Psychiatric nursing

Psychiatric Nursing
7/1/2018
Muhammad Baqir
Clinical Instructor
(Post RN BScN, MSPH)

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Contents
Theories of Personality Development:.....................................................................................................6
STRESS ..................................................................................................................................................10
Explaining the components of emotions ............................................................................................12
Special Fields of Psychiatry....................................................................................................................13
Principles of Psychiatric Nursing ............................................................................................................13
Traditional/ cultural/ concept about mental illness:...............................................................................14
Components of mental health: ..............................................................................................................14
Characteristics of mental healthy person:..............................................................................................15
Factors affecting Mental Health:............................................................................................................15
Major Criteria for the Diagnosis of Mental Illness (Psychosis) ................................................................15
Prevention of Mental Illness:.................................................................................................................16
Differences between neurosis and psychosis.........................................................................................16
Differences between Mental Health and Mental Illness.........................................................................17
Developing Therapeutic Relationship in Nursing....................................................................................18
Developing Acceptable Attitude towards Patients’ with Mental Disorder ..............................................19
Types of Admission................................................................................................................................20
Safety of nurses (while giving care to patient)........................................................................................21
Rights of Psychiatric/Mental Health Patients .........................................................................................21
Safety of the Patient..............................................................................................................................21
Purposes of defense mechanisms .........................................................................................................22
Therapeutic Communication:.............................................................................................................24
Therapeutic Relationship:......................................................................................................................25
Therapeutic Techniques:....................................................................................................................25
Non Therapeutic Techniques: ............................................................................................................25
Phases of Nurse-Client Relationship:..................................................................................................26
Personality and Personality Disorders....................................................................................................28
The Big Five factors ...........................................................................................................................28
Personality Disorders:............................................................................................................................30
Nursing management/ Care of Personality Disorders.........................................................................33
Anxiety Disorders ..................................................................................................................................34
Generalized Anxiety Disorder: ...............................................................................................................38

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Mood Disorders:....................................................................................................................................39
Categories of Mood Disorders:.......................................................................................................39
The primary mood disorders .................................................................................................................39
Major Depressive Disorder (Major, Uni polar, Psychotic depression) .................................................39
Mania....................................................................................................................................................41
Bipolar Disorder (manic depression, manic-depressive illness)...........................................................42
Minor Depressive Disorder (Minor, Neurotic Depression)..................................................................42
Dysthymic Disorder ...........................................................................................................................42
Bereavement (loss) versus Depressive Disorder: ........................................................................42
Bipolar and Unipolar Comparison..........................................................................................................43
Difference between Bipolar and Unipolar Disorder................................................................................43
Difference between, Psychotic and Neurotic depression .......................................................................44
Suicidal Behavior...................................................................................................................................44
Schizophrenia........................................................................................................................................45
Negative symptoms .........................................................................................................................46
Substance abuse....................................................................................................................................48
Characteristics of Addiction: .......................................................................................................48
Abuse and Victim ..................................................................................................................................50
Differentiate Among Different Kinds of Abuse.......................................................................50
Cognitive Disorders or Organic Mental Disorders...................................................................................51
Delirium: ...............................................................................................................................................51
Dementia ..............................................................................................................................................52
Difference between Delirium and Dementia..........................................................................................53
Child and Adolescent Psychiatric Disorders............................................................................................54
Mental Retardation ...........................................................................................................................54
Hyperkinetic disorder ........................................................................................................................56
Eating Disorders ....................................................................................................................................58
Anorexia nervosa...............................................................................................................................58
Bulimia nervosa.................................................................................................................................58
Somatoform Disorders.......................................................................................................................60
Conversion Disorder..........................................................................................................................60
Hypochondriasis................................................................................................................................61

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Sexual Disorders / Dysfunction ..............................................................................................................62
ECT Electroconvulsive Therapy ..............................................................................................................63
Psychotherapy.......................................................................................................................................64
Type of Psychotherapy: .....................................................................................................................65
Psychoanalytic Therapy ...................................................................................................................65
Supportive Psychotherapy ...............................................................................................................65
Cognitive Therapy: ...........................................................................................................................65
Behavior Modification .....................................................................................................................65
Operant Conditioning .......................................................................................................................65
Group Therapy...................................................................................................................................66
Family Therapy .................................................................................................................................66
Couples’ therapy ...............................................................................................................................66
Music Therapy ...................................................................................................................................66
Milieu Therapy ..................................................................................................................................66
Functions of a Psychiatric Nurse ............................................................................................................67
Psychiatric Team ...................................................................................................................................67
Psychiatric History ...........................................................................................................................68
The Mental Status Examination .............................................................................................................68
Components of Mental Status Examination ...................................................................................68
(Psychosocial Assessment Components) ........................................................................................68
Crisis .....................................................................................................................................................69
Stages of Crisis:..................................................................................................................................69
Types of crisis ................................................................................................................................69
Concept of Psychiatric Rehabilitation.....................................................................................................70
Stages of Rehabilitation:-.......................................................................................................................70
Psychopharmacology.............................................................................................................................71
General Guidelines Regarding Drug in Psychiatry...............................................................................71
Psychotropic drugs Classification/ Types............................................................................................71
Antipsychotic Agents.............................................................................................................................72
Typical/Dopamine blocking agents: - .................................................................................................72
Antidepressants.................................................................................................................................73
Tricyclic Antidepressant: -..............................................................................................................73

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Monoamine Oxidase Inhibitors (MAOI)..........................................................................................74
S.S.R.I (Selective Serotonin Reuptake Inhibitors): -.........................................................................75
Anxiolytic / Anti-anxiety Medications.................................................................................................75
Benzodiazepines (BZD): -................................................................................................................76
Non- Benzodiazipines: - .................................................................................................................77
Mood Stabilizing Drugs – lithium .......................................................................................................77
Anticonvulsant medications...............................................................................................................78
Common Psychiatric Symptoms and Key Terms in Psychiatric Nursing...................................................78

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UNIT-1
Review Normal Psychological
development
Theories of Personality Development:
Sigmund Freud, the Father of Psychoanalysis (6 May 1856 – 23 September
1939)
Founded the personality components (1923/1962) s; Id, Ego, and Superego
Id: The part of one’s nature that reflects basic or natural desires such a pleasure seeking
behavior, aggression, and sexual impulses. The id seeks immediate gratification, causes
impulsive thinking behavior, and has no rules or regard for social principle.
Superego: The part of one’s nature that reflects moral and ethical concepts, values, parental and
social expectations; therefore, it is the directional opposite to the id.
Ego: 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.
Topographic Model of the Mind
Freud’s topographic model deals with levels of awareness and is divided into three
categories:
Unconscious mind: All mental content and memories outside of conscious awareness; becomes
conscious through the preconscious mind
Preconscious mind: Not within the conscious mind but can more easily be brought to conscious
awareness (repressive function of instinctual desires or undesirable memories). Reaches
consciousness through word linkage
Conscious mind: All content and memories immediately available and within conscious
awareness of lesser importance to psychoanalysts
Psychosexual development:
Oral (birth to 18 months) Infancy: Stage of the Id. Major site of tension and gratification is the
mouth, lips, and tongue; includes biting and sucking activities. Id is present at birth.
Anal (18 to 36 months) Toddler: Stage of the Ego. Anus and surrounding area are major source
of interest. Voluntary sphincter control (toilet training) is acquired
Phallic/Oedipal (3 to 5 years) Preschooler: Stage of the Superego (conscience) Genital is the
focus of interest, stimulation, and excitement. Penis is organ of interest for both sexes.

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Masturbation is common. Penis envy (wish to possess penis) is seen in girls; oedipal complex
(wish to marry opposite-sex parent and be rid of same-sex parent) is seen in boys and girls.
Latency (5 to 11 or 13 years) Schooler: Stage of the Strict Superego. Resolution of oedipal
complex
1. Sexual drive channeled into socially appropriate activities such as school work and sports.
2. Formation of the superego
3. Final stage of psychosexual development
Genital (11 or 13 years) Adolescent: Begins with puberty and the biologic capacity for orgasm;
involves the capacity for true intimacy.
Developmental Theorists: Erikson (1902–1994) and Piaget: (1896–1980)
Erikson focused on personality development across the life span while focusing on social and
psychological development in life stages.
Erikson’s Psychosocial Theory
Age Stage Task
0 – 18 month Trust vs mistrust Basic trust in mother figure
& generalizes
18 month – 3 yr Autonomy vs shame/doubt Self control/ independence
3 – 6 yr Initiative vs guilt Initiate and direct own
activities
6 – 12 yr Industry vs inferiority Self confidence through
successful performance and
appreciation
12 – 20 yr Identity vs role confusion Task combination from
previous stages; secure sense
of self
20 – 30 yr Intimacy vs isolation Form a lasting relationship
or commitment
30 – 65 yr Generativity vs stagnation Achieve life’s goals; consider
future generations
65 yr – death Ego integrity vs despair Life review with meaning
from both positives and
negatives; positive self worth

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Piaget explored how intelligence and cognitive functioning develop in
children.
Sensorimotor (birth to 2 years): The child develops a sense of self as separate from the
environment and the concept of object permanence begins to form mental images.
Preoperational (2-6 years): Child begins to express himself with language, understands the
meaning of symbolic gestures, and begins to classify objects.
Concrete operations (6-12 years): Child begins to apply logical thinking, understands
reversibility, is progressively more social and able to apply rules; however, thinking still
concrete.
Formal operations (12 to 15 years and beyond): Child learns to think and reason in abstract
terms, further develops logical thinking and reasoning, and achieves cognitive maturity.
Harry Stacks Sullivan (1892–1949): Interpersonal Relationships and Milieu
therapy
The importance and significance of interpersonal relationships in one’s life was Sullivan’s
greatest contribution to the field of mental health.
Sullivan developed the first therapeutic community or milieu with young men with schizophrenia
in 1929. He found that within the milieu, the interactions among clients were beneficial, and then
the treatment should emphasize on the roles of the client-client interaction.
Milieu therapy is used in the acute care setting; one of the nurses’ primary roles is to provide
safety and protection while promoting social interaction.
Hildegard Peplau (1909–1999): Therapeutic nurse-patient relationship (The
bomb diggity of nursing)
Developed the concept of the therapeutic nurse-patient relationship, which includes 4 phases:
Orientation, Identification, Exploitation, and Resolution
The orientation phase is directed by the nurse and involves engaging the client in treatment,
providing explanations and information, and answering questions. During this time the nurse
would orient the patient to the rules and expectations (if in an acute setting).
The identification phase begins when the client works interdependently with the nurse,
expresses feelings, and begins to feel stronger. This phase can begin either within a few hours to
a few days; the patient can identify the nurse and environment on his own. They “come together”
Kinky.
In the exploitation phase, the client makes full use of the services offered. He moves toward
independence.
In the resolution phase, the client no longer needs professional services and gives up dependent
behavior.

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Keep in mind that after the resolution phase, the client can regress and move back into the above
mentioned phases.
Paplau defined anxiety as the initial response to a psychic threat, describing 4
levels of anxiety: acute, moderate, severe, and panic.
Acute anxiety is a positive state of heightened awareness and sharpened senses, allowing the
person to learn new behaviors and solve problems. The person can take in all available stimuli
(perceptual field).
Moderate anxiety involved a decreased perceptual field (focus on immediate task only); the
person can learn new behavior or solve problems only with assistance. Another person can
redirect the person to the task. Remember, this is the ideal anxiety state for teaching a client
regarding health concerns such as diabetes, as Cathy says so.
Severe anxiety involves feelings of dread or terror. The person CANNOT be redirected to a
task; he focuses only on scattered details and has physiologic symptoms such as tachycardia,
diaphoresis, and chest pain. The client may go to the ER thinking he is having a heart attack. In
lecture, Cathy stated that this person can still be “talked down”. The first priority is to move the
person away from all stimuli, and then attempt to talk with them to calm down.
Panic anxiety can involve loss of rational thought, delusions, hallucinations, and complete
physical immobility and muteness. The person may bolt and run aimlessly, often exposing
himself and others to injury.
Humanistic Theories; Maslow’s Hierarchy of needs (1921–1970)
He used a pyramid to arrange and illustrate the basic drives or needs to motivate people.
The most basic needs, physiologic needs, need to be met first. This includes food, water, shelter,
sleep, sexual expression, and freedom of pain. These MUST be met first.
The second level involves safety and security needs, which involve protection, security,
freedom from harm or threatened deprivation.
The third level is love and belonging needs, which include enduring intimacy, friendship, and
acceptance.
The fourth level involves esteem needs, which includes the need for self-respect and esteem
from others.
The highest level is self-actualization, the need for beauty, truth, and justice. Few people
actually become self-actualized.
Remember, traumatic life experiences or compromised health can cause a person to regress to a
lower level of motivation.

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Pavlov: Classic conditioning (Behavior theory)
Pavlov believed that behavior can be changed through conditioning with external or
environmental conditions or stimuli.
STRESS
Stress is the reaction people have to excessive pressures or other types of demand placed upon
them. It arises when they worry that they can’t cope.
TYPES OF STRESS
Negative stress
Positive stress
NEGATIVE STRESS
It is a contributory factor in minor conditions, such as headaches, digestive problems, skin
complaints, insomnia and ulcers.
Excessive, prolonged and unrelieved stress can have a harmful effect on mental, physical and
spiritual health
POSITIVE STRESS
Stress can also have a positive effect, stimulating motivation and awareness, providing the
stimulation to cope with challenging situations.
Stress also provides the sense of urgency and alertness needed for survival when confronting
threatening situations.
TYPES OF STRESSORS
External
Internal
EXTERNAL STRESSORS
Physical Environment:
Social Interaction:
Organizational:
Major Life Events:
Daily Hassles

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INTERNAL STRESSORS
Lifestyle choices
Negative self - talk
Mind traps
Personality traits
SYMPTOMS OF STRESS
Behavioral
Sleep Disturbance
Use of alcohol/ drugs
Increase Smoking
Nail biting
Apatite changes
Physical
High blood pressure
Rapid shallow breathing
Increased Heart rate
Dilatation of pupils
Muscle tension
Dry Mouth
Emotional
Depression/anxiety
Irritability
Crying
Suicide
Deterioration of personal hygiene
Mental
Lack of concentration
Negative thoughts
Worrying
Poor Memory
Stress management
Simplify Your Life
Ask for help
Practice Time Management
Minimize Alcohol Use
Humor--Take Time to Play
Relaxation Techniques
Get Counseling If Needed
Alternatives
Conventional Medicine
Counseling & psychotherapy
Relaxation
Meditation
Massage
Yoga
Aromatherapy
Nursing intervention
o Assess individual present coping status
o Reassure the client by hope full and
realistic perspectives.
o Maintain an environment off with low
level of stimuli.
o Offer option to increase sense of control.
o Assets the parson to solve problem
o Discuss possible alternatives.
o Instruct person in relaxation techniques
o Use stressful management techniques, eg
jogging, yoga
o Explore previous method of dealing with
life problem.
o Encourage verbalization of feeling,
perception and fears

Emotion:
A feeling state involving physiological arousal, a cognitive appraisal of the situation arousing the
state, and an outward expression of the state
Explaining the components of emotions
Typically, psychologists have studied emotions in terms of three components
1. The physical,
2. The cognitive, and
3. The behavioral
The physical component is the physiological arousal that accompanies the emotion
E.g. Tachycardia, Dilated pupils Etc
The cognitive component determines the specific emotion we feel, thought, beliefs.
The behavioral component of emotions is the outward expression of the emotions
E.g. Facial expression, body posture, gestures, tone of Voice, joy, fear, Sorrow etc

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Unit 2
INTRODUCTION TO PSYCHIATRIC
NURSING
Psychiatry: Is the branch of medicine dealing with prevention diagnosis and management of
mental disorders.
Psychiatric Nursing: It is also known as mental health nursing concerned with the provision of
care and treatment to the mentally sick patients.
Psychiatric Nurse: A Nurse who has received special training in the care and management of
Psychiatric patient.
Special Fields of Psychiatry
Child Psychiatry: Child psychiatry deals with the diagnosis and management of psychiatric
problems that have their onset in childhood.
Adolescent Psychiatry: Adolescence – the period between puberty and young adulthood
(approx. 12 – 17 years) is marked by a great course of physical development and major social
and psychological adjustments.
Geriatric Psychiatry: Geriatric Psychiatry is the study of mental disorders affecting older
people
Community Psychiatry: This is a new but realistic approach of the Psychiatrists and other
members of the Psychiatric team of preventing, identifying and treating psychiatric patients
Transcultural Psychiatry: The study of mental disorder against diverse cultural
backgrounds is an extension of cultural psychiatry.
Social Psychiatry: It is a branch of study and research with important clinical applications
that is concerned with the etiology, diagnosis, treatment and prevention of mental disorders.
Principles of Psychiatric Nursing
1. Allow client opportunity to set own step in working with problems.
2. Nursing interventions should center on the client as a person, not on control of the symptoms.
Symptoms are important, but not as important as the person having them.
3. Recognize your own feelings toward clients and deal with them.
4. Go to the client who needs help the most.
5. Do not allow a situation to develop or continue in which a client becomes the focus of
attention in a negative manner.
6. If client behavior is bizarre, base your decision to get involved on whether the client is
endangering self or others.

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7. Ask for help—do not try to be a hero when dealing with a client who is out of control!
8. Avoid highly competitive activities that are, having one winner and a room full of losers.
9. Make frequent contact with clients—it lets them know they are means your time and effort.
10. Remember to assess the physical needs of your client.
11. Have tolerance! Move at the client’s pace and ability.
12. Suggesting, requesting, or asking works better than commanding.
13. Therapeutic thinking is not thinking about or for, but with the client.
14. Be honest so the client can rely on you.
15. Make reality interesting enough that the client prefers it to his or her fantasy.
16. Compliment, reassure, and model appropriate behavior
Mental Health: It is a positive state of mind, in which one is responsible, self aware, self
directed, reality oriented, and able to cope with worries and tensions in daily life.
Mental health is defined by the World Health Organization (WHO) as:
“A state of well-being in which the individual realizes his or her own abilities, can cope with the
normal stresses of life, can work productively and fruitfully, and is able to make a contribution to
his or her community”
Mental Hygiene
Mental hygiene is the prevention of mental disorders and the promotion of mental health for the
enrichment of human life
Mental illness:
It is a state of imbalance characterized by a disturbance in a person’s thoughts, feelings and
behavior.
Traditional/ cultural/ concept about mental illness:
1. Psychiatric illness is due to evil causes
2. It is believed that mental illness is acquired by own fault. Therefore they do not need
treatment.
3. It is believed that mental illness does not occur in young age.
4. All attention seeking mental disorders are labeled as hysteric because of “Taveez” or” Gin”
and seek treatment religious leader.
5. Drugs used in psychiatry believed to be hot and addictive.
6. Most people think that mental disorders are untreatable.
7. Most people think that mental disorders are the result of possession by evil spirits, curses,
astrological influences, character weakness, laziness, karma or black magic.
Components of mental health:
1. Autonomy and independence
2. Maximizing one’s potential,
3. Tolerance of uncertainty,
4. Self-esteem,
5. Mastery of the environment,
6. Reality orientation,
7. Stress management.

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Characteristics of mental healthy person:
1. A sense of well-being
2. The use of sublimation as the main
defense mechanism
3. The ability to postpone present pleasures
for future ones
4. The presence of an intact sense of reality
5. Good interpersonal relationship
6. Optimal adjustment.
7. Adaptation to the work situation
8. Leisure time activity
9. Management of social contacts
10. Adjustment to the opposite sex.
Factors affecting Mental Health:
Stressful life events / Social factors
Biological factors:
Individual psychological factors:
Stressful Life Events/social factors:
Family conflicts, unemployment, death of a loved one, money problem, infertility and violence,
Poverty, Lack of support from relationships;
Difficulties in childhood such as sexual or physical violence, emotional neglect, or early death of
a parent can sometimes lead to a mental disorder later in life.
Unhealthy behaviors such as drug and alcohol abuse can lead to the development of a mental
disorder as well as being the result of a mental disorder.
Biological Factors:
Chemical imbalance in brain: e.g. Dopamine, serotonin, norepinephrine levels etc
Genetics: Family
Brain injury: Pre-natal damage; Birth trauma, head injury
Chronic illness: viral infections, cerebrovascular disease, metabolic or endocrine conditions,
autoimmune disorders, human immunodeficiency virus (HIV) infections, or certain cancers etc.
Medications: Alcohol, Sedatives, Opioids, Caffeine
Individual psychological factors:
E.g. poor self-esteem, negative thinking
Events in Childhood
Adverse life experiences during childhood
Major Criteria for the Diagnosis of Mental Illness (Psychosis)
The criteria for psychosis include:
1. Abnormal behavior
2. Abnormal experience
3. Loss of reality contact
4. Lack of insight

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Prevention of Mental Illness:
1. Avoid marriages in first cousin
2. Give appropriate and adequate pre and postnatal care.
3. Prevent separation of parents.
4. Avoid over exertion, criticizing and punishment
5. A person may be strong in one subject and work in the other ways of life. Encourage him/her
in supportive/ positive manner
6. Early diagnoses of any abnormal behavior reduce the chances of severe mental illness.
7. Educate community for substance additional drug abuse.
8. Communicate problems; find solutions with discussion, self-expression and understanding.
9. Improve skills of coping with stress and crisis by self-analysis of strength and weakness.
10. Find new ways of satisfactory needs and reacting on unpleasant experiences.
11. Have adequate sleep, Balance diet and reasonable physical exercises.
12. Establish successful relationship and emotional relationship stability with others.
Differences between neurosis and psychosis
Neurosis: A condition in which mal adaptive behaviors serves as a protection against a source of
unconscious anxiety.
Psychosis (from the Greek "psyche", for mind/soul, and "-osis", for abnormal condition or
derangement) refers to an abnormal condition of the mind, and is a generic psychiatric term for a
mental state often described as involving a "loss of contact with reality". People suffering from
psychosis are described as psychotic.
Neurotic Behavior/ neurosis Psychotic behavior/ psychosis
Reality oriented Out of contact with reality denies reality
Demonstrates acceptable behavior socially Demonstrates bizarre inappropriate,
behavior
Interacts with the real environment Creates a new world or environment
withdraws from reality in an effort to seek
security in the newly created world
Doesn’t exhibit maladaptive behavior (e.g.
hallucinations or delusions)
Exhibits maladaptive behaviors (e.g.
delusions, hallucinations, and autism)

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Differences between Mental Health and Mental Illness
(Shives: 1990)
People who are mentally healthy do not necessarily possess all the characteristics of mental
health listed. Under stress they may exhibit some of the traits of mental illness but are able to
respond to the stress with automatic, unconscious behavior that serves to satisfy their basic needs
in a socially acceptable way.
Mental Health Mental Illness
1. Accepts self and others 1. - Feelings of inadequacy-Poor self-
concept
2. Ability to cope or tolerate stress. Can
return to normal functioning if temporarily
disturbed
2. - Inability to cope-Maladaptive behavior
3. Ability to form close and lasting
Relationships
3. Inability to establish a meaningful
relationship
4. Uses sound judgment to make decisions 4. Displays poor judgment
5. Accepts responsibility for actions 5. Irresponsibility or inability to accept
responsibility for actions
6. Optimistic 6. Pessimistic
7. Recognizes limitations (abilities and
deficiencies)
7. Does not recognize limitations (abilities
and deficiencies)
8. Can function effectively and
independently
8. Exhibits dependency needs because of
feelings of inadequacy
9. Able to perceive imagined circumstances
from reality
9. Inability to perceive reality
10. Able to develop potential and talents to
fullest extent
10. Does not recognize potential and talents
due to a poor self-concept
11. Able to solve problems 11. Avoids problems rather than handling
them or attempting to solve them
12. Can delay immediate gratification 12. Desires or demands immediate
gratification
13. Mental health reflects a person’s
approach to life by communicating
emotions, giving and receiving. Working
alone as well as with other, accepting
authority, displaying a sense of humor, and
coping successfully with emotional conflict
13. Mental illness reflects a person’s
inability to cope with stress, resulting in
disruption, disorganization, inappropriate
reactions, unacceptable behavior and the
inability to respond according to his
expectations and the demands of society.

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Mental Disorders Psychosis Mental Disorders Neuroses
1. Schizophrenia Anxiety disorders(GAD,PTSD Phobia.OCD)
2. Mania Somatoform disorders
3. Depression Sexual disorders
4. Delusional disorders Eating disorders
Developing Therapeutic Relationship in Nursing
A psychiatric nurse may be afraid of mentally sick patient because some patients do not accept
health team, do not take food and even do not like to talk with anybody. In severe cause they
become abusive, aggressive and harmful to others. Some precautions are needed in dealing with
difficult patients.
A. Only trained staff should be allowed to interact with different patients.
B. Those relatives and friend are allowed to meet patient who know patients nature of illness and
way to deal with.
C. Adequate time should give to understand patients’ need.
1. Relationship with withdrawn behavior patient: Thee patients suffer from feeling of
hopeless and need assurance. Nurse should show attempt to develop emotional bonding and talk
with the patient be responsive or not. She will have to assess patients’ interest and talk on such
topics. In this way she/he gradually will get response and then motivation to do simple tasks and
encourage for next and next. Some extremely withdraw patient need biological care when they
do not take food orally gives via I/V or N/G.
2. Relationship of nurse with suspicious behavior patient: These patients are more difficult to
deal with because they do not trust in any one even in nurse and do not take food due the fear of
poison in the food. Nurse should select a person even a family member or friend whom he trust
and food should serve by him the main object of nurse is to established trust of patient through
behavior and good care but it develop s slowly so it needs patience. Patient begins to trust in
nurse when he has improved for this nurse never talks lie or low voice with others in front of
such patients.
3. Relationship with Demanding behavior Patient: These patients are likely to be friendlier
and cooperative ones get attention they want. The duty of the nurse would be ensure that be off
the personality that do not seek unnecessary attention.
4. Relationship with Aggressive behavior patient: To deal with the aggressive patient is the
test of skill of a good psychiatric nurse. It is impossible to develop relationship with dangerously
aggressive psychiatric patient. Therefore he/she should not try unless aggressiveness is
controlled by medical treatment otherwise it will be harmful for the nurse. Nurse should tolerant
and patience in his dealing with patient. He/ she avoid arguments or conflict. He/she should not
speak harshly patient should not be threatened restaurant is also bas experience for the patient
unless there is no alternate.
5. Relationship with Manipulative Behavior Patient: These patients try to gain freedoms with
manipulation by praise of mental health team .Nurse should try to discourage this behavior .some

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patients can thereat staff members when manipulating , if patient do so this behavior should
immediately be in the notice of administration
6. Relationship with Obsessive behavior patient: These patients have obsession thoughts of ideas
in the mind that make patient disturb and patient come again and again to nurse for report his
symptoms which are illogical and times out rageous. Nurse deal patient and should not try to be
irritable and angry but ensure him that subsided and try to keep patient busy in certain tasks.
7. Relationship with Suicidal Behavior patient: Noting is more important than life is the idea
of such patients. Therefore challenge to nurse to fulfill their tasks efficiency because such a
patient can get their life any time. Such patient should be received in wards in sympathetic and
friendly manner. Nurse should ensure that no body in the ward should irritate him. Nurse should
give medication at night time and right dose to keep patient calm Patient should be observed a
reassured on time to time.
Developing Acceptable Attitude towards Patients’ with Mental Disorder
The basic acceptable attitudes are required to develop good relationship with the patient are to
be:
1. Friendly
2. Polite
3. Not emotionally involved
4. Mutual respect
5. Free to ask their needs and requirements.
6. To discuss problem without hesitation.
7. Not to allow patient too much depended.
8. As that, enable nurse to do duty
efficiently.

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Unit-3
LEGAL ASPECTS OF PSYCHIATRIC
HOSPITALIZATION
It is vital that nurses who work in psychiatric settings know and understand the legal parameters
of treating person with a mental illness in hospital.
Method of Psychiatric Admission
The arrest of persons considered to have a mental illness is permitted by law although the
specifics of the law differ from state to state.
Types of Admission
1. Voluntary admission
2. Involuntary admission
Voluntary Admission
Voluntarily admission is to be characterized by the individual admission
and discharge via his or her own signature. It means that individual makes direct application to
the institution for services and make stay as long as treatment is necessary. He/ she may sign out
of the hospital at any time following a mental status examination.
Involuntary Admission
Involuntary admission is under taken by someone other than the client.
Three type of involuntary admission result in legal commitment to a psychiatric hospital the first
is an,
A. Emergency commitment.
B. Temporary commitment:
C. Indefinite commitment (extended Criminal commitment: )
Emergency commitment: In the emergency for the client who is dangerous for self and others
Temporary commitment: In which the individual can be involuntary hospitalized for a longer
period, in some states this is 6 months.
Indefinite commitment (extended): It is valid for an unspecified, period, usually subjective to
periodic judicial review.

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Criminal commitment: It is form of extended or indefinite commitment allowing involuntary
hospitalization of persons charged with crimes who are waiting path or who have been in the
clear of a crime by reason of craziness.
Safety of nurses (while giving care to patient)
1. Practice within the scope of nursing
2. Observe the hospital policy.
3. Measure up to date and establish practice
standards.
4. Always kept the clients’ welfare.
5. Develop relationship with each client and
his/her family.
Rights of Psychiatric/Mental Health Patients
1. Right to refuse treatment
2. Right to informed consent ( and the right
to know about rights)
3. Right to confidentiality
4. Right to receive visitors and telephone
calls
5. Right to be treated with respect
6. Right to be treated in the least restrictive
environment
Concept of Least Restrictive Environment:
a) Should guide nursing decisions
b) Isolation is used when the person is a
danger to others
c) Limit is used when the person is a danger
to self
d) Never used to get a patient to comply.
Safety of the Patient
1. Cribs bed should be used for restless patient.
2. Make sure that all the electrical appliances are routinely checked and maintained.
3. Precautions must be taken to prevent fire.
4. Quarrels between irritable patients should be avoided.
5. Ropes, ties, sharp equipments should not be kept in ward.

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Unit -4
DEFENSE MECHANISM OR MENTAL
MECHANISMS
Defense Mechanisms: Defense mechanisms are used to reduce anxiety or resolved conflict by
modifying or changing our behavior.
Defense Mechanisms: which are methods of attempting to protect the self and cope with basic
drives or emotionally painful thoughts, feelings, or events.
Purposes of defense mechanisms are:
1. To resolve a mental conflict
2. To reduce anxiety or fear
3. To protect one's self esteem
4. To protect one's sense of security
Defense mechanisms do not usually get free of the problem, and are often negative or not a very
effective way to deal with stress.
1. Repression: subconsciously blocking out unpleasant memories
Example: Sexually abused as a child blocks the experience from her consciousness and is
confused about inability to respond sexually.
2. Regression: using childlike ways for expressing emotions.
Crying, name calling, throwing things,
Five-year-old asks for a bottle when new baby brother is being fed.
3. Suppression: Willingly or voluntarily putting unacceptable thoughts or feelings out of
one’s mind with the ability to recall the thoughts or feelings at will.
Example: Voluntary forgetfulness or “I rather not talk about it, right now!”
Example: A nurse working in the ward and there is a sick child at home but she keeps it out of
mind until she finishes her duty time
4. Dissociation: The unconscious separation of painful feelings and emotions from an
unacceptable idea, situation, or object
Example: A woman raped found wandering a busy highway
5. Identification: A conscious or unconscious attempt to model oneself after a respected
person such as a parent or teacher
Example: without being aware that he is copying his teacher.
6. Introjection: Attributing to oneself the good qualities of another. Incorporate feelings &
emotions, values & beliefs, traits and personality.
Example: a little boy tells his younger sister to let him hold her hand as his mother used to hold
her hand while crossing the road.
7. Sublimation: redirecting bad or unacceptable behavior/emotions into positive behavior.
Example: We sublimate the desire to fight into the ritualistic activities of formal competition.
Wife who is angry enough to hot husband goes around scrubbing and cleaning the whole house.

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8. Compensation: also called substitution: It involves trying to make up for feelings of
inadequacy or frustration in one area by excelling or overusing in another.
Example: An adolescent takes up jogging because he failed to make the swimming team.
“I am not good at football so I will try the swim team
Example: An unattractive girl became a very good tennis player.
9. Rationalization: Unconsciously used to justify ideas, actions and/or feelings with good
acceptable reasons or explanation. Irrational/illogical excuses to escape responsibility.
Example: Student fails an exam, blames it on the poor lectures
10. Projection: Blame other people or things for failure.
Example: “It’s my psychiatric teacher’s fault I failed the test”
Or
Person rejects unwanted characteristics of self and assigns them to others.
Example: man who was late for work blames wife for not setting the alarm clock.
11. Displacement: the transfer of negative emotions from one person or thing to an unrelated
person or thing.
Or Mechanism that serves to transfer feelings such as frustration, aggression or anxiety from one
idea, person or object to another
Example: Shouting at a subordinate after being shouted at by the boss.
12. Undoing or restitution: Doing something to counteract or make up for a misbehavior or
wrongdoing
Example: Sending flowers after embarrassing her in public.
13. Reaction formation: expressing emotions that are the exact opposite of what ones feel.
Mask anger/hate with kindness. Teasing/bothering someone you like. Ex. Man who dislikes his
mother in low is very polite towards her.
14. Intellectualization: Using only logical explanations without feelings or an affective
component
Example: person who does not want close to the women emotionally give intellectual
explanation for lack of involvement of getting close to a women
15. Denial: failure to accept reality.
This is not happening. It can’t happen to me.”
Or This is the unconscious refusal to face thoughts, feeling, wishes, needs or reality factors that
are intolerable:
Example: a student who is determinedly late for a scheduled class because that student is actually
very fearful of the topic, so he/she expresses the fear by being absent from the class, or a person
who has just been admitted to a mental hospital states “I am really not sick, I am just in here to
get a rest”
16. Fantasy /Daydreaming: Escaping from an unpleasant situation by using imagination.
Living in a fantasy world
OR
This refers to imagined events or mental images to express unconscious ideas, conflict, gratify
unconscious wishes, or prepare for anticipated future events

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Unit-5
THERAPEUTIC NURSE| PATIENT
RELATIONSHIP AND COMMUNICATION
Communication
Communication is the process people use to exchange information through verbal and nonverbal
messages.
Communication is the giving and receiving of information.
It is a mutual interaction or give-and-take action that can occur between or among people.
(Shives1990.)
Therapeutic Communication:
An interaction between a health care professional and a patient that aims to enhance the patient's
comfort, safety, trust, or health and well-being.
Non-verbal communication is sometimes considered a more accurate description of true feelings
because one has less control over non-verbal reactions.
Non-verbal communication includes:
1. Position or posture
2. Gesture
3. Touch
4. Physical appearance
5. Facial expressions
6. Vocal cues and Distance or four-
dimensional territory.
Models of Communication (elements of communication):
There are four models of communication according to David and these are:
1. Source (a person who is responsible to create the message)
2. Message (the idea which is transmitted from the source to the receiver)
3. Channel (it is a means by which a message can be transmitted from a source to the receiver)
4. Receiver (a person who is receiving the message from the source)
The main goal of therapeutic communication is to develop or maintain a healthy personality.
This is done by reliving stress and assisting the patient in developing better coping mechanisms.
Barriers to Effective Communication:
There are some barriers to effective communication:
1. Barriers caused by reception, need, attitude, environmental stimuli etc.
2. Barriers caused by a lack of understanding language, knowledge etc.
3. Barriers caused acceptance, prejudices, emotional conflict etc.
4. Psychological barriers to listening such as day dreaming, detouring, debating, private
planning.

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Communication Skills:
The following suggestions are given to enable the student psychiatric nurse to develop good
communication skills for effective therapeutic interactions.
1. Know yourself
2. Be honest with your feelings
3. Be sure in your ability to relate to people
4. Be sensitive to needs of others
5. Be reliable
6. Recognize symptoms of anxiety
7. Watch your non-verbal reactions
8. Use words carefully
9. Recognize differences
10. Recognize and evaluate your own
actions and responses.
Therapeutic Relationship:
It is a relationship that is established between a health care professional and a client for the
purpose of assisting the client to solve his problems.
Components of Therapeutic Relationship
Following are Components of Therapeutic Relationship
1. Trust
2. Genuine interest
3. Empathy
4. Acceptance
5. Positive regard
6. Self-awareness
7. Therapeutic use of self
Therapeutic Techniques:
1. Offering Self
2. Active listening
3. Exploring
4. Giving broad openings
5. Silence
6. Stating the observed
7. Encouraging
comparisons
8. Summarizing
9. Placing the event in time
or sequence
10. Encouraging
descriptions of perceptions
11. Presenting reality or
confronting
12. Seeking clarification
13. Reflecting
14. Restating
15. Asking question
16. Empathy
17. Focusing
18. Interpreting
19. Suggesting
collaboration
20. Encouraging
formulation of a plan of
action
21. Encouraging decisions
22. Giving information
23. Limit setting
24. Role playing
25. Feedback
26. Reinforcement
Non Therapeutic Techniques:
1. Overloading
2. Value Judgments
3. Incongruence
4. Under loading
5. False reassurance/ agreement
6. Invalidation
7. Focusing on self
8. Changing the subject
9. Giving advice
10. Internal validation

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Phases of Nurse-Client Relationship:
1. Pre-Orientation
2. Orientation
3. Working/ Exploration/ Identification
Stage
4. Termination/ Resolution stage
Pre-Orientation:- Self assessment examine own feelings, fears, and anxieties. Data gathering
and learn as much as possible regarding patients’ previous history attitudes and behaviors
Make plan for interaction with the client e.g. suitable environment.
Orientation: - establish trust, share information with client; discrete self-disclosure. convey
support, facilitate healing educate
Working/ Exploration/ Identification Stage – Exploration- guide client to examine
feelings/responses, develop new coping skills
Termination/ Resolution stage: - Examine goals achieved; Explore feelings regarding
termination. Establish plan for continuing assistance.

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Unit-6
PSYCHIATRIC DISORDERS AND NURSING
MANAGEMENTS OF PSYCHIATRIC
DISORDERS
Psychiatric/Mental Disorder is state of imbalance characterized by a disturbance in a person’s
thoughts, feelings and behavior.
There are many different conditions that are recognized as psychiatric disorders / mental
illnesses. The more common types include:
1. Personality disorders
2. Anxiety disorders
3. Mood disorders
4. Psychotic Disorders
5. Eating Disorders
6. Impulse and control and addiction
Disorders
7. Sexual and gender disorders
8. Dissociative disorders etc
Also classified as
1. Non psychosis Normal variation
Emotional disturbance (Neurosis)
Anxiety neurosis
Neurotic depression
Hysteria-dissociative hysteria -conversion hysteria
Obsessive compulsive neurosis
Phobic neurosis
Traumatic neurosis
2. Psychosis Organic Acute Delirium
Chronic Dementia
Inorganic Affective Mania
Depression
Non affective
Schizophrenia
Schizoaffective
Paranoidillness
Reactive psychosis
3. Addiction Alcohol
Drugs
4. Mental sub normality (Mental retardation)
5. Personality disorders
6. Sexual disorders

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Personality and Personality Disorders
Concept of Personality:
Personality is the total quality of an individual as revealed in his character habits, thoughts,
experience, attitudes, interest, manner of actions and general outlooks.
Definition of Personality:
Personality is defined as distinctive and relatively enduring ways of thinking, feeling, and acting
Or
Personality is a combination of all the characteristics that make a person unique’
Components of Personality:
1. Id
2. Ego
3. Superego
Personality Traits Assessment:
Personality Traits:
Personality traits are characteristics personality in different quantity and combination which
makes individual unique from others. Personality traits are:
Able, active, ambitious, alert, beautiful, famous, energetic, Lucky, loyal, shy, Social, honest,
impulsive, intelligent etc are the traits of personality.
In psychology, the Big Five personality traits are five broad domains or dimensions of
personality that are used to describe human personality.
The Big Five factors are:
1. Openness,
2. Conscientiousness
3. Extraversion,
4. Agreeableness
5. Neuroticism.
Openness:
It is a general appreciation for art, emotion, adventure, unusual ideas, imagination, curiosity, and
variety of experience.
Sample openness items
I have a rich vocabulary.
I have a bright imagination.
I have excellent ideas.
I am quick to understand things.
I use difficult words.
I spend time reflecting on things.
I am full of ideas.
I am not interested in abstractions.
(reversed)
I do not have a good imagination. (reversed)
I have difficulty understanding abstract
ideas. (reversed)
Conscientiousness:
It is a tendency to show self-discipline, act dutifully, and aim for achievement against measures
or outside expectations

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Sample conscientiousness items
I am always prepared
I pay attention to details.
I get chores done right away.
I like order.
I follow a schedule.
I am exacting in my work.
I leave my belongings around. (Reversed)
I make a confusion of things. (Reversed)
I often forget to put things back in their
proper place. (Reversed)
I shirk my duties. (Reversed)
Extraversion:
Extraversion: implies an energetic approach to the social and material world and includes traits
such as sociability, activity, assertiveness, and positive emotionality.
Introverts:
Introverts have lower social engagement and energy levels than extraverts. They tend to seem
quiet, low-key, deliberate, and less involved in the social world.
Sample extraversion items
I am the life of the party.
I don't mind being the center of attention.
I feel comfortable around people.
I start conversations.
I talk to a lot of different people at parties.
I don't talk a lot. (reversed)
I keep in the background. (reversed)
I think a lot before I speak or act. (reversed)
I don't like to draw attention to myself.
(reversed)
I am quiet around strangers. (reversed)
I have no intention of talking in large
crowds. (reversed)
Agreeableness:
Agreeableness is a tendency to be compassionate and cooperative rather than suspicious and
aggressive towards others. They are generally considerate, friendly, kind, helpful, and willing to
compromise their interests with others. Agreeable people also have an hopeful view of human
nature.
Disagreeable:
Disagreeable individuals place self-interest above getting along with others. They are generally
unconcerned with others’ well-being, and are less likely to extend themselves for other people.
Sometimes their doubt about others’ motives causes them to be suspicious, unfriendly, and
uncooperative.
Sample agreeableness items:
I am interested in people.
I sympathize with others' feelings.
I have a soft heart.
I take time out for others.
I feel others' emotions.
I make people feel at ease.
I am not really interested in others.
(reversed)
I insult people. (reversed)
I am not interested in other people's
problems. (reversed)
I feel little concern for others. (reversed)

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Neuroticism:
Neuroticism is the tendency to experience negative emotions, such as anger, anxiety, or
depression. It is sometimes called emotional instability, or is reversed and referred to as
emotional stability.
At the other end of the scale, individuals who score low in neuroticism are less easily upset and
are less emotionally reactive. They tend to be calm, emotionally stable, and free from persistent
negative feelings. Freedom from negative feelings does not mean that low scorers experience a
lot of positive feelings.
Sample neuroticism items:
I am easily disturbed.
I change my mood a lot.
I get irritated easily.
I get stressed out easily.
I get upset easily.
I have frequent mood swings.
I often feel blue.
I worry about things.
I am relaxed most of the time. (reversed)
I seldom feel blue. (reversed)
I am much more anxious than most people.
Personality Disorders:
Personality disorder is "a permanent pattern of inner experience and behavior that deviates
markedly from the expectations of the culture of the individual who displays it".
Or
Personality disorders form a class of mental disorders that are characterized by long-lasting rigid
patterns of thought and behavior. Because of the inflexibility and frequency of these patterns,
they can cause serious problems and impairment of functioning for the persons who are afflicted
with these disorders
Or
Personality disorder is described as a non-psychotic illness characterized by maladaptive
behavior, which the person utilizes to fulfill his or her needs and bring satisfaction to self.
What Causes Personality Disorders?
Etiology is unknown
1. Genetics.
2. Childhood trauma.
3. Verbal abuse
4. High reactivity: Overly sensitive.
5. Upper class
Characteristics of personality disorder
1. The person denies the maladaptive behavior S/he show evidence of; such behavior has become
a way of life for him.
2. The maladaptive behaviors are inflexible
3. Minor stress is poorly tolerated, resulting in increased inability to cope with anxiety

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4. Ego functioning is intact but may be defective therefore, it may not control impulsive
actions of the id
5. The person is in contact with reality although S/he has difficulty dealing with it
6. Disturbance of mood, such as anxiety or depression may be present
7. Psychiatric help rarely is sought because the person is unaware or denies that his or her
8. Behavior is maladaptive (incomplete, inadequate, or faulty adaptation)
The general personality disorder symptoms are classified as:
1. Frequent mood swings
2. Unstable relationships
3. Isolating oneself from social interactions
4. Anger outburst
5. Mistrust and suspicion of family and
friends
6. Difficulty in making friends
7. Alcohol or drug abuse
8. Poor desire control
9. Suicidal tendency
10. Causing harm on others without
provocation
PERSONALITY DISORDERS
1. Paranoid personality disorder
2. Schizoid personality
3. Schizotypal personality disorder
4. Antisocial personality disorder
5. Borderline personality disorders
6. Histrionic personality disorders
7. Narcissistic personality disorders
8. Avoidant personality disorders
9. Dependent personality disorders.
10. Obsessive-compulsive personality
disorders
Cluster A Odd and Eccentric
Paranoid personality disorder
Characterized by Long-standing suspiciousness and generalized mistrust of others
1. Very secretive-not likely to trust anyone
or disclose in anyone
2. Hyperalert to danger
3. Argumentative-keep distance that way
4. Rarely seek help
5. Severe jealousy
Schizoid Personality Disorder
A general pattern of detachment from social relationships and a restricted range of expression of
emotions in interpersonal settings
1. Lacks desire for close relationships or
friends including family
2. Chooses to be alone
3. Lack of sexual experiences
4. Avoids activities
5. Appears cold and detached
6. Has no close or trustful friend.
7. Appears indifferent to praise or criticism.

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Schizotypal Personality Disorder
A general pattern of social and interpersonal deficits marked by acute discomfort with and
reduced capacity for close relationships as well as by cognitive or perceptual alterations and
abnormality of behavior
1. Ideas of reference
2. Magical thinking or odd beliefs(claiming
that they tell the future, read the thoughts
of others, and so on)
3. Odd thinking or speech
4. Suspiciousness or paranoid ideation
5. Suspiciousness
6. Narrowed or inappropriate affect
7. Unusual appearance or behavior
8. Few close relationships
9. Uncomfortable in social situations
Cluster B: ~ I, Me, Myself
Dramatic, Erratic and Emotional
Anti-social Personality Disorder
Characterized by dishonesty, handling, revenge and harm to others with an absence of guilt or
anxiety
1. Violates rights of others
2. Engages in illegal activities
3. Aggressive behavior
4. Lack of guilt or shame
5. Irresponsible in work and with finances
6. Impulsiveness
7. Irresponsibility
8. Manipulative
Borderline Personality Disorder
Characterized by general pattern of unstable interpersonal relationships; self-image and distress;
and marked impulsivity
1. Worried avoidance of leaving behind;
real or imagined
2. Unstable and extreme interpersonal
relationships
3. Identity disturbances
4. Impulsivity
5. Self-injury behavior
6. Rapid mood shifts
7. Chronic feelings of emptiness
8. Problems with anger
9. Temporary dissociative and paranoid
symptoms
Narcissistic Personality Disorder
The essential feature of narcissistic personality disorder is a grandiose of self-importance, often
combined with interrupted feelings of inferiority.
1. Grandiose self-importance
2. Fantasies of unlimited power, success or
brilliance
3. Believes he or she is special
4. Needs to be prized
5. Sense of power
6. Takes advantage of others for own
benefit
7. Lacks empathy
8. Jealous of others or others are jealous of
him
9. Overconfident

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Histrionic personality Disorder
An insidious pattern of excessive emotionality and attentive seeking
1. Overly dramatic
2. Draws attention to self
3. Extroverted and grow well on being the
center of attraction
4. Uncomfortable if not the center of
attention
5. Shows inappropriate provocative or
seductive manner.
6. Detachment
CLUSTER C ~ I'm Not Sure, I'm Nervous... Do You Think I Look Okay???
Anxious/Fearful
Dependent personality disorder
A general and excessive need to be taken care of that leads to obedient and clinging behavior and
fears of separation
1. Needs others to be responsible for important areas of life.
2. Problems with starting with projects or doing things on his own because of little self
confidence
3. Performs unpleasant tasks to obtain support from others
4. Urgently seeks another relationship for support and care after a close relationship ends
5. Preoccupied with fear of being alone to care for self
Avoidant Personality Disorder
A contained pattern of social reserve, feelings of inadequacy and hypersensitivity to negative
evaluation
1. Avoids occupations involving interpersonal contact due to fears of disapproval or rejection
2. Preoccupied with being criticized or rejected in social situations
3. Inhibited and feels inadequate in new interpersonal situations
4. Very reluctant to take risks or engage in new activities due to the possibility of being
uncomfortable
Obsessive Compulsive Personality Disorder
A general pattern of concern with orderliness, perfectionism and mental and interpersonal
control at the expense of flexibility, openness and efficiency
1. Inattentive with details, lists, rules,
organization
2. Perfectionist
3. Too busy working to have friends or
leisure activities
4. Unable to discard worthless or worn-out
objects
5. Unwilling to pay out and saves money
6. Rigid and inflexible
Nursing management/ Care of Personality Disorders
1. Develop a relationship with the person based on empathy and trust, while also maintaining
appropriate boundaries.
2. Ensure duty of care responsibilities are appropriately addressed, with regards to treatment for
the presenting medical and physical issues and by remaining alert to suicide risk.

34
3. Promote effective and functional coping and problem solving skills, in a way that is
empowering to the person.
4. Promote the person’s development of and engagement with their support network, including
access to appropriate service providers.
5. Ensure good collaboration and communication with other staff members and service providers
treating the person to ensure regularity in treatment and approach.
6. Support and promote self-care activities for families and careers of the person with the
personality disorder.
Anxiety Disorders
1. Anxiety is an unpleasant feeling of fearfulness. It often includes physical symptoms.
2. "Is characterized by a diffuse, unpleasant, unclear sense of apprehension, often accompanied
by autonomic symptoms, such as headache, perspiration, palpitations, tightness in the chest, and
mild stomach discomfort"
3. It is subjective feeling of apprehension and uneasiness that stem from fear.
Clinical Features
Physiologic
1. Gastrointestinal: dry mouth, difficulty in swallowing, epigastric discomfort, frequent or loose
motions
2. Respiratory: Constriction in the chest, difficulty inhaling, over breathing
3. Cardiovascular: Palpitations, discomfort in chest
4. Genitourinary: frequency or urgent micturition, failure of erection, menstrual discomfort,
amenorrhea
5. Neuromuscular system: tremor, prickling sensations, tinnitus, dizziness, headache, aching
muscles
6. Sleep disturbances: Insomnia, night fear
7. Other symptoms: obsessions, depersonalization, derealization
Psychological
1. Irritability,
2. Sensitivity to noise,
3. Restlessness,
4. Poor concentration,
5. Worrying thoughts and apprehension
6. Fear of going crazy or doing something
Uncontrolled
Etiology of Anxiety Disorders
Psychological Contributions
1. Childhood fear situations
2. Stressful life events
Many stressors activate biological and
psychological exposures to anxiety
3. Biological Causal Factors
Genetic factors: Most frequent among
Family.
Deficiency of GABA

35
4. Social factors: Economic effects
,Problem-solving abilities, Social
supports
Cultural beliefs
There are four levels of anxiety
1. Mild anxiety
2. Moderate anxiety
3. Sever anxiety
4. Panic level of anxiety
Types of Anxiety Disorders
Majors Anxiety disorders
1. Panic Disorder/Panic attack
2. Obsessive-Compulsive Disorder
3. Post-Traumatic Stress Disorder
4. Phobias
5. Generalized Anxiety Disorder
6. Conversion disorder
Panic Disorder/Panic attack
1. Discrete period in which there is a sudden onset of intense apprehension, fearfulness, or
shock, often associated with feelings of impending trouble.
2. It is a condition characterized by separate period of intense fear or discomfort, in which four
(or more) of the following symptoms developed sharply and reached a peak within 10
minutes:
Clinical Features
1. Shortness of breath and smothering
sensations
2. Choking, chest discomfort or pain
3. Palpitations
4. Sweating, dizziness, unsteady feelings or
5. Faintness
6. Nausea or abdominal discomfort
7. Depersonalization or derealization
8. Numbness or tingling sensations
9. Trembling or shaking
10. Fear of dying
11. Fear of going crazy or doing something
uncontrolled
Three types of Panic Attacks:
1. Unexpected - the attack "comes out of the blue" without warning and for no visible reason.
2. Situational - situations in which an individual always has an attack, for example, upon
entering a bridge.
3. Situationally Predisposed - situations in which an individual is likely to have a Panic Attack,
but does not always have one. An example of this would be an individual who sometimes has
attacks while driving.
Nursing interventions for Clients with panic Attacks
1. Provide a safe environment and ensure client’s privacy during a panic attack.
2. Remain with the client during a panic attack.
3. Help client to focus on deep breathing.
4. Talk to client in a calm, reassuring voice.

36
5. Teach client to use relaxation techniques.
6. Help client to use cognitive restructuring techniques.
7. Engage client to explore how to decrease stressors and anxiety-provoking situations.
Obsessive-Compulsive Disorder (OCD):
Obsessive-Compulsive Disorder is characterized by obsession (recurring thoughts) and or by
compulsions (repetitive behaviors) which cause anxiety.
Nursing interventions:
1. Remember, a lot of the time people feel guilty about their thoughts and behaviors.
2. Do not try to stop the act unless the act is harmful (dangerous)
3. Talk to them! Use “I” statements
4. If they are too down on themselves, limit your time with them. For instance, “I hate myself.
No one cares about me. I’m fat and ugly.” The nurse would then say, “I am going to come back
in 30 minutes. In that time frame, I want you to think of your good qualities.”
5. Do not argue with OCD person.
6. Inject reality. If a young adult thinks she is pregnant despite a negative pregnancy test, tell her
the TEST IS NEGATIVE. Take them back into reality.
7. If they repetitively do an act over and over again; help them set a goal. For example, “Let’s try
to only wash your hands once every ten minutes.”
Post-Traumatic Stress Disorder (PTSD)
Is an anxiety disorder that typically occurs after fear-provoking events most often exposure to
traumas such as a serious accident, a natural disaster, or criminal attack can result in PTSD.
At risk people include:
1. Battle troupers
2. Victims of violence
3. Abused victims
4. Children in traffic accident (and the
parents)
Symptoms of PTSD occur 3 months or more after the trauma.
Some more signs of PTSD:
1. Have issues with authority figures
2. Their first emotions are anger, rage, and
guilt
3. Their guilt comes out as anger (violent
behavior)
4. Isolate themselves
5. Cry
6. Don’t want to talk about it
7. Drug and alcohol abuse
8. Bad dream
9. in evidence in physiological symptoms (
GI distress)
10. Irritable
11. Insomnia

37
Nursing interventions:
1. Have specific staff members assigned to client to facilitate building trust
2. Regularity is the key
3. Be non-judgmental; encourage client to talk
4. Help them acknowledge where grief is coming from
5. Involve family
6. Give positive feedback
Goals for PTSD:
1. Short term: Safety, decrease insomnia, identify source, grieve!
2. Long term: Accept the fact that the experience happened and live healthy.
Phobia:
1. Marked & determined unreasonable fear of object or situation
2. Anxiety response
3. Unreasonable
4. Object or situation avoided or endured with distress
5. Specific phobia: Fear of a single object, situation or activity that cannot be avoided
Common Specific Phobias
1. Acrophobia: - High places
2. Algophobia: - Pain
3. Astraphobia: - Storms and thunder
4. Claustderophobia: - Closed place
5. Haemotophobia: - Blood
6. Mysophobia: - Germs and contamination
7. Nyctophobia: - Darkness
8. Ochlophobia: - Crowds
9. Pathophobia: - Disease
10. Pyrophobia: - Fire
11. Zoophobia: - Animals or particular
animals
2. Social phobia: the intense fear of being inspected, evaluated negatively or being the centre of
attention and resulting avoidance of situations where this may occur.
3. Agoraphobia: Is anxiety about or, avoidance of places or situations from which escape might
be difficult or uncomfortable or in which help may not be available in the event of having a panic
attack or panic like symptoms.
Agoraphobia comes from the Greek word “Agora” Meaning “market place” Fear of being alone
in open or public spaces

38
Generalized Anxiety Disorder:
Excessive anxiety or worry occurring more days than not for at least 6 months about a number of
events or activities..
Diagnostic Criteria
1. Excessive anxiety at least 6 months
Difficulty controlling worry
2. 3 of 6 symptoms are present for more
days than not:
3. Restlessness,
4. Easily fatigued
5. Difficulty concentrating
6. Irritability
7. Muscle tension
8. Sleep disturbance
Treatment
1. Behavioral Therapy
2. Cognitive Behavioral Therapy
3. Psychodynamic Psychotherapy
4. Medications (Drug Therapy):
Like diazepam 5-15 mg per day in divided
doses for two to six weeks
Alternative Treatments
1. Acupuncture
2. Aromatherapy
3. Breathing Exercises
4. Exercise
5. Meditation
6. Nutrition and Diet Therapy
7. Vitamin
8. Self-Love
Interventions
Social interventions
1. Assist with life style and relationship reevaluation, restructuring
2. Assist with time management and decreasing lifestyle stress
3. Review child rearing practices (if patient is a parent)
4. Refer to family therapy if indicated
5. Encourage use of support group
Biological interventions
1. Teaching breathing control
2. Maintaining regular, balanced eating pattern
3. Reduce intake of caffeine and food additives
4. Encourage routine exercise
5. Administer medications;
6. Monitor for side effects
Psychological interventions
1. Stay with patient during acute panic attack
2. Perform behavioral analysis to identify antecedent events
3. Teach progressive muscle relaxation
4. Encourage use of direction behaviors
5. Provide education to correct myths and misinterpretation

39
Mood Disorders:
Also called emotional disorders, are general alterations in emotions that are expressed by
depression, mania, or both.
Categories of Mood Disorders:
The primary mood disorders are
1. Major depressive disorder
2. Manic Episode
3. Bipolar disorder (Formerly called manic-
depressive illness)
Other Mood disorders but with symptoms that are less severe or of shorter duration includes the
following:
1. Minor Depressive Disorder:
2. Dysthymic Disorder:
3. Bereavement versus Depressive Disorder:
4. Cyclothymic disorder:
Major Depressive Disorder (Major, Uni polar, Psychotic depression)
It is mental disorder in which an individual experiences mood to be down, blue (sadness) with
impaired social and occupational functioning that has be present for at least 2 weeks with no
history of manic behavior.
It is also required that five or more symptoms be present without clear cause,
1. Depressed mood or loss of interest previously enjoyable activities
2. Change in appetite or weight
3. Difficulty concentrating, remembering or making decisions
4. Feeling guilty, hopeless or worthless
5. Irritability or restlessness
6. Thoughts of death or suicide, including suicide attempts
Additional Sign includes
1. Disorganized thinking
2. Delusion
3. Hallucination
4. Disturb sleep pattern–early morning
waking
5. Loss of sexual desire
6. Menstrual disturbance
7. Constipation
8. Feelings of self blame
9. Loss of warm feeling for family or friends
10. Lack of energy
11. Un expected headaches or backaches
Etiology of Depression
1. Genetic: first-degree relative, 40% increased risk if family history.
2. Biological factors: serotonin, norepinephrine, abnormal cortisol levels,
3. Psychological and interpersonal factors: low self-esteem, unresolved grief.

40
4. Life events: long term unemployment, losing job, living in an abusive or uncaring relationship,
divorce, work issues, financial problems, stress, crisis etc
5. Serious medical illness: HIV, DM, etc
Treatment
1. Antidepressants
2. BCT
3. E.C.T.
4. Psychotherapy.
Nursing Diagnoses
1. Risk for Self-Directed Violence
evidenced by previous attempts of violence
2. Impaired Social Interaction
3. Spiritual Distress
4. Chronic Low Self-Esteem
5. Disturbed Thought Processes
6. Self-Care Deficit
Nursing Management
1. Provide for patient’s physical needs:
a) Self-care, tepid bath,
b) Personal hygiene,
c) Encourage patient to eat.
d) Establishing a bedtime routine
e) Gives warm milk to improve sleep
1. Assume active role in initiating communication.
a) Sharing observation of patient’s behavior
b) Speaking slowly and allowing sufficient
time for him to respond
c) Encouraging him to talk and write down
feelings
2. Educate patient about depression:
a) Explain that depression can be relieved by
expressing feelings,
b) Engaging in pleasurable activities,
c) Help patient recognize unclear
perceptions and link them to his depression
4. Ask patient whether he thinks about death or suicide
5. Stress the need for medication compliance

41
Mania
Mania is a state of extreme physical and emotional elation.
This is a type of functional psychosis. The disease is characterized by a triad of symptoms like,
elevation of mood, flight of ideas and increased psychomotor activity.
Clinical Features
A person experiencing mania or a manic episode may present with the following symptoms:
1. Elevated mood.
2. Increased energy and over activity.
3. Reduced need for sleep or food.
4. Irritability.
5. Rapid thinking and speech.
6. Grandiose plans and beliefs.
7. Lack of insight.
8. Distractibility.
Episodes that are characterized by the above, but are not associated with marked social or
occupational disturbance, a need for hospitalization or psychotic features are called hypo manic
episodes.
Nursing diagnoses:
1. Risk for Other-Directed Violence
2. Risk for Injury
3. Imbalanced Nutrition: Less than Body
Requirements
4. Ineffective Coping
5. Noncompliance
6. Ineffective Role Performance
7. Self-Care Deficit
8. Chronic Low Self-Esteem
9. Disturbed Sleep Pattern
Nursing Interventions
1. Provide for client’s physical safety and those around.
2. Set limits on client’s behavior when needed.
3. Remind the client to respect distances between self and others.
4. Use short, simple sentences to communicate.
5. Clarify the meaning of client’s communication.
6. Frequently provide finger foods that are high in calories and protein.
7. Promote rest and sleep.
8. Protect the client’s dignity when inappropriate behavior occurs.
9. Channel client’s need for movement into socially acceptable motor activities.

42
Bipolar Disorder (manic depression, manic-depressive illness)
This is characterized by recurrent episodes of mania and depression in the same patient at
different times.
Classification of Bipolar Disorder
1. Bipolar Disorder 1:- Episodes of severe mania and severe depression.
2. Bipolar Disorder 2:- Episodes of hypomania and severe depression.
3. Cyclothymic disorder 3: Characterized by 2 years of many periods of both hypomanic
symptoms that does not meet the criteria for bipolar disorder.
Nursing Diagnoses
1. High risk for violence, directed at self or
others
2. Impaired verbal communication
3. Anxiety
4. Individual coping, ineffective
5. Disturbance of self-esteem
6. Alteration in thought processes
7. Alteration in sensory perceptions
8. Self-care deficits
9. Sleep pattern disturbances
4. Alteration in nutrition
Therapeutic Nursing Management
1. Provide Safety
2. Provide for patient’s physical needs:
3. Providing Therapeutic Communication
4. Promoting Appropriate Behaviors
5. Providing Client and Family Teaching
6. electroconvulsive therapy
7. Psychopharmacology
Minor Depressive Disorder (Minor, Neurotic Depression)
Also known as minor depression is a mood disorder that does not meet five symptoms required
for criteria of major depressive disorder but in which at least two depressive symptoms are
present for two weeks.
Dysthymic Disorder
Mood disturbance that is considered similar to, but milder than, those ascribed Minor Depressive
Disorder
No evidence of psychotic symptoms regularly depressed mood for most of the day, more days
than not, for at least 2 years
Bereavement (loss) versus Depressive Disorder:
Summed to be a normal human condition grief

43
Bipolar and Unipolar Comparison
Difference between Bipolar and Unipolar Disorder
UNIPOLAR BIPOLAR
Gender and
Age
of Onset
Affects women more often than
men, appears later in life
Affects men and woman equally, average age of
onset suspected to be 18 years
Sleep Generally insomnia, difficulty
falling asleep or waking repeatedly
during the night
Generally hypersonic, excessive tiredness and
difficulty walking in the morning
Appetite Often has a loss of appetite and
diminished interest in eating
Often binge-eating and hungers for
carbohydrates, may alternate with loss of appetite
Activity Level Agitated, walk up and down and
restlessness are more common
Inactivity, somnolence, a slowing down of
movements (psychomotor retardation) more
common
Mood Sadness, hopelessness, feelings of
worthlessness
Same as for unipolar, although guilt is often much
more prominent
Other Episodes often last longer,
sometimes more responsive to
treatment
Risk of drug abuse and suicide higher than in
unipolar depression

44
Difference between, Psychotic and Neurotic depression
Neurotic(Minor )depression Psychotic(Major) depression
1. neurotic traits are seen in childhood 1. Usually good and stable personality
in childhood.
2. Family history usually absent. 2. Family history often present.
3. Precipitation factors are always
present
3. Precipitation factors are often
absent.
4. Patient usually feels worse in the
evening
4. Patient usually feels worse in the
morning.
5. Appetite may be increased or
decreased.
5. Appetite is always decreased
6. Course of illness fluctuating 6. Course of illness steady and progressive.
7. There may be gain or loss in weight 7. There is loss in weight.
8. There is difficulty in going off to
sleep.
8. There patient goes to sleep but wakeup
early in the morning.
9. Psychomotor retardation usually
absent.
9. Psychomotor retardation often present.
10. Self- pity present. 10. Self-blame present.
11. Depressive delusions usually
absent.
11. Depressive delusions often present.
12. Insight usually good. 12. Insight usually poor.
Suicidal Behavior
Suicide is a type of planned self-harm and is defined as an intentional human act of killing
oneself.
Self-imposed death stemming from depression
Etiology:
The following are some of the possible causes of suicide:
1. Psychiatric Disorders
2. Personality disorder
3. Patients with incurable or painful physical
disorders like cancer and AIDS.
4. Psychological Factor
5. Sex
a) Men have greater risk of completed
suicide
b) Suicide is 3 times more common in men
than women
c) Women have higher rate of attempted
suicide
d) Being unmarried, divorced, widowed or
separated having a sure suicidal plan
6. History of previous suicidal attempts
7. Recent losses

45
Signs and Symptoms
1. Self-injury
2. Unexplained decrease in daily functioning
3. Isolation and withdrawal, decreased social
interaction
4. Channeling of anger and aggression
towards self
5. Inability to discuss the future
6. Destructive coping mechanisms
7. Express anger toward self
8. Previous suicide attempts
9. Low self-esteem
10. Anxious and apprehensive
Nursing Diagnoses
1. High risk for violence, self-directed or
directed at others
2. Risk for self-mutilation
3. Ineffective individual coping
4. Ineffective family coping
5. Spiritual distress
Nursing Management
1. Establish a therapeutic relationship
2. Talk directly with the client about suicide and plans
3. Communicate the potential for suicide to team members and family
4. Stay with the client
5. Accept the person. Listen to the person.
6. Secure a “no suicide/harm” contract
7. Give the person a message of hope based on reality
8. When client is able, encourage gradual increase in activities
9. Maintain suicide precautions, be particularly concerned with personal items the client may
used to harm self, remove all dangerous and potentially dangerous items (belts, glass, sharps).
Schizophrenia
1. Schizophrenia: is defined as a mental disorder characterized by disordered thoughts,
hallucination, and delusions.
2. Schizophrenia is a form of psychosis involving disorders of perception, language, thought,
emotion, and behavior
3. Schizophrenia: A group of characteristic positive and negative symptoms deterioration in
social, occupational, or interpersonal relationships continuous signs of the disturbance for at least
6 months
Etiological Implications unknown
1. Genetic factors: High prevalence in first degree relatives
2. Biological factors: age, virus, Chemical imbalance & physical abnormalities-
neurotransmitters, brain structures Dopamine activity is excessive in the schizophrenic brain
3. Brain damage: enlarged ventricles are evident in schizophrenia
4. Environmental factors: Life stressors, changes,
5. Social factors: Loneliness, isolation, recent sadness, Lack of a supportive social network
decreased mobility Due to illness or loss of influential rights
6. Psychological factors: Traumatic experiences, Abuse Damage to body image, Fear of death
Frustration with memory loss Role transitions

46
Subtype of Schizophrenia:
Paranoid: Preoccupation with delusion or hallucinations, often with themes of persecution or
grandiosity.
Disorganized: Disorganized speech or behavior, flat or inappropriate emotion.
Catatonic: Immobility (or excessive, purposeless movement) extreme negativism and /or parrot
like repeating of another’s speech or movements.
Undifferentiated: Many and varied symptoms.
Residual: Withdrawal, after hallucination and delusions have disappeared.
The severity of symptoms varies from one person to another, and typically symptoms will
decline and then reappear.
Symptoms are divided into Positive and Negative symptoms.
Positive Symptoms: Positive symptoms are characterized by abnormal thoughts, perceptions,
language and behavior
Negative Symptoms: Negative symptoms are characterized by restrictions in range and intensity
of emotional expression, communication, body language and interest in normal activities.
Positive symptoms
1. Delusions
2. Hallucinations
3. Associative looseness
4. Ideas of reference
5. Flight of ideas
Negative symptoms
1. Blunted (or flat) Affect
2. Alogia
3. Lack of volition
4. Anhedonia
5. Catatonia
Schizophrenia treatment
1. Psychosocial
2. Clinical and family support services
3. Rehabilitation
4. Pharmacological and physical treatments
5. Neuroleptic medications
Prioritized Nursing Diagnoses For All Types Of Schizophrenia:
1. Risk for violence: Directed toward self or
other (priority!!!)
2. Self-care deficit
3. Thought process, altered
4. Sensory/perceptual alterations (related to
illusion, delusion & hallucination)
5. Social isolation
Nursing management:
Interventions:
 Promoting safety of client and others and right to Privacy and dignity
 Establishing therapeutic relationship by establishing trust
 Using therapeutic communication (clarifying feelings and statements when speech and
thoughts are disorganized or confused)

47
Interventions for delusions:
 Do not openly confront the delusion or argue with the client.
 Establish and maintain reality for the client.
 Teach the client positive self-talk, positive thinking, and to ignore delusional beliefs.
Interventions for hallucinations:
 Help present and maintain reality by frequent contact and communication with client.
 Engage client in reality-based activities such as card playing, occupational therapy, or
listening to music.
 Coping with socially inappropriate behaviors
 Redirect client away from problem situations
 Reassure others that the client’s inappropriate
 Behaviors or comments are not his or her fault (without violating client confidentiality).
 Do not make the client feel punished or shunned for inappropriate behaviors
 Teach social skills through education, role modeling, and practice.
 Client and family teaching
 Establishing community support systems and care

48
Substance abuse
Drug: A drug is defined (by WHO) as any substance that, when taken into the living being, may
modify one or more of its functions.
Define substance abuse: Substance abuse is the excess in, and dependence on, a psychoactive
material leading to effects that are harmful to the individual’s physical or mental health, or the
welfare of others.
Etiological Factors in Substance Use Disorders
Biological Factors
1. Genetic vulnerability (family history)
2. Psychiatric disorders or personality
disorders
3. Co-morbid medical disorder (e.g. to
control chronic pain).
Psychological Factors
1. Poor impulse control
2. Low self-esteem
3. Childhood trauma or loss
4. Escape from reality
5. Psychological distress
6. Pleasure-seeking
Social Factors
1. Peer pressure
2. Ease of availability of alcohol and drugs
3. Poor social/familial support
4. Religious reasons
5. Perceived distance’ within the family
6. Unemployment
7. Effects of television and other mass media
8. Loneliness, unmet needs
Characteristics of Addiction:
1. Desire to take drug
2. The person is fully aware of the harmful
effects of drugs
3. Wants to take drug at any cost by any
means
4. Development of tolerance
5. Physiological dependence
6. Psychological dependence
Effects of Addiction:
1. Poor performance at school / job
2. Irresponsible behavior
3. Untrustworthy for family and friends
4. Impairment of moral and ethical values
5. Involved in criminal activities
List the Major Drugs That Are Abused
1. Opioids, e.g. opium, heroin
2. Cannabinoids, e.g. cannabis
3. Cocaine
4. Amphetamine and other
sympathomimetics
5. Hallucinogens
6. Sedatives and hypnotics,
7. Inhalants,
8. Nicotine
9. Other stimulants (e.g. caffeine)

49
Patterns of substance use disorders
There are four important patterns of substance use disorders.
1. Acute intoxication,
2. Withdrawal state,
3. Dependence syndrome
4. Harmful use.
Acute intoxication: Acute intoxication develops during or shortly after alcohol ingestion. It is
characterized by clinically significant maladaptive behavior or psychological changes,
E.g: inappropriate sexual or aggressive behavior, mood lability, impaired judgment, inaudible
speech, in coordination, uneven gait, impaired attention and memory finally resulting in stupor or
coma.
Withdrawal state: In persons who have been drinking heavily over a prolonged period of time,
any rapid decrease in the amount of alcohol in the body is likely to produce
Withdrawal symptoms: Restlessness, irritability, anxiety, insomnia, excessive perspiration,
nausea, vomiting, abdominal cramps, diarrhea, muscular pain, spasms.
Dependence syndrome: is a cluster of physiological, behavioral, and cognitive phenomena in
which the use of a substance or a class of substances takes on a much higher priority for a given
individual than other behaviors that once had greater value.
Harmful use: is characterized by: Continued drug use, despite the awareness of harmful medical
and/or social effect of the drug being used, and/or a pattern of physically hazardous use of drug
(e.g. driving during intoxication)
Nursing management:
1. When patient enters into the hospital nurse should check that he has brought any drug with
himself.
2. May try to achieve the drug by his friend and family members, so visitors’ entry should be
restricted
3. She /He should observe for withdrawal features
4. The addict should be encouraged frequently not to take drug in future
5. Patient should not be allowed to leave alone in the ward
6. She/he should try tom know the cause of addiction
7. Special attention should be paid to patient’s diet, personal hygiene and recreational activities.
8. Physical assessment
9. Vital signs
10. Symptom scale
11. Medication administration
12. Patient teaching
13. Actions and consequences
14. Provision of adequate hydration and nutrition
15. Reassurance and support for anxiety
16. Relapse prevention

50
Abuse and Victim
Abuse is a general term for the use or treatment of someone or something that causes some kind
of harm or is unlawful or wrong.
A victim is one who is harmed by or made to suffer from an act, circumstance, agency, or
condition
Differentiate Among Different Kinds of Abuse
1. Sexual abuse
2. Physical abuse
3. Verbal abuse
4. Emotional abuse
5. Incest
6. Child abuse
7. Spousal abuse
8. Elder abuse
Characteristics of an Abuser
1. Jealousy
2. Controlling behavior
3. Quick involvement
4. Isolation
5. Blames others for feelings
6. Unkindness to animals
7. Anger while drinking
8. Breaking or striking objects when angry
9. Threats of violence
10. Use of force during an argument
Characteristics of a Victim
1. Blames self for violence or harmful acts
2. Dependent on abuser
• wants to be controlled
• Feels need to be taken care of
3. Poor self-image
4. Expects abuser to change
5. Returns to abuser after assault(s)
6. Makes excuses for abuser
7. Defends abuser’s action
Nursing management:
1. Assess client for possible abuse history
2. Provide abuse hotline phone numbers
3. Remove client from aggressive situation
4. Refer client to community resources
5. Treat client for depression, anxiety, and suicidal thoughts
6. Provide supportive, nurturing environment to discuss feelings

51
Cognitive Disorders or Organic Mental Disorders
• An Organic mental disorder may be defined as any disorder which occurs as a result of some
pathology in the brain, associated with disturbance the physiologic function of brain tissue at any
level of organization i.e. structural, hormonal, biochemical, etc.
• Characterized by the syndromes of Delirium, Dementia & Amnesia, which are caused by
General Medical Conditions, Substances or both.
• Cognitive disorders include those in which a clinically significant deficit in cognition or
memory exists, representing a significant change from a previous level of functioning.
Type of Organic Mental Disorders
1. Acute: in this brain impairment is temporary or reversible e.g Delirium
2. Chronic: In which the impairment of the brain is permanent e.g. Dementia
Risk Factors/Etiology
1. Very young or advanced age
2. People w/ Debilitation
3. Presence of specific general medical
conditions
4. Excessive exposure to a variety of
Substances
Presenting Symptoms
1. Memory Impairment, especially Recent Memory
2. Aphasia: Failure of language function
3. Apraxia: Failure of ability to execute complex Motor Behaviors
4. Agnosia: Failure to recognize or identify People or Objects
5. Disturbances in executive functioning: Inability to think abstractly & plan activities (i.e.
organizing, shopping & maintaining a home)
6. Disturbances in executive functioning: Inability to think abstractly & plan
Delirium:
Delirium is an acute reversible organic mental disorder characterized by acute change in person’s
level of consciousness, orientation, attention, thought and emotion.
Risk Factors/Etiology
1. Medical conditions (i.e. Systemic Infections, Metabolic Disorders, Hepatic & Renal Diseases,
Seizures & Brain Injuries)
2. Substance Intoxications or Withdraws
3. Occurs in 25% of elderly, hospitalized patients
Symptoms
1. Easily distracted
2. Difficulty concentrating
3. Illusions, hallucinations
4. Level of consciousness is impaired
5. Unclear speech
6. Anxious mood

52
Nursing process: Intervention
1. Patient safety
2. Managing confusion
• Often afraid at night.
3. Promote comfort and rest
4. Adequate fluids and nutrition
5. Client and family education about avoidance of recurrence
6. Monitor chronic health problems
7. Careful use of medications no alcohol or other non-prescribed drugs
Dementia
Dementia is the term used to describe the symptoms of a large group of illnesses that cause a
progressive decline in a person’s functioning.
It is a broad term used to describe a loss of memory, intellect, rationality and social skills
Key Symptoms
1. Asphasia (deterioration of language
function)
2. Apraxia (impaired ability to execute
motor functions)
3. Agnosia (inability to name or recognize
objects)
4. Anxiety
5. Depression
6. Hallucinations,
7. Delusions
8. Personality Disturbance
Nursing Process: Interventions
1. Demonstrate caring attitude
2. Keep clients involved; relate to environment
3. Validate client’s feelings of dignity
4. Offer limited choices
5. Reframing (offering alternate points of view to explain events)
6. SAFETY!
• Physical and Chemical limit should be the last option

53
Difference between Delirium and Dementia
Indicator Delirium Dementia
Onset Rapid Gradual and insidious
Duration Brief (hours to days) Progressive deterioration
Level of consciousness Impaired, fluctuates Not affected
Memory Short-term memory
impaired
Short- then long-term
memory impaired,
eventually destroyed
Speech May be unclear, rambling,
pressured,
Irrelevant
Normal in early stage,
progressive aphasia in
later stage
Thought processes Temporarily disorganized Impaired thinking, eventual
loss of thinking
Abilities
Perception Visual or tactile
hallucinations, delusions
Often absent, but can have
paranoia, hallucinations,
Illusions
Mood Anxious, fearful if
hallucinating; weeping,
Irritable
Depressed and anxious in
early stage, labile
mood, restless wandering,
angry outbursts in
later stages

54
Child and Adolescent Psychiatric Disorders
Mental Retardation
“Mental retardation refers to significantly sub average general intellectual functioning resulting
in or associated with concurrent impairments in adaptive behavior and manifested during the
developmental period”
Etiology
Genetic
Chromosomal abnormalities (such as Down’s syndrome
Prenatal Factors
Infections:
Rubella, Cytomegalovirus, Syphilis, Toxoplasmosis, herpes simplex
Endocrine disorders
Hypothyroidism, Hypoparathyroidism, Diabetes mellitus
Physical damage and disorders
Injury, Hypoxia, Radiation, Hypertension, Anemia, Emphysema
Intoxication
Drugs, Substance abuse
Placental dysfunction
Toxemia of pregnancy, Placenta previa, Cord prolapsed, Nutritional growth retardation
Perinatal Factors
Infections: Encephalitis, Measles, Meningitis, Septicemia, Accidents, Lead poisoning
Environmental and Sociocultural Factors
Cultural deprivation, Low socioeconomic status, inadequate caretakers, Child abuse
Classification
Mental retardation is classified into the following levels based on the intelligent quotient of
individuals. Intelligent Quotient (IQ)
1. Mild (Educable) 50-70(IQ)
2. Moderate (Trainable) 35-50(IQ)
3. Severe (Dependent retarded) 20-35
4. Profound (Life support) <20
Mild (Educable) 50-70(IQ)
It is common type, 85 to 90% of all cases. Individuals have minimum retardation in sensory-
motor areas. Progress up to VI standard in school and can achieve vocational and social self-
sufficiency with a little support. Develop social and communication skills, but have deficits in
cognitive function like poor ability for abstraction and egocentric thinking.
Moderate Retardation (l.Q. 35-50)
10%of mentally retarded come under this group. Communication skills develop much slowly in
these individuals. They can be trained to support themselves by performing semiskilled or
unskilled work under supervision
Severe Retardation (l.Q. 20-35)
Severe mental retardation is often recognized early in life with poor motor development and
absent or markedly delayed speech and communication skills. There is a possibility of teaching

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