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

["CHAPTER 2 \u25cf MENTAL HEALTH\/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 23 THE DSM-IV-TR MULTIAXIAL Axis II\u2014Personality Disorders and Mental Retardation. EVALUATION SYSTEM These disorders usually begin in childhood or adoles- cence and persist in a stable form into adult life. The APA endorses case evaluation on a multiaxial system, \u201cto facilitate comprehensive and systematic evaluation Axis III\u2014General Medical Conditions. These include with attention to the various mental disorders and general any current general medical condition that is poten- medical conditions, psychosocial and environmental prob- tially relevant to the understanding or management of lems, and level of functioning that might be overlooked if the individual\u2019s mental disorder. the focus were on assessing a single presenting problem.\u201d Each individual is evaluated on five axes. They are defined Axis IV\u2014Psychosocial and Environmental Problems. by the DSM-IV-TR in the following manner: These are problems that may affect the diagnosis, treat- ment, and prognosis of mental disorders named on axes Axis I\u2014Clinical Disorders and Other Conditions That I and II. These include problems related to primary May Be a Focus of Clinical Attention. This includes all support group, social environment, education, occupa- mental disorders (except personality disorders and tion, housing, economics, access to health care services, mental retardation). interaction with the legal system or crime, and other types of psychosocial and environmental problems. B O X 2 \u2013 2 Global Assessment of Functioning (GAF) Scale Consider psychological, social, and occupational functioning on a hypothetical continuum of mental health-illness. Do not include impairment in functioning due to physical (or environmental) limitations. Code (Note: Use intermediate codes when appropriate, e.g., 45, 68, 72) 100 Superior functioning in a wide range of activities, life\u2019s problems never seem to | get out of hand, is sought out by others because of his or her many positive 91 qualities. No symptoms. 90 Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas | interested and involved in a wide range of activities, socially effective, generally satisfied with 81 life, no more than everyday problems or concerns (e.g., an occasional argument with family members). 80 If symptoms are present, they are transient and expectable reactions to psychosocial | stressors (e.g., difficulty concentrating after family argument); no more than slight impairment 71 in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork). 70 Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, | occupational, or school functioning (e.g., occasional truancy, or theft within the household), 61 but generally functioning pretty well, has some meaningful interpersonal relationships. 60 Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR | moderate difficulty in social, occupational, or school functioning (e.g., few friends, 51 conflicts with peers or co-workers). 50 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent | shoplifting) OR any serious impairment in social, occupational, or school 41 functioning (e.g., no friends, unable to keep a job). 40 Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, | or irrelevant) OR major impairment in several areas, such as work or school, family relations, 31 judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school). 30 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in | communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal 21 preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends). 20 Some degree of hurting self or others (e.g., suicide attempts without clear expectation of death; | frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene 11 (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute). 10 Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent | inability to maintain minimal personal hygiene OR serious suicidal act with clear 1 expectation of death. 0 Inadequate information. SOURCE: Diagnostic and Statistical Manual of Mental Disorders (4th ed.) Text Revision. Washington, DC: American Psychiatric Association (2000). With permission.","24 UNIT I \u25cf BASIC CONCEPTS IN PSYCHIATRIC\/MENTAL HEALTH NURSING TABLE 2\u20133 Example of a Psychiatric whether or not they are able to understand the moti- Diagnosis vation behind the behavior. \u25cf Another consideration is cultural relativity. The \u201cnor- Axis I 300.4 Dysthymic Disorder mality\u201d of behavior is determined by cultural and soci- Axis II etal norms. Axis III 301.6 Dependent Personality Disorder \u25cf For purposes of this text, the definition of mental illness Axis IV is viewed as maladaptive responses to stressors from the Axis V 244.9 Hypothyroidism internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the Unemployed local and cultural norms, and interfere with the individ- ual\u2019s social, occupational, and\/or physical functioning. GAF = 65 (current) \u25cf Anxiety and grief have been described as two major, primary psychological response patterns to stress. Axis V\u2014Global Assessment of Functioning. This \u25cf Peplau defined anxiety by levels of symptom severity: allows the clinician to rate the individual\u2019s overall mild, moderate, severe, and panic. functioning on the Global Assessment of Functioning \u25cf Behaviors associated with levels of anxiety include (GAF) Scale. This scale represents in global terms a coping mechanisms, ego defense mechanisms, psy- single measure of the individual\u2019s psychological, social, chophysiological responses, psychoneurotic responses, and occupational functioning. A copy of the GAF and psychotic responses. Scale appears in Box 2\u20132. \u25cf Grief is described as a response to loss of a valued The DSM-IV-TR outline of axes I and II categories and entity. Loss is anything that is perceived as such by the codes is presented in Appendix C. An example of a psy- individual. chiatric diagnosis presented according to the multiaxial \u25cf K\u00fcbler-Ross, in extensive research with terminally ill evaluation system appears in Table 2\u20133. patients, identified five stages of feelings and behaviors that individuals experience in response to a real, per- SUMMARY AND KEY POINTS ceived, or anticipated loss: denial, anger, bargaining, \u25cf Psychiatric care has its roots in ancient times, when depression, and acceptance. \u25cf Anticipatory grief is grief work that is begun, and etiology was based in superstition and ideas related to sometimes completed, before the loss occurs. the supernatural. \u25cf Resolution is thought to occur when an individual is \u25cf Treatments were often inhumane and included brutal able to remember and accept both the positive and beatings, starvation, or other torturous means. negative aspects associated with the lost entity. \u25cf Hippocrates associated insanity and mental illness \u25cf Grieving is thought to be maladaptive when the with an irregularity in the interaction of the four body mourning process is prolonged, delayed or inhibited, fluids (humors)\u2014blood, black bile, yellow bile, and or becomes distorted and exaggerated out of propor- phlegm. tion to the situation. Pathological depression is con- \u25cf Conditions for care of the mentally ill have improved, sidered to be a distorted reaction. largely because of the influence of leaders such as \u25cf Psychiatric diagnoses are presented by the American Benjamin Rush, Dorothea Dix, and Linda Richards, Psychiatric Association on a multiaxial evaluation sys- whose endeavors provided a model for more humanis- tem. Individuals are evaluated on 5 axes: major mental tic treatment. disorders, personality disorders\/developmental level, \u25cf Maslow identified a \u201chierarchy of needs\u201d that individ- general medical conditions, psychosocial and environ- uals seek to fulfill on their quest to self-actualization mental problems, and level of functioning. (one\u2019s highest potential). \u25cf For purposes of this text, the definition of mental health For additional clinical tools and is viewed as the successful adaptation to stressors from study aids, visit DavisPlus. the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropri- ate and congruent with local and cultural norms. \u25cf In determining mental illness, individuals are influ- enced by incomprehensibility of the behavior. That is,","CHAPTER 2 \u25cf MENTAL HEALTH\/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 25 REVIEW QUESTIONS Self-Examination Situation: Anna is 72 years old. She has been a widow for 20 years. When her husband had been dead for a year, her daughter gave Anna a puppy, which she named Lucky. Lucky was a happy, lively mutt of unknown origin, and he and Anna soon became inseparable. Lucky lived to a ripe old age of 16, dying in Anna\u2019s arms three years ago. Anna\u2019s daughter has consulted the community mental health nurse practitioner about her mother, stating, \u201cShe doesn\u2019t do a thing for herself anymore, and all she wants to talk about is Lucky. She visits his grave every day! She still cries when she talks about him. I don\u2019t know what to do!\u201d Select the answers that are most appropriate for this situation. 1. Anna\u2019s behavior would be considered maladaptive because: a. It has been more than three years since Lucky died. b. Her grief is too intense just over loss of a dog. c. Her grief is interfering with her functioning. d. People in this culture would not comprehend such behavior over loss of a pet. 2. Anna\u2019s grieving behavior would most likely be considered to be: a. Delayed b. Inhibited c. Prolonged d. Distorted 3. Anna is most likely fixed in which stage of the grief process? a. Denial b. Anger c. Depression d. Acceptance 4. Anna is of the age when she may have experienced many losses coming close together. What is this called? a. Bereavement overload b. Normal mourning c. Isolation d. Cultural relativity 5. Anna\u2019s daughter has likely put off seeking help for Anna because: a. Women are less likely to seek help for emotional problems than men. b. Relatives often try to \u201cnormalize\u201d the behavior, rather than label it mental illness. c. She knows that all old people are expected to be a little depressed. d. She is afraid that the neighbors \u201cwill think her mother is crazy.\u201d 6. On the day that Lucky died, he got away from Anna while they were taking a walk. He ran into the street and was hit by a car. Anna cannot remember any of these circumstances of his death. This is an example of what defense mechanism? a. Rationalization b. Suppression c. Denial d. Repression 7. Lucky sometimes refused to obey Anna, and indeed did not come back to her when she called to him on the day he was killed. But Anna continues to insist, \u201cHe was the very best dog. He always minded me. He always did everything I told him to do.\u201d This represents the defense mechanism of: a. Sublimation b. Compensation c. Reaction Formation d. Undoing","26 UNIT I \u25cf BASIC CONCEPTS IN PSYCHIATRIC\/MENTAL HEALTH NURSING 8. Anna\u2019s maladaptive grief response may be attributed to: a. Unresolved grief over loss of her husband. b. Loss of several relatives and friends over the last few years. c. Repressed feelings of guilt over the way in which Lucky died. d. Any or all of the above. 9. For what reason would Anna\u2019s illness be considered a neurosis rather than a psychosis? a. She is unaware that her behavior is maladaptive. b. She exhibits inappropriate affect (emotional tone). c. She experiences no loss of contact with reality. d. She tells the nurse, \u201cThere is nothing wrong with me!\u201d 10. Which of the following statements by Anna might suggest that she is achieving resolution of her grief over Lucky\u2019s death? a. \u201cI don\u2019t cry anymore when I think about Lucky.\u201d b. \u201cIt\u2019s true. Lucky didn\u2019t always mind me. Sometimes he ignored my commands.\u201d c. \u201cI remember how it happened now. I should have held tighter to his leash!\u201d d. \u201cI won\u2019t ever have another dog. It\u2019s just too painful to lose them.\u201d Match the following defense mechanisms to the appropriate situation: _____11. Compensation a. Tommy, who is small for his age, is teased at school by the older _____12. Denial boys. When he gets home from school, he yells at and hits his lit- _____13. Displacement tle sister. _____14. Identification b. Johnny is in a wheelchair as a result of paralysis of the lower _____15. Intellectualization limbs. Before his accident, he was the star athlete on the football _____16. Introjection team. Now he obsessively strives to maintain a 4.0 grade point _____17. Isolation average in his courses. _____18. Projection c. Nancy and Sally are 4 years old. While playing with their dolls, Nancy says to Sally, \u201cDon\u2019t hit your dolly. It\u2019s not nice to hit peo- ple!\u201d d. Jackie is 4 years old. He has wanted a baby brother very badly, yet when his mother brings the new sibling home from the hos- pital, Jackie cries to be held when the baby is being fed and even starts to soil his clothing, although he has been toilet trained for 2 years. e. A young man is late for class. He tells the professor, \u201cSorry I\u2019m late, but my stupid wife forgot to set the alarm last night!\u201d f. Nancy was emotionally abused as a child and hates her mother. However, when she talks to others about her mother, she tells them how wonderful she is and how much she loves her. g. Pete grew up in a rough neighborhood where fighting was a way of coping. He is tough and aggressive and is noticed by the foot- ball coach, who makes him a member of the team. Within the year he becomes the star player. h. Fred stops at the bar every night after work and has several drinks. During the last 6 months he has been charged twice with driving under the influence, both times while driving recklessly after leaving the bar. Last night, he was stopped again. The judge ordered rehabilitation services. Fred responded, \u201cI don\u2019t need rehab. I can stop drinking anytime I want to!\u201d","CHAPTER 2 \u25cf MENTAL HEALTH\/MENTAL ILLNESS: HISTORICAL AND THEORETICAL CONCEPTS 27 _____19. Rationalization i. Mary tries on a beautiful dress she saw in the store window. She _____20. Reaction Formation discovers that it costs more than she can afford. She says to the _____21. Regression salesperson, \u201cI\u2019m not going to buy it. I really don\u2019t look good in this color.\u201d _____22. Repression _____23. Sublimation j. Janice is extremely upset when her boyfriend of 2 years breaks up _____24. Suppression with her. Her best friend tries to encourage her to talk about the _____25. Undoing breakup, but Janice says, \u201cNo need to talk about him anymore. He\u2019s history!\u201d k. While jogging in the park, Linda was kidnapped and taken as a hostage by two men who had just robbed a bank. She was held at gunpoint for 2 days until she was able to escape from the robbers. In her account to the police, she speaks of the encounter with no display of emotion whatsoever. l. While Mark is on his way to work a black cat runs across the road in front of his car. Mark turns the car around, drives back in the direction from which he had come, and takes another route to work. m. Fifteen-year-old Zelda has always wanted to be a teacher. Ms. Fry is Zelda\u2019s history teacher. Zelda admires everything about Ms. Fry and wants to be just like her. She changes her hair and dress style to match that of Ms. Fry. n. Bart is turned down for a job he desperately wanted. He shows no disappointment when relating the situation to his girlfriend. Instead, he reviews the interview and begins to analyze systemati- cally why the interaction was ineffective for him. o. Eighteen-year-old Jennifer can recall nothing related to an auto- mobile accident in which she was involved 8 years ago and in which both of her parents were killed. REFERENCES American Psychiatric Association. (2003). American psychiatric glossary Sadock, B.J., & Sadock, V.A. (2007). Synopsis of psychiatry: Behavioral (8th ed.). Washington, DC: American Psychiatric Publishing. sciences\/clinical psychiatry (10th ed.). Baltimore: Lippincott Williams & Wilkins. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Text revision. Washington, DC: Robinson, L. (1983). Psychiatric nursing as a human experience (3rd ed.). American Psychiatric Association. Philadelphia: W.B. Saunders. Horwitz, A.V. (2002). The social control of mental illness. Clinton Corners, NY: Percheron Press. CLASSICAL REFERENCES Bowlby, J., & Parkes, C.M. (1970). Separation and loss. In E.J. K\u00fcbler-Ross, E. (1969). On death and dying. New York: Macmillan. Anthony & C. Koupernik (Eds.), International yearbook for child psy- Maslow, A. (1970). Motivation and personality (2nd ed.). New York: chiatry and allied disciplines: The child and his family, (Vol. 1). New York: John Wiley & Sons. Harper & Row. Menninger, K. (1963). The vital balance. New York: Viking Press. Freud, A. (1953). The ego and mechanisms of defense. New York: Peplau, H. (1963). A working definition of anxiety. In S. Burd & M. International Universities Press. Marshall (Eds.), Some clinical approaches to psychiatric nursing. New Freud, S. (1961). The ego and the id. In Standard edition of the complete York: Macmillan. psychological works of Freud, Vol. XIX. London: Hogarth Press. Jahoda, M. (1958). Current concepts of positive mental health. New York: Basic Books.","","UNIT TWO FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING","3 CHAPTER Theoretical Models of Personality Development CHAPTER OUTLINE OBJECTIVES COGNITIVE DEVELOPMENT THEORY PSYCHOANALYTIC THEORY THEORY OF MORAL DEVELOPMENT INTERPERSONAL THEORY A NURSING MODEL\u2014HILDEGARD E. PEPLAU THEORY OF PSYCHOSOCIAL DEVELOPMENT SUMMARY AND KEY POINTS THEORY OF OBJECT RELATIONS REVIEW QUESTIONS KEY TERMS CORE CONCEPT personality cognitive development psychodynamic nursing cognitive maturity superego counselor surrogate ego symbiosis id technical expert libido temperament OBJECTIVES After reading this chapter, the student will be able to: 1. Define personality. c. Theory of psychosocial development\u2014 2. Identify the relevance of knowledge Erikson associated with personality development d. Theory of object relations to nursing in the psychiatric\/mental development\u2014Mahler health setting. 3. Discuss the major components of the fol- e. Cognitive development theory\u2014Piaget lowing developmental theories: f. Theory of moral development\u2014 a. Psychoanalytic theory\u2014Freud b. Interpersonal theory\u2014Sullivan Kohlberg g. A nursing model of interpersonal development\u2014Peplau The DSM-IV-TR (American Psychiatric Association Developmental theories identify behaviors associated [APA], 2000) defines personality traits as \u201cenduring pat- with various stages through which individuals pass, there- terns of perceiving, relating to, and thinking about the by specifying what is appropriate or inappropriate at each environment and oneself that are exhibited in a wide developmental level. range of social and personal contexts\u201d (p. 686). Specialists in child development believe that infancy Nurses must have a basic knowledge of human per- and early childhood are the major life periods for the sonality development to understand maladaptive behav- origination and occurrence of developmental change. ioral responses commonly seen in psychiatric clients. Specialists in life-cycle development believe that people 30","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 31 continue to develop and change throughout life, thereby Id suggesting the possibility for renewal and growth in The id is the locus of instinctual drives: the \u201cpleasure adults. principle.\u201d Present at birth, it endows the infant with instinctual drives that seek to satisfy needs and achieve Developmental stages are identified by age. Behaviors immediate gratification. Id-driven behaviors are impul- can then be evaluated by whether or not they are recog- sive and may be irrational. nized as age-appropriate. Ideally, an individual successfully fulfills all the tasks associated with one stage before mov- Ego ing on to the next stage (at the appropriate age). In reality, The ego, also called the rational self or the \u201creality princi- however, this seldom happens. One reason is related to ple,\u201d begins to develop between the ages of 4 and temperament, or the inborn personality characteristics 6 months. The ego experiences the reality of the external that influence an individual\u2019s manner of reacting to the world, adapts to it, and responds to it. As the ego devel- environment, and ultimately his or her developmental ops and gains strength, it seeks to bring the influences of progression (Chess & Thomas, 1986). The environment the external world to bear upon the id, to substitute the may also influence one\u2019s developmental pattern. reality principle for the pleasure principle (Marmer, Individuals who are reared in a dysfunctional family sys- 2003). A primary function of the ego is one of mediator, tem often have retarded ego development. According to that is, to maintain harmony among the external world, specialists in life-cycle development, behaviors from an the id, and the superego. unsuccessfully completed stage can be modified and cor- rected in a later stage. Superego If the id is identified as the pleasure principle, and the ego Stages overlap, and an individual may be working on the reality principle, the superego might be referred to as tasks associated with several stages at one time. When an the \u201cperfection principle.\u201d The superego, which develops individual becomes fixed in a lower level of development, between ages 3 and 6 years, internalizes the values and with age-inappropriate behaviors focused on fulfillment of morals set forth by primary caregivers. Derived out of a those tasks, psychopathology may become evident. Only system of rewards and punishments, the superego is com- when personality traits are inflexible and maladaptive and posed of two major components: the ego-ideal and the con- cause either significant functional impairment or subjec- science. When a child is consistently rewarded for \u201cgood\u201d tive distress do they constitute \u201cpersonality disorders\u201d behavior, self-esteem is enhanced, and the behavior (APA, 2000). These disorders are discussed in Chapter 34. becomes part of the ego-ideal; that is, it is internalized as part of his or her value system. The conscience is formed CORE CONCEPT when the child is punished consistently for \u201cbad\u201d behav- Personality ior. The child learns what is considered morally right or The combination of character, behavioral, tempera- wrong from feedback received from parental figures and mental, emotional, and mental traits that are unique from society or culture. When moral and ethical princi- to each specific individual. ples or even internalized ideals and values are disregarded, the conscience generates a feeling of guilt within the PSYCHOANALYTIC THEORY individual. The superego is important in the socialization Freud (1961), who has been called the father of psychia- of the individual because it assists the ego in the control try, is credited as the first to identify development by of id impulses. When the superego becomes rigid and stages. He considered the first 5 years of a child\u2019s life to punitive, problems with low self-confidence and low self- be the most important, because he believed that an indi- esteem arise. Examples of behaviors associated with these vidual\u2019s basic character had been formed by the age of 5. components of the personality are presented in Box 3\u20131. Freud\u2019s personality theory can be conceptualized accord- Topography of the Mind ing to structure and dynamics of the personality, topogra- Freud classified all mental contents and operations into phy of the mind, and stages of personality development. three categories: the conscious, the preconscious, and the unconscious. Structure of the Personality \u25cf The conscious includes all memories that remain within Freud organized the structure of the personality into three major components: the id, ego, and superego. an individual\u2019s awareness. It is the smallest of the three They are distinguished by their unique functions and dif- categories. Events and experiences that are easily ferent characteristics.","32 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING B O X 3 \u2013 1 Structure of the Personality Behavioral Examples Ego Superego Id \u201cI already have money. This money \u201cIt is never right to take something that \u201cI found this wallet; I will keep the doesn\u2019t belong to me. Maybe the person doesn\u2019t belong to you.\u201d money.\u201d who owns this wallet doesn\u2019t have any money.\u201d \u201cNever disobey your parents.\u201d \u201cMom and Dad are gone. Let\u2019s \u201cMom and Dad said no friends over while \u201cSex outside of marriage is always party!!!!!\u201d they are away. Too risky.\u201d wrong.\u201d \u201cI\u2019ll have sex with whomever I \u201cPromiscuity can be very dangerous.\u201d please, whenever I please.\u201d remembered or retrieved are considered to be within these three components, with the ego retaining the one\u2019s conscious awareness. Examples include tele- largest share to maintain a balance between the impul- phone numbers, birthdays of self and significant oth- sive behaviors of the id and the idealistic behaviors of ers, the dates of special holidays, and what one had for the superego. If an excessive amount of psychic energy is lunch today. The conscious mind is thought to be stored in one of these personality components, behavior under the control of the ego, the rational and logical will reflect that part of the personality. For instance, structure of the personality. impulsive behavior prevails when excessive psychic ener- \u25cf The preconscious includes all memories that may have gy is stored in the id. Overinvestment in the ego reflects been forgotten or are not in present awareness but self-absorbed, or narcissistic, behaviors; an excess within with attention can be readily recalled into conscious- the superego results in rigid, self-deprecating behaviors. ness. Examples include telephone numbers or address- es once known but little used and feelings associated Freud used the terms cathexis and anticathexis to describe with significant life events that may have occurred at the forces within the id, ego, and superego that are used some time in the past. The preconscious enhances to invest psychic energy in external sources to satisfy awareness by helping to suppress unpleasant or needs. Cathexis is the process by which the id invests nonessential memories from consciousness. It is energy into an object in an attempt to achieve gratifica- thought to be partially under the control of the super- tion. An example is the individual who instinctively turns ego, which helps to suppress unacceptable thoughts to alcohol to relieve stress. Anticathexis is the use of psy- and behaviors. chic energy by the ego and the superego to control id \u25cf The unconscious includes all memories that one is impulses. In the example cited, the ego would attempt to unable to bring to conscious awareness. It is the largest control the use of alcohol with rational thinking, such as, of the three topographical levels. Unconscious materi- \u201cI already have ulcers from drinking too much. I will call al consists of unpleasant or nonessential memories that my AA counselor for support. I will not drink.\u201d The have been repressed and can be retrieved only through superego would exert control with thinking such as \u201cI therapy, hypnosis, or with certain substances that alter shouldn\u2019t drink. If I drink, my family will be hurt and awareness and have the capacity to restructure angry. I should think of how it affects them. I\u2019m such a repressed memories. Unconscious material may also weak person.\u201d Freud believed that an imbalance between emerge in dreams and in seemingly incomprehensible cathexis and anticathexis resulted in internal conflicts, behavior. producing tension and anxiety within the individual. Freud\u2019s daughter Anna devised a comprehensive list of Dynamics of the Personality defense mechanisms believed to be used by the ego as a Freud believed that psychic energy is the force or impetus protective device against anxiety in mediating between required for mental functioning. Originating in the id, it the excessive demands of the id and the excessive restric- instinctually fulfills basic physiological needs. Freud tions of the superego (see Chapter 2). called this psychic energy (or the drive to fulfill basic physiological needs such as hunger, thirst, and sex) the Freud\u2019s Stages of Personality Development libido. As the child matures, psychic energy is diverted Freud described formation of the personality through from the id to form the ego and then from the ego to five stages of psychosexual development. He placed much form the superego. Psychic energy is distributed within emphasis on the first 5 years of life and believed that characteristics developed during these early years bore","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 33 heavily on one\u2019s adaptation patterns and personality traits feces production. The child becomes extroverted, pro- in adulthood. Fixation in an early stage of development ductive, and altruistic. will almost certainly result in psychopathology. An out- line of these five stages is presented in Table 3\u20131. Phallic Stage: 3 to 6 Years In the phallic stage, the focus of energy shifts to the gen- Oral Stage: Birth to 18 Months ital area. Discovery of differences between genders During the oral stage, behavior is directed by the id, and results in a heightened interest in the sexuality of self and the goal is immediate gratification of needs. The focus of others. This interest may be manifested in sexual self- energy is the mouth, with behaviors that include sucking, exploratory or group-exploratory play. Freud proposed chewing, and biting. The infant feels a sense of attach- that the development of the Oedipus complex (males) or ment and is unable to differentiate the self from the Electra complex (females) occurred during this stage of person who is providing the mothering. This includes development. He described this as the child\u2019s uncon- feelings such as anxiety. Because of this lack of differenti- scious desire to eliminate the parent of the same sex and ation, a pervasive feeling of anxiety on the part of the to possess the parent of the opposite sex for him- or her- mother may be passed on to her infant, leaving the child self. Guilt feelings result with the emergence of the vulnerable to similar feelings of insecurity. With the superego during these years. Resolution of this internal beginning of development of the ego at age 4 to 6 conflict occurs when the child develops a strong identifi- months, the infant starts to view the self as separate from cation with the parent of the same sex and that parent\u2019s the mothering figure. A sense of security and the ability attitudes, beliefs, and value systems are subsumed by the to trust others is derived from the gratification of fulfill- child. ing basic needs during this stage. Latency Stage: 6 to 12 Years Anal Stage: 18 Months to 3 Years During the elementary school years, the focus changes The major tasks in the anal stage are gaining independ- from egocentrism to more interest in group activities, ence and control, with particular focus on the excretory learning, and socialization with peers. Sexuality is not function. Freud believed that the manner in which the absent during this period but remains obscure and imper- parents and other primary caregivers approach the task of ceptible to others. The preference is for same-sex rela- toilet training may have far-reaching effects on the child tionships, even rejecting members of the opposite sex. in terms of values and personality characteristics. When toilet training is strict and rigid, the child may choose to Genital Stage: 13 to 20 Years retain the feces, becoming constipated. Adult retentive In the genital stage, the maturing of the genital organs personality traits influenced by this type of training results in a reawakening of the libidinal drive. The focus include stubbornness, stinginess, and miserliness. An is on relationships with members of the opposite sex and alternate reaction to strict toilet training is for the child preparations for selecting a mate. The development of to expel feces in an unacceptable manner or at inappro- sexual maturity evolves from self-gratification to behav- priate times. Far-reaching effects of this behavior pattern iors deemed acceptable by societal norms. Interpersonal include malevolence, cruelty to others, destructiveness, relationships are based on genuine pleasure derived from disorganization, and untidiness. the interaction rather than from the more self-serving implications of childhood associations. Toilet training that is more permissive and accepting attaches the feeling of importance and desirability to TABLE 3 \u2013 1 Freud\u2019s Stages of Psychosexual Development Age Stage Major Developmental Tasks Birth\u201318 months Oral Relief from anxiety through oral gratification of needs 18 months\u20133 years Anal Learning independence and control, with focus on the excretory function 3\u20136 years Phallic Identification with parent of same sex; development of sexual identity; focus on genital organs 6\u201312 years Latency Sexuality repressed; focus on relationships with same-sex peers 13\u201320 years Genital Libido reawakened as genital organs mature; focus on relationships with members of the opposite sex","34 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING Relevance of Psychoanalytic Theory force in interpersonal relations and the main factor in to Nursing Practice the development of serious difficulties in living.\u201d It Knowledge of the structure of the personality can assist arises out of one\u2019s inability to satisfy needs or to nurses who work in the mental health setting. The ability achieve interpersonal security. to recognize behaviors associated with the id, the ego, \u25cf Satisfaction of needs is the fulfillment of all requirements and the superego assists in the assessment of develop- associated with an individual\u2019s physiochemical envi- mental level. Understanding the use of ego defense ronment. Sullivan identified examples of these require- mechanisms is important in making determinations ments as oxygen, food, water, warmth, tenderness, rest, about maladaptive behaviors, in planning care for clients activity, sexual expression\u2014virtually anything that, to assist in creating change (if desired) or in helping when absent, produces discomfort in the individual. clients accept themselves as unique individuals. \u25cf Interpersonal security is the feeling associated with relief from anxiety. When all needs have been met, one expe- CLINICAL PEARL: ASSESSING CLIENT riences a sense of total well-being, which Sullivan BEHAVIORS termed interpersonal security. He believed individuals have an innate need for interpersonal security. ID BEHAVIORS \u25cf Self-system is a collection of experiences, or security Behaviors that follow the principle of \u201cif it feels measures, adopted by the individual to protect against good, do it.\u201d Social and cultural acceptability are anxiety. Sullivan identified three components of the not considered. They reflect a need for immediate self-system, which are based on interpersonal experi- gratification. Individuals with a strong id show little if ences early in life: any remorse for their unacceptable behavior. \u2022 The \u201cgood me\u201d is the part of the personality that EGO BEHAVIORS develops in response to positive feedback from the These behaviors reflect the rational part of the per- primary caregiver. Feelings of pleasure, content- sonality. An effort is made to delay gratification and ment, and gratification are experienced. The child to satisfy societal expectations. The ego uses defense learns which behaviors elicit this positive response as mechanisms to cope and regain control over id it becomes incorporated into the self-system. impulses. \u2022 The \u201cbad me\u201d is the part of the personality that develops in response to negative feedback from the SUPEREGO BEHAVIORS primary caregiver. Anxiety is experienced, eliciting Behaviors that are somewhat uncompromising and feelings of discomfort, displeasure, and distress. The rigid. They are based on morality and society\u2019s val- child learns to avoid these negative feelings by alter- ues. Behaviors of the superego strive for perfection. ing certain behaviors. Violation of the superego\u2019s standards generates \u2022 The \u201cnot me\u201d is the part of the personality that devel- guilt and anxiety in an individual who has a strong ops in response to situations that produce intense superego. anxiety in the child. Feelings of horror, awe, dread, and loathing are experienced in response to these sit- INTERPERSONAL THEORY uations, leading the child to deny these feelings in an effort to relieve anxiety. These feelings, having then Sullivan (1953) believed that individual behavior and per- been denied, become \u201cnot me,\u201d but someone else. sonality development are the direct result of interpersonal This withdrawal from emotions has serious implica- relationships. Before the development of his own theoret- tions for mental disorders in adult life. ical framework, Sullivan embraced the concepts of Freud. Later, he changed the focus of his work from the intraper- Sullivan\u2019s Stages of Personality sonal view of Freud to one with more interpersonal flavor in Development which human behavior could be observed in social interac- Infancy: Birth to 18 Months tions with others. His ideas, which were not universally During the beginning stage, the major developmental accepted at the time, have been integrated into the practice task for the child is the gratification of needs. This is of psychiatry through publication only since his death in accomplished through activity associated with the mouth, 1949. Sullivan\u2019s major concepts include the following: such as crying, nursing, and thumb sucking. \u25cf Anxiety is a feeling of emotional discomfort, toward Childhood: 18 Months to 6 Years the relief or prevention of which all behavior is aimed. At ages 18 months to 6 years, the child learns that inter- Sullivan believed that anxiety is the \u201cchief disruptive ference with fulfillment of personal wishes and desires","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 35 may result in delayed gratification. He or she learns to Relevance of Interpersonal Theory accept this and feel comfortable with it, recognizing that to Nursing Practice delayed gratification often results in parental approval, a The interpersonal theory has significant relevance to more lasting type of reward. Tools of this stage include nursing practice. Relationship development, which is a the mouth, the anus, language, experimentation, manip- major concept of this theory, is a major psychiatric nurs- ulation, and identification. ing intervention. Nurses develop therapeutic relation- ships with clients in an effort to help them generalize this Juvenile: 6 to 9 Years ability to interact successfully with others. The major task of the juvenile stage is formation of satis- factory relationships within peer groups. This is accom- Knowledge about the behaviors associated with all plished through the use of competition, cooperation, and levels of anxiety and methods for alleviating anxiety helps compromise. nurses to assist clients achieve interpersonal security and a sense of well-being. Nurses use the concepts of Preadolescence: 9 to 12 Years Sullivan\u2019s theory to help clients achieve a higher degree The tasks at the preadolescence stage focus on develop- of independent and interpersonal functioning. ing relationships with persons of the same sex. One\u2019s abil- ity to collaborate with and show love and affection for THEORY OF PSYCHOSOCIAL another person begins at this stage. DEVELOPMENT Erikson (1963) studied the influence of social processes Early Adolescence: 12 to 14 Years on the development of the personality. He described During early adolescence, the child is struggling with eight stages of the life cycle during which individuals developing a sense of identity that is separate and inde- struggle with developmental \u201ccrises.\u201d Specific tasks asso- pendent from the parents. The major task is formation of ciated with each stage must be completed for resolution satisfactory relationships with members of the opposite sex. of the crisis and for emotional growth to occur. An out- Sullivan saw the emergence of lust in response to biologi- line of Erikson\u2019s stages of psychosocial development is cal changes as a major force occurring during this period. presented in Table 3\u20133. Late Adolescence: 14 to 21 Years Erikson\u2019s Stages of Personality The late adolescent period is characterized by tasks associ- Development ated with the attempt to achieve interdependence within Trust versus Mistrust: Birth to 18 Months the society and the formation of a lasting, intimate relation- Major Developmental Task. From birth to 18 months, the ship with a selected member of the opposite sex. The gen- major task is to develop a basic trust in the mothering ital organs are the major developmental focus of this stage. figure and learn to generalize it to others. \u25cf Achievement of the task results in self-confidence, An outline of the stages of personality development according to Sullivan\u2019s interpersonal theory is presented optimism, faith in the gratification of needs and in Table 3\u20132. desires, and hope for the future. The infant learns to trust when basic needs are met consistently. TABLE 3\u20132 Stages of Development in Sullivan\u2019s Interpersonal Theory Age Birth\u201318 months Stage Major Developmental Tasks 18 months\u20136 years Infancy Relief from anxiety through oral gratification of needs 6\u20139 years Childhood Learning to experience a delay in personal gratification without undue anxiety 9\u201312 years Juvenile Learning to form satisfactory peer relationships Preadolescence Learning to form satisfactory relationships with persons of same sex; initiating feelings of 12\u201314 years Early adolescence affection for another person 14\u201321 years Learning to form satisfactory relationships with persons of the opposite sex; developing a Late adolescence sense of identity Establishing self-identity; experiencing satisfying relationships; working to develop a lasting, intimate opposite-sex relationship","36 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING TABLE 3\u20133 Stages of Development in Erikson\u2019s Psychosocial Theory Age Stage Major Developmental Tasks Infancy Trust vs. mistrust To develop a basic trust in the mothering figure and learn to generalize it to others (Birth\u201318 months) Autonomy vs. shame To gain some self-control and independence within the environment Early childhood and doubt To develop a sense of purpose and the ability to initiate and direct own activities (18 months\u20133 years) Initiative vs. guilt Late childhood To achieve a sense of self-confidence by learning, competing, performing success Industry vs. inferiority fully, and receiving recognition from significant others, peers, and acquaintances (3\u20136 years) School age Identity vs. role To integrate the tasks mastered in the previous stages into a secure sense of self confusion (6\u201312 years) To form an intense, lasting relationship or a commitment to another person, cause, Adolescence Intimacy vs. isolation institution, or creative effort (12\u201320 years) Generativity vs. To achieve the life goals established for oneself, while also considering the welfare Young adulthood stagnation of future generations (20\u201330 years) Ego integrity vs. To review one\u2019s life and derive meaning from both positive and negative events, Adulthood despair while achieving a positive sense of self-worth (30\u201365 years) Old age (65 years\u2013death) \u25cf Nonachievement results in emotional dissatisfaction behaviors. Assertiveness and dependability increase, with the self and others, suspiciousness, and difficulty and the child enjoys learning and personal achieve- with interpersonal relationships. The task remains ment. The conscience develops, thereby controlling unresolved when primary caregivers fail to respond to the impulsive behaviors of the id. Initiative is achieved the infant\u2019s distress signal promptly and consistently. when creativity is encouraged and performance is rec- ognized and positively reinforced. Autonomy versus Shame and Doubt: \u25cf Nonachievement results in feelings of inadequacy and 18 Months to 3 Years a sense of defeat. Guilt is experienced to an excessive Major Developmental Task. The major task during the degree, even to the point of accepting liability in situ- ages of 18 months to 3 years is to gain some self-control ations for which one is not responsible. The child may and independence within the environment. view him- or herself as evil and deserving of punish- \u25cf Achievement of the task results in a sense of self-con- ment. The task remains unresolved when creativity is stifled and parents continually expect a higher level of trol and the ability to delay gratification, and a feeling achievement than the child produces. of self-confidence in one\u2019s ability to perform. Autonomy is achieved when parents encourage and Industry versus Inferiority: 6 to 12 Years provide opportunities for independent activities. Major Developmental Task. The major task for 6- to \u25cf Nonachievement results in a lack of self-confidence, a 12-year-olds is to achieve a sense of self-confidence by lack of pride in the ability to perform, a sense of being learning, competing, performing successfully, and receiv- controlled by others, and a rage against the self. The ing recognition from significant others, peers, and task remains unresolved when primary caregivers acquaintances. restrict independent behaviors, both physically and \u25cf Achievement of the task results in a sense of satisfac- verbally, or set the child up for failure with unrealistic expectations. tion and pleasure in the interaction and involvement with others. The individual masters reliable work Initiative versus Guilt: 3 to 6 Years habits and develops attitudes of trustworthiness. He Major Developmental Task. During the ages of 3 to 6 years or she is conscientious, feels pride in achievement, the goal is to develop a sense of purpose and the ability and enjoys play but desires a balance between fanta- to initiate and direct one\u2019s own activities. sy and \u201creal world\u201d activities. Industry is achieved \u25cf Achievement of the task results in the ability to exer- when encouragement is given to activities and responsibilities in the school and community, as well cise restraint and self-control of inappropriate social as those within the home, and recognition is given for accomplishments.","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 37 \u25cf Nonachievement results in difficulty in interpersonal \u25cf Achievement of the task results in the capacity for relationships because of feelings of personal inadequa- mutual love and respect between two people and the cy. The individual can neither cooperate and compro- ability of an individual to pledge a total commitment mise with others in group activities nor problem solve to another. The intimacy goes far beyond the sexual or complete tasks successfully. He or she may become contact between two people. It describes a commit- either passive and meek or overly aggressive to cover ment in which personal sacrifices are made for anoth- up for feelings of inadequacy. If this occurs, the indi- er, whether it be another person or, if one chooses, a vidual may manipulate or violate the rights of others to career or other type of cause or endeavor to which an satisfy his or her own needs or desires; he or she may individual elects to devote his or her life. Intimacy is become a workaholic with unrealistic expectations for achieved when an individual has developed the capac- personal achievement. This task remains unresolved ity for giving of oneself to another. This is learned when parents set unrealistic expectations for the child, when one has been the recipient of this type of giving when discipline is harsh and tends to impair self- within the family unit. esteem, and when accomplishments are consistently met with negative feedback. \u25cf Nonachievement results in withdrawal, social isola- tion, and aloneness. The individual is unable to form Identity versus Role Confusion: 12 to 20 lasting, intimate relationships, often seeking intimacy Years through numerous superficial sexual contacts. No Major Developmental Task. At 12 to 20 years, the goal is career is established; he or she may have a history of to integrate the tasks mastered in the previous stages into occupational changes (or may fear change and thus a secure sense of self. remain in an undesirable job situation). The task \u25cf Achievement of the task results in a sense of confi- remains unresolved when love in the home has been deprived or distorted through the younger years dence, emotional stability, and a view of the self as a (Murray & Zentner, 2001). One fails to achieve the unique individual. Commitments are made to a value ability to give of the self without having been the system, to the choice of a career, and to relationships recipient early on from primary caregivers. with members of both genders. Identity is achieved when adolescents are allowed to experience independ- Generativity versus Stagnation or Self- ence by making decisions that influence their lives. Absorption: 30 to 65 Years Parents should be available to offer support when Major Developmental Task. The major task here is to needed but should gradually relinquish control to the achieve the life goals established for oneself while also maturing individual in an effort to encourage the considering the welfare of future generations. development of an independent sense of self. \u25cf Achievement of the task results in a sense of gratifica- \u25cf Nonachievement results in a sense of self-conscious- ness, doubt, and confusion about one\u2019s role in life. tion from personal and professional achievements, and Personal values or goals for one\u2019s life are absent. from meaningful contributions to others. The individ- Commitments to relationships with others are nonex- ual is active in the service of and to society. istent, but instead are superficial and brief. A lack of Generativity is achieved when the individual expresses self-confidence is often expressed by delinquent and satisfaction with this stage in life and demonstrates rebellious behavior. Entering adulthood, with its responsibility for leaving the world a better place in accompanying responsibilities, may be an underlying which to live. fear. This task can remain unresolved for many reasons. \u25cf Nonachievement results in lack of concern for the Examples include the following: welfare of others and total preoccupation with the self. \u2022 When independence is discouraged by the parents, He or she becomes withdrawn, isolated, and highly self-indulgent, with no capacity for giving of the self to and the adolescent is nurtured in the dependent others. The task remains unresolved when earlier position developmental tasks are not fulfilled and the individual \u2022 When discipline within the home has been overly does not achieve the degree of maturity required to harsh, inconsistent, or absent derive gratification out of a personal concern for the \u2022 When there has been parental rejection or frequent welfare of others. shifting of parental figures Ego Integrity versus Despair: 65 Years Intimacy versus Isolation: 20 to 30 Years to Death Major Developmental Task. The objective for 20- to Major Developmental Task. Between the age of 65 years 30-year-olds is to form an intense, lasting relationship or and death, the goal is to review one\u2019s life and derive a commitment to another person, a cause, an institution, or a creative effort (Murray & Zentner, 2001).","38 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING meaning from both positive and negative events, while CLINICAL PEARL achieving a positive sense of self. \u25cf Achievement of the task results in a sense of self-worth During assessment, nurses can determine if a client is experiencing difficulties associated with specific and self-acceptance as one reviews life goals, accepting life tasks as described by Erikson. Knowledge about that some were achieved and some were not. The indi- a client\u2019s developmental level, along with other vidual derives a sense of dignity from his or her life assessment data, can help to identify accurate nurs- experiences and does not fear death, viewing it instead ing interventions. as another phase of development. Ego integrity is achieved when individuals have successfully completed THEORY OF OBJECT RELATIONS the developmental tasks of the other stages and have little desire to make major changes in how their lives Mahler (Mahler, Pine, & Bergman, 1975) formulated a have progressed. theory that describes the separation\u2013individuation \u25cf Nonachievement results in a sense of self-contempt and process of the infant from the maternal figure (primary disgust with how life has progressed. The individual caregiver). She describes this process as progressing would like to start over and have a second chance at life. through three major phases. She further delineates phase He or she feels worthless and helpless to change. Anger, III, the separation\u2013individuation phase, into four sub- depression, and loneliness are evident. The focus may phases. Mahler\u2019s developmental theory is outlined in be on past failures or perceived failures. Impending Table 3\u20134. death is feared or denied, or ideas of suicide may prevail. The task remains unresolved when earlier tasks are not fulfilled: self-confidence, a concern for others, and a strong sense of self-identity were never achieved. Relevance of Psychosocial Development Phase I: The Autistic Phase Theory to Nursing Practice (Birth to 1 Month) Erikson\u2019s theory is particularly relevant to nursing prac- In the autistic phase, also called normal autism, the infant tice in that it incorporates sociocultural concepts into exists in a half-sleeping, half-waking state and does not the development of personality. Erikson provided a sys- perceive the existence of other people or an external envi- tematic, stepwise approach and outlined specific tasks ronment. The fulfillment of basic needs for survival and that should be completed during each stage. This infor- comfort is the focus and is merely accepted as it occurs. mation can be used quite readily in psychiatric\/mental health nursing. Many individuals with mental health Phase II: The Symbiotic Phase problems are still struggling to achieve tasks from a (1 to 5 Months) number of developmental stages. Nurses can plan care to Symbiosis is a type of \u201cpsychic fusion\u201d of mother and assist these individuals to complete these tasks and move child. The child views the self as an extension of the on to a higher developmental level. TABLE 3 \u2013 4 Stages of Development in Mahler\u2019s Theory of Object Relations Age Birth\u20131 month Phase\/Subphase Major Developmental Tasks 1\u20135 months I. Normal autism Fulfillment of basic needs for survival and comfort II. Symbiosis Development of awareness of external source of need fulfillment 5\u201310 months III. Separation\u2013individuation Commencement of a primary recognition of separateness from the 10\u201316 months a. Differentiation mothering figure 16\u201324 months b. Practicing Increased independence through locomotor functioning; increased sense of separateness of self 24\u201336 months c. Rapprochement Acute awareness of separateness of self; learning to seek \u201cemotional d. Consolidation refueling\u201d from mothering figure to maintain feeling of security Sense of separateness established; on the way to object constancy (i.e., able to internalize a sustained image of loved object\/person when it is out of sight); resolution of separation anxiety","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 39 mother, but with a developing awareness that it is she Subphase 4: Consolidation (24 to 36 Months) who fulfills his or her every need. Mahler suggests that With achievement of the consolidation subphase, a defi- absence of, or rejection by, the maternal figure at this nite individuality and sense of separateness of self are phase can lead to symbiotic psychosis. established. Objects are represented as whole, with the child having the ability to integrate both \u201cgood\u201d and Phase III: Separation\u2013Individuation \u201cbad.\u201d A degree of object constancy is established as the (5 to 36 Months) child is able to internalize a sustained image of the moth- This third phase represents what Mahler calls the \u201cpsy- ering figure as enduring and loving, while maintaining the chological birth\u201d of the child. Separation is defined as the perception of her as a separate person in the outside world. physical and psychological attainment of a sense of per- sonal distinction from the mothering figure. Individuation Relevance of Object Relations Theory to occurs with a strengthening of the ego and an acceptance Nursing Practice of a sense of \u201cself,\u201d with independent ego boundaries. Understanding of the concepts of Mahler\u2019s theory of Four subphases through which the child evolves in his or object relations assists the nurse to assess the client\u2019s level her progression from a symbiotic extension of the moth- of individuation from primary caregivers. The emotional ering figure to a distinct and separate being are described. problems of many individuals can be traced to lack of ful- fillment of the tasks of separation\/individuation. Subphase 1: Differentiation (5 to 10 Months) Examples include problems related to dependency and The differentiation phase begins with the child\u2019s initial excessive anxiety. The individual with borderline person- physical movements away from the mothering figure. A ality disorders is thought to be fixed in the rapproche- primary recognition of separateness commences. ment phase of development, harboring fears of abandon- ment and underlying rage. This knowledge is important in the provision of nursing care to these individuals. Subphase 2: Practicing (10 to 16 Months) COGNITIVE DEVELOPMENT THEORY With advanced locomotor functioning, the child experi- Piaget (Piaget & Inhelder, 1969) has been called the ences feelings of exhilaration from increased independ- father of child psychology. His work concerning cogni- ence. He or she is now able to move away from, and tive development in children is based on the premise return to, the mothering figure. A sense of omnipotence that human intelligence is an extension of biological is manifested. adaptation, or one\u2019s ability to adapt psychologically to the environment. He believed that human intelligence pro- Subphase 3: Rapprochement gresses through a series of stages that are related to age, (16 to 24 Months) demonstrating at each successive stage a higher level of This third subphase, rapprochement, is extremely critical logical organization than at the previous stages. to the child\u2019s healthy ego development. During this time, the child becomes increasingly aware of his or her sepa- From his extensive studies of cognitive development rateness from the mothering figure, while the sense of in children, Piaget discovered four major stages, each of fearlessness and omnipotence diminishes. The child, now which he believed to be a necessary prerequisite for the recognizing the mother as a separate individual, wishes to one that follows. An outline is presented in Table 3\u20135. reestablish closeness with her but shuns the total re- engulfment of the symbiotic stage. The need is for the Stage 1: Sensorimotor (Birth to 2 Years) mothering figure to be available to provide \u201cemotional At the beginning of his or her life, the child is concerned refueling\u201d on demand. only with satisfying basic needs and comforts. The self is not differentiated from the external environment. As the Critical to this subphase is the mothering figure\u2019s sense of differentiation occurs, with increasing mobility response to the child. If she is available to fulfill emotion- and awareness, the mental system is expanded. The child al needs as they arise, the child develops a sense of secu- develops a greater understanding regarding objects with- rity in the knowledge that he or she is loved and will not in the external environment and their effects upon him or be abandoned. However, if emotional needs are inconsis- her. Knowledge is gained regarding the ability to manip- tently met or if the mother rewards clinging, dependent ulate objects and experiences within the environment. behaviors and withholds nurturing when the child The sense of object permanence\u2014the notion that an object demonstrates independence, feelings of rage and a fear of will continue to exist when it is no longer present to the abandonment develop and often persist into adulthood. senses\u2014is initiated.","40 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING TABLE 3 \u2013 5 Piaget\u2019s Stages of Cognitive Development Age Birth\u20132 years Stage Major Developmental Tasks Sensorimotor With increased mobility and awareness, development of a sense of self as separate from the external 2\u20136 years 6\u201312 years Preoperational environment; the concept of object permanence emerges as the ability to form mental images 12\u201315+ years evolves Concrete Learning to express self with language; development of understanding of symbolic gestures; operations achievement of object permanence Learning to apply logic to thinking; development of understanding of reversibility and Formal spatiality; learning to differentiate and classify; increased socialization and application of rules operations Learning to think and reason in abstract terms; making and testing hypotheses; capability of logical thinking and reasoning expand and are refined; cognitive maturity achieved Stage 2: Preoperational (2 to 6 Years) more rational prospects. Formal operations, however, Piaget believed that preoperational thought is character- enable individuals to distinguish between the ideal and ized by egocentrism. Personal experiences are thought to the real. Piaget\u2019s theory suggests that most individuals be universal, and the child is unable to accept the differ- achieve cognitive maturity, the capability to perform all ing viewpoints of others. Language development pro- mental operations needed for adulthood, in middle to gresses, as does the ability to attribute special meaning to late adolescence. symbolic gestures (e.g., bringing a story book to mother is a symbolic invitation to have a story read). Reality is Relevance of Cognitive Development often given to inanimate objects. Object permanence cul- Theory to Nursing Practice minates in the ability to conjure up mental representa- Nurses who work in psychiatry are likely to be involved tions of objects or people. in helping clients, particularly depressed clients, with techniques of cognitive therapy. In cognitive therapy, the Stage 3: Concrete Operations individual is taught to control thought distortions that (6 to 12 Years) are considered to be a factor in the development and The ability to apply logic to thinking begins in this stage; maintenance of mood disorders. In the cognitive model, however, \u201cconcreteness\u201d still predominates. An under- depression is characterized by a triad of negative distor- standing of the concepts of reversibility and spatiality is tions related to expectations of the environment, self, and developed. For example, the child recognizes that changing future. In this model, depression is viewed as a distortion the shape of objects does not necessarily change the in cognitive development, the self is unrealistically deval- amount, weight, volume, or the ability of the object to ued, and the future is perceived as hopeless. Therapy return to its original form. Another achievement of this focuses on changing \u201cautomatic thoughts\u201d that occur stage is the ability to classify objects by any of their several spontaneously and contribute to the distorted affect. characteristics. For example, he or she can classify all poo- Nurses who assist with this type of therapy must have dles as dogs but recognizes that all dogs are not poodles. knowledge of how cognition develops in order to help clients identify the distorted thought patterns and make The concept of a lawful self is developed at this stage the changes required for improvement in affective func- as the child becomes more socialized and rule conscious. tioning (see Chapter 20). Egocentrism decreases, the ability to cooperate in inter- actions with other children increases, and understanding THEORY OF MORAL DEVELOPMENT and acceptance of established rules grow. Kohlberg\u2019s (1968) stages of moral development are not closely tied to specific age groups. Research was conducted Stage 4: Formal Operations with males ranging in age from 10 to 28 years. Kohlberg (12 to 15+ Years) believed that each stage is necessary and basic to the next At this stage, the individual is able to think and reason in stage and that all individuals must progress through each abstract terms. He or she can make and test hypotheses stage sequentially. He defined three major levels of moral using logical and orderly problem solving. Current situ- development, each of which is further subdivided into ations and reflections of the future are idealized, and a two stages each. An outline of Kohlberg\u2019s developmental degree of egocentrism returns during this stage. There stages is presented in Table 3\u20136. Most people do not may be some difficulty reconciling idealistic hopes with progress through all six stages.","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 41 TABLE 3\u20136 Kohlberg\u2019s Stages of Moral Development Level\/Age* Stage Developmental Focus I. Preconventional (common from 1. Punishment and Behavior motivated by fear of punishment Behavior motivated by egocentrism and concern for self. age 4\u201310 years) obedience orientation 2. Instrumental Behavior motivated by expectations of others; strong desire for II. Conventional (common from approval and acceptance age 10\u201313 years, and into adulthood) relativist orientation Behavior motivated by respect for authority III. Postconventional (can occur from 3. Interpersonal Behavior motivated by respect for universal laws and moral adolescence on) concordance orientation principles; guided by internal set of values 4. Law and order Behavior motivated by internalized principles of honor, justice, orientation 5. Social contract and respect for human dignity; guided by the conscience legalistic orientation 6. Universal ethical principle orientation *Ages in Kohlberg\u2019s theory are not well defined. The stage of development is determined by the motivation behind the individual\u2019s behavior. Level I. Preconventional Level: Rules and laws are required and override personal princi- (Prominent from Ages 4 to 10 Years) ples and group mores. The belief is that all individuals and Stage 1: Punishment and Obedience Orientation. At the groups are subject to the same code of order, and no one punishment and obedience orientation stage, the individ- shall be exempt (e.g., \u201cI\u2019ll do it because it is the law\u201d). ual is responsive to cultural guidelines of good or bad and right or wrong, but primarily in terms of the known relat- Level III. Postconventional Level: ed consequences. Fear of punishment is likely to be the (Can Occur from Adolescence Onward) incentive for conformity (e.g., \u201cI\u2019ll do it, because if I don\u2019t Stage 5: Social Contract Legalistic Orientation. Individuals I can\u2019t watch TV for a week.\u201d) who reach stage 5 have developed a system of values and principles that determine for them what is right or Stage 2: Instrumental Relativist Orientation. Behaviors wrong; behaviors are acceptably guided by this value sys- at the instrumental relativist orientation stage are guid- tem, provided they do not violate the human rights of ed by egocentrism and concern for self. There is an others. They believe that all individuals are entitled to intense desire to satisfy one\u2019s own needs, but occasion- certain inherent human rights, and they live according to ally the needs of others are considered. For the most universal laws and principles. However, they hold the part, decisions are based on personal benefits derived idea that the laws are subject to scrutiny and change as (e.g., \u201cI\u2019ll do it if I get something in return,\u201d or occa- needs within society evolve and change (e.g., \u201cI\u2019ll do it sionally, \u201c. . . because you asked me to\u201d). because it is the moral and legal thing to do, even though it is not my personal choice\u201d). Level II. Conventional Level: (Prominent from Ages 10 to 13 Years and into Stage 6: Universal Ethical Principle Orientation. Adulthood)* Behavior at stage 6 is directed by internalized principles Stage 3: Interpersonal Concordance Orientation. Behavior at of honor, justice, and respect for human dignity. Laws are the interpersonal concordance orientation stage is guided abstract and unwritten, such as the \u201cGolden Rule,\u201d by the expectations of others. Approval and acceptance \u201cequality of human rights,\u201d and \u201cjustice for all.\u201d They are within one\u2019s societal group provide the incentive to con- not the concrete rules established by society. The con- form (e.g., \u201cI\u2019ll do it because you asked me to,\u201d \u201c. . . because science is the guide, and when one fails to meet the self- it will help you,\u201d or \u201c. . . because it will please you\u201d). expected behaviors, the personal consequence is intense guilt. The allegiance to these ethical principles is so Stage 4: Law and Order Orientation. In the law and order strong that the individual will stand by them even know- orientation stage, there is a personal respect for authority. ing that negative consequences will result (e.g., \u201cI\u2019ll do it because I believe it is the right thing to do, even though *Eighty percent of adults are fixed in level II, with a majority of it is illegal and I will be imprisoned for doing it\u201d). women in stage 3 and a majority of men in stage 4.","42 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING Relevance of Moral Development Theory \u2022 A teacher identifies learning needs and provides to Nursing Practice information to the client or family that may aid in Moral development has relevance to psychiatric nursing improvement of the life situation. in that it affects critical thinking about how individuals ought to behave and treat others. Moral behavior reflects \u2022 A leader directs the nurse\u2013client interaction and the way a person interprets basic respect for other per- ensures that appropriate actions are undertaken to sons, such as the respect for human life, freedom, justice, facilitate achievement of the designated goals. or confidentiality. Psychiatric nurses must be able to assess the level of moral development of their clients in \u2022 A technical expert understands various profession- order to be able to help them in their effort to advance in al devices and possesses the clinical skills necessary their progression toward a higher level of developmental to perform the interventions that are in the best maturity. interest of the client. A NURSING MODEL\u2014 \u2022 A surrogate serves as a substitute figure for another. HILDEGARD E. PEPLAU Phases of the nurse\u2013client relationship are stages of overlap- Peplau (1991) applied interpersonal theory to nursing ping roles or functions in relation to health problems, practice and, most specifically, to nurse\u2013client relation- during which the nurse and client learn to work coopera- ship development. She provides a framework for tively to resolve difficulties. Peplau identifies four phases: \u201cpsychodynamic nursing,\u201d the interpersonal involvement \u25cf Orientation is the phase during which the client, nurse, of the nurse with a client in a given nursing situation. Peplau states, \u201cNursing is helpful when both the patient and family work together to recognize, clarify, and and the nurse grow as a result of the learning that occurs define the existing problem. in the nursing situation.\u201d \u25cf Identification is the phase after which the client\u2019s initial impression has been clarified and when he or she Peplau correlates the stages of personality develop- begins to respond selectively to those who seem to ment in childhood to stages through which clients offer the help that is needed. Clients may respond in advance during the progression of an illness. She also one of three ways: (1) on the basis of participation or views these interpersonal experiences as learning situa- interdependent relations with the nurse; (2) on the tions for nurses to facilitate forward movement in the basis of independence or isolation from the nurse; or development of personality. She believes that when (3) on the basis of helplessness or dependence on the there is fulfillment of psychological tasks associated nurse (Peplau, 1991). with the nurse\u2013client relationship, the personalities of \u25cf Exploitation is the phase during which the client pro- both can be strengthened. Key concepts include the ceeds to take full advantage of the services offered to following: him or her. Having learned which services are avail- \u25cf Nursing is a human relationship between an individual able, feeling comfortable within the setting, and serv- ing as an active participant in his or her own health who is sick, or in need of health services, and a nurse care, the client exploits the services available and especially educated to recognize and to respond to the explores all possibilities of the changing situation. need for help. \u25cf Resolution occurs when the client is freed from identi- \u25cf Psychodynamic nursing is being able to understand fication with helping persons and gathers strength to one\u2019s own behavior, to help others identify felt difficul- assume independence. Resolution is the direct result ties, and to apply principles of human relations to the of successful completion of the other three phases. problems that arise at all levels of experience. \u25cf Roles are sets of values and behaviors that are specific Peplau\u2019s Stages of Personality to functional positions within social structures. Peplau Development identifies the following nursing roles: Psychological tasks are developmental lessons that must be \u2022 A resource person provides specific, needed informa- learned on the way to achieving maturity of the person- ality. Peplau identifies four psychological tasks that she tion that helps the client understand his or her prob- associates with the stages of infancy and childhood lem and the new situation. described by Freud and Sullivan. She states: \u2022 A counselor listens as the client reviews feelings related to difficulties he or she is experiencing in any When psychological tasks are successfully learned at each aspect of life. \u201cInterpersonal techniques\u201d have been era of development, biological capacities are used produc- identified to facilitate the nurse\u2019s interaction in the tively and relations with people lead to productive living. process of helping the client solve problems and When they are not successfully learned they carry over into make decisions concerning these difficulties. adulthood and attempts at learning continue in devious ways, more or less impeded by conventional adaptations that provide a superstructure over the baseline of actual learning. (Peplau, 1991, p. 166).","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 43 In the context of nursing, Peplau (1991) relates these the client with the intent of helping him or her grow, four psychological tasks to the demands made on nurses in mature, and become more independent. their relations with clients. She maintains the following: Learning to Delay Satisfaction Nursing can function as a maturing force in society. Since Peplau relates this stage to that of toddlerhood, or the illness is an event that is experienced along with feelings that first step in the development of interdependent social derive from older experiences but are reenacted in the rela- relations. Psychosexually, it is compared to the anal stage tionship of nurse to patient, the nurse-patient relationship is of development, when a child learns that, because of cul- seen as an opportunity for nurses to help patients to com- tural mores, he or she cannot empty the bowels for relief plete the unfinished psychological tasks of childhood in of discomfort at will, but must delay to use the toilet, some degree. (p. 159) which is considered more culturally acceptable. When toilet training occurs too early or is very rigid, or when Peplau\u2019s psychological tasks of personality develop- appropriate behavior is set forth as a condition for love ment include the four stages outlined in the following and caring, tasks associated with this stage remain unful- paragraphs. An outline of the stages of personality filled. The child feels powerless and fails to learn the sat- development according to Peplau\u2019s theory is presented isfaction of pleasing others by delaying self-gratification in Table 3\u20137. in small ways. He or she may also exhibit rebellious behavior by failing to comply with demands of the moth- Learning to Count on Others ering figure in an effort to counter the feelings of power- Nurses and clients first come together as strangers. Both lessness. The child may accomplish this by withholding bring to the relationship certain \u201craw materials,\u201d such as the fecal product or failing to deposit it in the culturally inherited biological components, personality characteris- acceptable manner. tics (temperament), individual intellectual capacity, and specific cultural or environmental influences. Peplau Peplau cites Fromm (1949) in describing the following relates these to the same \u201craw materials\u201d with which an potential behaviors of individuals who have failed to infant comes into this world. The newborn is capable of complete the tasks of the second stage of development: experiencing comfort and discomfort. He or she soon learns \u25cf Exploitation and manipulation of others to satisfy to communicate feelings in a way that results in the ful- fillment of comfort needs by the mothering figure who their own desires because they are unable to do so provides love and care unconditionally. However, fulfill- independently ment of these dependency needs is inhibited when goals \u25cf Suspiciousness and envy of others, directing hostility of the mothering figure become the focus, and love and toward others in an effort to enhance their own self- care are contingent on meeting the needs of the caregiver image rather than those of the infant. \u25cf Hoarding and withholding possessions from others; miserliness Clients with unmet dependency needs regress during \u25cf Inordinate neatness and punctuality illness and demonstrate behaviors that relate to this stage \u25cf Inability to relate to others through sharing of feel- of development. Other clients regress to this level ings, ideas, or experiences because of physical disabilities associated with their ill- \u25cf Ability to vary the personality characteristics to those ness. Peplau believed that when nurses provide uncondi- required to satisfy personal desires at any given time tional care, they help these clients progress toward more When nurses observe these types of behaviors in mature levels of functioning. This may involve the role of clients, it is important to encourage full expression and to \u201csurrogate mother,\u201d in which the nurse fulfills needs for TABLE 3\u20137 Stages of Development in Peplau\u2019s Interpersonal Theory Age Infancy Stage Major Developmental Tasks Learning to count on Learning to communicate in various ways with the primary caregiver in order to Toddlerhood others have comfort needs fulfilled Early childhood Learning to delay Learning the satisfaction of pleasing others by delaying self-gratification in Late childhood satisfaction small ways Identifying oneself Learning appropriate roles and behaviors by acquiring the ability to perceive the Developing skills in expectations of others participation Learning the skills of compromise, competition, and cooperation with others; establishment of a more realistic view of the world and a feeling of one\u2019s place in it","44 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING convey unconditional acceptance. When the client learns undergone an abortion with disapproval and disrespect. to feel safe and unconditionally accepted, he or she is more The nurse may respond in this manner without even likely to let go of the oppositional behavior and advance in realizing he or she is doing so. Attitudes and values are the developmental progression. Peplau (1991) states: introjected during early development and can be inte- grated so completely as to become a part of the self-sys- Nurses who aid patients to feel safe and secure, so that wants tem. Nurses must have knowledge and appreciation of can be expressed and satisfaction eventually achieved, also their own concept of self in order to develop the flexibil- help them to strengthen personal power that is needed for ity required to accept all clients as they are, uncondition- productive social activities. (p. 207) ally. Effective resolution of problems that arise in the interdependent relationship can be the means for both Identifying Oneself client and nurse to reinforce positive personality traits \u201cA concept of self develops as a product of interaction and modify those more negative views of self. with adults\u201d (Peplau, 1991, p. 211). A child learns to structure self-concept by observing how others interact Developing Skills in Participation with him or her. Roles and behaviors are established out Peplau cites Sullivan\u2019s (1953) description of the \u201cjuvenile\u201d of the child\u2019s perception of the expectations of others. stage of personality development (ages 6 through 9). When children perceive that adults expect them to main- During this stage, the child develops the capacity to tain more-or-less permanent roles as infants, they per- \u201ccompromise, compete, and cooperate\u201d with others. ceive themselves as helpless and dependent. When the These skills are considered basic to one\u2019s ability to partic- perceived expectation is that the child must behave in a ipate collaboratively with others. If a child tries to use the manner beyond his or her maturational level, the child is skills of an earlier level of development (e.g., crying, deprived of the fulfillment of emotional and growth whining, demanding), he or she may be rejected by peers needs at the lower levels of development. Children who of this juvenile stage. As this stage progresses, children are given freedom to respond to situations and experi- begin to view themselves through the eyes of their peers. ences unconditionally (i.e., with behaviors that are Sullivan (1953) called this \u201cconsensual validation.\u201d appropriate to their feelings) learn to improve on and Preadolescents take on a more realistic view of the world reconstruct behavioral responses at their own individual and a feeling of their place in it. The capacity to love oth- pace. Peplau (1991) states, \u201cThe ways in which adults ers (besides the mother figure) develops at this time and appraise the child and the way he functions in relation to is expressed in relation to one\u2019s self-acceptance. his experiences and perceptions are taken in or introject- ed and become the child\u2019s view of himself\u201d (p. 213). Failure to develop appropriate skills at any point along the developmental progression results in an individual\u2019s dif- In nursing, it is important for the nurse to recognize ficulty with participation in confronting the recurring cues that communicate how the client feels about him- or problems of life. It is not the responsibility of the nurse to herself and about the presenting medical problem. In the teach solutions to problems, but rather to help clients initial interaction, it is difficult for the nurse to perceive the improve their problem-solving skills so that they may \u201cwholeness\u201d of the client, because the focus is on the con- achieve their own resolution. This is accomplished through dition that has caused him or her to seek help. Likewise, it development of the skills of competition, compromise, is difficult for the client to perceive the nurse as a \u201cmother cooperation, consensual validation, and love of self and (or father)\u201d or \u201csomebody\u2019s wife (or husband)\u201d or as having others. Nurses can assist clients to develop or refine these a life aside from being there to offer assistance with the skills by helping them to identify the problem, define a immediate presenting problem. As the relationship devel- goal, and take the responsibility for performing the actions ops, nurses must be able to recognize client behaviors that necessary to reach that goal. Peplau (1991) states: indicate unfulfilled needs and provide experiences that pro- mote growth. For example, the client who very proudly Participation is required by a democratic society. When it announces that she has completed activities of daily living has not been learned in earlier experiences, nurses have an independently and wants the nurse to come and inspect her opportunity to facilitate learning in the present and thus to room may still be craving the positive reinforcement asso- aid in the promotion of a democratic society. (p. 259) ciated with lower levels of development. Relevance of Peplau\u2019s Model to Nursing Nurses must also be aware of the predisposing factors Practice that they bring to the relationship. Attitudes and beliefs Peplau\u2019s model provides nurses with a framework to about certain issues can have a deleterious effect on the interact with clients, many of whom are fixed in\u2014or client and interfere not only with the therapeutic rela- because of illness have regressed to\u2014an earlier level of tionship but also with the client\u2019s ability for growth and development. For example, a nurse who has strong beliefs against abortion may treat a client who has just","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 45 development. She suggests roles that nurses may assume \u25cf Erikson described eight stages of the life cycle from to assist clients to progress, thereby achieving or resum- birth to death. He believed that individuals struggled ing their appropriate developmental level. Appropriate with developmental \u201ccrises,\u201d and that each must be developmental progression arms the individual with the resolved for emotional growth to occur. ability to confront the recurring problems of life. Nurses serve to facilitate learning of that which has not been \u25cf Margaret Mahler formulated a theory that describes learned in earlier experiences. the separation\u2013individuation process of the infant SUMMARY AND KEY POINTS from the maternal figure (primary caregiver). Stages of \u25cf Growth and development are unique with each indi- development describe the progression of the child from birth to object constancy at age 36 months. vidual and continue throughout the life span. \u25cf Personality is defined as the combination of character, \u25cf Jean Piaget has been called the father of child psychol- ogy. He believed that human intelligence progresses behavioral, temperamental, emotional, and mental through a series of stages that are related to age, traits that are unique to each specific individual. demonstrating at each successive stage a higher level \u25cf Sigmund Freud, who has been called the father of psy- of logical organization than at the previous stages. chiatry, believed the basic character has been formed by the age of 5. \u25cf Lawrence Kohlberg outlined stages of moral develop- \u25cf Freud\u2019s personality theory can be conceptualized ment. His stages are not closely tied to specific age according to structure and dynamics of the personali- groups or the maturational process. He believed that ty, topography of the mind, and stages of personality moral stages emerge out of our own thinking and the development. stimulation of our mental processes. \u25cf Freud\u2019s structure of the personality includes the id, ego, and superego. \u25cf Hildegard Peplau provided a framework for \u201cpsy- \u25cf Freud classified all mental contents and operations chodynamic nursing,\u201d the interpersonal involve- into three categories: the conscious, the preconscious, ment of the nurse with a client in a given nursing and the unconscious. situation. \u25cf Harry Stack Sullivan, author of the Interpersonal Theory of Psychiatry, believed that individual behav- \u25cf Peplau identified the nursing roles of resource per- ior and personality development are the direct result son, counselor, teacher, leader, technical expert, and of interpersonal relationships. Major concepts include surrogate. anxiety, satisfaction of needs, interpersonal security, and self-system. \u25cf Peplau describes four psychological tasks that she \u25cf Erik Erikson studied the influence of social processes associates with the stages of infancy and childhood as on the development of the personality. identified by Freud and Sullivan. \u25cf Peplau believed that nursing is helpful when both the patient and the nurse grow as a result of the learning that occurs in the nursing situation. For additional clinical tools and study aids, visit DavisPlus.","46 UNIT I\u00ce \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING REVIEW QUESTIONS Self-Examination\/Learning Exercise Situation: Mr. J. is 35 years old. He has been admitted to the psychiatric unit for observation and evaluation following his arrest on charges that he robbed a convenience store and sexually assaulted the store clerk. Mr. J. was the child of an unmarried teenage mother who deserted him when he was 6 months old. He was shuffled from one relative to another until it was clear that no one wanted him. Social services placed him in foster homes, from which he continuously ran away. During his teenage years he was arrested a number of times for stealing, vandalism, arson, and various other infractions of the law. He was shunned by his peers and to this day has little interaction with others. On the unit, he appears very anxious, paces back and forth, and darts his head from side to side in a continuous scanning of the area. He is unkempt, with poor personal hygiene. He has refused to eat, making some barely audible comment related to \u201cbeing poisoned.\u201d He has shown no remorse for his misdeeds. Select the answer that is most appropriate for this situation. 1. Theoretically, in which level of psychosocial development (according to Erikson) would you place Mr. J.? a. Intimacy vs. isolation b. Generativity vs. self-absorption c. Trust vs. mistrust d. Autonomy vs. shame and doubt 2. According to Erikson\u2019s theory, where would you place Mr. J. based on his behavior? a. Intimacy vs. isolation b. Generativity vs. self-absorption c. Trust vs. mistrust d. Autonomy vs. shame and doubt 3. According to Mahler\u2019s theory, Mr. J. did not receive the critical \u201cemotional refueling\u201d required during the rapprochement phase of development. What are the consequences of this deficiency? a. He has not yet learned to delay gratification. b. He does not feel guilt about wrongdoings to others. c. He is unable to trust others. d. He has internalized rage and fears of abandonment. 4. In what stage of development is Mr. J. fixed according to Sullivan\u2019s interpersonal theory? a. Infancy. He relieves anxiety through oral gratification. b. Childhood. He has not learned to delay gratification. c. Early adolescence. He is struggling to form an identity. d. Late adolescence. He is working to develop a lasting relationship. 5. Which of the following describes the psychoanalytical structure of Mr. J.\u2019s personality? a. Weak id, strong ego, weak superego b. Strong id, weak ego, weak superego c. Weak id, weak ego, punitive superego d. Strong id, weak ego, punitive superego 6. In which of Peplau\u2019s stages of development would you assess Mr. J.? a. Learning to count on others b. Learning to delay gratification c. Identifying oneself d. Developing skills in participation 7. In planning care for Mr. J., which of the following would be the primary focus for nursing? a. To decrease anxiety and develop trust b. To set limits on his behavior","CHAPTER 3 \u25cf THEORETICAL MODELS OF PERSONALITY DEVELOPMENT 47 c. To ensure that he gets to group therapy d. To attend to his hygiene needs Match the nursing role as described by Peplau with the nursing care behaviors listed on the right: 8. Surrogate a. \u201cMr. J., please tell me what it was like when you were growing up.\u201d 9. Counselor b. \u201cWhat questions do you have about being here on this unit?\u201d 10. Resource person c. \u201cSome changes will have to be made in your behavior. I care about what happens to you.\u201d REFERENCES American Psychiatric Association (2000). Diagnostic and statistical man- Murray, R., & Zentner, J. (2001). Health promotion strategies through ual of mental disorders (4th ed.) Text Revision. Washington, DC: the life span (7th ed.). Upper Saddle River, NJ: Prentice-Hall. American Psychiatric Association. Peplau, H.E. (1991). Interpersonal relations in nursing. New York: Springer, Marmer, S.S. (2003). Theories of the mind and psychopathology. pp. 107\u2013154. In R.E. Hales & S.C. Yudofsky (Eds.), Textbook of clinical psychiatry (4th ed.). Washington, DC: American Psychiatric Publishing. CLASSICAL REFERENCES Chess, S., & Thomas, A. (1986). Temperament in clinical practice. New Kohlberg, L. (1968). Moral development. In International encyclopedia York: Guilford Press. of social science. New York: Macmillan. Erikson, E. (1963). Childhood and society (2nd ed.). New York: WW Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of Norton. the human infant. New York: Basic Books. Freud, S. (1961). The ego and the id. Standard edition of the Piaget, J., & Inhelder, B. (1969). The psychology of the child. New York: complete psychological works of Freud, Vol XIX. London: Hogarth Basic Books. Press. Sullivan, H.S. (1953). The interpersonal theory of psychiatry. New York: Fromm, E. (1949). Man for himself. New York: Farrar & Rinehart. WW Norton.","4 CHAPTER Concepts of Psychobiology CHAPTER OUTLINE OBJECTIVES PSYCHOIMMUNOLOGY IMPLICATIONS FOR NURSING THE NERVOUS SYSTEM: AN ANATOMICAL SUMMARY AND KEY POINTS REVIEW REVIEW QUESTIONS NEUROENDOCRINOLOGY GENETICS KEY TERMS CORE CONCEPTS genetics axon neuron neuroendocrinology cell body neurotransmitter psychobiology circadian rhythms phenotype dendrites receptor sites genotype synapse limbic system OBJECTIVES After reading this chapter, the student will be able to: 1. Identify gross anatomical structures 6. Discuss the correlation of alteration in of the brain and describe their brain functioning to various psychiatric functions. disorders. 2. Discuss the physiology of neurotransmis- 7. Identify various diagnostic procedures sion in the central nervous system. used to detect alteration in biological functioning that may be contributing to 3. Describe the role of neurotransmitters in psychiatric disorders. human behavior. 8. Discuss the influence of psychological 4. Discuss the association of endocrine factors on the immune system. functioning to the development of psychiatric disorders. 9. Discuss the implications of psychobio- logical concepts to the practice of 5. Describe the role of genetics in the psychiatric\/mental health nursing. development of psychiatric disorders. In recent years, a greater emphasis has been placed on considered as physical disorders that are the result of the study of the organic basis for psychiatric illness. This malfunctions and\/or malformations of the brain. \u201cneuroscientific revolution\u201d began in earnest when the 101st legislature of the United States designated the This is not to imply that psychosocial and socio- 1990s as the \u201cdecade of the brain.\u201d With this legislation cultural influences are totally discounted. Such a came the challenge for studying the biological basis of notion would negate the transactional model of behavior. Several mental illnesses are now being stress\/adaptation on which the framework of this 48 textbook is conceptualized.","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 49 The systems of biology, psychology, and sociology are l. Forebrain not mutually exclusive\u2014they are interacting systems. a. Cerebrum This is clearly indicated by the fact that individuals b. Diencephalon experience biological changes in response to various environmental events. Indeed, each of these disciplines 2. Midbrain may be, at various times, most appropriate for explaining a. Mesencephalon behavioral phenomena. 3. Hindbrain This chapter focuses on the role of neurophysiological, a. Pons neurochemical, genetic, and endocrine influences on psy- b. Medulla chiatric illness. Various diagnostic procedures used to c. Cerebellum detect alteration in biological function that may contribute Each of these structures is discussed individually. A to psychiatric illness are identified, and the implications for psychiatric\/mental health nursing are discussed. summary is presented in Table 4\u20131. CORE CONCEPT Cerebrum Psychobiology The cerebrum consists of a right and left hemisphere and The study of the biological foundations of cognitive, constitutes the largest part of the human brain. The right emotional, and behavioral processes. and left hemispheres are connected by a deep groove, which houses a band of 200 million neurons (nerve cells) THE NERVOUS SYSTEM: AN called the corpus callosum. Because each hemisphere con- ANATOMICAL REVIEW trols different functions, information is processed The Brain through the corpus callosum so that each hemisphere is The brain has three major divisions, subdivided into six aware of the activity of the other. major parts: The surface of the cerebrum consists of gray matter and is called the cerebral cortex. The gray matter is so called because the neuron cell bodies of which it is composed look gray to the eye. These gray matter cell bodies are thought to be the actual thinking structures of the brain. Another pair of masses of gray matter called TABLE 4\u20131 Structure and Function of the Brain Structure Primary Function I. The Forebrain A. Cerebrum Composed of two hemispheres separated by a deep groove that houses a band of 200 million neurons called the corpus callosum. The outer shell is called the cortex. It is extensively folded and consists of billions of 1. Frontal lobes neurons. The left hemisphere appears to deal with logic and solving problems. The right hemisphere 2. Parietal lobes may be called the \u201ccreative\u201d brain and is associated with affect, behavior, and spatial-perceptual functions. 3. Temporal lobes Each hemisphere is divided into four lobes. 4. Occipital lobes B. Diencephalon Voluntary body movement, including movements that permit speaking, thinking and judgment formation, 1. Thalamus and expression of feelings. 2. Hypothalamus 3. Limbic system Perception and interpretation of most sensory information (including touch, pain, taste, and body position). Hearing, short-term memory, and sense of smell; expression of emotions through connection with limbic II. The Midbrain A. Mesencephalon system. Visual reception and interpretation. III. The Hindbrain Connects cerebrum with lower brain structures. A. Pons Integrates all sensory input (except smell) on way to cortex; some involvement with emotions and mood. B. Medulla Regulates anterior and posterior lobes of pituitary gland; exerts control over actions of the autonomic C. Cerebellum nervous system; regulates appetite and temperature. Consists of medially placed cortical and subcortical structures and the fiber tracts connecting them with one another and with the hypothalamus. It is sometimes called the \u201cemotional brain\u201d\u2014associated with feelings of fear and anxiety; anger and aggression; love, joy, and hope; and with sexuality and social behavior. Responsible for visual, auditory, and balance (\u201crighting\u201d) reflexes. Regulation of respiration and skeletal muscle tone; ascending and descending tracts connect brain stem with cerebellum and cortex. Pathway for all ascending and descending fiber tracts; contains vital centers that regulate heart rate, blood pressure, and respiration; reflex centers for swallowing, sneezing, coughing, and vomiting. Regulates muscle tone and coordination and maintains posture and equilibrium.","50 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING basal ganglia is found deep within the cerebral hemi- The Parietal Lobes. Somatosensory input occurs in the spheres. They are responsible for certain subconscious parietal lobe area of the brain. These include touch, pain aspects of voluntary movement, such as swinging the and pressure, taste, temperature, perception of joint and arms when walking, gesturing while speaking, and regu- body position, and visceral sensations. The parietal lobes lating muscle tone (Scanlon & Sanders, 2006). also contain association fibers linked to the primary sen- sory areas through which interpretation of sensory- The cerebral cortex is identified by numerous folds, perceptual information is made. Language interpretation called gyri, and deep grooves between the folds, called is associated with the left hemisphere of the parietal lobe. sulci. This extensive folding extends the surface area of the cerebral cortex, and thus permits the presence of millions The Temporal Lobes. The upper anterior temporal lobe more neurons than would be possible without it (as is the is concerned with auditory functions, while the lower case in the brains of some animals, such as dogs and cats). part is dedicated to short-term memory. The sense of Each hemisphere of the cerebral cortex is divided into the smell has a connection to the temporal lobes, as the frontal lobe, parietal lobe, temporal lobe, and occipital impulses carried by the olfactory nerves end in this area lobe. These lobes, which are named for the overlying of the brain (Scanlon & Sanders, 2006). The temporal bones in the cranium, are identified in Figure 4\u20131. lobes also play a role in the expression of emotions through an interconnection with the limbic system. The The Frontal Lobes. Voluntary body movement is con- left temporal lobe, along with the left parietal lobe, is trolled by the impulses through the frontal lobes. The involved in language interpretation. right frontal lobe controls motor activity on the left side of the body and the left frontal lobe controls motor activ- The Occipital Lobes. The occipital lobes are the primary ity on the right side of the body. Movements that permit area of visual reception and interpretation. Visual percep- speaking are also controlled by the frontal lobe, usually tion, which gives individuals the ability to judge spatial rela- only on the left side (Scanlon & Sanders, 2006). The tionships such as distance and to see in three dimensions, is frontal lobe may also play a role in the emotional experi- also processed in this area (Scanlon & Sanders, 2006). ence, as evidenced by changes in mood and character Language interpretation is influenced by the occipital lobes after damage to this area. The alterations include fear, through an association with the visual experience. aggressiveness, depression, rage, euphoria, irritability, and apathy and are likely related to a frontal lobe connec- Diencephalon tion to the limbic system. The frontal lobe may also be The second part of the forebrain is the diencephalon, involved (indirectly through association fibers linked to which connects the cerebrum with lower structures of primary sensory areas) in thinking and perceptual inter- the brain. The major components of the diencephalon pretation of information. Premotor area Motor area Frontal lobe General sensory area Sensory association area Parietal lobe Occipital lobe Visual association area Visual area Motor speech area Cerebellum Auditory Auditory area FIGURE 4\u20131 Left cerebral hemi- association sphere showing some of the functional area areas that have been mapped. (From Scanlon, V.C., & Sanders, T: Essentials of Temporal lobe anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.)","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 51 include the thalamus, the hypothalamus, and the limbic posterior lobe stores antidiuretic hormone (which system. These structures are identified in Figures 4\u20132 helps to maintain blood pressure through regula- and 4\u20133. tion of water retention) and oxytocin (the hormone responsible for stimulation of the uterus during Thalamus. The thalamus integrates all sensory input labor, and the release of milk from the mammary (except smell) on its way to the cortex. This helps the glands). Both of these hormones are produced in cerebral cortex interpret the whole picture very rapidly, the hypothalamus. When the hypothalamus rather than experiencing each sensation individually. The detects the body\u2019s need for these hormones, it thalamus is also involved in temporarily blocking minor sends nerve impulses to the posterior pituitary for sensations, so that an individual can concentrate on one their release. important event when necessary. For example, an indi- b. The anterior lobe of the pituitary gland consists of vidual who is studying for an examination may be glandular tissue that produces a number of hor- unaware of the clock ticking in the room, or even of mones used by the body. These hormones are regu- another person walking into the room, because the thal- lated by \u201creleasing factors\u201d from the hypothalamus. amus has temporarily blocked these incoming sensations When the hormones are required by the body, the from the cortex (Scanlon & Sanders, 2006). releasing factors stimulate the release of the hor- mone from the anterior pituitary and the hormone Hypothalamus. The hypothalamus is located just below in turn stimulates its target organ to carry out its the thalamus and just above the pituitary gland and has a specific functions. number of diverse functions. 2. Direct Neural Control over the Actions of the 1. Regulation of the Pituitary Gland. The pituitary Autonomic Nervous System. The hypothalamus regulates the appropriate visceral responses during var- gland consists of two lobes: the posterior lobe and the ious emotional states. The actions of the autonomic anterior lobe. nervous system are described later in this chapter. a. The posterior lobe of the pituitary gland is actually extended tissue from the hypothalamus. The Corpus callosum Parietal lobe Frontal lobe Occipital lobe Choroid plexus in Midbrain third ventricle Cerebellum Thalamus Optic nerve Choroid plexus in fourth ventricle Hypothalamus Pituitary gland Pons Temporal lobe Medulla Spinal cord FIGURE 4\u20132 Midsagittal section of the brain as seen from the left side. This medial plane shows internal anatomy as well as the lobes of the cerebrum. (From Scanlon, V.C., & Sanders, T: Essentials of anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.)","52 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING Cingulate Septum gyrus pellucidum Thalamus Fornix Hypothalamus Olfactory Hippocampus FIGURE 4\u20133 Structures of the limbic tract system (Adapted from Scanlon, V.C., & Sanders, T: Essentials of anatomy and Mammillary body physiology, ed. 5. F.A. Davis, Philadelphia, Amygdala 2006.) 3. Regulation of Appetite. Appetite is regulated Mesencephalon through response to blood nutrient levels. Structures of major importance in the mesencephalon, or midbrain, include nuclei and fiber tracts. The mesen- 4. Regulation of Temperature. The hypothalamus cephalon extends from the pons to the hypothalamus and senses internal temperature changes in the blood that is responsible for integration of various reflexes, includ- flows through the brain. It receives information ing visual reflexes (e.g., automatically turning away from through sensory input from the skin about external a dangerous object when it comes into view), auditory temperature changes. The hypothalamus then uses reflexes (e.g., automatically turning toward a sound that this information to promote certain types of respons- is heard), and righting reflexes (e.g., automatically keep- es (e.g., sweating or shivering) that help to maintain ing the head upright and maintaining balance) (Scanlon body temperature within the normal range (Scanlon & & Sanders, 2006). The mesencephalon is identified in Sanders, 2006). Figure 4\u20132. Limbic System. The part of the brain known as the lim- Pons bic system consists of portions of the cerebrum and the The pons is a bulbous structure that lies between the diencephalon. The major components include the medi- midbrain and the medulla (Fig. 4\u20132). It is composed of ally placed cortical and subcortical structures and the large bundles of fibers and forms a major connection fiber tracts connecting them with one another and with between the cerebellum and the brainstem. It also con- the hypothalamus. The system is composed of the amyg- tains the central connections of cranial nerves V dala, mammillary body, olfactory tract, hypothalamus, through VIII and centers for respiration and skeletal cingulate gyrus, septum pellucidum, thalamus, hip- muscle tone. pocampus, and neuronal connecting pathways, such as the fornix and others. This system has been called \u201cthe emotional brain\u201d and is associated with feelings of fear and anxiety; anger, rage, and aggression; love, joy, and hope; and with sexuality and social behavior.","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 53 Medulla as integrators in the pathways between afferent and effer- The medulla is the connecting structure between the ent neurons. They account in large part for thinking, feel- spinal cord and the pons and all of the ascending and ings, learning, language, and memory. The directional descending fiber tracts pass through it. The vital centers pathways of afferent, efferent, and interneurons are pre- are contained in the medulla, and it is responsible for sented in Figure 4\u20135. regulation of heart rate, blood pressure, and respiration. Also in the medulla are reflex centers for swallowing, Synapses sneezing, coughing, and vomiting (Scanlon & Sanders, Information is transmitted through the body from one 2006). It also contains nuclei for cranial nerves IX neuron to another. Some messages may be processed through XII. The medulla, pons, and midbrain form the through only a few neurons, while others may require structure known as the brainstem. These structures are thousands of neuronal connections. The neurons that identified in Figure 4\u20132. transmit the impulses do not actually touch each other. The junction between two neurons is called a synapse. Cerebellum The small space between the axon terminals of one neu- The cerebellum is separated from the brainstem by the ron and the cell body or dendrites of another is called the fourth ventricle but has connections to the brainstem synaptic cleft. Neurons conducting impulses toward the through bundles of fiber tracts. It is situated just below synapse are called presynaptic neurons and those conduct- the occipital lobes of the cerebrum (Figs. 4\u20131 and 4\u20132). ing impulses away are called postsynaptic neurons. The functions of the cerebellum are concerned with involuntary movement, such as muscular tone and coordi- A chemical, called a neurotransmitter, is stored in nation and the maintenance of posture and equilibrium. the axon terminals of the presynaptic neuron. An electri- cal impulse through the neuron causes the release of this Nerve Tissue neurotransmitter into the synaptic cleft. The neurotrans- The tissue of the central nervous system (CNS) consists mitter then diffuses across the synaptic cleft and com- of nerve cells called neurons that generate and transmit bines with receptor sites that are situated on the cell electrochemical impulses. The structure of a neuron is membrane of the postsynaptic neuron. The result of the composed of a cell body, an axon, and dendrites. The cell combination of neurotransmitter-receptor site is the body contains the nucleus and is essential for the contin- determination of whether or not another electrical ued life of the neuron. The dendrites are processes that impulse is generated. If one is generated, the result is transmit impulses toward the cell body, and the axon called an excitatory response and the electrical impulse transmits impulses away from the cell body. The axons moves on to the next synapse, where the same process and dendrites are covered by layers of cells called neu- recurs. If another electrical impulse is not generated by roglia that form a coating, or \u201csheath,\u201d of myelin. Myelin the neurotransmitter-receptor site combination, the is a phospholipid that provides insulation against short- result is called an inhibitory response, and synaptic trans- circuiting of the neurons during their electrical activity mission is terminated. and increases the velocity of the impulse. The white mat- ter of the brain and spinal cord is so called because of the The cell body or dendrite of the postsynaptic neuron whitish appearance of the myelin sheath over the axons also contains a chemical inactivator that is specific to the and dendrites. The gray matter is composed of cell bod- neurotransmitter that has been released by the presy- ies that contain no myelin. naptic neuron. When the synaptic transmission has been completed, the chemical inactivator quickly inac- The three classes of neurons include afferent (sensory), tivates the neurotransmitter to prevent unwanted, efferent (motor), and interneurons. The afferent neurons continuous impulses, until a new impulse from the carry impulses from receptors in the internal and external presynaptic neuron releases more neurotransmitter. A periphery to the CNS, where they are then interpreted schematic representation of a synapse is presented in into various sensations. The efferent neurons carry impuls- Figure 4\u20136. es from the CNS to effectors in the periphery, such as muscles (that respond by contracting) and glands (that Autonomic Nervous System respond by secreting). A schematic of afferent and effer- The autonomic nervous system (ANS) is actually consid- ent neurons is presented in Figure 4\u20134. ered part of the peripheral nervous system. Its regulation is integrated by the hypothalamus, however, and there- Interneurons exist entirely within the CNS, and 99 per- fore the emotions exert a great deal of influence over its cent of all nerve cells belong to this group. They may functioning. For this reason, the ANS has been implicated carry only sensory or motor impulses, or they may serve in the etiology of a number of psychophysiological disorders.","54 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING Afferent (sensory) neuron Efferent (motor) neuron Axon terminal Dendrites Axon Cell body Nucleus Nucleus Axon Schwann cell nucleus Myelin sheath Cell body Node of Dendrite Ranvier Myelin sheath Schwann cell Receptors A Axon Neurolemma Layers of myelin sheath FIGURE 4\u20134 Neuron structure. C (A) A typical sensory neuron. (B) A typical motor neuron. The arrows Axon terminal indicate the direction of impulse B transmission. (C) Details of the myelin sheath and neurolemma formed by Schwann cells. (From Scanlon, V.C., & Sanders, T: Essentials of anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.) The ANS has two divisions: the sympathetic and the The neuronal cell bodies of the parasympathetic divi- parasympathetic. The sympathetic division is dominant sion originate in the brainstem and the sacral segments in stressful situations and prepares the body for the \u201cfight of the spinal cord, and extend to the parasympathetic or flight\u201d response that was discussed in Chapter 1. The ganglia where the synapse takes place either very close neuronal cell bodies of the sympathetic division originate to or actually in the visceral organ being innervated. In in the thoracolumbar region of the spinal cord. Their this way, a very localized response is possible. The axons extend to the chains of sympathetic ganglia where parasympathetic division dominates when an individual they synapse with other neurons that subsequently inner- is in a relaxed, nonstressful condition. The heart and vate the visceral effectors. This results in an increase in respirations are maintained at a normal rate and secre- heart rate and respirations and a decrease in digestive tions and peristalsis increase for normal digestion. secretions and peristalsis. Blood is shunted to the vital Elimination functions are promoted. A schematic repre- organs and to skeletal muscles to ensure adequate sentation of the autonomic nervous system is presented oxygenation. in Figure 4\u20137.","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 55 Central Peripheral Nervous System Nervous System Axon cell Receptors terminals body (e.g., skin, muscles, Afferent Neuron Dendrites viscera) Axon terminals Efferent Neuron Effector (e.g., muscles or gland) Synapses Interneurons FIGURE 4\u20135 Directional pathways of neurons Neurotransmitters neuron to allow the impulse to continue its course or to Neurotransmitters were described during the explana- prevent the impulse from continuing. After the neuro- tion of synaptic activity. They are being discussed sepa- transmitter has performed its function in the synapse, it rately and in detail because of the essential function they either returns to the vesicles to be stored and used again, play in the role of human emotion and behavior and or it is inactivated and dissolved by enzymes. The process because they are the target for mechanism of action of of being stored for reuse is called reuptake, a function that many of the psychotropic medications. holds significance for understanding the mechanism of action of certain psychotropic medications. Neurotransmitters are chemicals that convey informa- tion across synaptic clefts to neighboring target cells. Many neurotransmitters exist in the central and They are stored in small vesicles in the axon terminals of peripheral nervous systems, but only a limited number neurons. When the action potential, or electrical impulse, have implications for psychiatry. Major categories reaches this point, the neurotransmitters are released from include cholinergics, monoamines, amino acids, and the vesicles. They cross the synaptic cleft and bind with neuropeptides. Each of these is discussed separately and receptor sites on the cell body or dendrites of the adjacent summarized in Table 4\u20132.","56 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING Vesicles of neurotransmitter Receptor site Axon of presynaptic Inactivator neuron (cholinesterase) Dendrite of postsynaptic neuron Na+ Na+ Na+ Inactivated neurotransmitter Mitochondrion Neurotransmitter (acetylcholine) FIGURE 4\u20136 Impulse transmission at a synapse. The arrow indicates the direction of electrical impulses. (From Scanlon, V.C., & Sanders, T: Essentials of anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.) Cholinergics nerve terminals in the ANS resulting in the \u201cfight or Acetylcholine. Acetylcholine was the first chemical to be flight\u201d responses in the effector organs. In the CNS, nor- identified and proven as a neurotransmitter. It is a major epinephrine pathways originate in the pons and medulla effector chemical in the ANS, producing activity at all and innervate the thalamus, dorsal hypothalamus, limbic sympathetic and parasympathetic presynaptic nerve ter- system, hippocampus, cerebellum, and cerebral cortex. minals and all parasympathetic postsynaptic nerve termi- When norepinephrine is not returned for storage in the nals. It is highly significant in the neurotransmission that vesicles of the axon terminals, it is metabolized and inac- occurs at the junctions of nerve and muscles. tivated by the enzymes monoamine oxidase (MAO) and Acetylcholinesterase is the enzyme that destroys acetyl- catechol-O-methyl-transferase (COMT). choline or inhibits its activity. The functions of norepinephrine include the regula- In the CNS, acetylcholine neurons innervate the cere- tion of mood, cognition, perception, locomotion, cardio- bral cortex, hippocampus, and limbic structures. The vascular functioning, and sleep and arousal (Murphy & pathways are especially dense through the area of the Deutsch, 1991). The activity of norepinephrine also has basal ganglia in the brain. been implicated in certain mood disorders such as depression and mania, in anxiety states, and in schizo- Functions of acetylcholine are manifold and include phrenia (Sadock & Sadock, 2007). sleep, arousal, pain perception, the modulation and coor- dination of movement, and memory acquisition and Dopamine. Dopamine pathways arise from the mid- retention (Murphy & Deutsch, 1991). Cholinergic brain and hypothalamus and terminate in the frontal cor- mechanisms may have some role in certain disorders of tex, limbic system, basal ganglia, and thalamus. motor behavior and memory, such as Parkinson\u2019s disease, Dopamine neurons in the hypothalamus innervate the Huntington\u2019s disease, and Alzheimer\u2019s disease. posterior pituitary and those from the posterior hypo- thalamus project to the spinal cord. As with norepineph- Monoamines rine, the inactivating enzymes for dopamine are MAO Norepinephrine. Norepinephrine is the neurotransmitter and COMT. that produces activity at the sympathetic postsynaptic Dopamine functions include regulation of movements and coordination, emotions, voluntary decision-making ability, and because of its influence on the pituitary gland,","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 57 Sympathetic Parasympathetic Eye Ciliary ganglion III Midbrain Pons Pterygopalatine VII ganglion Medulla Salivary IX glands Otic ganglion Trachea Submandibular ganglion X Preganglionic neurons Vagus nerve Postganglionic T1 neurons Heart Preganglionic T2 Stomach neuron T3 Lung Postganglionic T4 Celiac ganglion neuron T5 T6 Adrenal gland Small intestine T7 Kidney T8 Pancreas Colon Rectum T9 Superior mesenteric T10 ganglion T11 Large intestine T12 L1 L2 Chain of Inferior S2 sympathetic mesenteric S3 ganglia ganglion S4 Bladder Reproductive organs FIGURE 4\u20137 The autonomic nervous system. The sympathetic division is shown on the left, and the parasympathetic division is shown on the right (both divisions are bilateral). (From Scanlon, V.C., & Sanders, T: Essentials of anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.) it inhibits the release of prolactin (Sadock & Sadock, that is not returned to be stored in the axon terminal vesi- 2007). Increased levels of dopamine are associated with cles is catabolized by the enzyme monoamine oxidase. mania (Dubovsky, Davies, & Dubovsky, 2003) and schiz- ophrenia (Ho, Black, & Andreasen, 2003). Serotonin may play a role in sleep and arousal, libido, appetite, mood, aggression, and pain perception. The Serotonin. Serotonin pathways originate from cell bod- serotoninergic system has been implicated in the etiolo- ies located in the pons and medulla and project to areas gy of certain psychopathological conditions including including the hypothalamus, thalamus, limbic system, anxiety states, mood disorders, and schizophrenia cerebral cortex, cerebellum, and spinal cord. Serotonin (Sadock & Sadock, 2007).","58 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING TABLE 4\u20132 Neurotransmitters in the Central Nervous System Neurotransmitter Location\/Function Possible Implications for Mental Illness I. Cholinergics ANS: Sympathetic and parasympathetic Increased levels: Depression A. Acetylcholine Decreased levels: Alzheimer\u2019s disease presynaptic nerve terminals; Huntington\u2019s disease, Parkinson\u2019s disease parasympathetic postsynaptic nerve terminals II. Monoamines CNS: Cerebral cortex, hippocampus, Decreased levels: Depression A. Norepinephrine limbic structures, and basal ganglia Increased levels: Mania, anxiety states, B. Dopamine Functions: Sleep, arousal, pain schizophrenia perception, movement, memory C. Serotonin Decreased levels: Parkinson\u2019s disease and D. Histamine ANS: Sympathetic postsynaptic nerve depression III. Amino Acids terminals A. Gamma-amino- Increased levels: Mania and schizophrenia CNS: Thalamus, hypothalamus, limbic butyric acid system, hippocampus, cerebellum, Decreased levels: Depression (GABA) cerebral cortex Increased levels: Anxiety states B. Glycine Decreased levels: Depression C. Glutamate and Functions: Mood, cognition, perception, Aspartate locomotion, cardiovascular functioning, Decreased levels: Huntington\u2019s disease, and sleep and arousal anxiety disorders, schizophrenia, and IV. Neuropeptides various forms of epilepsy A. Endorphins and Frontal cortex, limbic system, basal Enkephalins ganglia, thalamus, posterior pituitary, Toxic levels: \u201cglycine encephalopathy,\u201d B. Substance P and spinal cord decreased levels are correlated with C. Somatostatin spastic motor movements Functions: Movement and coordination, emotions, voluntary judgment, release Increased levels: Huntington\u2019s disease, of prolactin temporal lobe epilepsy, spinal cerebellar degeneration Hypothalamus, thalamus, limbic system, cerebral cortex, cerebellum, spinal cord Modulation of dopamine activity by opioid peptides may indicate some link Functions: Sleep and arousal, libido, to the symptoms of schizophrenia appetite, mood, aggression, pain perception, coordination, judgment Decreased levels: Huntington\u2019s disease and Alzheimer\u2019s disease Hypothalamus Functions: Wakefulness; pain sensation Increased levels: Depression Decreased levels: Alzheimer\u2019s disease and inflammatory response Increased levels: Huntington\u2019s disease Hypothalamus, hippocampus, cortex, cerebellum, basal ganglia, spinal cord, retina Functions: Slowdown of body activity Spinal cord and brain stem Functions: Recurrent inhibition of motor neurons Pyramidal cells of the cortex, cerebellum, and the primary sensory afferent systems; hippocampus, thalamus, hypothalamus, spinal cord Functions: Relay of sensory information and in the regulation of various motor and spinal reflexes Hypothalamus, thalamus, limbic structures, midbrain, and brain stem; enkephalins are also found in the gastrointestinal tract Functions: Modulation of pain and reduced peristalsis (enkephalins) Hypothalamus, limbic structures, midbrain, brain stem, thalamus, basal ganglia, and spinal cord; also found in gastrointestinal tract and salivary glands Function: Regulation of pain Cerebral cortex, hippocampus, thalamus, basal ganglia, brain stem, and spinal cord Function: Depending on part of the brain being affected, stimulates release of dopamine, serotonin, norepinephrine, and acetylcholine, and inhibits release of norepinephrine, histamine, and glutamate. Also acts as a neuromodulator for serotonin in the hypothalamus.","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 59 Histamine. The role of histamine in mediating allergic hippocamus, thalamus, hypothalamus, and spinal cord. and inflammatory reactions has been well documented. Glutamate and aspartate are inactivated by uptake into Its role in the CNS as a neurotransmitter has only the tissues and through assimilation in various metabolic recently been confirmed, and the availability of informa- pathways. tion is limited. The highest concentrations of histamine are found within various regions of the hypothalamus. Glutamate and aspartate function in the relay of sen- Histaminic neurons in the posterior hypothalamus are sory information and in the regulation of various motor associated with sustaining wakefulness (Gilman & and spinal reflexes. Alteration in these systems has been Newman, 2003). The enzyme that catabolizes histamine implicated in the etiology of certain neurodegenerative is MAO. Although the exact processes mediated by hista- disorders, such as Huntington\u2019s disease, temporal lobe mine with the central nervous system are uncertain, some epilepsy, and spinal cerebellar degeneration. data suggest that histamine may play a role in depressive illness. Neuropeptides Numerous neuropeptides have been identified and stud- Amino Acids ied. They are classified by the area of the body in which Inhibitory Amino Acids they are located or by their pharmacological or function- Gamma-Aminobutyric Acid. Gamma-aminobutyric acid al properties. Although their role as neurotransmitters (GABA) has a widespread distribution in the CNS, with has not been clearly established, it is known that they high concentrations in the hypothalamus, hippocampus, often coexist with the classic neurotransmitters within a cortex, cerebellum, and basal ganglia of the brain, in the neuron; however, the functional significance of this coexis- gray matter of the dorsal horn of the spinal cord, and in tence still requires further study. Hormonal neuropeptides the retina. Most GABA is associated with short inhibitory are discussed in the section of this chapter on psychoen- interneurons, although some long-axon pathways within docrinology. the brain also have been identified. GABA is catabolized by the enzyme GABA transaminase. Opioid Peptides. Opioid peptides, which include the endorphins and enkephalins, have been widely studied. Inhibitory neurotransmitters, such as GABA, prevent Opioid peptides are found in various concentrations in postsynaptic excitation, interrupting the progression of the hypothalamus, thalamus, limbic structures, midbrain, the electrical impulse at the synaptic junction. This func- and brainstem. Enkephalins are also found in the gas- tion is significant when slowdown of body activity is trointestinal (GI) tract. Opioid peptides are thought to advantageous. Enhancement of the GABA system is the have a role in pain modulation, with their natural mor- mechanism of action by which the benzodiazepines pro- phine-like properties. They are released in response to duce their calming effect. painful stimuli, and may be responsible for producing the analgesic effect following acupuncture. Opioid peptides Alterations in the GABA system have been implicated alter the release of dopamine and affect the spontaneous in the etiology of anxiety disorders, movement disorders activity of the dopaminergic neurons. These findings (e.g., Huntington\u2019s disease), and various forms of epilepsy. may have some implication for opioid peptide-dopamine interaction in the etiology of schizophrenia. Glycine. The highest concentrations of glycine in the CNS are found in the spinal cord and brainstem. Little is Substance P. Substance P was the first neuropeptide to known about the possible enzymatic metabolism of be discovered. It is present in high concentrations in the glycine. hypothalamus, limbic structures, midbrain, and brain- stem, and is also found in the thalamus, basal ganglia, and Glycine appears to be the neurotransmitter of recur- spinal cord. Substance P has been found to be highly rent inhibition of motor neurons within the spinal cord, concentrated in sensory fibers, and for this reason is and is possibly involved in the regulation of spinal and thought to play a role in sensory transmission, and par- brainstem reflexes. It has been implicated in the patho- ticularly in the regulation of pain. Substance P abnormal- genesis of certain types of spastic disorders and in ities have been associated with Huntington\u2019s disease, \u201cglycine encephalopathy,\u201d which is known to occur with dementia of the Alzheimer\u2019s type, and mood disorders toxic accumulation of the neurotransmitter in the brain (Sadock & Sadock, 2007). and cerebrospinal fluid (Murphy & Deutsch, 1991). Excitatory Amino Acids Somatostatin. Somatostatin (also called growth hor- Glutamate and Aspartate. Glutamate and aspartate appear mone-inhibiting hormone) is found in the cerebral cor- to be primary excitatory neurotransmitters in the pyram- tex, hippocampus, thalamus, basal ganglia, brainstem, idal cells of the cortex, the cerebellum, and the primary and spinal cord, and has multiple effects on the CNS. In sensory afferent systems. They are also found in the its function as a neurotransmitter, somatostatin exerts both stimulatory and inhibitory effects. Depending on the part of the brain being affected, it has been shown to","60 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING stimulate dopamine, serotonin, norepinephrine, and 15 percent of hospitalized psychiatric patients. Other fac- acetylcholine, and inhibit norepinephrine, histamine, and tors correlated with this behavior include adverse effects glutamate. It also acts as a neuromodulator for serotonin of psychotropic medications and features of the behav- in the hypothalamus, thereby regulating its release (i.e., ioral disorder itself. ADH also may play a role in learn- determining whether it is stimulated or inhibited). It is ing and memory, in alteration of the pain response, and possible that somatostatin may serve this function for in the modification of sleep patterns. other neurotransmitters as well. High concentrations of somatostatin have been reported in brain specimens of Oxytocin. Oxytocin stimulates contraction of the clients with Huntington\u2019s disease, and low concentrations uterus at the end of pregnancy and stimulates release of in those with Alzheimer\u2019s disease. milk from the mammary glands (Scanlon & Sanders, 2006). It is also released in response to stress and during CORE CONCEPT sexual arousal. Its role in behavioral functioning is Neuroendocrinology unclear, although it is possible that oxytocin may act in Study of the interaction between the nervous system certain situations to stimulate the release of adrenocorti- and the endocrine system, and the effects of various cotropic hormone (ACTH), thereby playing a key role in hormones on cognitive, emotional, and behavioral the overall hormonal response to stress. functioning. The Anterior Pituitary (Adenohypophysis) NEUROENDOCRINOLOGY The hypothalamus produces releasing hormones that pass Human endocrine functioning has a strong foundation in through capillaries and veins of the hypophyseal portal the CNS, under the direction of the hypothalamus, system to capillaries in the anterior pituitary, where they which has direct control over the pituitary gland. The stimulate secretion of specialized hormones. This path- pituitary gland has two major lobes\u2014the anterior lobe way is presented in Figure 4\u20139. The hormones of the (also called the adenohypophysis) and the posterior lobe anterior pituitary gland regulate multiple body functions (also called the neurohypophysis). The pituitary gland is and include growth hormone, thyroid-stimulating hor- only about the size of a pea, but despite its size and mone, ACTH, prolactin, gonadotropin-stimulating hor- because of the powerful control it exerts over endocrine mone, and melanocyte-stimulating hormone. Most of functioning in humans, it is sometimes called the \u201cmaster these hormones are regulated by a negative feedback mech- gland.\u201d (Figure 4\u20138 shows the hormones of the pituitary anism. Once the hormone has exerted its effects, the gland and their target organs.) Many of the hormones information is \u201cfed back\u201d to the anterior pituitary, which subject to hypothalamus-pituitary regulation may have inhibits the release, and ultimately decreases the effects, implications for behavioral functioning. Discussion of of the stimulating hormones. these hormones is summarized in Table 4\u20133. Growth Hormone. The release of growth hormone Pituitary Gland (GH), also called somatotropin, is stimulated by growth The Posterior Pituitary (Neurohypophysis) hormone-releasing hormone (GHRH) from the hypo- The hypothalamus has direct control over the posterior thalamus. Its release is inhibited by growth hormone- pituitary through efferent neural pathways. Two hor- inhibiting hormone (GHIH), or somatostatin, also from mones are found in the posterior pituitary: vasopressin the hypothalamus. It is responsible for growth in chil- (antidiuretic hormone) and oxytocin. They are actually dren, as well as continued protein synthesis throughout produced by the hypothalamus and stored in the posteri- life. During periods of fasting, it stimulates the release of or pituitary. Their release is mediated by neural impulses fat from the adipose tissue to be used for increased ener- from the hypothalamus (Fig. 4\u20139). gy. The release of GHIH is stimulated in response to periods of hyperglycemia. GHRH is stimulated in Antidiuretic Hormone. The main function of antidi- response to hypoglycemia and to stressful situations. uretic hormone (ADH) is to conserve body water and During prolonged stress, GH has a direct effect on pro- maintain normal blood pressure. The release of ADH is tein, carbohydrate, and lipid metabolism, resulting in stimulated by pain, emotional stress, dehydration, increased serum glucose and free fatty acids to be used increased plasma concentration, and decreases in blood for increased energy. There has been some indication of volume. An alteration in the secretion of this hormone a possible correlation between abnormal secretion of may be a factor in the polydipsia observed in about 10 to growth hormone and anorexia nervosa. Thyroid-Stimulating Hormone. Thyrotropin-releasing hormone (TRH) from the hypothalamus stimulates the release of thyroid-stimulating hormone (TSH), or thy- rotropin, from the anterior pituitary. TSH stimulates the thyroid gland to secrete triiodothyronine (T3) and","Hypothalamus CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 61ADH Posterior pituitary Anterior pituitary Kidneys Bones, organs Oxytocin Prolactin GH ACTH Uterus TSH Breasts FSH LH Adrenal cortex Thyroid Ovaries Testes Anterior pituitary hormones Posterior pituitary hormones FIGURE 4\u20138 Hormones of the pituitary gland and their target organs. (From Scanlon, V.C., & Sanders, T: Essentials of anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.) tmheytraobxoinliesm(To4f).foTodhyarnodidthheorremgounlaetsioanreofintetemgprealrattourteh. e correlated various forms of thyroid dysfunction with A correlation between thyroid dysfunction and mood disorders, anxiety, eating disorders, schizophre- nia, and dementia. altered behavioral functioning has been studied. Early reports in the medical literature associated hyperthy- Adrenocorticotropic Hormone. Corticotropin-releasing roidism with irritability, insomnia, anxiety, restlessness, hormone (CRH) from the hypothalamus stimulates the weight loss, and emotional lability, and in some release of ACTH from the anterior pituitary. ACTH instances with progressing to delirium or psychosis. stimulates the adrenal cortex to secrete cortisol. The role Symptoms of fatigue, decreased libido, memory impair- of cortisol in human behaviors is not well understood, ment, depression, and suicidal ideations have been asso- although it seems to be secreted under stressful situa- ciated with chronic hypothyroidism. Studies have tions. Disorders of the adrenal cortex can result in hyposecretion or hypersecretion of cortisol.","62 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING TABLE 4\u20133 Hormones of the Neuroendocrine System Hormone Location and Target Organ Function Possible Behavioral Antidiuretic Stimulation of Release Kidney (causes Conservation of Correlation to hormone (ADH) Posterior pituitary; release increased body water and Altered Secretion Oxytocin stimulated by reabsorption) maintenance of Polydipsia; altered pain Growth hormone dehydration, pain, stress Uterus; breasts blood pressure Contraction of the response; modified (GH) Posterior pituitary; release Bones and uterus for labor; sleep pattern Thyroid-stimulating stimulated by end of tissues release of breast May play role in stress pregnancy; stress; during milk response by hormone (TSH) sexual arousal Thyroid gland Growth in children; stimulation of ACTH protein synthesis Anorexia nervosa Adrenocorticotropic Anterior pituitary; release in adults hormone (ACTH) stimulated by growth Increased levels: hormone-releasing Stimulation of insomnia, anxiety, Prolactin hormone from secretion of emotional lability Gonadotropic hypothalamus needed thyroid hormones for Decreased levels: fatigue, hormones Anterior pituitary; release metabolism of depression stimulated by food and Melanocyte- thyrotropin-releasing regulation of Increased levels: mood stimulating hormone from temperature disorders, psychosis hormone (MSH) hypothalamus Stimulation of Decreased levels: depres- Anterior pituitary; release Adrenal cortex secretion of sion, apathy, fatigue stimulated by cortisol, which corticotropin-releasing Breasts plays a role in Increased levels: hormone from Ovaries and response to depression, anxiety, hypothalamus stress decreased libido, testes irritability Anterior pituitary; release Stimulation of milk stimulated by prolactin- production Decreased levels: releasing hormone from depression and hypothalamus Stimulation of anorexia nervosa secretion of Anterior pituitary; release estrogen, Increased testosterone: stimulated by progesterone, increased sexual gonadotropin-releasing and testosterone; behavior and hormone from role in ovulation aggressiveness hypothalamus and sperm production Increased levels: Anterior pituitary; release Pineal gland depression stimulated by onset of Stimulation of darkness secretion of melatonin Addison\u2019s disease is the result of hyposecretion of the lates milk production by the mammary glands in the pres- hormones of the adrenal cortex. Behavioral symptoms of ence of high levels of estrogen and progesterone during hyposecretion include mood changes with apathy, social pregnancy. Behavioral symptoms associated with hyper- withdrawal, impaired sleep, decreased concentration, and secretion of prolactin include depression, decreased libido, fatigue. Hypersecretion of cortisol results in Cushing\u2019s stress intolerance, anxiety, and increased irritability. disease and is associated with behaviors that include depression, mania, psychosis, and suicidal ideation. Gonadotropic Hormones. The gonadotropic hormones Cognitive impairments also have been commonly are so called because they produce an effect on the observed. gonads\u2014the ovaries and the testes. The gonadotropins include follicle-stimulating hormone (FSH) and luteiniz- Prolactin. Serum prolactin levels are regulated by pro- ing hormone (LH), and their release from the anterior lactin-releasing hormone (PRH) and prolactin-inhibiting pituitary is stimulated by gonadotropin-releasing hor- hormone (PIH) from the hypothalamus. Prolactin stimu- mone (GnRH) from the hypothalamus. In women, FSH","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 63 Hypothalamus Hypothalamus Optic chiasma Releasing hormones Capillaries in hypothalamus Hypothalamic-hypophyseal tract Hypophyseal portal veins Optic chiasma Posterior pituitary Superior hypophyseal Capillaries in arteries anterior pituitary Inferior hypophyseal artery Hormones of anterior pituitary Hormones of posterior Posterior lobe vein pituitary Lateral hypophyseal vein A B FIGURE 4\u20139 Structural relationships of hypothalamus and pituitary gland. (A) Posterior pituitary stores hormones produced in the hypothalamus. (B) Releasing hormones of the hypothalamus circulate directly to the anterior pituitary and influence its secretions. Notice the two networks of capillaries. (From Scanlon, V.C., & Sanders, T: Essentials of anatomy and physiology, ed. 5. F.A. Davis, Philadelphia, 2006.) initiates maturation of ovarian follicles into the ova and depression has led to the implication of melatonin in the stimulates their secretion of estrogen. LH is responsible etiology of seasonal affective disorder (SAD), in which for ovulation and the secretion of progesterone from the individuals become depressed only during the fall and corpus luteum. In men, FSH initiates sperm production winter months when the amount of daylight decreases. in the testes, and LH increases secretion of testosterone by the interstitial cells of the testes (Scanlon & Sanders, Circadian Rhythms 2006). The gonadotropins are regulated by a negative Human biological rhythms are largely determined by feedback of gonadal hormones at the hypothalamic or genetic coding, with input from the external environment pituitary level. influencing the cyclic effects. Circadian rhythms in humans follow a near\u201324-hour cycle and may influence a Limited evidence exists to correlate gonadotropins to variety of regulatory functions, including the sleep\u2013wake behavioral functioning, although some observations have cycle, body temperature regulation, patterns of activity been made to warrant hypothetical consideration. such as eating and drinking, and hormone secretion. The Studies have indicated decreased levels of testosterone, 24-hour rhythms in humans are affected to a large degree LH, and FSH in depressed men. Increased sexual behav- by the cycles of lightness and darkness. This occurs ior and aggressiveness have been linked to elevated because of a \u201cpacemaker\u201d in the brain that sends messages testosterone levels in both men and women. Decreased to other systems in the body and maintains the 24-hour plasma levels of LH and FSH commonly occur in rhythm. This endogenous pacemaker appears to be the patients with anorexia nervosa. Supplemental estrogen suprachiasmatic nuclei of the hypothalamus. These nuclei therapy has resulted in improved mentation and mood in receive projections of light through the retina, and in turn some depressed women. stimulate electrical impulses to various other systems in the body, mediating the release of neurotransmitters or Melanocyte-Stimulating Hormone. Melanocyte-stimu- hormones that regulate bodily functioning. lating hormone (MSH) from the hypothalamus stimulates the pineal gland to secrete melatonin. The release of Most of the biological rhythms of the body operate over melatonin appears to depend on the onset of darkness and a period of about 24 hours, but cycles of longer lengths is suppressed by light. Studies of this hormone have indi- have been studied. For example, women of menstruating cated that environmental light can affect neuronal activi- ty and influence circadian rhythms. Correlation between abnormal secretion of melatonin and symptoms of","64 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING age show monthly cycles of progesterone levels in the sali- episodes are characterized by rapid eye movement and va, of skin temperature over the breasts, and of prolactin are called REM sleep. The sleep-wake cycle is represented levels in the plasma of the blood (Hughes, 1989). by six distinct stages. 1. Stage 0\u2014Alpha Rhythm. This stage of the sleep\u2013wake Some rhythms may even last as long as a year. These circannual rhythms are particularly relevant to certain cycle is characterized by a relaxed, waking state with medications, such as cyclosporine, that appears to be eyes closed. The alpha brain wave rhythm has a fre- more effective at some times than others during the period of quency of 8 to 12 cycles per second. about a year (Hughes, 1989). Recently, clinical studies 2. Stage 1\u2014Beta Rhythm. Stage 1 characterizes the have shown that administration of chemotherapy during \u201ctransition\u201d into sleep, or a period of dozing. the appropriate circadian phase can significantly increase Thoughts wander, and there is a drifting in and out of the efficacy and decrease the toxic effects of certain sleep. Beta brain wave rhythm has a frequency of 18 to cytotoxic agents (Lis et al., 2003). 25 cycles per second. 3. Stage 2\u2014Theta Rhythm. This stage characterizes The Role of Circadian Rhythms in the manner in which about half of sleep time is spent. Psychopathology Eye movement and muscular activity are minimal. Circadian rhythms may play a role in psychopathology. Theta brain wave rhythm has a frequency of 4 to Because many hormones have been implicated in behav- 7 cycles per second. ioral functioning, it is reasonable to believe that peak 4. Stage 3\u2014Delta Rhythm. This is a period of deep and secretion times could be influential in predicting certain restful sleep. Muscles are relaxed, heart rate and blood behaviors. The association of depression to increased pressure fall, and breathing slows. No eye movement secretion of melatonin during darkness hours has already occurs. Delta brain wave rhythm has a frequency of been discussed. External manipulation of the light\u2013dark 1.5 to 3 cycles per second. cycle and removal of external time cues often have bene- 5. Stage 4\u2014Delta Rhythm. The stage of deepest sleep. ficial effects on mood disorders. Individuals who suffer from insomnia or other sleep disorders often do not experience this stage of sleep. Symptoms that occur in the premenstrual cycle have Eye movement and muscular activity are minimal. also been linked to disruptions in biological rhythms. A Delta waves predominate. number of the symptoms associated with this syndrome 6. REM Sleep\u2014Beta Rhythm. The dream cycle. Eyes strongly resemble those attributed to depression, and dart about beneath closed eyelids, moving more rapidly hormonal changes have been implicated in the etiology. than when awake. The brain wave pattern is similar to Some of these changes include progesterone-estrogen that of stage 1 sleep. Heart and respiration rates imbalance, increase in prolactin and mineralocorticoids, increase and blood pressure may increase or decrease. high level of prostaglandins, decrease in endogenous opi- Muscles are hypotonic during REM sleep. ates, changes in metabolism of biogenic amines (sero- Stages 2 through REM repeat themselves throughout tonin, dopamine, norepinephrine, acetylcholine), and the cycle of sleep. One is more likely to experience longer variations in secretion of glucocorticoids or melatonin. periods of stages 3 and 4 sleep early in the cycle and longer periods of REM sleep later in the sleep cycle. Sleep disturbances are common in both depression Most people experience REM sleep about four to five and premenstrual dysphoric disorder. Because the times during the night. The amount of REM sleep and sleep\u2013wakefulness cycle is probably the most funda- deep sleep decreases with age, while the time spent in mental of biological rhythms, it will be discussed in drowsy wakefulness and dozing increases. greater detail. A representation of bodily functions Neurochemical Influences. A number of neurochemicals affected by 24-hour biological rhythms is presented in have been shown to influence the sleep\u2013wake cycle. Several Figure 4\u201310. studies have revealed information about the sleep-induc- ing characteristics of serotonin. L-Tryptophan, the amino Sleep acid precursor to serotonin, has been used for many years The sleep\u2013wake cycle is genetically determined rather as an effective sedative-hypnotic to induce sleep in individ- than learned and is established some time after birth. uals with sleep-onset disorder. Serotonin and norepineph- Even when environmental cues such as the ability to rine both appear to be most active during non-REM sleep, detect light and darkness are removed, the human whereas the neurotransmitter acetylcholine is activated sleep\u2013wake cycle generally develops about a 25-hour during REM sleep (Skudaev, 2008). The exact role of periodicity, which is close to the 24-hour normal circadi- GABA in sleep facilitation is unclear, although the sedative an rhythm. effects of drugs that enhance GABA transmission, such as the benzodiazepines, suggest that this neurotransmitter Sleep can be measured by the types of brain waves that plays an important role in regulation of sleep and arousal. occur during various stages of sleep activity. Dreaming","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 65 (Clock Hours) 0800 1000 1200 1400 1600 1800 2000 2200 2400 0200 0400 0600 -- -- -- -- -- -- -- -- -- -- -- -- (Daylight) (Darkness) Body \u25b2 temperature \u25b2 \u25b2 Pulse \u25bc rate \u25bc \u25bc \u25bc Blood pressure \u25bc Growth \u25b2 \u25b2 hormone \u25bc Cortisol Thyroid \u25b2 hormones \u25b2 Prolactin \u25bc\u25b2 Melatonin \u25bc \u25b2 Testosterone (males) Progesterone \u25bc \u25bc\u25b2 (females)** \u25b2 Estrogen \u25bc Days 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 * \u25bc indicates low point and \u25b2 indicates peak time of these biological factors within a 24-hour circadian rhythm. ** The female hormones are presented on a monthly rhythm because of their influence on the reproductive cycle. Daily rhythms of female gonadotropins are difficult to assay and are probably less significant than monthly. FIGURE 4\u201310 Circadian biological rhythms*. Some studies have suggested that acetylcholine induces CORE CONCEPT and prolongs REM sleep, whereas histamine appears to have an inhibitive effect. Neuroendocrine mechanisms Genetics seem to be more closely tied to circadian rhythms than to Study of the biological transmission of certain charac- the sleep\u2013wake cycle. One exception is growth hormone teristics (physical and\/or behavioral) from parent to secretion, which exhibits increases during the early sleep offspring. period and may be associated with slow-wave sleep (Van Cauter et al., 1992).","66 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING GENETICS concordant when both members suffer from the same dis- Human behavioral genetics seeks to understand both the order in question. Concordance in monozygotic twins is genetic and environmental contributions to individual considered stronger evidence of genetic involvement variations in human behavior (McInerney, 2004). This than it is in dizygotic twins. Disorders in which twin type of study is complicated by the fact that behaviors, studies have suggested a possible genetic link include like all complex traits, involve multiple genes. alcoholism, schizophrenia, major depression, bipolar dis- order, anorexia nervosa, panic disorder, and obsessive\u2013 The term genotype refers to the total set of genes compulsive disorder (Gill, 2004; Baker, 2004). present in an individual at the time of conception, and coded in the DNA. The physical manifestations of a par- Adoption studies allow comparisons to be made of the ticular genotype are designated by characteristics that influences of genetics versus environment on the devel- specify a specific phenotype. Examples of phenotypes opment of a psychiatric disorder. Knowles (2003) include eye color, height, blood type, language, and hair describes the following four types of adoption studies type. As evident by the examples presented, phenotypes that have been conducted: are not only genetic, but may also be acquired (i.e., influ- 1. The study of adopted children whose biological par- enced by the environment) or a combination of both. It is likely that many psychiatric disorders are the result of ent(s) had a psychiatric disorder but whose adoptive a combination of genetics and environmental influences. parent(s) did not. 2. The study of adopted children whose adoptive par- Investigators who study the etiological implications ent(s) had a psychiatric disorder but whose biological for psychiatric illness may explore several risk factors. parent(s) did not. Studies to determine if an illness is familial compare the 3. The study of adoptive and biological relatives of adopt- percentages of family members with the illness to those ed children who developed a psychiatric disorder. in the general population or within a control group of 4. The study of monozygotic twins reared apart by dif- unrelated individuals. These studies estimate the preva- ferent adoptive parents. lence of psychopathology among relatives, and make pre- Disorders in which adoption studies have suggested a dictions about the predisposition to an illness based on possible genetic link include alcoholism, schizophrenia, familial risk factors. Schizophrenia, bipolar disorder, major depression, bipolar disorder, attention-deficit\/hyper- major depression, anorexia nervosa, panic disorder, som- activity disorder, and antisocial personality disorder atization disorder, antisocial personality disorder, and (Knowles, 2003). alcoholism are examples of psychiatric illness in which A summary of various psychiatric disorders and the familial tendencies have been indicated. possible biological influences discussed in this chapter is presented in Table 4\u20134. Various diagnostic procedures Studies that are purely genetic in nature search for a used to detect alteration in biological functioning that specific gene that is responsible for an individual having may contribute to psychiatric disorders are presented in a particular illness. A number of disorders exist in which Table 4\u20135. the mutation of a specific gene or change in the number or structure of a chromosome has been associated with CORE CONCEPT the etiology. Examples include Huntington\u2019s disease, Psychoimmunology cystic fibrosis, phenylketonuria, Duchenne\u2019s muscular The branch of medicine that studies the effects of psy- dystrophy, and Down\u2019s syndrome. chological and social factors on the functioning of the immune system. The search for genetic links to certain psychiatric dis- orders continues. Risk factors for early-onset Alzheimer\u2019s PSYCHOIMMUNOLOGY disease have been linked to mutations on chromosomes 21, 14, and 1 (National Institute on Aging, 2004). Other Normal Immune Response studies have linked a gene in the region of chromosome Cells responsible for nonspecific immune reactions include 19 that produces apolipoprotein E (ApoE) with late- neutrophils, monocytes, and macrophages. They work to onset Alzheimer\u2019s disease. Additional research is required destroy the invasive organism and initiate and facilitate before definitive confirmation can be made. damaged tissue. If these cells are not effective in accom- plishing a satisfactory healing response, specific immune In addition to familial and purely genetic investiga- mechanisms take over. tions, other types of studies have been conducted to estimate the existence and degree of genetic and environ- Specific immune mechanisms are divided into two mental contributions to the etiology of certain psychi- major types: the cellular response and the humoral atric disorders. Twin studies and adoption studies have been successfully employed for this purpose. Twin studies examine the frequency of a disorder in monozygotic (genetically identical) and dizygotic (frater- nal; not genetically identical) twins. Twins are called","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 67 TABLE 4\u20134 Biological Implications of Psychiatric Disorders Anatomical Brain Neurotransmitter Possible Implications of Possible Structures Hypothesis Endocrine Circadian Genetic Involved Correlation Rhythms Schizophrenia Dopamine hyperactivity Decreased prolactin Link Frontal cortex, temporal levels May correlate antipsy- Twin, familial, and Decreased levels of chotic medication lobes, limbic system norepinephrine, Increased cortisol levels; administration to adoption studies Depressive Disorders dopamine, and thyroid hormone times of lowest level suggest genetic link Frontal lobes, limbic serotonin hyposecretion; Twin, familial, and increased melatonin DST* used to predict adoption studies system, temporal lobes Increased levels of norepi- effectiveness of antide- suggest a genetic link nephrine and dopamine Some indication of pressants; melatonin Bipolar Disorder in acute mania elevated thyroid hor- linked to depression Twin, familial, and Frontal lobes, limbic mones in acute mania during periods of adoption studies Increased levels of nor- darkness suggest a genetic link system, temporal lobes epinephrine; decreased Elevated levels of thyroid Panic Disorder GABA activity hormones May have some applica- Twin and familial studies Limbic system, midbrain tion for times of med- suggest a genetic link Decreased levels of Decreased levels of ication administration Anorexia nervosa norepinephrine, sero- gonadotropins and Twin and familial studies Limbic system, particu- tonin, and dopamine growth hormone; DST* often shows same suggest a genetic link increased cortisol levels results as in depression larly the hypothalamus Decreased levels of Twin studies suggest a Obsessive\u2013Compulsive serotonin Increased cortisol levels DST* often shows same possible genetic link results as in depression Disorder Decreased levels of Decreased corticotropin- Familial studies suggest a Limbic system, basal acetylcholine, norepi- releasing hormone Decreased levels of genetic predisposition; nephrine, serotonin, acetylcholine and sero- late-onset disorder ganglia (specifically and somatostatin tonin may inhibit linked to marker on caudate nucleus) hypothalamic-pituitary chromosome 19; early- Alzheimer\u2019s Disease axis and interfere with onset to chromosomes Temporal, parietal, and hormonal releasing 21, 14, and 1 occipital regions of factors cerebral cortex; hip- pocampus *DST = dexamethasone suppression test. Dexamethasone is a synthetic glucocorticoid that suppresses cortisol secretion via the feedback mecha- nism. In this test, 1 mg of dexamethasone is administered at 11:30 P.M. and blood samples are drawn at 8:00 A.M., 4:00 P.M, and 11:00 P.M. on the following day. A plasma value greater than 5 \u03bcg\/dL suggests that the individual is not suppressing cortisol in response to the dose of dexamethasone. This is a positive result for depression and may have implications for other disorders as well. response. The controlling elements of the cellular The humoral response is activated when antigen- response are the T lymphocytes (T cells); those of the specific T4 cells communicate with the B cells in the humoral response are called B lymphocytes (B cells). spleen and lymph nodes. The B cells in turn produce the When the body is invaded by a specific antigen, the antibodies specific to the foreign antigen. Antibodies T cells, and particularly the T4 lymphocytes (also called attach themselves to foreign antigens so that they are T helper cells), become sensitized to and specific for the unable to invade body cells. These invader cells are then foreign antigen. These antigen-specific T4 cells divide destroyed without being able to multiply. many times, producing antigen-specific T4 cells with other functions. One of these, the T killer cell, destroys Implications of the Immune System viruses that reproduce inside other cells by puncturing in Psychiatric Illness the cell membrane of the host cell and allowing the con- In studies of the biological response to stress, it has been tents of the cell, including viruses, to spill out into the hypothesized that individuals become more susceptible to bloodstream, where they can be engulfed by physical illness following exposure to a stressful stimulus macrophages. Another cell produced through division of or life event (see Chapter 1). This response is thought to the T4 cells is the suppressor T cell, which serves to stop be due to the effect of increased glucocorticoid release the immune response once the foreign antigen has been destroyed (Scanlon & Sanders, 2006).","68 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING TABLE 4\u20135 Diagnostic Procedures Used to Detect Altered Brain Functioning Exam Technique Used Purpose of the Exam and Possible Findings Electroencephalography Electrodes are placed on the scalp in a standard- Measures brain electrical activity; identifies (EEG) ized position. Amplitude and frequency of beta, dysrhythmias, asymmetries, or suppression of brain Computerized EEG mapping alpha, theta, and delta brain waves are rhythms; used in the diagnosis of epilepsy, graphically recorded on paper by ink markers neoplasm, stroke, metabolic, or degenerative Computed tomographic for multiple areas of the brain surface. disease. (CT) scan EEG tracings are summarized by computer- Measures brain electrical activity; used largely in assisted systems in which various regions of the research to represent statistical relationships Magnetic resonance imaging brain are identified and functioning is between individuals and groups or between two (MRI) interpreted by color coding or gray shading. populations of subjects (e.g., patients with schizophrenia vs. control subjects). Positron emission CT scan may be used with or without contrast Measures accuracy of brain structure to detect tomography (PET) medium. X-ray films are taken of various possible lesions, abscesses, areas of infarction, or transverse planes of the brain while a aneurysm. CT has also identified various anatomi- Single photon emission computerized analysis produces a precise cal differences in patients with schizophrenia, computed tomography reconstructed image of each segment. organic mental disorders, and bipolar disorder. (SPECT) Measures anatomical and biochemical status of Within a strong magnetic field, the nuclei of various segments of the brain; detects brain edema, hydrogen atoms absorb and reemit ischemia, infection, neoplasm, trauma, and other electromagnetic energy that is computerized changes such as demyelination. Morphological dif- and transformed into image information. No ferences have been noted in brains of patients with radiation or contrast medium is used. schizophrenia as compared with control subjects. Measures specific brain functioning, such as glucose The patient receives an intravenous (IV) injection metabolism, oxygen utilization, blood flow, and, of of a radioactive substance (type depends on particular interest in psychiatry, neurotransmitter- brain activity to be visualized). The head is receptor interaction. surrounded by detectors that relay data to a computer that interprets the signals and Measures various aspects of brain functioning, as produces the image. with PET; has also been used to image activity of cerebrospinal fluid circulation. The technique is similar to PET, but longer-act- ing radioactive substance must be used to allow time for a gamma-camera to rotate about the head and gather the data, which are then computer assembled into a brain image. from the adrenal cortex following stimulation from the Immunological abnormalities have also been investigated hypothalamic-pituitary-adrenal axis during stressful situa- in a number of other psychiatric illnesses, including alco- tions. The result is a suppression in lymphocyte prolifer- holism, autism, and dementia. ation and function. Evidence exists to support a correlation between psy- Studies have shown that nerve endings exist in tissues chosocial stress and the onset of illness. Research is still of the immune system. The CNS has connections in required to determine the specific processes involved in both bone marrow and the thymus, where immune sys- stress-induced modulation of the immune system. tem cells are produced, and in the spleen and lymph nodes, where those cells are stored. IMPLICATIONS FOR NURSING The discipline of psychiatric\/mental health nursing has Growth hormone, which may be released in response always spoken of its role in holistic health care, but his- to certain stressors, may enhance immune functioning, torical review reveals that emphasis has been placed on whereas testosterone is thought to inhibit immune func- treatment approaches that focus on psychological and tioning. Increased production of epinephrine and norep- social factors. Psychiatric nurses must integrate knowl- inephrine occurs in response to stress, and may decrease edge of the biological sciences into their practices if they immunity. Serotonin has demonstrated both enhancing are to ensure safe and effective care to people with men- and inhibitory effects on immunity (Irwin, 2000). tal illness. In the Surgeon General\u2019s Report on Mental Health (U.S. Department of Health and Human Studies have correlated a decrease in lymphocyte Services, 1999), Dr. David Satcher wrote: functioning with periods of grief, bereavement, and depression, associating the degree of altered immunity The mental health field is far from a complete understand- with severity of the depression. A number of research ing of the biological, psychological, and sociocultural bases studies have been conducted attempting to correlate of development, but development clearly involves interplay the onset of schizophrenia to abnormalities of the among these influences. Understanding the process of immune system. These studies have considered autoim- development requires knowledge, ranging from the most mune responses, viral infections, and immunogenetics (Sadock & Sadock, 2007). The role of these factors in the onset and course of schizophrenia remains unclear.","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 69 fundamental level\u2014that of gene expression and interactions SUMMARY AND KEY POINTS between molecules and cells\u2014all the way up to the highest \u25cf It is important for nurses to understand the interaction levels of cognition, memory, emotion, and language. The challenge requires integration of concepts from many differ- between biological and behavioral factors in the devel- ent disciplines. A fuller understanding of development is not opment and management of mental illness. only important in its own right, but it is expected to pave the \u25cf Psychobiology is the study of the biological founda- way for our ultimate understanding of mental health and tions of cognitive, emotional, and behavioral processes. mental illness and how different factors shape their expres- \u25cf The limbic system has been called \u201cthe emotional sion at different stages of the life span. (pp. 61\u201362) brain.\u201d It is associated with feelings of fear and anxi- ety; anger, rage, and aggression; love, joy, and hope; To ensure a smooth transition from a psychosocial and with sexuality and social behavior. focus to one of biopsychosocial emphasis, nurses must \u25cf The three classes of neurons include afferent (senso- have a clear understanding of the following: ry), efferent (motor), and interneurons. The junction \u25cf Neuroanatomy and neurophysiology: the structure and between two neurons is called a synapse. \u25cf Neurotransmitters are chemicals that convey informa- functioning of the various parts of the brain and their tion across synaptic clefts to neighboring target cells. correlation to human behavior and psychopathology. Many neurotransmitters have implications in the etiol- \u25cf Neuronal processes: the various functions of the nerve ogy of emotional disorders and in the pharmacological cells, including the role of neurotransmitters, recep- treatment of those disorders. tors, synaptic activity, and informational pathways. \u25cf Major categories of neurotransmitters include cholin- \u25cf Neuroendocrinology: the interaction of the endocrine ergics, monoamines, amino acids, and neuropeptides. and nervous systems, and the role that the endocrine \u25cf The endocrine system plays an important role in human glands and their respective hormones play in behav- behavior through the hypothalamic-pituitary axis. ioral functioning. \u25cf Hormones and their circadian rhythm of regulation \u25cf Circadian rhythms: regulation of biochemical function- significantly influence a number of physiological and ing over periods of rhythmic cycles and their influence psychological life cycle phenomena, such as moods, in predicting certain behaviors. sleep and arousal, stress response, appetite, libido, and \u25cf Genetic influences: hereditary factors that predispose fertility. individuals to certain psychiatric disorders. \u25cf Research continues to validate the role of genetics in \u25cf Psychoimmunology: the influence of stress on the immune psychiatric illness. system and its role in the susceptibility to illness. \u25cf Familial, twin, and adoption studies suggest that genet- \u25cf Psychopharmacology: the increasing use of psychotropics ics may be implicated in the etiology of schizophrenia, in the treatment of mental illness, demanding greater bipolar disorder, depression, panic disorder, anorexia knowledge of psychopharmacological principles and nervosa, alcoholism, and obsessive\u2013compulsive disorder. nursing interventions necessary for safe and effective \u25cf Psychoimmunology examines the impact of psycho- management. logical factors on the immune system. \u25cf Diagnostic technology: the importance of keeping \u25cf Evidence exists to support a link between psychosocial informed about the latest in technological procedures stressors and suppression of the immune response. for diagnosing alterations in brain structure and \u25cf Technologies such as magnetic resonance imagery function. (MRI), computed tomographic (CT) scan, positron Why are these concepts important to the practice of psy- emission tomography (PET), and electroencephalog- chiatric-mental health nursing? The interrelationship raphy (EEG) are used as diagnostic tools for detecting between psychosocial adaptation and physical function- alterations in psychobiological functioning. ing has been established. Integrating biological and \u25cf Integrating knowledge of the expanding biological behavioral concepts into psychiatric nursing practice is focus into psychiatric nursing is essential if nurses are to essential for nurses to meet the complex needs of mental- meet the changing needs of today\u2019s psychiatric clients. ly ill clients. Psychobiological perspectives must be incorporated into nursing practice, education, and For additional clinical tools and study research to attain the evidence-based outcomes necessary aids, visit DavisPlus. for the delivery of competent care.","70 UNIT II \u25cf FOUNDATIONS FOR PSYCHIATRIC\/MENTAL HEALTH NURSING REVIEW QUESTIONS Self-Examination\/Learning Exercise Match the following parts of the brain to their functions described in the right-hand column: 1. Frontal lobe a. Sometimes called the \u201cemotional brain\u201d; associated with multiple feelings and behaviors 2. Parietal lobe b. Concerned with visual reception and interpretation 3. Temporal lobe c. Voluntary body movement; thinking and judgment; expression of feeling 4. Occipital lobe d. Integrates all sensory input (except smell) on way to cortex 5. Thalamus e. Part of the cortex that deals with sensory perception and interpretation 6. Hypothalamus f. Hearing, short-term memory, and sense of smell 7. Limbic system g. Control over pituitary gland and autonomic nervous system; regulates appetite and temperature. Select the answer that is most appropriate for each of the following questions. 8. At a synapse, the determination of further impulse transmission is accomplished by means of a. Potassium ions b. Interneurons c. Neurotransmitters d. The myelin sheath 9. A decrease in which of the following neurotransmitters has been implicated in depression? a. GABA, acetylcholine, and aspartate b. Norepinephrine, serotonin, and dopamine c. Somatostatin, substance P, and glycine d. Glutamate, histamine, and opioid peptides 10. Which of the following hormones has been implicated in the etiology of seasonal affective disorder (SAD)? a. Increased levels of melatonin b. Decreased levels of oxytocin c. Decreased levels of prolactin d. Increased levels of thyrotropin 11. In which of the following psychiatric disorders do genetic tendencies appear to exist? a. Schizophrenia b. Dissociative disorder c. Conversion disorder d. Narcissistic personality disorder 12. With which of the following diagnostic imaging technologies can neurotransmitter-receptor interaction be visualized? a. Magnetic resonance imaging (MRI) b. Positron emission tomography (PET) c. Electroencephalography (EEG) d. Computerized EEG mapping 13. During stressful situations, stimulation of the hypothalamic\u2013pituitary\u2013adrenal axis results in suppression of the immune system because of the effect of a. Antidiuretic hormone from the posterior pituitary b. Increased secretion of gonadotropins from the gonads c. Decreased release of growth hormone from the anterior pituitary d. Increased glucocorticoid release from the adrenal cortex","CHAPTER 4 \u25cf CONCEPTS OF PSYCHOBIOLOGY 71 REFERENCES Baker, C. (2004). Behavioral genetics. Washington, DC: American McInerney, J. (2004). Behavioral genetics. The Human Genome Project. Association for the Advancement of Science. Retrieved June 12, 2008 from http:\/\/www.ornl.gov\/sci\/techresources\/ Human Genome\/elsi\/behavior.shtml Dubovsky, S.L., Davies, R., & Dubovsky, A.N. (2003). Mood disor- ders. In R.E. Hales & S.C. Yudofsky (Eds.). Textbook of clinical Murphy, M., & Deutsch, S.I. (1991). Neurophysiological and psychiatry (4th ed.). Washington, DC: American Psychiatric neurochemical basis of behavior. In K. Davis, H. Klar, & J.T. Coyle Publishing, pp. 439\u2013542. (Eds.), Foundations of psychiatry. Philadelphia: W.B. Saunders. Gill, M. (2004). Genetic approaches to the understanding of mental National Institute on Aging. (2004). The Alzheimer\u2019s Disease illness. Genes and Mental Health. Public symposium, October 9, Education and Referral Center. Alzheimer\u2019s disease genetics. Retrieved 2004, Department of Psychiatry. Dublin: Trinity College. June 12, 2008 from http:\/\/www.nia.nih.gov\/ Gilman, S., & Newman, S.W. (2003). Essentials of clinical neuroanatomy Sadock, B.J., & Sadock, V.A. (2007). Synopsis of psychiatry: Behavioral and neurophysiology (10th ed.). Philadelphia: F.A. Davis. sciences\/clinical psychiatry (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ho, B.C., Black, D.W., & Andreasen, N.C. (2003). Schizophrenia and other psychotic disorders. In R.E. Hales & S.C. Yudofsky (Eds.), Scanlon, V.C., & Sanders, T. (2006). Essentials of anatomy and physiology Textbook of clinical psychiatry (4th ed.). Washington, DC: American (5th ed.). Philadelphia: F.A. Davis. Psychiatric Publishing, pp. 379\u2013438. Skudaev, S. (2008). Neurophysiology and neurochemistry of sleep. Hughes, M. (1989). Body clock: The effects of time on human health. New Retrieved June 12, 2008 from http:\/\/www.healthstairs.com\/ York: Andromeda Oxford. sleep_mechanisms.php Irwin, M. (2000). Psychoneuroimmunology of depression. In F.E. U.S. Department of Health and Human Services. (1999). Mental Bloom & D.J. Kupfer (Eds)., Psychopharmacology\u2014The fourth health: A report of the Surgeon General. Rockville, MD: U.S. generation of progress. Nashville, TN: American College of Department of Health and Human Services. Neuropsychopharmacology. Van Cauter, E., Kerkhofs, M., Caufriez, A., Van Onderbergen, A., Knowles, J.A. (2003). Genetics. In R.E. Hales, & S.C. Yudofsky Thorner, M.O., & Copinschi, G. (1992). A quantitative estimation (Eds.), Textbook of psychiatry (4th ed.). Washington, DC: American of growth hormone secretion in normal man: reproducibility and Psychiatric Publishing, pp. 3\u201366. relation to sleep and time of day. Journal of Clinical Endocrinology and Metabolism, 74, 1441\u20131450. Lis, C.G., Grutsch, J.F., Wood, P., You, M., Rich, I., & Hrushesky, W.J. (2003). Circadian timing in cancer treatment: The biological foundation for an integrative approach. Integrative Cancer Therapies, 2(2), 105\u2013111.","5 CHAPTER Ethical and Legal Issues in Psychiatric\/Mental Health Nursing CHAPTER OUTLINE OBJECTIVES SUMMARY AND KEY POINTS ETHICAL CONSIDERATIONS REVIEW QUESTIONS LEGAL CONSIDERATIONS KEY TERMS CORE CONCEPTS bioethics assault justice ethics autonomy Kantianism moral behavior battery libel right beneficence malpractice values Christian ethics natural law values clarification civil law negligence common law nonmaleficence criminal law privileged defamation of communication character slander ethical dilemma statutory law ethical egoism tort false imprisonment utilitarianism informed consent veracity OBJECTIVES After reading this chapter, the student will be able to: 1. Differentiate among ethics, morals, 6. Describe ethical issues relevant to values, and rights. psychiatric\/mental health nursing. 2. Discuss ethical theories including 7. Define statutory law and common law. utilitarianism, Kantianism, Christian 8. Differentiate between civil and criminal ethics, natural law theories, and ethical egoism. law. 9. Discuss legal issues relevant to 3. Define ethical dilemma. 4. Discuss the ethical principles of autono- psychiatric\/mental health nursing. 10. Differentiate between malpractice and my, beneficence, nonmaleficence, justice, and veracity. negligence. 5. Use an ethical decision-making model 11. Identify behaviors relevant to the to make an ethical decision. psychiatric\/mental health setting for which specific malpractice action could be taken. 72"]