Module 1: Overview of Psychiatric nursing mental health disorder

57.3%

• reported deaths caused by intentional self-harm or suicide according to PSA

15.08%

• percentage of youth suffering from at least one major depressive episode in the past year

• childhood depression is more likely to persists into adulthood if gone untreated

Mental health

• A state emotional, social, and psychological wellness as evidenced by:

• E - effective behavior and coping,

• S - satisfying interpersonal relationship

• P - positive self-concept and

• E - emotional stability

(WHO)

Factors influencing mental health

• individual/ Personal factors

• Intrapersonal

• Social/Cultural

• Nurturing during childhood

Components of mental health

• maximization of one’s potential

• self-esteem

• Mastery of the environment

• Autonomy and independent

• Tolerance of life’s uncertainties

• Stress management

mental illness

is a condition that impacts a person's thinking, feeling or mood may affect and his or her ability to relate to others and function on a daily basis. Each person will have different experiences, even people with the same diagnosis.

Mental Disorder

as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom”. (APA)

Criteria to Diagnose Mental Disorders

• L - lack of personal growth

• D - Dissatisfaction with one’s characteristics, accomplishments, abilities

• I - Ineffective or dissatisfying relationships

• D - Dissatisfaction with one’s place in the world

• I - Ineffective coping with life’s events

Psychiatric nursing

pertains to:

A. Assessment of behavior, planning and evaluation of care for individuals with mental disorders

B. Promotion of optimal mental health for individual, through early diagnosis, treatment and rehabilitation

C. Use of therapeutic interactions between the nurse and the individua

Interpersonal process of Psychiatric Nursing

• whereby the nurse through the therapeutic use of self

• assist an individual, family, group or community to promote mental health

• help prevent mental illness and suffering

• participate in the treatment and rehabilitation of the mentally ill

• Help find meaning in these experience

Mental Health Psychiatric Nursing

• is a specialized area of nursing that uses the theories of human behavior and the purposeful use of self, as its art. It is an interpersonal process whereby it promotes mental health, prevents mental illness, early identification and intervention of emotional problems, and follow-up care to minimize long term effects of mental disturbance.

3 Levels of Care

1. Primary prevention

2. Secondary Prevention

3. Tertiary Prevention

Primary prevention

• Altering the causative or risk factors to hinder development of illness

• Interventions

  • a. Client and family teaching

  • b. stress reduction

  • c. psychosocial support

Secondary Prevention

• Reducing the effects of mental illness

• Interventions

  • a. screening

  • b. crisis intervention

  • c. suicide prevention

  • d. short term counseling

  • e. emergency counseling & short term hospitalization

Tertiary Prevention

• Minimizing long term residual effect

• Interventions

  • a. rehabilitation program

  • b. vocational training

  • c. after care support

  • d. partial hospitalization options

Goals of Psychiatric Nursing

• To help the client accepts himself

• To promote relationship with other people

• To learn to function independently on a realistic basis

Roles of a Psychiatric Nurse

• Creator of the Therapeutic Environment

• Technical Nursing Role

• Therapist

• Performs functions such as bathing, feeding, backrubs

• Assist the client to participate in group activities

• Shows active listening, assisting client in identifying stresses that causes anxiety

• Checks vital signs

• Assist client in finding solutions to his problem

• Performs treatments and procedures

Essential Qualities of a Psychiatric Nurse

• Socializing Agent

• Counselor

• Teacher

• Parent Surrogate

Psychosexual/ Psychoanalytic Theory

• author: Sigmund Freud

  1. Human behavior is motivated by repressed sexual impulses and desires.

• Structure of Personality

  • Id

  • Ego

  • Superego

    1. Behavior is motivated by Subconscious thoughts and feelings

    2. Human Personality was believed to function at Three Levels of Awareness

• Phases of the theory

  • Oral phase

  • Anal phase

  • Phallic Phase

  • Latency Phase

  • Genital Phase

Oral phase (Psychosexual development)

• Age ranges: Birth - 18th months

• Developmental Focus: Mouth is the major site of tension ang gratification including biting and sucking activities

• Id is present at birth

Anal Phase (Psychosexual development)

• Age ranges: 1 ½ years , - 3 years

• Developmental Focus: Anus and surrounding area are major source of interest.

• Voluntary sphincter control is the goal.

• Ego develops gradually.

Phallic Phase (Psychosexual development)

• Age ranges: 3 years - 5 years

• Developmental focus: Genital is the focus.

• Penis envy & Elektra Complex (girls).

• Castration fear & Oedipus Complex (boys)

Latency Phase (Psychosexual development)

• Age ranges: 5-11 extended to 13 years

• Developmental focus: Complexes are resolved. Genital focus is turned to social activities.

• Formation of Superego

Genital phase (Psychosexual development)

• Age ranges: 11-13 over lapping with previous

• Developmental focus: Development of biologic capacity for orgasm. Starts to appreciate capacity for True Intimacy

Id

• sexual and aggressive drive

• Inborn

• Operates on pleasure principle

• Primary thinking process: Imagery

• Irrational and not based on reality

Ego

• Chief executive officer

• Operates on reality principle

• Secondary thinking process: logical and reality-oriented

• Major functions: adaptation to reality, modulation of anxiety, problem solving, control and regulates instinctual dives. Use Reality Testing and Defense Mechanisms

Superego

Conscience, punishes one for something wrong that was done. EGO-Ideal, rewards one for something good that was done. Residue of internalized values and moral training of early childhood

Three Levels of Awareness

• Conscious

• Pre-conscious Subconscious

• Unconscious

Conscious

functions when the person is awake, aware of himself, his thoughts, feelings, perceptions and what is going on in the environment

Pre-conscious Subconscious

• Ideas and reactions are stored and partially forgotten

• acts as WATCHMAN it prevents unacceptable, disturbing unconscious memories from reaching the conscious mind

• Brought into consciousness by recall

Unconscious

• largest part of the mind

• serves as storage or reservoir of painful memories & experiences which are difficult to recall

• realm of thoughts and feelings that motivate a person even he is totally unaware of them.

• can be recalled by psychoanalysis

Level of Consciousness

1. Can be recalled by psychoanalysis

2. Serves as storage or reservoir of painful stimuli

3. Acts as watchman – prevents unacceptable memories to comes to awareness

4. Functions when the person is fully awake

5. Ideas are stored and partially forgotten

6. Slips of the tongue

Psychosocial Theory

• Author: Erik Erikson

• personality develops in a predetermined order through eight stages of psychosocial development, from infancy to adulthood

• During each stage, the person experiences a psychosocial crisis which could have a positive or negative outcome for personality development.

• According to the theory, successful completion of each stage results in a healthy personality and the acquisition of basic virtues. Basic virtues are characteristic strengths which the ego can use to resolve subsequent crises

• Failure to successfully complete a stage can result in a reduced ability to complete further stages and therefore a more unhealthy personality and sense of self. These stages, however, can be resolved successfully at a later time

• Stages

  • Infancy - trust vs mistrust

  • Early childhood - autonomy vs shame and doubt

  • Preschool - Initiative vs Guilt

  • School age - Industry vs Inferiority

  • Adolescence - Identity vs. Role confusion

  • Young adulthood - Intimacy vs Isolation

  • Middle adulthood - generativity vs stagnation

  • Old adulthood - Ego integrity vs Despair

Moral development theory

• Author: Lawrence Kohlberg

• focuses on the thinking process that occurs when one decides whether a behavior is right or wrong. Thus, the theoretical emphasis is on how one decides to respond to a moral dilemma, not what one decides or what one actually does

• distinctive levels

  • Preconventional

  • conventional

  • postconventional

Preconventional (Moral development theory)

1. Punishment and obedience orientation. Obey rules to avoid punishment

2. Naive hedonism. conforms to get rewards and to have favors returned

• 1-6 years old

Conventional (Moral development theory)

3. Good boy/girl morality. conforms to avoid disapproval or dislike by others

4. conforms to avoid censure by authorities

• 7 - 11 years old

Postconventional (Moral development theory)

5. Conforms to maintain communities. emphasis om individual rights.

6. individual principles

• 11 years and older

Interpersonal theory

• Author: Harry Stack Sullivan

• Deals with people's characteristic interaction patterns

• Sullivan insisted personality is shaped almost entirely by the relationships we have with people

• He believed that a close interpersonal relationship has the power to transform an immature preadolescent into a psychologically healthy individual

  • Dynamism

    • The Self-System

  • Personifications

    • Bad Mother, Good Mother

    • Me Personification

    • Eidetic Personification

  • Stages of Development

    • Infancy Period - syntaxic language

    • Childhood - playmates of equal status

    • Juvenile Era - develops a need for an intimate relationship with a friend

    • Preadolescence - Perhaps the most crucial stage

    • Early Adolescence - may confuse lust with love

    • Late Adolescence - stable pattern of sexual activity

    • Adulthood - consistent pattern of viewing the world

Dynamism

• A typical pattern of behavior

• Specific dynamisms include:

  • Malevolence

  • Intimacy

  • Lust

  • The self-system

The Self-System

• Most inclusive of all dynamisms

• Patterns of behavior:

  • Protects us against anxiety and maintains our interpersonal security

  • Tends to stifle personality change

  • Experiences that are inconsistent with our self-system threaten our security and necessitate our use of security operations such as dissociation or selective inattention

Personifications

• People acquire certain images of self and others throughout the developmental stages

• These subjective perceptions are personifications

  • Bad Mother, Good Mother personification

  • Me Personification

  • Eidetic Personification

Bad Mother, Good Mother

• Bad mother personification grows out of infants' experiences with a nipple that does not satisfy their hunger needs

• All infants experience this even though their real mother may be loving and nurturing

• Infants later acquire a good mother personification

  • become mature enough to recognize the tender and cooperative behavior of their mother

• These two personifications combine to form a complex and contrasting image of the real mother

Me Personification

• During infancy, children acquire three "me" personifications

  • The bad-me, which grows from experiences of punishment and disapproval

  • The good-me, which results from experiences with rewards and approval

  • The not-me, which allows a person to disassociate or selectively in attend the experiences related to anxiety

Eidetic Personification

• People often create imaginary traits that they project onto others

• Included in these eidetic personifications are the imaginary playmates that pre-school aged children often have

• These imaginary friends enable children to have a safe and secure relationship with another person even though that person is imaginary

Infancy Period (Interpersonal Theory)

• from birth until emergence of syntaxic language

• Child receives tenderness from mother

  • learns anxiety through an empathic linkage with the mother

Childhood (Interpersonal Theory)

• Lasts from the beginning of syntaxic language until the need for playmates of equal status

• Primary interpersonal relationship continues to be with the mother

  • Mother now differentiated from other persons who nurture the child

Juvenile Era (Interpersonal Theory)

• Begins with the need for peers of equal status and continues until the child develops a need for an intimate relationship with a friend

• Children should learn how to compete, compromise, and cooperate

  • These abilities, as well as an orientation toward living, help a child develop intimacy

Preadolescence (Interpersonal Theory)

• Perhaps the most crucial stage

• Mistakes made earlier can be corrected during preadolescence

• Mistakes made during preadolescence are nearly impossible to overcome later in life

• Spans the time from the need for a single best friend until puberty

• Children who do not learn intimacy during preadolescence have added difficulties relating to potential sexual partners during later stages

Early Adolescence (Interpersonal Theory)

• With puberty comes the lust dynamism and the beginning of early adolescence

• Development during this stage marked by a coexistence of intimacy with a single friend of the same gender sexual interest in many persons of the opposite gender

• If children have no preexisting capacity for intimacy, they may confuse lust with love and develop sexual relationships that are devoid of true intimacy

Late Adolescence (Interpersonal Theory)

• May start at any time after age 16

• Psychologically, it begins when a person is able to feel both intimacy and lust toward the same person

• Characterized by a stable pattern of sexual activity the growth of the syntaxic mode

Adulthood (Interpersonal Theory)

• Late adolescence flows into adulthood

• 70+A time when a person establishes a stable relationship with a significant other person and develops a consistent pattern of viewing the world

Ego Defense Mechanisms

• Functions:

  • To ward off anxiety

  • To resolve a conflict

  • To protect self-esteem

  • To protect one’s sense of security

• without defense mechanisms, anxiety might overwhelm and paralyze and interfere with daily

• cab be therapeutic or pathologic

• supposedly in action by 10 years of age

Coping/ Defense mechanism

Level 1 : Psychotic Mechanisms

Level 2 : Immature Mechanisms

Level 3 : Neurotic Defenses

Level 4 : 4: Mature Mechanisms

Level 1: Psychotic Mechanisms

• (common to healthy individuals before age of 5)

  • Delusional Projection

  • Denial

  • Distortion

Level 2: Immature Mechanisms

• (common in ages 3-15)

  • Projection

  • Schizoid fantasy

  • Hypochondriasis

  • Passive-aggressive behavior

  • Acting out

Level 3: Neurotic Defenses

• (common to individuals aged teenagers and early adult)

  • Intellectualization

  • Repression

  • Displacement

  • Reaction Formation

  • Dissociation

Level 4: Mature Mechanisms

• common well-adjusted persons)

  • Altruism

  • Humor

  • Sublimation

Adaptive coping

for mild form of disorder

Pallative coping

for moderate form of disorder

Maladaptive coping

for severe form of disorder

Dysfunctional coping

for high level of form of disorder

Displacement

• Feelings are transferred or redirect to other person or object that is less threatening

• Negative Defense Mechanism; 3 entities involved

• E.g.

  • A husband comes home and yells at his wife after a bad day at work

  • Mrs. Faust screams at another patient after being told by her psychiatrist that she cannot have a weekend pass

Dissociation

• Separating and detaching a strong emotionally charged conflict from one’s consciousness

• “traumatic amnesia”

• E.g.

  • Amnesia that prevents recall of yesterday’s auto accident

Denial

• Failure to acknowledge an unacceptable trait or situation

• E.g.

  • A student refuses to admit that she is flunking a course despite an F on the 1st exam.

  • Mr. Davis, who is alcohol dependent, states that he can control his drinking.

Regression

• Returning to an earlier developmental stage

• E.g.

  • a 6-year-old wets the bed at night since the birth of his baby sister

  • Mr. Hivey has isolated himself in his room and has lain in a fetal position since his admission

Rationalization

• Self-saving with incorrect illogical explanation

• Look for reasoning or “because”

• E.g.

  • A student states, “I got a C on the test because the teacher asked poor questions.”

  • Mr. Jones, a paranoid schizophrenic, states that he cannot go to work because he is afraid of his co-workers instead of admitting that he is mentally ill.

Regression

• Unconscious forgetting of an anxiety provoking situation

• E.g.

  • A car accident victim is unable to remember details of the impact, but was aware at the time.

  • Mrs. Yong, a victim of incest, does not know why she has always hated her uncle

Reaction Formation

• Opposite of intention

• 1 feeling (-) and 1 action (+) or 1 feeling(+) and 1 action (-)

• E.g.

  • An older brother who dislikes his younger brother sends him gifts for every holiday.

  • Miss Marla, who unconsciously hates her mother, continuously tells staff how wonderful her mother is.

Intellectualization

• Excessive use of abstract thinking; technical explanation

• No emotions involved

• E.g.

  • A wife states to her husband that a dented car fender is much better than a completely wrecked car and garage door.

  • Mrs. Mann talks about her son’s death and bout with cancer as being mercifully short without showing signs of sadness.

Introjection

• Acceptance of another’s values and opinions as one’s own

• Imitation but no admiration, “like”

• E.g.

  • While her mother is gone, a young girl disciplines her brother just like her mother would.

  • Without realizing it, a patient talks and acts like his therapist, analyzing other patients.

Identification

• A conscious or unconscious attempt to model oneself after a respected person

• Superficial, imitation with admiration, “like”

• E.g.

  • When a little girl dresses up like her mother to play house, she tries to talk and act like her mother.

  • Sheila states to the nurse, “When I get out of the hospital, I want to be a nurse just like you.”

Fantasy

• Magical thinking

• E.g.

  • Daydreaming

Fixation

• occurs when a person is stuck in a certain developmental stage

• E.g.

  • Lack of a clear sense of identity as an adult. Oral fixations

Conversion

• Anxiety converted to physical symptoms

• Presence of physical complaints

• E.g.

  • A student awakens with a migraine the morning of a final examination and feels ill to take it.

  • Mr. Jenson suddenly develops impotence after his wife discovers he is having an affair with his secretary

Compensation

• Overachievement in one area to overpower weaknesses or defective area.

• Can also be compensating for another’s weaknesses

• No relatedness on the weakness compensated with strength.

• E.g.

  • An academically weak high school student becomes a star in the school play.

  • A schizophrenic patient who is unable to talk to other patients becomes known for his expressive poetry

Undoing

• Doing the opposite of what have done

• 1 (-) action, then 1 (+) action; this is constant

• E.g.

  • After spanking her son, a mother bakes his favorite cookies.

  • After eating another patient’s cookies, Mrs. Donnelly apologizes to the patients, cleans the refrigerator, and labels everyone’s snack with their names.

Projection

• Blaming; Falsely attributing to another his/her own unacceptable feelings.

• 2 entities involved always; (Adam to God)

• E.g.

  • A teenager comes home late from a date and states that her friend did not bring her home on time.

  • Katrina states that she used marijuana while her boyfriend made her smoke it

Sublimation

• Channeling instinctual drives to a more productive activity.

• Positive; 3 entities involve

• E.g.

  • An adolescent arrested once for stealing later opens a business installing security systems in banks

  • A former perpetrator of incest who fears relapse initiates a local chapter of Parents United.

Substitution

• Replaces a goal that can’t be achieved for another that is more realistic.

• Weakness has relatedness to strength

• E.g.

  • A student nurse decides to be a teacher because he or she is unable to master clinical competencies

Symbolization

• Creates a representation to an anxiety provoking thing or concept

• Use of tangible things as symbols

• E.g.

  • An engagement ring symbolizes love and a commitment to another person

Suppression

• Voluntary or conscious exclusion from awareness, anxiety-producing feelings, ideas and situations

• E.g.

  • A student states, “ I cannot think about my wedding tonight. I have to study.”

  • Michelle states to the nurse that she is not ready to talk about her recent divorce.

Splitting

• Labile emotions; all bad – all good