Psychiatric Mental Health Nursing

Philippine Mental Health Law (RA 11036) – June 21, 2018

Depression is the 2nd biggest global illness (WHO)

Psychiatric – Mental Health Nursing

- A specialized area of nursing practice employing theories of human behavior as its science &
purposeful use of self as its art
- Partnership + change help patient to become self-directed, self-reliant, and has autonomy
Psychodynamics
- Psychological aspect of human behavior
Psychopathology
- Study of mental disorders and unusual or maladaptive behaviors
 Biologic basis – nature; genetic vulnerability
 Psychodynamic basis – nurture; environmental influence; treatable

Therapeutic Tools of Psychiatric Mental Health Nursing – “Tools of Trade”

Therapeutic Use of Self
- Ability of a nurse to use his or her personality consciously and in full awareness in an attempt to
establish relatedness and to structure nursing intervention. (KKK+D: Katauhan, Kaalaman,
Kakayanan + Damdamin)
- Elements:
 Self-awareness – genuine feelings in the relation to one’s environment (concerned with
beliefs & facts)
 Self-disclosure – self-revelation; a symptom of a healthy personality; judicious in
sharing; criteria: proper timing, dosage (refocus immediately)
 Empathy – entering into a person’s life situation by perceiving the person’s current
situation & problem
 Respect – ignore the behavior, not the patient
Therapeutic Skills of a Psychiatric Nurse
- Communication skills
- Observation skills – ability to detect slight changes in the client
- Reporting/recording skills – avoid psychiatric terminologies; charting aids [quotation marks
(verbatim), parenthesis (words preceding the parenthesis), short dashes (if incomprehensible),
long dashes (if incomplete)]
[side note: forensic patients: patients transferred from various jail facilities]

Communication as a Process
Communication
- Is an exchange of my world of meanings with your world of meanings
 Validate the feelings & experiences of the patient before one draws a conclusion
- It is a dynamic, on-going process
Modes of Communication
- Verbal – 7%
- Non-verbal – 93%; more reflective of one’s attitude & more reliant because one is more non-
conscious of it
 Kinesis or body cues
o Facial expression – least susceptible: eyes, corners of the mouth

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 o Eye contact – a person who can maintain eye contact is trustworthy; culturally-
bounded
o Gestures
 Paralanguage/Paraverbal/Paralinguistics or non-verbal cues
o Intonation
 Proxemics
o Territoriality – permanent space that a person prevents from intrusion
o Personal space – temporary space that a person prevents from intrusion
 Four tones of personal spaces:
 Intimate distance (6-18inches)
 Personal distance (1 ½-4ft) – known as comfort zone
 Social distance (4-12ft) – consultative/business distance 
paranoid patients: primary defense mechanism: projection
(denial precedes this); prominent symptom: persecutory
delusion (most dangerous); utilize passive friendliness
 Public distance (12ft or more)
 Touch
o Most personal of the non-verbal messages (Smith et al, 1997)
o Not always therapeutic
o Always ask permission prior
 Cultural articles
o Hair, clothing, fragrance, eyeglasses, bear, moustache
Therapeutic Communication
- Purposeful use of dialogue to bring about the client’s insight (awareness), control of symptoms,
and feelings
 Interactive verbal & non-verbal strategies that focus on the needs of patients facilitate a
goal-directed, patient-centered communication process.
 Involves active listening, understanding the client, promoting insight & clarification
(encourage patient to share feelings explicitly).
 Remember:
o Safety
o Encourage expressions of feelings
o Assist in solving problems
- Active listening includes the five (5) aspects of physical attending which are:
 Face to face contact
 Lean forward
 Maintain eye contact
 Relatively relaxed posture
 Open posture

Non-Therapeutic Responses of Questions

- Don’t worry statements: false reassurance, blocking opportunity to talk more, belittling
patient’s feelings, doesn’t address patient’s feelings
- Why questions: not all whys are wrong; universal: why questions aren’t utilized because it can
be subjective, threatening, accusatory, & judgmental; highly conclusive
- Exploratory questions: not allowed: deep-probing questions

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 - Authoritarian statements: rules & regulations in the area may be given, but empathy must
precede it. Give correct information.
- Close-ended question: can be used if safety is addressed fist & if you’re in the orientation phase
- Advising: can cause heightened dependency of the patient to nurse; counter productive
- Giving approval: nurse-focused. Can cause patient to seek approval from nurse, even if against
patient’s will.
- Rejecting: rejecting patient’s ideas can cause patient to seek approval/push his ideas unto
others
- Disapproving: hurts patient’s ego
- Agreeing:
 Psychopathology (Hallucinations/Delusion: not all are dangerous)
o Sus something
o Cherished means
- Arguing: reinforcing
- Challenging: don’t challenge patient’s false beliefs
- Disagreeing: counterproductive
- Testing: if the client won’t be able to answer question, it can cause anxiety to the patient; can
be part of MSE (Mental Status Examination) done by the physician, nurses orient only.
- Defending
- Requesting an explanation: authoritative
- Indicating the existence of an external source
- Belittling feelings expressed
- Using denial: does not address patient’s concerns
- Interpreting: must focus on patient, not one’s own opinion
- Introducing an unrelated topic:

Therapeutic Communication
- Empathetic listening: gives sense of security, gives lasting impression
- Broad openings: client has choice on topics to be discussed
- Offering general leads
- Restating: repeat exact words said by patient while getting the main theme; can cause
annoyance from the client; declarative (client) to interrogative (nurse)
- Reflecting: dialogue with oneself; intrapersonal;
 Reflecting content – listen to patient’s thoughts & feeling; use fewer & fresher words
 Reflecting feeling – similar to validation, paraphrasing
- Clarification: encourages patient to express feelings implicitly
- Focusing: example: placing of events in time sequence; similar to open-ended questions
- Encouraging comparison: focused on the feelings of the client still; comparison between two
events
- Using silence
- Accepting
- Exploring
- Offering self
- Confronting: give the client a feedback that there is an incongruence between the verbal & the
non-verbal cues; discrepancy between what is seen & what is being said.
- Give correct information
- Seeking information: am I understood?

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 - Presenting reality: used in hallucinations; not used in dementing patients because it can disturb
the patient’s schedule
- Voicing out doubts: used for delusions
- Suggesting collaboration: “perhaps you & I can determine the source of your anxiety”
- Giving recognition: if positive action is noticed
- Making observation: if negative is noticed
- Summarizing:
- Encouraging formulation of a plan: “next time you get in trouble, what would you do?”

Psychodynamics
Health
- A state of complete physical, mental, and social well-being and not merely the absence of
disease of infirmity.
- There is no health without mental health. (WHO)
Mental Health
- A state of well-being in which the individual realizes his/her own abilities, can cope with the
normal stresses of life, can work productively & fruitfully & is able to make a contribution to
his/her community. (WHO)
- Is the ability to:
 Meet & handle problems
 Make choices & decisions
 Find satisfaction in accepting tasks to carry on without undue dependence on others
 Contribute to one’s share in life
 Enjoy
 Be able to love & be loved

Principles to achieve optimum Mental Health (NEWSTART)

- Nutrition/No to drugs & alcohol
- Exercise
- Water/Writing  journaling: cognition, less dominant, emotions
- Sunshine/Stress reduction/Self-care
- Talk/Time management
- Air/Act of kindness
- Rest & Relaxation
- Trust

Personality
- Sum total of one’s physical, emotional, social, intellectual, & spiritual well-being. (WHO)
- Enduring patterns of perceiving relating to & thinking about the environment and oneself. (APA)
- Two portions:
 Body or soma (tangible)
 Mind or psyche (intangible)  potassium is the vehicle for serotonin

Three levels of consciousness

1. Conscious – awake
2. Subconscious/preconscious – partly forgotten/remembered; watchman; “tip of my tongue”
3. Unconscious – storage

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  Methods of recalling the unconscious
o Hypnosis by Anton Mesmer
o Psychoanalysis by Sigmund Freud
 Steps in Psychoanalysis
 Free Association – similar to orientation; childhood memories &
dreams
 Transference – client to nurse; negative to positive; feelings for
someone in the present is actually intended for someone in the
past
 Countertransference – nurse to client
 Catharsis – termination
 Proof/evidence that we have unconscious
o Dreams
o Jokes
o Freudian slip
o Forgetting well-known names & telephone numbers

Defense Mechanism
- Psychological ways of resolving a problem
- Used by the ego unconsciously to reduce anxiety

Coping Mechanism
- Can be either constructive or destructive
- Are conscious way of decreasing anxiety
- Cognitive
- A
- P

Stress
- Wear & tear on the body
- Any +/- occurrence or any emotion requiring a response [(-) distress: sadness, anger without
apparent reason, (+/-) eustress]
- A person has adaptive energy to respond to any stressor

General Adaptation Syndrome

- Specific, predictable, physiologic, psychosocial responses to stress
- Stages of GAS (ARE)
 Stage I Alarm Reaction
o Alarm reaction
 Mobilization of the body’s defensive forces and activation of the fight or
flight mechanism
o Psychosocial responses
 Increased levels of alertness & task-oriented, defense-oriented inefficient,
or maladaptive behavior may occur
 Stage II Stage of Resistance
o Optimal adaptation to stress within the person’s capabilities
o Psychosocial responses

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  Increase & intensified use of coping mechanism
 Tendency to rely on defense oriented behavior
 Stage III Stage of Exhaustion
o Loss of ability to resist stress because of depletion of body resources
o Psychosocial responses
 Defense-oriented behavior become exaggerated
 Disorganization of thinking & personality
 Sensory stimuli may be misperceived with appearance of illusion

Stress Assumptions:

Goals or approaches to stress

- developing effective coping mechanisms
- Reduction of body tensions
- Increasing resources and social supports
- Stress management

Anxiety
- Inner state that stress produces
- Stressor that precipitates anxiety is whatever the individual perceives as a danger, a loss, or a
threat to his safety & security.
- Etiology:
 Psychodynamic Theory
o Ego develops defenses to help individuals to control or cope with anxiety. The
need to cope stems from the conflicts between the id & the superego  early
conflicts are represses  later life  person experiences conflict afain 
defenses fall  anxiety
 Interpersonal Theory – Sullivan Interpersonal conflict – faulty
 Biologic theory – anxiety is genetic
 Otto-Rank Birth Trauma Theory
- Levels of Anxiety
 Mild
o Increased attention & motivation; total focus on the situation; no need to use
defense mechanisms. Use of adaptive mechanisms – like logical reasoning &
probem-solving
 Moderate
o Narrowed perception, decreased attention, selective inattention, problem-
solving & learning are possible with effort and assistance.
o Use of palliative coping mechanisms.
 Severe
o Scattered focus; psychologically painful, mental block, use of defense
mechanisms & maladaptive-coping mechanisms
 Panic
o Personality disorganization. Out of contact with reality. Wild & desperate
behaviors. Use of dysfunctional coping mechanism.

Crisis – from the Chinese worde Krinein  two-faceted: opportunity and danger/problem

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 - Psychological time wherein a person handles stress when he finds his old, usual coping ways to
be ineffective. (WHO)
- Normal duration to handle a crisis in [1-4 weeks]4-6 weeks.
- Crisis workers should be active and directive
 Positive resolution: with a support system  identified problem  learning opportunity
 Negative resolution: without a support system  sets in the pre-conscious  physical
or mental illnesses
- May be minor event  series of stressor  severe disorganization  lack of usual resources &
failure of individual’s coping mechanism  CRISIS
- Stages:
 Stage I
o Less, danger threat  anxiety  coping mechanism  anxiety not reduced
 Stage II
o Anxiety increases  coping mechanism decreases  person feels pressures &
unable to respond
 Stage III
o Anxiety continues to escalate person uses every means available to bring
anxiety level & situation under control  anxiety uncontrolled
 Stage IV
o Anxiety or panic  depression of panic disorder
- Nursing Process in Crisis
 Assessment – look into immediate precipitant
 Analysis: Nursing Diagnosis
o Ineffective coping
o Anxiety
o Risk for suicide
o situational low self-esteem
 Intervention – safety is the priority
o Intervene during the crisis
 The person is generally receptive to help
 Takes less time & more effective
 To prevent the development of dysfunctional coping pattern
 Flexible  feelings  extreme rage  cognition  consequences
 Never attack client’s defenses – the more the self-esteem & integrity
are lowered
 Gently encourage positive coping
 Gently discouraged negative coping
 Restore emotional stability & security
 Aim: long-term resolution
 Focus: unconscious

WHO-DOH Mental Health Psychological Support Services

- Psychosocial first aid/band-aid
- Psychosocial processing psychological relief
 Critical stress debriefing
 Multiple intervention
- Psychosocial processing to Children

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Psychopathology

Anxiety Disorders
- Excessive fear & anxiety and related behavioral disturbance for more than a month
 Fear – emotional response to real/perceived imminent threat or immediate danger
 Anxiety – anticipation of future threat/danger
- Types & Assessment
 Separation anxiety disorders
o Fearful or anxious about separation from attachment figures to a degree that is
developmentally inappropriate
 Selective mutism
o Consistent failure to speak in social situations in which there is an expectation to
speak even though the individual speaks in other situations
 Specific phobia
o Fearful or anxious about or avoidant of objects or situations
o Repression – displacement
o Systematic desensitization – gradual introduction to the feared object
o Flooding - threatening
 Social Anxiety Disorder (social phobia)
o Fearful or anxious about or avoidant of social interactions and situations that
involved the possibility of being scrutinized
 Panic disorder
o Recurrent unexpected panic attacks and is persistently concerned or worried
about having more panic attacks
o Panic attacks
 Abrupt surges of intense fear of discomfort that reach a peak within
minutes accompanied by physical and/or cognitive symptoms
 Can be expected or unexpected
 Agoraphobia – worst among the phobias
o House-bound syndrome
o Fearful or anxious about two or more of the situations: using public
transportation; being in open spaces; being in enclosed spaces; standing in line
of being in a crowd; or being outside of the home
 Generalized Anxiety Disorder
o Persistent and excessive anxiety and worry about various domains
- Analysis: Psychopathology
 Biological basis – genetic transmission, decreases GABA
 Psychodynamic basis – environmental factors: repression, displacement
- Nursing diagnoses:
 Anxiety
 Self-esteem disturbances
 Fear
 Ineffective coping
- Interventions: general nursing measures
 Focus on old scars
o Recognize the anxiety
o Establish trust

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 o Safety
o Do not criticize coping mechanism
o Do not force to go to situations that provoke anxiety
o Environmental modification by setting limits or limiting interactions with others
o Provide creative outlets
o Monitor for signs of impending destructive behavior
o Relaxation exercises
o Monitor vital signs and administer medication
- Psychopharmacotherapy
 Anxiolytics – potentiates GABA
o Benzodiazepines – Aprazolam (XANAX)
 Take on short-term basis because it causes dependence
 Taper dose to gradually avoid convulsion, headache, tremor, vomiting,
cramping, and sweating
 No alcohol
 No caffeine
 Side effects are:
 Drowsiness
 Hypotension
 Confusion
 Headache
 Incontinence
 Fatigue
 Decreased coordination
 Depression
 Double vision
 Urinary retention
o Anti-depressant
 A companion of anxiety is depression. An anxious client eventually
becomes depressed.
Obsessive Compulsive & Related Disorder
- Obsessive compulsive disorder
 Presence of obsession, compulsion, or both causing dysfunction
- Body dysmorphic disorders
 Preoccupation with perceived defects or flaws in physical appearance that are not
observable or appear only slight to others and by repetitive behaviors (e.g. mirror
checking) or mental acts (e.g. comparing one’s appearance with that or other people) in
response to the appearance concern.
- Hoarding disorder
 Persistent difficulty discarding or parting with possessions, regardless of their actual
value as a result of a strong perceived need to save the items & to distress associated
with discarding them
- Trichotillomania (Hair-pulling disorder)
 Recurrent pulling out of one’s hair resulting in hair loss and repeated attempts to
decrease or stop hair pulling
- Excoriation (skin picking)
 Recurrent picking of one’s skin resulting in skin lesions

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 - Analysis: psychopathology
 Biologic basis
o Genetic transmission
o Serotonin dysregulation
 Psychodynamic basis
o Anal phase – anal habit training – rigid
o Undoing – defense mechanism
o OCPD (30 minutes), OCD (more than 30 minutes)
- Key Nursing Interventions
 Ensure that basic need of food, rest, and grooming are met
 Provide time to perform rituals
 Explain expectations, routines, and changes
 Empathy
 Assist with connecting behaviors & feelings
 Structure simple activities, games, or tasks
 Reinforce & recognize non-ritualistic behaviors
- Psychopharmacology: antidepressants

Trauma & Stressor Related Disorders

- Individuals exposure to a traumatic or stressful event leads to psychological distress like
 Anhedonic & dysphoric symptoms
 Angry & aggressive symptoms
 Dissociative symptoms – rather than anxiety or fear-based
- Types:
 Reactive attachment disorder
o Absent or underdeveloped attachment between the child and the caregiver
o Depressive symptoms & withdrawn behavior
 Common etiology is social neglect. Evident before age 5 years.
Developmental age at least 9 months.
 Disinhibited social engagement
o Culturally inappropriate, overly familiar behavior with strangers
o Common etiology: social neglect
o Developmental age of at least 9 months
 Posttraumatic Stress Disorder
o Criteria A: Exposure – to actual or threatened death, serious injury or sexual
violence
o Criteria B: Intrusion – symptoms beginning after the traumatic event
 Intrusive – traumatic events are expressed
 Recurrent distressing dreams
 Dissociative reactions (e.g. flashbacks)
 Intense or prolonged psychological distress
o Criteria C: Persistent Avoidance – stimuli associated with the traumatic event
o Criteria A: Negative Alteration: in cognition & mood associated with the
traumatic event like inability to remember an important aspect of the traumatic
event. Duration: more than 1 month with dysfunctions
 Acute Stress Reaction
o Criteria

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  Intrusion symptoms
 Negative mood
 Dissociative symptoms
 Avoidant symptoms
 Arousal symptoms
o Duration: less than 1 month
 Adjustment Disorder
o Development of emotional or behavioral symptoms in response to an
identifiable stressor occurring within 3 months of this onset of stressor.
- Analysis: Psychopathology
 Biological basis – genetic transmission
o Increased noradrenergic & dopaminergic system activity & decreased
serotonergic activity
 Psychodynamic basis
o Exposure to a traumatic event
o Temperamental & environmental
o Repression  disassociation
- NANDA: Ineffective coping
- Key Nursing Interventions:
 Be non-judgmental & honest, empathy & support; acknowledge any unfairness or
injustices related to trauma
 Assure that their feelings and behaviors are typical to previous trauma
 Help patients to recognize the connections between the trauma experience & their
current feelings, behaviors, & problems.
 Encourage safe verbalization of feelings especially anger
 Encourage adaptive coping strategies, exercise, relaxation techniques, & sleep
promoting strategies
 Facilitate progressive review of the trauma & its consequences
 Encourage patient to establish or reestablish relationships
- Psychotherapeutic strategy: covert rehearsal
- Psychopharmacotherapy: anti-depressant

Dissociative Disorders

- Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity,

emotion, perception, body representation, motor control & behavior
- Etiology: frequently found in the aftermath of trauma
- Types:
 Depersonalization/derealization disorder
o Clinically significant persistent or recurrent depersonalization &/or derealization
with intact reality testing
 Dissociative amnesia
o Inability to recall autobiographical information that is inconsistent with normal
forgetting
o Can be selective (specific aspect of an event)
o Generalized (identity and life history)
 Dissociative Identity Disorder

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 o Presence or two or more distinct personalities states or an experience of
possession and recurrent episodes of amnesia.
- Analysis: psychopathology
 Psychodynamic basis: repression  dissociation (walling or splitting of some areas of
personality or extreme stress  emotional stability
- NANDA:
 Sensory perceptual disturbances
 Sleep pattern disturbance
 Social interaction impaired
 Social isolation
 Altered thought process
 Violence potential for self-directed or directed to others
- Key Nursing Interventions
 Trust & support
 Rule out organic cause
 Gather data regarding feelings, conflicts, or situations experienced prior to amnesia or
fatigue
 Safety
 Treatment goal: ultimately integrate the personalities or memories, so they can survive
or coexist in the original personality
- psychopharmacotherapy: Prozac

Somatic Symptom & Related Disorders

- common feature: the prominence of somatic symptoms associated with significant distress of
impairment.
- Typers:
 Somatic Symptoms Disorder (Somatization Disorder)
o Excessive thoughts, feelings, or behavior related to the distressing somatic
symptoms causing dysfunctions for more than 6 months
o Multiple, recurrent, frequent
 Illness anxiety disorder (Hypochondriasis)
o Preoccupation with having or acquiring a serious illness for at least 6 months.
 Conversion disorder (Functional Neurological Symptoms Disorder)
o Altered voluntary motor or sensory functions causing causing clinically
significant distress
o With disability to compare medical disease
 Psychological factors afecting other medical conditions
o Psychological or behavioral factors adversively affect the medical conditions,
such as denial of symptoms or poor adherence to medical recommendation.
(e.g. anxiety, excacerbating astmha, diabetes, cancer, migraine, IBS)
 Factitious disorder
o Falsification of physical or psychological signs & symptoms or induction of injury
or disese associated with identified deception.
- Defense Mechanisms:
 Repression
 Denial
 Displacement

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  Somatization
- NANDA:
 Pain chronic
 Post-trauma response
 Powerlessness
 Role performance alteres
 Interrupted family process
 Impaired adjustment
- Key Nursing Interventions:
 Matter-of-fact, caring approach for physical symptoms
 Allow verbalization of feelings and ask to describe feelings.
 Accept with developing more appropriate ways to verbalize feelings & needs
 Positive reinforcement to increase non-complaining behavior. Set limits by withdrawing
attention prom patients when they focus on physical complaints.
 Be persistent and have all requests directed to primary nurse provided care
 Diversionary activities through recreational games
 Do not push awareness of or insight into conflicts or behavior

Feeding & Eating Disorders

- Persistent disturbance or eating related behavior that results in the altered consumption or
absorption of food causing dysfunctions
- Types:
 Pica
o Eating of nonnutritive, non-food substance for more than 1 month
 Rumination disorder
o Repetitive regurgitation of food for at least 1 month
 Avoidant/restrictive food intake
o Persistent failure to meet nutritional and/or energy needs
 Anorexia nervosa
o Persistent energy intake restrictions; intense fear of gaining weight or of
becoming fat or persistent behavior that interferes with weight gain and a
disturbance in self-perceived weight or shape.
 Bulimia nervosa
o Recurrent episodes of binge eating & inappropriate compensatory behaviors to
prevent weight gain.
o Self-evaluation that is unduly influenced by body shape and weight.
o Binge eating & purge cycle at least once a week for 3 months.
o Binge 30x than normal caloric intake eaten in not more than two hours, in a
discreet place & time of day.
- Analysis: psychopathology
 Biological: increased serotonin activity  may lead to food restrictions
 Sociocultural factors  being this is over sensationalized
 Family factors  strict, tight family dynamics
 Cognitive & behavioral factors
 Psychodynamics: regression to a prepubertal; attempt to reduce the control of an over
controlling maternal figure; achievers & “perfect” children struggling for power struggle
& gain of control

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 - NANDA:
 Altered nutrition
 Powerlessness
 Fluid volume deficit
 Ineffective individual coping
 Disturbance in body image
- Key Nursing Interventions
 Monitor intake, output, & activity
 Weigh daily  face away from scale
 Observe signs of purging
 Plan for dietitian to meet with patients to discuss information nutrition & healthy diet
 Monitor electrolyte status
 Empathy

Depressive Disorders
- Presence of sad, empty, or irritable mood accompanied by somatic & cognitive changes that
lead to dysfunctions
- Mood: inner state: quality of affect: (0) apathy, (+1) flat/near absence of feelings, blunt (severe
absence), labile (irritable, swinging mood)

Major depressive disorder

- Criteria
 Depressed mood most of the day
 Markedly diminished interest or pleasure
 Increase(dysthymia) or decrease (psychotic depression) in appetite  weight loss
 Hypersomnia or insomnia
 Psychomotor retardation or agitation  downcast expression
 Fatigue or loss of energy
 Feelings of worthlessness & excessive guilt
 Inability to think, concentrate, & decide
 Recurrent thoughts of death, suicidal ideation, suicidal attempt, or with or without
specific plan to commit suicide.

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Persistent Depressive Disorder (Dysthymia)
- Depressed mood for most of the day, for more days than not for at least 2 years & 1 year for
children and adolescence.
Premenstrual Dysphoric Disorder

Disruptive Mood Dysregulation Disorder

- Severe, chronic, persistently irritable or angry mood between the severe temper outbursts that
is present 3 or more times per week for at least one year & noticeable by others
- Client between 6 to 18 years old.
Unspecified Depressive Disorder
- With peripartum onset – full criteria of major depressive episode are not met
- Onset of mood symptoms occur during pregnancy and 4 weeks after delivery.

- Analysis: Psychopathology

 Biological basis
o Hypofunction of the hypothalamus
o Decreased serotonin, dopamine, norepinephrine
o Dysregulation of acetylcholine and GABA
o Genetics
o Circadian rhythm changes
 Psychodynamics Basis
o Psychological Theories
 Adverse life experiences
 Loss, stress, intrapsychic conflict
o Psychoanalytical Theory
 Repression, denial, introjection, magical thinking
 Strong superego  internalized hostility  turned inward  suicide
o Cognitive Theory
 All stressful situations are negative
- NANDA: Nursing Diagnoses
 Risk for suicide
 Dysfunctional grieving
 Self-esteem disturbance

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  Hopelessness
 Powerlessness
- Nursing Interventions
 Risk for Harm
o Significant others
o Self
o Acronym:
 Sex none, support system none, single
 Unsuccessful attempts, unemployed
 Identification with a person who committed suicide
 Changes in life
 Illness (chronic)
 Drug use
 Age: adolescent (ambivalence), elderly (sure na), AIDS
 Loss in life, living alone
 Activities
o achievable activities so that they experience success; begin with one on one
activities.
o Walk with patient  small group activities  large groups
 Nutrition
 Hygiene Care
 Sleep Pattern
 Altered thoughts process
- Psychopharmacotherapy
 Tricyclic Anti-depressants (TCAs)
o S/E: orthostatic hypotension, urinary retention, constipation, manic states
cardiac arrhythmia
 Monoamine oxidase inhibitors (MAOIs)
o avoid tyramine rich food  hypertensive crisis (initial symptom: occipital
headache)
 Selective Serotonin Reuptake Inhibitors (SSRIs)
o Fluoxetine – Prozac
o S/E; decreased libido, impotence, nausea & vomiting, tremors
- Important points for administering anti-depressant & mood stabilizers
 Most antidepressant have a lag time of 1-4W after the full clinical effect occurs  they
have more energy to carry out suicide; Lithium carbonate lag time: 7-10D
 Watch out for hoarding of medicines TCAs & Lithium carbonate can be toxic
 Observe for early signs of toxicity

Bipolar & Related Disorders

- Bipolar I
 Preceded by mania may be followed by hypomanic or depressive episodes at least 1 week
present most of the day, nearly every day

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  Criteria for Manic episode
o Inflated self-esteem or grandiosity
o Decreased need for sleep (feels rested after only 3H of sleep)
o More talkative than usual or pressure to keep talking
o Flight of ideas or thought racing
o Distractibility
o Increased in goal-directed activity (socially at work or school) or psychomotor
agitation (non-goal directed activity)
o Excessive involvement in activities with painful consequences
o Elevated, expansive, or irritable mood
 Severe to cause dysfunctions & hospitalization
- Bipolar II
 One or more major depressive episodes at least 2 weeks & at least one hypomanic episode
at least 4 days
- Cyclothymic Disorder
 Chronic (at least 2 years for adult or 1 year in children or adolescent) fluctuating mood
disturbances of numerous periods of hypomanic symptoms & periods of depressive
symptoms.

- Analysis: Psychopathology
 Biological basis
o Genetic
o Decreased: serotonin, acetylcholine, dopamine
o Increased norepinephrine
o Bipolar II has one or more major depressive episodes (at least 2 weeks) & at least 1
hypomanic episode (at least 4 days)
 Psychodynamic basis
o Defense mechanisms – denial & reaction formation
o Faulty family dynamics
- Key Nursing Interventions for manic episodes
 Safety
 Simplify environment by reducing
 Stimuli
 Serve food in the run
 Set limits
o Matter-of-fact
o Homogenous grouping
- Psychopharmacotherapy
 Lithium Carbonate
o Starting dose 600mg TID, maintenance 900-1200mg/day, & maintaining serum
level of 0.6-1.2mEq/L. Therapeutic level can be reached 7-10 days later.
o Decreased sodium, increased lithium carbonate – Lithium toxicity or
hyponatremia
o Signs of toxicity: NELAC (Nausea & vomiting, Excessive thirst & voiding, LBM,
Anorexia, Coma)
 Carbamazepine
o Anti-convulsant

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 o With mood stabilizing qualities
 Valproic Acid
o Anti-convulsant
o With mood stabilizing qualities
 Atypical neuroleptics

Schizophrenia Spectrum & Other Psychotic Disorders

- Schizoid (Personality) Disorder
 Under psychotic disorders but discussed in Personality Disorders
- Delusional Disorder
 Presence of one or more delusions that persist for at least 1 month. Functioning not
markedly impaired & behavior is not obviously bizarre or odd.
 Subtype: can be erotomanic type – another person is in love with the individual
- Brief Psychotic Disorder
 Sudden onset of at least one of the positive psychotic symptoms [hallucination,
delusion, disorganized speech (incoherent) or grossly abnormal, psychomotor behavior
including catatonia
 Duration: at least 1 day  less than 1 month
- Schizophreniform Disorder
 At least one of these: hallucination, disorganized speech, delusion
 Grossly disorganized or catatonic behavior
 Negative symptoms at least 1 month less than 6 months
- Schizophrenia
 At least one of these must be 1, 2, & 3
1. Hallucination
2. Delusion
3. Disorganized or catatonic behavior
4. Grossly disorganized or catatonic behavior
5. Negative signs & symptoms
 Continuous signs of disturbance persist for at least 6 months.
- Analysis: Psychopathology
 Biological Basis (Nature)
o Genetic, increased dopamine receptor sites, decreased cortical blood flow
particularly in the pre-frontal cortex
 Psychodynamic Basis (Nurture)
o Developmental Theories
 Freud – poor ego boundaries; fragile ego & arrested psychosexual
development
 Erickson – trust vs mistrust crucial to later interpersonal relationship
 Sullivan – absence of warm nurturing attention during the early years
blocks the expression in the later years.
o Family theories
 Vulnerability-Stress Model
- NANDA Diagnoses:
 Altered thought process
 Sensory perceptual alteration
 Impaired verbal interaction

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  Impaired social interaction
- Key Nursing Interventions
 General principles for developing a therapeutic Nurse-Patient relationship
o Be calm when talking with patient
o Accept patients as they are, but do not accept all behaviors
o Keep promises
o Be honest
o Do not embarrass
o For withdrawn start with one on one interaction
o Allow verbalization of feelings
o Help identify stressor that may precipitate hallucination or delusions
o Focus on real people & real events
- Psychopharmacotherapy
 Neuroleptics or anti-psychotics
 Desired effects are sedation emotional quieting, psychomotor slowing
 Typical or Traditional Neuroleptics
o Chlorpromazine
 Decreased potency
 S/E: more of anti-cholinergic effects
o Haloperidol
 Increased potency
 S/E: more of EPS: dystonia (first 24H), akathisia, parkinsonism, tardive
dyskinesia
 Atypical or Novel Neuroleptics
o Clozapine
 S/E: agranulocytosis; few EPS & good for treatment resistance
o Risperidone
 A/E: neuroleptic malignant
o Olanzapine
 A/E: neuroleptic malignant

Substance Related Disorders

- Encompasses 10 separate classes of drugs
1. Alcohol
2. Caffeine
3. Cannabis
4. Hallucinogens
5. Inhalants
6. Opioids
7. Sedatives, hypnotics, & anxiolytics
8. Stimulants
9. Tobacco
10. Other unknown substances
- Two Groups of Substance Related Disorders
 Substance use disorders
o Cognitive behavioral & psychological symptoms indicating that the individual
continues using the substance despite significant substance related problems.

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 o Applied in all substances except caffeine.
o Criteria:
 Impaired control – craving
 Social impairment
 Risky use
 Tolerance
 Withdrawal
o Types
 Substance abuse – non-prescriptive substances
 Substance dependence
 Withdrawal symptom – physical need
 Compulsion
 Tolerance
 Withdrawal
 Substance Induced Disorder
o Cognitive behavioral & physiological symptoms contribute to the continued use
despite significant substance related problems.
 Intoxication
 Withdrawal
- Drug dependency
 CNS Depressants
o Alcohol, sedatives, hypnotics like benzodiazepines & barbiturates.
o Barbiturates
 Oral dosage
 1g – serious poisoning
 2-10g – fatal
 Avoid other CNS depressants like alcohol
o Intoxication
 Drowsiness, hypotension, impairment of memory, attention, judgment
& social or occupational functioning, incoordination & unsteady gait,
irritability & slurred speech.
o Withdrawal
 Nausea & vomiting; tachycardia; diaphoresis, irritability, tremors,
insomnia, & seizures
o Treatment
 Lower the dose gradually
o Sudden withdrawal  death
 CNS Stimulants – amphetamines, cocaine, crack
o Intoxication
 Tachycardia
 Euphoria
 Evident weight loss
 Potential for violence
 Pupillary dilatation
 Paranoid, delusion, hallucination
 Psychomotor retardation or agitation
 Insomnia

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  Impairment of judgment & social or occupational functioning
 Nausea & vomiting
o Over dosage
 Respiratory distress, ataxia, hyperpyrexia, seizures, coma, stroke,
myocardial infarction, death
 Treatment
 Antipsychotics & management of associated effects
o Withdrawal
 Fatigue
 Anxiety
 Apathy
 Disorientation
 Insomnia
 Increased appetite
 Craving
 Treatment
 Antidepressant
 Opioids
o Examples
 Narcotics
 Codeine
 Morphine-Methadone
 Heroin
 Demerol
 Opium
o Intoxication
 Constricted pupils
 Decreased respirations
 Drowsiness
 Euphoria
 Hypotension
 Memory impairment & judgment
 Psychomotor respirations
 Slurred speech
o Overdose
 Respiratory depression, shock, coma, seizures, and death
 Treatment: Naloxone
o Withdrawal
 Diarrhea, diaphoresis
 Anxiety & irritability
 Cold or flu-like symptoms
 Abdominal cramps
 Nausea & vomiting
o Treatment
 Methadone or tapering dosage
 Clonidine (Catapres) reduces withdrawal discomfort
 Hallucinogen

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 o Natural – cannabis sativa
o Synthetic – LSD, ecstasy
o Intoxication
 Terrifying psychosis – like reaction, hallucinations, depersonalization,
anxiety, confusion, paranoid reactions
 Frank psychosis – bad trip
 Psychedelic & euphoric effects – good trip
o Overdose
 Psychosis, brain damage, & death
o Treatment
 Decrease environmental stimuli
 anxiolytics
 inhalants
o hydrocarbon solvents
 gasoline & glue; aerosol propellants & anesthetics, butane, paint-
thinner, paint & wax remover, and nail polish remover
o intoxication
 Enhancement
 Euphoria
 Excitation followed by drowsiness, lightheadedness, disinhibition, &
agitation
 Giggling & laughter
o Overdose
 Damage to the Nervous system
o side effects
 mouth ulcers; GI problems; anorexia, confusion, headache & ataxia
o treatment
 supportive
 Caffeine Intoxication
o High dosage in excess of 250mg; restlessness, nervousness, excitement,
insomnia, flushed face, diuresis, GI disturbance, muscle twitching, rambling flow
of thoughts & speech, tachycardia or cardiac arrthymia, inexhaustibility &
psychomotor agitation; dysfunctions
o Withdrawal
 Within 24H – headache; marked fatigue or drowsiness; dysphoric mood,
depressed mood, irritability; difficulty in concentrating & flu-like
symptoms

Non-Substance Related Disorders

Gambling Disorders
- Persistent & recurring problematic gambling behavior leading to clinically significant impairment
or distress in a 12M period
- Analysis: psychopathology
 Biological basis
o Genetics
o Activation of the brain reward system  impairs brain inhibitory mechanism

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  Psychodynamics
o Strong oral tendencies
- Defense mechanisms:
 Denial
 Rationalization
 Projection
 Minimization
- NANDA Diagnoses
 Ineffective coping
 Family processes altered
 Risk for violence
- Nursing Interventions
 Withdrawal Delirium (Delirium Tremens)
o Safety
o Care during the acute phase
 Thiamine
 Magnesium sulfate
o Alcohol-free environment
o Matter-of-fact
o Detoxify
 Nursing Interventions for ALL Substance Related Disorders
o Confrontational strategies
o Tough love
o Point out consequences of behavior
o Non-judgmental attitude: matter-of-fact
o Lifestyle change
o Education
o Self-help group

Neurocognitive Disorders
- Primary clinical deficit is cognitive functions
- Acquired rather than developmental
- Cognitive domains: PORMA (Perception, Orientation, Reasoning, Memory, Attention)
- Classification:
 Delirium
o Disturbance of attention or awareness accompanied by a change in baseline
cognition
 Major or Mild Neurocognitive Disorders & their etiological subtypes (NCD d/t
Alzheimer’s Disease, Vascular NCD)
o Major NCD d/t another medical condition
 Cognitive deficit interferes with independence in everyday activities.
Decline from a previously attained level of functioning.
o Mild NCD
 Cognitive deficit does not interfere with capacity for independence;
modest cognitive decline from a previous level of performance.
DELIRIUM MAJOR & MILD NCD
Few hours to 1 month (usually 1 week) More than one month

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 Acute, temporary, reversible Gradual onset; progressive in course
Assessment Assessment
Acute confusion & anxiety Chronic Confusion
Sleep-wake disturbance Confabulation
Irritability Amnesia
Disturbance in attention/awareness Agnosia
Extreme restlessness Aphasia
Apraxia
Apathy
Analysis Analysis
Environmental – functional impairment, Environmental – traumatic brain injury
immobility, history of falls, low levels of Genetic & physiological: age, Down’s
activity, use of psychoactive drugs syndrome
Genetic & physiological
NANDA Diagnoses NANDA Diagnoses
Acute confusion Chronic confusion
Sensory perceptual alteration Thought process alteration
Nursing Intervention Nursing Intervention
Highest priority – maintain life Highest priority – maintain optimal level
of functioning
Remove the cause Well-lit rooms
Manage the symptoms judiciously Non-slippery floors
through nursing care & environmental Safety devices
manipulation Feelings – family – educate
Emotional support Flexible activities
Physical comfort Reality orientation – mild impairment
Reminiscence therapy – severe
impairment
Life review therapy
Clocks/calendars with big numbers
Concrete, short directions
Care self
Community
Consistent caregiver & environment

Personality Disorders (APA)

- Enduring pattern of inner experience & behavior that deviates markedly from the expectations
of the individual’s culture, is pervasive & inflexible, has an onset in adolescence or early
adulthood, is stable overtime & leads to distress or impairment.
- Cluster A Personality Disorder (Odd or Eccentric)
 Paranoid Personality Disorder
o Distrust & suspiciousness such that other motives are malevolent
 Schizoid Personality Disorder
o Detachment from social relationships & restricted range of emotional
expression
 Schizotypal Personality Disorder

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 o Acute discomfort in close relationships, cognitive, or perceptual distortions &
eccentric behavior
 Psychopathology
o Biological Basis
 Genetics
o Psychodynamic basis
 Oral phase – under gratified
 Stressful environment
 NANDA Diagnoses
o Altered family process
o Defensive coping
o Impaired verbal communication
 Nursing Intervention
o Trust
o No to group therapy
- Cluster B – dramatic, emotional, erratic
 Anti-social PD
o Disregard for & violation of the rights of others
o Analysis: Psychopathology
 Biological Basis
 Genetic
 Physiological
 Psychodynamic Basis
 Anal phase – lax  poor impulse control
 Unstable family pattern
 Inconsistent family pattern
 Low frustration tolerance
o NANDA Diagnoses
 Defensive coping
 High risk for violence: directed at self or others
o Intervention – key in working with them: consistency by the nursing staff &
accountability by the client
 Long term treatment in a therapeutic milieu for lasting changes to occur
 Set firm limits
 Consistent in confronting behavior & enforcing rules & policies
 Point out consequences of behavior
 Group them with same diagnosis
 Borderline
o Instability in interpersonal relationships, self-image, and effect & marked
impulsivity
o Analysis: Psychopathology
 Biological Basis
 Inadequate regulation of serotonin, dopamine, etc.
 Psychodynamic Basis
 Environmental factors – traumatic home environment
 Stress – related events trigger vulnerable temperament remind
earlier trauma

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  Splitting
 Recurrent self – mutilation – cry for help; expression of intense
anger; block emotional pain, reality testing
o NANDA
 High risk for self-mutilation
 Ineffective coping
o Interactions
 Empathy
 Safety
 Assist in finding acceptable ways to express anger & rage
 No self-harm contract to decrease self-harm & suicide
 Journaling
 Consistency
 Limit setting, supportive confrontation to manipulative behavior
 Offer superficial solutions to their problems – “safer” & less
frustrating to the nurse
 Histrionic
o Excessive emotionality & attention seeking
o Analysis: Psychopathology
 Psychodynamic Basis
 Mother negates the child’s inner feelings
 Child turns to father for nurturance
 Father responds to the child’s dramatic/emotional behavior
o Intervention
 Positive reinforcement like praise for unselfish or other-centered
behavior
 Narcissistic
o Grandiosity; need for admiration & lack of empathy
o Reality-based
o Analysis: Psychopathology
 Parents fail to mirror what is appropriate or inappropriate back to the
child
o Nursing interventions:
 Supportive confrontation
 Limit setting & consistency
- Cluster C – Anxious & Fearful
 Avoidant PD
o Social inhibition, feelings of inadequacy, & hyper sensitivity to negative
evaluation.
o Analysis: Psychopathology
 Few genetic, biological, & psychological studies have been conducted
o Nursing Intervention
 Allow verbalization of feelings
 Assertion & social skills training
 Stress reduction/relaxation techniques
 Dependent PD

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 o Submissive & clinging behaviors related to an excessive need to be taken care
of.
o Analysis: Psychopathology
 Psychosocial Theories – culture
o Nursing Intervention
 Manage Anxiety
 Assertiveness training
 Verbalization of feelings
 Obsessive Compulsive Personality Disorder
o Preoccupation with orderliness, perfectionism, & control.
o Analysis: Psychopathology
 Biological Basis
 Genetic
 Psychodynamic Basis
 Anal phase - rigid
o Nursing Intervention
 Support in exploring feelings
 Confront – procrastination & intellectualization
 Teach client to understand that it’s alright to make mistakes