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PSYCHIATRIC NURSING The interpersonal process whereby the professional nurse practitioner, through the THERAPEUTIC USE OF SELF assists an individual, family, group or community to promote mental health, prevent mental illness and suffering, participate in the treatment and rehabilitation of the mentally ill and if necessary, find meaning in these experiences. (Joyce Travelbee) MENTAL HEALTH A state of well-being in which a person is able to cope with the normal stresses of daily life and realize his/her potential. (WHO, 2005) MENTAL HYGIENE The science that deals with measures to promote mental health, prevent mental illness and suffering, and facilitate rehabilitation. MENTAL ILLNESS A state of imbalance characterized by a disturbance in a persons thoughts, feelings and behaviors. STIGMA a mark of shame, disgrace, dishonor THE EVOLUTION OF PSYCHIATRIC MENTAL HEALTH CARE I. EARLY HISTORY People believed that any sickness indicated displeasure of the Gods and in fact was punishment for sins and wrong doings. Mental disorders were viewed as either being divine or demonic depending on their behavior. MIDDLE AGES Hospital of St. Mary of Bethlehem, first mental asylum (mental haven/hospital) for the insane was built

II.

III. 15th 17th centuries

Skepticism about curability of mental illness The insane were treated more like animals than human beings

IV. 18th century

French and American revolutions inspired by the desire to broaden the rights of mankind and bring freedom and fair treatment 1773 First Psychiatric hospital in America at Williamsburg, VA Custodial care provided by non-nursing attendants MYRIADS OF SOCIETAL CONCERNS 1) BENJAMIN RUSH (1745 1813) Father of American Psychiatry Inventor of the: Tranquilizer chair insulin shock therapy no longer used; replaced by ECT Gyrator

2)

PHILIPPE PINEL (1745 1826) French man Advocated kindness and moral treatment of the mentally ill In-charge of a large hospital for the insane WILLIAM TUKE (1732 1872) English merchant Began a 4-year dynasty that advocated humane treatment of the mentally ill

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4) FRANZ ANTON MESNER (1734 1815) Austrian physician Discovered mesmerism

V. 19th century: THE EVOLUTION OF THE PSYCHIATRIC NURSE McLean Asylum in Massachusetts became the first institution to provide humane treatment of the mentally ill.

2 The first training of nurses to work with persons with mental illness was in 1882 at McLean Hospital in Waverly,
Massachusetts.

DOROTHEA LYNDE DIX (1802-1887) began a crusade in the USA to reform treatment of the mentally ill. She
opened 32 state hospitals that offered asylum. 1882 first training of school of nursing of the mentally-ill established at McLean Asylum LINDA RICHARDS first graduate American psychiatric nurse. She believed that, the mentally sick should be at least as well cared for as the physically sick.

VI. 20th century: THE ERA OF PSYCHIATRY

1920s 1940s National Mental Health Act of 1946: care focused on a disease model rather than on the client; curative care In 1920, Harriet Bailey published the first psychiatric nursing book, Nursing Mental Diseases 1950s 1960s Creation of Community Mental Health Center led to the development of community psychiatry Deinstitutionalization [decatastrophizing form of an outlet] 1970s 1980s Psychotherapeutic approaches: Behavior Modification; Cognitive Therapy; Descriptive Authority; and performing research Decreased psychiatric clinical experiences due to federal funding problem 1990 2000 DECADE OF THE BRAIN Advances in technology and understanding of mental illness within the domains of neurobiology Telemedicine a form of interactive media

1) ADOLF MEYER (1866 1950)

Swedish psychiatrist Emphasized the need to study the persons whole environment to determine its effect on the environment (MILIEU Therapy) Common sense psychiatry

2) CLIFFORD BEERS (1876 1943) A Mind That Found Itself, his classic work, provided a descriptive account of his tormenting experiences in
mental institutions.

3) EMIL KRAEPELIN (1856 1926)

Munich psychiatrist Devised a classification of mental disorders which gave momentum to the advancement of psychiatry Prae cox dementia (schizophrenia) and mania

4) EUGEN BLEULER (1857 1939)

Coined the term schizophrenia and included among its characteristics the four (4) As: Apathy

Associative Looseness Autism

Ambivalence coexistence of two (2) opposing emotions

5) SIGMUND FREUD (1856 1939) Viennese neurologist; Father of modern psychiatry; father of psychoanalysis
Development of psychoanalysis, psychosexual theories and neurosis Catharsis sudden outbursting of emotions Dream interpretation Hysteria CARL GUSTAV JUNG (1875 1961) Swiss psychiatrist; neo-Freudian Analytical psychology Concepts of introverted and extroverted personalities SCHIZOID:

6)

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Aloof Loner Low IQ introverted

7) KAREN HORNEY (1885 1952)

Psychologist; neo-Freudian Neuroses stems from cultural factors and impaired interpersonal relationships 8) HARRY STACK SULLIVAN (1892 1949) IPR theory Milieu therapy Anxiety interferes with the ability to cope and communicate effectively resulting in mental illness

VII. 21st century: NEUROSCIENCE AND GENETICS

Link between behavior and emotions, brain and genes Information systems: the Internet and cyberspace Telemedicine CRITERIA OF MENTAL HEALTH 1) SELF-CONCEPT (+) Joharis window 2) SELF-ACTUALIZATION considering the person as a fully-functioning person 3) INTEGRATION the balance between what is expressed and suppressed the inner drives (impulses) 4) AUTONOMY the state of independence or the balance between dependence and independence 5) MASTERY OF THE ENVIRONMENT The science of Psychiatric Nursing (Psychiatric Nursing is both a science and an art) 6) REALITY ORIENTATION evaluates whether the client has the ability to realize or distinguish between reality and imagination THE CONCEPTS OF PSYCHIATRIC CARE: THERAPEUTIC MODELS I. PSYCHOANALYTIC THEORY (Freud) Proposes that conflicts among unconscious motivating forces affect behavior A. DRIVES a state of excitation, instinctual urges and impulses arising from biological and psychological needs EROS includes instinct concerned with self-preservation and survival of the species THANATOS expressed in aggression or hate, which can be directed inwardly (suicide) or outwardly (murder) B. STRUCTURES OF PERSONALITY ID Pleasure Principle innate desires, pleasure seeking, aggression, sexual impulse Language: I want what I want when I want it. Infancy to school age M Manic hyperthermia and racing thoughts Hyperactive Always on the GO Talkative Stilted speech A Antisocial Selfish Not following rules N Narcissistic Self-importance Superiority complex Lowest IQ EGO Reality Principle Language: I can wait. Adult stage mature adaptive behaviour *a problem in the ego results in an schizophrenic behavior De-personalization De-realization SUPER EGO Conscience Principle (undoing) Language: I should not want that. moral, ethical values, parental

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SE OCD, obsessive-compulsive disorder organized, perfectionist ID A, anorexic perfectionist C. DEFENSE MECHANISMS Methods used by the EGO to fight instinctual outburst of the ID and the SE Two (2) Aspects: a) They keep unwanted thoughts out of the awareness and use energy to do this. b) Energy cannot be contained indefinitely; therefore, some defense mechanisms allow the energy to be discharged. VAILLANTS FOUR (4) LEVELS OF DEFENSE MECHANISMS LEVEL I (PSYCHOTIC MECHANISMS) Common in healthy individuals before age 5 1. Delusional projection 2. Denial the unconscious failure to acknowledge an event, thought, feeling that is too painful for conscious awareness 3. Distortion LEVEL II (IMMATURE MECHANISMS) Common in healthy individuals ages 3-5 1. Projection attributing ones own thought or impulses to another person. 2. Schizoid fantasy 3. Hypochondriasis faking 4. Passive-Aggressive Behavior procrastination blaming others for your misfortunes 5. Acting-out wishful thinking LEVEL III (NEUROTIC MECHANISMS) Common in healthy individuals ages 3-90 1. Intellectualization using reason to avoid emotional conflicts 2. Repression the INVOLUNTARY exclusion of a painful thought or memory from awareness. 3. Displacement the transference of feelings to another person or object 4. Reaction Formation 5. Dissociation LEVEL IV (MATURE MECHANISMS) Common in healthy individuals age 12-40 1. Altruism total sacrifice of self 2. Humor 3. Sublimation substitution of an unacceptable feeling with more socially acceptable one. Displacement the transference of feelings to another person or object. Projection attributing ones own thought or impulses to another person. Identification an attempt to be like someone or emulate the personality, traits, or behaviors of another person. Introjection the incorporation of values or qualities of an admired person or group into ones own ego structure. Splitting split behavior Symbolization PRINCIPLES 1. All behaviors have a meaning. 2. Behavior is meeting the needs of the individual. 3. We need to accept and respect the person regardless of his/her behavior. 4. Limit or reject the inappropriate behavior but NOT the individual. 5. Recognize and accept the dependency needs of the client while encouraging and supporting moves toward independence. 6. We must always encourage and support expression of feelings in a SAFE and NON-JUDGMENTAL WAY or manner. 7. Recognize that the client needs to use his/her defense mechanisms until other defenses can be substituted with more appropriate ones. 8. All behaviors ARE LEARNED.

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FIXED DEFENSE MECHANISMS ON THE FF. DISORDERS: AMNESIA dissociation ANOREXIA suppression

BIPOLAR high (manic) reaction formation

CATATONIA waxy flexibility repression DEPRESSION introjection O.C. undoing PARANOID projection

BIPOLAR low (depressed) reaction formation BORDERLINE splitting (the good me and the bad me)

PHOBIA displacement SCHIZOPHRENIA Paranoid projection SCHIZOPHRENIA Catatonic regression SCHIZOPHRENIA Hebephrenic regression SCHIZOPHRENIA Undifferentiated regression SCHIZOPHRENIA Residual regression SUBSTANCE ABUSE denial

II. PSYCHOSEXUAL THEORY OF DEVELOPMENT (Sigmund Freud) Oral Phase 1 yr. old (infancy; the stage of the id)

Fixation and regression defense mechanism Greatest need security Greatest fear if anger anxiety Narcissistic pleasure seeking is through eating & sucking; Mouth erogenous zone, area of satisfaction Insecurity in parting with breast or bottle may cause fixation Tension is relieved by sucking & swallowing Sucking need is independent of hunger satisfaction.

primary narcissm (self-love)

Anal phase 1-3 years old (toddlerhood; the stage of the ego) negative defense mechanism Anal retentiveness: (+) traits: Obedient Clean Organized Anal expulsive: Stubborn Messiness Disorganized Primary source of pleasure is elimination/retention This is the critical period for toilet training Anus site of tension & sexual gratification Greatest need: power first experience with discipline & authority Retention & expulsion (forcing out are experienced as pleasurable especially because these functions come under the child-control); child uses his new skill to please or annoy parenting adult.

Phallic phase 3-5 years old (school age: the stage of the SE)
Oedipal complex castration Elektra complex penis envy

Latency phase 5-11 (or 13) (the stage of the STRICT SE)
Homosexual relationships Resolution of Oedipal complex Final stage of psychosexual devt.

Genital phase 11-13 years

Heterosexual relationships Begins with puberty and the biologic capacity for orgasm; involves the capacity for true intimacy

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III. SOCIAL THEORIES IV. PSYCHOSOCIAL DEVELOPMENT Psychosocial Theories of Eric Erickson AGE BIRTH 18 mos. (infant) 1-3 years (toddler) 3-6 years (preschool) 6-12 years (school age) 12-20 years (adolescence) 18-25 years (young adult) 24-45 years (middle adult) 45 years + DEATH (maturity) VIRTUE Hope Will Purpose Competen ce Fidelity Love Care Wisdom STAGE TRUST vs. MISTRUST AUTONOMY vs. SHAME/DOUBT INITIATIVE vs. GUILT INDUSTRY vs. INFERIORITY IDENTITY vs. ROLE CONFUSION INTIMACY vs. ISOLATION GENERATIVITY vs. STAGNATION EGO INTEGRITY vs. DESPAIR

CARL JUNG Collective unconsciousness, is that part of unconscious material that is universal in humans, in contrast with the personal unconscious Archetypes: PERSONA public personality SHADOW contains the opposite of what we feel ourselves to be 2 Basic personality orientations: Introversion Extroversion V. INTERPERSONALSOCIAL THEORY Alfred Adler Harry Stack Sullivan Karen Horney

ALFRED ADLER INFERIORITY COMPLEX is an exaggeration of feelings of inadequacy and insecurity resulting in defensiveness and neurotic behavior. AVOIDANT PERSONALITY DISORDER Inferiority complex Lowest in IQ HARRY STACK SULLIVAN Personification, development of the self-system that refers to the I or me Good me perceived when the mother is rewarding the infant Bad me arises in response to the negative experience with the mother Not me arises out of extreme anxiety that the child rejects as part of the self KAREN HORNEY Basic Anxiety: ISOLATION and HELPLESSNESS People relate to each other in one of three ways: They can move toward others, seeking love, support, and cooperation They can move away from others, trying to be independent and self-sufficient They can move against each other, being competitive, critical and domineering JOHN BOWLBYS ATTACHMENT THEORY

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Attachment system plays a vital role in survival by allowing the infants undeveloped brain to use the caregivers developed or mature functions to regulate the life processes. Separation Anxiety (stages) 1. Protest crying 2. 3. Despair painful experience Detachment

VI. BEHAVIORAL THEORY B.F. SKINNER 2 Types of Behavior: RESPONDENT BEHAVIOR occurs when known and specific stimulus elicit a response OPERANT BEHAVIOR obtain a response or reinforcement from the environment or from another person CONDITIONING CLASSIC CONDITIONING the reinforcement is the presenting stimulus that causes the response (before an action) [OPERANT CONDITIONING occurs when behavior is produced without an observable external stimulus (after an action)] DIALECTICAL BEHAVIORAL THERAPY (DBT) The focus is the behavior control and mastering skills to resolve trauma issues. Formulation of Contingency Plan: Problem-solving skills Cognitive restructuring Exposure therapy desensitization systematic desensitization (gradual); implosion (abrupt) Self-efficacy skills training Psychoeducation AARON BECK (Depression Beck Inventory, DBI) SCHEMATA SHAPE PERSONALITY, are cognitive structures or patterns that consist of a persons beliefs, values and assumptions ALBERT ELLIS RATIONAL EMOTIVE THERAPY (RET), irrational thoughts cause maladaptive behavior and emotional distress Components: A Activation event/situation B Belief C Consequence or emotional response Context Content COGNITIVE THERAPY Therapist and the client, together, construct counters to the cognitive distortions Counter is a statement that counteracts or negates the thought. JEAN PIAGET Reasoning for Children Sensorimotor (birth to 2 years) object performance Preoperational (27 years) visual, symbolic (prelogical) Concrete operational (711 years) logical Formal operational (11adult) abstract or critical thinking VII. NEUROBIOLOGICAL THEORY All psychiatric behaviors are a reflection of brain function and all thought processes represent a range of functions mediated by nerve cells (neurons) in the brain. Central Nervous System 1. BRAIN In the average adult human, the brain weighs 1.3 to 1.4 kg (about 3 pounds). The brain contains about 100 billion nerve cells (neurons) & trillions of "support cells" called glia. Primary Parts:

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a. b. c. d. Cerebrum (1-4) Cerebellum (6) Limbic System Brain Stem (5)

i. Cerebrum The cerebrum controls many things, including How we think Left hemisphere: logical reasoning & analytical functions; intelligence Right hemisphere: center for creative thinking, intuition, artistic abilities; skills What kind of personalities we have. Voluntary movement The way we interpret sensations such as sight, touch and smell.

Lobes of the Brain Frontal cortex thinking/mentation Parietal cortex sensory and motor Temporal cortex speech; hearing; memory; affect Occipital cortex visual; language Cerebellum equilibrium; sensory perception; motor output Brain stem ii. Cerebellum The cerebellum controls (6) The way we walk (MOVEMENT). The way we maintain our POSTURE. Keep our sense of BALANCE.

The Cerebellum overlies the pons and medulla It is mainly concerned with motor functions that regulate muscle tone, coordination, & posture. Lack of Dopamine in this area is associated with Parkinsons & Dementia. iii. Diencephalon Extends from the cerebrum & sits above the brainstem

THREE (3) PRIMARY STRUCTURES: A. THALAMUS Receives & relays sensory information & plays a role in memory & in regulating mood. B. HYPOTHALAMUS Controls the body homeostasis C. LIMBIC SYSTEM Regulates emotional responses iv. Brain stem The brain stem is a major part of Corporate Headquarters The brain stem is a general term for the area of the brain between the thalamus and spinal cord. It controls such vital functions as respiration rate / breathing blood pressure Heartbeat / heart rate Structures within the brain stem include the medulla, pons, tectum, reticular formation & tegmentum. 2. Spinal Cord NEUROBIOLOGICAL THEORY Studies reveal that malfunction of certain CNS neurons which excrete substances known as neurotransmitters, appear to inhibit or trigger impulses in other neurons & may be responsible for distortions of behavior associated with psychiatric disorders. NEUROTRANSMITTERS Are chemical substances manufactured in the neuron that aid in the transmission of information throughout the body Necessary in just the right proportions to relay messages across the synapses. Are the chemicals which account for the transmission of signals from one neuron to the next across synapses. MAJOR NEUROTRANSMITTERS

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DOPAMINE (DA) Fine motor devt. Sensory integration Cognition Memory Schizophrenic and manic disorders (if DA) Depression and Parkinsons disease (if DA) DA elation; excitement DA depression anergia DA depression anhedonia DA depression avolition NOREPINEPHRINE (NE) Sympathetic fight or flight responses to a real or perceptive threat Depressive disorders, including Bipolar disorders SEROTONIN (5-HT) Modulate wakefulness and alertness and are known to influence the transmission of sensory pain Temperature regulation, sleep, hunger, consciousness, behavior Involved in depressive & anxiety disorders, including eating disorders ACETYLCHOLINE (ACH) Alzheimers Disease GAMMA-AMINO BUTYRIC ACID (GABA) Inhibitory neurotransmitters (Inhibitory brain modulator) Anxiety states GLUTAMATE Reversible N Trans Brain damage

VIII. HIERARCHY OF NEEDS IX. PRINCIPLES X. PSYCHIATRIC ASSESSMENT

XI.