CENTRO ESCOLAR UNIVERSITY

COLLEGE OF NURSING

MAKATI CITY

In Partial Fulfillment of the Requirements in NCM104

Bipolar Affective Disorder Current Episode Manic with Psychotic Symptoms

Submitted by:

Malbas, Aldrin O.

Zabala, Ranier Allan M.

BSN3D1

Submitted to:

Mrs. Marieta Lapuebla RN, MAN, RMT

Clinical Instructor

2nd Semester

SY 2010-2011
ACKNOWLEDGEMET
 Table of Contents

Chapter 1

A. Introduction

B. Theoretical Framework

1. Sigmund Freud

2. Erik Erikson

3. Jean Piaget

4. Harry Stack Sullivan

5. Hildegard Peplau

6. Abraham Maslow

7. Carl Rogers

8. B.F Skinner

9. William Glasser

10. Alfred Adler

11. Lawrence Kohlberg

12. Carl Jung

C. Biographical Data

D. Nursing History

a. Chief Complaint

b. History of Present Illness

c. Previous Illness

d. Past Personal History

e. Family History

f. Social History

Chapter II

A. General Appearance

B. Motor Behavior

C. Sensorium and Cognition

a. Consciousness

b. Orientation

c. Concentration

d. Memory

D. Perception
 E. Attitude

F. Defense Mechanism

G. Affective State

H. Thought Process

Chapter III

A. Predisposing Factor

B. Psychodynamics

C. Related Literature

a. Summary

b. Reaction

D. Drug Study

E. Nurse-Patient Interaction

a. Orientation Phase

b. Working Phase

c. Termination Phase

Chapter IV

A. List of Prioritized Psychiatric Nursing Diagnosis

B. Nursing Care Plan 1-

C. Nursing Care Plan 2-

D. Nursing Care Plan 3-

Chapter V

A. Play Therapy

B. Music and Art Therapy

C. Bibliotherapy

D. Occupational Therapy

E. Remotivational Therapy

Appendix

Bibliography
Chapter I

A. Introduction to Psychopathology

Bipolar disorder or manic-depressive disorder, also referred to

as bipolar affective disorder or manic depression, is a psychiatric diagnosis that
describes a category of mood disorders defined by the presence of one or more
episodes of abnormally elevated energy levels, cognition, and mood with or without one
or more depressive episodes. The elevated moods are clinically referred to as mania or,
if milder, hypomania. Individuals who experience manic episodes also commonly
experience depressive episodes, or symptoms, or mixed episodes in which features of
both mania and depression are present at the same time.

These episodes are usually separated by periods of "normal" mood; but, in some
individuals, depression and mania may rapidly alternate, which is known as rapid
cycling. Extreme manic episodes can sometimes lead to such psychotic symptoms
as delusions and hallucinations. The disorder has been subdivided into bipolar I, bipolar
II, cyclothymia, and other types, based on the nature and severity of mood episodes
experienced; the range is often described as the bipolar spectrum.

Genetic factors contribute substantially to the likelihood of developing bipolar

disorder, and environmental factors are also implicated. Bipolar disorder is often treated
with mood stabilizing medications and, sometimes, other psychiatric
drugs. Psychotherapy also has a role, often when there has been some recovery of the
subject's stability. In serious cases, in which there is a risk of harm to oneself or
others, involuntary commitment may be used. These cases generally involve severe
manic episodes with dangerous behavior or depressive episodes with suicidal ideation.
There are widespread problems with social stigma, stereotypes, and prejudice against
individuals with a diagnosis of bipolar disorder. People with bipolar disorder exhibiting
psychotic symptoms can sometimes be misdiagnosed as having schizophrenia, another
serious mental illness.

Bipolar disorder is a condition in which people experience abnormally elevated

(manic or hypomanic) and, in many cases, abnormally depressed states for periods of
time in a way that interferes with functioning. Not everyone's symptoms are the same,
and there is no simple physiological test to confirm the disorder. Bipolar disorder can
appear to be unipolar depression. Diagnosing bipolar disorder is often difficult, even for
mental health professionals. What distinguishes bipolar disorder from unipolar
depression is that the affected person experiences states of mania and depression.
Often bipolar is inconsistent among patients because some people feel depressed more
often than not and experience little mania whereas others experience predominantly
manic symptoms. Additionally, the younger the age of onset—bipolar disorder starts in
childhood or early adulthood in most patients—the more likely the first few episodes are
to be depression. Because a bipolar diagnosis requires a manic or hypomanic episode,
many patients are initially diagnosed and treated as having major depression.

Episodes of Bipolar Disorder

Depressive episode

Signs and symptoms of the depressive phase of bipolar disorder include

persistent feelings of sadness, anxiety, guilt, anger, isolation, or hopelessness;
disturbances in sleep and appetite; fatigue and loss of interest in usually enjoyable
activities; problems concentrating; loneliness, self-loathing, apathy or
indifference; depersonalization; loss of interest in sexual activity; shyness or social
anxiety; irritability, chronic pain (with or without a known cause); lack of motivation; and
morbid suicidal ideation. In severe cases, the individual may become psychotic, a
condition also known as severe bipolar depression with psychotic features. These
symptoms include delusions or, less commonly, hallucinations, usually unpleasant. A
major depressive episode persists for at least two weeks, and may continue for over six
months if left untreated.

Manic episode

Mania is the signature characteristic of bipolar disorder and, depending on its

severity, is how the disorder is classified. Mania is generally characterized by a distinct
period of an elevated mood, which can take the form of euphoria. People commonly
experience an increase in energy and a decreased need for sleep, with many often
getting as little as 3 or 4 hours of sleep per night, while others can go days without
sleeping. A person may exhibit pressured speech, with thoughts experienced as racing.
Attention span is low, and a person in a manic state may be easily distracted. Judgment
may become impaired, and sufferers may go on spending sprees or engage in behavior
that is quite abnormal for them. They may indulge in substance abuse, particularly
alcohol or other depressants, cocaine or other stimulants, or sleeping pills. Their
behavior may become aggressive, intolerant, or intrusive. People may feel out of control
or unstoppable, or as if they have been "chosen" and are "on a special mission" or have
other grandiose or delusional ideas. Sexual drive may increase. At more extreme
phases of bipolar I, a person in a manic state can begin to experience psychosis, or a
break with reality, where thinking is affected along with mood. Some people in a manic
state experience severe anxiety and are very irritable (to the point of rage), while others
are euphoric and grandiose.

To be diagnosed with mania according to the Diagnostic and Statistical Manual of

Mental Disorders (DSM), a person must experience this state of elevated or irritable
mood, as well as other symptoms, for at least one week, less if hospitalization is
required.

Hypomanic episode
 Hypomania is generally a mild to moderate level of mania, characterized by
optimism, pressure of speech and activity, and decreased need for sleep. Generally,
hypomania does not inhibit functioning like mania. Many people with hypomania are
actually in fact more productive than usual, while manic individuals have difficulty
completing tasks due to a shortened attention span. Some people have increased
creativity while others demonstrate poor judgment and irritability. Many people
experience signature hypersexuality. These persons generally have increased energy
and tend to become more active than usual. They do not, however, have delusions or
hallucinations. Hypomania can be difficult to diagnose because it may masquerade as
mere happiness, though it carries the same risks as mania.

Hypomania may feel good to the person who experiences it. Thus, even when
family and friends learn to recognize the mood swings, the individual often will deny that
anything is wrong. Also, the individual may not be able to recall the events that took
place while they were experiencing hypomania. What might be called a "hypomanic
event", if not accompanied by complementary depressive episodes ("downs", etc.), is
not typically deemed as problematic: The "problem" arises when mood changes are
uncontrollable and, more importantly, volatile or "mercurial". If unaccompanied by
depressive counterpart episodes or otherwise general irritability, this behavior is
typically called hyperthymia, or happiness, which is, of course, perfectly normal. Indeed,
the most elementary definition of bipolar disorder is an often "violent" or "jarring" state of
essentially uncontrollable oscillation between hyperthymia and dysthymia. If left
untreated, an episode of hypomania can last anywhere from a few days to several
years. Most commonly, symptoms continue for a few weeks to a few months.

Mixed affective episode

In the context of bipolar disorder, a mixed state is a condition during which

symptoms of mania and clinical depression occur simultaneously. Typical
examples include tearfulness during a manic episode or racing thoughts during a
depressive episode. Individuals may also feel incredibly frustrated in this state,
since one may feel like a failure and at the same time have a flight of ideas. Mixed
states are often the most dangerous period of mood disorders, during
which substance abuse, panic disorder, suicide attempts, and other
complications increase greatly.

Associated features

Associated features are clinical phenomena that often accompany the

disorder but are not part of the diagnostic criteria for the disorder. There are
several childhood precursors in children who later receive a diagnosis of bipolar
disorder. They may show subtle early traits such as mood abnormalities, full
major depressive episodes, and ADHD. BD is also accompanied by changes
in cognitive processes and abilities. This include
reduced attention and executive capabilities and impaired memory. How the
individual processes the world also depends on the phase of the disorder, with
differential characteristics between the manic, hypomanic and depressive
states. Some studies have found a significant association between bipolar
disorder and creativity.

Criteria and subtypes

Bipolar I disorder

One or more manic episodes. Subcategories specify whether there has been
more than one episode, and the type of the most recent episode. A depressive or
hypomanic episode is not required for diagnosis, but it frequently occurs.

Bipolar II disorder

No manic episodes, but one or more hypomanic episodes and one or more major
depressive episode.[45] However, a bipolar II diagnosis is not a guarantee that they will
not eventually suffer from such an episode in the future. Hypomanic episodes do not go
to the full extremes of mania (i.e., do not usually cause severe social or occupational
impairment, and are without psychosis), and this can make bipolar II more difficult to
diagnose, since the hypomanic episodes may simply appear as a period of successful
high productivity and is reported less frequently than a distressing, crippling depression.

Cyclothymia

A history of hypomanic episodes with periods of depression that do not

meet criteria for major depressive episodes. There is a low-grade cycling of mood
which appears to the observer as a personality trait, and interferes with
functioning.

Bipolar Disorder NOS (Not Otherwise Specified)

This is a catchall category, diagnosed when the disorder does not fall within a
specific subtype. Bipolar NOS can still significantly impair and adversely affect the
quality of life of the patient.

The bipolar I and II categories have specifies that indicate the presentation and
course of the disorder. For example, the "with full inter episode recovery" specified
applies if there was full remission between the two most recent episodes.

B. Theoretical Framework

Sigmund Freud

In the early 1900s, Sigmund Freud developed the psychodynamic view of human
behavior. This model relies on the premise that human behavior is brought about by
inner forces over which the individual has little control. Dreams and slips of the tongue
are clues to what the individual is really thinking.

We may have one point in our lives been caught speaking a Freudian slip, or slip
of the tongue. For example we may have intentions of saying to a member of the
opposite sex: "I believe we have not been properly introduced yet." Instead, we might
accidentally say: "I believe that we have not been properly seduced yet." According to

Freud such events are not just random slip ups. Rather, such slips of the tongue
may be an indication of deeply felt emotions and thoughts that reside in the
unconscious, a part of the personality of which a person is not aware. The unconscious
is the safe haven for our recollection of painful events and also it is where we store our
instinctual drives. It is in this part of the personality that infantile desires and demands
are hidden from the conscious of one's personality because they would conflict with a
person's day to day living.

To understand the conscious and unconscious forces guiding an individual's

behavior, Freud developed a personality model. He divided the personality into three
elements: the id, the ego and the superego. These elements are not physical structures
found in the brain, instead they represent a general model of personality that describes
the interaction of various behaviors and drives that motivate us.

The id refers to the raw, unorganized, inherited part of the personality. Its main
goal is to reduce tension created by our primitive drives which are related to hunger,
sex, aggression and irrational impulses. The id operates according to the pleasure
principle, in which its goal is immediate gratification and reduction of tension. In most
people, reality prevents the id's instant demands from being fulfilled. We cannot always
eat when we are hungry, and we can act on sexual drives only in the right place and
time.

The ego is the buffer between the id and the world's realities. The ego operates
on the reality principle. In this principle, instinctual energy is restrained in order to
maintain the safety of the individual and help integrate the person into society. The ego
is sometimes called "the executive" of an individual's personality. The ego makes the
decisions, controls actions and allows for a higher capability of problem solving. The id
is not capable of such higher level of thinking. The ego is responsible for the higher
cognitive functions such as intelligence, thoughtfulness and learning.

The superego is the final element of Freud's model of personality. It is similar to

the id in that it is somewhat unrealistic. The superego represents the rights and wrongs
of the society as handed down to an individual over their lifetime. The superego has two
subparts: the conscience and the ego-ideal. The conscience prevents us from doing
morally bad things. The ego-ideal motivates us to do what is morally proper. The
superego helps to control the id's impulses, making them less selfish and more morally
correct. Both the id and the superego are unrealistic in that they do not consider the
actualities of society. The lack of reality within the superego, if left unchecked, would
create perfectionists who would be unable to make compromises that life requires.
Likewise, an unrestrained id would create a pleasure-seeking thoughtless individual,
seeking to fulfill every desire without delay. It is the ego that compromises between the
demands of the id and superego, permitting a person to obtain some of the gratification
of the id while maintaining the superego, which would prevent such gratification.

Erik Erikson

Young adulthood: 18 to 35
Ego Development Outcome: Intimacy and Solidarity vs. Isolation
Basic Strengths: Affiliation and Love
In the initial stage of being an adult we seek one or more companions and love.
As we try to find mutually satisfying relationships, primarily through marriage and
friends, we generally also begin to start a family, though this age has been pushed back
for many couples who today don't start their families until their late thirties. If negotiating
this stage is successful, we can experience intimacy on a deep level.
If we're not successful, isolation and distance from others may occur. And when
we don't find it easy to create satisfying relationships, our world can begin to shrink as,
in defense, we can feel superior to others.
Our significant relationships are with marital partners and friends.
Jean Piaget

Piaget's theory of cognitive development is a comprehensive theory about the

nature and development of human intelligence first developed by Jean Piaget. It is
primarily known as a developmental stage theory, but in fact, it deals with the nature of
knowledge itself and how humans come gradually to acquire it, construct it, and use it.
Moreover, Piaget claims the idea that cognitive development is at the centre of human
organism and language is contingent on cognitive development. Below, there is first a
short description of Piaget's views about the nature of intelligence and then a
description of the stages through which it develops until maturity.

Piaget believed that reality is a dynamic system of continuous change, and as

such is defined in reference to the two conditions that define dynamic systems that
change. Specifically, he argued that reality involves transformations and states.
Transformations refer to all manners of changes that a thing or person can undergo.
States refer to the conditions or the appearances in which things or persons can be
found between transformations. For example, there might be changes in shape or form
(for instance, liquids are reshaped as they are transferred from one vessel to another,
humans change in their characteristics as they grow older), in size (e.g., a series of
coins on a table might be placed close to each other or far apart) in placement or
location in space and time (e.g., various objects or persons might be found at one place
at one time and at a different place at another time). Thus, Piaget argued, that if human
intelligence is to be adaptive, it must have functions to represent both the
transformational and the static aspects of reality. He proposed that operative
intelligence is responsible for the representation and manipulation of the dynamic or
transformational aspects of reality and that figurative intelligence is responsible for the
representation of the static aspects of reality).

Formal Operation (11 years-adulthood): Logically solves all types of problems; thinks
scientifically; solves complex problems; cognitive structures mature.

Harry Stack Sullivan

Through social interactions and our selective attention or inattention, we develop

what Sullivan called Personifications of ourselves and others. While defenses can
often help reduce anxiety, they can also lead to a misperception of reality. Again, he
shifts his focus away from Freud and more toward a cognitive approach to
understanding personality.

These personifications are mental images that allow us to better understand

ourselves and the world. There are three basic ways we see ourselves that Sullivan
called the bad-me, the good-me and the not-me. The bad me represents those
aspects of the self that are considered negative and are therefore hidden from others
and possibly even the self. The anxiety that we feel is often a result of recognition of
the bad part of ourselves, such as when we recall an embarrassing moment or
experience guilt from a past action.

The good me is everything we like about ourselves. It represents the part of us

we share with others and that we often choose to focus on because it produces no
anxiety. The final part of us, called the not-me, represents all those things that are so
anxiety provoking that we can not even consider them a part of us. Doing so would
definitely create anxiety which we spend our lives trying to avoid. The not-me is kept
out of awareness by pushing it deep into the unconscious.

Adulthood (Ages 23 and above): The struggles of adulthood include financial

security, career, and family. With success during previous stages, especially those in
the adolescent years, adult relationships and much needed socialization become more
easy to attain. Without a solid background, interpersonal conflicts that result in anxiety
become more commonplace.

Hildegard Peplau

• Middle range descriptive classification theory

• Influenced by Harry Stack Sullivan's theory of inter personal relations (1953)
• Also influenced by Percival Symonds , Abraham Maslow's and Neal Elger Miller

Identified four sequential phases in the interpersonal relationship:

1. Orientation
2. Identification
3. Exploitation
4. Resolution

Orientation phase

• Problem defining phase

• Starts when client meets nurse as stranger
• Defining problem and deciding type of service needed
• Client seeks assistance ,conveys needs ,asks questions, shares preconceptions
and expectations of past experiences
• Nurse responds, explains roles to client, helps to identify problems and to use
available resources and services

Factors influencing orientation phase

Identification phase

• Selection of appropriate professional assistance

• Patient begins to have a feeling of belonging and a capability of dealing with the
problem which decreases the feeling of helplessness and hopelessness

Exploitation phase

• Use of professional assistance for problem solving alternatives

• Advantages of services are used is based on the needs and interests of the
patients
• Individual feels as an integral part of the helping environment
• They may make minor requests or attention getting techniques
• The principles of interview techniques must be used in order to explore,
understand and adequately deal with the underlying problem
• Patient may fluctuates on independence
• Nurse must be aware about the various phases of communication
• Nurse aids the patient in exploiting all avenues of help and progress is made
towards the final step
Resolution phase

• Termination of professional relationship

• The patients needs have already been met by the collaborative effect of patient
and nurse
• Now they need to terminate their therapeutic relationship and dissolve the links
between them.
• Sometimes may be difficult for both as psychological dependence persists
• Patient drifts away and breaks bond with nurse and healthier emotional balance
is demonstrated and both becomes mature individuals

Interpersonal theory and nursing process

• Both are sequential and focus on therapeutic relationship

• Both use problem solving techniques for the nurse and patient to collaborate on,
with the end purpose of meeting the patients needs
• Both use observation communication and recording as basic tools utilized by
nursing

Assessment Orientation

• Data collection and analysis • Non continuous data collection

[continuous] • Felt need

• May not be a felt need • Define needs

Nursing diagnosis Identification
Planning
• Interdependent goal setting
• Mutually set goals
Implementation Exploitation

• Plans initiated towards achievement • Patient actively seeking and drawing

of mutually set goals help

• May be accomplished by patient , • Patient initiated

nurse or family
Evaluation Resolution

• Based on mutually expected • Occurs after other phases are

behaviors completed successfully

• May led to termination and initiation • Leads to termination a

of new plans

Abraham Maslow
 A visual aid Maslow created to explain his theory, which he called the Hierarchy
of Needs, is a pyramid depicting the levels of human needs, psychological and physical.
When a human being ascends the steps of the pyramid he reaches self actualization. At
the bottom of the pyramid are the “Basic needs or Physiological needs” of a human
being, food and water and sex. The next level is “Safety Needs: Security, Order, and
Stability.” These two steps are important to the physical survival of the person. Once
individuals have basic nutrition, shelter an d safety, they attempt to accomplish more.
The third level of need is “Love and Belonging,” which are psychological needs; when
individuals have taken care of themselves physically, they are ready to share
themselves with others. The fourth level is achieved when individuals feel comfortable
with what they have accomplished. This is the “Esteem” level, the level of success and
status (from self and others). The top of the pyramid, “Need for Self-actualization,”
occurs when individuals reach a state of harmony and understanding.

Maslow based his study on the writings of other psychologists, Albert

Einstein and people he knew who clearly met the standard of self actualization. Maslow
used Einstein's writings and accomplishments to exemplify the characteristics of the self
actualized person. He realized that all the individuals he studied had similar personality
traits. All were "reality centered", able to differentiate what was fraudulent from what
was genuine. They were also "problem centered", meaning that they treated life’s
difficulties as problems that demanded solutions. These individuals also were
comfortable being alone and had healthy personal relationships.

When Maslow introduced these ideas some weren't ready to understand them;
others dismissed them as unscientific. Sometimes viewed as disagreeing with Freud
and psychoanalytic theory, Maslow actually positioned his work as a vital complement
to that of Freud. Maslow stated in his book, “It is as if Freud supplied us the sick half of
psychology and we must now fill it out with the healthy half.” here are two faces of
human nature—the sick and the healthy—so there should be two faces of psychology.

Consequently, Maslow argued, the way in which essential needs are fulfilled is
just as important as the needs themselves. Together, these define the human
experience. To the extent a person finds cooperative social fulfillment, he establishes
meaningful relationships with other people and the larger world. In other words, he
establishes meaningful connections to an external reality—an essential component of
self-actualization. In contrast, to the extent that vital needs find selfish and competitive
fulfillment, a person acquires hostile emotions and limited external relationships—his
awareness remains internal and limited.
 Beyond the routine of needs fulfillment, Maslow envisioned moments of
extraordinary experience, known as Peak experiences, which are profound moments of
love, understanding, happiness, or rapture, during which a person feels more whole,
alive, self-sufficient and yet a part of the world, more aware of truth, justice, harmony,
goodness, and so on. Self-actualizing people have many such peak experiences.

Maslow used the term Metamotivation to describe self actualized people who are
driven by innate forces beyond their basic needs, so that they may explore and reach
their full human potential

Carl Rogers

Rogers’s view is that human organism has definitely an “actualizing tendency”

that is underlying in nature. The purpose of this is to develop all capacities in ways that
enhance and maintain and actually move towards autonomy. This tendency is actually
present in all human beings and is directional as well as constructive. This actualizing
tendency cannot be without the organism being destroyed. It can be only suppressed.
This tendency encompasses all tensions and motives, drive reductions as well as
needs. It also includes creativity as well as tendencies that are related to pleasure-
seeking. Every individual aspires to attain the maximum potential of his or her talents.

Tendencies of self-actualizing

Individuals try to that element of experience that symbolizes self. Related to

individual of self-actualization and self-concept development are other secondary needs
such as the need to develop positive attitude towards others and a need for self-regard
that too is positive. These tendencies favor one’s behavior that is consistent with the
person’s self-concept.

Self

Rogers’s theory of self brings into limelight how self is developed. The self is
developed through interactions with others and consists of the awareness of one’s
being as well as functioning.

Roger’s view on personality growth

Rogers holds the view that personality can be changed and it is part of personal
growth. In psychotherapy one can change one’s self-concept and bring about necessary
changes in personality. A person who is “maladjusted” happens to be just the opposite
of full and well functioning individual. Also those who are “self-accepting” accept others
also.

Carl Rogers was keen on improving the condition of human kind through
application of his own ideas. His contribution will help in others developing humane as
well as ethical approach towards others. It would also help in treating psychological as a
science of humans rather than as a being a natural science. This approach which
happens to person-centered has its influence on education, family life, conflict
resolution, community health as well as politics.

B.F Skinner
 Radical behaviorism seeks to understand behavior as a function of
environmental histories of reinforcing consequences.

Reinforcement processes were emphasized by Skinner, and were seen as

primary in the shaping of behavior. A common misconception is that negative
reinforcement is synonymous with punishment. This misconception is rather pervasive,
and is commonly found in even scholarly accounts of Skinner and his contributions. To
be clear, while positive reinforcement is the strengthening of behavior by the application
of some event (e.g., praise after some behavior is performed), negative reinforcement is
the strengthening of behavior by the removal or avoidance of some aversive event (e.g.,
opening and raising an umbrella over your head on a rainy day is reinforced by the
cessation of rain falling on you).

Both types of reinforcement strengthen behavior, or increase the probability of a

behavior reoccurring; the difference is in whether the reinforcing event is something
applied (positive reinforcement) or something removed or avoided (negative
reinforcement). Punishment and extinction have the effect of weakening behavior, or
decreasing the future probability of a behavior's occurrence, by the application of an
aversive stimulus/event (positive punishment or punishment by contingent stimulation),
removal of a desirable stimulus (negative punishment or punishment by contingent
withdrawal), or the absence of a rewarding stimulus, which causes the behavior to stop
(extinction).

Skinner also sought to understand the application of his theory in the broadest
behavioral context as it applies to living organisms, namely natural selection.

William Glasser

Choice Theory

The 1998 book, Choice Theory: A New Psychology of Personal Freedom, is

the primary text for all that is taught by The William Glasser Institute. Choice theory
states that:

• all we do is behave,
• that almost all behavior is chosen, and
• that we are driven by our genes to satisfy five basic needs: survival, love
and belonging, power, freedom and fun.

In practice, the most important need is love and belonging, as closeness and
connectedness with the people we care about is a requisite for satisfying all of the
needs.

Choice theory, with the Seven Caring Habits, replaces external control
psychology and the Seven Deadly Habits. External control, the present psychology of
almost all people in the world, is destructive to relationships. When used, it will destroy
the ability of one or both to find satisfaction in that relationship and will result in a
disconnection from each other. Being disconnected is the source of almost all human
problems such as what is called mental illness, drug addiction, violence, crime, school
failure, spousal abuse, to mention a few.

Relationships and our Habits

Seven Caring Habits Seven Deadly Habits

1. Supporting 1. Criticizing
2. Encouraging 2. Blaming
3. Listening 3. Complaining
4. Accepting 4. Nagging
5. Trusting 5. Threatening
6. Respecting 6. Punishing
7. Negotiating differences 7. Bribing, rewarding to control

The Ten Axioms of Choice Theory

1. The only person whose behavior we can control is our own.
2. All we can give another person is information.
3. All long-lasting psychological problems are relationship problems.
4. The problem relationship is always part of our present life.
5. What happened in the past has everything to do with what we are today,
but we can only satisfy our basic needs right now and plan to continue satisfying
them in the future.
6. We can only satisfy our needs by satisfying the pictures in our Quality
World.
7. All we do is behaving.
8. All behavior is Total Behavior and is made up of four components: acting,
thinking, feeling and physiology.
9. All Total Behavior is chosen, but we only have direct control over the acting
and thinking components. We can only control our feeling and physiology
indirectly through how we choose to act and think.
10. All Total Behavior is designated by verbs and named by the part that is the
most recognizable.

Alfred Adler

Alfred Adler, born in 1870, was a major influence on the field of psychoanalysis
and was one of the original members of Sigmund Freud's historic Vienna
Psychoanalytic Society. Though he is less well-known than either Freud or the equally
notable Carl Jung, Adler's theories of personality still provide important historic context
for the study of psychodynamic theory.

Because Adler was a weak and frequently ill toddler who struggled with feelings
of inferiority when comparing himself to his older, stronger brother, Adler developed a
theory that all people are born weak and thus resolve to overcome this weakness by
being at one with others. His more specific theories build on this understanding.

Subjective Perceptions as Motivation

 A person's personality and the manner in which he or she strives for success or
superiority is motivated more by expectations of the future than by understandings of
the past. Adler referred to these important future expectations as "fictions" because they
only represent the person's subjective perception of reality. Instead of reality providing
the impetus for action, Adler thought that the perception of future reality is the
inspiration for action.

The Self-Consistency of Personality

In history books, Adler is often cited as founding the school of "individual psychology."
This term refers to Adler's belief that every person is essentially unique and has a
personality unlike anybody else. For this to be the case, then, a person's character must
remain consistent and directed toward one very distinct goal or purpose.

Some may object to this notion on the grounds that a person can act
unpredictably, which would undermine the theory that all of a person's behavior is
motivated by a single purpose. In response, Adler explained that behavior that appears
inconsistent is actually an unconscious attempt to confuse other people.

The Importance of Social Interest in Personality

The term "social interest," as used by Adler, means a unity with humanity or a
membership in a social community. According to Adler, social interest is fundamental to
human survival because without it, parents would not care for their children and the
human species could not sustain itself.

Social interest plays a crucial role in moderating the effects of genetic predispositions
toward certain personality traits. Adler understood that by the age of about five-years-
old, a child's heredity has gone as far as it can, and innate predispositions are
moderated by the social environment. For him, the extent of social interest in a child
was the most important measure of his or her psychological health.

Development of a Style of Life

To Adler, a person's "style of life" was basically his or her personality, including
goals, self-concept, and social interest. By about the age of five, Adler believed that the
style of life is pretty well established in a child. The most psychologically healthy people
have a style of life that is complex and flexible and express social interest through
action.

Although style of life is influenced in large part by heredity and the environment,
Adler believed that each person has his or her ability to create a distinct personality. He
referred to this personal control over the development of style of life as "creative power."
It is this creative power that separates people as individuals with unique personalities.

Lawrence Kohlberg

Kohlberg's stages of moral development constitute an adaptation of a

psychological theory originally conceived of by the Swiss psychologist Jean
Piaget. Lawrence Kohlberg began work on this topic while a psychology postgraduate
student at the University of Chicago, and expanded and developed this theory
throughout the course of his life.

The theory holds that moral reasoning, the basis for ethical behavior, has six
identifiable developmental stages, each more adequate at responding to moral
dilemmas than its predecessor. Kohlberg followed the development of moral judgment
far beyond the ages studied earlier by Piaget, who also claimed that logic and morality
develop through constructive stages. Expanding on Piaget's work, Kohlberg determined
that the process of moral development was principally concerned with justice, and that it
continued throughout the individual's lifetime, a notion that spawned dialogue on the
philosophical implications of such research.

Kohlberg relied for his studies on stories such as the Heinz dilemma, and was
interested in how individuals would justify their actions if placed in similar moral
dilemmas. He then analyzed the form of moral reasoning displayed, rather than its
conclusion, and classified it as belonging to one of six distinct stages.

There have been critiques of the theory from several perspectives. Arguments
include that it emphasizes justice to the exclusion of other moral values, such as
caring; that there is such an overlap between stages that they should more properly be
regarded as separate domains; or that evaluations of the reasons for moral choices are
mostly post hoc rationalizations (by both decision makers and psychologists studying
them) of essentially intuitive decisions.

Nevertheless, an entirely new field within psychology was created as a direct

result of Kohlberg's theory, and according to Haggbloom et al.'s study of the most
eminent psychologists of the 20th century, Kohlberg was the 16th most frequently cited
psychologist in introductory psychology textbooks throughout the century, as well as the
30th most eminent overall.

Kohlberg's scale is about how people justify behaviors and his stages are not a
method of ranking how moral someone's behavior is. There should however be a
correlation between how someone scores on the scale and how they behave and the
general hypothesis is that moral behaviour is more responsible, consistent and
predictable from people at higher levels.

Carl Jung

In 1907, Carl Jung met Sigmund Freud in Vienna. Jung had been interested in
Freud’s ideas regarding the interpretation of dreams. Likewise, Freud took an interest to
Jung’s word association task that he used to understand the unconscious processes of
patients. In fact, Freud invited Jung along for his now-famous appearance at the Clark
conference in 1909, Freud’s first trip to America.

After some argument over the validity of psychoanalysis, Jung and Freud went
their separate ways, and Jung went on to develop the analytical psychology, which
differentiated the personal unconscious from the collective unconscious, which reflects
the shared unconscious thoughts among humans. Another notable contribution to
psychology involves Jung's personality theory, which was particularly notable due to its
definitions of introversion and extroversion.

Jung’s Introversion and Extroversion Attitudes

The first of Jung’s general psychological types was the general attitude type. An
attitude, according to Jung, is a person’s predisposition to behave in a particular way.
There are two opposing attitudes: introversion and extroversion. The two attitudes work
as opposing, yet complementary forces and are often depicted as the classing yin and
yang symbol.

The introvert is most aware of his or her inner world. While the external world is
still perceived, it is not pondered as seriously as inward movement of psychic energy.
The introverted attitude is more concerned with subjective appraisal and often gives
more consideration to fantasies and dreams.
 The extrovert, by contrast, is characterized by the outward movement of psychic
energy. This attitude places more importance on objectivity and gains more influence
from the surrounding environment than by inner cognitive processes.

Clearly, it is not a case of one versus the other. Many people carry qualities of
both attitudes, considering both subjective and objective information.

Jung’s Four Functions of Personality

For Carl Jung, there were four functions that, when combined with one of his two
attitudes, formed the eight different personality types. The first function — feeling — is
the method by which a person understands the value of conscious activity. Another
function — thinking — allows a person to understand the meanings of things. This
process relies on logic and careful mental activity.

The final two functions — sensation and intuition — may seem very similar, but
there is an important distinction. Sensation refers to the means by which a person
knows something exists and intuition is knowing about something without conscious
understanding of where that knowledge comes from.

The Eight Personality Types Defined by Carl Jung

Jung developed a theory of eight different personality types. Jung's personality types
are as follows:

• Extroverted Thinking – Jung theorized that people understand the world through
a mix of concrete ideas and abstract ones, but the abstract concepts are ones
passed down from other people. Extroverted thinkers are often found working in
the research sciences and mathematics.
• Introverted Thinking – These individuals interpret stimuli in the environment
through a subjective and creative way. The interpretations are informed by
internal knowledge and understanding. Philosophers and theoretical scientists
are often introverted thinking-oriented people.
• Extroverted Feeling – These people judge the value of things based on objective
fact. Comfortable in social situations, they form their opinions based on socially
accepted values and majority beliefs. They are often found working in business
and politics.
• Introverted Feeling – These people make judgments based on subjective ideas
and on internally established beliefs. Oftentimes they ignore prevailing attitudes
and defy social norms of thinking. Introverted feeling people thrive in careers as
art critics.
• Extroverted Sensing – These people perceive the world as it really exists. Their
perceptions are not colored by any pre-existing beliefs. Jobs that require
objective review, like wine tasters and proofreaders, are best filled by extroverted
sensing people.
• Introverted Sensing – These individuals interpret the world through the lens of
subjective attitudes and rarely see something for only what it is. They make
sense of the environment by giving it meaning based on internal reflection.
Introverted sensing people often turn to various arts, including portrait painting
and classical music.
• Extroverted Intuitive – These people prefer to understand the meanings of things
through subliminally perceived objective fact rather than incoming sensory
information. They rely on hunches and often disregard what they perceive
directly from their senses. Inventors that come upon their invention via a stroke of
insight and some religious reformers are characterized by the extraverted
intuitive type.
• Introverted Intuitive – These individuals, Jung thought, are profoundly influenced
by their internal motivations even though they do not completely understand
them. They find meaning through unconscious, subjective ideas about the world.
Introverted intuitive people comprise a significant portion of mystics, surrealistic
artists, and religious fanatics.
C. Biographical Data

Name: Ms. JAS

Address: 4856 Int. C Navarra St. Cor. Valenzuela

Birthday: September 10, 1975

Birth Place: Occidental Mindoro

Educational Attainment: 2nd year College

Religion: Born Again Christian

Date and Time of Admission: January 12, 2010 – 1:37pm

Admitting Diagnosis: Bipolar Affective Disorder Current Episode Manic with Psychotic
Symptoms

D. Nursing History

a. Chief Complaints:

- Emotional problems when she found out that she was adopted

- Doesn’t want to drink her medications due to the side effect of the drug such as
gaining weight.

- Slightly paranoid

- Separated

b. History of Present Illness:

1 day prior to admission, the client has experienced emotional problems. The day
prior to admission, around 1:37pm, Ms. JAS felt depressed and admitted to NCMH
accompanied by her mother

c. Previous Illness:

Ms. JAS reported that she has completed her vaccines. She was hospitalized
before for her previous delivery. The client has no allergic reactions upon food,
medication, or exposure to environmental factors.

d. Past Personal History:

Ms. JAS reported that she recognized that she was adopted. She got the
information at the age of 24. She felt depressed on that time because 24 years had
passed she doesn’t know her true parents. But she feels lucky because her biological
parents accepted her.

e. Family History
 Circle - Female
Square - Male
Red - HPN
Green - Asthma

f. Social History

Ms. JAS works in internet café before. She has stopped drinking and smoking
when she was admitted at NCMH but before she gradually smokes and drinks. She
smoke atleast 4 to 5 sticks per day. The educational attainment of the client is 2nd year
college.

Chapter II

A. General Appearance

Day 1 DAY 2 DAY 3 DAY 4 Day 5 Day 6

1. Grooming √ √ √
2. Facial √ √ √
Expression
3. Posture √ √ √
4. Eye √ √ √
Contact

B. Motor Behavior

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1. Waxy
flexibility
2. Hyperkinesia
3. Automatism
4. Catalepsy
5. Cataplexy
6. Stereotype
7. Echopraxia
8. Catatonic
stupor
9. Catatonic
Excitement
10. Tics and
Spasm

C. Sensorium and Cognition

C.1 CONSCIOUSNESS

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1.Clouding
2.
Somnolence
3.Stupor
4. Fugue
State

C.2 ORIENTATION

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1.Time √ √ √
2. Place √ √ √
3.Person √ √ √

C.3 CONCENTRATION

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1.Conversation √ √ √
2. Activity √ √ √

C.4 MEMORY

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1. Recent √ √ √
2. Remote √ √ √
3. Recent √ √ √
Past
4. √ √ √
Immediate
Retention
5. Recall √ √ √

D. PERCEPTION

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1.
Hallucinations
a. Visual
b. Auditory
c. Tactile
d. Gustatory
2. Illusions

E. ATTITUDE

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1. √ √ √
Cooperative
2. Outgoing √ √ √
3. Withdrawn
4. Evasive
5. Sarcastic
6. Aggressive
7. Peplexed
8.
Apprehensive
9. Arrogant
10. Dramatic
11.
Submessive
12. Fearful
13.Seductive
14.
Uncooperative
15. Impatient
16. Resistant
17. Impulsive
18. Apathetic

F. DEFENSE MECHANISM

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1. Denial
2. Repression
3. Rationalization √ √ √
4. Supression
5. Reaction √ √ √
Formation
6. Compensation
7. Over
Compensation
8. Sublimation
9. Projection
10. Displacement
11. Identification √ √ √
12. Introjection
13. Conversion √ √ √
14. Dissociation
15. Undoing
16. Regression
17. Substitution √ √ √
18. Isolation
19. Fantasy √ √ √
20. Intellectualization
21. Symbolization
22. Association

G. AFFECTIVE STATES

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1. Euphoria
2. Flat Affect
3. Blunting
4. Elation
5. Ecstasy
6. Exultation
7. Anxiety
8. Fear/Phobia
9. Ambivalence
10. Depersonalization
11. Irritability √
12. Rage
13. Lability
14. Depressed √ √
15. Hostile
a. Towards self
b. Towards others
H. THOUGHT PROCESS

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6

1. Blocking
2. Flight of Ideas
3. Word salad
4. Perseveration
5. Neologism
6. Circumstantialism
7. Echolia
8. Condensation
9. Delusions
a. Grandeur
b. Persecution
c. Jealousy
d. Guilt
e. Self accusation
10. Obsession
11. Verbigeration
12. Rhyming
13. Punning
14. Mutism

Chapter III:

A. Predisposing Factors:

The cause of bipolar disorder is unclear but hereditary, biological. and psychological
factors may playa part. For example, the incidence of bipolar disorder among relatives
of affected patients is higher than in the general population, and highest among
maternal relatives.

Scientists are learning about the possible causes of bipolar disorder through several
kinds of studies. Most scientists now agree that there is no single cause for bipolar
disorder-rather, many factors act together to produce the illness. Some of the causes of
bipolar disorder are as follows:

Biological cause of bipolar disorder

In considering the biological explanations, the first issue is inheritability. This

question has been researched via multiple family, adoption and twin studies. In families
of persons with bipolar disorder, first-degree relatives (parents, children, siblings) are
more likely to have a mood disorder than the relatives of those who do not have bipolar
disorder.

Studies of identical twins, who share all the same genes, indicate that both genes
and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely
by genes, then the identical twin of someone with the illness would always develop the
illness, and research has shown that this is not the case. But if one twin has bipolar
disorder, the other twin is more likely to develop the illness than is another sibling.

Psychological cause of bipolar disorder

The primary psychological culprit implicated in the manifestation of bipolar disorder

is stressful life events. These can range from a death in the family to the loss of a job,
from the birth of a child to a move. It can be pretty much anything, but it cannot be
precisely defined, since one person's stress may be another person's piece of cake.
With that in mind, research has found that stressful life events can lead to the onset of
symptoms in bipolar disorder.
 Brain-imaging studies are helping scientists learn what goes wrong in the brain to
produce bipolar disorder and other mental illnesses. New brain-imaging techniques
allow researchers to take pictures of the living brain at work, to examine its structure
and activity, without the need for surgery or other invasive procedures. These
techniques include

• magnetic resonance imaging,

• positron emission tomography, and
• functional magnetic resonance imaging.

There is evidence from imaging studies that the brains of people with bipolar
disorder may differ from the brains of healthy individuals. As the differences are more
clearly identified and defined through research, scientists will gain a better
understanding of the underlying causes of the illness, and eventually may be able to
predict which types of treatment will work most effectively.

B. Psychodynamics / Psychopathology

PSYCHOPATHOLOGY OF BIPOLAR DISORDER

The mood (affective) disorders are divided into 2 major categories.

1. Bipolar disorders
a. Bipolar disorders (mixed, manic, depressed)
b. Cyclothymia
2. Depressive disorders
a. Major Depression (single episode, recurrent)
b. Dysthymia

Bipolar disorders are of three different types: manic, mixed, and depressed. The
episode that leads to hospitalization the first time is usually a manic episode. Both
manic and depressive episodes occur more frequently than the depressive episodes
falling under the category of major depressive episodes. Often one type of episode
under the bipolar category will be immediately followed by a short episode of another
kind under the bipolar disorders. Thus, one might experience a manic episode and
appear to recover, only to develop symptoms of bipolar disorder, depressed.

In bipolar disorder, manic, the most recent or current episode exhibits the full
criteria for a manic episode exhibits the full criteria for a manic episode. The full criteria
need not be met, however, if there has been a previous manic episode. The full criteria
of a manic episode includes: (A) a distinct period of abnormally and persistently
elevated, expansive, or irritable mood; (B) During the period of a mood disturbance, at
least three of the following symptoms have persisted (four if the mood is only irritable)
and have been present to a significant degree: (1) inflated self-esteem or grandiosity;
(2) decreased need for sleep, e.g. feels rested after only three hours of sleep; (3) more
talkative than usual or pressure to keep talking; (4) flight of ideas or subjective
experience that thoughts are racing; (5) distractibility, i.e. attention too easily drawn to
unimportant or irrelevant external stimuli; (6) increase in goal-directed activity (either
socially, at work or school, or sexually) or psychomotor agitation; and (7) excessive
involvement in pleasurable activities that have a high potential for painful
consequences; and, (C) Mood disturbances sufficiently severe to cause marked
impairment in occupational functioning or in usual social activities or relationships with
others, or to necessitate hospitalization to prevent harm to self or others.

In bipolar disorders, mixed, the most recent or current episode is characterized

by symptoms of both manic and major depressive episodes. There is rapid
intermingling and alternation of symptoms. Depressive symptoms are prominent and
last at least a full day.

In bipolar disorder, depressed, the current or most recent episode is a major

depressive episode. There will have been one or more manic episodes, and full criteria
need not be met if there has been a previous major depressive episode. A major
depressive syndrome is defined as criterion: (A) At least 5 of the following symptoms
have been present during the same two-week period and represent a change from
previous functioning; at least one of the symptoms is either (1) depressed mood, or (2)
loss of interest or pleasure in all, or almost all, activities most of the day, nearly
everyday, as indicated either by subjective account or observation by others of apathy
most of the time. Other symptoms include: significant weight loss or weight gain when
not dieting, or decrease or increase in appetite nearly every day; insomnia or
hypersomnia nearly every day; psychomotor agitation or retardation nearly every day;
fatigue or loss of energy nearly every day; feelings of worthlessness or excessive or
inappropriate guilt nearly every day; diminished ability to think or concentrate, or
indecisiveness; recurrent thoughts of death, recurrent suicidal ideation without specific
plan, or a suicide attempt or a specific plan for committing suicide.

Cyclothymia is characterized by a period of two years, in which there have been

numerous periods with abnormally elevated, expansive, or irritable moods that did not
meet the symptom criteria for a manic episode, and numerous periods with depressed
mood or loss of interest or pleasure that did not meet the symptom criteria for a major
depressive episode. During the previous two years, there will not have been a period
without hypomanic or depressive symptoms for more than two months in a time. The
following are seen in a hypomanic episodes: (1) moods for a distinct period of time that
are abnormally and persistently elevated, expansive or irritable; (2) during the period
when mood changes occur, at least three of the following symptoms have persisted in a
significant degree. There will be four if the mood disturbance has been only irritable.
The symptoms include: (a) inflated self-esteem or grandiosity; (b) decreased need for
sleep, e.g. feels rested after only three hours of sleep; (c) more talkative than usual or
pressure to keep talking; (d) flight of ideas or subjective experience that thoughts are
racing; (e) distractibility; (f) increase in goal-directed activity or psychomotor agitation;
(g) excessive involvement in pleasurable activities that have a high potential for painful
consequences.
 Major depression may occur as a single episode or as a recurrent episode, but
the diagnosis is used when there is no history of a manic or hypomanic episode. The
illness may be further classified according to the severity of the episode, which will be
noted as mild, moderate, or severe and with or without psychotic symptoms. It is
believed that over 50% of those experiencing major depression, single episode, will
ultimately experience the illness again. Those with the diagnosis of a major depression,
recurrent, are at higher risk of developing a bipolar disorder.

Some individuals may experience only one episode of major depression in their
lifetime. As opposed to bipolar disorder where the occurrence is equal for males and
females, major depression, single episode occurs twice as often among females.

Major depression, recurrent, is diagnosed when there is no history of manic or

hypomanic episodes. Recurrent depressive episodes may be separated by many
years, may occur in clusters, or may increase, as one grows older. Between episodes,
functioning is generally at the premorbid level. There may be, however, some who
experience a chronic condition with considerable impairment.

Dysthymia, also known as depressive neurosis, is a condition essentially

consisting of chronic depressive mood disturbances for extended periods of time. The
diagnosis is made when the individual is never without symptoms for more than two
months over a two-year period (one year for children and adolescents). The diagnosis
is not made in the presence of a major depressive episode or when symptoms are
superimposed on some chronic psychotic condition. The symptoms that characterize
this condition are: poor appetite, or overeating, insomnia or hypersomnia, low energy or
fatigue, low self-esteem, poor concentration or difficulty making decisions and feelings
of hopelessness.

Schematic diagram showing the pathophysiology of the disorder:

Premorbid Personality:

Ψ shy and silent

Ψ keeps her problem to herself and solves it on her own

Ψ dependent on one person, her closest cousin

Ψ very secretive

Ψ has friends but is not open to them

Predisposing Factors: Precipitating Factors:

• Undergraguate (college level) - emotional and financial

problem
• low socio-economic status - death of her mother
• low social interaction to -family/relative conflicts
other people and to family -no communication to friends

regarding her problems

Coping behavior:

• Ψ sings and dances

• Ψ cries
• Ψ leaves home, roams around with no direction to go
• Ψ eats a lot
• Ψ isolates herself
• always talking/praying to God

Behavioral Changes:

Ψ becomes silent suddenly and isolate herself.

Ψ sometimes would yell suddenly to a certain person

Ψ hyreactivity

Ψ anger

Ψ irritable

Ψ elevated mood

Ψ murmurs

Signs and Symptoms of Bipolar Disorder:

Ψ elevated mood; distractibility

Ψ disorganized thought and speech; flight of ideas

Ψ disorganized behavior; hyperactivity

Ψ insomnia; anorexia

Ψ grandiosity; involvement of pleasurable activities

Ψ irritability; anger; depression

Ψ loud, rapid voice

C. Related Literature
"An Unquiet Mind" by Kay Redfield Jamison
Summary:
An Unquiet Mind is a powerful, uncompromising and illuminating story of severe
manic-depressive illness from the informed perspective of a psychologist,
psychotherapist and researcher who has lived with the illness for more than 30 years.
Kay Redfield Jamison's work clearly illustrates the complex nature of the most deadly
form of the illness - bipolar I disorder, severe, with psychotic features.

Manic depression (the author dislikes the term "bipolar disorder") is revealed as a
creature of many moods: the seductively effortless well-being, confidence and energy of
hypomania; the on- or over-the-edge frenzies of mania; the long, narrow gray prison of
depression. Readers will feel the lure of a psychotic flight through the rings and moons
of Saturn, share the terror of a experiencing a bloody hallucination, and even gain an
understanding of the dark obsession with death and the pressures and rationalizations
that led the author to a near-fatal suicide attempt. The importance of mixed episodes -
the agitated merge of mania and depression - is emphasized in painful detail.

Dr. Jamison makes an excellent case, through her own experiences, for the need
to treat manic depression with both medication and psychotherapy. And the
precautionary agreement she describes making with her family and psychiatrist in the
event she should become a danger to herself is something anyone who has
experienced suicidal impulses should consider.

Reaction:

Based on the text above, the book itself shows how the bipolar disorder affects
every individual. People would probably affected by the mood swings. It would lead to
sever depression which contributes to an abnormal mental health status. Many people
that I have read reactions from tend to agree that it is extremely difficult. According to
the client, the decision to become public about her illness, no matter how difficult it was,
is something I will forever be grateful for.
 Drug Name Indication Dose, Route, Action Contraindication Side Effect Nursing
Frequency Responsibilities

Lithium Carbonate Indicated in the 450g OD - Lithium alters - Patients with Neuromuscular: 1. Observe client for
treatment of manic sodium transport in severe Tremor, muscle signs and
episodes of manic- nerve and muscle cardiovascular or hyperirritability symptoms of
depressive illness. cells and effects a renal disease and (fasciculations, depression: mood
twitching, clonic changes, insomia,
Maintenance therapy shift toward those with evidence
movements of whole apathy, or lack of
prevents or intraneuronal of severe debilitation
limbs), ataxia, choreo- interest in
diminishes the metabolism of or dehydration, athetotic movements, activities.
intensity of catecholamines, but sodium depletion, hyperactive deep
subsequent episodes the specific brain damage. tendon reflexes. 2. Record client’s
in those manic- biochemical Conditions requiring vital signs.
depressive patients mechanism of low sodium intake. Central Nervous Orthostatic
with a history of lithium action in System: Blackout hypotension is
- renal disease., spells, epileptiform common.
mania. mania is unknown.
pregnancy, lactation, seizures, slurred
speech, dizziness, 3. Monitor for signs
- Alteration of ion severe cardiovascular
vertigo, incontinence of of lithium toxicity.
transport in muscle disease., severe
and nerve cells; dehydration, brain urine or feces,
4. Monitor client for
increased receptor tumor damage, somnolence,
suicidal
sensitivity to sodium depletion psychomotor
tendencies when
serotonin. retardation,
marked
restlessness,
depression is
confusion, stupor,
present.
coma, acute dystonia,
downbeat nystagmus. 5. Evaluate client’s
urine output and
Cardiovascular:
body weight. Fluid
Cardiac arrhythmia,
volume deficit may
hypotension, peripheral
occur as a result
circulatory collapse,
of polyuria.
sinus node dysfunction
with severe 6. Observe client for
bradycardia (which fine and gross
may result in syncope). motor tremors and
presence of
Neurological: Cases of
slurred speed,
pseudotumor cerebri
which are signs of
(increased intracranial
adverse reaction.
Chapter IV

A. Process Recording

Nurse – Patient Interaction

Interaction Therapeutic Analysis

Communication

Nurse: Maganda umaga Identification – to know Interpersonal Model

po… Pwede ko po the name of the client (Sullivan): Interaction
matanong ang inyong and to determine if I’m began by means of
pangalan? handling the correct asking the name of the
patient assigned to me. patient. The patient was
able to answer the
Patient: Magandang question.
umaga din. Jennifer
Salas ang

aking pangalan.

Nurse: Pwede ko po ba Identification – to get the Interpersonal Model

matanong kung ilan taon baseline data of the (Sullivan): Interaction
na kayo at ang inyong client. continues and the client
kaarawan? can answer the questions
properly.

Patient: 34 years old na

ako. September 10, 1975
ang petsa ng aking
kaarawan.

Nurse: Taga saan po Identification – to get the Interpersonal Model

kayo? Ano po ang inyong baseline data of the (Sullivan): Interaction
relihiyon? client. continues and the client
can answer the questions
properly.
Patient: Taga Sta. Mesa
ako.. Born Again ang
aking relihiyon.

Nurse: Kamusta naman Identification – to know Interpersonal Model

po kayo dito? the present situation or (Sullivan): the client was
feelings of my client. able to answer the
 question.

Patient: Ok lng naman

pero medyo boring.

Nurse: Nasabi nyo pong Clarifying – to identify the Interpersonal Model

boring ditto, pwede ko ba cause of boredom. (Sullivan): the client can
malaman kung ano ang interact with the nurse at
dahilan? appropriate behavior.
She can answer the
question honestly and
Patient: Wala kasi can answer it without a
masyado ginagawa dito. doubt.
Paulit ulit nalang.

Nurse: May tarabaho po Identification – to get the Interpersonal Model

ba kayo noon? baseline data of the (Sullivan): Interaction
client. continues and the client
can answer the questions
Patient: Dati meron, may properly.
computer shop kami
dati.. Naging gym
instructor din ako noon
pero ngayon wala na
dahil nga nandito ako…

Nurse: Meron po ba Exploring – to know the Stress Model: being

kayong kasama dito or living lifestyle of the client alone sometimes could
kaibigan? in the area. lead to stress. But most
of the time, she can cope
up with this problem by
Patient: Halos lahat talking with others.
naman kaibigan ko pero
yung pinaka close kong
kaibigan ay umuwi na.

Nurse: Ano po ang Identification – to know Stress Model: being

inyong nararamdaman ng the present situation or separated with her friend
umalis ang iyong feelings of my client. makes her lonely and this
kaibigan? situation can lead to
stress.
Patient: Medyo
malungkot saka naiinggit.

Nurse: Nasabi niyo po na Clarifying – to identify the Stress Model: being

nainggit ka iyong cause of jealousy. jealous is a common
kaibigan. Pwede ko po problem which can cause
ba malaman ang conflicts among them.
dahilan?

Patient: Naiinggit ako

kasi siya nakauwi na,
gusto ko narin umuwi
kasi nga naboboring na
ako dito.

Nurse: Kailan po kayo Identification – to know Interpersonal Model

naadmit dito? the exact date of (Sullivan): Interaction
admission of the client. continues and the client
can answer the questions
Patient: Noong January properly.
12, 2010

Nurse: Pwede ko po ba Identification – to know Interpersonal Model

malaman kung paano how the client was (Sullivan): Interaction
kayo napunta dito? admitted. continues and the client
can answer the questions
properly.
Patient: Dati kasi matigas
ulo ko tapos dinala ako
ng nanay ko dito.

Nurse: Nasabi niyo pong Clarifying – to clarify the Cognitive – Behavioral

matigas ang inyong ulo. proper behavior of the Model (Beck and Elis):
Pwede ko po ba client before the the client’s behavior is
malaman ang dahilan? admission at the center. sometimes inappropriate
to her age.

Patient: Wala lang.

Pasaway lang talaga ako
minsan.
Nurse: Pwede ko po Identification – to Interpersonal Model
malaman kung nasaan determine the family (Sullivan): Interaction
ang iyong mga history of the client. continues and the client
magulang? can answer the questions
properly.

Patient: Yung nanay ko

nasa Sta. Mesa tapos Stress Model: the death
pumanaw na ang aking of her father could lead to
tatay. stress and depression.

Nurse: Ano po ang Identification – to Interpersonal Model

trabaho ng iyong nanay? determine the family (Sullivan): Interaction
history of the client. continues and the client
can answer the questions
Patient: dati sa bar siya properly.
nagtatarabaho pero
ngayon nagbebenta siya
sa aming sari – sari
store.

Nurse: May anak na po Identification – to Stress Model: Being a

ba kayo at asawa? determine her family single parent is difficult
status and condition. and it can lead to stress
and depression.
Client: Meron na, isa.
Babae siya. Wala akong
asawa, hindi kami kasal

Nurse: May problema po Identification – to Stress Model: being an

ba kayo na gusto niyong determine the problem of adopted child is hard to
i-share? the client. accept and according to
her situation, it is harder
to accept the reality
Patient: Noong nalaman because 24 years had
ko na ampon lang pala passed and she never
ako. 24 years old na ako expected it to be like that.
nung nalaman ko yun.
Biruin mo ganun katagal
nila tinago.
Nurse: Ano po ang iyong Identification – to know Interpersonal Model
naramdaman nung the feelings of the client (Sullivan): Interaction
nalaman mo na ampon regarding on the continues and the client
ka lang? problem. can answer the questions
properly.

Patient: Nahirapan at
medyo nasaktan.

Nurse: Nakita mo na po Identification – to know Interpersonal Model

ba ang iyong totoong the feelings of the client (Sullivan): Interaction
magulang? regarding on the continues and the client
problem. can answer the questions
properly.
Patient: Nakita na, yung
totoo kong nanay ay
nasa mindoro at yung
totoong tatay ko naman
ay patay na.

Nurse: Galit po ba kayo Identification – to know Interpersonal Model

sa totoo mong the feelings of the client (Sullivan): Interaction
magulang? regarding on the continues and the client
problem. can answer the questions
properly.
Patient: Hindi naman…
Sila parin naman
magulang ko eh kaya ok
lang.

Nurse: Pero buti nalang Reflecting – to establish Psychoanalytic Model

po mabait ang kumupkop proper response (Sigmund Freud): The
sa iyo. Biruin niyo po yun regarding on the client’s client is satisfied based
24 years kayong personal problem. on her family condition
inalagaan. but she wanted to
improve it by staying with
them.
Patient: Oo nga eh. Reality Therapy Model
Maswerte parin ako kahit (Glasser): the client
papaano. agreed to me, she was
capable to realize that
 she was still lucky.

Nursing Diagnosis Rank Rationale

1. Chronic low self- 4 For us to know the early

esteem r/t anti social memories of negative
behaviors evaluations, subsequent or
precipitating failure events

2. Disturbed personal
3 For us to know the degree of
identity r/t poor ego
differentiation impairment and the nature of the
client’s perception of the threats

3. Ineffective coping r/t 1 For us to know the specific

high degree of threat stressors, degree impairment
and the client’s perception of
situations.

2
4. Disturbed thought
processes r/t For us to know our individual
emotional changes findings, including nature
problems, current and previous
level of function and the effect on
independence and lifestyle

5. Impaired Verbal 5
Communication r/t For us to know the meaning of
emotional conditions nonverbal cues, level of anxiety
that client has exhibits.
 Cues/ Clues Psychiatric Pschodyna Planning Therapeutic Approach Rationale (with Theories) Evaluation
Nursing mics
Diagnosis

OBJECTIVE: DISTURBED Risk factors Short Term Independent: 1. A calm approach helps to Outcome achieved:
THOUGHT are Outcome: avoid distorting the client’s
GA: PROCESS hereditary, 1. providing sensory perceptual field which • The patient
After 8 hours of general leads demonstrated reality based
• Poor RELATED TO socio a. approach the client in helps could promote disturbed
nursing thinking in verbal and non-
personal DISINTEGRATI economic slow, calm, matter of fact thoughts and perception. The verbal behavior
ON OF and intervention, the pt clients with disturbed thought
grooming matter • The patient
will be able to:
• Poor eye BOUNDARIES biochemical b. maintain facial expression process may have difficulty in demonstrated a reduction
contact BETWEEN and behaviors that are interpreting correct meanings if of frequency delusions
• Demonstrat
• Confused SELF AND consistent with verbal the nurse misinterprets intent • The patient
e reality
facial statements participated in social
RESOLVED based with a conflicting or double
expressio 2. Providing specific activities such as group
CONFLICTS thinking in message. Peplau defined
n questions therapies.
verbal and psychodynamic nursing as being
Motor Behavior • Avoid challenging
non verbal able to f understand one’s own
the clients delusional
behavior
• Stereotyp system or arguing with the behavior to help others identity
• Demonstrat
e Neuro client felt difficulties and to apply
ed reduction
3. presenting the reality principles of human relations to
development of frequency
al failure of delusions the problems that arise t all levels
Sensory and • Distract the client
Cognition: • Participate from the delusion by of experience.
in social engaging him in a less
activities 2. delusions cannot be changed
• Consciou threatening or a more
s, and group comforting topic or activity thru logic and challenging the
oriented therapies at the first sign of anxiety belief of the patient, no matter
to time, and discomfort. how irrational. As the client
person Alteration of 4. offering praise maybe forced to cling to it.
and place function in Roger’s described a variation of
• Impaired • Offer recognition
cognitive and self as the inherent potentialities
 memory Perceptive as soon as the client of the actualizing tendencies that
on fields begins to differentiate can suffer the distorted
personal between reality based and expression when maladjustment
informatio non reality based thoughts
occurs resulting in behavior
n and behaviors
destructive to one self and others
• Poor 5. giving information
concentra 3. Dwelling to the delusional
tion • Offer the client
clear, simple explanations content may increase the client’s
regarding
Fantasize of environmental events, anxiety, aggression and other
specific
topics ideal self and activities and the behavior dysfunctional behavior. We do
Attitude: family while of other clients as not come into the world
being aloof to necessary. estranged from ourselves,
• Manifest others socialization is behind this
fear as
Collaborative: alienation.
evidence
by 4. Positive Reinforcement
fidgeting 1. continue to administer and
monitor the effects of the increases self-esteem and
Affect:
Inaccurate prescribed medication encourage the client to identify
• Suspicion interpretation and continue reality based
s noted of incoming • CHLORPROMAZI behavior. Freud says that
• Shows information NE (Thorazine) positive reinforcement functions
anger to feed the ID which contains the
drives that people have

5. Clear direct explanations of

environment events help to
Disturbed
lessen the client’s
thought
suspiciousness and fear or
process
mistrust of the surroundings and
others.
CHLORPROMAZINE

Is a classified as a low potency

antipsychotic and in the past was
used for the treatment of both
acute and chronic psychosis. It is
still well recommended for short-
term management of severe
anxiety and aggressive episodes.
Chapter V
A. Play Therapy
English
Play Therapy:
A. DEFINITION
Play therapy is a technique used
in psychotherapy with people of
all ages but most often with
children. Help children address
and resolve their problems. It
helps build necessary skills,
such as communication,
expression, problem solving and
ways to relate to others.
B. PURPOSE
The aim of the play is to
decrease behavioral and
emotional difficulties that
interfere significantly with a
child’s normal functioning. Goals
include improved verbal
expression, ability for self-
observation, improved capacity
to trust and relate to other.
C. STANDARD RULES
Eggshell peeling off
Step 1: Each student nurse will explain
the mechanics to each respective
client.
Step 2: Gather materials (egg, trash
can, broom etc.).
Step 3: Make sure each egg has no
cracks or signs of easily breakage.
Step 4: Give each client 1 piece of
clean “Boiled” egg.
Step 5: With the facilitators mark, each
individual client must peel off the
eggshell simultaneously.
Step 6: The facilitator must time the
game or just pay attention to simply
distinguish the winner (fastest).
Step 7: Give reward to the winner and
consolation price for the other clients.
Step 8: Aftercare.
Tagalog
PLAY THERAPY
A. Kahulugan
Ang Play therapy ay isang
pamamaraan pangsikolohiya
naaayon sa anumang
gulang. Ito ay kadalasang sa
mga bata. Ito;y nakakatulong
sa kanila upang
masolusyunan ang kanilang
problema, nalilinang ang
pansatiling kaalaman at
naihahayag ang sariling
pananaw.
B. Hangarin
Ang hangarin ng larong ito ay
ang mapababa o
malimitahan ang mga
kaugalian o emosyon na
naglalayong sumasagabal sa
pang araw araw na Gawain
ng bata. Ang mga layunin
nito ay an gang paunlarin
ang angking abilidad na
paniniwala sa sarili at
magkaroon ng sariling
desisyon.
C. PARAAN NG PAGLALARO:
Una: Ang student nurse ay
ipapaliwanag qng para saan
ang laro sa bawat manlalaro.
Pangalawa: Ihanda ang mga
kailangang gamit sa laro
tulad ng itlog, basurahan,
walis tambo at iba pa.
Pangatlo: Ang mga itlog ay
dapat wlang sira o basag.
Pang apat:Bibigyan ng tig
iisang itlog ang mga
manlalaro.
Panglima: Sa signal ng
facilitator,mag uunahan ang
mga manlalaro na balatan
ang itlog .
Pang anim:Ito ay oorasan ng
tagapagbantay para

B. Music and Art Therapy
C. Bibliotherapy
D. Occupational Therapy
English
A. Definition
The therapeutic use of work, self-care,
and play activities to increase
development and prevent disability. It
may include adaptation of task or
environment to achieve maximum
independence and to enhance the
quality of life.
It promotes health by enabling
people to perform meaningful and
purposeful occupations. Occupation
can be defined as "active process of
living: from the beginning to the end of
life, ... occupations are all the active
processes of looking after ourselves
and others, enjoying life, and being
socially and economically productive
over the lifespan and in various
contexts" These include (but are not
limited to) work, leisure, self care,
domestic and community activities.
B. Purpose
The purpose of Occupational Therapy
(OT) is to help people increase their
functional independence in daily life
while preventing or minimizing
disability. Often OT is combined with
other treatments including Physical
Therapy.
These programs are very
malaman kung sino ang
nanalo.
Pangpito: Ang nanalo ay
bibigyan ng gantimpala.
Tagalog
A. Depinisyon
Ang panterapeutika paggamit ng
mga trabaho, pag-aalaga, at maglaro
ng mga gawainupang madagdagan
ang pag-unlad at maiwasan
ang kapansanan. Ito ay
maaaring isama
ang pagbagay ng gawain o sa
kapaligiran upang makamit
ang pinakamataas
nakasarinlan at upang mapahusay ang
kalidad ng buhay.
Ito nagtataguyod ng kalusugan sa
pamamagitan ng pagpapagana ng mga
tao upangmaisagawa makabuluhan at
mapakay trabaho. Trabaho ay
maaaring tinukoy bilang "mga
aktibong proseso ng buhay: mula
sa simula hanggang sa
wakas ng buhay, ... trabaho ayang
lahat ng mga aktibong proseso ng mga
naghahanap matapos ang ating sarili at
sa iba pa, enjoying
buhay, at pagiging sosyalan at matipid
produktibong sa paglipas ng habang-
buhay at sa iba't-ibang mga
konteksto "Kabilang (ngunit hindi
limitado sa) ng
trabaho,paglilibang, self-aalaga, domes
tic at mga gawain ng komunidad.
B. Layunin
structured, goal-oriented, and
customized to meet the patient's
needs. OT strives to promote emotional
well-being, independence, and an
enhanced quality of life. It could be said
OT teaches life skills.
OT can help a person with
activities of daily living (ADLs), which
include dressing, bathing, food
preparation, and return to work or
school following injury or illness.
C. Standard Rules
- listen to the nurse attentively
- focus your attention at the nurse
- follow the instructions of the
nurse
- do not talk when someone is
talking
- respect others
- do not initiate a fight during and
after the activity
- cooperate on the activity
D. Techniques
- get the attention of the client.
- ask the purpose of the activity
- demonstrate the activity properly
- make sure that the client follows
the steps of the activity
- repeat the steps of the activity
for better understanding
- ask the client to do the activity
on their own
E. Analysis
Occupational Therapy has the same
goal in mind (increasing function and
independence) in regards to physical
disabilities and limitations, and we may
use repetitive exercises, but most
often we use them in the context of a
"functional activity". This refers to
performing meaningful activities while
simultaneously working on increasing
function and mobility.
F. Interpretation
Ang
layunin ng trabaho Therapy (OT) ay up
ang matulungan ang mga
tao dagdagan
angkanilang pagsasarili functional sa ar
aw-araw na buhay habang
ang pumipigil o minimizingkapansanan.
Madalas OT ay pinagsama sa iba
pang paggamot kasama
ang PhysicalTherapy.
Ang mga programang
ito ay tunay nakabalangkas, layunin-
oriented, at customized naupang
matugunan
ang pangangailangan ng pasyente. OT
strives upang itaguyod angemosyonal
na kagalingan, kalayaan, at isang
pinahusay na kalidad ng buhay. Ito ay
maaaring maging sinabi OT nagtuturo
sa mga kasanayan sa buhay.
OT maaaring makatulong
sa isang tao sa mga gawain ng
mga araw-araw
na pamumuhay(ADLs), na kasama
ang sarsa, paliligo, paghahanda ng
pagkain, at bumalik sa trabaho opaaral
an sumusunod na pinsala o sakit.
C. Standard Rules
- makinig sa mga nars dinggin
- focus ang inyong pansin sa mga nars
- sundin ang mga tagubilin ng mga nars
- huwag makipag-usap kapag ang
isang tao ay pakikipag-usap
- paggalang sa iba
- huwag simulan ang isang away sa
panahon at pagkatapos ng
mga aktibidad
- tumulong sa mga aktibidad
D. Pamamaraan
- makakuha ng pansin ng mga client.
- tanungin ang layunin ng aktibidad
- ipakita ang mga aktibidad ng maayos
- tiyakin na ang client ay
sumusunod sa mga
hakbang ng mga aktibidad
- ulitin ang mga
hakbang ng mga aktibidad para sa mas

The client was asked to make a paper
rose which is the part of the activity.
The client was able to understand the
principles in making the paper roses.
They were able to make it successfully
and can make it without the assistance
of the nurse.
E. Remotivational Therapy
mahusay na-unawa
- hilingin sa client upang gawin ang
mga aktibidad sa kanilang sariling
E. Pagsusuri
Occupational Therapy ay
may parehong layunin sa isip (pagtaas
ng function at pagsasarili)sa mga
tungkol sa pisikal na kapansanan,
at mga limitasyon, at maaari
naming gamitinpaulit-ulit
na magsanay, ngunit karamihan sa
mga madalas naming gamitin ang mga
ito sa
konteksto ng isang "functional activity".
Ito ay tumutukoy sa pagganap
ng makabuluhangmga
gawain habang sabay
na nagtatrabaho sa pagtaas
ng function at kadaliang.
F. interpretasyon
Ang client ay tinanong na gumawa
ng papel ng isang rosas na kung
saan ay ang bahagi ng
mga aktibidad. Ang client ay maaaring
maunawaan ang mga
prinsipyo sa paggawa ng mga rosas na
papel. Sila ay marunong nang gawin
ito ng matagumpay at
maaaring gumawa itonang
walang tulong ng mga nars.