or loss of self-respect Student blames failure on teacher being mean. Man says he beats his wife because she doesnt listen to him.  Reaction Formation: Acting the opposite of what one thinks or feels Woman who never wanted to have children becomes a super-mom. Person who despises the boss tells everyone what a great boss she is.

EGO DEFENSE MECHANISMS

 Regression: Moving back to a previous developmental

stage in order to feel safe or have needs met Five-year-old asks for a bottle when new baby brother is being fed. Man pouts like a four-year-old if he is not the center of his girlfriends attention  Repression: Excluding emotionally painful or anxietyprovoking thoughts and feelings from conscious awareness Woman has no memory of the mugging she suffered yesterday. Woman has no memory before age 7 when she was removed from abusive parents

EGO DEFENSE MECHANISMS

 Resistance: Overt or covert antagonism toward

remembering or processing anxiety-producing information Nurse is too busy with tasks to spend time talking to a dying patient. Person attends court-ordered treatment for alcoholism but refuses to participate  Sublimation: Substituting a socially acceptable activity for an impulse that is unacceptable Person who has quit smoking sucks on hard candy when the urge to smoke arises. Person goes for a 15-minute walk when tempted to eat junk food.

EGO DEFENSE MECHANISMS

 Substitution: Replacing the desired gratification with one that is more

readily available one who would like to have her own children opens a day care centre.  Suppression: Conscious exclusion of unacceptable thoughts and feelings from conscious awareness A student decides not to think about a parents illness in order to study for a test. A woman tells a friend she cannot think about her sons death right now.  Undoing: Exhibiting acceptable behavior to make up for or negate unacceptable behavior A person who cheats on a spouse brings the spouse a bouquet of roses. A man who is ruthless in business donates large amounts of money to charity.

THE THEORY OF PSYCHOSEXUAL DEVELOPMENT

 In 1905, in Three essays on the theory of sexuality,

Freud enunciated his theory of infantile sexuality and described the psychosexual stages of development.  In his psychosexual theory, Freud also describes five phases of the psychobiologic process that have a great impact on personality development: oral, anal, phallic or oedipal, latency, and genital

THE ORAL PHASE

 The oral phase (0 to 18 months) is a period in which

pleasure is derived mainly through the mouth by the actions of sucking or biting. Major site of gratification is the oral region. It consists of 2 phases: 1) Oral erotic phase(Sucking) 2) Oral sadistic phase(biting)  Psychiatric syndromes result from fixation at this stage: 1) Dependent personality traits and disorder 2) Schizophrenia ( oral and pre oral stage) 3) Severe mood disorder 4) Alcohol dependence syndrome and drug dependence

THE ANAL PHASE

 During the anal phase (18 months to 3 years), attention

focuses on the excretory function, and the foundation is laid for the development of the superego.  Major site of gratification is the anal and pre anal area. Major achievement is the toilet training.(Sphincter control). It consist of 2 phases: 1) Anal erotic phase(Excretion) 2) Anal sadistic phase(Holding and letting go at will )  Psychiatric syndromes result from fixation at this stage: 1)Obsessive compulsive personality traits and disorder 2) )Obsessive compulsive disorder(Anal sadistic phase)

THE PHALLIC OR OEDIPAL STAGE

 In the phallic or oedipal stage (3 to 7 years), a stage of

growth and development, the child identifies with the parent of the same sex, forms a deep attachment to the parent of the opposite sex, develops a sexual identity of male or female role, and begins to experience guilt.  Major site of gratification is the genital area; genital masturbation is common at this stage.  Psychiatric syndromes result from fixation at this stage: 1) Sexual deviations 2) Sexual dysfunction 3) Neurotic disorders

According to Freud , development is different in both sexes.  Male development: The boy develops castration anxiety (fear of castration at the hand of his father in retaliation for the boys desire to replace his father in his mothers affections.). This leads to formation of the Oedipus complex Oedipus complex is usually resolves by identification with father attempting to adopt his characteristics.  Female development: The girl develops penis envy(discontent with female genitalia following a fantasy that they result from loss of penis).this is theorized by Freud to lead a wish to receive the penis and to bear a child. Resolution occurs by identification with the mother. This phase has been called as Electra complex.

THE LATENCY PHASE

 During the latency phase (7 years to adolescence), the person learns

to recognize and handle reality, has a limited sexual image, develops an inner control over aggressive or destructive impulses, and experiences intellectual and social growth.  Oedipus and Electra complex is usually resolved at the beginning of this stage. This is a stage of relative sexual quiescence. Superego is formed at this stage. Sexual drive is chanalised in to socially appropriate goals like development of interpersonal relationships, sports, schoolwork etc  Psychiatric syndromes result from fixation at this stage: Neurotic disorders

THE GENITAL PHASE

 In the genital phase (puberty or adolescence into adult life), the final

stage of psychosexual development, the individual develops the capacity for object love and mature sexuality and establishes identity and independence.  Adult sexuality develops with capacity for intimacy(puberty and respect for others. gradual release from parental controls with more influence of peer group.)true self identity develops.  Psychiatric syndromes result from fixation at this stage: Neurotic disorders

THEORY OF DREAMS
 The rich complex of data derived from Freud's clinical exploration of

his patients' dreams and the profound insights derived from his associated investigation of his own dreams were distilled into the landmark publication in 1900 of The Interpretation of Dreams.  Basing his analysis on these data, Freud presented a theory of the dream that paralleled his analysis of psychoneurotic symptoms. He viewed the dream experience as a conscious expression of an unconscious fantasy or wish not readily accessible to conscious waking experience.  The dream images represented unconscious wishes or thoughts disguised through a process of symbolization and other distorting mechanisms.

DREAM WORK
 The dream work used a variety of mechanisms, making it possible for

more neutral images to represent repressed infantile components.  These mechanisms included symbolism, displacement, condensation, projection, and secondary revision.
 SYMBOLISM

Symbolism is a complex process of indirect representation that in which the symbol is representative of or substitute for some other idea from which it derives a secondary significance that it does not possess itself.

 DISPLACEMENT

The mechanism of displacement refers to the transfer of amounts of energy (cathexis) from an original object to a substitute or symbolic representation of the object.  CONDENSATION Condensation is the mechanism by which several unconscious wishes, impulses, or attitudes can be combined into a single image in the manifest dream content.

 PROJECTION

The process of projection allows dreamers to rid themselves of their own unacceptable wishes or impulses and experience them as emanating in the dream from other people or independent sources.  SECONDARY REVISION Secondary revision uses intellectual processes that more closely resemble organized thought processes governing rational states of consciousness. It is through secondary revision, then, that the logical mental operations characteristic of the secondary process are introduced into and modify dream work.

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

 The term psychoanalysis literally means the breaking down

of the psyche into its constituent elements and their dynamic processes.  The current practice of psychoanalysis and psychoanalytic psychotherapy represents a century of revolution and evolution radical revision and gradual refinement by both its creator Sigmund Freud and his followers and detractors

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

HISTORY
 Pre-Freud: 18th and Early 19th Centuries  Eighteenth-century mesmerism, originated by Franz Anton Mesmer (1733 to 1815), sowed the earliest seed of psychoanalytic practice. Using a procedure referred to as the magnetic pass, Mesmer and his patient would sit face to face with knees touching, and the charismatic Mesmer would cast a spell through sweeping movements across the patient's body. In successful cases, a magnetic crisis, or hysterical seizure, ensued, after which the patient's symptoms would disappear.  Nineteenth-century followers of Mesmer remained within the same basic framework, retaining both the general theory of magnetic fluid and the patient's acting as a passive recipient of the therapist's active maneuvers. Changes in theory were minor until James Braid originated the term hypnotism to describe the earlier process.

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

HISTORY
Freud: Late 19th and Early 20th Century  Use of Hypnosis
The emergence of psychoanalysis as created by Freud in the late 1800s was a direct outgrowth of the treatment of neurotic patients at that time by physicians in general practice the use of hypnosis for hysteria. Freud used hypnosis only to enable patients to suppress or deny their symptoms while under its influence.

 Cathartic Method
At that time, the hypnotic method was used strictly for psychic catharsis that is, attempting to gain access to patients' reminiscences that they could not remember under any other conditions. The particular method that Freud borrowed was a form of cathartic therapy, originally Breuer's invention, that Freud revived 10 years later in 1887 at Breuer's personal suggestion

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

HISTORY
 Concentration Method
Freud developed a strategy in which he requested that the patient lie on a couch with eyes closed and then concentrate on a particular symptom and attempt to recall past memories. Freud would place his hands on the patient's forehead as a physical way of facilitating the memory process.

 Free Association
Freud discovered the method that is identified with the true creation of psychoanalysis, free association. He began to instruct his patients to express even the most irrelevant, unpleasant, or trivial material. The method of free association is, thus, the gradual consequence of experimentation with technique from hypnosis and the cathartic method to a concentration method to an approach almost antithetical to the original suggestive methods.

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

HISTORY
 Transference and Resistance

With the new emphasis on the removal of amnesia and the recovery of repressed memories, he observed that the same instinctive forces that brought about repression to obliterate pathogenic material from consciousness continued to exert force (resistance) against full disclosure through free association. Moreover, unexpected feelings toward the analyst (transference) provided additional resistance to treatment..

PSYCHOANALYSIS AND PSYCHOANALYTIC PSYCHOTHERAPY

HISTORY
 . Post-Freud: Early 20th Century to the Present

The history and growth of the psychoanalytic movement, from classic psychoanalysis to current practices, have been marked by repeated revisions by Freud himself, as well as by reappraisals and rebellions by neo-Freudian and non-Freudian contemporaries and descendants, as chronically manifest in internecine conflicts over diverse and intricate points of theory and practice.

CURRENT PSYCHOANALYTIC PRACTICE Psychoanalysis is still practiced today but on a very limited basis. Analysis is lengthy with weekly or more frequent sessions for several years. It is costly and not covered by conventional health insurance programs; thus, it has become known as therapy for the wealthy.

PSYCHOANALYTIC PROCESS
The psychoanalytic process involves bringing to the surface repressed memories and feelings .The analytical course may be subdivided into three major stages:  Stage one: the patient becomes familiar with the methods, routines, and requirements and a realistic therapeutic alliance is formed between patient and analyst. Basic rules are established, the patient describes his or her problems, there is some review of history,  Stage two: there is a continual battle within the psyche of the patient and between patient and analyst, wherein infantile problems of childhood are played out with the analyst as the object of the patient's repressed strivings..  Stage three: The termination phase is marked by the dissolution of the analytical bond as the patient prepares for leave-taking..The patient invariably has to continue to work through any problems outside of the therapy situation without the analyst

PATIENT REQUISITES
High motivation. Ability to form a relationship. Psychological-mindedness and capacity for insight Ego strength.

GOALS
 Psychoanalysis aims at the gradual removal of amnesias rooted in

early childhood.  The patient should be better able to relinquish former regressive patterns and to develop new, more adaptive ones, particularly as he or she learns the reasons for his or her behavior

GOALS...
 Achieve some measure of self-understanding or insight.  Psychoanalytic goals are often considered formidable (for example, a

total personality change), involving the radical reorganization of old developmental patterns based on earlier affects and the entrenched defenses built up against them.  Goals may also be elusive, framed as they are in theoretical intrapsychic terms (such as greater ego strength) or conceptually ambiguous ones (resolution of the transference neurosis)..  In practice, the goals of psychoanalysis for any patient naturally vary, as do the many manifestations of neuroses. The form that the neurosis takes unsatisfactory sexual or object relationships, inability to enjoy life, underachievement, and fear of work or academic success, or excessive anxiety, guilt, or depressive ideation determines the focus of attention and the general direction of treatment, as well as the specific goals.

Indications
 chronic cases of psychoneuroses (and relatively mild psychopathology), including all forms

of symptomatic anxiety, obsessional, and hysterical neurotic manifestations.  patients with neurotic depression has met with success.  Patients with hysteria and other neuroses

Contraindications
 dangerous behavioral or physical symptoms require more immediate attention or for virtually

      

the entire realm of the psychoses, in which severe ego deficits and tenuous reality are apparent. Narcissistic character disorders patients with deviant behaviors sexual disorders patients with psychosomatic illness Persons with schizoid or paranoid personality disorders substance use disorders (narcotic addictions and alcoholism) and antisocial personality disorder Infantile demands, poor impulse control, an inability to tolerate frustration, impaired social judgment, and the physical concomitants of substance abuse

ADVANTAGES OF PSYCHOANALYSIS
 Good method to study human behaviour.  Child centered education can be imported by identifying the needs, instincts and wishes of 

  

 

children. By identification of earlier childhood experiences, childhood education was modified by giving a maximum freedom to the children for expression of their biological urges and minimum freedom to the children for expression of their biological urges and minimum interferences in the course of their natural growth and development. Identification of behavioural deviations become easier , their by precautionary measures for preventing the problems related to maladjusted personalities. It promotes preservation of mental health and timely identification and treatment of the behavioural problems of individuals. It highlighted the importance of catharsis for releasing pent up emotions, expressed desired and wishes and also the importance of planning co-curricular and extracurricular activities, hobbies and freedom of expression for children in education and training. It also contributed to highlight the role of sex in ones life in terms of shaping the personality and determining the behaviour. Sex education has been developed-stages of psychosexual development, need for spontaneous expression of the sex instinct, changing the attitude of individuals towards sex a natural, essential, biological function

LIMITATIONS OF PSYCHOANALYSIS

 Limitations of psychoanalysis as a body of theory (for example,

biological orientation, deterministic viewpoint) and as a scientific instrument (for example, idiographic approach) have implications for its credibility as a form of therapy.  These limitations involve the complex issues of the universality and validity of major psychoanalytic constructs (from the Oedipus complex to the tripartite mental structure of id, ego, and superego) and the reliability of the case study method, which is considered the most subjective form of research observation in establishing effectiveness.  At present, the predominant treatment constraints are often economic, relating to the high cost in time and money, both for patients and in the training of future practitioners.

PSYCHOANALYTIC PSYCHOTHERAPY

Psychoanalytic psychotherapy is based on fundamental dynamic formulations and techniques that derive from psychoanalysis and is designed to broaden its scope. Psychoanalytic psychotherapy in its narrowest sense is the use of insight-oriented methods only.  The strategies of psychoanalytic psychotherapy currently range from expressive (insight-oriented, uncovering, evocative, or interpretive) techniques to supportive (relationship-oriented, suggestive, suppressive, or repressive) techniques. Although those two types of methods are sometimes regarded as antithetical, their precise definitions and the distinctions between them are by no means absolute.


RELEVANCE OF PSYCHOANALYTIC THEORY IN NURSING

 Nurses began to focus on human behavior, early stages of sexual development, and

use of maladaptive defense mechanisms.  A successful nurse needs to develop a pleasing and strong personality. Such qualities as integrity, dignity, mental alertness, self confidence, dependability, sympathetic understanding, a strong desire to help, high standards of values and the ability to develop healthy interpersonal relationships, are generally associated with the personality of a successful nurse.  Knowledge of the structure of personality can assist nurse who work in the mental health setting. The ability to recognize behaviours associated with the id, the ego and the super ego assist in assessment of developmental level. Understanding the use of ego defence mechanism is important in making determinations about maladaptive behaviours, in planning care for patients to assist in creating change(if desired), or in helping patients accept as unique individuals.  Education regarding child rearing practice, express love and belonging towards the child, to help the child to get rid off from the traumatic experience.

BIBLIOGRAPHY
 Harold I Kaplan &Benjamin J Sadock (2001) Comprehensive     

Textbook of psychiatry, Lippincott William and Wilkins, Philadelphia. Townsend CM .Psychiatric/Mental Health Nursing: Concepts of Care in Evidence-Based Practice (6 Edition)Davis FA Publishers Neeraja. K.P.(2008) Psychiatric mental health nursing, Jaypee Brothers. New Delhi, Sandeen S J & Stuart G W (1991) Principles and Practice of Psychiatric Nursing, 4th edition; Kapoor B (2003) Text Book of Psychiatric Nursing, 1st edition, Vol II; Kumar Publishing House. Ahuja N(2000)A short text book of psychiatry,Jay Pee publishers ;New Delhi

ANY QUESTIONS?