Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice, 6th Edition - townsend2009

SIXTH EDITION Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice Mary C. Townsend, DSN, APRN, BC Clinical Specialist/Nurse Consultant Adult Psychiatric Mental Health Nursing Former Assistant Professor and Coordinator, Mental Health Nursing Kramer School of Nursing Oklahoma City University Oklahoma City, Oklahoma F. A. DAVIS COMPANY • Philadelphia

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2009 by F. A. Davis Company Copyright © 2009 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Robert G. Martone Senior Developmental Editor: William F. Welsh Director of Content Development: Darlene D. Pedersen Project Editor: Padraic J. Maroney Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Townsend, Mary C., 1941- Psychiatric mental health nursing: concepts of care in evidence-based practice / Mary C. Townsend. — 6th ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1917-3 ISBN-10: 0-8036-1917-0 1. Psychiatric nursing. I. Title. [DNLM: 1. Psychiatric Nursing—methods. 2. Evidence-Based Medicine. 3. Mental Disorders—nursing. 4. Psychotherapy—methods. WY 160 T749p 2009] RC440.T693 2009 616.89’0231—dc22 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1169-2/04 0 + $.10.

THIS BOOK IS DEDICATED TO FRANCIE God made sisters for sharing laughter and wiping tears



Consultants Angeline Curtis, BSN, MS, APRN, BC Carol T. Miller, APRN-PMH, BC Clinical Nurse Specialist, Mental Health Service Line Assistant Professor VA Medical Center Frederick Community College Decatur, Georgia Frederick, Maryland Janine Graf-Kirk, RN, BC, MA Darlene D. Pedersen, MSN, APRN, BC Professor and Course Coordinator for Psychiatric Director and Psychotherapist, PsychOptions Philadelphia, Pennsylvania Mental Health Nursing Kathy Whitley, RN, MSN, FNP-C Trinitas School of Nursing Associate Professor, Nursing Elizabeth, New Jersey Patrick Henry Community College Dottie Irvin, DNS, APRN, BC Martinsville, Virginia Associate Professor Mara Lynn Williams, RN, BC St. John’s College Program Director, Psychiatry Springfield, Illinois Intrepid USA Healthcare Services Phyllis M. Jacobs, RN, MSN Montgomery, Alabama Assistant Professor; Director, Undergraduate Nursing Program Wichita State University School of Nursing Wichita, Kansas ix

Reviewers Teresa S. Burckhalter, MSN, RN, BC Angela Luciani, RN, BScN, MN Nursing Faculty Nursing Instructor Technical College of the Lowcountry Nunavut Arctic College Beaufort, South Carolina Iqaluit, Nunavut, Canada Elaine Coke, RN, MSN, MBA, HCA, CCRN Patricia Jean Hedrick Young, EdD, RN, C Faculty Instructor Nursing Instructor Keiser University The Washington Hospital School of Nursing Fort Lauderdale, Florida Washington, Pennsylvania x

Acknowledgments Robert G. Martone, Publisher, Nursing, F. A. Davis To those individuals who critiqued the manuscript Company, for your sense of humor and continuous opti- for this edition and shared your ideas, opinions, and mistic outlook about the outcome of this project. suggestions for enhancement. I sincerely appreciate your William F. Welsh, Senior Developmental Editor, contributions to the final product. Nursing, F. A. Davis Company, for all your help and My daughters, Kerry and Tina, for all the joy you have support in preparing the manuscript for publication. provided me and all the hope that you instill in me. I’m Cherie R. Rebar, Chair, Associate of Science Nursing so thankful that I have you. Program, Kettering College of Medical Arts, and My grandchildren, Meghan and Matthew, for show- Golden M. Tradewell, Chair, Department of Nursing, ing me what life is truly all about. I am blessed by your Southern Arkansas University, for your assistance in very presence. preparing test questions to accompany this textbook. My furry friends, Bucky, Chiro, and Angel, for the Berta Steiner, Director of Production, Bermedica pure pleasure you bring into my life every day that you Production Ltd., for your support and competence in live. the final editing and production of the manuscript. My husband, Jim, who gives meaning to my life in so The nursing educators, students, and clinicians, who many ways. You are the one whose encouragement keeps provide critical information about the usability of the me motivated, whose support gives me strength, and textbook, and offer suggestions for improvements. Many whose gentleness gives me comfort. changes have been made based on your input. xi



TO THE INSTRUCTOR There is a saying that captures the spirit of our times— study of the United States mental health service delivery the only constant is change. The twenty-first century system. They were to identify unmet needs and barriers continues to bring about a great deal of change in the to services and recommend steps for improvement in health care system in general and to nursing in particular. services and support for individuals with serious mental The body of knowledge in nursing continues to grow and illness. In July 2003, the commission presented its final expand as rapidly as nursing undergoes change. Nurses report to the President. The Commission identified the must draw upon this research base to support the care following barriers: fragmentation and gaps in mental that they provide for their clients. This sixth edition of health care for children, adults with serious mental ill- Psychiatric Mental Health Nursing: Concepts of Care in ness, and the elderly; and high unemployment and dis- Evidence-Based Practice strives to present a holistic ap- ability for people with serious mental illness. The report proach to evidenced-based psychiatric nursing practice. also pointed out that the fact that the U.S. has failed to identify mental health and suicide prevention as national Just what does this mean? Research in nursing has priorities has put many lives at stake. The Commission been alive for decades. But over the years there has outlined the following goals and recommendations for always existed a significant gap between research and mental health reform: practice. Evidence-based nursing has become a common • To address mental health with the same urgency as theme within the nursing community. It has been defined as a process by which nurses make clinical decisions using physical health the best available research evidence, their clinical • To align relevant Federal programs to improve access expertise, and client preferences. Nurses are account- able to their clients to provide the highest quality of care and accountability for mental health services based on knowledge of what is considered best practice. • To ensure appropriate care is available for every child Change occurs so rapidly that what is considered best practice today may not be considered so tomorrow, based with a serious emotional disturbance and every adult on newly acquired scientific data. with a serious mental illness • To protect and enhance the rights of people with men- Included in this sixth edition are a number of research tal illness studies that support psychiatric nursing interventions. As • To improve access to quality care that is culturally nurses, we are bombarded with new information and competent technological content on a daily basis. Not all of this • To improve access to quality care in rural and geo- information yields knowledge that can be used in clinical graphically remote areas practice. It is our hope that the information in this new • To promote mental health screening, assessment, and edition will serve to further the movement toward referral services evidence-based practice in psychiatric nursing. There is • To accelerate research to promote recovery and still a long way to go, and research utilization is the foun- resilience, and ultimately to cure and prevent mental dation from which to advance the progression. illness Psychiatric nurses must become involved in nursing • To advance evidence-based practices using dissemina- research, in disseminating research findings, and in tion and demonstration projects, and create a public- implementing practice changes based on current private partnership to guide their implementation evidence. • To improve and expand the workforce providing evidence-based mental health services and supports Well into the first decade of the new century, there are • To promote the use of technology to access mental many new challenges to be faced. In 2002, President health care and information George W. Bush established the New Freedom If these proposals become reality, it would surely mean Commission on Mental Health. This commission was improvement in the promotion of mental health and the charged with the task of conducting a comprehensive xiii

xiv TO THE INSTRUCTOR care of mentally ill individuals. Many nurse leaders see Twenty-two sample client teaching guides this period of health care reform as an opportunity for (Appendix G). nurses to expand their roles and assume key positions in education, prevention, assessment, and referral. Nurses Nursing interventions are now included under are, and will continue to be, in key positions to assist “Planning/Implementation” section of the text. In individuals with mental illness to remain as independent the diagnosis chapters, nursing interventions have been as possible, to manage their illness within the community identified by nursing diagnosis and included within the setting, and to strive to minimize the number of hospital- text portion of the chapter. Short- and long-term goals izations required. are included for each. Nursing care plans are included for selected nursing diagnoses. Nursing care plans In 2020, the ten leading causes of mortality through- have been retained in other chapters as presented in pre- out the world are projected to include heart disease; cere- vious editions. brovascular disease; pulmonary disease; lower respiratory infections; tracheal, bronchial and lung cancers; traffic Case studies with sample care plans are included accidents; tuberculosis; stomach cancer; HIV/AIDS; and in the diagnosis chapters. suicide. Behavior is an important element in prevention of these causes of mortality and in their treatment. In Chapter summaries are presented as “key points” 2020, the three leading causes of disability throughout that emphasize important facts associated with each the world are projected to include heart disease, major chapter. depression, and traffic accidents. Behavior is once again an important underpinning of these three contributors of NANDA Taxonomy II from the NANDA Nursing disability, and behavioral and social science research can Diagnoses: Definitions & Classification 2007–2008 lower the impact of these causes of morbidity and mor- (NANDA International). Used throughout the text. tality. Many of these issues are addressed in this new edition. FEATURES THAT HAVE BEEN RETAINED The major conceptual framework of stress-adapta- CONTENT AND FEATURES NEW tion has been retained for its ease of comprehensibility TO THIS EDITION and workability in the realm of psychiatric nursing. New content on Spiritual Concepts (Chapter 6). This framework continues to emphasize the multiple Important information on assessing the spiritual needs of causation of mental illness while accepting the increas- clients and planning for this aspect of their care has been ing biological implications in the etiology of certain included. Additional cultural concepts related to Arab disorders. Americans has also been included. Selected research studies with implications for A Brief Mental Status Evaluation Tool has been evidence-based practice. (In all relevant clinical chapters.) included in Chapter 9. The concept of holistic nursing is retained in the New content on Electronic Documentation sixth edition. The author has attempted to ensure that (Chapter 9). the physical aspects of psychiatric/mental health nursing are not overlooked. In all relevant situations, the mind/ New medications that have become available since body connection is addressed. the last edition are included in Chapter 21, as well as in the relevant diagnosis chapters. Nursing process is retained in the sixth edition as the tool for delivery of care to the individual with a psychi- New content related to the neurobiology of atric disorder or to assist in the primary prevention or Attention-Deficit/Hyperactivity Disorder (ADHD) exacerbation of mental illness symptoms. The six steps of (Chapter 25). Illustrations of the neurotransmitter path- the nursing process, as described in the ANA Nursing: ways and discussion of areas of the brain affected and the Scope and Standards of Practice (2004), are used to provide medications that target those areas are presented. guidelines for the nurse. These standards of care are included for the DSM-IV-TR diagnoses, as well as the Three new Concept Map Care Plans are included: aging individual, victims of abuse, the bereaved individ- ADHD (Chapter 25); Dementia (Chapter 26); and ual, and in forensic nursing practice. Other examples are Victims of Abuse (Chapter 36) for a total of 16 in the text. included in several of the therapeutic approaches. The six steps include: New content on Fetal Alcohol Syndrome (Chapter 27). Assessment: Data collection, under the format of Background Assessment Data: Boxes called “Clinical Pearls” have been included Symptomatology, which provides exten- in selected chapters. These boxes present important sive assessment data for the nurse to facts relevant to clinical care of psychiatric clients. draw upon when performing an assess- ment. Several assessment tools are also A comprehensive guide for conducting the included. Mental Status Assessment has been included (Appendix B).

TO THE INSTRUCTOR xv Diagnosis: Analysis of the data is included from Taxonomy and diagnostic criteria from the DSM-IV- Outcome which nursing diagnoses common to TR (2000). Used throughout the text. Identification: specific psychiatric disorders are Planning: derived. Web site. The F. A. Davis/Townsend website with Outcomes are derived from the nursing additional nursing care plans that do not appear in Implemen- diagnoses and stated as measurable the text, links to psychotropic medications, concept tation: goals. map care plans, and neurobiological content and Plans of care are presented (either illustrations. Evaluation: within the text, in care plan format, or both) with selected nursing diagnoses ADDITIONAL EDUCATIONAL for all DSM-IV-TR diagnoses, as well RESOURCES as for the elderly client, the elderly Faculty may also find the following teaching aids that homebound client, the primary care- accompany this textbook helpful: giver of the client with a chronic men- tal illness, forensic clients in trauma Instructor’s Resource Disk (IRD). This IRD contains: care and correctional institutions, and • Approximately 900 multiple choice questions (includ- the bereaved individual. Critical Pathways of Care are included for clients ing new format questions reflecting the latest in alcohol withdrawal, schizophrenic NCLEX blueprint). Most of these questions have psychosis, depression, manic episode, been written at the analysis and synthesis levels. PTSD, and anorexia nervosa. The • Lecture outlines for all chapters planning standard also includes tables • Learning activities for all chapters (including that list topics for educating clients and answer key) families about mental illness. Also • Answers to the Critical Thinking Exercises from the included: 22 concept map care plans textbook for all major psychiatric diagnoses. • PowerPoint Presentation to accompany all chapters The interventions that have been iden- in the textbook tified in the plan of care are included All chapters throughout the text have been updated along with rationale for each. Case and revised to reflect today’s health care reformation and studies at the end of each DSM-IV-TR to provide information based on the latest current state chapter assist the student in the practi- of the discipline of nursing. It is my hope that the cal application of theoretical material. revisions and additions to this sixth edition continue to Also included as a part of this particular satisfy a need within psychiatric/mental health nursing standard is Unit Three of the textbook: practice. Many of the changes reflect feedback that I have Therapeutic Approaches in Psychiatric received from users of the previous editions. To those Nursing Care. This section of the text- individuals I express a heartfelt thanks. I welcome com- book addresses psychiatric nursing ments in an effort to retain what some have called the intervention in depth, and frequently “user friendliness” of the text. I hope that this sixth edi- speaks to the differentiation in scope of tion continues to promote and advance the commitment practice between the basic level psychi- to psychiatric/mental health nursing. atric nurse and the advanced practice level psychiatric nurse. Advanced prac- MARY C. TOWNSEND tice nurses with prescriptive authority will find the extensive chapter on psy- chopharmacology particularly helpful. The evaluation standard includes a set of questions that the nurse may use to assess whether the nursing actions have been successful in achieving the objectives of care. Tables that list topics for client education. (Clinical chapters). Assigning nursing diagnoses to client behaviors. (Appendix E). Internet references with web site listings for infor- mation related to psychiatric disorders (Clinical chapters).



Contents UNIT ONE MENTAL HEALTH/MENTAL ILLNESS CONTINUUM 22 THE DSM-IV-TR MULTIAXIAL EVALUATION SYSTEM 23 BASIC CONCEPTS IN SUMMARY AND KEY POINTS 24 PSYCHIATRIC/MENTAL REVIEW QUESTIONS 25 HEALTH NURSING REFERENCES 27 CLASSICAL REFERENCES 27 CHAPTER 1 The Concept of Stress Adaptation 2 UNIT TWO FOUNDATIONS FOR STRESS AS A BIOLOGICAL RESPONSE 3 PSYCHIATRIC/MENTAL STRESS AS AN ENVIRONMENTAL EVENT 5 HEALTH NURSING STRESS AS A TRANSACTION BETWEEN CHAPTER 3 THE INDIVIDUAL AND THE ENVIRONMENT 5 Theoretical Models of Personality Precipitating Event 5 Development 30 The Individual’s Perception of the Event 5 Predisposing Factors 6 PSYCHOANALYTIC THEORY 31 STRESS MANAGEMENT 7 Structure of the Personality 31 Adaptive Coping Strategies 7 Topography of the Mind 31 SUMMARY AND KEY POINTS 8 Dynamics of the Personality 32 REVIEW QUESTIONS 9 Freud’s Stages of Personality Development 32 REFERENCES 10 Relevance of Psychoanalytic Theory CLASSICAL REFERENCES 10 to Nursing Practice 34 CHAPTER 2 INTERPERSONAL THEORY 34 Mental Health/Mental Illness: Sullivan’s Stages of Personality Development 34 Historical and Theoretical Relevance of Interpersonal Theory Concepts 11 to Nursing Practice 35 HISTORICAL OVERVIEW OF PSYCHIATRIC CARE 12 THEORY OF PSYCHOSOCIAL DEVELOPMENT 35 MENTAL HEALTH 13 Erikson’s Stages of Personality Development 35 MENTAL ILLNESS 14 Relevance of Psychosocial Development Theory PSYCHOLOGICAL ADAPTATION TO STRESS 15 to Nursing Practice 38 Anxiety 15 THEORY OF OBJECT RELATIONS 38 Behavioral Adaptation Responses to Anxiety 17 Phase I: The Autistic Phase (Birth to Grief 20 1 Month) 38 xvii

xviii CONTENTS CHAPTER 5 Ethical and Legal Issues in Psychiatric/ Phase II: The Symbiotic Phase (1 to 5 Mental Health Nursing 72 Months) 38 ETHICAL CONSIDERATIONS 73 Phase III: Separation-Individuation (5 to Theoretical Perspectives 73 36 months) 39 Ethical Dilemmas 74 Ethical Principles 74 COGNITIVE DEVELOPMENT THEORY 39 A Model for Making Ethical Decisions 75 Stage 1: Sensorimotor (Birth to 2 Years) 39 Ethical Issues in Psychiatric/Mental Stage 2: Preoperational (2 to 6 Years) 40 Health Nursing 76 Stage 3: Concrete Operations (6 to 12 Years) 40 Stage 4: Formal Operations (12 to LEGAL CONSIDERATIONS 76 15+ Years) 40 Nurse Practice Acts 76 Relevance of Cognitive Development Theory Types of Law 77 to Nursing Practice 40 Classifications Within Statutory and Common Law 78 THEORY OF MORAL DEVELOPMENT 40 Legal Issues in Psychiatric/Mental Level I: Preconventional Level (Prominent from Health Nursing 78 Ages 4 to 10 Years) 41 Commitment Issues 81 Level II: Conventional Level (Prominent from Ages Nursing Liability 82 10 to 13 Years and into Adulthood) 41 Level III: Postconventional Level (Can Occur from SUMMARY AND KEY POINTS 83 Adolescence Onward) 41 REVIEW QUESTIONS 85 Relevance of Moral Development Theory to REFERENCES 86 Nursing Practice 42 CHAPTER 6 A NURSING MODEL—HILDEGARD E. PEPLAU 42 Cultural and Spiritual Concepts Peplau’s Stages of Personality Development 42 Relevant to Psychiatric/Mental Relevance of Peplau’s Model to Nursing Health Nursing 87 Practice 44 CULTURAL CONCEPTS 88 SUMMARY AND KEY POINTS 45 HOW DO CULTURES DIFFER? 88 REVIEW QUESTIONS 46 REFERENCES 47 Communication 88 CLASSICAL REFERENCES 47 Space 89 Social Organization 89 CHAPTER 4 Time 89 Concepts of Psychobiology 48 Environmental Control 89 Biological Variations 89 THE NERVOUS SYSTEM: AN ANATOMICAL APPLICATION OF THE NURSING PROCESS 90 REVIEW 49 Background Assessment Data 90 The Brain 49 Culture-Bound Syndromes 99 Nerve Tissue 53 Diagnosis/Outcome Identification 99 Autonomic Nervous System 53 Planning/Implementation 99 Neurotransmitters 55 Evaluation 101 SPIRITUAL CONCEPTS 101 NEUROENDOCRINOLOGY 60 Spiritual Needs 101 Pituitary Gland 60 Assessment of Spiritual and Religious Circadian Rhythms 63 Sleep 64 Needs 103 Diagnoses/Outcome Identification/ GENETICS 66 PSYCHOIMMUNOLOGY 66 Evaluation 105 Normal Immune Response 66 IMPLICATIONS FOR NURSING 68 SUMMARY AND KEY POINTS 69 REVIEW QUESTIONS 70 REFERENCES 71

Planning/Implementation 105 CONTENTS xix Evaluation 105 SUMMARY AND KEY POINTS 107 Culture or Religion 128 REVIEW QUESTIONS 109 Social Status 129 REFERENCES 110 Gender 129 CLASSICAL REFERENCES 111 Age or Developmental Level 129 Environment in Which the Transaction UNIT THREE THERAPEUTIC APPROACHES IN Takes Place 129 PSYCHIATRIC NURSING CARE NONVERBAL COMMUNICATION 130 CHAPTER 7 Physical Appearance and Dress 130 Relationship Development 114 Body Movement and Posture 130 Touch 130 ROLE OF THE PSYCHIATRIC NURSE 115 Facial Expressions 131 DYNAMICS OF A THERAPEUTIC NURSE-CLIENT Eye Behavior 131 Vocal Cues, or Paralanguage 131 RELATIONSHIP 116 Therapeutic Use of Self 116 THERAPEUTIC COMMUNICATION Gaining Self-Awareness 116 TECHNIQUES 132 The Johari Window 117 NONTHERAPEUTIC COMMUNICATION CONDITIONS ESSENTIAL TO DEVELOPMENT TECHNIQUES 132 OF A THERAPEUTIC RELATIONSHIP 119 Rapport 119 ACTIVE LISTENING 135 Trust 119 PROCESS RECORDINGS 135 Respect 119 FEEDBACK 135 Genuineness 120 SUMMARY AND KEY POINTS 137 Empathy 120 REVIEW QUESTIONS 138 REFERENCES 139 PHASES OF A THERAPEUTIC NURSE-CLIENT CLASSICAL REFERENCES 139 RELATIONSHIP 121 The Preinteraction Phase 121 CHAPTER 9 The Nursing Process in Psychiatric/ The Orientation (Introductory) Mental Health Nursing 140 Phase 121 THE NURSING PROCESS 141 The Working Phase 121 Definition 141 The Termination Phase 122 Standards of Practice 141 BOUNDARIES IN THE NURSE-CLIENT RELATIONSHIP 123 WHY NURSING DIAGNOSIS? 149 SUMMARY AND KEY POINTS 124 NURSING CASE MANAGEMENT 149 REVIEW QUESTIONS 125 REFERENCES 126 Critical Pathways of Care 151 CLASSICAL REFERENCES 126 APPLYING THE NURSING PROCESS IN THE CHAPTER 8 PSYCHIATRIC SETTING 151 Therapeutic Communication 127 CONCEPT MAPPING 153 WHAT IS COMMUNICATION? 128 128 DOCUMENTATION OF THE NURSING THE IMPACT OF PREEXISTING CONDITIONS PROCESS 155 Values, Attitudes, and Beliefs 128 Problem-Oriented Recording 155 Focus Charting 156 The PIE Method 156 Electronic Documentation 157 SUMMARY AND KEY POINTS 158 REVIEW QUESTIONS 160 REFERENCES 160

xx CONTENTS Family Members’ Expectations 178 Handling Differences 179 CHAPTER 10 Family Interactional Patterns 180 Therapeutic Groups 161 Family Climate 180 FUNCTIONS OF A GROUP 162 THERAPEUTIC MODALITIES WITH FAMILIES 181 TYPES OF GROUPS 162 The Family as a System 181 Task Groups 162 The Structural Model 183 Teaching Groups 162 The Strategic Model 184 Supportive/Therapeutic Groups 162 The Evolution of Family Therapy 186 Self-Help Groups 163 THE NURSING PROCESS—A CASE STUDY 187 PHYSICAL CONDITIONS THAT INFLUENCE GROUP DYNAMICS 163 Assessment 187 Seating 163 Diagnosis 190 Size 163 Outcome Identification 190 Membership 163 Planning/Implementation 190 Evaluation 191 CURATIVE FACTORS 164 PHASES OF GROUP DEVELOPMENT 164 SUMMARY AND KEY POINTS 191 Phase I. Initial or Orientation Phase 164 REVIEW QUESTIONS 193 Phase II. Middle or Working Phase 164 Phase III. Final or Termination Phase 165 REFERENCES 194 LEADERSHIP STYLES 165 Autocratic 165 CLASSICAL REFERENCES 194 Democratic 165 Laissez-Faire 165 CHAPTER 12 MEMBER ROLES 166 Milieu Therapy—The Therapeutic PSYCHODRAMA 167 Community 195 THE ROLE OF THE NURSE IN GROUP THERAPY 167 SUMMARY AND KEY POINTS 167 MILIEU, DEFINED 195 REVIEW QUESTIONS 169 REFERENCES 171 CURRENT STATUS OF THE THERAPEUTIC CLASSICAL REFERENCES 171 COMMUNITY 196 CHAPTER 11 BASIC ASSUMPTIONS 196 Intervention with Families 172 CONDITIONS THAT PROMOTE A THERAPEUTIC 198 STAGES OF FAMILY DEVELOPMENT 173 COMMUNITY 197 Stage I. The Single Young Adult 173 Stage II. The Newly Married Couple 173 THE PROGRAM OF THERAPEUTIC COMMUNITY Stage III. The Family with Young Children 173 THE ROLE OF THE NURSE 199 Stage IV. The Family with Adolescents 173 SUMMARY AND KEY POINTS 201 Stage V. The Family Launching Grown REVIEW QUESTIONS 202 Children 174 REFERENCES 203 Stage VI. The Family in Later Life 175 CLASSICAL REFERENCES 203 MAJOR VARIATIONS 175 CHAPTER 13 Divorce 175 Crisis Intervention 204 Remarriage 175 Cultural Variations 175 CHARACTERISTICS OF A CRISIS 205 PHASES IN THE DEVELOPMENT OF A CRISIS 205 FAMILY FUNCTIONING 176 TYPES OF CRISES 206 Communication 177 Self-Concept Reinforcement 178 Class 1: Dispositional Crises 206 Class 2: Crises of Anticipated Life Transitions 207 Class 3: Crises Resulting from Traumatic Stress 207 Class 4: Maturational/Developmental Crises 208 Class 5: Crises Reflecting Psychopathology 208 Class 6: Psychiatric Emergencies 208

CONTENTS xxi CRISIS INTERVENTION 209 Nonassertive Behavior 231 PHASES OF CRISIS INTERVENTION: THE ROLE Assertive Behavior 232 Aggressive Behavior 232 OF THE NURSE 209 Passive-Aggressive Behavior 232 Phase 1. Assessment 209 Phase 2. Planning of Therapeutic Intervention 209 BEHAVIORAL COMPONENTS OF ASSERTIVE Phase 3. Intervention 210 BEHAVIOR 232 Phase 4. Evaluation of Crisis Resolution TECHNIQUES THAT PROMOTE ASSERTIVE and Anticipatory Planning 211 BEHAVIOR 233 DISASTER NURSING 211 THOUGHT-STOPPING TECHNIQUES 234 Method 235 APPLICATION OF THE NURSING PROCESS TO DISASTER NURSING 211 ROLE OF THE NURSE 235 Background Assessment Data 211 Assessment 235 Nursing Diagnoses/Outcome Identification 211 Diagnosis 236 Planning/Implementation 212 Outcome Identification/Implementation 236 Evaluation 212 Evaluation 238 SUMMARY AND KEY POINTS 217 SUMMARY AND KEY POINTS 238 REVIEW QUESTIONS 218 REVIEW QUESTIONS 239 REFERENCES 219 REFERENCES 240 CLASSICAL REFERENCES 219 CHAPTER 16 CHAPTER 14 Promoting Self-Esteem 241 Relaxation Therapy 220 COMPONENTS OF SELF-CONCEPT 242 THE STRESS EPIDEMIC 220 Physical Self or Body Image 242 PHYSIOLOGICAL, COGNITIVE, AND BEHAVIORAL Personal Identity 242 Self-Esteem 242 MANIFESTATIONS OF RELAXATION 221 METHODS OF ACHIEVING RELAXATION 223 DEVELOPMENT OF SELF-ESTEEM 242 Deep Breathing Exercises 223 Developmental Progression of Self-Esteem Through Progressive Relaxation 223 the Life Span 243 Modified (or Passive) Progressive Relaxation 224 Meditation 225 MANIFESTATIONS OF LOW SELF-ESTEEM 244 Mental Imagery 225 Focal Stimuli 244 Biofeedback 226 Contextual Stimuli 244 Physical Exercise 226 Residual Stimuli 245 Symptoms of Low Self-Esteem 245 THE ROLE OF THE NURSE IN RELAXATION THERAPY 226 BOUNDARIES 245 Assessment 227 Boundary Pliancy 246 Diagnosis 227 Rigid Boundaries 246 Outcome Identification/Implementation 227 Flexible Boundaries 246 Evaluation 228 Enmeshed Boundaries 247 Establishing Boundaries 247 SUMMARY AND KEY POINTS 228 REVIEW QUESTIONS 229 THE NURSING PROCESS 247 REFERENCES 229 Assessment 247 Diagnosis/Outcome Identification 247 CHAPTER 15 Outcome Criteria 248 Assertiveness Training 230 Planning/Implementation 248 Evaluation 250 ASSERTIVE COMMUNICATION 231 BASIC HUMAN RIGHTS 231 SUMMARY AND KEY POINTS 250 RESPONSE PATTERNS 231 REVIEW QUESTIONS 252 REFERENCES 253 CLASSICAL REFERENCES 253

xxii CONTENTS CHAPTER 17 254 CHAPTER 19 Anger/Aggression Management Behavior Therapy 279 ANGER AND AGGRESSION, DEFINED 255 CLASSICAL CONDITIONING 280 OPERANT CONDITIONING 281 PREDISPOSING FACTORS TO ANGER TECHNIQUES FOR MODIFYING CLIENT BEHAVIOR 281 AND AGGRESSION 256 Modeling 256 Shaping 281 Operant Conditioning 256 Modeling 281 Neurophysiological Disorders 256 Premack Principle 282 Biochemical Factors 256 Extinction 282 Socioeconomic Factors 256 Contingency Contracting 282 Environmental Factors 256 Token Economy 282 Time Out 282 THE NURSING PROCESS 257 Reciprocal Inhibition 282 Assessment 257 Overt Sensitization 283 Diagnosis/Outcome Identification 258 Covert Sensitization 283 Planning/Implementation 258 Systematic Desensitization 283 Evaluation 261 Flooding 283 ROLE OF THE NURSE IN BEHAVIOR THERAPY 283 SUMMARY AND KEY POINTS 261 SUMMARY AND KEY POINTS 285 REVIEW QUESTIONS 262 REVIEW QUESTIONS 287 REFERENCES 263 REFERENCES 288 CLASSICAL REFERENCES 288 CHAPTER 18 The Suicidal Client 264 CHAPTER 20 Cognitive Therapy 289 HISTORICAL PERSPECTIVES 264 HISTORICAL BACKGROUND 290 EPIDEMIOLOGICAL FACTORS 265 INDICATIONS FOR COGNITIVE THERAPY 290 GOALS AND PRINCIPLES OF COGNITIVE THERAPY 290 RISK FACTORS 265 BASIC CONCEPTS 291 Marital Status 265 Automatic Thoughts 291 Gender 265 Schemas (Core Beliefs) 292 Age 266 TECHNIQUES OF COGNITIVE THERAPY 292 Religion 266 Didactic (Educational) Aspects 292 Socioeconomic Status 266 Cognitive Techniques 293 Ethnicity 266 Behavioral Interventions 294 Other Risk Factors 266 ROLE OF THE NURSE IN COGNITIVE THERAPY 295 PREDISPOSING FACTORS: THEORIES SUMMARY AND KEY POINTS 298 OF SUICIDE 267 REVIEW QUESTIONS 299 REFERENCES 300 Psychological Theories 267 CLASSICAL REFERENCES 300 Sociological Theory 267 Biological Theories 268 CHAPTER 21 Psychopharmacology 301 APPLICATION OF THE NURSING PROCESS WITH THE SUICIDAL CLIENT 268 HISTORICAL PERSPECTIVES 302 ROLE OF THE NURSE 302 Assessment 268 Diagnosis/Outcome Identification 270 Ethical and Legal Implications 302 Planning/Implementation 270 Evaluation 275 SUMMARY AND KEY POINTS 275 REVIEW QUESTIONS 276 REFERENCES 277 CLASSICAL REFERENCES 278

Assessment 302 CONTENTS xxiii Medication Administration and CHAPTER 23 Evaluation 302 Complementary Therapies 344 Client Education 302 COMMONALITIES AND CONTRASTS 347 TYPES OF COMPLEMENTARY THERAPIES 347 HOW DO PSYCHOTROPICS WORK? 304 Herbal Medicine 347 APPLYING THE NURSING PROCESS IN Acupressure and Acupuncture 348 Diet and Nutrition 351 PSYCHOPHARMACOLOGICAL Chiropractic Medicine 355 THERAPY 306 Therapeutic Touch and Massage 356 Yoga 356 Antianxiety Agents 306 Pet Therapy 357 Antidepressants 308 SUMMARY AND KEY POINTS 358 Mood-Stabilizing Agents 315 REVIEW QUESTIONS 359 Antipsychotic Agents 321 REFERENCES 359 Sedative-Hypnotics 327 Agents for Attention-Deficit/Hyperactivity Disorder (ADHD) 329 SUMMARY AND KEY POINTS 332 REVIEW QUESTIONS 334 REFERENCES 335 CHAPTER 22 CHAPTER 24 Electroconvulsive Therapy 336 Client Education 361 ELECTROCONVULSIVE THERAPY, DEFINED 337 HISTORICAL PERSPECTIVES 362 HISTORICAL PERSPECTIVES 337 INDICATIONS 338 THEORIES OF TEACHING AND LEARNING 363 Major Depression 338 Behaviorist Theory 363 Mania 338 Cognitive Theory 363 Schizophrenia 338 Humanistic Theory 363 Other Conditions 338 CONTRAINDICATIONS 338 DOMAINS OF LEARNING 364 MECHANISM OF ACTION 338 SIDE EFFECTS 338 Affective Domain 364 Cognitive Domain 364 RISKS ASSOCIATED WITH ELECTROCONVULSIVE Psychomotor Domain 364 THERAPY 339 Mortality 339 AGE AND DEVELOPMENTAL CONSIDERATIONS 364 Permanent Memory Loss 339 Brain Damage 339 The Adult Learner 364 Teaching Children and Adolescents 365 THE ROLE OF THE NURSE IN ELECTROCONVULSIVE Teaching the Elderly 365 THERAPY 339 Assessment 339 THE NURSING PROCESS IN CLIENT 371 Diagnosis/Outcome Identification 340 EDUCATION 366 Planning/Implementation 340 Assessment 366 Evaluation 341 Nursing Diagnosis 368 Outcome Identification 368 SUMMARY AND KEY POINTS 341 Planning/Implementation 368 REVIEW QUESTIONS 342 Evaluation 370 REFERENCES 343 DOCUMENTATION OF CLIENT EDUCATION SUMMARY AND KEY POINTS 371 REVIEW QUESTIONS 373 REFERENCES 374 CLASSICAL REFERENCES 374

xxiv CONTENTS UNIT FOUR Family Therapy 408 Group Therapy 408 NURSING CARE OF CLIENTS Psychopharmacology 408 WITH ALTERATIONS IN SUMMARY AND KEY POINTS 408 PSYCHOSOCIAL ADAPTATION REVIEW QUESTIONS 410 REFERENCES 411 CHAPTER 25 INTERNET REFERENCES 412 Disorders Usually First Diagnosed in Infancy, Childhood, or CHAPTER 26 Adolescence 376 Delirium, Dementia, and Amnestic Disorders 413 MENTAL RETARDATION 377 Predisposing Factors 377 DELIRIUM 414 Application of the Nursing Process to Mental Clinical Findings and Course 414 Retardation 378 Predisposing Factors 414 AUTISTIC DISORDER 380 DEMENTIA 415 Clinical Findings 380 Clinical Findings, Epidemiology, and Course 415 Epidemiology and Course 380 Predisposing Factors 417 Predisposing Factors 381 Application of the Nursing Process to Autistic AMNESTIC DISORDERS 422 Disorder 381 Predisposing Factors 422 ATTENTION-DEFICIT/HYPERACTIVITY DISORDER 384 APPLICATION OF THE NURSING PROCESS 422 Assessment 422 Clinical Findings, Epidemiology, and Nursing Diagnosis/Outcome Identification 426 Course 384 Planning/Implementation 427 Concept Care Mapping 430 Predisposing Factors 385 Client/Family Education 430 Application of the Nursing Process to ADHD 387 Evaluation 432 Psychopharmacological Intervention for MEDICAL TREATMENT MODALITIES 432 ADHD 390 Delirium 432 CONDUCT DISORDER 393 Dementia 432 Predisposing Factors 394 SUMMARY AND KEY POINTS 437 Application of the Nursing Process to Conduct REVIEW QUESTIONS 438 REFERENCES 439 Disorder 394 INTERNET REFERENCES 440 OPPOSITIONAL DEFIANT DISORDER 397 CHAPTER 27 Clinical Findings, Epidemiology, and Course 397 Substance-Related Disorders 441 Predisposing Factors 397 Application of the Nursing Process to ODD 398 SUBSTANCE-USE DISORDERS 442 TOURETTE’S DISORDER 401 Substance Abuse 442 Clinical Findings, Epidemiology, and Course 401 DSM-IV-TR Criteria for Substance Abuse 442 Predisposing Factors 401 Substance Dependence 442 Application of the Nursing Process to Tourette’s DSM-IV-TR Criteria for Substance Dependence 443 Disorder 401 Psychopharmacological Intervention for Tourette’s SUBSTANCE-INDUCED DISORDERS 443 Substance Intoxication 443 Disorder 404 DSM-IV-TR Criteria for Substance SEPARATION ANXIETY DISORDER 404 Intoxication 443 Clinical Findings, Epidemiology, and Course 404 Predisposing Factors 404 Application of the Nursing Process to Separation Anxiety Disorder 405 GENERAL THERAPEUTIC APPROACHES 407 Behavior Therapy 407

CONTENTS xxv Substance Withdrawal 443 CLASSICAL REFERENCES 488 DSM-IV-TR Criteria for Substance Withdrawal 443 INTERNET REFERENCES 488 CLASSES OF PSYCHOACTIVE SUBSTANCES 444 CHAPTER 28 Schizophrenia and Other Psychotic PREDISPOSING FACTORS TO SUBSTANCE-RELATED Disorders 489 DISORDERS 444 NATURE OF THE DISORDER 490 Biological Factors 444 Phase I: The Premorbid Phase 490 Psychological Factors 444 Phase II: The Prodromal Phase 491 Sociocultural Factors 444 Phase III: Schizophrenia 491 Phase IV: Residual Phase 491 THE DYNAMICS OF SUBSTANCE-RELATED Prognosis 491 DISORDERS 445 PREDISPOSING FACTORS 492 Alcohol Abuse and Dependence 445 Biological Influences 492 Alcohol Intoxication 449 Psychological Influences 494 Alcohol Withdrawal 450 Environmental Influences 494 Stressful Life Events 494 Sedative, Hypnotic, or Anxiolytic Abuse and The Transactional Model 494 Dependence 450 TYPES OF SCHIZOPHRENIA AND OTHER Sedative, Hypnotic, or Anxiolytic Intoxication 452 PSYCHOTIC DISORDERS 496 Sedative, Hypnotic, or Anxiolytic Withdrawal 452 Disorganized Schizophrenia 496 CNS Stimulant Abuse and Dependence 452 Catatonic Schizophrenia 496 CNS Stimulant Intoxication 455 Paranoid Schizophrenia 496 CNS Stimulant Withdrawal 455 Undifferentiated Schizophrenia 496 Inhalant Abuse and Dependence 456 Residual Schizophrenia 496 Inhalant Intoxication 456 Schizoaffective Disorder 496 Opioid Abuse and Dependence 456 Brief Psychotic Disorder 497 Opioid Intoxication 458 Schizophreniform Disorder 497 Opioid Withdrawal 458 Delusional Disorder 497 Hallucinogen Abuse and Dependence 459 Shared Psychotic Disorder 497 Hallucinogen Intoxication 461 Cannabis Abuse and Dependence 461 Psychotic Disorder Due to a General Cannabis Intoxication 463 Medical Condition 498 APPLICATION OF THE NURSING PROCESS 463 Substance-Induced Psychotic Disorder 498 APPLICATION OF THE NURSING PROCESS 498 Assessment 463 Diagnosis/Outcome Identification 470 Background Assessment Data 498 Planning/Implementation 471 Diagnosis/Outcome Identification 502 Concept Care Mapping 474 Planning/Implementation 503 Client/Family Education 474 Concept Care Mapping 506 Evaluation 474 Client/Family Education 506 Evaluation 506 THE CHEMICALLY IMPAIRED NURSE 476 TREATMENT MODALITIES FOR SCHIZOPHRENIA CODEPENDENCY 477 AND OTHER PSYCHOTIC DISORDERS 508 Psychological Treatments 508 The Codependent Nurse 477 Social Treatment 509 Treating Codependence 478 Organic Treatment 510 TREATMENT MODALITIES FOR SUBSTANCE-RELATED SUMMARY AND KEY POINTS 514 DISORDERS 478 REVIEW QUESTIONS 516 REFERENCES 517 Alcoholics Anonymous 478 INTERNET REFERENCES 518 Pharmacotherapy 478 Counseling 480 Group Therapy 481 Psychopharmacology for Substance Intoxication and Substance Withdrawal 481 SUMMARY AND KEY POINTS 484 REVIEW QUESTIONS 485 REFERENCES 487

xxvi CONTENTS CHAPTER 29 CLASSICAL REFERENCES 560 Mood Disorders 519 INTERNET REFERENCES 560 HISTORICAL PERSPECTIVE 520 CHAPTER 30 Anxiety Disorders 561 EPIDEMIOLOGY 520 HISTORICAL ASPECTS 562 Gender 521 EPIDEMIOLOGICAL STATISTICS 562 Age 521 HOW MUCH IS TOO MUCH? 564 Social Class 521 APPLICATION OF THE NURSING PROCESS 564 Race and Culture 521 Marital Status 522 Panic Disorder 564 Seasonality 522 Generalized Anxiety Disorder 565 Phobias 566 TYPES OF MOOD DISORDERS 522 Obsessive-Compulsive Disorder 571 Posttraumatic Stress Disorder 574 Depressive Disorders 522 Anxiety Disorder Due to a General Medical Bipolar Disorders 524 Other Mood Disorders 525 Condition 576 Substance-Induced Anxiety Disorder 576 DEPRESSIVE DISORDERS 525 Diagnosis/Outcome Identification 576 Planning/Implementation 578 Predisposing Factors 525 Concept Care Mapping 580 Developmental Implications 529 Client/Family Education 583 Evaluation 583 APPLICATION OF THE NURSING PROCESS TO TREATMENT MODALITIES 583 DEPRESSIVE DISORDERS 532 Individual Psychotherapy 583 Cognitive Therapy 584 Background Assessment Data 532 Behavior Therapy 584 Diagnosis/Outcome Identification 534 Group/Family Therapy 585 Planning/Implementation 535 Psychopharmacology 585 Concept Care Mapping 538 SUMMARY AND KEY POINTS 588 Client/Family Education 538 REVIEW QUESTIONS 589 Evaluation of Care for the Depressed Client 538 REFERENCES 590 BIPOLAR DISORDER (MANIA) 540 CLASSICAL REFERENCES 591 INTERNET REFERENCES 591 Predisposing Factors 540 Developmental Implications 542 CHAPTER 31 Somatoform and Dissociative APPLICATION OF THE NURSING PROCESS Disorders 592 TO BIPOLAR DISORDER (MANIA) 543 HISTORICAL ASPECTS 593 Background Assessment Data 543 EPIDEMIOLOGICAL STATISTICS 593 Diagnosis/Outcome Identification 544 APPLICATION OF THE NURSING PROCESS 595 Planning/Implementation 545 Concept Care Mapping 547 Background Assessment Data: Types of Somatoform Client/Family Education 547 Disorders 595 Evaluation of Care for the Manic Client 547 Predisposing Factors Associated with Somatoform TREATMENT MODALITIES FOR MOOD DISORDERS 549 Disorders 598 Individual Psychotherapy 549 Background Assessment Data: Types of Dissociative Group Therapy for Depression and Mania 550 Disorders 600 Family Therapy for Depression and Mania 550 Cognitive Therapy for Depression and Mania 550 Electroconvulsive Therapy for Depression and Mania 551 Transcranial Magnetic Stimulation 551 Light Therapy for Depression 551 Psychopharmacology 551 SUMMARY AND KEY POINTS 556 REVIEW QUESTIONS 557 REFERENCES 559

CONTENTS xxvii Predisposing Factors Associated with Dissociative Background Assessment Data (Anorexia Disorders 602 Nervosa) 648 Diagnosis/Outcome Identification 604 Background Assessment Data (Bulimia Planning/Implementation 605 Nervosa) 649 Concept Care Mapping 609 Evaluation 609 Background Assessment Data (Obesity) 650 TREATMENT MODALITIES 609 Diagnosis/Outcome Identification 652 Somatoform Disorders 609 Planning/Implementation 652 Dissociative Amnesia 612 Concept Care Mapping 658 Dissociative Fugue 612 Client/Family Education 658 Dissociative Identity Disorder 612 Evaluation 658 Depersonalization Disorder 613 TREATMENT MODALITIES 659 SUMMARY AND KEY POINTS 614 Behavior Modification 659 REVIEW QUESTIONS 616 Individual Therapy 660 REFERENCES 617 Family Therapy 660 CLASSICAL REFERENCES 618 Psychopharmacology 660 INTERNET REFERENCES 618 SUMMARY AND KEY POINTS 662 REVIEW QUESTIONS 663 CHAPTER 32 REFERENCES 664 Issues Related to Human INTERNET REFERENCES 665 Sexuality 619 CHAPTER 34 DEVELOPMENT OF HUMAN SEXUALITY 620 Personality Disorders 666 Birth Through Age 12 620 Adolescence 620 HISTORICAL ASPECTS 668 Adulthood 621 TYPES OF PERSONALITY DISORDERS 668 SEXUAL DISORDERS 622 Paranoid Personality Disorder 668 Paraphilias 622 Schizoid Personality Disorder 669 Sexual Dysfunctions 626 Schizotypal Personality Disorder 670 Application of the Nursing Process to Sexual Antisocial Personality Disorder 671 Disorders 630 Borderline Personality Disorder 671 Treatment Modalities for Sexual Dysfunctions 636 Histrionic Personality Disorder 671 Narcissistic Personality Disorder 672 VARIATIONS IN SEXUAL ORIENTATION 638 Avoidant Personality Disorder 673 Homosexuality 638 Dependent Personality Disorder 674 Transsexualism 640 Obsessive-Compulsive Personality Disorder 675 Bisexuality 640 Passive-Aggressive Personality Disorder 676 APPLICATION OF THE NURSING PROCESS 676 SEXUALLY TRANSMITTED DISEASES 641 SUMMARY AND KEY POINTS 643 Borderline Personality Disorder (Background REVIEW QUESTIONS 645 Assessment Data) 676 REFERENCES 646 CLASSICAL REFERENCES 646 Predisposing Factors to Borderline Personality INTERNET REFERENCES 646 Disorder 678 CHAPTER 33 Diagnosis/Outcome Identification 679 Eating Disorders 647 Planning/Implementation 679 Concept Care Mapping 683 EPIDEMIOLOGICAL FACTORS 648 Evaluation 683 APPLICATION OF THE NURSING PROCESS 648 Antisocial Personality Disorder (Background Assessment Data) 683 Diagnosis/Outcome Identification 686 Planning/Implementation 687 Concept Care Mapping 689 Evaluation 689

xxviii CONTENTS SUMMARY AND KEY POINTS 720 REVIEW QUESTIONS 723 TREATMENT MODALITIES 690 REFERENCES 724 Interpersonal Psychotherapy 690 CLASSICAL REFERENCES 725 Psychoanalytical Psychotherapy 690 INTERNET REFERENCES 725 Milieu or Group Therapy 690 Cognitive/Behavioral Therapy 690 CHAPTER 36 Psychopharmacology 690 Victims of Abuse or Neglect 726 SUMMARY AND KEY POINTS 692 HISTORICAL PERSPECTIVES 727 REVIEW QUESTIONS 693 PREDISPOSING FACTORS 727 REFERENCES 695 CLASSICAL REFERENCES 695 Biological Theories 728 INTERNET REFERENCES 695 Psychological Theories 728 Sociocultural Theories 728 UNIT FIVE APPLICATION OF THE NURSING PROCESS 730 Background Assessment Data 730 PSYCHIATRIC/MENTAL HEALTH Diagnosis/Outcome Identification 736 NURSING OF SPECIAL Planning/Implementation 736 POPULATIONS Concept Care Mapping 739 Evaluation 739 CHAPTER 35 TREATMENT MODALITIES 739 The Aging Individual 698 Crisis Intervention 739 The Safe House or Shelter 741 HOW OLD IS OLD? 699 Family Therapy 741 EPIDEMIOLOGICAL STATISTICS 699 SUMMARY AND KEY POINTS 742 REVIEW QUESTIONS 743 The Population 699 REFERENCES 745 Marital Status 699 CLASSICAL REFERENCES 745 Living Arrangements 700 INTERNET REFERENCES 745 Economic Status 700 Employment 700 CHAPTER 37 Health Status 700 Community Mental Health THEORIES OF AGING 700 Nursing 746 Biological Theories 700 Psychosocial Theories 701 THE CHANGING FOCUS OF CARE 747 THE NORMAL AGING PROCESS 702 THE PUBLIC HEALTH MODEL 748 Biological Aspects of Aging 702 THE ROLE OF THE NURSE 749 Psychological Aspects of Aging 705 Sociocultural Aspects of Aging 707 The Psychiatric-Mental Health Registered Nurse Sexual Aspects of Aging 707 (RN-PMH) 749 SPECIAL CONCERNS OF THE ELDERLY The Psychiatric-Mental Health Advanced Practice POPULATION 708 Registered Nurse (APRN-PMH) 750 Retirement 708 Long-Term Care 710 CASE MANAGEMENT 750 Elder Abuse 711 THE COMMUNITY AS CLIENT 751 Suicide 713 Primary Prevention 751 APPLICATION OF THE NURSING PROCESS 713 Secondary Prevention 757 Assessment 713 Tertiary Prevention 758 Diagnosis/Outcome Identification 714 SUMMARY AND KEY POINTS 772 Planning/Implementation 715 REVIEW QUESTIONS 774 Evaluation 715

REFERENCES 775 CONTENTS xxix CLASSICAL REFERENCES 776 LENGTH OF THE GRIEF PROCESS 796 CHAPTER 38 ANTICIPATORY GRIEF 797 Forensic Nursing 777 MALADAPTIVE RESPONSES TO LOSS 797 WHAT IS FORENSIC NURSING? 777 Delayed or Inhibited Grief 797 HISTORICAL PERSPECTIVES 778 Distorted (Exaggerated) Grief Response 797 Chronic or Prolonged Grieving 797 THE CONTEXT OF FORENSIC NURSING Normal versus Maladaptive Grieving 798 PRACTICE 778 APPLICATION OF THE NURSING PROCESS 798 Background Assessment Data: Concepts FORENSIC NURSING SPECIALTIES 778 Clinical Forensic Nursing Specialty 778 of Death—Developmental Issues 798 The Sexual Assault Nurse Examiner (SANE) 779 Background Assessment Data: Concepts Forensic Psychiatric Nursing Specialty 779 Correctional/Institutional Nursing Specialty 779 of Death—Cultural Issues 799 Nurses in General Practice 779 Nursing Diagnosis/Outcome APPLICATION OF THE NURSING PROCESS Identification 801 IN CLINICAL FORENSIC NURSING IN Planning/Implementation 801 TRAUMA CARE 780 Evaluation 801 Assessment 780 ADDITIONAL ASSISTANCE 804 Nursing Diagnosis 781 Hospice 804 Planning/Implementation 781 Advance Directives 806 Evaluation 783 SUMMARY AND KEY POINTS 807 REVIEW QUESTIONS 809 APPLICATION OF THE NURSING PROCESS IN REFERENCES 810 FORENSIC PSYCHIATRIC NURSING IN CLASSICAL REFERENCES 810 CORRECTIONAL FACILITIES 783 INTERNET REFERENCES 810 Assessment 783 Nursing Diagnosis 786 APPENDICES Planning/Implementation 786 Evaluation 789 APPENDIX A: ANSWERS TO CHAPTER REVIEW QUESTIONS 811 SUMMARY AND KEY POINTS 789 REVIEW QUESTIONS 790 APPENDIX B: MENTAL STATUS ASSESSMENT 815 REFERENCES 791 APPENDIX C: DSM-IV-TR CLASSIFICATION: AXES I CLASSICAL REFERENCE 791 INTERNET REFERENCES 791 AND II CATEGORIES AND CODES 819 APPENDIX D: NANDA NURSING DIAGNOSES: CHAPTER 39 The Bereaved Individual 792 TAXONOMY II 827 APPENDIX E: ASSIGNING NURSING DIAGNOSES THEORETICAL PERSPECTIVES ON LOSS AND BEREAVEMENT 793 TO CLIENT BEHAVIORS 831 Stages of Grief 793 APPENDIX F: CONTROLLED DRUG CATEGORIES AND PREGNANCY CATEGORIES 833 APPENDIX G: SAMPLE TEACHING GUIDES 834 GLOSSARY 851 INDEX 865



UNIT ONE BASIC CONCEPTS IN PSYCHIATRIC/ MENTAL HEALTH NURSING

1 CHAPTER The Concept of Stress Adaptation CHAPTER OUTLINE OBJECTIVES STRESS MANAGEMENT SUMMARY AND KEY POINTS STRESS AS A BIOLOGICAL RESPONSE REVIEW QUESTIONS STRESS AS AN ENVIRONMENTAL EVENT STRESS AS A TRANSACTION BETWEEN THE INDIVIDUAL AND THE ENVIRONMENT KEY TERMS CORE CONCEPTS adaptation “fight or flight syndrome” precipitating event maladaptation general adaptation predisposing factors stressor syndrome OBJECTIVES After reading this chapter, the student will be able to: 1. Define adaptation and maladaptation. 5. Explain the concept of stress as a 2. Identify physiological responses to stress. transaction between the individual and 3. Explain the relationship between stress the environment. and “diseases of adaptation.” 6. Discuss adaptive coping strategies in the 4. Describe the concept of stress as an management of stress. environmental event. Psychologists and others have struggled for many years viewed as positive and is correlated with a healthy to establish an effective definition of the term stress. This response. When behavior disrupts the integrity of the term is used loosely today and still lacks a definitive individual, it is perceived as maladaptive. Maladaptive explanation. Stress may be viewed as an individual’s responses by the individual are considered to be negative or reaction to any change that requires an adjustment or unhealthy. response, which can be physical, mental, or emotional. Responses directed at stabilizing internal biological Various twentieth-century researchers contributed to processes and preserving self-esteem can be viewed as several different concepts of stress. Three of these con- healthy adaptations to stress. cepts include stress as a biological response, stress as an environmental event, and stress as a transaction between Roy (1976) defined adaptive response as behavior that the individual and the environment. This chapter maintains the integrity of the individual. Adaptation is includes an explanation of each of these concepts. 2

CHAPTER 1 ● THE CONCEPT OF STRESS ADAPTATION 3 CORE CONCEPT and 1–2. Selye called this general reaction of the body to Stressor stress the general adaptation syndrome. He described A biological, psychological, social, or chemical factor the reaction in three distinct stages: that causes physical or emotional tension and may be 1. Alarm Reaction Stage. During this stage, the physi- a factor in the etiology of certain illnesses. ological responses of the “fight or flight syndrome” STRESS AS A BIOLOGICAL RESPONSE are initiated. 2. Stage of Resistance. The individual uses the physio- In 1956, Hans Selye published the results of his research logical responses of the first stage as a defense in the concerning the physiological response of a biological sys- attempt to adapt to the stressor. If adaptation occurs, tem to a change imposed on it. Since his initial publica- the third stage is prevented or delayed. Physiological tion, he has revised his definition of stress, calling it “the symptoms may disappear. state manifested by a specific syndrome which consists of 3. Stage of Exhaustion. This stage occurs when there is a all the nonspecifically-induced changes within a biologic prolonged exposure to the stressor to which the body system” (Selye, 1976). This syndrome of symptoms has has become adjusted. The adaptive energy is depleted, come to be known as the “fight or flight syndrome.” and the individual can no longer draw from the Schematics of these biological responses, both initially resources for adaptation described in the first two stages. and with sustained stress, are presented in Figures 1–1 Diseases of adaptation (e.g., headaches, mental disor- ders, coronary artery disease, ulcers, colitis) may occur. Without intervention for reversal, exhaustion ensues, and in some cases even death (Selye, 1956, 1974). HYPOTHALAMUS Stimulates Sympathetic Nervous System Innervates Adrenal Eye Lacrimal Respiratory Cardiovascular GI system Liver Urinary Sweat Fat medulla glands system system system glands cells Pupils Bronchioles Gastric and Ureter Lipolysis dilated dilated intestinal motility motility Bladder Respiration Secretions muscle rate increased Sphincters contracts; contract sphincter relaxes Norepinephrine Secretion Force of cardiac Glycogenolysis Secretion and epinephrine increased contraction and released Cardiac output gluconeogenesis Heart rate Glycogen synthesis Blood pressure FIGURE 1–1 The “fight or flight” syndrome: the initial stress response.

4 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING HYPOTHALAMUS Stimulates Pituitary Gland Releases Adrenocorticotropic hormone Vasopressin Growth hormone Thyrotropic hormone Gonadotropins (ACTH) (ADH) Stimulates Blood pressure Direct effect on Stimulates (Initially) Adrenal cortex through constriction protein, carbohydrate, Sex hormones; of blood and lipid metabolism, Thyroid gland Releases vessels resulting in Later, with increased serum Basal metabolic sustained Fluid glucose and free rate (BMR) stress: retention fatty acids Secretion of sex hormones Glucocorticoids Mineralocorticoids Libido Gluconeogenesis Retention Frigidity Immune of sodium Impotence and water response Inflammatory response FIGURE 1–2 The “fight or flight” syndrome: the sustained stress response. This “fight or flight” response undoubtedly served our depleted of its adaptive energy more readily than it is ancestors well. Those Homo sapiens who had to face the from physical stressors. The “fight or flight” response giant grizzly bear or the saber-toothed tiger as part of may be inappropriate, even dangerous, to the lifestyle of their struggle for survival must have used these adaptive today, in which stress has been described as a psychoso- resources to their advantage. The response was elicited in cial state that is pervasive, chronic, and relentless. It is emergency situations, used in the preservation of life, and this chronic response that maintains the body in the followed by restoration of the compensatory mechanisms aroused condition for extended periods of time that pro- to the preemergent condition (homeostasis). motes susceptibility to diseases of adaptation. Selye performed his extensive research in a controlled CORE CONCEPT setting with laboratory animals as subjects. He elicited Adaptation the physiological responses with physical stimuli, such as Adaptation is said to occur when an individual’s exposure to heat or extreme cold, electric shock, injection physical or behavioral response to any change in his of toxic agents, restraint, and surgical injury. Since the or her internal or external environment results in publication of his original research, it has become appar- preservation of individual integrity or timely return to ent that the “fight or flight” syndrome of symptoms equilibrium. occurs in response to psychological or emotional stimuli, just as it does to physical stimuli. The psychological or emotional stressors are often not resolved as rapidly as some physical stressors, and therefore the body may be

CHAPTER 1 ● THE CONCEPT OF STRESS ADAPTATION 5 STRESS AS AN ENVIRONMENTAL concept of the etiology of disease. No longer is causation EVENT viewed solely as an external entity; whether or not illness A second concept defines stress as the “thing” or “event” occurs depends also on the receiving organism’s suscepti- that triggers the adaptive physiological and psychological bility. Similarly, to predict psychological stress as a responses in an individual. The event creates change in reaction, the properties of the person in relation to the the life pattern of the individual, requires significant environment must be considered. adjustment in lifestyle, and taxes available personal resources. The change can be either positive, such as out- Precipitating Event standing personal achievement, or negative, such as being Lazarus and Folkman (1984) define stress as a relationship fired from a job. The emphasis here is on change from the between the person and the environment that is appraised existing steady state of the individual’s life pattern. by the person as taxing or exceeding his or her resources and endangering his or her well being. A precipitating Miller and Rahe (1997) have updated the original event is a stimulus arising from the internal or external Social Readjustment Rating Scale devised by Holmes and environment and is perceived by the individual in a spe- Rahe in 1967. Just as in the earlier version, numerical val- cific manner. Determination that a particular person/ ues are assigned to various events, or changes, that are environment relationship is stressful depends on the indi- common in people’s lives. The updated version reflects vidual’s cognitive appraisal of the situation. Cognitive an increased number of stressors not identified in the appraisal is an individual’s evaluation of the personal signif- original version. In the new study, Miller and Rahe found icance of the event or occurrence. The event “precipitates” that women react to life stress events at higher levels than a response on the part of the individual, and the response men, and unmarried people gave higher scores than mar- is influenced by the individual’s perception of the event. ried people for most of the events. Younger subjects rated The cognitive response consists of a primary appraisal and a more events at a higher stress level than did older secondary appraisal. subjects. A high score on the Recent Life Changes Questionnaire (RLCQ) places the individual at greater The Individual’s Perception of the Event susceptibility to physical or psychological illness. The Primary Appraisal questionnaire may be completed considering life stres- Lazarus and Folkman (1984) identify three types of pri- sors within a 6-month or 1-year period. Six-month totals mary appraisal: irrelevant, benign-positive, and stressful. equal to or greater than 300 life change units (LCUs) or An event is judged irrelevant when the outcome holds no 1-year totals equal to or greater than 500 LCU are con- significance for the individual. A benign-positive outcome sidered indicative of a high level of recent life stress, is one that is perceived as producing pleasure for the thereby increasing the risk of illness for the individual. individual. Stress appraisals include harm/loss, threat, and The RLCQ is presented in Table 1–1. challenge. Harm/loss appraisals refer to damage or loss already experienced by the individual. Appraisals of a It is unknown whether stress overload merely predis- threatening nature are perceived as anticipated harms or poses a person to illness or actually precipitates it, but losses. When an event is appraised as challenging, the there does appear to be a causal link (Pelletier, 1992). Life individual focuses on potential for gain or growth, rather changes questionnaires have been criticized because they than on risks associated with the event. Challenge pro- do not consider the individual’s perception of the event. duces stress even though the emotions associated with it Individuals differ in their reactions to life events, and these (eagerness and excitement) are viewed as positive, and variations are related to the degree to which the change is coping mechanisms must be called upon to face the new perceived as stressful. These types of instruments also fail encounter. Challenge and threat may occur together to consider the individual’s coping strategies and available when an individual experiences these positive emotions support systems at the time when the life change occurs. along with fear or anxiety over possible risks associated Positive coping mechanisms and strong social or familial with the challenging event. support can reduce the intensity of the stressful life change and promote a more adaptive response. When stress is produced in response to harm/loss, threat, or challenge, a secondary appraisal is made by the STRESS AS A TRANSACTION BETWEEN individual. THE INDIVIDUAL AND THE ENVIRONMENT Secondary Appraisal This definition of stress emphasizes the relationship This secondary appraisal is an assessment of skills, between the individual and the environment. Personal resources, and knowledge that the person possesses to characteristics and the nature of the environmental event are considered. This illustration parallels the modern

6 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING TABLE 1–1 The Recent Life Changes Questionnaire Life Change Event LCU Life Change Event LCU Health Home and Family 42 74 25 An injury or illness which: 44 Major change in living conditions 47 Kept you in bed a week or more, or sent you to the 26 Change in residence: 25 hospital 27 55 Was less serious than above 26 Move within the same town or city 50 28 Move to a different town, city, or state 67 Major dental work 51 Change in family get-togethers 65 Major change in eating habits 35 Major change in health or behavior of family 66 Major change in sleeping habits 29 member 65 Major change in your usual type/amount of recreation 21 Marriage 59 Work 31 Pregnancy 46 Change to a new type of work 42 Miscarriage or abortion 41 Change in your work hours or conditions 32 Gain of a new family member: 41 Change in your responsibilities at work: 29 Birth of a child 45 35 Adoption of a child 50 More responsibilities 35 A relative moving in with you 38 Fewer responsibilities 28 Spouse beginning or ending work 59 Promotion 60 Child leaving home: 50 Demotion 52 To attend college 53 Transfer 68 Due to marriage 76 Troubles at work: 79 For other reasons 96 With your boss 18 Change in arguments with spouse 43 With coworkers 26 In-law problems With persons under your supervision 38 Change in the marital status of your parents: 119 Other work troubles 35 Divorce 123 Major business adjustment 24 Remarriage 102 Retirement 29 Separation from spouse: 100 Loss of job: 27 Due to work Laid off from work 24 Due to marital problems 38 Fired from work 37 Divorce 60 Correspondence course to help you in your work 45 Birth of grandchild 56 Personal and Social 39 Death of spouse 43 Change in personal habits 44 Death of other family member: 20 Beginning or ending school or college 47 Child 37 Change of school or college 48 Brother or sister 58 Change in political beliefs 20 Parent Change in religious beliefs 75 Financial Change in social activities 70 Major change in finances: Vacation 51 Increased income New, close, personal relationship 36 Decreased income Engagement to marry Investment and/or credit difficulties Girlfriend or boyfriend problems Loss or damage of personal property Sexual difficulties Moderate purchase “Falling out” of a close personal relationship Major purchase An accident Foreclosure on a mortgage or loan Minor violation of the law Being held in jail Death of a close friend Major decision regarding your immediate future Major personal achievement SOURCE: Miller and Rahe (1997), with permission. deal with the situation. The individual evaluates by con- Predisposing Factors sidering the following: A variety of elements influence how an individual per- ● Which coping strategies are available to me? ceives and responds to a stressful event. These predis- ● Will the option I choose be effective in this situation? posing factors strongly influence whether the response ● Do I have the ability to use that strategy in an effective is adaptive or maladaptive. Types of predisposing factors include genetic influences, past experiences, and existing manner? conditions. The interaction between the primary appraisal of the event that has occurred and the secondary appraisal of Genetic influences are those circumstances of an indi- available coping strategies determines the quality of the vidual’s life that are acquired through heredity. Examples individual’s adaptation response to stress. include family history of physical and psychological con- ditions (strengths and weaknesses) and temperament

CHAPTER 1 ● THE CONCEPT OF STRESS ADAPTATION 7 (behavioral characteristics present at birth that evolve STRESS MANAGEMENT* with development). The growth of stress management into a multimillion- dollar-a-year business attests to its importance in Past experiences are occurrences that result in learned our society. Stress management involves the use of cop- patterns that can influence an individual’s adaptation ing strategies in response to stressful situations. Coping response. They include previous exposure to the stressor strategies are adaptive when they protect the individual or other stressors, learned coping responses, and degree from harm (or additional harm) or strengthen the indi- of adaptation to previous stressors. vidual’s ability to meet challenging situations. Adaptive responses help restore homeostasis to the body and Existing conditions incorporate vulnerabilities that impede the development of diseases of adaptation. influence the adequacy of the individual’s physical, psy- chological, and social resources for dealing with adaptive Coping strategies are considered maladaptive when the demands. Examples include current health status, moti- conflict being experienced goes unresolved or intensifies. vation, developmental maturity, severity and duration of Energy resources become depleted as the body struggles the stressor, financial and educational resources, age, to compensate for the chronic physiological and psycho- existing coping strategies, and a support system of caring logical arousal being experienced. The effect is a signifi- others. cant vulnerability to physical or psychological illness. This transactional model of stress/adaptation will serve Adaptive Coping Strategies as a framework for the process of nursing in this text. A Awareness graphic display of the model is presented in Figure 1–3. The initial step in managing stress is awareness—to become aware of the factors that create stress and the CORE CONCEPT feelings associated with a stressful response. Stress can be Maladaptation controlled only when one recognizes that it is being Maladaptation occurs when an individual’s physical experienced. As one becomes aware of stressors, he or she or behavioral response to any change in his or her can omit, avoid, or accept them. internal or external environment results in disruption Relaxation of individual integrity or in persistent disequilibrium. Individuals experience relaxation in different ways. Some individuals relax by engaging in large motor activities, Precipitating Event such as sports, jogging, and physical exercise. Still others use techniques such as breathing exercises and progres- Predisposing Factors sive relaxation to relieve stress. (A discussion of relaxation Genetic Influences therapy can be found in Chapter 14.) Past Experiences Meditation Existing Conditions Practiced 20 minutes once or twice daily, meditation has Cognitive Appraisal been shown to produce a lasting reduction in blood pressure and other stress-related symptoms (Davis, * Primary * Eshelman, & McKay, 2008). Meditation involves assuming a comfortable position, closing the eyes, casting off all Irrelevant Benign- Stress other thoughts, and concentrating on a single word, sound, No positive appraisals or phrase that has positive meaning to the individual. The technique is described in detail in Chapter 14. response Pleasurable Challenge Interpersonal Communication with Caring response Other Threat As previously mentioned, the strength of one’s available Harm/ support systems is an existing condition that significantly loss influences the adaptiveness of coping with stress. * Secondary * *Techniques of stress management are discussed at greater length in Unit 3 of this text. Availability of coping strategies Perceived effectiveness of coping strategies Perceived ability to use coping strategies effectively Quality of Response Adaptive Maladaptive FIGURE 1–3 Transactional model of stress/adaptation.

8 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING Sometimes just “talking the problem out” with an indi- ● When behavior disrupts the integrity of the individual vidual who is empathetic is sufficient to interrupt escala- or results in persistent disequilibrium, it is perceived as tion of the stress response. Writing about one’s feelings maladaptive. Maladaptive responses by the individual in a journal or diary can also be therapeutic. are considered to be negative or unhealthy. Problem Solving ● A stressor is defined as a biological, psychological, An extremely adaptive coping strategy is to view the sit- social, or chemical factor that causes physical or emo- uation objectively (or to seek assistance from another tional tension and may be a factor in the etiology of individual to accomplish this if the anxiety level is too certain illnesses. high to concentrate). After an objective assessment of the situation, the problem-solving/decision-making model ● Hans Selye identified the biological changes associated can be instituted as follows: with a stressful situation as the “fight or flight ● Assess the facts of the situation. syndrome.” ● Formulate goals for resolution of the stressful situation. ● Study the alternatives for dealing with the situation. ● Selye called the general reaction of the body to stress ● Determine the risks and benefits of each alternative. the “general adaptation syndrome,” which occurs in ● Select an alternative. three stages: the alarm reaction stage, the stage of ● Implement the alternative selected. resistance, and the stage of exhaustion. ● Evaluate the outcome of the alternative implemented. ● If the first choice is ineffective, select and implement a ● When individuals remain in the aroused response to stress for an extended period of time, they become sus- second option. ceptible to diseases of adaptation, some examples of which include headaches, mental disorders, coronary Pets artery disease, ulcers, and colitis. Studies show that those who care for pets, especially dogs and cats, are better able to cope with the stressors of life ● Stress may also be viewed as an environmental event. (Allen, Blascovich, & Mendes, 2002; Barker et al., 2005). This results when a change from the existing steady The physical act of stroking or petting a dog or cat can state of the individual’s life pattern occurs. be therapeutic. It gives the animal an intuitive sense of being cared for and at the same time gives the individual ● When an individual experiences a high level of life the calming feeling of warmth, affection, and interde- change events, he or she becomes susceptible to phys- pendence with a reliable, trusting being. One study ical or psychological illness. showed that among people who had had heart attacks, pet owners had one-fifth the death rate of those who did ● Limitations of this concept of stress include failure to not have pets (Friedmann & Thomas, 1995). Another consider the individual’s perception of the event, cop- study revealed evidence that individuals experienced a ing strategies, and available support systems at the statistically significant drop in blood pressure in response time when the life change occurs. to petting a dog or cat (Whitaker, 2000). ● Stress is more appropriately expressed as a transaction Music between the individual and the environment that is It is true that music can “soothe the savage beast.” Creating appraised by the individual as taxing or exceeding his or and listening to music stimulate motivation, enjoyment, her resources and endangering his or her well being. and relaxation. Music can reduce depression and bring about measurable changes in mood and general activity. ● The individual makes a cognitive appraisal of the pre- cipitating event to determine the personal significance SUMMARY AND KEY POINTS of the event or occurrence. ● Stress has become a chronic and pervasive condition in ● Primary cognitive appraisals may be irrelevant, the United States today. benign-positive, or stressful. ● Adaptive behavior is viewed as behavior that maintains ● Secondary cognitive appraisals include assessment and the integrity of the individual, with a timely return to evaluation by the individual of skills, resources, and equilibrium. It is viewed as positive and is correlated knowledge to deal with the stressful situation. with a healthy response. ● Predisposing factors influence how an individual per- ceives and responds to a stressful event. They include genetic influences, past experiences, and existing conditions. ● Stress management involves the use of adaptive coping strategies in response to stressful situations in an effort to impede the development of diseases of adaptation. ● Examples of adaptive coping strategies include devel- oping awareness, relaxation, meditation, interpersonal communication with caring other, problem solving, pets, music, and others. For additional clinical tools and study aids, visit DavisPlus.

CHAPTER 1 ● THE CONCEPT OF STRESS ADAPTATION 9 REVIEW QUESTIONS Self-Examination/Learning Exercise Select the answer that is most appropriate for questions 1 through 4. 1. Sondra, who lives in Maine, hears on the evening news that 25 people were killed in a tornado in south Texas. Sondra experiences no anxiety upon hearing of this stressful situation. This is most likely because Sondra: a. Is selfish and does not care what happens to other people. b. Appraises the event as irrelevant to her own situation. c. Assesses that she has the skills to cope with the stressful situation. d. Uses suppression as her primary defense mechanism. 2. Cindy regularly develops nausea and vomiting when she is faced with a stressful situation. Which of the following is most likely a predisposing factor to this maladaptive response by Cindy? a. Cindy inherited her mother’s “nervous” stomach. b. Cindy is fixed in a lower level of development. c. Cindy has never been motivated to achieve success. d. When Cindy was a child, her mother pampered her and kept her home from school when she was ill. 3. When an individual’s stress response is sustained over a long period, the endocrine system involve- ment results in which of the following? a. Decreased resistance to disease. b. Increased libido c. Decreased blood pressure. d. Increased inflammatory response. 4. Management of stress is extremely important in today’s society because: a. Evolution has diminished human capability for “fight or flight.” b. The stressors of today tend to be ongoing, resulting in a sustained response. c. We have stress disorders that did not exist in the days of our ancestors. d. One never knows when one will have to face a grizzly bear or saber-toothed tiger in today’s society. 5. Match each of the following situations to its correct component of the Transactional Model of Stress/Adaptation. 1. Mr. T is fixed in a lower level of development. a. Precipitating stressor 2. Mr. T’s father had diabetes mellitus. b. Past experiences 3. Mr. T has been fired from his last five jobs. c. Existing conditions 4. Mr. T’s baby was stillborn last month. d. Genetic influences 6. Match the following types of primary appraisals to their correct definition of the event as perceived by the individual. 1. Irrelevant a. Perceived as producing pleasure 2. Benign-positive b. Perceived as anticipated harms or losses 3. Harm/loss c. Perceived as potential for gain or growth 4. Threat d. Perceived as having no significance to the individual. 5. Challenge e. Perceived as damage or loss already experienced

10 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING REFERENCES Allen, K., Blascovich, J., & Mendes, W.B. (2002). Cardiovascular Friedmann, E., & Thomas, S.A. (1995). Pet ownership, social support, reactivity and the presence of pets, friends, and spouses: The truth and one-year survival after acute myocardial infarction in the car- about cats and dogs. Psychosomatic Medicine, 64, 727–739. diac arrhythmia suppression trial. American Journal of Cardiology, 76(17), 1213. Barker, S.B., Knisely, J.S., McCain, N.L., & Best, A.M. (2005). Measuring stress and immune response in healthcare professionals Miller, M.A., & Rahe, R.H. (1997). Life changes scaling for the 1990s. following interaction with a therapy dog: A pilot study. Psychological Journal of Psychosomatic Research, 43(3), 279–292. Reports, 96, 713–729. Pelletier, K.R. (1992). Mind as healer, mind as slayer: A holistic approach Davis, M.D., Eshelman, E.R., & McKay, M. (2008). The relaxation and to preventing stress disorders. New York: Dell. stress reduction workbook (6th ed.). Oakland, CA: New Harbinger Publications. Whitaker, J. (2000). Pet owners are a healthy breed. Health & Healing, 10(10), 1–8. CLASSICAL REFERENCES Holmes, T., & Rahe, R. (1967). The social readjustment rating scale. Selye, H. (1956). The stress of life. New York: McGraw-Hill. Journal of Psychosomatic Research, 11, 213–218. Selye, H. (1974). Stress without distress. New York: Signet Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal and coping. New Books. York: Springer. Selye, H. (1976). The stress of life (rev. ed.). New York: McGraw Hill. Roy, C. (1976). Introduction to nursing: An adaptation model. Englewood Cliffs, NJ: Prentice-Hall.

2 CHAPTER Mental Health/Mental Illness: Historical and Theoretical Concepts CHAPTER OUTLINE OBJECTIVES MENTAL HEALTH/MENTAL ILLNESS CONTINUUM HISTORICAL OVERVIEW OF PSYCHIATRIC CARE THE DSM-IV-TR MULTIAXIAL EVALUATION SYSTEM MENTAL HEALTH SUMMARY AND KEY POINTS MENTAL ILLNESS REVIEW QUESTIONS PSYCHOLOGICAL ADAPTATION TO STRESS KEY TERMS CORE CONCEPTS anxiety anticipatory grieving reaction formation grief bereavement overload regression defense mechanisms repression sublimation compensation suppression denial undoing displacement humors identification mental health intellectualization mental illness introjection neurosis isolation psychosis projection “ship of fools” rationalization OBJECTIVES After reading this chapter, the student will be able to: 1. Discuss the history of psychiatric care. 4. Describe psychological adaptation 2. Define mental health and mental illness. responses to stress. 3. Discuss cultural elements that influence 5. Identify correlation of adaptive/ attitudes toward mental health and maladaptive behaviors to the mental mental illness. health/mental illness continuum. 11

12 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING The consideration of mental health and mental illness During the same period in the Middle Eastern Islamic has its basis in the cultural beliefs of the society in which countries, however, a change in attitude began to occur, the behavior takes place. Some cultures are quite liberal from the perception of mental illness as the result of in the range of behaviors that are considered acceptable, witchcraft or the supernatural to the idea that these indi- whereas others have very little tolerance for behaviors viduals were actually ill. This notion gave rise to the that deviate from the cultural norms. establishment of special units for the mentally ill within general hospitals, as well as institutions specifically A study of the history of psychiatric care reveals some designed to house the insane. They can likely be consid- shocking truths about past treatment of mentally ill indi- ered the first asylums for the mentally ill. viduals. Many were kept in control by means that today could be considered less than humane. Colonial Americans tended to reflect the attitudes of the European communities from which they had immigrated. This chapter deals with the evolution of psychiatric Particularly in the New England area, individuals were care from ancient times to the present. Mental health punished for behavior attributed to witchcraft. In the 16th and mental illness are defined, and the psychological and 17th centuries, institutions for the mentally ill did not adaptation to stress is explained in terms of the two major exist in the United States, and care of these individuals responses: anxiety and grief. A mental health/mental ill- became a family responsibility. Those without family or ness continuum and the Diagnostic and Statistical Manual of other resources became the responsibility of the communi- Mental Disorders, 4th edition, Text Revision (DSM-IV-TR), ties in which they lived and were incarcerated in places multiaxial evaluation system are presented. where they could do no harm to themselves or others. HISTORICAL OVERVIEW The first hospital in America to admit mentally ill OF PSYCHIATRIC CARE clients was established in Philadelphia in the middle of Primitive beliefs regarding mental disturbances took sev- the 18th century. Benjamin Rush, often called the father eral views. Some thought that an individual with mental of American psychiatry, was a physician at the hospital. illness had been dispossessed of his or her soul and that He initiated the provision of humanistic treatment and the only way wellness could be achieved was if the soul care for the mentally ill. Although he included kindness, returned. Others believed that evil spirits or supernatural exercise, and socialization, he also employed harsher or magical powers had entered the body. The “cure” for methods such as bloodletting, purging, various types of these individuals involved a ritualistic exorcism to purge physical restraints, and extremes of temperatures, reflect- the body of these unwanted forces. This often consisted of ing the medical therapies of that era. brutal beatings, starvation, or other torturous means. Still others considered that the mentally ill individual may The 19th century brought the establishment of a sys- have broken a taboo or sinned against another individual tem of state asylums, largely the result of the work of or God, for which ritualistic purification was required or Dorothea Dix, a former New England schoolteacher, who various types of retribution were demanded. The correla- lobbied tirelessly on behalf of the mentally ill population. tion of mental illness to demonology or witchcraft led to She was unfaltering in her belief that mental illness was some mentally ill individuals being burned at the stake. curable and that state hospitals should provide humanistic therapeutic care. This system of hospital care for the men- The position of these ancient beliefs evolved with tally ill grew, but the mentally ill population grew faster. increasing knowledge about mental illness and changes in The institutions became overcrowded and understaffed, cultural, religious, and sociopolitical attitudes. The work and conditions deteriorated. Therapeutic care reverted to of Hippocrates, about 400 B.C., began the movement away custodial care. These state hospitals provided the largest from belief in the supernatural. Hippocrates associated resource for the mentally ill until the initiation of the com- insanity and mental illness with an irregularity in the munity health movement of the 1960s (see Chapter 37). interaction of the four body fluids—blood, black bile, yel- low bile, and phlegm. He called these body fluids The emergence of psychiatric nursing began in 1873 humors, and associated each with a particular disposition. with the graduation of Linda Richards from the nursing Disequilibrium among these four humors was thought to program at the New England Hospital for Women and cause mental illness, and it was often treated by inducing Children in Boston. She has come to be known as the first vomiting and diarrhea with potent cathartic drugs. American psychiatric nurse. During her career, Richards was instrumental in the establishment of a number of psy- During the Middle Ages (A.D. 500 to 1500), the asso- chiatric hospitals and the first school of psychiatric nurs- ciation of mental illness with witchcraft and the supernat- ing at the McLean Asylum in Waverly, Massachusetts, in ural continued to prevail in Europe. During this period, 1882. The focus in this school, and those that followed, many severely mentally ill people were sent out to sea on was “training” in how to provide custodial care for clients sailing boats with little guidance to search for their lost in psychiatric asylums—training that did not include the rationality. The expression “ship of fools” was derived study of psychological concepts. Significant change did from this operation. not occur until 1955, when incorporation of psychiatric nursing into their curricula became a requirement for all undergraduate schools of nursing.

CHAPTER 2 ● MENTAL HEALTH/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 13 Nursing curricula emphasized the importance of the American psychiatric care has its roots in ancient times. nurse-patient relationship and therapeutic communica- A great deal of opportunity exists for continued advance- tion techniques. Nursing intervention in the somatic ment of this specialty within the practice of nursing. therapies (e.g., insulin and electroconvulsive therapy) provided impetus for the incorporation of these concepts MENTAL HEALTH into nursing’s body of knowledge. A number of theorists have attempted to define the con- cept of mental health. Many of these concepts deal with With the apparently increasing need for psychiatric various aspects of individual functioning. Maslow (1970) care in the aftermath of World War II, the government emphasized an individual’s motivation in the continuous passed the National Mental Health Act of 1946. This leg- quest for self-actualization. He identified a “hierarchy of islation provided funds for the education of psychiatrists, needs,” the lower ones requiring fulfillment before those psychologists, social workers, and psychiatric nurses. at higher levels can be achieved, with self-actualization Graduate-level education in psychiatric nursing was being fulfillment of one’s highest potential. An individ- established during this period. Also significant at this time ual’s position within the hierarchy may reverse from a was the introduction of antipsychotic medications, which higher level to a lower level based on life circumstances. made it possible for psychotic clients to more readily par- For example, an individual facing major surgery who has ticipate in their treatment, including nursing therapies. been working on tasks to achieve self-actualization may become preoccupied, if only temporarily, with the need Knowledge of the history of psychiatric/mental health for physiological safety. A representation of this needs care contributes to the understanding of the concepts hierarchy is presented in Figure 2–1. presented in this chapter and those in Chapter 3, which describe the theories of personality development accord- ing to various 19th-century and 20th-century leaders in the psychiatric/mental health movement. Modern SELF- ACTUALIZATION (The individual possesses a feeling of self- fulfillment and the realization of his or her highest potential.) SELF-ESTEEM ESTEEM-OF-OTHERS (The individual seeks self-respect and respect from others, works to achieve success and recognition in work, and desires prestige from accomplishments.) LOVE AND BELONGING (Needs are for giving and receiving of affection, companionship, satisfactory interpersonal relationships, and identification with a group.) SAFETY AND SECURITY (Needs at this level are for avoiding harm, maintaining comfort, order, structure, physical safety, freedom from fear, and protection.) PHYSIOLOGICAL NEEDS (Basic fundamental needs include food, water, air, sleep, exercise, elimination, shelter, and sexual expression.) FIGURE 2–1 Maslow’s hierarchy of needs.

14 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING Maslow described self-actualization as being “psycho- 6. Environmental Mastery. This indicator suggests that logically healthy, fully human, highly evolved, and fully the individual has achieved a satisfactory role within mature.” He believed that “healthy,” or “self-actualized,” the group, society, or environment. It suggests that he individuals possessed the following characteristics: or she is able to love and accept the love of others. ● An appropriate perception of reality When faced with life situations, the individual is able ● The ability to accept oneself, others, and human to strategize, make decisions, change, adjust, and adapt. Life offers satisfaction to the individual who has nature achieved environmental mastery. ● The ability to manifest spontaneity The American Psychiatric Association (APA, 2003) ● The capacity for focusing concentration on problem defines mental health as: solving A state of being that is relative rather than absolute. The ● A need for detachment and desire for privacy successful performance of mental functions shown by ● Independence, autonomy, and a resistance to encultur- productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with ation adversity. ● An intensity of emotional reaction Robinson (1983) has offered the following definition ● A frequency of “peak” experiences that validates the of mental health: worthwhileness, richness, and beauty of life a dynamic state in which thought, feeling, and behavior that ● An identification with humankind is age-appropriate and congruent with the local and cultural ● The ability to achieve satisfactory interpersonal rela- norms is demonstrated. (p. 74) For purposes of this text, and in keeping with the tionships ● A democratic character structure and strong sense of framework of stress/adaptation, a modification of Robinson’s definition of mental health is considered. ethics Thus, mental health is viewed as the successful adapta- ● Creativeness tion to stressors from the internal or external environ- ● A degree of nonconformance ment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and Jahoda (1958) has identified a list of six indicators that cultural norms. she suggests are a reflection of mental health: 1. A Positive Attitude Toward Self. This includes an MENTAL ILLNESS A universal concept of mental illness is difficult, because objective view of self, including knowledge and of the cultural factors that influence such a definition. acceptance of strengths and limitations. The individ- However, certain elements are associated with individu- ual feels a strong sense of personal identity and a secu- als’ perceptions of mental illness, regardless of cultural rity within the environment. origin. Horwitz (2002) identifies two of these elements as 2. Growth, Development, and the Ability to Achieve (1) incomprehensibility and (2) cultural relativity. Self-actualization. This indicator correlates with whether the individual successfully achieves the tasks Incomprehensibility relates to the inability of the gener- associated with each level of development (see al population to understand the motivation behind the Erikson, Chapter 3). With successful achievement in behavior. When observers are unable to find meaning or each level the individual gains motivation for advance- comprehensibility in behavior, they are likely to label ment to his or her highest potential. that behavior as mental illness. Horwitz states, 3. Integration. The focus here is on maintaining an “Observers attribute labels of mental illness when the equilibrium or balance among various life processes. rules, conventions, and understandings they use to inter- Integration includes the ability to adaptively respond pret behavior fail to find any intelligible motivation to the environment and the development of a philoso- behind an action.” The element of cultural relativity con- phy of life, both of which help the individual maintain siders that these rules, conventions, and understandings anxiety at a manageable level in response to stressful are conceived within an individual’s own particular cul- situations. ture. Behavior that is considered “normal” and “abnor- 4. Autonomy. This refers to the individual’s ability to mal” is defined by one’s cultural or societal norms. perform in an independent, self-directed manner. The Therefore, a behavior that is recognized as mentally ill individual makes choices and accepts responsibility for in one society may be viewed as “normal” in another the outcomes. society, and vice versa. Horwitz identified a number of 5. Perception of Reality. Accurate reality perception is a positive indicator of mental health. This includes perception of the environment without distortion, as well as the capacity for empathy and social sensitivity—a respect and concern for the wants and needs of others.

CHAPTER 2 ● MENTAL HEALTH/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 15 cultural aspects of mental illness, which are presented in B O X 2 – 1 Cultural Aspects of Mental Illness Box 2–1. 1. Usually members of the lay community, rather than a In the DSM-IV-TR (American Psychiatric Association psychiatric professional, initially recognize that an indi- [APA], 2000), the APA defined mental illness or a mental vidual’s behavior deviates from the societal norms. disorder as 2. People who are related to an individual or who are of the same cultural or social group are less likely to label a clinically significant behavioral or psychological syndrome an individual’s behavior as mentally ill than someone or pattern that occurs in a person and that is associated with who is relationally or culturally distant. Relatives (or present distress (e.g., a painful symptom) or disability (i.e., people of the same cultural or social group) try to “nor- impairment in one or more important areas of functioning), malize” the behavior; that is, they try to find an explana- or with a significantly increased risk of suffering death, pain, tion for the behavior. disability, or an important loss of freedom . . . and is not 3. Psychiatrists see a person with mental illness most often merely an expectable and culturally sanctioned response to a when the family members can no longer deny the illness particular event (e.g., the death of a loved one). (p. xxxi) and often when the behavior is at its worst. The local or cultural norms define pathological behavior. For purposes of this text, and in keeping with the 4. Individuals in the lowest social class usually display the framework of stress/adaptation, mental illness will be char- highest amount of mental illness symptoms. However, acterized as maladaptive responses to stressors from the they tend to tolerate a wider range of behaviors that internal or external environment, evidenced by thoughts, deviate from societal norms and are less likely to consid- feelings, and behaviors that are incongruent with the er these behaviors as indicative of mental illness. Mental local and cultural norms, and interfere with the individ- illness labels are most often applied by psychiatric pro- ual’s social, occupational, and/or physical functioning. fessionals. 5. The higher the social class, the greater the recognition PSYCHOLOGICAL ADAPTATION TO of mental illness behaviors. Members of the higher STRESS social classes are likely to be self-labeled or labeled by All individuals exhibit some characteristics associated family members or friends. Psychiatric assistance is with both mental health and mental illness at any given sought near the first signs of emotional disturbance. point in time. Chapter 1 described how an individual’s 6. The more highly educated the person, the greater the response to stressful situations was influenced by his or recognition of mental illness behaviors. However, even her personal perception of the event and a variety of pre- more relevant than the amount of education is the type of disposing factors, such as heredity, temperament, learned education. Individuals in the more humanistic types of response patterns, developmental maturity, existing cop- professions (lawyers, social workers, artists, teachers, ing strategies, and support systems of caring others. nurses) are more likely to seek psychiatric assistance than professionals such as business executives, computer Anxiety and grief have been described as two major, specialists, accountants, and engineers. primary psychological response patterns to stress. A vari- 7. In terms of religion, Jewish people are more likely to ety of thoughts, feelings, and behaviors are associated seek psychiatric assistance than are Catholics or with each of these response patterns. Adaptation is deter- Protestants. mined by the degree to which the thoughts, feelings, and 8. Women are more likely than men to recognize the behaviors interfere with an individual’s functioning. symptoms of mental illness and seek assistance. 9. The greater the cultural distance from the mainstream of CORE CONCEPT society (i.e., the fewer the ties with conventional society), Anxiety the greater the likelihood of negative response by society A diffuse apprehension that is vague in nature and to mental illness. For example, immigrants have a is associated with feelings of uncertainty and greater distance from the mainstream than the native helplessness. born, blacks greater than whites, and “bohemians” greater than bourgeoisie. They are more likely to be Anxiety subjected to coercive treatment, and involuntary psychi- Feelings of anxiety are so common in our society that atric commitments are more common. they are almost considered universal. Anxiety arises from SOURCE: Adapted from Horwitz (2002). the chaos and confusion that exists in the world today. Fears of the unknown and conditions of ambiguity offer a perfect breeding ground for anxiety to take root and grow. Low levels of anxiety are adaptive and can provide the motivation required for survival. Anxiety becomes problematic when the individual is unable to prevent the anxiety from escalating to a level that interferes with the ability to meet basic needs. Peplau (1963) described four levels of anxiety: mild, moderate, severe, and panic. It is important for nurses to be able to recognize the symptoms associated with each level to plan for appropriate intervention with anxious individuals.

16 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING TABLE 2–1 Levels of Anxiety Level Perceptual Ability to Physical Emotional/Behavioral Mild Field Learn Characteristics Characteristics Moderate Restlessness Severe Heightened Learning is enhanced Irritability May remain superficial with perception (e.g., others. Panic noises may seem Learning still Increased restlessness. louder; details occurs, but not at Increased heart and Rarely experienced as distressful. within the optimal ability. Motivation is increased. environment are respiration rate. clearer) Decreased Increased perspiration. A feeling of discontent. attention span. Gastric discomfort. May lead to a degree of Increased Increased muscular awareness Decreased ability impairment in interpersonal to concentrate. tension. relationships as individual begins Increased alertness Increase in speech rate, to focus on self and Extremely limited the need to relieve personal Reduction in attention span. volume, and pitch. discomfort. perceptual field. Headaches Feelings of dread, loathing, horror Unable to Dizziness Total focus on self and intense Reduced alertness concentrate or Nausea desire to relieve the anxiety. to environmental problem-solve. Trembling events (e.g., Insomnia Sense of impending doom. someone talking Effective learning Palpitations Terror may not be heard; cannot occur. Tachycardia Bizarre behavior, including part of the room Hyperventilation may not be Learning cannot Urinary frequency shouting, screaming, running noticed) occur. Diarrhea about wildly, clinging to anyone or anything from which a sense of Greatly diminished; only Unable to Dilated pupils safety and security is derived. extraneous concentrate. Labored breathing Hallucinations; delusions. details are Severe trembling Extreme withdrawal into self. perceived, or Unable to Sleeplessness fixation on a comprehend Palpitations single detail may even simple Diaphoresis and pallor occur. directions. Muscular incoordination Immobility or purposeless May not take notice of an hyperactivity event even Incoherence or inability to when attention is directed by verbalize another Unable to focus on even one detail within the environment. Misperceptions of the environment common (e.g., a perceived detail may be elaborated and out of proportion) ● Mild Anxiety. This level of anxiety is seldom a problem ● Severe Anxiety. The perceptual field of the severely for the individual. It is associated with the tension expe- anxious individual is so greatly diminished that concen- rienced in response to the events of day-to-day living. tration centers on one particular detail only or on many Mild anxiety prepares people for action. It sharpens the extraneous details. Attention span is extremely limited, senses, increases motivation for productivity, increases and the individual has much difficulty completing even the perceptual field, and results in a heightened aware- the simplest task. Physical symptoms (e.g., headaches, ness of the environment. Learning is enhanced and the palpitations, insomnia) and emotional symptoms (e.g., individual is able to function at his or her optimal level. confusion, dread, horror) may be evident. Discomfort is experienced to the degree that virtually all overt ● Moderate Anxiety. As the level of anxiety increases, the behavior is aimed at relieving the anxiety. extent of the perceptual field diminishes. The moder- ately anxious individual is less alert to events occurring ● Panic Anxiety. In this most intense state of anxiety, in the environment. The individual’s attention span and the individual is unable to focus on even one detail in ability to concentrate decrease, although he or she may the environment. Misperceptions are common, and a still attend to needs with direction. Assistance with loss of contact with reality may occur. The individual problem solving may be required. Increased muscular may experience hallucinations or delusions. Behavior tension and restlessness are evident. may be characterized by wild and desperate actions or

CHAPTER 2 ● MENTAL HEALTH/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 17 extreme withdrawal. Human functioning and commu- others, but all are used either consciously or uncon- nication with others is ineffective. Panic anxiety is sciously as a protective device for the ego in an effort to associated with a feeling of terror, and individuals may relieve mild to moderate anxiety. They become maladap- be convinced that they have a life-threatening illness tive when they are used by an individual to such a degree or fear that they are “going crazy” or losing control that there is interference with the ability to deal with (APA, 2000). Prolonged panic anxiety can lead to phys- reality, with effective interpersonal relations, or with ical and emotional exhaustion and can be a life-threat- occupational performance. Maladaptive use of defense ening situation. mechanisms promotes disintegration of the ego. The A synopsis of the characteristics associated with each major ego defense mechanisms identified by Anna Freud of the four levels of anxiety is presented in Table 2–1. are discussed here and summarized in Table 2–2. 1. Compensation is the covering up of a real or per- Behavioral Adaptation Responses to Anxiety ceived weakness by emphasizing a trait one considers more desirable. A variety of behavioral adaptation responses occur at each level of anxiety. Figure 2–2 depicts these behavioral Example: responses on a continuum of anxiety ranging from mild (a) A handicapped boy who is unable to participate in to panic. sports compensates by becoming a great scholar. (b) A young man who is the shortest among members of his Mild Anxiety. At the mild level, individuals employ any peer group views this as a deficiency and compensates of a number of coping behaviors that satisfy their needs by being overly aggressive and daring. for comfort. Menninger (1963) described the following types of coping mechanisms that individuals use to relieve 2. Denial is the refusal to acknowledge the existence of a anxiety in stressful situations: real situation or the feelings associated with it. Example: ● Sleeping ● Drinking (a) A woman has been told by family doctor that she ● Eating ● Daydreaming has a lump in her breast. An appointment is made for ● Physical exercise ● Laughing her with a surgeon; however, she does not keep the ● Smoking ● Cursing appointment and goes about her activities of daily ● Crying ● Nail biting living with no evidence of concern. (b) Individuals ● Pacing ● Finger tapping continue to smoke cigarettes even though they have ● Foot swinging ● Talking to someone with been told of the health risk involved. ● Fidgeting ● Yawning whom one feels comfortable 3. Displacement is the transferring of feelings from one target to another that is considered less threatening or Undoubtedly there are many more responses too numer- neutral. ous to mention here, considering that each individual Example: develops his or her own unique ways to relieve anxiety at (a) A man who is passed over for promotion on his job the mild level. Some of these behaviors are more adaptive says nothing to his boss but later belittles his son for than others. not making the basketball team. (b) A boy who is teased and hit by the class bully on the playground Mild-to-Moderate Anxiety. Sigmund Freud (1961) comes home after school and kicks his dog. identified the ego as the reality component of the per- sonality that governs problem solving and rational think- 4. Identification is an attempt to increase self-worth by ing. As the level of anxiety increases, the strength of the acquiring certain attributes and characteristics of an ego is tested, and energy is mobilized to confront the individual one admires. threat. Anna Freud (1953) identified a number of Example: defense mechanisms employed by the ego in the face of (a) A teenage girl emulates the mannerisms and style threat to biological or psychological integrity. Some of of dress of a popular female rock star. (b) The young these ego defense mechanisms are more adaptive than son of a famous civil rights worker adopts his father’s attitudes and behaviors with the intent of pursuing Mild Moderate Severe Panic similar aspirations. Coping Ego Psycho- Psycho- Psychotic mechanisms defense physiological neurotic responses mechanisms responses responses FIGURE 2–2 Adaptation responses on a continuum of anxiety.

18 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING TABLE 2–2 Ego Defense Mechanisms Defense Mechanism Example Defense Mechanism Example Compensation A physically handicapped boy is Rationalization John tells the rehab nurse, “I Covering up a real or unable to participate in Attempting to make excuses or drink because it’s the only way perceived weakness by football, so he compensates by formulate logical reasons to I can deal with my bad emphasizing a trait one becoming a great scholar. justify unacceptable feelings or marriage and my worse job.” considers more desirable. A woman drinks alcohol every behaviors. Jane hates nursing. She attended Denial day and cannot stop, failing to Reaction Formation nursing school to please her Refusing to acknowledge the acknowledge that she has a Preventing unacceptable or parents. During career day, she existence of a real situation or problem. undesirable thoughts or speaks to prospective students the feelings associated with it. behaviors from being about the excellence of nursing expressed by exaggerating as a career. Displacement A client is angry with his opposite thoughts or types of When 2–year-old Jay is The transfer of feelings from physician, does not express it, behaviors hospitalized for tonsillitis he one target to another that is but becomes verbally abusive Regression will drink only from a bottle, considered less threatening or with the nurse. Retreating in response to even though his mom states he that is neutral. stress to an earlier level of has been drinking from a cup development and the comfort for 6 months. Identification A teenager who required lengthy measures associated with that An accident victim can An attempt to increase self- rehabilitation after an accident level of functioning. remember nothing about his worth by acquiring certain decides to become a physical accident. attributes and characteristics of therapist as a result of his Repression an individual one admires experiences. Involuntarily blocking A mother whose son was killed unpleasant feelings and by a drunk driver channels her Intellectualization S’s husband is being transferred experiences from one’s anger and energy into being An attempt to avoid expressing with his job to a city far away awareness the president of the local actual emotions associated from her parents. She hides chapter of Mothers Against with a stressful situation by anxiety by explaining to her Sublimation Drunk Drivers. using the intellectual processes parents the advantages Rechanneling of drives or of logic, reasoning, and associated with the move. impulses that are personally or Scarlett O’Hara says, “I don’t analysis socially unacceptable into want to think about that now. Children integrate their parents’ activities that are constructive I’ll think about that Introjection value system into the process tomorrow.” Integrating the beliefs and of conscience formation. A Suppression values of another individual child says to friend, “Don’t The voluntary blocking of Joe is nervous about his new job into one’s own ego structure cheat. It’s wrong.” unpleasant feelings and and yells at his wife. On his experiences from one’s way home he stops and buys Isolation A young woman describes being awareness her some flowers. Separating a thought or attacked and raped, without memory from the feeling, showing any emotion. Undoing tone, or emotion associated Symbolically negating or with it. Sue feels a strong sexual canceling out an experience attraction to her track coach that one finds intolerable Projection and tells her friend, “He’s Attributing feelings or coming on to me!” impulses unacceptable to one’s self to another person 5. Intellectualization is an attempt to avoid expressing off their engagement. He shows no emotion when dis- actual emotions associated with a stressful situation by cussing this with his best friend. Instead he analyzes using the intellectual processes of logic, reasoning, his fiancée’s behavior and tries to reason why the rela- and analysis. tionship failed. Example: (a) A man whose brother is in a cardiac intensive care 6. Introjection is the internalization of the beliefs and unit following a severe myocardial infarction (MI) values of another individual such that they symbolically spends his allotted visiting time in discussion with the become a part of the self to the extent that the feeling nurse, analyzing test results and making a reasonable of separateness or distinctness is lost. determination about the pathophysiology that may Example: have occurred to induce the MI. (b) A young psychol- (a) A small child develops her conscience by internal- ogy professor receives a letter from his fiancée breaking izing what the parents believe is right and wrong.

CHAPTER 2 ● MENTAL HEALTH/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 19 The parents literally become a part of the child. The dangerous front-line duty. (b) A secretary is sexually child says to a friend while playing, “Don’t hit peo- attracted to her boss and feels an intense dislike ple. It’s not nice!” (b) A psychiatric client claims to be toward his wife. She treats her boss with detachment the Son of God, drapes himself in sheet and blanket, and aloofness while performing her secretarial duties “performs miracles” on other clients, and refuses to and is overly courteous, polite, and flattering to his respond unless addressed as Jesus Christ. wife when she comes to the office. 7. Isolation is the separation of a thought or a memory 11. Regression is the retreating to an earlier level of from the feeling tone or emotions associated with it development and the comfort measures associated (sometimes called emotional isolation). with that level of functioning. Example: Example: (a) A young woman describes being attacked and (a) When his mother brings his new baby sister home raped by a street gang. She displays an apathetic from the hospital, 4-year-old Tommy, who had been expression and no emotional tone. (b) A physician is toilet trained for more than a year, begins to wet his able to isolate her feelings about the eventual death pants, cry to be held, and suck his thumb. (b) A per- of a terminally ill cancer client by focusing her atten- son who is depressed may withdraw to his or her tion instead on the chemotherapy that will be given. room, curl up in a fetal position on the bed, and sleep for long periods of time. 8. Projection is the attribution of feelings or impulses unacceptable to one’s self to another person. The 12. Repression is the involuntary blocking of unpleas- individual “passes the blame” for these undesirable ant feelings and experiences from one’s awareness. feelings or impulses to another, thereby providing Example: relief from the anxiety associated with them. (a) A woman cannot remember being sexually assaulted Example: when she was 15 years old. (b) A teenage boy cannot (a) A young soldier who has an extreme fear of par- remember driving the car that was involved in an ticipating in military combat tells his sergeant that accident in which his best friend was killed. the others in his unit are “a bunch of cowards.” (b) A businessperson who values punctuality is late for a 13. Sublimation is the rechanneling of drives or impulses meeting and states, “Sorry I’m late. My assistant for- that are personally or socially unacceptable (e.g., got to remind me of the time. It’s so hard to find aggressiveness, anger, sexual drives) into activities good help these days.” that are more tolerable and constructive. Example: 9. Rationalization is the attempt to make excuses or (a) A teenage boy with strong competitive and formulate logical reasons to justify unacceptable feel- aggressive drives becomes the star football player on ings or behaviors. his high school team. (b) A young unmarried woman Example: with a strong desire for marriage and a family (a) A young woman is turned down for a secretarial achieves satisfaction and success in establishing and job after a poor performance on a typing test. She operating a daycare center for preschool children. claims, “I’m sure I could have done a better job on a word processor. Hardly anyone uses an electric type- 14. Suppression is the voluntarily blocking of unpleas- writer anymore!” (b) A young man is unable to afford ant feelings and experiences from one’s awareness. the sports car he wants so desperately. He tells the Example: salesperson, “I’d buy this car but I’ll be getting mar- (a) Scarlett O’Hara says, “I’ll think about that tomor- ried soon. This is really not the car for a family man.” row.” (b) A young woman who is depressed about a pending divorce proceeding tells the nurse, “I just 10. Reaction formation is the prevention of unaccept- don’t want to talk about the divorce. There’s nothing able or undesirable thoughts or behaviors from being I can do about it anyway.” expressed by exaggerating opposite thoughts or types of behaviors. 15. Undoing is the act of symbolically negating or can- Example: celing out a previous action or experience that one (a) The young soldier who has an extreme fear of finds intolerable. participating in military combat volunteers for

20 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING Examples: behavior (e.g., phobias, obsessive-compulsive disorder, (a) A man spills some salt on the table, then sprinkles panic disorder, generalized anxiety disorder, and post- some over his left shoulder to “prevent bad luck.” (b) traumatic stress disorder). A man who is anxious about giving a presentation at 2. Somatoform Disorders. Disorders in which the work yells at his wife during breakfast. He stops on characteristic features are physical symptoms for his way home from work that evening to buy her a which there is no demonstrable organic pathology. dozen red roses. Psychological factors are judged to play a significant role in the onset, severity, exacerbation, or mainte- Moderate-to-Severe Anxiety. Anxiety at the moderate- nance of the symptoms (e.g., hypochondriasis, conver- to-severe level that remains unresolved over an extended sion disorder, somatization disorder, pain disorder). period of time can contribute to a number of physiologi- 3. Dissociative Disorders. Disorders in which the char- cal disorders. The DSM-IV-TR (APA, 2000) describes acteristic feature is a disruption in the usually integrat- these disorders as “the presence of one or more specific ed functions of consciousness, memory, identity, or psychological or behavioral factors that adversely affect a perception of the environment (e.g., dissociative general medical condition.” The psychological factors amnesia, dissociative fugue, dissociative identity disor- may exacerbate symptoms of, delay recovery from, or der, and depersonalization disorder). interfere with treatment of the medical condition. The Panic Anxiety. At this extreme level of anxiety, an indi- condition may be initiated or exacerbated by an environ- vidual is not capable of processing what is happening in mental situation that the individual perceives as stressful. the environment, and may lose contact with reality. Measurable pathophysiology can be demonstrated. Psychosis is defined as a loss of ego boundaries or a gross impairment in reality testing (APA, 2000). Psychoses are The DSM-IV-TR states: serious psychiatric disturbances characterized by the Psychological and behavioral factors may affect the course presence of delusions or hallucinations and the impair- of almost every major category of disease, including cardio- ment of interpersonal functioning and relationship to the vascular conditions, dermatological conditions, endocrino- external world. The following are common characteris- logical conditions, gastrointestinal conditions, neoplastic tics of people with psychoses: conditions neurological conditions, pulmonary conditions, ● They experience minimal distress (emotional tone is renal conditions, and rheumatological conditions. (p. 732) flat, bland, or inappropriate). ● They are unaware that their behavior is maladaptive. Severe Anxiety. Extended periods of repressed severe ● They are unaware of any psychological problems. anxiety can result in psychoneurotic patterns of behaving. ● They are exhibiting a flight from reality into a less Neurosis is no longer a separate category of disorders in stressful world or into one in which they are attempt- the DSM-IV-TR (APA, 2000). However, the term is still ing to adapt. used in the literature to further describe the symptoma- Examples of psychotic responses to anxiety include the tology of certain disorders. Neuroses are psychiatric dis- schizophrenic, schizoaffective, and delusional disorders. turbances, characterized by excessive anxiety that is They are discussed at length in Chapter 28. expressed directly or altered through defense mecha- nisms. It appears as a symptom, such as an obsession, a CORE CONCEPT compulsion, a phobia, or a sexual dysfunction (Sadock & Grief Sadock, 2007). The following are common characteristics Grief is a subjective state of emotional, physical, and of people with neuroses: social responses to the loss of a valued entity. 1. They are aware that they are experiencing distress. 2. They are aware that their behaviors are maladaptive. Grief 3. They are unaware of any possible psychological Most individuals experience intense emotional anguish in response to a significant personal loss. A loss is anything causes of the distress. that is perceived as such by the individual. Losses may be 4. They feel helpless to change their situation. real, in which case they can be substantiated by others 5. They experience no loss of contact with reality. (e.g., death of a loved one, loss of personal possessions), The following disorders are examples of psychoneurotic or they may be perceived by the individual alone, unable responses to anxiety as they appear in the DSM-IV-TR. to be shared or identified by others (e.g., loss of the feel- They are discussed in this text in Chapters 30 and 31. ing of femininity following mastectomy). Any situation 1. Anxiety Disorders. Disorders in which the character- istic features are symptoms of anxiety and avoidance

CHAPTER 2 ● MENTAL HEALTH/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 21 that creates change for an individual can be identified as Anticipatory Grief a loss. Failure (either real or perceived) also can be When a loss is anticipated, individuals often begin the viewed as a loss. work of grieving before the actual loss occurs. Most peo- ple re-experience the grieving behaviors once the loss The loss, or anticipated loss, of anything of value to an occurs, but having this time to prepare for the loss can individual can trigger the grief response. This period of facilitate the process of mourning, actually decreasing the characteristic emotions and behaviors is called mourning. length and intensity of the response. Problems arise, par- The “normal” mourning process is adaptive and is char- ticularly in anticipating the death of a loved one, when acterized by feelings of sadness, guilt, anger, helplessness, family members experience anticipatory grieving and hopelessness, and despair. Indeed, an absence of mourn- the mourning process is completed prematurely. They ing after a loss may be considered maladaptive. disengage emotionally from the dying person, who may then experience feelings of rejection by loved ones at a Stages of Grief time when this psychological support is so necessary. Kübler-Ross (1969), in extensive research with terminal- ly ill patients, identified five stages of feelings and behav- Resolution iors that individuals experience in response to a real, per- The grief response can last from weeks to years. It cannot ceived, or anticipated loss: be hurried, and individuals must be allowed to progress at their own pace. In the loss of a loved one, grief work usu- Stage 1—Denial. This is a stage of shock and disbelief. ally lasts for at least a year, during which the grieving per- The response may be one of “No, it can’t be true!” The son experiences each significant “anniversary” date for the reality of the loss is not acknowledged. Denial is a protec- first time without the loved one present. tive mechanism that allows the individual to cope in an immediate time frame while organizing more effective Length of the grief process may be prolonged by a defense strategies. number of factors. If the relationship with the lost entity had been marked by ambivalence or if there had been an Stage 2—Anger. “Why me?” and “It’s not fair!” are com- enduring “love-hate” association, reaction to the loss ments often expressed during the anger stage. Envy and may be burdened with guilt. Guilt lengthens the grief resentment toward individuals not affected by the loss are reaction by promoting feelings of anger toward the self common. Anger may be directed at the self or displaced on for having committed a wrongdoing or behaved in an loved ones, caregivers, and even God. There may be a pre- unacceptable manner toward that which is now lost, and occupation with an idealized image of the lost entity. perhaps the grieving person may even feel that his or her behavior has contributed to the loss. Stage 3—Bargaining. During this stage, which is usu- ally not visible or evident to others, a “bargain” is made Anticipatory grieving is thought to shorten the grief with God in an attempt to reverse or postpone the loss. response in some individuals who are able to work “If God will help me through this, I promise I will go to through some of the feelings before the loss occurs. If the church every Sunday and volunteer my time to help oth- loss is sudden and unexpected, mourning may take longer ers.” Sometimes the promise is associated with feelings of than it would if individuals were able to grieve in antici- guilt for not having performed (or having the perception pation of the loss. of not having performed) satisfactorily, appropriately, or sufficiently. Length of the grieving process is also affected by the number of recent losses experienced by an individual and Stage 4—Depression. During this stage, the full impact whether he or she is able to complete one grieving process of the loss is experienced. The sense of loss is intense, and before another loss occurs. This is particularly true for feelings of sadness and depression prevail. This is a time elderly individuals who may be experiencing numerous of quiet desperation and disengagement from all associa- losses, such as spouse, friends, other relatives, independ- tion with the lost entity. It differs from pathological depres- ent functioning, home, personal possessions, and pets, in sion, which occurs when an individual becomes fixed in an a relatively short time. Grief accumulates, and this repre- earlier stage of the grief process. Rather, stage four of the sents a type of bereavement overload, which for some grief response represents advancement toward resolution. individuals presents an impossible task of grief work. Stage 5—Acceptance. The final stage brings a feeling Resolution of the process of mourning is thought to of peace regarding the loss that has occurred. It is a time have occurred when an individual can look back on the of quiet expectation and resignation. The focus is on the relationship with the lost entity and accept both the reality of the loss and its meaning for the individuals pleasures and the disappointments (both the positive and affected by it. the negative aspects) of the association (Bowlby & Parkes, 1970). Disorganization and emotional pain have All individuals do not experience each of these stages been experienced and tolerated. Preoccupation with the in response to a loss, nor do they necessarily experience them in this order. Some individuals’ grieving behaviors may fluctuate, and even overlap, between stages.

22 UNIT I ● BASIC CONCEPTS IN PSYCHIATRIC/MENTAL HEALTH NURSING lost entity has been replaced with energy and the desire may be evident. The individual may remain in denial for to pursue new situations and relationships. many years until the grief response is triggered by a reminder of the loss or even by another, unrelated loss. Maladaptive Grief Responses Maladaptive responses to loss occur when an individual is The individual who experiences a distorted response is not able to satisfactorily progress through the stages of fixed in the anger stage of grieving. In the distorted grieving to achieve resolution. These responses usually response, all the normal behaviors associated with griev- occur when an individual becomes fixed in the denial or ing, such as helplessness, hopelessness, sadness, anger, anger stage of the grief process. Several types of grief and guilt, are exaggerated out of proportion to the situa- responses have been identified as pathological. They tion. The individual turns the anger inward on the self, is include responses that are prolonged, delayed or inhibit- consumed with overwhelming despair, and is unable to ed, or distorted. The prolonged response is characterized function in normal activities of daily living. Pathological by an intense preoccupation with memories of the lost depression is a distorted grief response (see Chapter 29). entity for many years after the loss has occurred. Behaviors associated with the stages of denial or anger are manifest- MENTAL HEALTH/MENTAL ILLNESS ed, and disorganization of functioning and intense emo- CONTINUUM tional pain related to the lost entity are evidenced. Anxiety and grief have been described as two major, pri- mary responses to stress. In Figure 2–3, both of these In the delayed or inhibited response, the individual responses are presented on a continuum according to becomes fixed in the denial stage of the grieving process. degree of symptom severity. Disorders as they appear in The emotional pain associated with the loss is not experi- the DSM-IV-TR are identified at their appropriate place- enced, but anxiety disorders (e.g., phobias, hypochondriasis) ment along the continuum. or sleeping and eating disorders (e.g., insomnia, anorexia) Feelings of Dysthymia Major Depression Sadness Cyclothymia Bipolar Disorder Life's Everyday Neurotic Psychotic Disappointments Responses Responses Mild Moderate Severe Severe Moderate Grief Grief Mental Mental Health Illness Anxiety Anxiety Mild Panic Coping Ego Defense Psychophysiological Psychoneurotic Psychotic Mechanisms Mechanisms Responses Responses Responses Sleeping Compensation Headaches Phobias Schizophrenia Eating Denial Anorexia Obsessions Schizoaffective Yawning Displacement Arthritis Compulsions Drinking Identification Colitis Hypochondriasis disorder Exercise Isolation Ulcers Conversion Delusional Smoking Projection Asthma Crying Rationalization Pain disorder disorders Pacing Regression Cancer Multiple Laughing Repression CHD Talking it Sublimation Sexual personalities Suppression Amnesia out with Undoing dysfunction Fugue someone FIGURE 2–3 Conceptualization of anxiety and grief responses along the mental health/mental illness continuum.