PT 32

PSYCHIATRY
MINERVA G. MARCIAL,PTRP,RN,MPH
 HEALTH

• a state of complete physical, mental and social well-

being without the absence of disease or infirmity”
 MENTAL HEALTH

• “is defined as a state of well-being in which every

individual realizes his or her own potential, can cope
with the normal stresses of life, can work productively
and fruitfully, and is able to make a contribution to her
or his community.”
• A state of emotional, psychological, and social
wellness evidenced by satisfying interpersonal
relationships, effective behavior, and coping, positive
self-concept, and emotional stability.
 MENTAL ILLNESS

• “a clinically significant behavioral or

psychological syndrome experienced by a person,
marked by distress, disability, or the risk of suffering,
disability, or loss of freedom”

(APA American Psychiatric Association)

 ELEMENTS OF MENTAL
HEALTH
• Self-governance
• Progress toward growth or self-realization
• Tolerance of uncertainty
• Self-esteem
• Reality orientation
• Mastery of environment
• Stress management
 INFLUENCES ON MENTAL
HEALTH
Biologic makeup
• Biological Sense of harmony in life
Emotional resilience/hardiness
• Interpersonal Spirituality
• Sociocultural Positive identity

o
Effective communication
Sense of community
Ability to help others
Access to adequate resources
Intimacy
Intolerance of violence
Balance of separateness and
Support of diversity among people
connection
 PROBLEMS IN TREATING
MENTAL ILLNESS

• Cost-related issues
• Stigma
• Revolving door treatment
• Lack of parity
• Limited access to services
METHODS OF ACHIEVING OPTIMAL CARE
FOR MENTAL ILLNESS

• Beyond response to recovery

• Reintegration into society
• Mental health parity
• Culturally competent care
• Medication adherence
 DIAGNOSTIC AND STATISTICAL MANUAL
OF
MENTAL DISORDERS

• Diagnostic and Statistical Manual of Mental Disorders, fifth edition

(DSM-5)
• The DSM-5 has three purposes:
• • To provide a standardized nomenclature and language for all
mental health professionals
• • To present defining characteristics or symptoms that
differentiate specific diagnoses
• • To assist in identifying the underlying causes of disorders
History of Psychiatry

MINERVA G. MARCIAL , MPH,RN, PRTP

 Begin at the beginning

• For the most part, through the ages, most people with
mental health problems were simply cared for in the
community.
• Much like modern day developing world, they probably
did better than most clients do today.
 What was it like then?
• Different presentations of mental illness – less learning
disability, no schizophrenia, more delirium and organic
mental illness – esp. syphilis
• No asylums until 8th century. None in Britain until
1300’s.
Ancient times
 Hippocrates (460-375 BC)

• Pre medicine illness, including mental illness thought

to be related to spiritual phenomena requiring
prayer, sacrifice, exorcism.
• Hippocrates thought that mental illness based in the
brain. Described mania, delirium, melancholia,
anxieties, phobias and puerperal psychosis and
paranoia.
 Humors
Mental illness thought due to disturbances of humours
– black bile, yellow bile, blood and phlegm

• Black bile: earth, cold and dry, associated with

melancholia.

• Yellow bile: fire, hot and dry, associated with mania.

• Needed to rebalance the humours to cure people –

warm, cold, purging, bloodletting, diet, activity, rest and
exercise etc. Persisted until 19th century.
 Aristotle 382–322 BC
and Galen 130-200BC
• Mind was associated with the heart
• A Greek physician stated that emotional or mental
disorders were associated with the brain.
Socrates -Weird and wonderful

• the womb wandered around the body causing

problems.
• Therefore have babies to make it stay in the proper
place – the womb as a cause of problems for women
persisted as a belief right until the 20th Century.
 Mania

• The manifestations of mania are countless. Some

manics, who are intelligent and well educated, deal with
astronomy, although they never studied it, with
philosophy, but auto didactically, they consider poetry a
gift of muses (Kappadokien)
 Persian times

• Both physical and spiritual causes proposed.

• Many advances in medicine, including in mental illness.
• First psychiatric hospitals, which used baths, drugs,
music and activities and counselling.
 Early Christian times
(1–1000 AD)

• Superstitions were strong

• Demonology: All diseases were blamed on
demons, mentally ill were viewed as
possessed
• Priest performed exorcisms
• Incarceration in dungeons, flogging, starving
 Renaissance Period
(1300A–1600)

• Mental illness mixture of spiritual and medical causes –

most understanding from ‘humors’.
• Also the first asylums started here St. Mary of Bethlehem
hospital, later changed to Bedlam.
• The first place to use incarceration as a treatment for mad
people.
• Mentally ill were considered evil or possessed- punished
 Victorian times
Bedlam
• Patients chained to the walls if violent.
• Filthy living conditions
• Patients beaten, poor sanitation.
• Abused
• Treatments:
• Bloodletting, purging,
blistering, whipping – to
restore humors and let out
evil spirits.
• Inhalation of mercury.
• Also rest, music, diet,
exercise.
 Incarceration
• The idea of incarceration increased after Tudor times,
as society shifted, and people were poorer and could
not afford to care for non productive mad relatives.
 Aversion therapy

• Moral therapy encouraged good behaviour, but

also punished ‘bad’ behaviour to act as an
aversion to ‘mad rantings and violence’.
Weird treatments
• Dr. Rushes spinning chair – to relieve
brain congestion
• Warm baths for mania, cold baths for
depression.
• Near drowning
• Malaria for syphillis
• Tooth extraction
• Hysterectomies
• Lobotomies – mobile lobotomy van –
• Insulin coma
• Electric currents for mutism and shell
shock.
• Insomnia for depression
TREPHINATION
TRANQUILIZER CHAIR
O'HALLORAN'S SWING
HYDROTHERAPY
LUNATIC BOX
HOLLOW WHEEL RESTRAINT CAGE
 Diagnostics

• Diagnostics started properly –

• Sigmund Frued (1856-1939)
• Emil Kraepelin ( 1856-1926)
• Eugene Bleuler (1857-1939)
• Diagnostic classifications and descriptions
burgeoned.
 PERIOD OF PSYCHOTROPIC DRUG

• 1950
• Chlorpromazine (Thorazine) Lithium, were
invented and age of drug treatment began.
• MAOI’s
• Haloperidol
• TCA
• Benzodiazepines
 Recent developments 1963

• Outpatient work and community care

developed
• Psychiatry split into subspecialties – adult, old
age,forensic and child.
• New treatments developed, others diminished
(ECT, psychosurgery, sterilisation).
 Today 21ST Century
• Community care developed.
• Person centred approaches
• Increased rights in law
• Reduced hospital admissions
• Debate on formulation vs diagnostics
• Holistic care.
• Nurse practitioners.
 Today 21ST Century
• According to the National Institutes of Health
(2018), 44.7 million people in the United States have
a mental illness, though only 19.2 million received
treatment with in the past year.
• The 18 to 25 age group had the highest prevalence
of mental illness as well as the lowest percent of
people receiving treatment.
• Mental disorders are the leading cause of disability in
the United States and Canada for persons 15 to 44
years of age.
 MENTAL STATE IN THE PH
• A qualitative study conducted by Tanaka et al. (2018) showed that this
stigma is considered to be an effect of the public belief about mental
disorders which consist of three themes:
• First is familial problems, wherein the family rejects or disowns the
family member who suffers from a mental disorder because they believe
that it can be inherited.
• Second is unrealistic pessimism and optimism about the severity of
the disorder, wherein the mentally ill either would certainly suffer from
severe functional impairment or would be able to overcome any
psychological suffering by themselves.
• Last is the oversimplified chronic course, wherein people without
mental illnesses apply an acute illness model to those ill, and expect full
recovery in the short term.
https://www.frontiersin.org/articles/10.3389/fpsyg.2021.7
06483/full
 • mental health has been given very little attention by the
Philippine government and public sectors. Even after the
country has recently passed its first Mental Health Act and
Universal Health Care Law, only 5% of the healthcare
expenditure is directed toward mental health.
• there are only 7.76 hospital beds and 0.41 psychiatrists per
100,000 people (World Health Organization—Assessment
Instrument for Mental Health Systems, 2007; Department of
Health, 2018).
• This ratio was known to be lower than other Western Pacific
countries with similar economic statuses, like Malaysia and
Indonesia (Lally et al., 2019).

https://www.frontiersin.org/articles/10.3389/fpsyg.2021.706483/full
  The Philippine government does not even provide
economic support for organizations that have been
involved in the formulation and implementation of mental
health policies and legislation (World Health
Organization—Assessment Instrument for Mental Health
Systems, 2007).
 Consequently, mental illness has become the third most
common disability in the Philippines, wherein six million
Filipinos live with depression and anxiety.
 Because of this, the country has the third highest rate of
mental disorders in the Western Pacific (Martinez et al.,
2020).

https://www.frontiersin.org/articles/10.3389/fpsyg.2021.706483/full
 Philippine World Health Organization (WHO) Special Initiative for
Mental Health conducted in 2020 showed that ≥3.6 million Filipinos
suffer from at least one kind of mental, neurological, or substance
use disorder (Department of Health, 2020).
 Suicide rates are reported to be at 3.2 per 100,000 population with
higher rates among males (4.3/100,000) than females
(2.0/100,000). However, these numbers may be underreported
because suicide cases may sometimes be misclassified as
“undetermined deaths” (Lally et al., 2019; Martinez et al., 2020).
 WHO estimated that 154 million Filipinos suffer from depression, 1
million from schizophrenia, and 15.3 million from substance use
disorders, while 877,000 die due to suicide every year (Department of
Health, 2018).
 Thus, mental disorders could greatly affect employment and levels of
education, most especially in ages 25 to 52 years (Hakulinen et al.,
2019).

https://www.frontiersin.org/articles/10.3389/fpsyg.2021.706483/full
 The state of mental health
in the Philippines in
summarized in Figure 1
(World Health
Organization—Assessment
Instrument for Mental
Health Systems, 2007;
Department of Health,
2018; Tanaka et al., 2018;
Martinez et al., 2020).

https://www.frontiersin.org/articles/10.3389/fpsyg.2021.706483/full
 Conclusion

• Mental health is changing, presentations are

evolving
• Treatments and thinking around mental illness are
changing
• Challenge is always there.
 SELF-AWARENESS
• is the process by which the nurse gains recognition of his or her own
feelings, beliefs, and attitudes., being aware of one's feelings, thoughts, and
values is a primary focus.
Thank you…
 PSYCHOSOCIAL
THEORIES AND
THERAPY

MINERVA G.MARCIAL,PTRP,RN,MPH
PSYCHOSOCIAL
THEORIES

– This chapter discusses the following types

• Psychoanalytic
• Developmental
• Interpersonal
• Humanistic
• Behavioral
• Existential
PSYCHOSOCIAL
THEORIES

Sigmund Freud :
Psychoanalytic Theory
“Study of the unconscious “
o Stressed on the unconscious
o feelings, ideas, and thoughts
which we are not normally aware
o Repressed sexual desires &
impulses = motivate human
behavior
o His ideas form the basis for
Psychoanalysis
 Deterministic theory

– Psychoanalytic theory
– UNMEET NEEDS
supports the notion that
all human behavior is – Freud concluded that many
caused and can be of their problems resulted
explained ( from childhood trauma or
failure to complete tasks of
– Freud believed that
psychosexual development.
repressed(driven from
conscious awareness)
sexual impulses and
desires motivatemuch
human behavior.
 Personality Structure

www.tetsuccesskey.com
 ID EGO SUPEREGO
 is the part of one’s  superego is the part  ego, is the balancing
nature that reflects of a person’s nature or mediating force
basic orinnate that reflects moral betweenthe id and
desires such as and ethical the superego. The
pleasure-seeking concepts, ego represents
behavior, values,and parental mature and
aggression, and and social adaptive behavior
sexual impulses. expectations; that allows a person
 seeks instant therefore, it is in to function
gratification, causes direct opposition to successfully in the
impulsive the id. world
unthinking behavior,
and has no regard
for rules or social
convention.
 FOR FREUD: PARTS OF THE MIND
Freudian slip
Behavior Motivated by Subconscious
Thoughts and Feelings

– Conscious refers to the perceptions, thoughts, and

emotions that exist in the person’s awareness, such as
being aware of happy feelings or thinking about a loved
one.
– Preconscious thoughts and emotions are not currently in
the person’s awareness, but he or she can recall them with
some effort
– Unconscious is the realm of thoughts and feelings that
motivates a person even though he or she is totally
unaware of them.
PSYCHOANALYSIS

therapy that aims to treat mental disorders by

investigating the interaction of conscious and
unconscious elements in the mind and bringing
repressed fears and conflicts into the conscious
mind by techniques such as dream interpretation
and free association.
– Dream analysis, a primary technique used in
psychoanalysis, involves discussing a client’s dreams to
discover their true meaning and significance
– Free association, in which the therapist tries to uncover the
client’s true thoughts and feelings by saying a word and
asking the client to respond quickly with the first thing that
comes to mind
Five Stages of Psychosexual
Development

– Freud based his theory of childhood development on the

belief that sexual energy, termed libido, was the driving
force of human behavior
– Psychopathology results when a person has difficulty
making the transition from one stage to the next or when a
person remains stalled at a particular stage or regresses to
an earlier stage
Transference and
Countertransference

– Transference occurs when the client displaces onto the

therapist attitudes and feelings that the client originally
experienced in other relationships (Freud, 1923, 1962)

– Countertransference occurs when the therapist displaces

onto the client attitudes or feelings from his or her past.
 www.myinterestingfacts.com

DEVELOPMENTAL THEORY
ERIK ERIKSON
ERIC ERICKSON: Psychosocial
Development

 work on personality development across the life span

while focusing on social and psychological
development in the life stages.
 the person must complete a life task that is essential
to his or her well-being and mental health.
 These tasks allow the person to achieve life’s virtues:
hope, purpose, fidelity, love, caring, and wisdom.
- quality of parent-child relationship
- Children can be disciplined in away that leaves them
feeling loved or being hated.
ERIC ERICKSON: Psychosocial
Development

– Important point:

– children should feel that their own

needs and desires are compatible to
those with society. Only if children feel
comfortable and valuable in their own
eyes and in society’, they will develop a
secure sense of identity.
Erickson’s Eight Ages of Man
Approximate Chronological Developmental Task
Age
Infant Trust vs. Mistrust
Toddler Autonomy vs. Shame and
doubt
Preschool age child Initiative vs. Guilt
School- age child Industry vs. Inferiority
Adolescence Identity vs. Role confusion
Young adult Intimacy vs. Isolation
Adulthood Generativity vs. Stagnation
Maturity Ego integrity vs. Isolation
JEAN PIAGET

www.timetoast.com
JEAN PIAGET :Cognitive
Development

- how intelligence and cognitive functioning develop in children

- human intelligence progresses through a series of stages based
on age

- Biologic changes and maturation

were responsible for development.
 Stages of Cognitive Development
Sensorimotor Pre-operational Concrete Operations Formal Operations

birth-2 yrs. 2- 6 years 6 -12 years 12 -1 5 years &

beyond

Object Express self with children can perform The child learns to
permanence language, learn to a number of logical think
use symbols in word mental operations on and reason in
or mental images; concrete objects, inc. abstract terms,
begins to classify social , apply rules further develops
things logical thinking
and reasoning

Begins to form conservation of Achieves cognitive

mental imges quantity maturity
Main ideas of Piaget:

1. Children progressively develop reasoning

abilities through active involvement with the
environment
2. Children use assimilation and accommodation
to develop reasoning abilities
3. Specific kinds of reasoning abilities and specific
kinds of cognitive limitations are characteristics
of different ages
Interpersonal theory
 Milieu therapy

 Sullivan envisioned the goal of treatment as the

establishment of satisfying interpersonal
relationships.
involved clients’ interactions with one another,
including practicing interpersonal relationship
skills, giving one another feedback about
behavior, and working cooperatively as a group to
solve day-to-day problems.
Milieu therapy was one of the primary modes of
treatment in the acute hospital setting.
HILDEGARD PEPLAU
THERAPEUTIC
NURSE–PATIENT
RELATIONSHIP
– Peplau developed the concept of the therapeutic nurse–
patient relationship, which includes four phases:
– orientation, identification, exploitation, and resolution
HUMANISTIC
THEORIES
ABRAHAM MASLOW

– Maslow hypothesized that the basic needs at

the bottom of the pyramid would dominate
the person’s behavior until those needs were
met, at which time the next level of needs
would become dominant
 CARL ROGERS
Client- centered therapy

– “ Each persons experiences the world

differently and knows his or her own
experience .” (rogers,1961)
– focused on the therapeutic
relationship
– THREE CENTRAL CONCEPT
– Unconditional positive regard
– Genuineness
– Empathetic understanding
 BEHAVIORAL
THEORIES
Behaviorists believe that behavior can be changed
through a system of
rewards and punishments.

IVAN PAVLOV
B.F SKINNER
IVAN PAVLOV
CLASSICAL CONDITIONING

– Behavior can be changed – B.F. SKINNER: OPERANT

through conditioning CONDITIONING
– with external or environmental  people learn their
conditions or stimuli. behavior from their hx.
or past experiences,
particularly those
experiences that were
repeatedly reinforced.
 Behavior modification
 + and – reinforcement
 EXISTENTIAL
THEORIES
Existential theorists believe that behavioral
deviations result when a person is
out of touch with him or herself or the
environment.

All existential therapies have the goal of helping the person

discover an authentic sense of self. They emphasize personal
responsibility for oneself, feelings, behaviors, and choices
EXISTENTIAL THEORIES
 TREATMENT MODALITIES

Self-Help Groups Support groups

share a common purpose

and are expected to
contribute to the group
to benefit others
and receive benefit from understanding how
others in return family dynamics
OPEN contribute to the
CLOSE client’s
psychopathology
– Treatment of mental disorders and emotional problems can
include one or more of the following:

 individual psychotherapy
group psychotherapy
 family therapy
family education psychiatric rehabilitation
 self-help groups support groups, education groups, and other
psychosocial interventions such as setting limits or giving
positive feedback.
Complementary and
Alternative Therapies

– Complementary medicine includes therapies used with

conventional medicine practices (the medical model).
– Alternative medicine includes therapies used in place of
conventional treatment.
– Integrative medicine combines conventional medical
therapy and CAM therapies that have scientific evidence
supporting their safety and effectiveness
– REFER BOX 3.1 Mindfulness-Based Stress Reduction
Psychiatric Rehabilitation

– involves providing services to people with severe and

persistent mental illness to help them to live in the
community.
– community support services or community support programs.
– Psychiatric rehabilitation focuses on the client’s strengths, not
just on his or her illness.
– The client actively participates in program planning.
– are designed to help the client manage the illness and
symptoms, gain access to needed services, and live
successfully in the community.
THANK YOU..
DEFENSE
MECHANISMS
DEFENSE MECHANISM

– Defense Mechanisms
- collection of coping strategies to deal with stress.
- serve as to lower anxiety, maintain ego function &
protect or defend one’s sense of self.
– Characteristics:
1) they are denials or distortions of reality
2) they operate unconsciously
Properties:

1) Major means of managing conflict & affect

2) Relatively unconscious
3) Discrete from one another
4) Although, often hallmarks of major psychiatric
syndromes, defenses are reversible
5) Are adaptive as well as pathological
Category of Defenses

– MATURE
– IMMATURE
– PSYCHOTIC
REFER TO TABLE 3.1
READ AND STUDY : FOR NEXT WEEK
SESSION

I.WHAT IS THERAPEUTIC COMMUNICATION OR

TECHNIQUES?
B. WHAT ARE THE TECHNIQUES IN
 THERAPEUTIC COMMUNICATION
 NON THERAPEUTIC COMMUNICATION

II. NEUROBIOLOGIC THEORIES AND

PSYCHOPHARMACOLOGY
 THERAPEUTIC
COMMUNICATION

Asst. Prof. Minerva G. Marcial ,

PTRP,RN,MPH
 COMMUNICATION

• 3 elements

SENDER
RECEIVER

MESSAGE
 2 TYPES OF COMMUNICATION

• VERBAL

• NON-VERBAL
Verbal Communication
• Terminology/Word Selection
• Voice
• Tone
• Use of Silence
Nonverbal Communication
• Dress And Appearance
• Facial Expression
• Space, Time, Boundaries,
• Body Movements And Posture
• Touch
• Eye Contact
 COMMUNICATION SKILLS

• Know yourself
• Be honest with your feelings
• Be secure in your ability to relate to people
• Be sensitive to the needs of others
• Be consistent
• Recognize symptoms of anxiety
• Watch your non-verbal reactions
• Use words carefully
• Recognize differences
• Recognize and evaluate your own actions and responses
It requires…
Sensitivity to recognize important cues and make
decisions about the priority of these cues.

Objectivity is the process of remaining open to as

many aspects of patient, their problems, and
potential solutions as possible.
• Self-Awareness
Process of understanding one’s own beliefs,
thoughts, motivations, biases, and limitations
and recognizing how they affect others.
 THERAPEUTIC COMMUNICATION
• is an interpersonal interaction between the
nurse and the client during which the nurse
focuses on the client’s specific needs to
promote an effective exchange of information
 GOALS OF TC
• Establish a therapeutic nurse–client relationship.
• Identify the most important client concern at that moment (the client-
centered goal).
• Assess the client’s perception of the problem as it unfolds.
• This includes detailed actions (behaviors and messages) of the people
involved and the client’s thoughts and feelings about the situation, others,
and self.
• Facilitate the client’s expression of emotions.
• Teach the client and family necessary self-care skills.
• Recognize the client’s needs.
• Implement interventions designed to address the client's needs.
• Guide the client toward identifying a plan of action to asatisfying and
socially acceptable resolution.
 Requirements for therapeutic
relationship
• Rapport

• Trust

• Respect

• Genuineness

• Empathy
 Context of Therapeutic
communication
• Values, attitudes, and beliefs
• Culture or religion
• Social status
• Gender
• Age or developmental level
• The environment
• Use of space
• Non verbal- body language
• Communication is the means by which a
therapeutic relationship is
initiated, maintained, and terminated
 Proxemics
• is the study of distance zones between people during
communication.
• Intimate zone (0 to 18 inches between people): This amount
of space is comfortable for parents with young children,
people who mutually desire personal contact, or people
whispering.
• Personal zone (18 to 36 inches): This distance is comfortable
between family and friends who are talking.
• Social zone (4 to 12 feet): This distance is acceptable for
communication in social, work, and business settings.
• Public zone (12 to 25 feet): This is an acceptable distance
between a speaker and an audience, small groups, and other
informal functions (Hall, 1963).
• TOUCH
• ACTIVE LISTENING
– refraining from other internal mental activities and
concentrating exclusively on what the client says.
– ACTIVE OBSERVATION means watching the speaker’s
nonverbal actions as he or she communicates.
– Empathy is the ability to place oneself into the
experience of another for a moment in time
 Active listening and observation help
the nurse to
• Recognize the issue that is most important to the
client at this time.
• Know what further questions to ask the client.
• Use additional therapeutic communication
techniques to guide the client to describe his or her
perceptions fully.
• Understand the client’s perceptions of the issue
instead of jumping to conclusions.
• Interpret and respond to the message objectively
 concrete messages
Abstract messages,
 THERAPEUTIC COMMUNICATION
TECHNIQUES
• Using silence
• Accepting
• Giving recognition
• Offering self
• Giving broad openings
• Offering general leads
• Placing the event in time or sequence
•Reflection of feelings
•Paraphrasing
•Silence
•Validation
•Active Listening
•Asking direct questions
•Summarizing
 Non therapeutic communication
techniques
• Giving reassurance • Responses such as “Everything
will work out”
• Rejecting • “Maybe tomorrow will be a
• Approving or better day” may be intended to
comfort the client, but instead
disapproving may impede the communication
• Agreeing or disagreeing process.
• Giving advice • Asking “why” questions (in an
effort to gain information) may be
• Probing perceived as criticism by the
client, conveying a negative
• Defending judgment from the nurse.
• Requesting an
explanation
 Non therapeutic communication
techniques
• Indicating the existence of an external source of
power
• Belittling feelings expressed
• Making stereotyped comment, clichés, and trite
expressions
• Using denial
• Interpreting
• Introducing an unrelated topic
 Listening to the patient
• S-sit squarely facing the • Interpreting Signals or Cues
(overt and covert)
client • Overt cues are clear, direct
statements of intent, such
• O-observe an open posture
as “I want to die.”
• L-lean forward toward the • The message is clear that
the client is thinking of
client suicide or self-harm.
• E-establish eye contact • Covert cues are vague or
indirect messages that
• R-relax need interpretation
• Understanding the context of communication is extremely
important in accurately identifying the meaning of a message

• Understanding spirituality

• Cultural consideration
• Barriers to Effective communication:
Ineffective communication skills
Failure to listen
Lack of regard or respect for the
patient
Conflicting verbal and non verbal
messages
A judgmental attitude
Changing the subject
Inability to receive information because
of preoccupied or impaired thought
process
 HELPFUL ADVICE
Speak briefly
When you don’t know what to say , say
nothing
When in doubts focus on feelings
Avoid advice
Avoid relying on questions
Pay attention to non verbal cues
Keep the focus to the client
 DO NOT !!!!!
 Argue, minimize or challenge the client
 Praise the client, give false reassurance
 Interpret to the client
 Question the client about sensitive areas
 Try to sell the client on accepting treatment
 Join the attacks the client launches on his/her mate
 Participate in criticism of another nurse or staff
 Conclusion
• Effective communication is the core skill in
mental health care in primary care settings
• Self-awareness and ability to collaborate with
other health care providers are also skills that
will facilitate accurate inquiry into the
patients true concerns and the context in
which they occur.
 “

“Kind words are like honey sweet

to the SOUL and healthy for the
BODY .”
PSYCHOPHARMACOLOGY
Asst. Prof. Minerva G. Marcial, PTRP,RN,MPH
• Is the subspecialty of pharmacology that includes
medications affecting the brain and behaviors
used to treat psychiatric disorders.
• PHARMACODYNAMICS
• PHARMACOKINETICS

PSYCHOPHARMACOLOGY
Routes
• A drug’s route of administration affects
the rate and extent of absorption of
that drug.
– Enteral
– Parenteral
– Topical
Pharmacokinetics:Absorption
Enteral Route
• Drug is absorbed into the systemic
circulation through the oral or gastric
mucosa, the small intestine, or rectum.
– Oral
– Sublingual
– Buccal
– Rectal
Drug Absorption of Various Oral
Preparations
Liquids, elixirs, syrups Fastest
Suspension solutions 🡻
Powders 🡻
Capsules 🡻
Tablets 🡻
Coated tablets 🡻
Enteric-coated tablets Slowest
PHARMACOKINETICS:
ABSORPTION

Parenteral Route
• Intravenous*
• Intramuscular
• Subcutaneous
• Intradermal
• Intrathecal
• Intra-articular
*Fastest delivery into the blood circulation
Pharmacokinetics: Absorption
Topical Route
• Skin (including transdermal patches)
• Eyes
• Ears
• Nose
• Vagina

• Lungs (inhalation)
• Psychotherapeutic medications DO
NOT cure mental illness, but they
do lessen its burden.

▪ Like any medication, psychotherapeutic

medications do not produce the same effect in
everyone.
Some people may respond better to one
medication than another.

Some may need larger dosages than others

do.
Common Side Effects of Psychiatric
Medications
■ Dermatitis
• Blurred Vision ■ Postural hypotension
■ Impaired psychomotor
• Dry Eyes functions
• Dry mouth and lips ■ Drowsiness
• Constipation ■ Weight gain
■ Edema
• Urinary hesitancy or
retention ■ Irregular menstruation
■ Amenorrhea
• Nasal congestion
■ Vaginal dryness
• Sinus tachycardia ■ Sedation
• Decreased libido and
inhibition of ejaculation
• photosensitivity
Main classification of psychotropics drugs
ANTIPSYCHOTIC
Neuroleptics

MOOD
ANTIDEPRESSANT STABILIZERS

ANTIANXIETY STIMULANTS
 TERMS refer to our textbook
• Efficacy
• Potency
• Half life
• Black-box warning
• Tapering
• Rebound
• Withdrawal
• Off –label use
• Tolerance
 – Conventional (D2, D3, and D4)
– Atypical (D2)
– New generation /3RD generation
• psychosis, such as the delusions and hallucinations seen in
schizophrenia, schizoaffective disorder, and the manic phase of
bipolar disorder
• It may take 2-4 weeks to see improvement
• Mechanism of action
• Blocks receptors (D1,D2,D3,D4,D5)of neurotransmitter
dopamine

ANTIPSYCHOTIC DRUGS
ADMINISTRATION

• oral, in liquid or pill form, or by injection (depot)

• CHECK Table 2.3 lists available dosage forms, usual daily

oral dosages, and extreme dosage ranges for conventional
and atypical antipsychotic drugs.
ANTIPSYCHOTIC DRUGS
CONVENTIONAL ATYPICAL NEW GENERATION
Chlorpromazine Clozapine Aripirazole
( Thorazine) (Clozaril) (Abilify)
Thioridazine Respiridone
(Mellaril) (Risperdal)
Mesoderazine Olanzapine
( Serentil) (Zyprexa)

Haloperidol Qeutiapine
(Haldol) ( Seroquel)
Molindone Paliperidone
(Moban) (Invega)

X: CARDIAC ARREST X: ELDERLY DEMETED

CARDIAC Pt.
DYSRHYTMIAS
ANTIPSYCHOTIC DRUGS
• SIDE EFFECTS:
• EPS – serious neurologic sx. ( akathisia, acute dystonia , pseudo
parkinsonism

• ANTICHOLINERGIC
• TARDIVE DYSKINESIA
• NEUROLEPTIC MALIGNANT SYNDROME
– rigidity; high fever; autonomic instability such as unstable blood
pressure, diaphoresis, and pallor; delirium; and elevated levels of
enzymes creatine phosphokinase
– D/C OF MEDS.
• BREAST ENLARGEMENT AND TENDERNESS IN MEN AND
WOMEN
• DIMINISHED LIBIDO, ERECTILE AND ORGASMIC DYSFUNCTION
• MENSTRUAL IRREGULARITIES
• INCREASED RISK FOR BREAST CANCER
• WEIGTH GAIN
• Most antipsychotic drugs cause relatively minor cardiovascular adverse
effects such as postural hypotension, palpitations, and tachycardia.
• Certain antipsychotic drugs, such as thioridazine (Mellaril), droperidol
(Inapsine), and mesoridazine (Serentil), can also cause a lengthening of
the QT interval

Other Side Effects.

 ANTI-DEPRESSANTS
DRUGS
Researchers believe that the actions of these drugs
are an “initiating event” and that eventual therapeutic effectiveness
results when neurons respond more slowly, making serotonin
available at the synapses (Burchum & Rosenthal, 2018).
ANTI-DEPRESSANTS
• Indications:
• Major depressive illness
• Anxiety disorders
• Depressed phase of bipolar disorder
• Psychotic depression
INTERACT WITH NOREPINEPHRINE AND
SEROTONIN
3 CLASSIFICATIONS

TCA

OTHER ANTIDEPRESSANTS

SSRI MAOI
MECHANISM OF ACTION
• MAO’S need 2-4 weeks to be effective
ENZYME METABOLISM
• TCA’S need 4-6 weeks..
NOREPINEPHRINE AND SEROTONIN
• SSRI’S need 2-3 weeks.. S
SEROTONIN

• If no improvement is seen after a trial of adequate

length (at least 2 months) and adequate dose, either
switch to another antidepressant or augment with
another agent.
 SSRIs, venlafaxine, nefazodone, and bupropion are often
bette choices for those who are potentially suicidal or highly
impulsive because
they carry no risk of lethal overdose

CHECK THE LISTOF DRUGS

FOR ANTIDEPRESSANTS
 TCA’s
▪ Taken at bedtime
▪ I : Used to tx.symptoms of depression insomia, decreased
appetite, dec. libido, excessive fatigue, feeling of worthlessness..
▪ SE:anticholinergic effects such as dry mouth, constipation, urinary
hesitancy or retention, dry nasal passages, and blurred near vision.
▪ More severe anticholinergic effects: agitation, delirium, and ileus may occur,
particularly in older adults.
▪ Other common side effects:orthostatic hypotension, sedation, weight gain, and
tachycardia

▪ CONTRINDICATIONS:
Pregnant or lactating women
Person recovering from MI
Person who have severe kidney or liver disease
TCA Generic (Trade) Name
– Amitriptyline ( Amitril, Elavil, Endep)
– Doxepin ( Sinequan, Adapin)
– Imiprmanine ( Tofranil)
– Clomipramine ( Anafranil)
– Amoxapine ( Ascendin)
– Trimipramine ( Surmontil)
– Protiptyline ( Vivactil)
 MAOI’S
*MA: Acts by blocking reuptake of NE and serotonin in CNS.

*SE: daytime sedation, insomnia, weight gain, dry mouth, orthostatic

hypotension, and sexual dysfunction

▪ Serotonin syndrome (or serotonergic syndrome) can result from

taking an MAOI and an SSRI at the same time
▪ agitation, sweating, fever, tachycardia, hypotension, rigidity, hyperreflexia,
and, in extreme reactions, even coma and death (Burchum & Rosenthal,
2018)

Most serious side effect - interaction with tyramine-rich food and certain
medications.

Hypertensive Crisis *
Results to severe headaches and hypertension, stroke, hyperpyrexia, tachycardia
,tremulousness, cardiac dysrhythmias
even death..
 MAOI’s
Examples :
• Phenelzine (Nardil)
• Tranylcyopromine (Parnate)
• Isocarboxazid ( Marplan)

• MAOIs cannot be given in combination with other

MAOIs, tricyclic antidepressants, meperidine
(Demerol), CNS depressants, many
antihypertensive, or general anesthetics.
• potentially lethal in overdose and pose a potential
risk in clients with depression
 MAOI’s contraindications
• pregnancy Drugs with fatal
Interaction:
• Congestive heart failure ▪ Buspirone
• Hypertension ▪ Dextromethorpan
• Asthma ▪ Meperidine
• Cardiovascular disease
• Liver disease
• Alcoholism
• Glaucoma
• Impaired kidney function
• Patients over 60 y.o and
• children under age 16
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRI’S)
MA:
▪ SSRIs block the reabsorption (reuptake) of the
neurotransmitter serotonin in the brain.
▪ Changing the balance of serotonin seems to help
brain cells send and receive chemical messages,
which in turn boosts mood.
▪ SSRIs are called selective because they seem to
primarily affect serotonin, not other
neurotransmitters.
SSRI
▪ Frequently causes more energy and are often give in the
morning.
▪ SE: anxiety, agitation, akathisia (motor restlessness), nausea,
insomnia, and sexual dysfunction, specifically diminished
sexual drive or difficulty achieving an erection or orgasm.
▪ Less common side effects include sedation (particularly with
paroxetine[Paxil]), sweating, diarrhea, hand tremor, and headaches.
▪ Examples
• Flouxetine (Prozac)
• Fluvoxamine (Luvox)
• Sertraline (Zoloft)
• Paroxetine (Paxil)
• Citalopram (Celexa)
MOOD STABILIZERS DRUGS
• Indications:
• Bipolar, cyclothymia
• Schizoaffective
• impulse control and intermittent explosive disorders.
• Examples :
• Lithium – Most established mood stabilizer
• Anticonvulsants
• Valproic acid (Depakote,Depakene)
• Carbamazepine (Tegretol)
• Lamotgrine (Lamictal)

MOOD STABILIZERS
MECHANISM OF ACTION

• LITHIUM – normalizes the reuptake of Serotonin, NE,E, ACTH,

Dopamine.
– Only medication to reduce suicide rate
– Effective in long-term prophylaxis of both mania and depressive
episodes
– Dosage; 900-3600mg daily
– Serum Lithium; about 1.0 mEq/L
– LESS THAN 0.5 mEq/L – rarely therapeutic
– MORE THAN 1.5 mEq/L - toxic

• VALPROIC ACID- increase level of GABA.

• Side effects:

• Valproic acid and carbamazepine

• drowsiness, dry mouth, blurred vision, rashes ,orthostatic
hypotension, Weight gain , alopecia, hand tremor

• Topiramate causes dizziness, sedation,

• weight loss (rather than gain), and increased incidence of renal calculi (Burchum
& Rosenthal, 2018).
• Lithium
– mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia,
polyuria, a metallic taste in the mouth, and fatigue or lethargy.
– Weight gain and acne
– Toxic effects of lithium are severe diarrhea, vomiting, drowsiness,
muscle weakness, and lack of coordination.
– Renal failure, coma ,death
ANTI-ANXIETY AGENTS
TWO GENERAL CATEGORIES:
• BENZODIAZEPINES
• NON- BENZODIAZEPINES
• Drugs that are classified as sedative-hypnotics are used
both to relax the patient and to promote sleep.
• As the name “sedative” implies, these drugs exert a
calming effect and serve to pacify the patient.
• Sedative-hypnotic and antianxiety drugs are among the
most commonly used drugs worldwide.
• many patients receiving physical therapy and
occupational therapy take sedative-hypnotic and
antianxiety agents to help promote sleep and decrease
anxiety.
 Mechanism of action:
• The benzodiazepines exert their effects by increasing the
inhibitory effects at CNS synapses that use the
neurotransmitter gamma-aminobutyric acid (GABA).
• By increasing the inhibitory effects at GABAergic
synapses located in the reticular formation,
benzodiazepines can decrease the level of arousal in the
individual.
• In other words, the general excitation level in the reticular
activating system decreases, and relaxation and sleep
are enhanced.
• Benzodiazepine and nonbenzodiazepine
sedative hypnotics are usually highly lipid
soluble.
• They are typically administered orally and
are absorbed easily and completely from
the gastrointestinal tract.
Benzodiazepines also seem to increase inhibition in the spinal cord,
which produces some degree of skeletal muscle relaxation, which
may contribute to their antianxiety effects by making the individual
feel more relaxed.
 Side effects Benzodiazepines
❑ Physical & psychological dependence
❑ Discontinuation syndrome
❑ Hang –over effect *
❑ CNS depression
❑ Drowsiness, sedation , poor coordination , impaired memory(
anterograde amnesia) , clouded sensorium
❑ GIT discomfort
❑ Cardiovascular and respiratory depression

NONBENZODIAZEPINES
Dizziness, sedation , nausea, headache
Nonbenzodiazepines
Barbiturates
• very addictive, and their prolonged use is often
a problem in terms of drug abuse.
NONBENZODIAZEPINE
 • Used to tx. Psychiatric disorders for their
pronounced effects on CNS stimulation (1930’s)
• Depression and obesity
• Primary use today : ADHD in children and
adolescents, narcolepsy, residual attention deficit
disorder in adults

Potential for abuse is high. Prolonged administration may lead to

drug dependence

STIMULANTS: AMPHETAMINES
 STIMULANTS
• Dextroamphetamine ( Dexedrine)
• Widely abused to produce a high remain
awake from long periods of time
• Ritalin , Adderall, Dexedrine : ADHD

• SIDE EFFECTS:
– anorexia, weight loss, nausea, irritability,
dizziness, dry mouth, blurred vision ,
palpitation, weight and growth
suppression occurs in children
– The client should avoid caffeine, sugar,
and chocolate, which may worsen these
symptoms
DISULFRAM ( ANTABUSE)
• Disulfiram inhibits the enzyme aldehyde dehydrogenase
• only use is as a deterrent to drinking alcohol in persons
receiving treatment for alcoholism.

• 5-10 minutes after taking the agent:

– Facial and body flushing , throbbing headache , sweating , dry
mouth , nausea , vomiting , dizziness , weakness , fatigue,
drowsiness, halitosis, tremor , impotence
– Severe; chest pain , dyspnea, severe hypotension , confusion,
death
– Last from 30 minutes -2 hours.
https://globalpharmacystore.com/catalog/Other/Antabuse.htm

• Avoid : shaving cream , after shave, cologne , deodorant,

OTC that contains alcohol.
• Acamprosate (Campral) is sometimes prescribed for
persons in recovery from alcohol abuse or dependence.
BETA-ADRENORECEPTOR
BLOCKERS
• Beta blockers, effective in alleviating somatic
manifestation of anxiety caused by sympathetic
arousal, such as palpitations, tremor, sweating &
diarrhea
• I: patients w predominantly somatic symptoms🡪
prevent worry & fear; no benefit for those with
predominant psychological symptoms.
🡻 useful in social phobias & to reduce
performance anxiety in musicians.
• CI: should not be used in patients with
asthma and heart failure
✔ a slow heart rate
✔ a serious heart condition such as "sick
sinus syndrome" or "AV block" (unless you
have a pacemaker)
✔ allergic to propranolol

BETA-ADRENORECEPTOR
BLOCKERS
GUIDELINES: ANTI-ANXIETY
MEDICATIONS
• Instruct client/family not to increase the dose or
frequency of meds without prior approval from doctor.
Benzodiazepines can be addictive!
• Explain that these medications reduce the ability to
handle mechanical equipment such as cars, saws, and
other machineries.
• Advise client to avoid alcoholic beverages & taking
other anti-anxiety drugs.
• Instruct client to avoid beverages that contain caffeine
because it decreases the desired effects of the drug.
 GUIDELINES: ANTI-ANXIETY MEDICATIONS

• Advise female clients to inform doctor immediately is

pregnancy occurs.
BNZ can increase the risk of congenital anomalies!
• Advise new mothers taking these drugs not to breastfeed
infants. BNZ are excreted in the milk and can have serious
side effects on infants.
• Caution client & family to avoid stopping BNZ abruptly
after 3-4 months of daily use because may cause
withdrawal symptoms. The drug has to be tapered down.
• If client is elderly, lower doses are often considered for
elderly clients
CULTURAL CONSIDERATIONS
• African Americans responded more rapidly to antipsychotic medications and
tricyclic antidepressants than did white people and had a greater risk for
developing side effects from both these classes of drugs
• Asians metabolized antipsychotics and tricyclic antidepressants more slowly than
did white people and therefore required lower dosages to achieve the same
effects

•HERBAL MEDICINES
• John’s Wort – depression
• Kava - anxiety
• Valerian- produce sleep, relieve stress & anxiety
• Ginkgo biloba - improve memory, fatigue, anxiety, and depression.
Reference:
• Psychiatric–Mental Health Nursing,8th Ed.
—Sheila L. Videbeck
Thank you!!!
 ANXIETY, ANXIETY
DISORDERS, AND
STRESS-RELATED ILLNESS

MINERVA G. MARCIAL, PTRP,RN,MPH

Learning Objectives

I. Describe anxiety as a response to stress.

II. Describe the levels of anxiety with
behavioral changes related to each level.
III. Describe the current theories regarding
the etiologies of major anxiety disorders
IV. Describe the other disorders that include
excessive anxiety.
 Anxiety inte exter
rna nal
l st
imu
li

IS A VAGUE FEELING of dread or

apprehension

feeling afraid or threatened by a

clearly identifiable external
stimulus that represents
danger to the person.
 ANXIETY AS A RESPONSE TO STRESS
• Stress is the wear and tear that life causes on the body. (Selye,
1956)
• difficulty dealing with life situations, problems, and goals.
• Factors for stress
– Marriage, children, airplanes, snakes, a new job, a new school, and leaving
home ,internship…. etc.
TYPES OF STRESS
• Eustress (good) – arises in any situation or
circumstances that a person finds motivation and
inspiring.
• Neustress ( neutral) – a sensory stimuli that have no
consequential effect
• Distress ( bad) – when the arousal is too high or too
low
Types of Stress according to duration
• Acute stress
- type of stress that comes immediately , quite intense & disappears
quickly
- short term

• Chronic stress
- not intense but linger for prolonged periods of time
Three Stages Of Reaction To Stress:
(Selye, 1956).

- Stages:
▪ Alarm reaction –prepare for potential
defense needs

▪ Stage of resistance –fight 0r flight

reaction, homeostatic state

▪ Stage of exhaustion - cannot meet

the demands and fail to function
proper
• ANXIETY
Uncomfortable cognitive, psychomotor,
and physiologic responses, such as
difficulty with logical thought, increasingly
agitated motor activity, and elevated vital
signs

- VERBALLY AND NONVERBALLY

• Adaptive behaviors/defense mechanisms
Adaptive behaviors can be positive and help the person to learn, for example, using
imagery techniques to refocus attention on a pleasant scene, practicing sequential
relaxation of the body from head to toe, and breathing slowlyand steadily to reduce
muscle tension and vital signs.

– Positive response

– Negative responses
LEVELS OF ANXIETY

Panic-level anxiety is not sustained indefinitely but can last from 5–30 minutes.
• Mild anxiety is a sensation that
something is different and warrants special
attention
• Moderate anxiety is the disturbing feeling
that something is definitely wrong; the
person becomes nervous or agitated.
• Severe/panic anxiety more primitive
survival skills take over, defensive
responses ensue, and cognitive skills
decrease significantly
WHAT TO DO? • I. TEACH
• II. GUIDE
• III. REMAIN
• IV. SAFETY

• WHAT TO GIVE?
• ANXIOLYTIC DRUGS
– Check :Table 14.2
– Benzodiazepines
– Nonbenzodiazepines
ANXIETY DISORDERS

• Agoraphobia with or without panic disorder

• Panic disorder
• Specific phobia
• Social phobia
• OCD
• Generalized anxiety disorder (GAD)
• Acute stress disorder
• Posttraumatic stress disorder
• Anxiety disorders have many manifestations, but anxiety is the
key feature of each (American Psychiatric Association [APA],
2000).
• INCIDENCE: highest prevalence rates of all mental disorders in
the United States
- >in women, younger than age 45,divorced or separated, lower
socioeconomic status

• ONSET AND CLINICAL COURSE : extremely variable

• RELATED DISORDERS
– Selective mutism
– Anxiety disorder due to a general medical condition
– Substance-induced anxiety disorder
– Separation anxiety disorder
 GENETIC THEORIES

–Heritability
– First degree relatives of clients with increased
anxiety have higher rates of developing anxiety.

– Panic disorder and social and specific phobias,

including agoraphobia, have moderate heritability

– GAD and OCD common in families

 NEUROCHEMICAL THEORIES
• Gamma-aminobutyric acid (-aminobutyric acid [GABA])
• GABA reduces anxiety and norepinephrine increases it,
researchers believe that a problem with the regulation of
these neurotransmitters occurs in anxiety disorders.
• Serotonin - OCD, panic disorder, and GAD
• Norepinephrine – EXCESS, is suspected in panic disorder,
GAD, and posttraumatic stress disorder (Feder, Costi,
Murrough, & Charney, 2017)
 Psychodynamic Theories

•Freud - Intrapsychic / Psychoanalytic Theories

•Harry Stack Sullivan – Interpersonal Theory

•Hildegard Peplau –exist in interpersonal and

physiological realms ,4 levels of anxiety
 Behavioral Theory
•Behavioral theorists view anxiety as being learned
through experiences.
•People can change or “unlearn” behaviors
through new experiences
CULTURAL CONSIDERATIONS
• ASIANS
– express anxiety through somatic symptoms such as headaches, backaches,
fatigue, dizziness, and stomach problems.

• KORO or a man’s profound fear that his penis will retract into the
abdomen and he will then die.
– forms of treatment include having the person firmly hold his penis until the fear
passes, often with assistance from family members or friends, and clamping the
penis to a wooden box.

• In women, koro is the fear that the vulva and nipples will disappear
((Dan, Mondal, Chakraborty, Chaudhuri, & Biswas, 2017)
CULTURAL CONSIDERATIONS
• HISPANICS

– SUSTO
– cases of high anxiety, sadness, agitation, weight loss, weakness,
and heart rate changes.
• supernatural spirits or bad air from dangerous places and
cemeteries invades the body.
 TREATMENT
MEDICATION AND THERAPY
Table 14.3.
Cognitive–behavioral therapy

Positive reframing turning negative

messages into positive messages.

Antidepressants

Decatastrophizing Assertiveness training

the therapist’s use of questions Techniques help the person
to more realistically appraise the situation negotiate interpersonal situations and
foster self- assurance.
https://www.apa.org/ptsd-guideline/patients-and-fa
milies/cognitive-behavioral.pdf
 TIPS FOR MANAGING STRESS
• Keep a positive attitude and believe in
yourself.
• Accept there are events you cannot control.
• Communicate assertively with others: talk
about your feelings to others and express
your feelings through laughing, crying, and
so forth.
• Learn to relax.
• Exercise regularly.
• Eat well-balanced meals.
• Limit intake of caffeine and alcohol.
• Get enough rest and sleep.
• Set realistic goals and expectations and find
an activity that is personally meaningful.
• Learn stress management techniques, such
as relaxation, guided imagery, and
meditation
PANIC DISORDER
• is composed of discrete episodes of
panic attacks, that is, 15 to 30 minutes of
rapid, intense, escalating anxiety in which
the person experiences great emotional
fear as well as physiologic discomfort
• 4> of the symptoms
• palpitations, sweating, tremors, shortness
of breath, sense of suffocation, chest
pain, nausea, abdominal distress,
dizziness, paresthesia's, chills, or hot
flashes.
• PANIC DISORDER dx. When the person has
recurrent, unexpected panic attacks followed by at
least 1 month of persistent concern or worry about
future attacks or their meaning or a significant
behavioral change related to them
• More common in people who have not graduated
from college and are not married.
• suicidal ideation prevalent in 17% to 32% of those
with panic disorder, while one-third had a history of
suicide attempts (De La Vega, Giner, & Courtet,
2018).
Onset of panic disorder peaks in late
adolescence and the mid-30s.
• Avoidance behavior
• Concepts of primary and secondary gain
• PRIMARY GAIN

• SECONDARY GAIN
Treatment

• Cognitive–behavioral techniques (CBT)

• Deep breathing and relaxation
• Medications
– Benzodiazepines
– SSRI antidepressants
– Tricyclic antidepressants
– antihypertensives such as clonidine (Catapres) and
propranolol (Inderal).

• Tool : Hamilton Rating Scale for Anxiety

Managing Anxiety
• Relaxation techniques
• Deep breathing
• Guided imagery and progressive relaxation
• Cognitive restructuring techniques
PHOBIAS
 PHOBIAS
• is an illogical, intense, and persistent fear of a
specific object or a social situation that causes
extreme distress and interferes with normal
functioning.
• People with phobias have a reaction that is out of
proportion to the situation On circumstance.
Some individuals may even recognize that their
fear is unusual and irrational but still feel
powerless to stop it (Kimmel & Roy-Byrne, 2017).
 PHOBIAS
• The diagnosis of a phobic disorder is made only when the phobic
behavior significantly interferes with the person’s life by creating
marked distress or difficulty in interpersonal or occupational
functioning.

• childhood or adolescence
• The peak age of onset for social phobia is middle adolescence
• course of social phobia is often continuous
 Specific phobias are subdivided into the
following categories:

• Natural environmental phobias: fear of storms, water, heights, or other

natural phenomena
• Blood-injection phobias: fear of seeing one’s own or others’ blood,
traumatic injury, or an invasive medical procedure such as an injection
• Situational phobias: fear of being in a specific situation such as on a bridge
or in a tunnel, elevator, small room, hospital, or airplane
• Animal phobia: fear of animals or insects (usually a specific type; often this
fear develops in childhood and can continue through adulthood in both men
and women; cats and dogs are the most common phobic objects)
• Other types of specific phobias: fear of getting lost while driving if not
able to make all right (and no left) turns to get to one’s destination
According to the Child Anxiety
Network: extremely common and
considered normal

•0-2 years
•Loud noises, strangers, separation from parents, large
objects

•3-6 years
•Imaginary things such as ghost, monsters, the dark,
sleeping alone, strange noises

•7-16 years
•More realistic fears such as injury, illness, school
performance, death, natural disasters
When to seek treatment?
• It causes intense & disabling fear, anxiety
and panic
• You recognize that your fear is excessive
and unreasonable
• You avoid certain situation & places
• Your avoidance interferes with your normal
routine or causes significant
• You've have phobia for at least six months
distress
Treatment
• Medications 14.3 DRUGS USED TO TREAT ANXIETY
DISORDERS
• Behavioral therapy
– Positive reframing ,assertiveness
– Systematic (serial) desensitization
– progressively exposes the client to the threatening object
– Flooding is a form of rapid desensitization in which a
behavioral therapist confronts the client with the
phobic object
 OBSESSIVE-COMPULSIVE DISORDER
(OCD)
• characterized by repetitive thoughts and/or behaviors,
such as OCD, can be grouped together and described in
terms of an obsessive–compulsive spectrum.
• The spectrum approach includes repetitive behaviors of
various types:
– self-soothing behaviors, such as trichotillomania,
dermatillomania, or onychophagia;
– reward-seeking behaviors, such as hoarding, kleptomania,
pyromania, or oniomania;
– disorders of body appearance or function, such as body
dysmorphic disorder (BDD).
ETIOLOGY
• The cognitive model describes the person’s thinking as :
• (1) believing one’s thoughts are overly important
• (2) perfectionism and the intolerance of uncertainty
• (3) inflated personal responsibility (from a strict moral or religious
upbringing) and overestimation of the threat posed by one’s
thoughts.
 OBSESSIVE-COMPULSIVE DISORDER (OCD)

• Obsessions are recurrent, persistent, intrusive, and unwanted

thoughts, images, or impulses that cause marked anxiety and
interfere with interpersonal, social, or occupational function.
• Compulsions are ritualistic or repetitive behaviors or mental acts
that a person carries out continuously in an attempt to neutralize
anxiety.
ONSET:
• OCD can start in childhood, especially in males.
• females, it more commonly begins in the 20s.
• Onset is usually gradual

Eighty percent
of those treated with behavior therapy and medication
report success in managing obsessions and
compulsions, whereas 15% show progressive deterioration
in occupational and social functioning
(APA,2000).
 Common compulsions
• Checking rituals (repeatedly making sure the door is locked or the
coffee pot is turned off)
• Counting rituals (each step taken, ceiling tiles, concrete blocks, or
desks in a classroom)
• Washing and scrubbing until the skin is raw
• Praying or chanting
• Touching, rubbing, or tapping (feeling the texture of each material
in a clothing store; touching people, doors, walls, or oneself)
• Hoarding items (for fear of throwing away something important)
• Ordering (arranging and rearranging furniture or items on a desk or
shelf into perfect order; vacuuming the rug pile in one direction)
• Exhibiting rigid performance (getting dressed in an unvarying
pattern)
• Having aggressive urges (for instance, to throw one’s child against
a wall).
WHAT TO OBSERVED?
• tense, anxious, worried, and fretful.
• ongoing, overwhelming feelings of anxiety
• difficulty concentrating or paying attention when obsessions are
strong
• can make sound judgments, cant act on them
• Feelings of powerlessness to control the obsessions or compulsions
contribute to low self-esteem.
• OCD may have trouble sleeping.
• loss of appetite or unwanted weight loss
• severe cases, personal hygiene may suffer because the client
cannot complete needed tasks.
WHEN TO DIAGNOSED?
• OCD is diagnosed only when these thoughts, images, and
impulses consume the person or he or she is compelled to act out
the behaviors to a point at which they interfere with personal,
social, and occupational function.
• Tool
Treatment
• Combines medication SSRI,antipsychotic and behavior therapy.
– exposure and response prevention

– Exposure involves assisting the client to deliberately confront the

situations and stimuli that he or she usually avoids.

– Response prevention focuses on delaying or avoiding

performance of rituals.

–CHECK AND ANSWER :Yale-Brown

Obsessive–Compulsive Scale. Box 15.1
 • Using Therapeutic Communication
• Teaching Relaxation and Behavioral
Techniques

To manage anxiety and ritualistic behaviors, a baseline

of frequency and duration is necessary. The client can
keep a diary to chronicle situations that trigger
obsessions, the intensity of the anxiety, the time spent
performing rituals, and the avoidance behaviors.
GENERALIZED ANXIETY DISORDER

• worries excessively and feels highly anxious at least 50% of the

time for 6 months or more.
• SYMPTOMS: 3+ symptoms
– uneasiness, irritability, muscle tension, fatigue, difficulty thinking,
and sleep alterations.
• Buspirone (BuSpar) and SSRI antidepressants are the most
effective treatments (Starcevic, 2006).
POSTTRAUMATIC-STRESS DISORDER (PTSD)
• is a disturbing pattern of behavior demonstrated by someone who
has experienced, witnessed, or been confronted with a traumatic
event such as a natural disaster, combat, or an assault
• symptoms occur 3 months or more after the trauma

• Tool: BOX 13.1 Life Events Checklist Box

• Box 13.2 is the PTSD Checklist that details many of the symptoms
people experience.
Posttraumatic-Stress Disorder (PTSD)

• The person experienced, witness or

confronted with an event that involved
actual, threatened death to self or other,
responding in fear, helplessness or horror
• The event is persistently re-experienced by:
a) Recurrent intrusive recollections of the
event, including images, thoughts or
perceptions
b) Distressing dreams or images
c) Reliving the event thru flashback, illusions,
hallucinations
Posttraumatic-Stress Disorder (PTSD)

• PTSD can occur at any age, including during childhood

• Victims of rape have one of the highest rates of PTSD at
approximately 70% (Shalev & Marmar, 2017).
• sleep difficulties, hypervigilance, thinking difficulties, severe startle
response, and agitation (APA, 2000)

• TREATMENT:
• Counseling or therapy
• Medication
Management for Patients with Anxiety Disorders
• Counseling
• Milieu Therapy
• Self-Care Activities
• Psychopharmacology
• Alternative & Complimentary Therapies
• Exposure therapy
Any COMMENTS ,REACTIONS,QUESTION ?

• Include in your readings the

•Trauma and stressors related disorders

•OCD
SCHIZOPHRENIA
MINERVA G. MARCIAL,PTRP,RN , MPH
Learning Objectives

1. Discuss various theories of the etiology of

schizophrenia.
2. Describe the positive and negative symptoms
of schizophrenia.
3. Describe a functional and mental status
assessment for a client with schizophrenia.
 History

Greek roots Schizo ( spilt) and phrene ( mind)

Written description about schizophrenia have been
traced back to Egypt during the year 200 BC.
Greek physicians blamed delusions and paranoia on
imbalance of bodily humors.
Hippocrates believed that insanity was caused by
morbid state of the liver.
18th century understanding between nerves and organs,
CNS were the cause of insanity.
EMIL KRAEPELIN
Psychiatrist *
founder of modern scientific psychiatry, as
well as of psychopharmacology and
psychiatric genetics
Born: February 15, 1856, Neustrelitz
Died: October 7, 1926, Munich,.
Eugen Bleuler
Psychiatrist
Swiss psychiatrist most notable for his contributions
to the understanding of mental illness and for
coining the terms "schizophrenia", "schizoid",
"autism",
positive & negative symptoms
Born: April 30, 1857, Zollikon
Died: July 15, 1939, Zürich
 Bleuler’s 4 A’s:
Affective disturbance – person’s inability to show
appropriate emotional responses
Autistic thinking – a thought process in which the
individual is unable to relate to others or to the
environment
Ambivalence – refers to contradictory or opposing
emotions, attitudes, ideas, or desires for the same
person, thing or situation.
Looseness of association – the inability to think
logically. Ideas have little (if any) connection and
shift from one subject to another
 SCHIZOPHRENIA

Is considered the most common and disabling of

the psychotic disorders.
Chronic syndrome deteriorating course
Impairs self-awareness
Has been Linked to violence
 EPIDEMIOLOGY
Affects all races
More prevalent in in MEN than in women
Occurs twice as often in people who are unmarried
or divorced
Lower socioeconomic groups
Approx. 50% have substance –abuse disorder
(Sullivan,2004)
approx,. 2.2 million people ,or 1% of the earth’s
population ,suffer from Schizophrenia and
Schizophrenic-like disorders
 GENDER & AGE

Onset: occurs late in adolescence or early

childhood, before the age of 30.
The prevalence is estimated at about 1% of the
total population in the United States
“The region with the highest prevalence rate is
Southern Tagalog at 132.9 cases per 100,000
population, followed by NCR at 130.8 per 100,000
population and Central Luzon at 88.2 per 100,000
population,” the NSO revealed.*
Peak onset:
The peak incidence of onset is 15 to 25 years of age
for men and 25 to 35 years of age for women
(American Psychiatric Association [APA], 2000).

*http://www.philstar.com/science-and-technology/51171/hallucinations-delusions
-common-schizophrenia
 Etiology Of Schizophrenia

Biologic Theories
Genetic/Hereditary Predisposition Theory
Biochemical and Neuro-structural Theory
Environmental or Cultural Theory
Perinatal Theory
Psychological or Experiential Theory
 Genetic/Hereditary Predisposition Theory

suggests that the risk

of inheriting
schizophrenia is
10-20% in those who
have one immediate
family member with
the disease, and
approx. 50% on
identical twin.
Fraternal twins have
only a 15% risk.
one biologic parent
with schizophrenia
have a 15% risk, 35%
both parents
 Neurochemical Factor

Dopamine wherein an excessive amount of the

neurotransmitter dopamine allows nerve impulses
to bombard the mesolimbic pathway, the part of
the brain normally involved in arousal and
motivation.
Serotonin modulates and helps to control excess
dopamine ; excess serotonin

Normal cell communication is disrupted, resulting

in the development of hallucinations and
delusions
 Neuroanatomic Factors

Findings have demonstrated that people with schizophrenia

have relatively less brain tissue and cerebrospinal fluid than
those who do not have schizophrenia -(Schneider-Axmann
et al., 2006)
decreased brain volume and abnormal brain function in
the frontal - and temporal + areas of persons with
schizophrenia
CT SCAN - enlarged ventricles in the brain and cortical
atrophy.
PET SCAN - suggest that glucose metabolism and oxygen
are diminished in the frontal cortical structures of the brain.
Environmental or Cultural Theory

they state that the person who develops

schizophrenia has a faulty reaction to the
environment, being unable to respond
selectively to numerous social stimuli.

there are higher rates of schizophrenia

among children born in crowded areas in
cold weather, conditions that are
hospitable to respiratory ailments
(Brown, Bresnahan, & Susser, 2005).
Immunovirologic Factors

exposure to a virus or the body’s immune

response to a virus could alter the brain
physiology of people with schizophrenia.
infections in pregnant women as a possible origin
for schizophrenia
higher rates of schizophrenia among children
born in crowded areas in cold weather,
conditions that are hospitable to respiratory
ailments (Kendall et al., 2017)
 Perinatal Theory

Intrauterine influences on developing fetus or

newborn is deprived of oxygen during pregnancy or
if the mother suffers from malnutrition or starvation ,
tobacco, alcohol, and other drugs, and stress during
the first trimester of pregnancy.
fetal life at critical points in brain development,
generally the 34th or 35th week of gestation.
The incidence of trauma and injury during the
second trimester and birth
Psychological or Experiential
Theory
this theory explores stressors regarding
negative responses adding to an
unstable neurologic state.
poor mother-child relationship, deeply
disturbed family interpersonal
relationships, impaired sexual identity
and body image, rigid concept of
reality, etc.
SYMPTOMS OF SCHIZOPHRENIA ARE DIVIDED INTO TWO MAJOR
CATEGORIES:
 DSM-5 DIAGNOSTIC CRITERIA:
Schizophrenia 295.90 (F20.9)

A. Evidence/symptoms of two (or more) of

the following, each present during a 1
–month period:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms ( alogia,avolition)
DSM –IV DIAGNOSTICS CRITERIA
B. Social/occupational dysfunction
C. Duration – Continuous signs of the disturbance persist for
at least 6 months. This 6-
month period must include at least 1 month of symptoms
(or less Is successfully treated) that meet Criterion A (i.e.,
active-phase symptoms) and may include periods of
prodromal or residual symptoms
D. Schizoaffective and mood disorder exclusion
E. Substance /general medical condition exclusion
F. If there is a history of autism spectrum disorder or a
communication disorder of childhood onset, the additional
diagnosis of schizophrenia is made only if prominent
delusions or hallucinations present for at least 1month
SUBTYPES DSM-IV-TR (APA, 2000)
 PARANOID TYPE

Characteristics: Ego is greater than those

Preoccupation with one or with catatonic and
more persecutory /grandiose disorganized
delusions or frequent auditory schizophrenia.
hallucinations , excessive Anger, hostility, violent
religiosity, hostile and behavior
aggressive behavior
None of the following is prominent:
Prognosis is more
1. disorganized or catatonic favorable for this subtype
behavior than for the other
2. flat or inappropriate affect subtypes.
3. disorganized speech
HALLUCINATION
DELUSION
Illusion
 VARIOUS TYPES OF HALLUCINATIONS
(Kirkpatrick & Tek, 2005):

• Auditory: Hearing voices or

sounds60% of people with
schizophrenia (Waters, 2014)
• Visual: Seeing people or
things
• Olfactory: Smelling odors
• Gustatory: Experiencing
tastes
• Tactile: Feeling bodily
sensations
command hallucination
EXAMPLE

John Nash, the world-renowned mathematician with

schizophrenia portrayed in the film A Beautiful Mind
(2001), describes his hallucinations:
I thought of the voices as…something a little different
from aliens. I thought of them more like angels…
It’s really my subconscious talking; it was really that, I
know that now.
CATATONIC TYPE

Characteristics: (At least 2 of the following)

Motor immobility (i.e. Rigidity), waxy flexibility,
or stupor
Excessive motor activity that is purposeless
Extreme negativism or mutism
Peculiarities of voluntary movement as
evidenced by posturing, stereotyped
movements, prominent mannerisms or
prominent grimacing
Echolalia (repeats all words or phrases heard)
or echopraxia (mimics actions of others)
 DISORGANIZED TYPE
Most severe clinical
symptoms,
Characteristics:
disintegration of personality
All of the following are and is withdrawn
prominent and criteria are
not met for catatonic type: Speech may by incoherent
grossly inappropriate or flat Behavior is uninhibited along
affect with a lack of attention to
personal hygiene and
Incoherence grooming.
loose associations YOUNG AGE
extremely disorganized Poor prognosis
behavior
 DISORGANIZED SYMPTOMS

Incoherent speech
Disorganized speech
Repetitive rhythmic gestures (such as
walking in circles or pacing)
Attention deficits
Cognitive defects/ confusion
Best described as
SILLY & FATUOUS
Inappropriate
social behavior:
Burst into laughter
Incongruous
grinning &
grimacing
 UNDIFFERENTIATED TYPE

Characteristics:
characterized by mixed schizophrenic symptoms
thought, affect, and behavior disturbance
Client may exhibit positive and negative
symptoms.
Odd behavior, delusions, hallucinations and
incoherence may occur.
Prognosis is favorable if the onset of symptoms is
acute or sudden.
 RESIDUAL TYPE
Characteristics:
Absence of prominent delusions, hallucinations,
disorganized speech, and grossly disorganized or
catatonic behavior.
clients experiencing negative symptoms following at
least one acute episode of schizophrenia.
Social withdrawal; flat affect; and looseness of
associations
Clinical symptoms may persist over time, or the client
may experience a complete remission.
CULTURAL CONSIDERATIONS
 ASSESSMENT
History
General Appearance, Motor Behavior, and Speech. (Box
16.3)
Mood and Affect ( flat, blunted), mask-like
Thought Process and Content (thought blocking , (thought
broadcasting , thought withdrawal, thought insertion,
tangential thinking, alogia).
Sensorium and Intellectual Processes ( Hallucination,
depersonalization )
Delusions (Box 16.4)
Judgment and Insight- lacking /severely impaired
Self-Concept (loss of ego boundaries)
Roles and Relationships- Social isolation
Physiologic and Self-Care Considerations - have significant
self-caredeficits.
SCHIZOPHRENIC – LIKE DISORDERS
Intervention

Promoting the Safety of Client and

Others

Establishing a Therapeutic Relationship

 TREATMENT
PSYCHOPHARMACOLOGY
ANTIPSYCHOTIC DRUGS - neuroleptics
used to manage the symptoms of the disease(+) signs, no
effect (-) signs
Fluphenazine (Prolixin) in decanoate and enanthate
preparations
• Haloperidol (Haldol) in decanoate
• Risperidone (Risperdal Consta)
• Paliperidone (Invega Sustenna)
• Olanzapine (Zyprexa Relprevv)
• Aripiprazole (Abilify Maintena)

Table 16.1 Antipsychotic Drugs, Usual Daily Dosages, and

Incidence of Side Effects
PSYCHOTHERAPY

Is widely recommended and used in the

treatment of schizophrenia, although services
may often be confined to pharmacotherapy
because of reimbursement problems or lack of
training.

Individual and group therapies, family therapy,

family education, and social skills training
Cognitive Behavioral
Therapy
- Isused to target specific symptoms and
improve related issues such as
self-esteem, social functioning, and
insight.
CBT is an effective treatment for the
psychotic symptoms of schizophrenia
COGNITIVE ENHANCEMENT
THERAPY (CET)
Combines computer-based cognitive training
with group sessions that allow clients to practice
and develop social skills.
This approach is designed to remediate or
improve the clients’ social and neurocognitive
deficits, such as attention, memory, and
information processing.
CET has also been effective in decreasing
substance misuse in people with schizophrenia
(Sandoval et al., 2017).
Family Education

- Has been consistently found to be

beneficial, at least if the duration of
intervention is longer-term.
Aside from therapy, the impact of
schizophrenia on families and the
burden on careers has been recognized,
with the increasing availability of
self-help books on the subject.
 Electroconvulsive Therapy

Is not considered a first line treatment but may be

prescribed in cases where other treatments have
failed.
It is more effective where symptoms of catatonia,
though there is no recommendation for use for
schizophrenia otherwise.
Remember