NUR 201
MODULE C
INTRODUCTION TO MENTAL HEALTH
CONCEPTS AND ISSUES
MENTAL HEALTH VS. MENTAL ILLNESS
 The concepts of mental health and mental
illness are culturally defined.
 Individuals experience both physical and
psychological responses to stress.
MENTAL HEALTH
Maslow identified:
 A “hierarchy of needs”
 Self-actualization as
fulfillment of one’s
highest potential
 Defined as “The successful
adaptation to stressors from the
internal or external environment,
evidenced by thoughts, feelings,
and behaviors that are ageappropriate and congruent with
local and cultural norms.”
MENTAL ILLNESS
 Defined as “Maladaptive responses to
stressors from the internal or external
environment, evidenced by thoughts,
feelings, and behaviors that are incongruent
with the local and cultural norms and interfere
with the individual’s social, occupational, or
physical functioning.”
MENTAL ILLNESS (cont)
 Horwitz describes cultural influences that affect how
individuals view mental illness. These include:


Incomprehensibility
Cultural relativity
PHYSICAL RESPONSE
 Hans Selye defined stress as “the state
manifested by a specific syndrome which
consists of all the nonspecifically induced
changes within a biologic system.”



Selye’s General Adaptation Syndrome
The Fight-or-Flight Syndrome
Sustained physical responses to stress
promote susceptibility to diseases of
adaptation
PSYCHOLOGICAL
RESPONSES
 Anxiety and grief
 A variety of thoughts, feelings, and behaviors
 Adaptation
PSYCHOLOGICAL RESPONSES
(CONT.)
 Peplau’s four levels of anxiety




Mild - seldom a problem
Moderate - perceptual field diminishes
Severe - perceptual field is so diminished that
concentration centers on one detail only or on
many extraneous details
Panic - the most intense state
PSYCHOLOGICAL RESPONSES (CONT.)
 Behavioral adaptation responses to
anxiety:

At the mild level
 At
the mild to moderate level
PSYCHOLOGICAL RESPONSES
(CONT.)
 defense mechanisms








Compensation
Denial
Displacement
Identification
Intellectualization
Introjection
Isolation
Projection







Rationalization
Reaction formation
Regression
Repression
Sublimation
Suppression
Undoing
PSYCHOLOGICAL RESPONSES
(cont)
 Anxiety at the moderate to severe level
 Extended periods of functioning at the panic
level of anxiety
PSYCHOLOGICAL RESPONSES
(CONT.)
Grief
 The subjective state of emotional, physical,
and social responses to the loss of a valued
entity; the loss may be real or perceived.
 Elisabeth Kübler-Ross

(5 Stages of Grief)
 Maladaptive grief responses
MENTAL ILLNESS THROUGH
THE AGES








EVIL SPIRITS; DEMONS
WILDERNESS TO FEND FOR THEMSELVES
“RATIONAL THEORIES” OF GREEKS
DEMONS; LUNACY
SUPERTITIONS, WITCHES, BURNING
LUNATIC ASYLUM
BRAIN DISORDER VS DEMONS
CRUEL, HARSH TREATMENT
EMERGENCE OF MENTAL
HEALTH
 PHILIPPE PINEL
 DOROTHEA DIX
 DR. BENJAMIN RUSH
 CLIFFORD BEERS
IMPACT OF WW’s I & II
 Need for mental health services
 National Committee for Mental Hygiene in
1917
 National Mental Health act 1946
 Funds for research, training and treatment
for mental illness
PSYCHOTHERAPEUTIC DRUGS
 Drugs affecting the mind
 Alters emotions, perceptions, consciousness
 Psychopharmacologic agents, psychoactive,
psychotropic
 Lithium carbonate in 1949
 Thorazine in 1956
 Imipramine
 Late 50’s/early 60’s antianxiety (Valium)
DEINSTITUTIONALIZATION
 1950’s half of hospital beds in U. S. were psych beds
 Psychotherapeutic drugs assisted people in
controlling behavior
 Persons were then discharged from mental
institutions
 Least restrictive alternative
COMMUNITY MENTAL HEALTH CENTER
 1961 Joint Commission on Mental Health
 1963 Congress passed Community Mental Health






Centers Act
1965 Medicare/Medicaid bill
Along with Mental Health Centers act
75% of institutionalized persons were discharged
Communities not ready
1970s funding cut
1975 Congress passed amendments for funding
community mental health centers
OMNIBUS BUDGET RECONCILIATION ACT
 1981
 Repealed Mental Health System Act
 Block grant funding – each state received a
designated amount of money
 Many states not committed to mental health
OMNIBUS BUDGET REFORM ACT
 1987
 Decrease inappropriate placement of
chronically mentally ill
 Persons discharged from nursing homes etc
sometimes “to the streets.”
 Funding for mental health care has continued
to decrease
INPATIENT PSYCH CARE






SAFE ENVIRONMENT
FOCUSES ON WORKING WITH PROBLEMS
CONTINUED EMOTIONAL SUPPORT
INTENSIVE INPATIENT THERAPY
MONITORING TREATMENT, MEDICATIONS
OPPORTUNITIES FOR RESOLVING
INTERPERSONAL ISSUES
 NEW COPING SKILLS TRIED
 DETOX FROM CHEMICALS
OUTPATIENT CARE
 ALLOWS MENTALLY ILL PERSONS TO
LIVE AND WORK WITHIN THEIR OWN
COMMUNITIES WITHIN A “LEAST
RESTRICTIVE SETTING”
MENTAL HEALTH ADMISSIONS
 VOLUNTARY—CLIENT ORIGINATES OR
AGREES WITH
 INVOLUNTARY – ADMISSION PROCESS IS
INITIATED BY SOMEONE OTHER THAN
THE CLIENT
SETTINGS
 COMMUNITY HOSPITAL EMERGENCY
ROOMS
 RESIDENTIAL PROGRAMS
 PARTIAL HOSPITALIZATION PROGRAMS
 PSYCHIATRIC HOME CARE VISITS
 COMMUNITY MENTAL HEALTH CENTERS
CULTURAL INFLUENCES ON
MENTAL HEALTH AND MENTAL ILLNESS
 A way of life
 The learned pattern of behavior that shapes
an individual’s thinking and that serves as the
basis for one’s social, religious, and family
structure.
 A shared system of values that helps provide
the framework for who we are
Ethnicity
 The socialization patterns, customs, and cultural habits
 Ethnic groups play important roles in preserving cultures
 Values, traditions, expectations, and customs
 Help people form relationships
 Provide established guidelines for living
 Function as focal points
 Ethnicity helps establish one’s point of view
Religion
 Relates to a defined, organized, and
practiced system of worship
 The values of religious groups range from
those that allow for individual variation to
those that require a commitment to place the
religion before family, work, or friends
Stereotyping Mental Health
Clients
 Stereotype – an oversimplified mental picture
of a cultural group
 Extreme form of negative stereotyping is
prejudice
 Traditional stereotyping – assumes that all
members of a culture behave in a certain
manner or are a certain way
Six Components of Cultural
Assessment
 Communication
 Space
 Social organization
 Time
 Environmental control
 Biological variations
Nursing Diagnoses









Altered Health Maintenance
Ineffective Management of Therapeutic Regimen
Impaired Thought Processes
Fear
Anxiety
Powerlessness
Self-esteem Disturbance
Impaired Coping
Social Isolation
NURSING PROCESS
 Expected outcomes and goals are developed with






cultural preferences in mind
Nursing care is formulated and then communicated
by means of a written care plan
Implementation includes actual delivery of the
planned nursing actions.
Client responses to care are assessed.
Many nursing actions are culturally significant to the
client
Open mind is needed when observing client’s
responses
Many reactions are culturally determined
DSM-IVTR
MULTIAXIAL EVALUATION SYSTEM
 Axis I - Clinical disorders and other conditions




that may be a focus of clinical attention
Axis II - Personality disorders and mental
retardation
Axis III - General medical conditions
Axis IV - Psychosocial and environmental
problems
Axis V - The measurement of an individual’s
psychological, social, and
occupational functioning on the GAF
Scale
Multidisciplinary Mental Health Team
 Main purpose
 Psychiatrists, social workers, psychologists, nurses and





others
Develop comprehensive therapeutic plans
Cost-effective
Clients and significant others contribute to the plan of
care
Remain actively involved
Interdisciplinary mental health care team
Health team members and their
roles






Psychiatrist
Clinical Psychologist
Psychiatric Clinical
Nurse Specialist
Psychiatric Nurse
Mental Health
Technician
Psychiatric Social
Worker






Occupational Therapist
Recreational Therapist
Music Therapist
Art Therapist
Dietician
Chaplain
LEGAL AND ETHICAL ISSUES
 Ethics
 Bioethics
 Moral behavior
 Values
 Values clarification
 Right
 Absolute right
 Legal right
ETHICAL CONSIDERATIONS
 Theoretical perspectives


Utilitarianism
Kantianism
 Christian ethics
 Natural law theories
 Ethical egoism
ETHICAL DELIMMAS
 Ethical dilemmas occur when moral appeals
can be made for taking either of two opposing
courses of action.
 Taking no action is considered an action
taken.
ETHICAL PRINCIPLES
 Autonomy
 Beneficence
 Nonmaleficence
 Justice
 Veracity
A MODEL FOR MAKING ETHICAL
DECESIONS
 Assessment
 Problem identification
 Plan
 Implementation
 Evaluation
Ethical Issues in Psychiatric/Mental Health Nursing
 The right to refuse medication
 The right to the least restrictive
treatment alternative
LEGAL CONSIDERATIONS


Nurse Practice Act defines the legal
parameters of professional and practical
nursing
Types of Laws


Statutory law
Common law
Classifications Within Statutory and
Common Law
 Civil Law - protects the private and property
rights of individuals and businesses
 Torts
 Contracts
 Criminal law - provides protection from
conduct deemed injurious to the public welfare
Legal Issues in Psychiatric/Mental
Health Nursing

Confidentiality and right to privacy
Doctrine of privileged communication
Informed consent
Restraints and seclusion
False imprisonment
Commitment issues











Voluntary commitment
Involuntary commitment
Emergency commitment
The “mentally ill” person in need of treatment
Involuntary outpatient commitment
The gravely disabled client
Legal Issues in Psychiatric/Mental
Health Nursing (cont.)





Malpractice and negligence
Types of lawsuits that occur in psychiatric nursing

Breach of confidentiality

Defamation of character

Libel

Slander
Invasion of privacy
Assault and battery
False imprisonment
LEAST RESTRICTIVE
ALTERNATIVE
 Providing mental health in the least restrictive




environment.
Utilizing the least restrictive treatment.
Must look at alternatives such as day treatment,
group home, home health etc.
Application of protective devices and restrains may
constitute false imprisonment.
Must be used only to protect the client/others and as
a last alternative.
RESTRAINTS
 Physical and chemical
 Documentation of other interventions and their lack of




success r/t safety
Written order—if ER situation, verbal order may be
obtained, then written within 4-8 hours.
Q15 min checks
Bathroom, exercise of limbs, offer liquids etc q2h
Released as soon as behavior under control
Nursing Actions to Avoid Liability







Responding to the patient
Educating the patient
Complying with the standard of care
Supervising care
Adhering to the nursing process
Documentation
Follow-up
THERAPUTIC RELATIONSHIPS
 The nurse-client relationship
 The therapeutic interpersonal relationship
 Therapeutic use of self
 Interpersonal communication techniques
The Therapeutic Nurse-Client Relationship
 Therapeutic nurse-client relationships .
 Therapeutic relationships are goal




Identify the client’s problem.
Promote discussion of desired changes.
Discuss aspects that cannot realistically be
changed and ways to cope with them more
adaptively.
Discuss alternative strategies for creating
changes the client desires to make.
The Therapeutic Nurse-Client Relationship (cont)





Weigh benefits and consequences of each
alternative.
Help client select an alternative.
Encourage client to implement the change.
Provide positive feedback for client’s attempts
to create change.
Help client evaluate outcomes of the change
and make modifications as required.
THEORIES
 Personality
 Life-cycle develop mentalists
 Stages are identified by age.
 It is possible for behaviors from an unsuccessfully
completed stage to be modified and corrected in a
later stage.
 Stages overlap, and individuals may be working on
tasks from more than one stage at a time.
 Individuals may become fixed in a certain stage and
remain developmentally delayed.
THEROIES (cont.)
 The DSM-IV-TR states that personality
disorders occur when personality traits
become inflexible and maladaptive, causing
either significant functional impairment or
subjective distress.
Psychoanalytic Theory – Freud
 Freud believed basic character was formed by age 5
years.
 He organized the structure of the personality into
three major components:



Id
Ego
Superego
 Topography of the Mind



The conscious
The preconscious
The unconscious
Psychoanalytic Theory – Freud (cont.)
 Dynamics of the personality
 Psychic energy
 Cathexis
 Anticathexis
 Development of the personality
 Oral stage (birth to 18 months)
 Anal stage (18 months to 3 years)
 Phallic stage (3 – 6 years)
 Latency stage (6 – 12 years)
 Genital stage (13 – 20 years)
Interpersonal Theory – Sullivan
 Based on the belief that individual behavior and
personality development are the direct result of
interpersonal relationships
 Major concepts of this theory




Anxiety
Satisfaction of needs
Interpersonal security
Self-system
Interpersonal Theory – Sullivan (cont.)
Stages of development






Infancy (birth - 18 months)
Childhood (18 months – 6 years)
Juvenile (6 - 9 years)
Preadolescence (9 – 12 years)
Early adolescence (12 – 14 years)
Late adolescence (14 – 21 years)
Theory of Psychosocial Development –
Erikson
 Stages of Development








Trust vs Mistrust (birth - 18 months)
Autonomy vs Shame and Doubt (18 months –3 years)
Initiative vs Guilt (3 - 6 years)
Industry vs Inferiority (6 - 12 years)
Identity vs Role Confusion (12 - 20 years)
Intimacy vs Isolation (20 - 30 years)
Generativity vs Stagnation (30 - 65 years)
Ego Integrity vs Despair (65 years - death)
Theory of Object Relations – Mahler
 Stages of development



Phase I – The Autistic Phase
Phase II – The Symbiotic Phase
Phase III - Separation-Individuation
A Nursing Model - Peplau
 Peplau identifies six nursing roles in which nurses
function to assist individuals in need of health
services:
 Resource person






Counselor
Teacher
Leader
Technical expert
Surrogate
A Nursing Model – Peplau (cont.)
 Four stages of personality development




Stage 1 – Learning to count on others
Stage 2 – Learning to delay satisfaction
Stage 3 – Identifying oneself
Stage 4 – Developing skills in participation
MENTAL HEALTH THERAPY
 BEHAVIORAL THERAPY
 SOMATIC THERAPY
 ECT
 COGNITIVE THERAPY
 ALTERNATIVE AND COMPLEMENTARY
THERAPIES
 MILIEU MANAGEMENT
 GROUP THERAPY
 FAMILY THERAPY

GENOGRAM
BEHAVIORAL THERAPY
 PAVLOV – MODEL OF CLASSICAL
CONDITIONING
 SKINNER – OPERANT CONDITIONING
 BEHAVIORAL MODIFICATION

For the program to be successful, the client
must perceive that he or she is in control of
the treatment.
SOMATIC THERAPY
 Electroconvulsive Therapy
 For depression and mania




Mechanism of action: thought to increase
levels of biogenic amines
Side effects: temporary memory loss and
confusion
Risks: mortality; permanent memory loss;
brain damage
Medications: pretreatment medication; muscle
relaxant; short-acting anesthetic
COGNITIVE THERAPY
 Cognitive Therapy
Commonly used in the
treatment of mood disorders
 Teaches ways to control thought distortions
that may be a factor in the development and
maintenance of mood disorders

ALTERNATIVE AND COMPLEMENTARY
THERAPIES
 The connection between mind and body is
well recognized.
 Allopathic medicine
 Alternative medicine
 Insurance coverage.
MILIEU THERAPY
 Milieu therapy, or therapeutic community, is
defined as a scientific structuring of the
environment to effect behavioral changes and
to improve the psychological health and
functioning of the individual.
GROUP THERAPY – TYPES OF
GROUPS
 Task groups
 Teaching groups
 Supportive/therapeutic groups
GROUP THERAPY
 Therapeutic groups vs. group therapy
 Group therapy
 Therapeutic groups
 Leaders of both types of groups must be
knowledgeable about group process (the way in
which group members interact with each other) and
group content (the topic or issue being discussed in
the group).
 Self-help groups
Family Therapy
 Involves educating the family about the
disorder
 Assesses the family’s impact on
maintaining the disorder
 Assists in methods to promote normal
functioning of the patient
 GENOGRAM
CRISIS
 Assumptions on which the concept of crisis is based





Crisis occurs in all individuals at one time or
another and is not necessarily equated with
psychopathology.
Crises are precipitated by specific identifiable
events.
Crises are personal by nature.
Crises are acute, not chronic, and are resolved
in one way or another within a brief period.
A crisis situation contains the potential for
psychological growth or deterioration.
PHASES IN THE DEVELOPMENT
OF CRISIS
The individual is exposed to a precipitating stressor.
2. When previous problem-solving techniques do not
relieve the stressor, anxiety increases further.
3. All possible resources, both internal and external,
are called on to resolve the problem and relieve the
discomfort.
4. If resolution does not occur in previous phases, the
tension mounts beyond a further threshold or its
burden increases over time to a breaking point.
Major disorganization of the individual occurs, often
with drastic results.
1.
TYPES OF CRISIS
 Dispositional crisis
 Crisis of anticipated life transitions
 Crisis resulting from traumatic stress
 Maturational/developmental crisis
 Crisis reflecting psychopathology
 Psychiatric emergency
CRISIS INTERVENTION
 The minimum therapeutic goal of crisis
intervention is psychological resolution of the
individual’s immediate crisis and restoration
to at least the level of functioning that existed
before the crisis period.
 A maximum goal is improvement in
functioning above the precrisis level.
Phases of Crisis Intervention:
The Role of the Nurse
Phase 1. Assessment
 Phase 2. Planning of therapeutic
intervention
 Phase 3. Intervention
 Phase 4. Evaluation of crisis
resolution and anticipatory planning.

Anger/aggression management
 ASSESSMENT
 Anger can be identified by
a cluster or characteristics
that include





Intense distress
Frowning
Pacing
Eyebrow displacement
Clenched fists
COGNITIVE DISORDERS
 DELIRIUM
 AMNESTIC
 DEMENTIA
DELIRIUM

Symptoms




Difficulty sustaining and shifting attention
Extreme distractibility
Disorganized thinking
Speech that is rambling, irrelevant,
pressured, and incoherent
DELIRIUM (cont)
 Symptoms include autonomic
manifestations such as





Tachycardia
Sweating
Flushed face
Dilated pupils
Elevated blood pressure
PREDESPOSING FACTORS
 Delirium due to a General Medical Condition
 Substance-Induced Delirium
 Substance-Intoxication Delirium
 Substance-Withdrawal Delirium
 Delirium due to Multiple Etiologies
DEMENTIA
 Symptoms





Impairment exists in abstract thinking,
judgment, and impulse control.
Conventional rules of social conduct are
disregarded.
Personal appearance and hygiene are
neglected.
Language may or may not be affected.
Personality change is common.
DEMENTIA (cont)
 As the disease progresses, signs include




Apraxia
Irritability and moodiness, with sudden
outbursts over trivial issues
Inability to care for personal needs
independently
Wandering away from the home or
care setting
DEMENTIA OF THE ALZHEIMER’S
TYPE (DAT)
 Etiologies may include

Acetylcholine alterations

Accumulation of aluminum in body

Alterations in the immune system

Head trauma

Genetic factors
DEMENTIA OF THE ALZHEIMER’S
TYPE (DAT)
 The progressive nature of symptoms
associated with DAT has been described
according to the following stages:







Stage 1.
Stage 2.
Stage 3.
Stage 4.
Stage 5.
Stage 6.
Stage 7.
No apparent symptoms
Forgetfulness
Early confusion
Late confusion
Early dementia
Middle dementia
Late dementia
VASCULAR DEMENTIA

Etiologies may include

Arterial hypertension

Cerebral emboli

Cerebral thrombosis
DEMENTIA (cont)
 DUE TO HIV
 DUE TO HEAD TRAUMA
 DUE TO PARKINSON’S DISEASE
AMNESTIC
 Amnestic disorders are characterized by an
inability to
Learn new information despite normal
attention
 Recall previously learned
information

 Other symptoms
AMNESTIC (CONT)
 Onset may be acute or insidious, depending
on underlying pathological process.
 Duration and course may be variable and are
correlated with extent and severity of the
cause
AMNESTIC (CONT)
 Amnestic Disorder due to a General
Medical Condition







Head trauma
Cerebrovascular disease
Cerebral neoplastic disease
Cerebral anoxia
Herpes simplex encephalitis
Poorly controlled insulin-dependent diabetes
Surgical intervention to the brain
AMNESTIC (CONT)
 Substance-Induced Persisting Amnestic
Disorder
 Related to the persisting effects of abuse of, or
exposure to, substances such as




Alcohol
Sedatives, hypnotics, and anxiolytics
Medications (e.g., anticonvulsants, intrathecal
methotrexate)
Toxins (e.g., lead, mercury, carbon monoxide,
organophosphate insecticides, industrial
solvents)
NURSING PROCESS
 The client history: Areas of concern to be addressed





Type, frequency, and severity of mood swings
Personality and behavioral changes
Catastrophic emotional reactions
Cognitive changes
Language difficulties
 History: Areas of concern to be addressed





Orientation to person, place, time, and situation
Appropriateness of social behavior
Current and past use of medications, drugs,
and alcohol
Possible exposure to toxins
Client and family history of specific illnesses
NURSING PROCESS (CONT)
 Physical assessment



Assessment for diseases of various organ
systems that can induce confusion, loss of
memory, and behavioral changes
Neurological examination to assess mental
status, alertness, muscle strength, reflexes,
sensory perception, language skills, and
coordination
Psychological tests to differentiate between
dementia and pseudodementia (depression)
NURSING PROCESS (CONT)
 Diagnostic laboratory evaluations
 Other diagnostic evaluations may include





Electroencephalogram (EEG)
Computed tomography (CT) scan
Positron emission tomography (PET)
Magnetic resonance imaging (MRI)
Lumbar puncture to examine cerebrospinal fluid
(CSF)
NURSING DIAGNOSIS
 Risk for trauma related to impairments in cognitive





and psychomotor functioning
Risk for suicide related to depressed mood
Risk for other-directed violence related to impairment
of impulse control
Disturbed thought processes related to cerebral
degeneration
Low self-esteem related to loss of independent
functioning
Self-care deficit related to disorientation, confusion,
memory deficits
OUTCOMES
 The client





Has not experienced physical injury
Has not harmed self or others
Has maintained reality orientation to the best
of his or her capability
Discusses positive aspects about self and life
Fulfills activities of daily living (ADLs) with
assistance
NURSING PROCESS
 Planning and Implementation

Formulate a plan of care for the client with a
cognitive disorder
 Nature of the illness
 Management of the illness
 Support services
 EVALUATION

Based on the accomplishment of outcome
criteria
TREATMENT MODALITIES
 Dementia
Primary consideration is given to etiology, with focus on
identification and resolution of potentially reversible
processes.
 For cognitive impairment
 Antilirium
 Cogex
 Aricept
 Exelon
 Reminyl
 For agitation, aggression, hallucinations, thought
disturbances, and wandering
 Risperdal
 Zyprexa
 Seroquel
 Geodon

ANXIETY DISORDERS
 GENERALIST ANXIETY DISORDERS
 PANIC DISORDERS
 OBSESSIVE COMPULSIVE DISORDER
 PHOBIC DISORDERS
 ACUTE STRESS/POST TRAUMATIC
STRESS DISORDER
 SOMATOFORM DISORDER
 DISSASOCIATIVE DISORDERS
ANXIETY DISORDERS
 Anxiety provides the motivation for achievement, a necessary
force for survival.
 Anxiety is often used interchangeably with the word stress;
however, they are not the same.
 Anxiety may be differentiated from fear in that the former is an
emotional process, whereas fear is cognitive.
 Epidemiological statistics



Anxiety disorders most common type of all psychiatric
illnesses
More common in women than men
Also occurs in children


More prevalent in girls than in boys
Children in lower socioeconomic environments at greatest risk
PANIC DISORDERS
 Panic disorder: assessment
 Characterized by recurrent panic attacks, onset of
which are unpredictable, and manifested by intense
apprehension, fear, or terror, often associated with
feelings of impending doom and accompanied by
intense physical discomfort
 Panic disorder with agoraphobia
 Assessment
 Characterized by same symptoms characteristic of
panic disorder
 In addition, affected person experiences a fear of
being in places or situations from which escape might
be difficult (or embarrassing) or in which help might
not be available in the event that a panic attack should
occur
Generalized anxiety disorder

Panic and generalized anxiety disorders
 Psychodynamic theory
 Overuse or ineffective use of ego defense mechanisms results
in maladaptive responses to anxiety.
 Cognitive theory
 Faulty, distorted, or counterproductive thinking patterns
accompany or precede maladaptive behaviors and emotional
disorders.
 Biological aspects
 Genetics
 Neuroanatomical
 Biochemical
 Neurochemical
 Medical conditions
NURSING DIAGNOSIS
 Panic anxiety related to real or perceived threat
to biological integrity or self-concept
 Powerlessness related to impaired cognition
PHOBIAS




Agoraphobia without history of panic disorder:
Social phobia: Assessment
Specific phobia: Assessment
DSM-IV-TR subtypes:





Animal type
Natural environment type
Blood-injection-injury type
Situational type
Other type
PHOBIAS (CONT)
 Etiological implications for phobias

Psychoanalytical theory
Learning theory

Cognitive theory

NURSING DIAGNOSIS
 Fear related to causing embarrassment to
self in front of another, to being in a place
from which one is unable to escape, or to a
specific stimulus
 Social isolation related to fears of being in a
place from which one is unable to escape
OBSESSIVE COMPULSIVE
DISORDERS (OCD)
 Assessment data
 Obsessions
 Compulsions
Etiological implications of OCD
 Psychoanalytical theory
 Learning theory
 Biological aspects
 Neuroanatomy
 Physiology
 Biochemical
Diagnosis: outcome identification
 Ineffective coping related to underdeveloped
ego, punitive superego; avoidance learning,
possible biochemical changes
 Ineffective role performance related to need
to perform rituals evidenced by inability to
fulfill usual patterns of responsibility
POST-TRAUMATIC STRESS DISORDER
 Assessment
 Development of characteristic symptoms following
exposure to an extreme traumatic stressor involving a
personal threat to physical integrity or to the physical
integrity of others
 Characteristic symptoms include re-experiencing the
traumatic event, a sustained high level of anxiety or
arousal, or a general numbing of responsiveness.
Intrusive recollections or nightmares of the event
are common.
Etiological implications
 Psychosocial theory

The traumatic experience

The individual
 The recovery environment
 Learning theory
 Cognitive theory
 Biological aspects
Diagnosis/Outcome Identification
 Post-trauma syndrome related to distressing
event considered to be outside the range of
usual human experience
 Dysfunctional grieving related to loss of self
as perceived before the trauma or other
actual or perceived losses incurred during or
after the event
Anxiety Disorder
 Anxiety Disorder due to General Medical Condition

Assessment - Symptoms of this disorder are
judged to be the direct physiological
consequence of a general medical condition.
 Substance-Induced Anxiety Disorder

Assessment - Prominent anxiety symptoms
that are judged to be due to the direct
physiological effects of a substance
CLIENT/FAMILY EDUCATION
 Nature of the illness
 Symptoms of anxiety disorders
 Management of the illness
 Management of the illness
 Support services
 Crisis hotline


Support groups
Individual psychotherapy
TREATMENT MODALITIES
 Individual psychotherapy
 Cognitive therapy
 Behavior therapy
 Group/family therapy
 Psychopharmacology




Panic and generalized anxiety disorder
Phobic disorders
OCD
PTSD
SOMATOFORM DISORDERS
 Somatoform disorders are more commonly
found in:




Women than men
The poorly educated
Residents of rural communities
Lower socioeconomic classes
 Dissociative disorders are thought to be rare.
 Amnesia is the most common dissociative symptom.
 DID is more prevalent in women than men.
 Brief episodes of depersonalization symptoms appear
to be common in young adults, particularly in times of
severe stress.
Types of psychophysiological disorders
 Asthma
 Cancer
 Coronary heart disease
 Peptic ulcer
 Essential hypertension
 Migraine headache
 Rheumatoid arthritis
 Ulcerative colitis
NURSING DIAGNOSIS
 Ineffective coping
 Deficient knowledge
 Low self-esteem
 Ineffective role performance
 Outcomes: identified for
measuring the effectiveness of
nursing care
Types of somatoform disorders
 Somatization disorder:


Chronic anxiety, depression, and suicidal
ideations are frequently manifested
Drug abuse and dependence are not
uncommon
 Personality characteristics
Pain disorder
 Pain disorder may be maintained by:



Primary gains
Secondary gains
Tertiary gains
 Symptoms of depression and
substance abuse are common.
Hypochondriasis
 A preoccupation with the fear of contracting,
or the belief of having, a serious disease.



The fear becomes disabling
Symptoms are grossly disproportionate to the
degree of pathology.
Anxiety and depression are common
Conversion disorder
 A loss of or change in body function resulting
from a psychological conflict, the physical
symptoms of which cannot be explained by
any known medical disorder or
pathophysiological mechanism


“classic” conversion symptoms are those that
suggest neurological disease
la belle indifference
Body dysmorphic disorder
 Family dynamics
 Learning theory

PRIMARY GAIN
SECONDARY GAIN
TERTIARY GAIN

Hypochondriasis


NURSING DIAGNOSIS
 Ineffective coping
 Chronic pain
 Fear
 Disturbed sensory perception
 Disturbed body image
Dissociative disorders
Dissociative amnesia involves


An inability to recall important personal
data that is too extensive to be explained
by ordinary forgetfulness
Finding is not due to the direct effects of
substance use or a general medical
condition
Treatment modalities
 Somatoform disorders




Individual psychotherapy
Group psychotherapy
Behavior therapy
Psychopharmacology
 Five types of disturbance in recall:





Localized amnesia
Selective amnesia
Continuous amnesia
Generalized amnesia
Systematized amnesia
APPLICATION OF THE NURSING
PROCESS (CONT)
 Dissociative fugue
 Dissociative identity disorder (DID)
 Depersonalization disorder
 Symptoms of depersonalization disorder are often
accompanied by:
 Anxiety and depression
 Fear of going insane
 Obsessive thoughts
 Somatic complaints
 Disturbance in the subjective sense of time
Etiological Implications
 Genetics
 Neurobiological
 Psychodynamic theory
 Psychological trauma
NURSING PROCESS
 Disturbed thought processes
 Ineffective coping
 Disturbed personal identity
 Disturbed sensory perception
MEDICAL TREATMENT
MODALITIES
 Individual psychotherapy
 Hypnosis
 Supportive care
 Integration therapy (DID)
SUICIDE
 FACTS AND FABLES
 RISK FACTORS
 PROTECTIVE FACTORS
 ASSESSING DEGRESS OF RISK
 “NO HARM” CONTRACT
 SOURCES FOR INFORMATION
ADVERSE EFFECTS OF MENTAL HEALTH
ALTERATIONS ON OBSTETRIC AND PEDIATRIC
CLIENTS
 OBSTETRIC


POSTPARTUM DEPRESSION
“FALSE” PREGNANCY
 PEDIATRIC

SEPERATION ANXIETY