Maladaptive Patterns of Behavior

Maladaptive Patterns of Behavior

Overview of Psychiatric Nursing

Marcus Tullius Cicero• Was a roman philosopher,

statesman, Lawyer, Political Theorist and Roman Constitutionalist

• Introduced the Romans to the chief schools of Greek Philosophy

• Was the first known person to create a questionnaire for the mentally ill using biographical information

Mental Health in the Middle Ages• Persons who displayed abnormal behavior were

considered Lunatics, Witches, or demons possessed by evil spirits

• Superstition, Mysticism, Magic and Witchcraft prevailed as patients were locked in asylums, flogged, starved, tortured or subjected to bloodletting.

Mental Health in the Middle Ages• In 13th century Medieval Europe Psychiatric

Hospitals were built to house the mentally ill, but there were no nurses to care for them

• The first mental hospital ,Bethlehem Royal Hospital, opened in England in 1403. Pronounced as â€œBedlam,â€, the name came to symbolize �the inhumane treatment of persons who were put on public display for twopence a look.

Colonial United States • Individuals with Mental defects that were deemed

as dangerous were incarcerated or kept in cages. • Wealthier colonists kept their insane relatives in

the attics or cellars and hired attendants• In other communities the mentally ill was sold as

slave labor or forced to leave town

Trephining /Trepanation • Also known as trephination,

trephining is a surgical intervention in which a hole is drilled or scraped in the human skull

• Cave painting indicate that the practice would cure epileptic seizures, migraines and mental disorders

• Evidence also suggest that trepanation was primitive emergency surgery after head wounds to remove shattered bits of bone form a fractured skull

Humorism / Humoralism • Humorism is a now discredited theory of the

makeup and the workings of he Human Body • It was believed that an excess or deficiency of any

of the four distinct bodily fluids in a person directly influences temperament and health

• The four humors of Hippocratic Medicine include Black Bile (melan chole), Yellow Bile (chole), Phlegm (phlegma), and Blood (sanguis) and each corresponds to one of the traditional four temperaments.

Humour Season Element Organ Qualities Ancient name Modern

Ancient characteristics

Blood spring air liver warm & moist sanguine artisan

courageous, hopeful, amorous

Yellow bile summer fire gall bladder

warm & dry choleric idealist

easily angered, bad tempered

Black bile autumn earth spleen cold & dry melancholic guardian

despondent, sleepless, irritable

Phlegm winter water brain/lungs

cold & moist

phlegmatic rational

calm, unemotional

Theories in Psychiatric and Mental Health

Psychoanalytic Theory

• Refers to the definition and dynamics of personality development which underlie and guide psychoanalytic and psychodynamic psychotherapy

• First laid out by Sigmund Freud, Freud gave up the study of the brain and abandoned his physiological laboratory to focus on the mind and the psychological laboratory of his consulting room

Psychosexual Theory • According to Freud, personality develops through

a series of childhood stages during which the pleasure seeking energies of the id become focused on certain erogenous areas

• This psychosexual energy, or libido was described as the driving force behind behavior.

• If these psychosexual stages are completed successfully, the result is a healthy personality, If certain issues are not resolved at the appropriate stage, fixation can occur.

Psychosexual Theory

• Oral Stage • The infant’s primary source of interaction occurs through the mouth • The primary conflict at this stage is the weaning process – the child must become less dependent on the caretakers• If fixation occurs at this stage, Freud believed the individual would have issues with dependency or aggression • Oral fixation can result in problems with drinking, eating, smoking or nail biting.

Psychosexual Theory • Anal Stage • The primary focus of the libido was on controlling bladder and bowel movements• The major conflict at this stage is toilet training – developing this control leads to a sense of accomplishment and independence • If parents take an approach that is too lenient, an anal-expulsive personality could develop in which the individual has a messy, wasteful or destructive personality • If the parents are too strict or begin toilet training too early, Freud believed that an Anal-retentive personality develops in which the individual is stringent, orderly, rigid and obsessive

Psychosexual Theory

• Phallic Stage • The primary focus of the libido is at the genitals. • At this age, children also begin to discover the differences between males and females • Oedipus Complex, Electra Complex, Castration Anxiety and Penis Envy • Eventually, the child begins to identify with the same-sex parent as a means of vicariously possessing the other parent

Psychosexual Theory

• Latent Stage • The Libido interests are suppressed. The development of the ego and the superego contribute to this period of calm • The latent period is a time for exploration in which the sexual energy is still present, but is directed into areas such as intellectual pursuits and social interactions

Psychosexual Theory

• Genital Stage • The individual develops a strong sexual interest in the opposite sex• The stage begins during puberty but last throughout the rest of a persons life• The goal of this stage is to establish a balance between the various life areas

Behavioral Theory / Behaviorism

• The proponent was B.F. Skinner• Skinner was influential in defining Radical

Behaviorism, codifying the basis of his school of research (named the EAB or the Experimental Analysis of Behavior)

• EAB or Behaviorism differs from other approaches to behavioral research in accepting feelings, states of mind and introspection as existent and scientifically treatable

Behavioral Theory / Behaviorism

• Studies on the behavior of respondents is done by identifying them as something non-dualistic

• The most widely known experiment by Skinner can best be exemplified by the Dog-Bone-Bell Test.

Erik Eriksson’s Developmental Tasks

• Eriksson was a pioneer, defying the theories first established by both Sigmund Freud a d Skinner

• Eriksson’s Developmental tasks suggested that the lifetime of an individual can be divided into 7 age-specific groups that have been delegated with “tasks” that have to be accomplished before the age group ends.

• Failure to accomplish these tasks lead to specific disorders related to “rewards” gained.

Trust vs. Mistrust

• Infancy (0 – 12 months)• Major task is development of trust• Inability to develop adequate trust leads to

severe mistrust or exaggerated trust issues

Autonomy vs. Shame and Doubt

• Toddlerhood (1-3 years)• Major task is establishment of

independence• Child is mostly negativistic; Learns and

takes advantage of the word “NO”• Temper Tantrums are common• Should be attended to with a firm manner.

Initiative vs. Guilt

• Pre-School (3-6 years)• Child open to new experiences • Children should be given time and freedom

to explore • Safety should always be a priority

Industry and Inferiority

• School Age (6-12 years)• Unlike during pre-school age, focus shifts

from starting activities to finally completing and gaining a sense of achievement

• Considered as the most productive years in a child’s life

• Competition with other children of the same age is common

Identity vs. Role Confusion

• Adolescence (13-18 years)• Main focus is the establishment of identity• Adolescents are very conscious with their

appearance • Peer pressure is strong

Intimacy vs. Isolation

• Early Adulthood (18 - 25 years)• Establishment of meaningful relationship• “Best” time to start a family • Adults are pressured to “do something with

their life”

Generativity vs. Stagnation

• MIddle Adulthood (25 - 35 years)

Ego Integrity vs. Despair

• Late Adulthood (35 – Above)

Mental Status Examination

Client Assessment • The assessment phase of the Nursing Process

includes the collection of data about a person, family or group by the methods of observing, examining and interviewing.

• Two types of data are collected, • Objective Data include information to determine the

client’s physical alterations, limits and assets. Objective data are tangible and measurable data collected by palpation, percussion, inspection and auscultation.• Subjective data are obtained as the client, family

members or significant others provide information spontaneously during questioning or during the health history.

Client Assessment • Three kinds of assessment exist, comprehensive, focused

and screening assessments. • A comprehensive assessment includes data related to

the client’s biologic, psychological, cultural, spiritual and social needs. This type of assessment is generally completed in collaboration with other health care professionals

• A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member or a crisis situation.

• A screening assessment includes the use of assessment or rating scales such as the Brief Psychiatric Rating Scale of Hamilton rating Scale for Depression

Collection of Data • Much data are collected by the psychiatric mental

nurse during a comprehensive assessment, which may take place in a variety of settings.

• Specific questions or guidelines are at times included in the assessment to alert the nurse to information that could be overlooked or misinterpreted

Appearance

• General appearance includes physical characteristics, apparent age, peculiarity of dress, cleanliness and use of cosmetics

• A client’s general appearance, including facial expressions, is a manner of nonverbal communication in which emotions, feelings and moods are related

Affect

• Affect is the outward manifestation of a person’s feelings, tone or mood. The relationship between affect or emotional state and thought processes is of particular importance.

• A client’s emotional state, as expressed objectively on his/her face, can be widely divergent from what the client says or does.

Affect (Types of affective responses)• Blunted affect – Severe reduction or limitation in the

intensity of one’s affective response to a situation• Flat Affect – Absence or near absence of any signs of

affective responses, such as an immobile face and monotonous tone of voice when conversing with others

• Inappropriate Affect – Discordance or lack of harmony between one’s voice and movements with one’s speech or verbalized thoughts

• Labile Affect – Abnormal fluctuation or variability of one’s expressions, such as repeated, rapid, or abrupt shifts

Behavior, Attitude and Coping Patterns• Do they exhibit strange, threatening, suicidal,

violent behavior. Aggressive behavior may be displayed verbally or physically against self, objects or other people.

• Is there any evidence of any unusual mannerisms or motor activity, such as grimacing, tremors, tics, impaired gait, psychomotor retardation or agitation?

• Do they appear friendly, embarassed, evasive, fearful, resentful, angry, negativistic or impulsive?

• Is behavior overactive or underactive? Is it purposeful, disorganized, or stereotyped? Are reactions fairly consistent?

Impaired Communication

• Blocking • Refers to a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason • Blocking is most often found in clients with schizophrenia experiencing auditory hallucinations


• Circumstantiality • the person gives much unnecessary detail that delays meeting a goal or stating a point. • This impairment is commonly found in clients with mania and those with some cognitive impairment disorders, such as the early stage of dementia or mild delirium. • Individuals who use substances may also exhibit this pattern of speech


• Flight of Ideas• Is characterized by over-productivity of talk and verbal skipping from one idea to another. Although talk is continuous, the ideas are fragmentary. Connections between segments of speech often are determined by chance associations.• It is most commonly observed in clients with mania


• Perseveration• The person emits the same verbal response.

Perseveration is also defined as repetitive motor responses to various stimuli.

• This impairment is found in clients experiencing some cognitive impairment disorders and clients experiencing catatonia.


• Verbigeration• Describes the meaningless repetition of

specific words or phrases. • It is observed in clients with certain psychotic

reactions or clients with cognitive impairment disorders.


• Neologism • Describes the use of a new word or

combination of several words coined or self-invented by a person and not readily understood by others • This impairment is found in clients with

certain schizophrenic disorders


• Mutism • Refers to the refusal to speak even though the person may give indications of being aware of the environment •Mutism may occur due to the conscious and unconscious reasons and is observed in patients with catatonic schizophrenic disorders, profound depressive disorders, and stupors of organic and psychogenic origin.

The Nurse-Client Relationship

Communication

- refers to the giving and receiving of information involving three elements: the sender, the message and the receiver - Communication is incomplete when feedback, or a reply is absent

Types of Communication

Verbal Communication Primarily referring to spoken verbal

communication, typically relies on both words, visual aids and non-verbal elements to support the conveyance of meaning

Includes discussion , speeches, presentations, interpersonal communication and many other varieties

Types of Communication

Non-Verbal Communication Is said to reflect a more accurate description

of one’s true feelings Peoples have less control over non-verbal

reactions

Non-Verbal Communication

Vocal Cues Gestures Physical Appearance Distance or Spatial Territory Position or posture Touch Facial Expression

Barriers to Effective Verbal Communication

Lacking Clarity Using Stereotypes and Generalizations Jumping to Conclusions Dysfunctional Responses Lack of Confidence Physical Barriers Physiological Barriers

Four Zones of Spatial Territory

Intimate Zone Body Contact such as touching, hugging, wrestling

Personal Zone 1 ½ to 4 feet; some body contact such as holding

hands; therapeutic communication occurs in this zone

Social Zone 1 to 12 feet; formal business; social discourse

Public Zone 12 to 25 feet; no physical contact; minimal eye

contact; people remain strangers

The Therapeutic Nurse-Client Relationship

Is a planned and goal-directed communication process between a nurse an a client.

The sole purpose is providing care to the client and the client’s family and significant others.

Conditions for a Therapeutic Relationship

Empathy Empathy is the nurse’s ability to zero in on the

feelings of another person Is different from sympathy


Respect The nurse considers the client to be deserving

of high regard


Genuineness The nurse is sincere, honest, and authentic

when interacting with the client


Self-Disclosure The nurse shares the appropriate attitudes,

feelings, and beliefs as a role model to the client


Concreteness and Specificity The nurse identifies the client’s feelings by

skillful listening and maintains a realistic, not theoretical, response to clinical symptoms


Confrontation The nurse uses an accepting, gentle manner

after having established a good rapport with the client


Immediacy of relationship The nurse shares spontaneous feelings when

he or she believes the client benefit from such a discussion


Client self-exploration The nurse encourages the client to learn

positive adaptive coping skills

Phases of a Therapeutic Relationship

Pre-Orientation Phase Phase of the relationship with no client

contact The nurse utilizes this time to engage in

reading the health history of the client Used as time to plan a means of action


Orientation Phase The nurse sets the stage for a one-to-one

relationship by becoming acquainted with the client

The nurse also begins the assessment process Establishing rapport and the feeling of

acceptance is most important in this phase


Orientation Phase Establish a therapeutic environment, include

privacy Establish a mode of communication

acceptable with both client and nurse Initiate a therapeutic contract by establishing

a time, place, and duration for each meeting, as well as the length of time the relationship will be in effect

Assess the client’s strengths and weakness


Working Phase The client begins to relax, trust the nurse, and

is able to discuss mutually agreed on goals with the nurse and is able to discuss mutually agreed-on goals

The nurse continues the process of assessment as a plan of care develops

Alternate behaviors and techniques are explored tok replace those that are maladaptive


Working Phase Explore client’s perception of reality Identify available support systems Encourage verbalization of feelings Implement a plan of action Evaluate the results of the plan of action Promote client independence


Termination Phase The nurse terminates the relationship when

mutually agreed on goals are reached, the client is transferred or discharged, or the nurse has finished the clinical rotation

The clients commonly exhibit regressive behavior, demonstrate hostility or experience sadness

The client may attempt to prolong the relationship


Termination Phase At this stage the client should be able to:

Provide self-care and maintain his or her environment

Demonstrate independence and work interdependently with other

Recognize signs of increased anxiety Cope positively when experiencing feelings of

anxiety, anger or hostility Demonstrate emotional stability

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Maladaptive Patterns of Behavior