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MALADAPTIVE PATTERNS

OF BEHAVIOR
Stanley C. Luces,
MD,DPSP, PAFR
1ST Ready Reserve Airlift
Tactical Wing
Philippine Air Force
• Maladaptive Patterns of Behavior
• Table of Contents
• Introduction to Psychiatry -1
• Neurosis and Psychosis - 85
• Psychosomatic disorders - 139
• Schizophrenia - 152
• Personality Disorders - 207
• Mood disorders - 239
• Eating disorders - 270
• Abuse ( alcohol, non alcohol) - 307
• Children disorders - 327
• Adult disorders - 346
• Pharmacology - 362
• Psychotherapeutic Intervention - 395

• INTRODUCTION TO PSYCHIATRY -
OVERVIEW
• Definition of terms
• Dynamic of Hum an Behavior
• Nature of Psychiatric Nursing
• Therapeutic Relationship
• Legal Aspect Of Psychiatric Nursing
• Theoretical Foundations
• Definition of terms
• ACTING OUT: The active expression of
emotions through actions, not words,
that occurs when the client relives the
feelings, wishes or conflicts that are
• AFFECT: The emotion or mood an
individual shows as a response, such
as flat affect or inappropriate affect.

• AMBIVALENCE: The simultaneous


presence of strong but contradictory
or opposite feelings or ideas, about
something or someone.  
• ANXIETY: Fear or apprehension caused
by an unknown or unrecognized
threat.
• AUTISM: A syndrome involving
abnormal sensory perception and
developmental (usually language and
psychosocial) issues.

• BODY IMAGE: One's perception of he's body.
• CATATONIC STATE: Immobility.
• COHESIVENESS: Group togetherness.
• COMPULSION: Emotional urge or need to act.
 Definition of terms

• CONFABULATION: A compensatory
mechanism for memory loss. Filling in
the memory gaps with imaginary stories
the teller believes to be true.
• CONFUSION: Mental bewilderment from
disorientation.
• CRISIS: A conflict which can-not readily be
resolved by using usual coping
• DEFENSE MECHANISMS: Mental strategies
used to help cope with areas of conflict.

• DELIRIUM TREMENS: Alcohol withdrawal
syndrome, including restlessness
continuing to disorientation,
hallucinations and convulsions.
• DELUSIONS; A fixed false idea.
• DENIAL: Unconscious refusal to
acknowledge that which is anxiety
provoking
• Definition of terms
• DESENSITIZATION: Gradual systematic
exposure of the client to feared
situations under controlled conditions.
• ECHOLALIA: Repetition by one person of
what is said by another.

•  EMPATHY: Objective and insightful
awareness of another's feelings.
• EXTRA PYRAMIDAL REACTIOIN: A reversible
side effect of some psychotropic drugs
characterized by muscle rigidity,
drooling, restlessness, shuffling gait and
blurred vision.
• FAMILY THERAPY: Treatment which involves
the family and explores the relationships
among the members.
• FANTASY: Daydreams.
• FLIGHT OF IDEAS: Rapid shift from an idea
to another before the first idea has been
• Definition of terms
• GRIEF: An emotional response to a
recognized loss.
• GROUP THERAPY: Application of
psychotherapy techniques by a skilled
leader to a group of people.
• HALLUCINATION: False sensory perceptions
involving any of the senses.
• HOSTILITY: Feeling similar to anger but of
longer duration.
• IDEAS OF REFERENCE: Ideas stemming from
the incorrect interpretation of incidents as
referring directly to self.
• ILLUSIONS: Misinterpretation of a real,
external sensory experience.
• INSIGHT: Self understanding.
• INTRAPSYCHIC: Within the mind.
• LABILE: Rapidly changing emotions.
• LIMIT SETTING: Clear statement of rules with
consistent reinforcement.
• LOOSENESS OF ASSOCIATION: Ideas appear
unrelated or only slightly related.
• MANIA: Elated, excited mood state.
• MANIPULATION: Control of another's behavior for
one's own purposes.
• NEOLOGISM: Coined word with special meaning to
the user.
• OBSESSION: Repetitive, uncontrollable thought.
• PARANOID: Suspicion, mistrust, without a basis in
reality.
• PHOBIA: Irrational fear.
• PREMORBID: Occurring before development of a
PSYCHOSIS: State in which there is impairment in

a person's ability to recognize reality,


communicate and relate to others appropriately.
 
• RESISTANCE; Opposition to uncovering
unconscious material.
• ROLE: Pattern of behavior.
• SECONDARY GAINS: Benefits from being ill, such
as attention.
• SELF ESTEEM: The degree of feeling worthwhile
or valued.
• SELF IMAGE: One's thoughts about one's own
self.
• SOMATIC THERAPY: Treatment of the
emotionally ill by physiological means.
• STEREOTYPED BEHAVIOR: Persistent mechanical

• TRANSFERENCE: Unconscious phenomenon in


which feelings, attitudes and wishes toward
significant others in one's early life are linked to
and projected onto others, usually a therapist in
one's current life.

• WAXY FLEXIBILITY: The extremities remain in a


fixed position for along period of time.
• Dynamics of Human Behavior
• Dynamics of Human Behavior
• Dynamics of Human Behavior
• Dynamics of Human Behavior
• Personality

• Nature of Psychiatric Nursing
• Mentally Healthy Person
• Accepts himself
• Perceives reality
• Mastery of self and environment
• Autonomy
• Unifying, integrated outlook in life
•  
• Mental illness
• Nature of Psychiatric Nursing
• Nature of Psychiatric Nursing
• Self Awareness
•  
• Therapeutic Self

Definition: Psychiatric Nursing

• THE ROLES OF THE PSYCHIATRIC NURSE


• Technical nurse- vital signs checks, medical or
surgical procedures, administration of
medication, physical assessment.
•  
• Mother Substitute
•  
• Nurse-teacher – educates clients about illness and
medication
•  
• Counselor or nurse therapist – uses therapeutic
skills to help client to identify and deal with
stressors or problems
•  
• Social Agent- promotes social skills
• THE ROLES OF THE PSYCHIATRIC NURSE
• Therapeutic Relationships
• This is a nurse-client interaction that is directed
toward enhancing the client’s well-being (Isaacs)
• A relationship established between a health care
professional and a client for the purpose of
assisting the client to solve his problems  
• FACTORS INFLUENCING COMMUNICATION
• Therapeutic Relationships
• The nurse- patient relationship is characterized by a
helping process
• The nurse and client work together for his benefit
• The nurse uses herself therapeutically and this is
achieved by self-awareness

• Therapeutic Relationships
• ELEMENTS OF THE THERAPEUTIC RELATIONSHIP
• Contract
• Boundaries
• Confidentiality
• Therapeutic Behaviors
•  
• Requisites of a Therapeutic Relationship

 

• Listen
• When I ask you to listen to me and you start giving
advise, you have not done what I asked.
• When I ask you to listen to me and you begin to tell
me why I shouldn’t feel that way, you are trampling
on my feelings.
• When I ask you to listen to me and you feel you have
to do something to solve my problem, you have
failed me, strange as that may seem.
• Listen! All I asked was that you listen, not talk or do-
just hear me.
• When you do something for me that I can and need to
do myself, you contribute to my fear and weakness.
• And when the answers are obvious and I don’t need
advise.
• So, please listen and just hear me. And, if you want to
talk, wait a minute for your turn; and I listen for you.
• Anonymous
• Therapeutic Relationships
• NON VERBAL COMMUNICATION
• Proxemics- the physical space between the sender
and receiver
• Kinetics- the body movements such as gestures, facial
expressions and mannerisms
• Touch- intimate physical contact
• Therapeutic Relationships

• NON VERBAL COMMUNICATION


• 4. Silence
• 5. Paralanguage- voice quality (tone, inflection) or how
a message is delivered
• Therapeutic Relationships
• VERBAL COMMUNICATION
• Use of therapeutic communication techniques
• Effective communication should be therapeutic,
appropriate, simple, adaptive, concise and credible
• Non-therapeutic communication
• These are blocks to communication
• Usually, these are the common
pitfalls of communicating non-
therapeutically:
• Giving advise
• Talking about self
• Telling client is wrong
• False reassurance
• Cliché’
• Asking ‘Why’


• Proxemics
• Distances
• INTIMATE= Touching to 1 ½ ft
•  
• PERSONAL= 1 ½ to 4 ft
•  
• SOCIAL= 4 to 12 ft
•  
• PUBLIC= 12 to 15 ft

• Phases of N-P Relationship
• 1. Pre- interaction phase
• Begins before the initial NPI
• Self-awareness – very necessary
• Gathering data/ chart reading and
planning the first interaction.
• 2. Orientation/ introductory phase
• Nurse- stranger, should establish
rapport through consistency of
communication and actions.
• Planning, contract outlining,
confidentiality
• Termination begins during this
phase.
• Therapeutic Tasks:
• 1.Building trust and rapport by demonstrating
acceptance
• Establishing therapeutic environment, including
privacy
• Establishing a mode of communication acceptable to
both client and nurse
• Initiating a therapeutic contract by establishing a
time, place, and duration for each meeting, as well
as the length of time the relationship will be in
effect
• Assessing the client’s strength and weaknesses.
• Phases of N-P Relationship
• 3.Working phase
• nurse and client discuss areas of concern.
• client is helped to plan , implement and evaluate.
• problems must be discussed and resolved and new
behaviors can be learned.
• Transference and Counter Transference
• Therapeutic tasks:
• Exploring client’s perception of reality
• Helping clients to develop positive
coping behaviors
• Identifying available support system
• Promoting a positive self-concept
• Encouraging verbalization of feelings
• Developing a plan of action with
realistic goals
• Implementing the plan of actions
• Evaluating the results of the plan of
actions
• Promoting client independence
• Phases of N-P Relationship
• 4. Termination phase
• The end of the therapeutic relationship
between the nurse and the client.
• Time parameters should be shortened
as termination time comes gradually spacing
farther apart near the termination.
• Phases of N-P Relationship
• Activities : Termination
• a. Goals and objectives must be
summarized.
• b. Adaptive behaviors must be reinforced.
• c. feelings and experiences for both the
nurse and the client should be shared.
• d. rejection, anger, regression, or other
negative behaviors maybe expressed as a
means of handling loss.
• Phases of NURSE-Patient Relationship
• Preparation for discharge
•  
• 1. An understanding of illness.
• 2. An understanding of the nature of the prescribed
medications and the
• importance of taking them.
• 3. Ability to provide for the client’s daily living
needs.
• 4. Ability to handle questions about the client’s
absence and illness.
• Nature of Psychiatric Nursing
• The DSM- IV Criteria
• A taxonomy that describes all mental disorders, outlining
specific diagnostic criteria for each based on clinical
experience and research
• Clinicians utilize this to diagnose psychiatric disorders
• Purpose of DSM-TR:
• Standard nomenclature
• Defining characteristics
• Underlying cause of disorders
• Nature of Psychiatric Nursing
• The DSM-IV : Multi Axis Classification
• AXIS I- Major Psychiatric Disorders
• AXIS II- Mental Retardation and Personality
Disorders
• AXIS III- Current Medical Condition
• AXIS IV- Psychosocial and Environmental
Problems
• AXIS V- Global Assessment of Function
• Nature of Psychiatric Nursing
• Scope of Nursing Practice
• Individual, family and community
• Healthy and ill person

• LEGAL ISSUES IN NURSING
• Malpractice
• Conduct that falls below the standard of care
•  
• Negligence
• - An unreasonable risk of harm to a client
• Four Elements of Nursing Malpractice:
(Schipske, 2002; Calloway, 1986)
• Failure to act in acceptable way
• Failure to conform to required standard of care
• Approximate cause, which requires that there be
a reasonably close connection between the
defendant’s conduct and the resultant injury
(ie, the performance of the health care provider
caused the injury

• The occurrence of actual damage
• Cases of Malpractice:
• Client falls
• Failure to fallow physician
orders/protocols
• Medication errors
• Improper use of equipment
• Failure to remove foreign objects
• Failure to provide sufficient
monitoring
• Failure to communicate
• Other forms:
• Intentional torts
• Willful or wanton conduct to do a wrongful act with
disregard of the interests of the others
• a. Assault – is an act that puts another person in
apprehension of being touched or of bodily harm
without consent
• b. Battery – is unlawful touching of another
without consent
•  
• 2. Defamation
• Involves injury to a person’s reputation or character
through oral (slander) or written (Libel)
communications to a third party
• 3. False imprisonment
• Intentional and unjustifiable detention of a person
• CLIENT CONFIDENTIALITY
• Nondisclosure of private information related by
one individual to another
• CLIENT PRIVACY
• - Right to be left alone and free from
intrusion or control of the public

• Potential Legal Issues In Psychiatric-Mental Health


Nursing:

• Abandonment
• Diversion of narcotics
• Falsification of medical records
• Impairment

• Negligence
• Unprofessional practice
• Legal Aspect of Psychiatric Nursing
• The Mc Naghten Rule
• Legal Aspects of Psychiatric Nursing
• Tarasoff vs The Regents of the University of California

• Neurosis
•  
• contact with reality is retained the condition is
recognized by the patient as abnormal.
•  
• ( anxiety disorders ;oc d/o, panic d/o, PTSD,
GAD)
•  
• Benefits from Behavior Therapy
• Anxiolytic medications

• Theoretical Foundations

• Psychosexual/Psychoanalytical
• Ego defense mechanism
• Therapeutic Relationships

• Psychosis
• looses contact with reality
• Presence of delusions, hallucinations,
severe thought disturbances,
alteration of mood, poverty of thought
and abnormal behavior
• (schizophrenia , major disorder of affect
(bipolar d/o) , major paranoid

• states and organic mental disorder
• Benefits from psychoanalysis and
antipsychotic medications
• Mental disorders
• Neurosis
• Does not require hospitalization
• Considered moderate reaction to
stress
• Reality testing remains sound
• Patient feels suffering and wants
to get well
• Does not ignores reality
• Exploits symptoms for secondary
gain
• Desires are not externalized

• Origin of anxiety
•  
• BIRTH is the prototypical separation
anxiety- the threat to life and the
separation from the mother.
•  
• Origin of anxiety
• The PSYCHOSEXUAL theory believes
that anxiety is a response to the
emergence of the ID impulses that are
NOT acceptable to SUPEREGO
• The EGO detects a real or potential
conflict between the ID and the
SUPEREGO resulting to the
• Anxiety
•  
• This is defined as a “Sense of
impending doom” , an
apprehension of dread that
seemingly has no basis in reality

• Characteristics of Anxiety
• Always perceived as a negative
feeling
• Extremely communicable
• Cannot be distinguished from fear
easily
• Occurs in degrees: mild, moderate,
severe, panic
• Mild Anxiety
• Psychological responses
• Wide perceptual field, sharpened
senses, increased motivation, effective
problem solving, increased learning activity
and irritability.
• Physiological responses
• restlessness, fidgetting, GI butterflies,
difficulty sleeping, hypersensitivity to
noise.
• Anxiety Levels
• 2. Moderate Anxiety
 Psychological responses
• perceptual field narrowed to immediate
task, selectively attentive, cannot connect
thoughts and events, increased used of
automatisms.
• Physiological responses
• muscle tension, diaphoresis, pounding
pulse, headache , dry mouth, high voice pitch,
faster rate of speech, GI upset, frequent
urination.
• 3. Severe Anxiety
• Psychological responses
• perceptual field narrowed to one detail
• cannot complete task/ solve problem,
dread, horror, cries, ritualistic behavior,
behavior geared towards anxiety relief but is
usually effective.
• Physiologic responses
• severe headache, nausea, vomitting,
diarrhea, trembling rigid stance, vertigo pale,
tachycardia, chest pain.

• 4. Panic Anxiety
• Psychological responses
• perceptual field focus to self,
cannot process environmental stimuli,
distorted perception, loss of rational
thought, does not recognize potential
danger, devoid of communication,
possible delusions and
hallucination, maybe suicidal.
• Physiologic responses
• may bolt or run about, totally
immobile and mute, dilated pupils,
increase B/P and pulses,
• Flight, Fight or Freeze.
• Adaptation to anxiety
• Use of unconscious ego defense
mechanisms
• Utilized when the person experiences
conflict between the id and superego
• Use of coping mechanisms
• This is adaptation to anxiety based on
conscious acknowledgement of a problem
• Anxiety Disorders
• Major manifestations for all types:
• Autonomic nervous arousal
• Sense of doom
• Depersonalization
• Avoidant behaviors
• Paresthesias

• Recurrent attacks of intense fear or
discomfort
• Anxiety Disorders
• Global Manifestations of Anxiety disorders
• Biological- tachypnea, tachycardia,
diaphoresis
• Behavioral- rituals, avoidance, increased
dependence, clinging
• Motor- tension, pacing, tremors,
restlessness
• Cognitive- Sense of doom, Confusion,
Helplessness, Intense fear,
powerlessness
• Anxiety Disorders: Epidemiology
• Affects 15% of the population
• Most common reason for seeking medical
help

• Anxiety Disorders
• Panic Disorder- recurrent unexpected
panic attacks that can occur with or
without agoraphobia.
• Agoraphobia-disabling conditions in
which patients fear places in which
escape might be difficult.
• Epidemiology- women- 2-3%, age-20`s,
before are 30.
• Etiology : Unknown
• Theories: Abnormality in Locus
Ceruleus( a region of the brain that
regulates arousal) and elevated
cathecolamine levels.
• Panic attacks typically come on
suddenly, peak within minutes and
• DSM IV CRITERIA for Panic Attack
• A discrete period of intense fear or
discomfort in which 4 or more of the
following are present within a 10 min.
period.
• Palpitations. Tachycardia
• Sweating
• Trembling or Shaking
• Shortness of breath
• Feeling of Choking
• Chest pain or discomfort
• Nausea abdominal distress
• Derealization ( feeling of unreality)
• Depersonalization( feelings of detached to
ones self)
• Loosing control, paresthesia, chills and hot

• Panic Disorder
• to warrant diagnosis one of the following must occur for
atleast 1 month:
• Persistent concern of having additional attacks.
• Worry about implications of attacks( losing control, getting
crazy)
• Significant change in behavior due to attacks ( restriction of
activities).
• MGT.
• Pharmacotherapy- TCA, MAOI, SSRI
• Cognitive- Behavioral Therapy- relaxations
exercises and desensitization and exposure therapy
•  
• Anxiety Disorders: related terms
• Phobias and related disorders
• The individuals recognize the fear as irrational but
they feel inadequate or powerless to control the
fear
• There may be genetic component
• Most common psychiatric disorder
• Epidemiology- women, 25% of the population, onset is
in childhood, occur before age 12.
• Etiology- genetic, run in families
• MGT:
• Remit spontaneously with age
• If persistent till childhood, - chronic
• Treated with systematic desensitization and flooding.
• Medication is not needed.
• Phobias
• Social Phobias- intense fear of being scrutinized in
social or public situations. ( giving speech, speaking
in class)
• Epidemiology: equal men: women ratio, 3-5% of the
population. before age 25.
• Etiology: familial predisposition, traumatic events,
hypersensitivity to social rejection.
• MGT: Cognitive Behavioral Therapy (CBT)
• MAOIs, Beta Blockers, SSRI`s

• OCD Disorders
• Obsession= persistent thought or intrusive idea
that is forced into conscious awareness
• Compulsion= performance of an unwanted act
or ritual
• stereotypical and repetitive manner
• OCD Disorders
• Obsessive -Compulsive disorder
• Recurrent obsession and compulsion that are
severe enough to be time consuming
•  
• The most common obsessions are repeated
thoughts about contamination, repeated
doubts
•  
• The most common compulsion involve repeated
hand-washing, counting, checking
•  
• OCD Disorder
• Obsessive -Compulsive disorder
• The client is WEL aware of his
unrealistic behavior
• He uses the defense mechanisms of :
UNDOING and SYMBOLIZATION
• Indulgence in obsessive thoughts and
performance of the behaviors causes
temporary anxiety relief ( a primary
gain)
• OCD disorders
• MGT:
• SSRI`s
• Systematic desensitization
• Limit setting

• PTSD
• re-experiencing of the terror associated with a
psychologically distressing event
• Former names: hysteria, war shock, battle
fatigue
• Epidemiology: 0.5 % in men, 1.2 % in women,
• The event is usually beyond the breath of
normal human experience
• PTSD
• Major characteristics:
• Persistent recurrent and intrusive thoughts,
flashbacks, dreams and intense psychological
distress
• Avoidance behaviors (depersonalization)
• Emotional numbing, hyper vigilance and ANS
arousal
• MGT:
• TCA and MAOI
• Psychotherapy ( individual and group)- nature
or trauma, degree of coping skills, support

• Generalized Anxiety Disorders


(GAD)
• characterized by pervasive unrealistic or
excessive anxiety, worry about every aspect
of life.
• Persist for 6 months
• 5 % in the general population
• Onset is early 20`s but my occur at any age
• Women affected more than men
• GAD
• Patient with GAD has difficulty in controlling the worry,
and must be associated with atleast 3 of the
following symptoms:
• Restlessness, easy fatigue, difficulty concentrating,
blank stares, irritability, muscle tension, and sleep
disturbance.
• MGT:
• Benzodiazepines

• Nursing Process for patients with


Anxiety Disorders
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
• Nursing Process for patients with
Anxiety Disorders
• Assessment
• Process begins with a complete
medical and physical examination to
RULE out physical and substance
• Utilize the mental status examination
• Assessment: Anxiety Disorders
• Physiologic Assessment
• Tightness of stomach
• Tachycardia
• Anorexia
• Palpitation
• Shortness of breath
• Feelings of exhaustion
• Motor restlessness
• Alertness

• Nursing Diagnoses: Anxiety Disorders


• Ineffective individual coping
• Altered role performance
• Impaired social interaction
• Defensive coping
• Sleep pattern disturbances
• Altered thought process
• Anxiety
• Fear
• Powerlessness
•  
• Planning: Anxiety Disorders
• The general nursing goals are to help patients lower
their anxiety
• develop functional pattern of adaptations
• develop awareness of the effects of the disorders
• Implementation: Anxiety Disorders
• Foster Activity process
• Allow , carry out the anxiety-releasing rituals for
them to develop security
• Provide time-limit to individual rituals.
• Rituals may e schedule earlier

• Assessment: Anxiety Disorders


• Physiologic Assessment
• Tightness of stomach
• Tachycardia
• Anorexia
• Palpitation
• Shortness of breath
• Feelings of exhaustion
• Motor restlessness
• Alertness

• Implementation: Anxiety Disorders


• Encourage verbalization of
concerns and feelings
• Introduce relaxation techniques
and other positive anxiety
management strategies
• Implementation: Anxiety Disorders
•  
• Cognitive and behavioral Therapy:
desensitization
• Pharmacotherapy: use of the
anxiolytic drugs like
 

• Implementation: Anxiety Disorders


Cognitive-Behavioral Therapy
• Implementation: Anxiety Disorders
Cognitive-Behavioral Therapy
• Interventions for the client with
OCD
• Convey acceptance of the client
• Allow time to perform rituals-
ANXIETY
• LIMIT setting on ritualistic
behaviors
• The best time to interact with
• Interventions for the client with PHOBIA
• DO NOT force the client to approach the
specific object or situation
• Allow clients to verbalize feelings
• HELP client identify coping measures
• Practice relaxation with the clients
• Participate in the desensitization therapy
•  
• Evaluation
• Client identifies own anxiety responses
• Identifies stressors in past and current life
situations
• Utilizes coping strategies rather than
symptomatic behaviors
• Identifies and actively participates in
continued treatment plan

• Psychosomatic Disorders
• Disorders characterized by somatic
complaints for which no organic cause
could be demonstrated
• Usually result from emotional factors
• Psychosomatic Disorders
• Characteristics:
• Involve the organ system innervate by
the autonomic nervous system
• Physiologic changes accompany
emotional responses that are intense
• Symptoms are physiological rather
than symbolic, the emotions beings
expressed through the viscera
• Persistent psychosomatic reactions

• Psychosomatic Disorders
• Characteristics:
• 5. The somatic symptoms afford generous
secondary gains for the for the patients
in terms of attention
• Somatoform disorders
• The clients often present with multiple,
recurrent clinically significant somatic
complaints, usually colorful and
exaggerated hut lacking in factual basis
• symptoms cause global impairment
•  
• Somatoform disorders
• The condition is characterized by PRIMARY
GAIN (relief of anxiety) and SECONDARY
GAIN (special attention)
• The individual becomes totally focused on
• The person visits MULTIPLE health care
providers and may undergo
unnecessary procedures
• Types of Somatoform disorders
• Types of Somatoform disorders
• Somatoform disorders
• NURSING MANAGEMENT
• Mainstay treatment is a long term
relationship with a health care
provider to prevent the patient from
seeking multiple providers with
multiple recommendations
• Assist in psychotherapy as part of the
treatment plan
• Family Education
• Psychiatry lecture
• SCHIZOPHRENIA
• Schizophrenia
• Gross impairment of reality testing.
•  
• Specific psychotic symptoms : delusions,
hallucinations, ideas of reference and
disorders of thought.
• Schizophrenia
•  
• Not a split personality, but different
disorder characterized by “split” to
reality
•  
• Thought Disorders
• Schizophrenia
• A MENTAL DISORDER CHARACTERIZED BY
DISTURBANCES IN THOUGHTS and
sensory perception and social and /or
• Epidemiology
• Onset is usually during adolescence
and early adulthood
• Affects 1% of the population.
• Women > Men in age 30`s
• Men >Women in early and mid20`s

• Bleuler’s Diagnostic Criteria
• Fundamental symptoms
•  
• Non-schizophrenic symptoms

 • SYMPTOMS

• Constellation of distinctive &


predictable symptoms
• ( + ) POSITIVE symptoms
• Denotes the presence of grossly
abnormal behavior
• Include thought disorder,
delusions, & hallucinations
• ( - ) NEGATIVE symptoms
• Represent the absence of normal
behavior
• Flat or blunted affect (i.e lack of
emotional expression), apathy,
• Symptoms of Schizophrenia
• THEORIES
• Biochemical theories
• Neuro-structural theories
• Genetic theories
• Perinatal risk factors
• Psychodynamic theories
• Developmental theory
• Family theory


 Causation of Schizophrenia
• BIOLOGIC theory= genetics, excessive
neurotransmitters like DOPAMINE, SEROTONIN,
and Glutamate
• Psychologic theory= poor mother-child
relationship
• Socio-Cultural= low socio economic
• Psychoanalytic theory= weak ego, person is
utilizing ego defense mechanism excessively
• Organic theory   
• CAUSES
• GENETIC LINK
• The probability of two parents, neither of whom
has the disease – 1 percent
• The probability of one parent with the
disease is approximately 35 percent 
• Onset
• Onset by age – three-quarters- develop the
disease between 16 & 25 years of age. – onset
is uncommon after age 30, & rare after age 40
• Onset by Sex – in the 16-25 - men than women.
• In the 25-30- higher in women

• CAUSES
• Environmental and Psychosocial process
•  
• Socio-economic status= usually of the low status
• Stress-Vulnerability model- clients with
schizophrenia may have a genetic, biologic and
psychological vulnerability to schizophrenia


 Causes
• Seasonality of birth- those born winter and early
spring.
• Northern hemisphere- USA, Jan – April
• Southern Hemisphere- Phil, July to Sept.
• Suicide – common cause of death, assoc. with mood
d/o –depression.

• Causes
• Risk Factors Suicide
• Depressive symptoms
• Young age
• High levels of premorbid functioning
• esp. college education
• substance abuse- cigarettes about ¾ of the schizo
• associated with high dosages of antipsychotic drugs.
• Causes
• Cultural and socio-economic factors
• Down drift hypothesis- affected people move
into or fail to rise out of low socio economic
group because of the illness.
• Social Causation-stresses experience by the
members of the low socio economic group
contribute to development of schizophrenia

• COMMON QUESTIONS
• Is Schizophrenia inherited?
• Schizophrenia associated with a neurochemical
dysfunction in the brain?

• Does street drugs increase the risk of
schizophrenia?
• Are they violent?
• Are they suicidal?
• Can children have Schizophrenia?
• Does high level of family stress increase risk
of schizophrenia?
•  
• Types of Schizophrenia
• Paranoid Type
• Catatonic Type
• Disorganized type
• Undifferentiated type
• Residual type

• SUBTYPES OF SCHIZOPHRENIA
• Paranoid type:
•  
• PARANOID SCHIZOPHRENIA
• Psychotherapeutic interventions:
• CATATONIC TYPE
• Characterized by marked psychomotor disturbance, either
motionless (catatonic stupor) or excessive motor
activity (catatonic excitement)
•  
• CATATONIC TYPE
• Manifestations:
• Cataplexy (waxy flexibility) , stupor
• Extreme negativism ( motiveless resistance to all
instructions or maintenance of a rigid posture ) or
mutism.
• CATATONIC TYPE
• Peculiarities of voluntary movement. Stereotyped
movements, prominent mannerisms, or prominent
• CATATONIC TYPE
• PSYCHOSOCIAL INTERVENTIONS:
• DISORGANIZED TYPE
• Characteristics:
•  
• Disorganized speech
• Disorganized behavior
• Flat or inappropriate affect
• Does not meet the criteria for catatonic
type.
•  
• DISORGANIZED TYPE
• Also known as ‘hebephrenic”
• Posturing, mirror gazing and grimacing are
symptomatic of the disease.
• DISORGANIZED TYPE
• PSYCHOTHERAPEUTIC
INTERVENTIONS:
• Be consistent, honest & direct
• Encourage the patient to verbalize
feelings.
• Use active friendliness
• Arrange non-threatening activities
• Help patient become independent
• Reinforce proper grooming & hygiene
• Provide calm environment
• UNDIFFERENTIATED TYPE
• Characterized by mix schizophrenic
symptoms along with disturbances of
thought, affect & behavior
• With delusions, hallucinations, disorganized
speech & grossly disorganized/catatonic
behavior.
•  
• UNDIFFERENTIATED TYPE
• PSYCHOTHERAPEUTIC INTERVENTIONS:
• Gain trust
• Maintain eye contact
• Use passive friendliness
• Don’t reinforce hallucinations &
delusions
• RESIDUAL TYPE
• THE FOLLOWING CRITERIAS ARE MET:
• Absence of prominent delusions, hallucinations,
disorganized speech, & grossly disorganized or
catatonic behavior.
• Characterized by odd beliefs, unusual perceptual
experience.
• Presence of negative symptoms
•  
• RESIDUAL TYPE
• Emotional blunting
• Social withdrawal
• Eccentric behavior
• Illogical thinking
• Mild loosening of associations
• Psychotic Disorders
• Schizophrenia
• Schizophreniform disorder
• Schizoaffective Disorder
• Brief Psychotic disorder
• Shared Psychotic disorder
• Delusional Disorder
• Other psychotic disorder
• SCHIZOAFFECTIVE DISORDER
• have psychotic episodes with prominent mood
disturbances
• Etiology- unknown
• A variant of both schizo and mood d/o with
psychotic symptoms, but more likely to be
schizophrenics than mood d/o.

• Schizoaffective d/o
• Does not resolve into a mood d/o
• Treatment is anti-psychotics and mood
stabilizers
• Prognosis- better than schizophrenia but
worse than for a mood disorder.
• SCHIZOPHRENIFORM D/O
• Otherwise tagged as short course schizo
• Does not last for 6 months and does not
have social withdrawal as a symptom.
• Resembles schizophrenia
• Resolves within 6 months
• Either results to overt schizophrenia and /or
mood disorder.
• It is self limited

• Delusional Disorder
• Characterized by nonbizarre delusions without other
psychotic symptoms .
• Its rare , its cause is chronic
• Treatment is supportive
• Common in migrating individuals exposed to
psychosocial stressors.
• Associated with paranoid personality d/o
• Also called migration psychosis
• Brief Psychotic Disorders
• Full psychotic disorder that is short lived.
• Lasting for 1- 30 days
• Related to a stressor and/ or pregnancy
• Post partum psychosis- last 2-3 months
• Can occur without an antecedent
• Condition is self limited

• Management
• For the other psychotic disorders mgt is
supportive
• Establish rapport, talk to patient , prevent form
harming self and others.
• Trial medications could be given to alleviate
symptoms.
• MANAGEMENT for Psychotic d/o
• Antipsychotic drugs
• Psychosocial treatments
• Rehabilitation
• Individual Psychotherapy
• Family education
• Assessment
• Interview
• Mental Status Examination
• Common Behavioral Signs and Symptoms

• Disturbances in perception
• Illusion- misinterpretation of an actual external stimuli
• Hallucinations – false sensory perception in the
absence of external stimuli
• AUDITORY- most common
• VISUAL
• GUSTATORY
• TACTILE
• OLFACTORY
• Disturbances in thinking and speech

• Neologism – coining of words that people do not


understand
• Circumstantiality – over inclusion of
inappropriate thoughts and details
• Word salad – incoherent mixture of words and
phrases with no logical sequence
• Perseveration – persistence of a response to
a previous question
• Echolalia – pathological repetition of words
of others
• Aphasia – speech difficulty and disturbance
• Expressive , receptive or global

• Disturbances in thinking and speech

• Flight of ideas- shifting of one topic from


one subject to another in a somewhat
related way
• Looseness of association-incoherent
,illogical flow of thoughts (unrelated way)

• Clang association – sound of word
gives direction to the flow of thought
• Delusion – persistent false belief,rigidly
held
• Delusions of grandeur- special
/important in a way
• Persecutory-threatened
• Ideas of reference-situation/events
involve them
• Somatic- body reacting in a particular
way
•  
• Disturbances in thinking and speech

• Magical thinking – primitive thought process


thoughts alone can change events
• Autistic thinking – regressive thought

• Disturbances of affect

• Inappropriate – disharmony between


the stimuli and the emotional
reaction
• Blunted affect – severe reduction in
emotional reaction
• Flat affect – absence or near absence
of emotional reaction
• Apathy – dulled emotional tone
• Depersonalization – feeling of
strangeness from one’s self
• Derealization– feeling of strangeness
towards environment
• Agnosia – lack of sensory stimuli
integration
• Disturbances in motor activity
• Echopraxia – imitation of posture of others
• Waxy flexibility – maintaining position for a long
period of time
• Ataxia – loss of balance
• Akathesia – extreme restlessness
• Dystonia- uncoordinated spastic movements of the
body
• Tardive dyskinesia – involuntary twitching or muscle
movements
• Apraxia – involuntary un-purposeful movements
•  
• Disturbances in memory

• Confabulation – filling of memory gaps


• Déjà vu – 2nd time-like feeling
• Jamais vu- not having been to the place one has
been before
• Amnesia – memory loss (inability to recall past
events)
• NURSING INTERVENTION
• Place in a less stimulating environment
• Provide a calm environment, talk & appear calm.
• Provide safe and simple activities.
• Provide information boards with schedule and
refer to them when patient asks about activities
and routines so patient will learn to use them
as an orienting function.
•  
• Nursing intervention
• For Physical problems
• Place in a less stimulating environment
• Provide calm environment
• Provide safe and simple activities
• Assist with meeting the physical needs
• Nursing intervention
• For withdrawn patients
• Build a trusting relationship
• Initiate interaction and always
address name
• Gradually increase patient contact
• Do not force interaction. Sit in
silence if client is not ready
• Attend to physical needs
• Reinforce positive behavior
• Increase self-esteem

• Nursing intervention
• For extreme motor manifestation: Catatonia
• For hyperactivity, allow standing for a few minutes during
group discussions
• Provide a safe environment
• Encourage participation in activities that do not require fine
skills
• For extreme immobility: meet basic needs and protect
patient from others
•  
• Nursing intervention
• For Thought process disturbance
• Analyze the delusions
• Present reality
• For perceptual distortions
• DO NOT Agree or disagree with the delusions or
hallucinations
• Assess the content of the delusion and hallucinations
• Nursing intervention
• For suspiciousness and paranoia
• Establish a trusting relationship
• Regular time of meeting and discussion
• DO not argue with patient
• Avoid talking and laughing when client can see you but not hear
you
• Avoid touching
• If client think that food is poisoned, give him sealed foods and
open them in front
•  
• Nursing intervention
• For violent behavior
• Inform the client what the staff will do
• Stay out of striking distance
• Always watch the patient's hands
• Remove unnecessary furniture in the room
• Do not go into room alone
• Call staff for assistance
• DO NOT TOUCH client without approval
• If anger escalates= Place in quiet environment and give prn
• Prognosis
• Good prognosis Bad Prognosis
• Late onset Young onset
• Obvious precipitating No precipitating
• factors Factors
• Acute onset insidious onset
• Good premorbid, social Bad premorbid
• Sexual and work History
• Mood Disorder sx Withdrawn, autistic
• Married single, widowed
• Family hx of mood d/o family hx of schizo
• Good support system Bad support system
• Positive sx Negative sx
• Schizophrenia
• End of lecture
• Psychiatry Lecture 4
• Personality Disorder

What is Personality?

• “A pattern of behaving and relating to


self , others and the environment;
includes perception , attitudes and
emotions”.
• One is not usually aware of their own
personality.
• Personality can not be changed
overnight
• Characteristic of personality disorders
• Maladaptive traits are often RIGID and
INFLEXIBLE that exist in attitudes and
behavior of the person
• Features of PD
•  
• The Onset begins during adolescence and young
adulthood
• Features
• Characteristics
• Poor impulse control
• Acting out to manage internal pain
• Forms of acting out include physical and verbal attacks,
manipulation, substance abuse, promiscuous sexual
behaviors, and suicide attempts
• Types of Personality Disorders
• Prevalence of Personality Disorders
• 13.4 % prevalence rate
• Most common of which are the avoidant, schizoid and
paranoid personality disorders
• Etiologies of Personality Disorders
• Multi-causation; genetic and environmental factors
• TEMPERAMENT- emotional climate
• Biologic – hormonal

 Introvert type
• Assessment
• Social detachment and lack of close relationships
• Interest in solitary activities
• Aloof and indifferent
• Restricted expression of emotions
• Lack of interest in others
• Schizotypal personality disorder
• Description: Exhibits abnormal or highly unusual
thoughts, perceptions, speech, and behavior
patterns.
• Slight losses of reality
• Odd thinking , aloof and withdrawn
• Discomfort in close relationships
• Cognitive and perceptual distortion

• Schizotypal personality disorder
• Assessments
• Magical thinking
• Odd thinking and speech
• Relationship deficits
• Paranoid personality disorder
• Description:
• Characterized by suspiciousness and
mistrust of others
• Envy , jealousy, rigidity, excessive
self importance
• A tendency to blame and to ascribe
evil things to others.
• Paranoid personality disorder
• Assessment
• Suspicious and distrusting
• Argumentative
• Hostile aloofness
• Rigid, critical, and controlling of others
• Grandiosity
• Histrionic personality disorder
• Description
• “OA”
• Lively and dramatic and enjoys being the
center of attention
• Emotional instability, excitability,
overactivity, vanity, immaturity,
dependency and seductive.

• Histrionic personality disorder


• Assessment
• Marlon’s Syndrome
• Attention seeking
• Needs to be the center of attention
• Sexually seductive or provocative
• Self-dramatizing and theatrical
• Overly concerned with appearance
• Has romantic fantasies and controls partners
• Bores easily
• Displays dependency
• Narcissistic personality disorders
• Description
• Increased sense of self-importance
• The client is preoccupied with fantasies and unlimited
success and has a constant need attention and
admiration.

• Narcissistic personality disorders


• Assessment
• Grandiosity
• Requires admiration and inflated accomplishments
• Overestimates abilities and underestimates
contributions of others
• Lacks empathy and sensitivity to needs of others
• Avoidant personality disorder

• Description:
• Characterized by social withdrawal and extreme
sensitivity to potential rejection.
• Low energy, easy fatigability, lack of enthusiasm, and
inability to enjoy life.
• Oversensitivity to stress
• Avoidant personality disorder Assessment
• Feelings of inadequacy
• Hypersensitive to reactions of others and
reacts poorly to criticism
• Social inhibition
• Lack of support system
• Dependent personality disorder
• Description
• The individual lacks self-confidence and the
ability to function independently
• Passively allows others to make decisions
and assume responsibility for major areas
in his or her life.
• Passive and submissive behavior.
• Dependent personality disorder
• Assessment
• Difficulty making decisions
• Lacks autonomy
• Cannot tolerate being alone and
must always have a close
relationship
• Needs others to assume
responsibility and make decisions

• Obsessive-compulsive personality disorder
• Description
• The client has difficulty expressing warm and
tender emotions and reflects perfectionism,
stubbornness, the need to control others, and
a devotion to work.
• Rigid, overconscientious, overdutiful, unable to
relax.
• Obsessive-compulsive personality disorder

• Assessment
• Orderliness and perfectionism
• Overly conscientious
• Inflexible and preoccupied with details and rules
• Devoted to work and lacks leisure activities and
friendships
• Miserly and stubborn
• Antisocial personality disorder

• Description
• A pattern of irresponsible and antisocial
behavior
• Characterized by selfishness, inability
to maintain lasting relationships, poor
sexual adjustment, and failure to
accept social norms, irritability, and
aggressiveness.
• Low level of frustration tolerance,
blames others, incapable of loyalty,
selfish and irresponsible.
• Antisocial personality disorder

• Assessment
• Perceives the world as hostile
• Superficial charm and hostility
• No shame or guilt
• Self-centered
• Unreliable
• Easily bored
• Poor work history
• Unable to tolerate frustration
• Views others as objects to be manipulated
• Poor judgment
• Impulsive
• Borderline personality disorder

• Description
• Characterized by instability in
interpersonal relationships, mood,
and self-image
• Behavior may be impulsive and
unpredictable .
• Chaotic sexuality, suicidal acts, self
mutilation, identity problems.


• Borderline personality disorder
• Assessment
• Unclear identity
• Easily angered
• Easily bored
• Argumentative
• Depression
• Self-destructive behavior
• Manipulation
• Unable to tolerate anxiety
• Chronic feelings of emptiness and
fear of being alone
• Splitting

• Passive-aggressive personality
disorder
• Description
• Characterized by passively
expressing covert aggression rather
than dealing with it directly
• The behavior can interfere with both
social and work activities

• Passive-aggressive personality disorder


• Assessment
• Procrastination
• Stubbornness
• Intentional inefficiency
• Forgetfulness
• Dependency
• Implementation for PD
• Nursing Interventions
• Maintain safe environment
• Develop a written contract with patient
• Establish therapeutic relationship
• Maintain objectivity and consistency
• Set limits to behavior

• Interventions for PD
• Treatment is a long tiring process
• Help the patient learn ways to reduce
anxiety
• Limit setting
• Develop a written contract
• Encourage to keep journal
• Recognize and deal with manipulative
behavior
• Discuss feeling rather acting out
•  
• End of lecture
• Personality disorders
• Unipolar Disorders
• Major Depressive Disorder
• 1. Diagnosed after a major episode of
depression.
• 2. Criteria MDD
• 3. Mood- depressed mood most of the day
everyday
• 4. Sleep-insomia or hypersomia
• 5. Interest- decrease interest and pleasure in
activities.
• 6. Guilt- feelings of inappropriate guilt and
worthlessness.
• 7. concentration-Decreased
• MDD
• 8. Appetite- increased or decrease appetite,
weight gain or loss.
• 9. Psychomotor retardation
• Requirements:
• 5 or more of the above symptoms present for 2
weeks duration.
• 1 symptom must be depressed mood or lack of
interest or pleasure
• Should not be secondary to substance- induce,
bereavement and medical condition.
• Sad Person Scale
• Suicide Risk
• Sex- most attempts- Female
• most successful- males- lethal
• Age- <18 >60- suicide prone
• Depression- Within the 2-3 weeks period before
antidepressant took effect
• Previous attempts- likely to repeat and be successful
• Ethanol- most vulnerable
• Rational thinking- Impaired
• Social Support- Impaired
• Organized Plan- giving away valued possession
• No spouse, or worse nagging spouse
• MDD
• Etiology
• Interpersonal losses- actual and perceived, most
common
• Genetic – more often in monozygotic twins than
on dizygotic twins
• Neurotransmitter- deficiencies of
norepinephrine and serotonin.
• Most universal complains- sleep disturbances
• Mgt. Psychotheraphy and Pharmacotheraphy
• MDD
• Key points
• A unipolar disorder
• Recurrent
• 15% suicide rate
• Managed by combined psychotheraphy and
pharmacotheraphy
• Unipolar Disorder
• Dysthymic Disorder
• Mild but chronic form of major
depression.
• Minimum of 2 years of
chronically depressed mood
associated with changes in
appetite, sleep and fatigue,
decrease concentration and
hopelessness.
• Key points
• A unipolar mood d/o
• It is chronic lasting for 2 years

• Bipolar Disorder
• Bipolar I- most serious, diagnosed after atleast
1 episode of mania.
• They also have major depressive episodes in the
course of their lives.
• Epidemiology- male/female ratio is equal
• Criteria for mania
• 3-4 of the following are required during the
elevated mood period.
• Self-esteem: highly elevated, grandiosity
• Sleep: decreased need for sleep
• Speech: pressured
• Thoughts: flight of ideas
• Attention: easy distractibility
• Activity: increased goal directed activity
• Hedonism: high excess involvement in
pleasurable activities ( sex, spending, travel).
• Bipolar I disorder
• Management: persons experiencing a
manic episode often have poor
insight and resist treatment.
• Anti psychotics- positive and negative
Sx.
• Benzodiazepines- rapid tranquilization
• Mood stabilizers- lithium
• ECT- medication intolerance, for
immediate response.
• Psychotheraphy- to encourage
medication compliance.
• Key points
• Bipolar I- biphasic mood disorder
• It is cyclic
• Suicide rate 10-15%
• Bipolar II
• Almost the same as that of the
bipolar I except that mania is not
found.
• Hypomania- a milder form of
elevated mood is essential for
diagnosis.
• Epidemiology- more common in
women
• Hypomania is determined by the
same symptom complex as mania
but the symptom as less severe,
cause less impairment, and
usually does not require
• Bipolar II
• Key points:
• Bipolar II disorder is a biphasic
mood disorder with hypomania.
• Its is recurrent
• Suicide rate of 10-15%
• Cyclothymic Disorder
• A recurrent , chronic mild form of
bipolar disorder in which mood
typically oscillates between
hypomania and dysthymia.
• Epidemiology- equal in male and
female.
• Mgt: psychotherapy, mood
stabilizers and anti depressant.

• Key points:
• Cyclothymic disorder is a biphasic mood
disorder without frank mania and
depression.
• It is chronic and recurrent.
• Mood Disorders with known etiology
• Substance induced
• Are diagnosed when medications, other
psychoactive substances, ECT or
phototherapy are proximate events that
led to the occurrence of mood
disturbance. Both unipolar and bipolar
symptoms may occur.
• Due to General Medical condition
• Caused by medical illness, endocrine d/o
such as thyroid and adrenal
dysfunctions. Postpartum etiologies are
• Subtypes and Modifiers
• Melancholic- severe form of depression
associated with guilt, remorse, loss
of pleasure and extreme vegetative
symptom.
• Postpartum-occurs within 4 weeks
after delivery. Presence of one
episode is indicative of recurrence.
• Seasonal-worsening depression at fall
and winter and improvement at
spring.
• Atypical-atypical depression show a
pattern of hypersomia, increased
appetite or weight gain, mood
reactivity, long standing rejection
sensitivity.
• Rapid Cycling- criteria for rapid cycling
includes, 4 mood disturbances/year.

• Nursing Intervention
• Determine what the client is
attempting to tell
• Assist client on focusing on a topic
• Provide quiet environment, decrease
stimuli
• Stay with client, use silence
• Remove harmful objects
• Be accepting to hostile statements
• Do not argue with client
• Use distraction to divert client from
behavior that are harmful to self and
others
• Set limits on disruptive behavior
• Offer finger foods, high nutrition foods

• Mood Disorders
• Nursing Intervention
• Monitor I and O.
• Weigh client regularly
• Maintain a schedule of regular
appointments
• Contact with client to report suicidal
ideation, impulses, plans, and check
client frequently
• Encourage discussion of
negative/positive aspects of self.
• Encourage change to more positive
topics if self-deprecating thoughts
persist
• Administer Anti-Dep meds

• ELECTROCONVULSIVE THERAPY
• An effective treatment for depression
• Inducing a grand mal (tonic-clonic)
seizure
• The administration of a muscle
relaxant minimizes seizure activity,
preventing damage to long bones
and cervical vertebrae
•  
• ELECTROCONVULSIVE THERAPY
• At-risk clients include:
• Those with recent myocardial
infarction
• cerebral vascular accident
• cerebral vascular malformation
• ECT
• Uses
• Manic clients whose conditions are
resistant to lithium and antipsychotic
medications
• Clients with schizophrenia (especially
catatonia), and psychotic clients.
• ECT
• Indications for use
• When antidepressant medications have
no effect
• Client is suicidal or homicidal
• The client is in extreme agitation or
stupor
• History of poor medication response
and good ECT response, or both
• ECT
• The usual course is 6-12 treatments in
• 2-3x per week
• MAINTENANCE ECT once a month
• Usual relief is seen after 2-3 ECTs
• If after 12 treatments, no relief is seen,
ECT is not anymore recommended
• ECT: Pre-procedure
• Pre-procedure
• Explain the procedure to the client
• Encourage the client to discuss
feelings, including myths regarding
ECT
• Discuss to the client and family what to
expect
• Informed consent must be obtained

• ECT: Pre-procedure
• Pre-procedure
• NPO 6-8 hours
• Baseline vital signs are taken
• The client is requested to void
• Hairpins, contact lenses, and dentures are
removed
• Administer preoperative medication if
prescribed; atropine sulfate may be
prescribed to prevent aspiration and brady-
arrhythmias
• ECT: DURING procedure
• Intra-procedure
• The nurse must obtain an IV line
• BP and Vitals taken
• ECG and EEG electrodes are attached to the
body
• ECT: DURING procedure
• Intra-procedure
• Oxygen is given by mask
• Tongue guard may be placed on the
mouth
• 110-150 volts of electricity is
delivered for 0.5 to 2 seconds to
initiate a tonic clonic seizure,
usually lasting for 1-minute
• ECT: POST procedure
• POST procedure
• Monitor vital signs
• RE-ORIENT the client when he is
awake
• Provide reassurance that the
• ECT: POST procedure
• POST procedure
• NPO temporarily and introduce foods
once GAG reflex will return
• Potential side-effects
• Confusion
• Disorientation
• Short term memory loss- which may
last up to 6 months
• Fractures
• Arrhythmias
• Personality/ Mood Disorders
• End of lecture
• RONALD L. HILARIO RN,MD,DPCOM
• PROFESSOR COLLEGE OF NURSING

• Psychiatry Lecture 5
• Eating disorders
• Substance abuse
• Child abuse
• BWS
• Elderly abuse

• Eating Disorders
• Bulimia Nervosa
• Anorexia Nervosa
• Other eating disorders
• Eating Disorders
• Significant health problem among children, adolescents and
young WOMEN
• 1% of young women ages 12 to 25 affected by anorexia
nervosa
•  
• Eating Disorders: Epidemiology
• Affects more women than men
• Depression commonly affects the clients
• Anorexia= 1%
• Bulimia= 3-5%
• Eating Disorders: Etiology
• 1. Socio-cultural= thinness is promoted by media and
culture
• 2. Cognitive-behavioral= obsessive compulsive behavior
and avoidant behavior are vulnerable to eating disorders
• Eating Disorders:
• Anorexia
• Weight less than ideal
• Intense fear of becoming fat
• Body image disturbance
• Engages in exercise and peculiar food
habits
• Lack of sense of control
•  
• Eating Disorders: Personality traits
• Anorexia
• Prefers HEALTH food
• Preoccupation with buying and
preparing foods
• Rigorous exercise
• Anorexia Nervosa
• A syndrome manifested by self-induced starvation
resulting from FEAR of fatness rather than from true
loss of appetite.
• Onset: adolescent years
• Female more than male
• Anorexia Nervosa
• The onset is often associated with a stressful life event
• 21 % mortality
• Anorexia Nervosa
• FEATURES of Anorexia Nervosa
• Relentless pursuit of thinness
• Amenorrhea
• Refusal to maintain ideal weight
• Distorted body image
• Fear of loss of control
• Alexithymia: lack of awareness, mistrust of others
and self, starvation-induced depression
• Anorexia Nervosa
• FEATURES of Anorexia Nervosa
• The patient is pre-occupied with foods that
prevent weight gain
• They are usually the achievers and perfectionist
•  
• Death usually occurs from starvation, suicide or
electrolyte imbalance
• Anorexia Nervosa: FINDINGS
• Refusal to eat
• Loss of appetite
• Feelings of lack of control
• Self-induced vomiting and self administered
enema
• Excessive exercise
• Weight Loss

• Bulimia Nervosa
• Literally means “ravenous appetite”
• A syndrome of binge eating followed
by self-induced vomiting or
“purging”
• More prevalent than AN
• Has LATE onset than AN
•  
• Bulimia Nervosa
• The client indulges in eating
binges followed by purging
behaviors 
• Most of them feel that their lives are dominated
by the eating-related conflict
• Bulimia Nervosa
• The measures to gain weight control include use of
laxative, cathartics, enemas, and diuretics
• The patient may resort to periods of strict dieting,
fasting and strenuous exercise
• WEIGHT MAY BE NORMAL!!!! Or underweight or
overweight
• Bulimia Nervosa
• Physical Features of the BN
• Thin body with swollen cheeks due to enlarge salivary
glands
• Signs of fluid retention
• Erosion of the tooth enamel
• Skin is dry with cuts and abrasions over the knuckles
(Russel’s sign)

• Bulimia Nervosa
• Features of the BN
• Pre-occupied with body shape and weight
• Consumes high calorie food in secret with guilt about
secretive eating
• Attempts to lose weight through diets, vomiting, laxatives
enemas, cathartics, amphetamines and diuretics
• Low self-esteem and mood swings
• Self-mutilating behavior: suicide thoughts and attempts at
suicide
• Other Eating Disorders
• 1. PICA= persistent eating of a non-nutritive substance.
This is considered acceptable for children less than 18
months. This is believed to be due to ZINC and IRON
deficiencies or related to lack of parenteral supervision
• Other Eating Disorders
• 2. RUMINATION= eating disorder characterized by repeated
regurgitation of food with resultant weight loss or failure
to gain weight
• ASSESSMENT
• Psychosocial assessment begins when the nurse
establishes a trusting relationship with the
client and families
• The nurse must identify the reason for
hospitalization and a complete family
assessment
•  
•  
• The Nursing Process for Eating Disorders
• DIAGNOSES
• Imbalanced Nutrition: Less than body
requirements related to dysfunctional eating
patterns
• Disturbed body image related to fear of weight
gain
• Powerlessness related to lack of control over
food avoidance
• Anxiety
• The Nursing Process for Eating Disorders
• PLANNING
• To maintain ideal body weight
• To provide insight and teach coping
skills
• The Nursing Process for Eating Disorders
• IMPLEMENTATION for Anorexia Nervosa
• Weight the patient at specific and
regular intervals (About 2x-3x a
week) with minimal clothing (hospital
gown), patient facing away from the
weighing scale
• Provide for safety and physical needs
• STAY with the patient and observe her
within 1 to 2 hours AFTER EATING
• The Nursing Process for Eating Disorders
• IMPLEMENTATION for Bulimia
• 1. Encourage development of
behavioral diary
• 2. Encourage expression of feelings
• 3. Educate about the physical
consequences of binging, self-
induced vomiting and use of drugs
• 4. Limit exercising, frequent weighing
and obsessive caloric counting
• The Nursing Process for Eating Disorders
• IMPLEMENTATION for Bulimia
• 5. Stay with client after eating for 1-2
hours
• 6. Use positive affirmations
• 7. Reinforce healthy coping
• General Interventions
• Assess the client’s nutritional status
• Establish a CONTRACT with the client
concerning the diet plan for the day
• Assist the client in identifying
precipitators of the eating disorder
• Encourage the client to state feelings
about the eating behavior
• Encourage behavior modification
• General Interventions
• Convey an accepting and non-judgmental
attitude
• Provide POSITIVE reinforcement for
accomplishments
• SUPERVISE client during mealtimes and
few hours after
• SET A TIME LIMIT FOR EACH MEAL
• General Interventions
• Monitor for signs of physical complications
related to the eating disorder
• WEIGH client daily with same scale, same
time, same clothing (hospital gown) and
AFTER VOIDING
• Encourage participation in diversional
activities
• ASSESS AND MANAGE SUICIDAL
BEHAVIORS
• General Interventions
• LIMIT SETTING:
• Restrict use of bathroom for 2 hours after
eating
• Accompany to bathroom to ensure that
they will not self-induce vomiting
• Stay with client during meals
• General Interventions
• DIET
• HIGH protein
• HIGH carbohydrates
• Serve foods preferred by patient
• Small frequent feedings
• NGT if patient refuses to eat
• General Interventions
• DRUG
• Antidepressant drugs may be given after
correcting the electrolyte and nutritional
imbalances
• Treatment modalities for Eating disorders
• PSYCHOTHERAPY
• Individual psychotherapy= anorexia is
considered food phobia. Goal of therapy
is to remove the phobia, restore weight
• FAMILY therapy
• Helping family define the problem in the context of
eating behaviors
• Treatment modalities for Eating disorders
•  
• PHARMACOTHERAPY
• Fluoxetine (Prozac)
•  
• NUTRITIONAL THERAPY
• Dietician should be consulted
•  
•  
• The Nursing Process for Eating Disorders
• EVALUATION
• Evaluate response to treatment
• Bulimia should have abstained from purging and
decrease time to count the calories of food
• Anorexia nervosa should stabilize her weight without
loss and able to ingest food
• ASSESSMENT
• Behavior and/or Appearance
• Signs of intoxication include smell of alcohol, slurred
speech, loud talking, loss of inhibition, loss of
coordination, and poor judgment.
• Sudden onset of signs of withdrawal
• Frequently talks or brags about alcohol use
• Justifies drinking or the need to drink
• Refuses to discuss drinking habits
• Drinks large quantities of alcohol
• Overacts to questions on drinking pattern.
•  
• Mood and/or Emotions
• Depressed
• Remorse after a binge
• Low frustration tolerance
• Anxiety
• Low self-esteem
• Thoughts, Beliefs, and Perceptions
•  
• Evidence of defense mechanisms of denial,
rationalization, projection
• Hallucinations ***
•  
• Diagnosis of alcohol intoxication is by serum
toxicologicscreening , (BAL).100-150mg/dl, .
15% at .40% respiratory depression and
death ensues
• Epidemiology- lifetime prevalence of 14%
• Male/female ratio- 4:1
• Etiology- male >female with family history.
• relatives are more likely to have
depression or ASP d/o.
• Multifactorial- genetics, environment, family
rearing all play a role.
• Neuropsychiatric complications
• Wernicke-Korsakoff syndrome- Thiamine
deficiency
• Triad of: (NAM)- (CN6 )Nystagmus, Ataxia,
Mental confusion.- acute and irreversible
• Mgt: injection of vit. B1- 100mg IM
• Sources : Pork meat
• If not manage will progress to – Korsakoff
Psychosis
• Korsakoff psychosis- anterograde amnesia,
confabulation.
• Most commonly irreversiblein 2/3 of patient
• Other pharmacological management
• Oral vitamine supplement- folate 1 mg/day and
100 mg thiamine
• Before patient is given any glucose
• Alcohol withdrawal syndromes
• Minor withdrawal “ The Shakes”, begin 12 – 18
hours after cessation of drinking peak at 24-

• Characteristics:
• Tremors, nausea , vomiting, tachycardia
and hypertension.
• MGT: Benzodiazepine Chlordiazepoxide
(Librium)
• Oxazepam (serax) and tapered through
period of days.
• Major Withdrawal
• Alcoholic Seizures- (“RUM FITS”) – 7- 10
hours after cessation of drinking and
peaks at between 24 – 48 hours and may
lead to status epilepticus.
• Alcoholic seizures precedes delirium
tremens .
• MGT: IV Benzodiazepine, prophylaxis
Phenytoin (Dilatin)
• Alcoholic Hallucinosis- 48 hours after

• MGT of alcoholic hallucinosis- neuroleptic


drug-
• Haloperidol (Haldol) 2.5 mg BID
• Alcohol Withdrawal Delirium ( Delirium
Tremens)
• A life-threatening condition manifested by
Delirium (perceptual disturbances,
confusion or disorientation, agitation),
autonomic hyperarousal, and mild fever.
• Affects 5% of hospitalized patients.
• Begins 2-3 days after cessation of alcohol.
• MGT: IV benzodiazepines, supportive care
• Alcohol Rehabilitation:
• Goal: Sobriety and Psychopathology
• Alcoholic Anonymous- (AA) world wide self
help group

• Anxiety is common in first 2-4 weeks of


treatment.
• Disulfuram ( Antabuse)- inhibits aldehyde
dehydrogenase enzyme, aldehyde
accumulates in blod steam causing Flushing ,
nausea and vomiting, palpitations and
hypotension.
•  
•  
• Patient and Family Education
•  
• Provide dieting information on good diet, vitamins,
and so on.
• Provide information to patient and family on
managing potential seizures.
• Provide health teaching on the potential if
gastrointestinal bleeding and liver disease.,
Diabetes
• Child Abuse
• intentional, physical, emotional, and/or
sexual misuse/trauma, or intentional
omission of basic needs (neglect); usually
related to diminished/ limited ability of
parents to cope, provide and relate to
child.
• High risk for premature children, under 3
y/o, with physical and mental disabilities.
• Assessment
• Inconsistency of type / location of injury
• Severe CNS or abdominal injuries
• Obvious disturbance in parent-child
interaction
• Sexual abuse
• Emotional neglect

• Nursing Management for Child


Abuse
• Provide for physical needs first
• Mandatory reporting of identified or
suspected cases to appropriate
agencies
• Non-judgmental treatment of parents
• Provide emotional support for child;
“play therapy “
• Provide role modeling to parents
• Documentation should reflect what the
nurse saw or was told, not the nurses
interpretation or opinion.

• Elder Abuse
• Assessment
• Battering, fractures, bruises
• Over/under medicated
• Absence of needed dentures/glasses
• Poor nutritional status, dehydration
• Physical evidence of sexual abuse
• Urine burns, pressure ulcers
• Nursing Management
• Provide for safety
• Provide for physical needs first
• Report to appropriate agencies
• Initiate protective placement or appropriate
replacement

• Battered Wife syndrome
• a form of cyclic domestic violence
• Men: low self esteem
• Women dependence
• Characteristics of abusive husbands
• > they come from violent families
• > immature, dependent and non assertive
• > strong feelings of inadequacy
• Tx: counselling
•  
•  
• Document vital signs and any evidence of symptoms of
withdrawal and delirium.
•  
• Describe in detail the description of the patient’s level of
consciousness and mental status.
•  
• Document the patient’s response to the medications being used
for withdrawal

• Cont’ ( Charting Tips)
•  
• Document the family’s response to
patient behavior.
•  
• Document any observations of continued
alcohol use.
•  
• Document any actions taken to prevent
violent
• behavior.
•  
• If restraints, reason they were applied,
the patient’s response to treatment,
when limbs were released, and the care
given while in restraints.
•  
• CHILDHOOD DISORDERS
• 2.Rett`s Disorders- loss pf speech and motor skills, and a
decrease in head growth.
• 3. Asperger`s disorder- stereotyped behavior with some ability
to communicate
•  
• Mental Retardation
• Levels of mental retardation
• Mild/ Moron- IQ: 50-70- Educable
• Moderate/ Imbecile- IQ- 35/50 -trainable
• Severe/Idiot- IQ 25-50
• Needs close supervision
• 4. Profound-Below 20-25- custodial care
•  
•  
• Attention Deficit Hyperactivity d/o
•  
• Drug of Choice-
• Methylphenidate ( Ritalin)

• TOURETTE`S DISORDER
• A Rare disorder in which the child demonstrates multiple
involuntary motor and vocal tics.
• Tic- a sudden, rapid, recurrent, non-rythmic, stereotyped
motor movement or vacalization.
• Epidemiology- 0.4% of Population
• M/F ratio: 3:1
• Etiology- familial, occurs with obsessive –compulsive
disorders.
• Tourette`s disorder
• Onset- before 18 y/o
• Vocal tic- are usually loud, grunts or barks, shouting words,
(coprolalia) obscene words- has uncontrollable urge to
say them.
• Motor tics- facial grimacing, tongue protrusions, blinking ,
snorting, or movements of body and extremities.
• MGT: Child and family education
• Supportive psychotheraphy
•  
• Cognitive Disorders/
Organic Mental Disorder
• Delirium
• Dementia
• Alzheimer’s Disease

• DELIRIUM
• Delirium is a disorder of attention and
• cognition.
• It has a abrupt onset and variable course.
• It has an identifiable precipitant.
• 1- year mortality rate is greater than 40%.

• Delirium
• Etiology:
• Most commonly cause by medical condition;
substance intoxication and withdrawal are
common causes. Ex. Mild anemia, hypoxia,
hyponatremia
• Common substance abuse causes are alcohol
and benzodiazepine.
• Other conditions old age, fractures, preexisting
dementias.
•  
• Delirium
• Key features
• Disturbances of consciousness, especially
attention and level of arousal
• Alteration in cognition, especially memory,
orientation, language and perception.
• Delirium
• Management:
• Keep the patient free from harm
• Due to medical condition- treat the
illness
• Remove or stop the medication causing
delirium or replace or taper dose.
•  
• Dementia
• Dementia is a disorder of memory
impairments coupled with other
cognitive defects.
• A gradual onset and progressive
course
• Maybe caused by a variety of illness
ex. Alzheimer`s disease, HIV
• Dementia
• Etiology: Brain neuronal loss due to neuronal
degeneration, or cell death secondary to trauma,
infarction, hypoxia, infection and hydrocephalus.
• Epidemiology: 2%-4% after age 65y/o
• Increased to 20% at age 85 y/o.
• Diagnosis: memory loss is required
• plus 1 or more of the cognitive defects;
• aphasia, apraxia, agnosia
• Dementia
• Causes:
• Alzheimers- most common, 50%
• Risk factors- familial, downs syndrome, prior head trauma,
increasing age.
• Post mortem- neurofibrillary tangles, cortical atrophy,
course is progressive- mortality 8-10 years after
diagnosis
• Vascular- 2nd most common cause,
• Risk – cardiovascular and cerebrovascular disease-
• Neuro imaging- neuronal damage
• Deficits are not reversible
• HIV- limited to those with HIV in the brain associated with
• Dementia
• Head Trauma- most common cause in young
males, deficits are stable unless there is
repeated head trauma.
• Parkinson`s-20-60% wit the disease.
• Due to lewy bodies disease
• Bradyphrenia-Slowed thinking
• Huntington`s disease- familial, autosomal
dominant on chromosome 4,
• Onset mid 30`s, emotional lability, Caudate
atrophy present on autopsy.
• Dementia
• Pick`s- onset – 50-60 y/o, frontal and temporal
atrophy, dementia responds poorly to
psychotropic medications.
• Creutzfeldt-Jacob- 10% familial, prions are agent
of transmission.
• Triad: Dementia, myoclonus, abnormal EEG
• Rapidly progressive course
• Dementia vs Delirium
• Dementia vs Delirium
• Sundowning- Nocturnal worsening of dementia, increased
agitation and confusion.
• Nursing Management
• Minimize sensory stimulation
• Provide orientation
• Proper lighting (Sundowning effect)
• Safety in physical care
• Self care (as much as possible)
• Drug administration (antibiotic/ anti-psychotic)
• Helping people with dementia and their families
• Maintaining a familiar environment helps a person stay
oriented
• Hiding car keys and placing detectors on doors may help
prevent accidents for those who wanders. Identification
bracelet is also helpful.
• Establish a regular routine for bathing, eating, sleeping,
and other activities.
• Regular contact with familiar faces.
• Scolding and punishing a person does not help, and it may
make matters worse.
• Enlisting the aid of organizations that provides social and
• Pharmacology in Psychiatry
• Pharmacology
•  
• Goal - To administer the medication and
dosage that will maximize the therapeutic
effects and minimize the side effects.
• Pharmacology
• Psychotropic medications
• chemicals that produced profound effects on
mind, emotions and body.
• 3 major psychotropic drugs.
• antimanic
• anti psychotic
• anti depressant

• Pharmacology
• Anti anxiety/ anxiolytic drugs
• Uses: Treatment of anxiety, alcohol withdrawal,
induction of sleep
• Effects : depresses the CNS
• Preparation: oral and IV preparations
•  
•  
• Benzodiazepines → ↑ GABA act.
• (inhibitory neurotransmitter in CNS)
• ↓
• opening Cl ion channel
• ↓
• inhibition of neuronal activity
• ↓
• ↓ firing rate of neurons
• ↓
• ↓ anxiety.

• Types
• A. Benzodiazepines
• Short acting
• Alprazolam (Xanax)
• Estazolam ( Prosan)
• Midazolam ( Versed, Dormicum)
• Oxazepam ( Serax)
• Triazolam ( Halcion)
• Medium acting
• Lorazepam ( Ativan)
• Temazepam ( Restoril)
• Long acting
• Chlordiazepoxide ( Librium)
• Clonazepam ( Klonopin)
• Clorazepate ( Tranxene)
• Diazepam ( Valium)
• Flurazepam ( Dalmane)
• Quazepam ( Doral)

• Pharmacology
• B. Non barbiturate
• Buspirone ( Buspar)
• Chloral hydrate ( Noctec)
• Diphenhydramine ( Benadryl)
• Doxylamine ( Unisom)
• Hydromxyzine ( Atarax. Vistaril)
• Zolpidem ( Ambien)
• C. Antidepressant for anxiety
• Clomipramine ( Anafranil)
• Fluoxetine ( Prozac)
• Fluvoxamine ( Luvox)
• Paroxetine ( Paxil)
• Sertraline ( Zoloft)
• Venlafaxine ( Effecxor XR)

• void abrupt discontinuation after prolonged
use
•  
• otgive if ↑ BP, renal/hepatic dysfunction or
hx of drug abuse
• anax, Ativan, Serax- a few examples
•  
• ncrease in 3D’s –drowsiness, dizziness,
decreased BP
•  
• nhances action of GABA (inhibitory
transmitter)
•  
• each to rise slowly from supine
•  
• Pharmacology
• Neuroleptics/ Antipsychotic
• Uses- for psychosis
• Actions: Blocks Dopa receptors - CNS.
• block muscarinic receptors for acetylcholine,
and alpha receptors for acetylcholine.
• Preparation: IV, IM, Oral
• taken with benzodiazepines – to lessen the dose
• Effects seen within 1-2 weeks of treatment
• Pharmacology
• These drugs are beneficial for
• 1. Positive symptoms ( Type I) – Hallucinations
and delusions
• Respond to newer and traditional antipsychotic
drugs.
• 2. Negative symptoms ( Type II) – Apathy, flat
affect are more responsive to
• Newer atypical anti psychotic drugs.
• Pharmacology
• Traditional drugs/ Typical drugs
• Phenothiazines
• aliphatics- Chlorpromazine ( Thorazine)
• Piperidines - Thioridazine ( Melleril)
• Piperazines- a. Fluphenazine ( prolixin, permitil)
• b. Perphenazine ( triaflon)
• c. Prochlorperazine-
( Compazine)
• B. Butyrophenones : Droperidol ( Inapsine)
• Haloperidol ( Haldol)
• C. Thioxanthines : Chlorprothixene
( Taractan)
• Thiothixene ( Navane)
• D. Dibenzoxapine : Loxapine ( loxitane)
• E. Dihydroindolone Molindone ( Moban)
• Pharmacology
• Atypical drugs
• Dibenzodiazepine-
• Clozapine ( Clozaril)
• Quetiapine ( Seroquel)
• B. Benzisoxazole- Respiradone
( Resperdal) Ziprasidone
( Zeldox, Geodon)
• C.Thienobenzodiazepine-
Olanzapine ( Zyprexa)

• Pharmacology
• Precaution:
• Drug interactions
• Potentiate action of alcohol barbiturates,
antihypertensives and anti cholinergics- must
be avoided
• Should be temporary discontinued when spinal
and epidural anesthesia will be used.
• Adverse Effects
• Agranulocyctosis- sore throat, colds
• Hepatotoxicity- Jaundice
• Drowsiness- CNS depression
• Orthostatic hypotension- CNS depression
• Constipation and urinary retention-
anticholinergic effect
• Anorexia- depressed appetite centers
• Hypersensitivity reactions
• Cardiac toxicity
• Pharmacology
• If conditions disappears with sleep- all anti
psychotics should be discontinued to see if
symptoms subside.
• Neuroleptic malignant syndrome- results from
dopamine blockade in the hypothalamus-
associated with high dosage of anti psychotic
drugs.
• Symptoms- Hyperthermia ( cardinal symptom)
• Muscular rigidity
• Tremors
• Impaired ventilation
• Unstable blood pressure
• Anti Parkinson drugs
• Blocks the extrapyramidal symptoms.
• Anti cholinergics- Benztropin ( Cogentin),
Biperiden (Akineton)
• Trihexyphenidyl ( Artane)
• Antihistamine- Diphenhydramine
• Pharmacology
• Extrapyramidal Side effects (EPS)
• Dystonia- early in treatment – after initial
dosage
• - grimacing , torticollis,
intermittent muscle spasms.
• Pseudoparkinsonism- resembles true
parkinsonism
• Manisfestation- tremor, mask like facies,
drooling , restlessness, festinating gait,
rigidity.
• Akathisia- motor agitation- restlessness ,
rigidity.
• Akinesia- fatigue, weakness, ( hypotonia,
painful muscles, lack of energy ( anergy)
• Tarditive Dyskinesia- Late appearing after
prolonged use of antipsychotic drugs.-
involuntary movement of face ,jaw and
• Pharmacology
• Others drugs
• Amantadine ( Symmetrel)-
neuroleptic malignant
syndrome
• Benzodiazepine- for akinesia,
akathisia
• Bromocriptine ( Parlodel)- NMS
• Clonidine ( Catapres)- EPS
• Nifedipine- tarditive dyskinesia
• Propranolol- EPS
• Verapamil( Calan) – Tarditive
• Pharmacology
• monitor for signs of hepatotoxicity-
Jaundice
• monitor for signs of infection – colds and
sore throat- CBC
• monitor B/P in supine and standing
position
• assist in ambulation- sit first before
standing
• Avoid alcohol intake
• Provide sunscreens
• EPS noted report to physician
• Prevent constipation
• Avoid juices and beverages ( Coffee, tea,
cola beverages) – ↓ effectiveness of the
drug.
• Avoid antacids- taken 1-2 hours after
• Pharmacology
• Anti depressants
• Indication- Major depressive illness
• For treatment of Panic disorder, Narcolepsy,
ADHD, Enuresis
• Mechanism of action: it affects the
neurotransmitter serotonin and norepinephrine-
by partially blocking their reuptake- down
regulation
• Preparation: oral, IM preparations
• Selective Serotonin Reuptake Inhibitors- use in
eating disorders and OCD
• It takes 2-3 weeks before therapeutic responses is
felt occurs.
• Monoamine Oxidase Inhibitors- Elevates
norepinephrine levels , by interfering with the
enzyme mao, rarely used due to food interaction
• Pharmacology
• 1.TCA nonselective/ Cyclic
• 1. Amitirptyline ( Elavil, Endep)
• 2. Clomipramine ( Anafril)
• 3. Desipramine ( Norpramin)
• 4. Doxepin ( Sinequan, Triadapin)
• 5. Imipramine ( Tofranil)
• 6. Nortrptyline ( Aventyl, Pamelor)
• 7. Protriptyline ( Vivactil, Triptal)
• 8. Trimipramine ( Surmontil)
• 2. Monoamine Oxidase Inihibitors
• 1. Phenelzine sulfate ( Nardil)
• 2. Selegiline ( Eldepryl)
• 3. Tranycypromine sulfate ( Parnate)

• 3. Selective serotonin reuptake inhibitors
• 1. Citaprolam ( Celexa)
• 2. Fluoxetine ( Prozac, Saralem)
• 3. Fluvoxamine ( Lexapro, Luvox)
• 4. Paroxetine ( Paxil)
• 5. Sertraline ( Zoloft)

• Pharmacology
• Atypical New Generation
• Amoxapine ( Ascendin)
• Bupropion (Wellbutrin) - tx smoking
• Maprotiline ( Ludiomil)
• Mirtazapine ( Remeron)
• Nefazodone ( Remeron)
• Trazodone ( Desyrel)
• Venlafaxine (Effexor)

• Anti-Depressants
• D on’t drive and operate machines
• E ffect has a delayed onset of 2-3
weeks
• P lanningpregnancy- consult with
provider of care
• R elieves symptoms, not cure
• E valuate vital signs
• S topping drug is briefly abrupt!
• S afety measures (i.e., change
position slowly)
• I nstruct client to report undesirable
effects
• O bserve for suicidal tendencies
• Pharmacology
• Drug Interactions- TCA
•  
• Potentiates effects of
anticholinergics and CNS depressant
• Adverse effects
• Orthostatic hypotension, skin
rash, drowsiness, dry mouth, blurred
vision, constipation, urine retention,
tachycardia, CNS stimulation .
• older patients – restlessness,
incoordination, fine tremors, night
mares , delusions disorientation.
• Not given to MI or with history of
cardiac dysrythmias and conduction
defects.

• Pharmacology
• MAO Inhibitors
• Drug interaction- MAO potentiates the effects of
alcohol, barbiturates, anesthetic agents,
cocaine , antihistamine, narcotics, corticoids,
anticholinergics.
•  
• MAOI’s
• Pharmacology
• Adverse Effects-
• CNS- orthostatic hypotension,
• Hypersensitivity reaction- skin rash
• CNS depression- drowsiness
• Anticholinergic effects- dry mouth, blurred vision,
tachycardia
• Autonomic effect- sexual dysfunction
• CNS stimulation- nightmares, delusion, disorientation,
• Pharmacology
• Selective Serotonin Reuptake
Inhibitor(SSRI`s)
• Drug interaction- may interact with
tryptophan..
• Diazepam, Warfarin, Digoxinshould be
discontinued 4-6 weeks before starting
SSRI.
• Adverse Effect- insomnia, head ache, dry
mouth sexual dysfunction, anxiety,
diarrhea.
• SSRI`s – are given at noon time to avoid
insomnia, or sleep disturbances.
• Pharmacology
• Atypical New Generations drugs
• Adverse effects- increase appetite, weight
gain and sleep disturbances.
• Bupropion- affect dopamine can result to
• Pharmacology
• Nursing Care for patients receiving
Antidepressants
• monitor self destructive behavior – esp. during
the 2nd week of treatment when suicidal
ideation remains and energy increases.
• Monitor serum glucose levels.
• Expect therapeutic effect to be delayed .
• < 3wks with MAOI , 3-4 wks with the other
antidepressants.
• Avoid concurrent administration with
adrenergics. , limit or eliminate caffeine use-
to prevent exacerbation of depression.
• Pharmacology
• Anti Manic and Mood stabilizing Agents
• Action: Use to control manic episodes and mood
disorders, it decrease psychomotor response/
activity to environmental stimuli.
• LITHIUM –affects neurotransmitters of multiple
systems including dopamine, serotonin,
• Pharmacology
• Types Anti manic agents and mood stabilizers
• Lithium Carbonate (Eskalith, Lithotabs, Lithane ,
Lithonate)
• Lithium Carbonate sustained released ( Eskalith C-R,
Lithobid)
• Alternative anti manic and mood stabilizing agents
• Carbamazepine ( Tegretol)
• Gabapentin ( Neurontin)
• Lamotrigine ( Lamictal, Lamivtal cd)
• Topiramate ( Topimax)
• Valproate ( Depakene, Dapakote, Depacon, Epival)
• Pharmacology
• Precautions:
• Diuretics increase the reabsorption of lithium.-
Toxicity
• When given with haloperidol and thioridazine-
encephalopathic syndrome
• Na bicarbonate, Na Cl – Increases the excretion of
Lithium.

• Pharmacology
• Nursing care
• Administer with meals- prevent gastric irritation
• Ensure that drug is not crushed nor chewed
• Medication should not be discontinued abruptly
• Maintain Na intake-Hyponatremia and dehydration-
Lithium toxicity
• Monitor therapeutic levels of lithium
• Check for signs of toxicity- vomiting , diarrhea,
tremors , weakness, severe thirst, tinnitus. visual
disturbances and skin rashes.
• Pharmacology
• Sedative and Hypnotic drugs
• Uses: insominia, hypersomnias, narcolepsy,
parasomnias, periodic leg movements (nocturnal
myoclonus), sleep apnea.
• Preparations : Available in Oral, IM
• Hypnotic cause sleep and have a more potent effect
on the CNS than sedatives.
• Pharmacology
• Precautions/ nursing consideration
• Intended only for short term use-
physiologic addiction, overdose
• Barbiturates- increase the
metabolism of anti coagulants
because they induce liver enzyme
synthesis.
• Chloral hydrate and paraldehyde-
not use in alcohol withdrawal-
toxic
• Paraldehyde- status epilepticus
when all drugs have failed
• Once tolerance have developed
abrupt discontinuation could lead
• Pharmacology
• Withdrawal- insomnia, weakness, muscle
tremors, anxiety, irritability, sweating,
anorexia, fever, nausea and vomiting, head
ache , incoordination.
• To avoid withdrawal- taper dosing of sedative
hypnotic medications.
• Any of the sedative hypnotic when taken in
excess could lead to unconsciousness, coma
and death.
• Assess for signs of alcohol and suicide attempts.
Assess for undesired effects such as
respiratory depression.
• Evaluate clients response to medications and
understanding of teaching.

• Pharmacology
• End of lecture
• Reference
• PSYCHOTHERAPEUTIC INTERVENTIONS
• Remotivation therapy
• Treatment modality that promotes expression of
feelings through interaction facilitated by
discussion of neutral topics.
• 5 Steps of Remotivation Therapy
• 1. Climate of acceptance
• 2. Creating of bridge to reality
• 3. Sharing the world we live in
• 4. Appreciation of works
• 5. Climate of appreciation
• Types of Remotivation Therapy
• Music therapy- use of music to facilitate relaxation,
expression of feelings and release of tension.
• Play therapy- enables patients to experience intense
emotions in a safe environment through play.

• Group therapy
• Therapeutic interaction of 3 or more patients with a
therapist.
• Done to relieve emotional difficulties, increase self
esteem, insight formation, and improve behavior
with other people.
• Minimum members is 3 but ideal is 8-10 members.
•  
• Milieu therapy- treatment by means of controlled
modification of environment to facilitate positive
behavioral change.
• Family Therapy- focuses in on the total family as an
interactional system.
•  
• Psychoanalysis- focuses on exploration of the
unconscious, to facilitate identification of the
patients defenses.

• Humor Therapy- use of humor to facilitate expression
of feelings and enhance interaction.
• Behavior modification- application of learning
principles in order to change maladaptive behavior.
•  
• Aversion therapy- a from of behavior modification in
which a painful stimulus is introduce to bring about
an avoidance of another stimulus with the end view
of facilitating behavioral change.
•  
• Token economy- a form of behavior modification
technique- Rewards to facilitate behavioral change.
• Desensitization- periodic exposure of an individual toa
feared object, until undesirable behavior disappears
or lessened.
•  
• Cognitive Therapy- short term structured therapy
between patient and therapist oriented towards
present problems and solutions, main focus are the
• CRISIS
• A disturbance caused by a
precipitating event such as
perceived loss, a threat of loss or
a challenge that is perceived as a
threat to self.
•  
•  
• Classification
• Maturational= role changes
• Situational= loss of job, death
• Adventitious= fires, earthquakes
and floods
• In a crisis, the person’s usual
methods of coping are
• Characteristics of Crisis:
• It is sudden
• It is short term may last for 4-6
weeks
• Individualized
• The person becomes dependent
and overwhelmed
•  
•  
• Factors that can produce crisis
• 1. Hazardous EVENTS
• 2. Threat to the individual’s
equilibrium
• 3. Inadequate coping skills

• Four PHASES of Crisis (DIDA)


• Denial
• Increased Tension- when the person knows the
existence of crisis and still continues ADL
• Disorganization= pre-occupied and unable to
perform function
• Attempts to Reorganize= by mobilizing previous
coping mechanisms
•  
•  
• CRISIS INTERVENTION
• A technique of helping the person go through
the crisis
• To mobilize his resources
• To help him deal with the here and now
• A five step problem solving technique designed
to promote a more adaptive outcome

• END OF LECTURE
• THANK YOU SO MUCH
• RON RN, MD, DPCOM
• LECTURE EXCLUSIVE FOR UPHSL
ONLY
• GOOD LUCK
•