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COACHING WITH THE ICONS: DOC ESPINOSA

Psychiatric Nursing

! THINGS TO REMEMBER FOR THE BOARDS ! o Visual hallucination: common in pt. with
 We are new/novice nurses – KNOW THE neurocognitive disorders
BASICS DISTURBANCES IN THOUGHT PROCESS
 Apply the nursing process: SAFETY during  Delusion: false belief which cannot be
assessment is the priority! – most likely to be corrected by evidences
the ans. o Persecutory delusion: false belief that
 Use Maslow’s Hierarchy of Needs in dealing someone is trying to harm them
with pt. w/ physical illnesses (physiologic first)
 Intervention: Exhaust all INDEPENDENT NSG. Note: Not all delusions and hallucinations are
FXN before referring and meet the client’s threatening some may be comforting (serviceable
needs as perceived by the client (each pt. is on the part of pt.). Hallucinations supply what reality
unique) denies and makes it real in their fantasy world.
 Know the CURRENT EMOTIONAL STATUS of
the country: Pandemic (crisis, depression, DISTURBANCES IN SPEECH PATTERN
emergency)  Neologism: coining of new words
 Communication process and its principle is  Tangentiality: going around the bush W/O
important arriving at an ans.
 Circumstantiality: going around the bush and
Mental Health Global Action Program: WHO ARRIVING at an ans.
findings claims that we have a total of 500
psychiatrist to care for people with mental health Psychotherapeutic Management Model of
illness showcasing a big gap in the mental health. Keltner with Modification
COMPONENTS
1. Tools of the trade/therapeutic tools of a Mental
Chapter 1: Concepts and Principles of Health Psychiatric Nurse
Mental Health Nursing a. Therapeutic Use of Self
PSYCHIATRIC – MENTAL HEALTH NURSING  use self as a model and act as a
 a specialized area of nursing practice, change agent.
employing theories of human behavior as its  ability of a nurse to use his or her
science and purposeful use of self as its art personality (katauhan or personality,
(ANA, 2000 p.7) karunungan or knowledge, karanasan
 Focus: Human behavior or experience, damdamin or feelings)
 Philippine Mental Health Law (RA 11036): It consciously and in full awareness in an
is considered as illegal detention if you confine attempt to establish relatedness or
a pt. for more than 6 mos. empathy and to structure nsg.
intervention
DISTURBANCES IN PERCEPTION  4 Elements (SSER):
 Hallucination: affects 5 senses of the pt. 1. Self-awareness
o Auditory hallucination: has command - ability to be aware of personal
voices or bulong; most common competence
hallucination in schizophrenic clients - Taylor and Sed: ability to
 Keltner said that it is best to avoid experience genuine feelings in
having discussions in pt. having relation to one’s environment
hallucination and delusion instead talk - care for oneself first before
about real people and events but if it caring for others (Wounded
concerns safety like in auditory healers – heal healers)
hallucination, ask “What are the voices 2. Self-disclosure
telling you?” - a sx. of healthy personality
used to understand their self
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- it can be done with the pt. so b. Therapeutic Nursing of Self (Nursing

longs as you have a Skills)
therapeutic objective but after  Communication skills
refocus immediately  Observation skills: ability to detect
- 2 criteria: (1) timing – slight changes in things
appropriate opportunity, (2)  must be planned and is done with
dosage certain objectives
 i.e., pt. with depression suddenly
! Test Taking Strategy ! becomes cheerful and grooms their
 Any answer that is RN focused in wrong most of self, this shift in behavior indicates
the time. resolution to ambivalence to commit
suicide
 Reporting/Recording Skills: official
 Countertransference by Sigmund Freud
account of things that were done
o RN’s feeling is transferred to the pt.
 no documentation, no care
o intense (+/-) feelings towards a person in
 uses for research and legal
the present but is intended for the significant purposes
person in the past  AVOID use of psychiatric
terminologies in charting FDAR
***Anger is conscious, hostility can either be (used in the manual of operation of
conscious or unconscious but is more of the DOH), these terminologies can only
unconscious (more destructive – X controlled). be used for the FOCUS
 Use of charting aids:
3. Empathy - Use of quotation marks to
- entering the person’s life quote the exact verbatim
situation by perceiving his communication of the pt.
current condition/problem - Parenthesis to indicate the
- put yourself into pt. shoes words preceding the
parenthesis
Sympathy - Use of short dashes – used
 2 Elements: Pity and Condolence for words mumbled by the pt.,
 If RN starts to pity the pt. especially those with hard to understand and
depression, the more one is pushing them to incomprehensible
feelings of worthlessness. - For incomplete statements,
use long dash
4. Respect  Do not leave spaces in the chart
- Respect the pt. and the client
should respect RN as well. 2. The pt. is having an auditory hallucination with
1. The pt. with a bipolar disorder is facing away command voices telling her to kill her husband and
from the group and refusing to cooperate despite his mistress. What should the RN do?
the RN telling them that their behavior is wrong A. Notify the husband
while in a small group meeting. What should the B. Notify the other woman
RN do? C. Notify the priest
A. Tell pt. that their behavior is unacceptable – D. Notify thee MD – will order for the security,
already told the pt. that their behavior is wrong inform the husband, etc.
B. Tell pt. to leave the room away from the group –
violation of pt. right (right to attend the activity) c. Therapeutic Nurse Client Relationship
C. Instruct a carer to accompany the client for a  It is important for the nurse to have the
walk – redirect the energy of pt. knowing that the pt. ability to establish a therapeutic nurse-
has excessive amt. of energy allowing them to have patient relationship/partnership.
appropriate discharge before the activity  Give pt. highest sense of self-direction
or autonomy – to fxn independently.

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2. Psychopharmacotherapy o validate person’s feelings and experiences

o Mental Health is INCURABLE, but the before we draw a conclusion (“You seem
symptoms can be treated. upset” – validating vs “You are upset” –
 i.e., Neuroleptics/anti-psychotic drugs assuming; concluding)
can block the release of dopamine  it is a dynamic, on-going process
controlling sx like hallucination
producing emotional quieting and MODES OF COMMUNICATION
psychomotor slowing.  Verbal – account for 7% of communication
 Medication are taken for life. Do not stop o Virginia Hall and Authority on
taking meds w/o DO. Communication, majority of the things we
o After psychopharmacotherapy offer other say are lies unless we cover them with non-
forms of treatment strategies as the pt. verbal communication.
becomes open and amenable to them.  Non-verbal – accounts for 93% of
 Pt. often refuses medication d/t their communications
S/E. o More reliable of true feelings – “Listen to
o 1990: Decade of the Brain d/t the discovery what the other person is not saying”
of innovative visual imaging techniques that
will give us the brain activity of a person TYPES OF NON-VERBAL COMMUNICATION
 PET (Positron Emission Tomography)  Steward and Sandine said that kinesis is 55%
– accuracy >80% while paralanguage is 38%.
 SPECT (Single Photon Emission  Whistle and Nestle identified 5 types of non-
Computerized Tomography) verbal: kinesis, paralanguage, proxemics,
 PET-CT Scan – accuracy 95% (almost touch, and cultural artifacts
100%)
1. Kinesis or body cues/ body language
3. Milieu Management  Subtypes (FEG):
o Mi (middle) lieu (locust/ local/ a place/ a. Facial expression
environment): manage the pt.’s  There are 2 parts of the face that are
environment creating a warm, home-like, least susceptible to control:
accepting atmosphere  Eyes – windows of the soul, where
o Safety feelings can be easily revealed
 wards and observation room has grills  Corner of the mouth
following concept of Aklan (sacrifice b. Eye contact
privacy for the sake of safety)  Maintain consistent eye contact while
o Degree of flexibility having NPI to build a trusting
 i.e., TV viewing is until 9pm but the relationship proving that the RN is
movie ends at 9:30pm sincere.
o Different structured activities  Consideration:
 Journaling – a therapeutic way of - Nationality (Pilgrimist and
expressing one’s feelings Thailander, it is discourteous if
 Use the non-dominant hand which a people maintain eye contact)
is associated with emotions or - If it is the first time you are
affective rather than the dominant seeing a person, avoid staring
hand associated with logical because it can become
reasoning challenging.
c. Gestures
 Clear understanding of psychopathology  When talking to pt., have a face-to-face
contact.
Communication as a Process  Position: Seat slanting while looking at
COMMUNICATION the pt.
 is an exchange of my world of meanings with
your world of meanings

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2. Paralanguage or Paraverbal or  Eyeglasses: used to hide something

Paralinguistic cues or Vocal cues: para  Beard/Moustache: masks depression
(false) – do not use any language
 Subtypes are: THERAPEUCTIC COMMUNICATION
a. Voice quality: tone of voice  Purposeful use of dialogue (interaction of 2 or
b. Non-language vocalization more person) to bring about the client’s insight
 Crying (awareness of condition), control of sx, and
 Sobbing or moaning promotes healing.
o Interactive verbal and non-verbal strategies
3. Proxemics: law of space relationship that focus on the needs of patients
 distance that we maintain away or towards the (feelings tone) facilitate a goal directed pt.-
person centered communication process.
 Subtypes are: o Involves active listening, understanding
a. Territoriality: PERMANENT space that a the client thru empathy, promoting
person prevents from intrusion insight and clarification.
b. Personal space: TEMPORARY space that  Remember:
a person prevents from intrusion Safety – priority
 Four Tones of Personal Spaces are: Encourage expressions of feelings
1. Intimate distance (6-18 inches) – Assist in solving problems – do not solve the
type of distance used for loved ones problem for pt. (supportive relationship)
but not recommended to be used for  NPI lasts for 15-20 mins. – very long, it
psych pt. becomes boring; very short, RN cannot reach
2. Personal distance (1 ½ - 4 ft.) – objective
known as comfort zone (Hall);
recommended to be used for psych NON-THERAPEUTIC RESPONSES OR
pt. (arm’s length) and in first time QUESTIONS
encounters 1. Don’t worry statements – a false reassurance
- Nearest distance for a and lacks the communication process (no
schizophrenic paranoid is 4 ft. empathy)
since their primary defense o Other everyday statements like “everything
mechanism which is will be alright,” “ipagpasadiyos mo
projection (attributing, nalang yan” are all considered as don’t
thoughts, feelings, and failures worry statements
to others) that often stems from 2. Why questions – universal rule: it is WRONG
denial because it is seeking reasons or explanation,
3. Social distance (4-12 ft.) – known subjective, conclusive, threatening, judgmental,
as consultative distance or and places the pt. on defensive
business distance o Not all “why” questions are wrong. It can be
4. Public distance (12 ft. or more) – used when addressing pt. safety.
used in concerts and public o “What made you think that?” – non-
performances therapeutic because it seeks reasons,
threatening, and places pt. on defensive
4. Touch: most personal of the non-verbal 3. Exploratory questions (deep probing
messages (Smith, et. al., 1997) questions like how) – threatening
 Remember: Touch clients WITH WARNINGS o Suspicious pt. will not tolerate how
especially paranoid pt. since they may find it
questions and think that the RN is plotting
threatening.
something.
 If pt. is aggressive or acting out, take vital signs
4. Close-ended question – can be used in the
at their back to protect yourself.
orientation phase of the relationship since RN is
gathering demographic data and client safety
5. Cultural artifacts: hair, clothing, fragrance,
o “Are you planning to kill yourself” is
eyeglasses, beard, moustache
therapeutic if addressing safety.
 Hair: Muslim wears hijab
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5. Advising – pt. will become dependent on RN 2. Broad openings – allows the pt. to initiate or
6. Giving approval – it becomes RN-focused; pt. lead the interaction
will do things to please RN 3. Offering general leads – “tell me more” is
7. Rejecting – invalidates the concerns of the pt. tantamount to exploring allowing pt. to express
8. Agreeing – further support and strengthen pt.’s themselves without RN taking the lead
hallucination, delusions, and their inner conflicts 4. Restating – repeat the main idea or theme of
(ambivalence, etc.) what the pt. said using same words
9. Disagreeing – client will become defensive o Client uses declarative statement while the
10. Disapproval – rejecting the pt. itself RN responds using interrogative
11. Arguing – reinforces hallucination and statement.
delusions by making the pt. more defensive o At times pt may be annoyed at the use of
12. Challenging – causes pt. to defend their restating instead use reflecting.
delusions or misconceptions more strongly 5. Reflecting – considered to be highly powerful
13. Testing – RN are not MD, it is used by MD to d/t the element of listening encouraging pt. to
diagnose while RN’s role is to orient go back to feelings and thoughts first
o increases frustration and anxiety of pt. o Types:
14. Defending – does not change the client’s  Reflecting content: use fewer and
feelings but blocks further communication and fresher (newer) words; paraphrasing
cause annoyance  Reflecting feelings: similar to validation
o instead of defending, clarify o “He kept on using your money? What are
15. Requesting an explanation – same as with your feelings regarding this?”
why questions 6. Clarification – encouraging pt. to express
16. Indicating the existence of an external feelings elaborately/explicitly
source – RN will go along with pt’s 7. Focusing – pt. may manifest tangentiality or
misconceptions which only exacerbates their circumstantial; allows the pt. to concentrate on
hallucinations and delusions a single point and redirects the topic to the
17. Belittling feelings expressed – dismisses pt.’s focus
concerns as unimportant, temporary, mild, or 8. Encouraging comparison – brings out
self-limiting recurring themes and allows the pt. to recall
18. Using denial – dismissing pt.’s feelings and past coping strategies
concerns 9. Using silence – giving pt. chance to talk
19. Interpreting – RN decides pt.’s feelings and 10. Accepting – indicates that RN has heard and
thoughts followed pt.’s train of thought
20. Introducing an unrelated topic – RN focused; 11. Exploring – helps pt. examine and better
dismissive of pt.’s feelings and concerns understand the issue
12. Offering self – client is given a sense of
THERAPEUTIC RESPONSES OR QUESTIONS comfort
1. Empathetic Listening o “I will stay with you all throughout the
o Active listening includes the 5 aspects of meeting.”
physical attending which are (FOMOR): 13. Confronting – a powerful tool that can be seen
a. Face to face contact: sit directly or as a threatening if not used properly
slantly across pt. o It is used to give the pt. feedback that there
b. Open posture: never close arms and is an incongruence b/n the verbal and non-
legs – defensive and evasive verbal leading to acceptance.
c. Maintain eye contact: sincere and 14. Giving correct information – increases pt.’s
trustworthy knowledge, letting them know what to expect,
d. Occasionally lean forward: tantamount and is a way to gain their trust
to telling the RN is interested in what the 15. Seeking information – a form of clarification
pt. is saying allowing pt. to articulate their thoughts, feelings,
e. Relatively relax posture: rigid or stiff and ideas more clearly
posture indicates anxiety which is highly
contagious

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16. Presenting reality – indicates an alternative Demographic data of client – use close
line of thought for pt. to consider esp. among pt. ended questions
with hallucination  Confidentiality – the things that we will
17. Voicing out doubts – allows pt. to reconsider be discussing will only be between you
or reevaluate what is happening; used among and me but if it threatens safety it will be
pt. with delusion shared to most immediate members of
18. Suggesting collaboration – used instead of staff to foster trust
interpreting to do things WITH the pt. rather  Terms and conditions re: termination
than for (you and I) forming a satisfactory o Identify feelings, roles, actions, thoughts of
relationship both client and nurse, client’s status,
19. Encouraging expression – encourages concerns, needs, and problems
verbalization allowing them to make their own o Define mutually agreed goals
appraisal 3. Working
20. Giving recognition – indicates that RN  Primary tasks are (SICO):
recognizes the pt. as a person; used for positive o Stressor or triggers
behaviors/changes o Insight or awareness
21. Making observation – used for negative o Change
behaviors o Overcome resistance
o “I noticed you are biting your lips”
 Resistance transference and
22. Summarizing – brings out important points countertransference are highly evident
allowing RN and pt. to depart with same ideas during working phase since it is the
and provides a sense of closure period for problem solving approaches
23. Encouraging formulation of a plan – and can be brought by lack of mutually
increases likelihood of effective pt. coping agreed goals.
o “Next time that you and your husband
fights. What will you do?” 3. What is considered to be the most common
among all form of resistance?
! Test Taking Strategy ! A. The use of silence
 Choices with validation (i.e., seem) is usually B. One word statement
the correct ans. C. Tangentiality
D. Circumstantiality
THERAPEUTIC NURSE CLIENT RELATIONSHIP
 Brief (usually lasts for 2 weeks), planned, client- 4. Termination: most difficult
centered and goal directed  Summary of progress/evaluation
 Benefits of the relationship
1. Pre-interaction Phase  Referrals/ Endorsement
 Primary tasks:  Feelings: loss, rejection, separation – painful
o self exploration – undertake self-awareness  Establish reality of the loss
sessions
o gather data – read pt.’s chart
o plan nurse client interaction
2
Chapter : Psychodynamics
 Psycho (mind) dynamics (reasons or
2. Orientation Phase
motivations): talks about reasons behind
 Primary aim: know reason behind client’s
normal and abnormal human behavior
admission
o It is the psychological aspect behind human
o “What is the motivation as to why your loved
behavior.
ones have brought you here?” is AVOIDED
 Admission of female pt. under childbearing
instead “What happened prior to your
age requires the use of pregnancy test since
admission here?”
some mood stabilizers can be teratogenic.
 Primary tasks are (FID):
 Use of medications in older adults are started
o Formulate: contract – time, duration, place
in low dose of risperidone (psychotropic drugs)
of nurse-client interaction because their central cholinergic system is

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easily compromised which is responsible for the THREE LEVELS OF CONSCIOUSNESS

manufacture of choline acetyltransferase – (Sigmund Freud)
precursor of acetylcholine. 1. Conscious: here and now
o Size of a dot and only functions when a
HEALTH person is awake.
 A state of complete physical, mental, and social o Majority of our conscious activities is
well-being and not merely the absence of motivated by the unconscious.
disease or infirmity (WHO) o Ego operates in the conscious,
 There is no health without mental health (WHO) subconscious, and unconscious but mostly
n the conscious.
MENTAL HEALTH 2. Subconscious or Preconscious: watchman of
 A state of well-being in which the individual the mind
realizes his or her own abilities, can cope with o partly forgotten and partly remembered
the normal stresses of life, can work memories (i.e., It is at the tip of my tongue”)
productively and fruitfully and is able to make a o Function: Prevent all painful occurrences
contribution to his or her community (WHO) within the conscious to immediately go
 Is the ability to (Jonathan Appel): down the unconscious (acts as a buffer).
o Meet and handle problems o If the subconscious is too weak, the painful
o Make choices and decisions memories will go down the unconscious.
o Find satisfaction in accepting tasks to carry o Assist pt. through use of stress debriefing
on without undue dependence on others where pt. share facts, feelings, reactions,
o Contribute one’s share in life coping, etc.
o Enjoy 3. Unconscious: storage of painful memories just
o Be able to love and be loved like a tape recorder
o Proofs of the unconscious:
PRINCIPLES TO ACHIEVE OPTIIMUM MENTAL  Dreams – language of the unconscious;
HEALTH (NEW STTART) wishful fulfillment (may be repressed
 Nutrition/ No to drugs and alcohol anger or feelings); continuation of
 Exercise waking hours
 Water/ Writing  Jokes – have tendencies towards
 Sunshine/ Stress reduction/ Self-care/ Support hidden meanings or with a specific
 Talk/ Time management hidden or partly hidden purpose
 Air/ Act of kindness  Freudian slip - an unintentional error
 Rest and Relaxation regarded as revealing subconscious
 Trust feelings (slip of the tongue or slip of pen)
 Forgetting well known names and
PERSONALITY telephone numbers
 Sum total of one’s physical, emotional, social, o Methods of recalling the unconscious
intellectual and spiritual well-being (WHO) 1. Hypnosis (Mesmeruism) by Anton
 Enduring patterns of perceiving relating to and Mesmer
thinking about the environment and oneself 2. Psychoanalysis by Sigmund Freud –
(APA) compared to therapeutic nursing
o Deeply ingrained pattern of using 5 senses relationship
and our ability to enter a relationship  Steps in Psychoanalysis
particularly intrapersonal relationship (rel. a. Free association: compared to
b/n self). the orientation phase
 Two portions of Personality - (+) sharing of dreams and
1. Body or soma: tangible, can be seen, can childhood experiences
be measured b. Transference
2. Mind or Psyche: intangible, cannot be c. Countertransference
seen nor measured d. Catharsis: similar to termination
phase of relationship

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 Pt. is lying in a couch similar to a o used in pt. with dissociative identity

dental chair, while analyst is at the disorder (Multiple Personality Disorder)
back of the pt. to prevent resistance. and Dissociative Fugue (Psychogenic
o Id operates on the unconscious while Fugue)
superego operates in the conscious, 11. Conversion
subconscious, and unconscious but 12. Undoing: exhibiting acceptable behavior to
predominantly in the unconscious. make up for or negate unacceptable behavior
o primary defense mechanism for people with
Defense Mechanism/ Ego Mechanism obsessive-compulsive disorder
 Psychological ways of resolving a problem 13. Reaction formation: acting the opposite of
 Use by the ego UNCONSCIOUSLY to reduce what he thinks or feels
anxiety and are mostly unhealthy o common among pt. with bipolar disorder
 It is productive provided it is done temporarily. 14. Displacement: ventilation of intense feelings
towards persons less threatening than the one
Coping Mechanism who aroused those feelings
 can be constructive or destructive o primary defense mechanism for pt. with
 are CONSCIOUS way of decreasing anxiety phobia (fear is detached from the source
and are mostly healthy and is attached to a specific object, person,
 Cognitive – problem solving or situation)
Affective – emotion oriented 15. Substitution: replacing unattained goals by
Physical – task oriented one that is more attainable
16. Sublimation: rechanneling of unacceptable
1. Identification (Idolization): imitating or impulses to acceptable ones ((bad to good)
emulating others while searching for identity 17. Altruism
2. Condensation 18. Compensation: overachieve in another area to
3. Introjection: accepting another person’s compensate for failure
attitude, beliefs, and values as one’s own 19. Symbolization
(conforms feelings for approval) 20. Withdrawal
o “Blaming self” 21. Fantasy
4. Projection: unconscious blaming of
unacceptable inclinations or thoughts on an Stress
external object  A part of being alive and is a person-
o “Blaming others” environment interaction
o Common among pt. with Paranoia/  Wear and tear on the body
Paranoids  Any positive or negative occurrence or any
5. Denial: failure to admit the reality of a situation emotion requiring a response (it is observable,
o Common among alcoholics more on the objective side)
6. Rationalization: distortion of facts, unjustifiable  A person has adaptive energy to respond to any
excuse stressor
o Most commonly used defense mechanism  Types of Stress:
according to most psychologist o Eustress: something normal and has a
o Common among antisocial pt. positive force
7. Intellectualization: acknowledging the facts o Stress: has a negative force and is
but not the emotions pathological and abnormal leading to crisis
8. Suppression: conscious forgetting and illness
o prolonged use can lead to repression
9. Repression: unconscious forgetting GENERAL ADAPTATION SYNDROME
o Most commonly used defense mechanism  Specific, predictable, physiologic, psychosocial
according to Freud responses too stress
10. Dissociation: unconscious forgetting with  Stages of GAS (ARE):
disintegration of personality, consciousness, o Stage I: Alarm Reaction
memory, identity, and emotion d/t trauma

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 mobilization of the body’s defensive  Stress Mgt.

forces and activation of the fight
(assertive and aggressive) or flight Anxiety
(conservative and wary but can lead to  Anxiety – inner state that stress produces
withdrawal) mechanisms (subjective)
 Psychosocial responses: ↑ level of  Stressor that precipitates anxiety is whatever
alertness and task oriented, defense- the individual perceives as a danger, a loss, or
oriented inefficient (reduces stress but a threat to his safety and security.
does not eliminate it), or maladaptive
behavior may occur GENERAL ETIOLOGY OF ANXIETY
 Mgt: Look for the shock organ (part of 1. Psychodynamic Theory (Sigmund Freud)
body that is highly vulnerable to the  Ego develops defenses to help individuals to
negative reaction from the stress) to control or cope with anxiety.
anticipate physical manifestation.  The need to cope stems from the conflicts
o Stage II: Stage of Resistance between the id and the superego → early
 Optimal adaptation to stress within the conflicts are repressed → late life → person
person’s capabilities experiences conflicts again → defenses fail →
 Psychosocial responses: anxiety
 ↑ and intensified use of coping  Id (pleasure principle) → ego (balance b/n Id
mechanism and superego – develops at 6 mos.) →
 Tendency to relay on defense- superego (moral principle)
oriented behavior o i.e., 1 ½ - 3 y/o → conflicts occurs in the
o Stage III: Stage of Exhaustion ego (toilet learning) → love vs. hate to
 Loss of ability to resist stress because of mother → guilt feelings → regression →
depletion of body resources conflict occurs again later on in life →
 Psychosocial responses: anxiety
 Defense-oriented behavior become
exaggerated that can lead to use of 2. Interpersonal Theory (Interpersonal Conflict)
pathological defense mechanisms by Harry Stack Sullivan
 Disorganization of thinking and  Multiple, frequent, and recurrent interpersonal
personality conflicts may rise into anxiety.
 Sensory stimuli may be
misperceived with appearance of 3. Biologic Theory
illusion  Anxiety can be brought about by a decrease in
 Realty contact may be reduced with GABA (Gamma Amino Butyric Acid) which is
appearance of delusions or an inhibitory neurotransmitter – reduces anxiety.
hallucination  Caffeine destroys GABA.
 If exposure to the stressor continues
stupor or violence ay occur (Hans 4. Otto Rank Birth Trauma Theory
Selye)  Explain and assure everyone that is normal for
 Mgt: Share your feelings with other everyone to be anxious.
people  The most conducive of all environment is the
intrauterine environment.
STRESS ASSUMPTIONS o Sudden change in temperature and cutting
 Stress produces physiological and of umbilical cord brings anxiety to the fetus.
psychological responses.  Mgt.: Place the infant in the mother’s
 Inadequate handling of stress can lead to abdomen or chest for the infant to feel
physical or mental illness. that there is still a connection to the
mother.
GOALS OR APPROACHES TO STRESS
 Developing effective coping mechanisms LEVELS OF ANXIETY
 Reduction of body tensions 1. Mild
 Increasing resources and social support
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 ↑ attention and motivation; total focus on the resource mechanism → failure of coping →
situation; no need to use defense mechanisms CRISIS
 Use of adaptive mechanism – like logical
reasoning and problem-solving. STAGES OF CRISIS
2. Moderate  Stage I: loss, danger, threat → anxiety →
 ⭐Narrowed perception, ↓ attention, selective coping mechanism → anxiety not reduced
inattention (withdrawing attention from an  Stage II: anxiety increases → coping
anxiety provoking situation), problem-solving mechanisms decrease → person feels
and learning are possible with effort or pressured and unable to respond
assistance  Stage III: anxiety continues to escalate →
 Use of palliative coping mechanisms - watch person uses every means available to bring
TV, freshen up, brisk walking. anxiety level and situation under control →
3. Severe anxiety uncontrolled
 Scattered focus; psychologically painful; mental  Stage IV: anxiety or panic → depression or
block (no learning), use of defensive psychosis
mechanisms and maladaptive-coping
mechanism (use of alcohol, casino, overeating) NURSING PROCESS IN CRISIS
 Mgt: Energy-draining activities 1. Assessment – immediate precipitant
4. Panic  Assess:
 Personality disorganization, out of contact with a. childhood – not assessed d/t lack of time
reality, wild (can result to homicide) and b. unconscious – not RN’s responsibility and is
desperate (can result to suicide) behaviors, done by psychoanalyst
use of dysfunctional coping mechanisms c. immediate situation/ problem, present
problem – focus for RN
4. The client is on the panic level of anxiety. The d. all – lack of time and the problem s/b
following can be instituted, which do not belong to addressed immediately
the category? (-)  Assess safety
A. Offer emergency help 2. Analysis: Nursing Diagnoses
B. Stay with the pt.  Ineffective coping – anxiety, crisis, stress, drug
C. Be a model. Stay calm. abuse
D. Tell pt. to have problem solving approaches. –  Anxiety
no learning  Risk for suicide
 Situational low self-esteem
Crisis 3. Intervention – SAFETY
 Came from the Chinese word “Krinein” may  Intervene DURING the crisis
mean opportunity and danger or problem. o The person is generally receptive to help
 Psychological time wherein a person handles a o It takes less time and more effective
stress wen he finds his old, usual coping ways o To prevent the development of dysfunctional
to be ineffective (WHO) coping pattern and further decompensation
 Normal duration to handle a crisis is 4-6 wks. and violence
(self-limiting) o Flexible strategies
o Crisis worker s/b active and directive and  Feelings → cognition → point extreme
quick since pt. are in a state of panic and rage consequences
overwhelmed unable to ask for help. o NEVER attack the client’s defense – the
o + resolution → with a support system (fam. more the self-esteem and ego integrity are
members are no. 1 support system) → lowered
identified problems → learning opportunity o Gently encourage positive coping
o – resolution → without a support system →  Never give advice but must go into
sets in the preconscious → physical or formulating plan of action.
mental illness o Gently discourage negative coping
 May be minor event, series of stressor, severe o Restore emotional stability and security
disorganization, lack of usual individual

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 To have optimal level of functioning person in an abnormal situation.

or a higher level of functioning if However, WOF signs thought process
possible. disturbances.
 Generally, we do not give anti-depressant 4. Coping. Explore coping mechanisms
medications because it takes 3-4 wks. to take that can aid the pt. to return to normal
effect which is too long for an immediate crisis. functioning.
 For short-term, anxiolytics can be given since 5. Contingency plan. Plans for future in
it can habituate. case that the same discussion occurs.
 RF homicide and suicide is expected and can  Multiple Intervention – combination of
persist up until 2-3 mos. since crisis has physical, financial, social, and psychological
abated. support for victims of disaster
 Goal:
a. Offer corrective emotional experience or a 3. Psychosocial Processing for Children
positive change – goal in therapeutic nurse-  Children do not have enough language to
pt. relationship express their feelings, so play becomes their
b. To have long-term resolution – focus in universal language.
psychoanalysis since it tackles the
unconscious
c. To be more stabilized with medications – 3
Chapter : Psychopathology (DSM ) 5
goal in psychopharmacotherapy  Psycho (mind) patho (abnormal) logo
d. For person to have normal functioning/ (study): study of mental disorders and unusual
normal homeostasis (emotional balance or or maladaptive behaviors
equilibrium) o counterpart of pathophysiology
 Etiology of mental illness: UNKNOWN
WHO – DOH Mental Health Psychosocial o However, it can be multifactorial
Support Services (combination of several factors).
1. Psychosocial First Aid/ Band-Aid o In general, it is still inconclusive.
 offered within 24 hrs. after a disaster such as 1. Biologic basis: role of nature
offering help in finding loved ones o Genetic vulnerability/loading, chemical
imbalances, etc.
2. Psychosocial Processing 2. Psychodynamic basis: role of nurture
 not a panacea, not a treatment – it is a crisis o Stressors, environmental factors, etc.
worker’s tool to assist victims too have some
emotional or psychological relief so that they Anxiety Disorders
become victors or survivors  In previous DSM4, this is included in anxiety
 Critical Incident Stress Debriefing – non- related disorders which includes dissociative
specialized strategy disorder and somatoform disorder.
o No. of participants: 10-12 (max. 18)  Excessive fear and anxiety and related
o Circular Arrangements for continuity of behavioral disturbance for more than 6 mos.
discussions. Facilitator is seated across to  Fear: emotional response to REAL OR
see all pt. PERCEIVED IMMINENT THREAT OR
o Drop job titles to encourage verbalization IMMINENT DANGER
and lessen intimidation. o has a specific source so the person is
o 5 Steps: aware/ conscious
1. Introduction. Tell your purpose and limit o acute
use implying mental health disability d/t  Anxiety: anticipate of FUTURE threat/danger
stigma. o Free floating and unattached to specific
2. Encourage verbalization of facts and objects and is often r/t the unconscious.
feelings. Maintain confidentiality. o chronic
3. Reactions. Can be emotional, physical,
behavioral, and cognitive should be TYPES AND ASSESSMENT
reassured as normal reactions that a 1. Separation Anxiety Disorders

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 Fearful or anxious about separation from o Using public transportation;

attachment figures to a degree that is o Being in open spaces where escape is
developmentally inappropriate impossible;
o Being in enclosed spaces;
2. Selective Mutism o Standing in line or being in a crowd; or
 Consistent failure to speak in social situations in o Being outside of the home alone in other
which there is an expectation to speak (e.g., situations
school) even though the individual speaks in  worst among all kinds of phobia causing it to be
other situations separated from other specific phobia d/t the fear
and anxiety developed even when the pt. is at
3. Specific Phobia home
 Fearful (specific abnormal intense fear) or  the client can have a picnic with his co-pt. in
anxious (intense anxiety) about or avoidant of an open park or any other public open space
objects or situations (driving in the highway) – sign of
 i.e., Coitophobia – fear of coitus; School improvement
phobia – the commonest which is the
separation anxiety felt by the child from leaving 7. Generalized Anxiety Disorder
mother (Mgt: Bring the child to school  Persistent and excessive anxiety and worry
immediately and assess relationship of mother about various domains
and child; Peek-a-boo; Ask the father to hold  Generalized non-specific fear – client
the child closely in the absence of mother) experiences all sorts of fear (fear of being
 Tx: insane, fear of death, fear of impending doom)
o Systematic desensitization – gradual  It becomes a disorder when the person have
introduction of the feared object dysfunction (cannot no longer report to work,
o Flooding or Enclosing Technique – school dysfunction, social dysfunction, family
sudden introduction of the feared object but dysfunction)
is apprehensive
ANALYSIS: PASYCHOPATHOLOGY
4. Social Anxiety Disorder (Social Phobia) 1. Biological Bases – genetic transmission, ↓
 Fearful or anxious about or avoidant of social GABA
interactions and situations that involved the
possibility of being scrutinized/ embarrassed Mood Disorders
 Mgt: Employ them as a filing clerk  DSM4: there is a prominent disturbance in the
mood of the client
5. Panic Disorder  DSM5: mood disorders have been placed in
 Recurrent unexpected panic attacks and is different category from bipolar and depressive
persistently concerned or worried about having disorders
more panic attacks
 Panic attacks Bipolar Disorder
o Abrupt surges of intense fear or discomfort  Psychopathology: there is rapid firing of
that reach a peak within mins. accompanied norepinephrine (negative neurotransmitter that
by physical (ends in “ion” – palpitation, is toxic to the heart) causing hyperkinesis/
suffocation, hyperventilation, and cold hypermobile
sensation) and/or cognitive symptoms (fear  Mood stabilizers
or thought of having heart attack)  Therapeutic level for Lithium: 0.6-1.2 mEq/L
 NEVER offer brown bag – can cause
death of pt. Depression
o can be expected or unexpected  Visual Imaging techniques shows hypofunction
of the hypothalamus (has an abundant supply
6. Agoraphobia (House Bound Syndrome) of nerves and blood; regulates thirst and
 Fearful or anxious about two or more of the hunger, sex, motivation, etc.)
following situations:

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Signs and Symptoms

 Criteria: difficulty in remembering
(pseudodementia), difficulty in deciding,
difficulty in problem solving
 has internalized hostility → danger to self and
others
 has downcast facial expression or drooping
posture – sign of poor self-concept (cognitive
view about self)

***Self-esteem: emotional view about self

Paranoid
 Prominent sx: Persecutory delusion – false
belief is about killing, harming, antagonizing,
scrutinizing
 Hate too much closeness
o Mgt: Passive friendliness – wait for pt. to
ask for help and do not approach rashly

Acute Stress Reaction

 Intrusion, negative symptoms, and exposure
occurred within a month only; considered as
PTSD if it occurs more than 1 mo.

AMBAG, ALINE O.