Essentials of Psychiatric Mental Health Nursing (4th Edition) PDF

Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Copyright © 2008 by F. A. Davis. Townsend(F)-FM 7/3/07 12:29 PM Page 2 Copyright © Copyright © 2008 2008 by by F. F.A. A. Davis. Davis. C O N T E N T S I N B R I E F UNIT ONE Chapter 15 Schizophrenia and Other Psychotic Disorders 304 Introduction to Psychiatric/ Mental Health Concepts Chapter 16 Mood Disorders 332 Chapter 1 Mental Health and Mental Illness 3 Chapter 17 Anxiety Disorders 379 Chapter 2 Concepts of Personality Chapter 18 Anxiety-Related Disorders 413 Development 15 Chapter 19 Disorders of Human Sexuality 448 Chapter 3 Biological Implications 31 Chapter 20 Eating Disorders 476 Chapter 4 Ethical and Legal Issues 50 Chapter 21 Personality Disorders 495 Chapter 5 Cultural and Spiritual Concepts Relevant to Psychiatric/Mental Health UNIT FOUR Nursing 66 Psychiatric/Mental Health Nursing of Special Populations UNIT TWO Chapter 22 Children and Adolescents 525 Psychiatric/Mental Health Nursing Interventions Chapter 23 Victims of Abuse or Neglect 561 Chapter 6 Relationship Development and Chapter 24 The Aging Individual 581 Therapeutic Communication 95 Chapter 25 Community Mental Health Nursing Chapter 7 The Nursing Process in 611 Psychiatric/Mental Health Nursing 115 Chapter 26 The Bereaved Individual 642 Chapter 8 Milieu Therapy—The Therapeutic Community 140 APPENDICES Chapter 9 Intervention in Groups 149 Appendix A. DSM-IV-TR Classification: Axes I and II Chapter 10 Intervening in Crises 162 Categories and Codes 663 Chapter 11 Psychopharmacology 182 Appendix B. NANDA Nursing Diagnoses: Taxonomy II Domains, Classes, and Chapter 12 Complementary and Psychosocial Diagnoses 670 Therapies 212 Appendix C. Assigning Nursing Diagnoses to Client Behaviors 674 UNIT THREE Appendix D. Mental Status Assessment 676 Care of Clients with Psychiatric Disorders Appendix E. Glossary 678 Chapter 13 Delirium, Dementia, and Amnestic Appendix F. Answers to Review Questions 699 Disorders 237 Index 703 Chapter 14 Substance-Related Disorders 262 Townsend(F)-FM 7/3/07 7:52 PM Page v Copyright © 2008 by F. A. Davis. FOURTH EDITION Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence-Based Practice MARY C. TOWNSEND, DSN, APRN, BC Clinical Specialist/Nurse Consultant Adult Psychiatric Mental Health Nursing Former Assistant Professor and Coordinator, Mental Health Nursing Kramer School of Nursing Oklahoma City University Oklahoma City, Oklahoma Townsend(F)-FM 7/3/07 12:30 PM Page vi Copyright © 2008 by F. A. Davis. F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2008 by F. A. Davis Company Copyright © 1999, 2002, 2005 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or trans- mitted in any form or by any means, electronic, mechanical, photocopying, recording, or oth- erwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Robert G. Martone Developmental Editor: William F. Welsh Senior Project Editor: Danielle J. Barsky Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recom- mended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no war- ranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is ad- vised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Townsend, Mary C., 1941- Essentials of psychiatric mental health nursing / Mary C. Townsend. — 4th ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1611-0 ISBN-10: 0-8036-1611-2 1. Psychiatric nursing. I. Title. [DNLM: 1. Psychiatric Nursing—methods. 2. Mental Disorders—nursing. WY 160 T749e 2008] RC440.T689 2008 616.89′0231—dc22 2007024871 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1611-0/07 6 $.10. Townsend(F)-FM 7/3/07 12:30 PM Page vii Copyright © 2008 by F. A. Davis. D E D I C A T I O N To my best friend, Jimmy Townsend(F)-FM 7/3/07 12:30 PM Page viii Copyright © 2008 by F. A. Davis. This page has been left intentionally blank. Townsend(F)-FM 7/3/07 12:30 PM Page ix Copyright © 2008 by F. A. Davis. A C K N O W L E D G M E N T S My special thanks to: Robert G. Martone, Publisher, Nursing, F. A. Davis Company, for your sense of humor and continuous opti- mistic outlook about the outcome of this project. William F. Welsh, Developmental Editor, Nursing, F. A. Davis Company, for all your help and support in preparing the manuscript for publication. Jane K. Brody, Associate Professor, Nursing Department, Nassau Community College; Golden M. Tradewell, Chair, Department of Nursing, Southern Arkansas University; and Cherie R. Rebar, Assistant Professor, Kettering College of Medical Arts, for your assistance in preparing test questions to accompany this textbook. Berta Steiner, Director of Production, Bermedica Production Ltd., for your support and competence in the final editing and production of the manuscript. The nursing educators, students, and clinicians, who provide critical information about the usability of the text- book, and offer suggestions for improvements. Many changes have been made based on your input. Those individuals who critiqued the manuscript for this edition and shared your ideas, opinions, and sugges- tions for enhancement. I sincerely appreciate your contributions to the final product. MARY C. TOWNSEND ix Townsend(F)-FM 7/3/07 12:30 PM Page x Copyright © 2008 by F. A. Davis. This page has been left intentionally blank. Townsend(F)-FM 7/3/07 12:30 PM Page xi Copyright © 2008 by F. A. Davis. T O T H E I N S T R U C T O R here is a saying that captures the spirit of our its final report to the President. The Commission iden- T times—the only constant is change. The twenty- first century continues to bring about a great deal of tified the following barriers: fragmentation and gaps in mental health care for children, adults with serious change in the health care system in general and to nurs- mental illness, and the elderly; and high unemployment ing in particular. The body of knowledge in nursing and disability for people with serious mental illness. continues to grow and expand as rapidly as nursing un- The report also pointed out that the fact that the U.S. dergoes change. Nurses must draw upon this research has failed to identify mental health and suicide preven- base to support the care that they provide for their tion as national priorities has put many lives as stake. clients. This fourth edition of Essentials of Psychiatric The Commission outlined the following goals and rec- Mental Health Nursing strives to present a holistic ap- ommendations for mental health reform: proach to psychiatric nursing practice based on sound To address mental health with the same urgency as research principles. physical health Research in nursing has been alive for decades. But To align relevant Federal programs to improve ac- over the years there has always existed a significant gap cess and accountability for mental health services between research and practice. Evidence-based nurs- To ensure appropriate care is available for every ing has become a common theme within the nursing child with a serious emotional disturbance and every community. It has been defined as a process by which adult with a serious mental illness nurses make clinical decisions using the best available To protect and enhance the rights of people with research evidence, their clinical expertise, and client mental illness preferences. Nurses are accountable to their clients to To improve access to quality care that is culturally provide the highest quality of care based on knowledge competent of what is considered best practice. Change occurs so To improve access to quality care in rural and geo- rapidly that what is considered best practice today may graphically remote areas not be considered so tomorrow, based on newly ac- To promote mental health screening, assessment, quired scientific data. and referral services Included in this fourth edition are a number of new To accelerate research to promote recovery and re- research studies that support psychiatric nursing inter- silience, and ultimately to cure and prevent mental ventions. As nurses, we are bombarded with new in- illness formation and technological content on a daily basis. To advance evidence-based practices using dissemi- Not all of this information yields knowledge that can be nation and demonstration projects, and create a used in clinical practice. There is still a long way to go public-private partnership to guide their implemen- toward evidence-based practice in psychiatric nursing, tation and research utilization is the foundation from which to To improve and expand the workforce providing advance the progression. evidence-based mental health services and supports Well into the first decade of the new century, there To promote the use of technology to access mental are many new challenges to be faced. In 2002, Presi- health care and information dent George W. Bush established the New Freedom Commission on Mental Health. This commission was If these proposals become reality, it would surely charged with the task of conducting a comprehensive mean improvement in the promotion of mental health study of the United States mental health service deliv- and the care of mentally ill individuals. Many nurse ery system. They were to identify unmet needs and bar- leaders see this period of health care reform as an op- riers to services and recommend steps for improvement portunity for nurses to expand their roles and assume in services and support for individuals with serious key positions in education, prevention, assessment, and mental illness. In July 2003, the commission presented referral. Nurses are, and will continue to be, in key xi Townsend(F)-FM 7/3/07 12:30 PM Page xii Copyright © 2008 by F. A. Davis. xii TO THE INSTRUCTOR positions to assist individuals with mental illness to re- lems and interventions. Compared to the commonly main as independent as possible, to manage their ill- used column format care plans, concept map care plans ness within the community setting, and to strive to are more succinct. They are practical, realistic, and minimize the number of hospitalizations required. time saving, and they serve to enhance critical-thinking In 2020, the ten leading causes of mortality through- skills and clinical reasoning ability. Fifteen (15) care out the world are projected to include heart disease; map care plans have been included with major diag- cerebrovascular disease; pulmonary disease; lower res- nostic categories in this textbook. piratory infections; tracheal, bronchial and lung can- New boxes that define core concepts (all chapters). cers; traffic accidents; tuberculosis; stomach cancer; Core concepts have been identified at the beginning of HIV/AIDS; and suicide. Behavior is an important ele- each chapter. Boxes with the definitions of these core ment in prevention of these causes of mortality and in concepts appear at the appropriate point within the their treatment. In 2020, the three leading causes of text. disability throughout the world are projected to include NANDA Taxonomy II (2007) from the NANDA heart disease, major depression, and traffic accidents. Nursing Diagnoses: Definitions & Classification 2007- Behavior is once again an important underpinning of 2008 (NANDA International). Used throughout the these three contributors of disability, and behavioral text. and social science research can lower the impact of New and updated psychotropic medication infor- these causes of morbidity and mortality. Many of these mation (Chapter 11 and in relevant clinical chapters). issues are addressed in this new edition. New research studies with implications for evidence based practice. (In all relevant clinical chapters). CONTENT AND FEATURES NEW FEATURES THAT HAVE BEEN TO THIS EDITION RETAINED IN THE 4TH EDITION All content has been updated to reflect current state The concept of holistic nursing is retained in the of the discipline of nursing. fourth edition. An attempt has been made to ensure New chapter on Cultural and Spiritual Concepts that the physical aspects of psychiatric/mental health relevant to Psychiatric/Mental Health Nursing. nursing are not overlooked. Both physical and psy- (Chapter 5) chosocial nursing diagnoses are included for physio- New content related to Neurobiological processes. logical disorders (such as asthma, migraine headache, (Chapters 13, 15, 16, 17, and 23). The neurobiology of and HIV disease) and for psychological disorders (such dementia, schizophrenia, depression, anxiety disorders, as somatoform and eating disorders). In all relevant sit- and violence is presented in the chapters that deal with uations, the mind/body connection is addressed. these disorders. Illustrations of the neurotransmitter Nursing process is retained in the fourth edition as pathways and discussion of areas of the brain affected the tool for delivery of care to the individual with a psy- and the medications that target those areas are pre- chiatric disorder or to assist in the primary prevention sented. or exacerbation of mental illness symptoms. The six New medication tables (in addition to the chapter steps of the nursing process, as described in the Amer- on Psychopharmacology). (Chapters 13, 15, and 16). ican Nurses Association Standards of Clinical Nursing New medication tables have been added to provide Practice are used to provide guidelines for the nurse. convenient, easy access to information related to med- These standards of care are included for the DSM-IV- ications that are relevant to specific psychiatric disor- TR diagnoses, as well as the aging individual, the be- ders (dementia, schizophrenia, depression, mania). reaved individual, victims of abuse and neglect, and as New content on Concept Mapping. Concept map- examples in several of the therapeutic approaches. The ping is discussed in Chapter 7. Concept mapping is a six steps include: diagrammatic teaching and learning strategy that al- lows students and faculty to visualize interrelationships Assessment: Background assessment data, including between medical diagnoses, nursing diagnoses, assess- a description of symptomatology, provides an exten- ment data, and treatments. The concept map care plan sive knowledge base from which the nurse may draw is an innovative approach to planning and organizing when performing an assessment. Several assessment nursing care. Basically, it is a diagram of client prob- tools are also included. Townsend(F)-FM 7/3/07 12:30 PM Page xiii Copyright © 2008 by F. A. Davis. TO THE INSTRUCTOR xiii Diagnosis: Analysis of the data is included, from Assigning nursing diagnoses to client behaviors. which nursing diagnoses common to specific psy- (Appendix C). chiatric disorders are derived. Taxonomy and diagnostic criteria from the DSM-IV- Outcome Identification: Outcomes are derived from TR (2000). Used throughout the text. the nursing diagnoses and stated as measurable A Student CD that contains practice test questions, goals. learning activities, concept map care plans, and client Planning: A plan of care is presented with selected teaching guides. nursing diagnoses for all DSM-IV-TR diagnoses, as well as for the elderly client, the bereaved individ- ual, victims of abuse and neglect, the elderly home- ADDITIONAL EDUCATIONAL bound client, and the primary caregiver of the client RESOURCES with a severe and persistent mental illness. The plan- ning standard also includes tables that list topics for Faculty may also find the following teaching aids that educating clients and families about mental illness. accompany this textbook helpful: New to this edition: Concept map care plans for Instructor’s Resource Disk (IRD). This IRD con- all major psychiatric diagnoses. tains: Implementation: The interventions that have been identified in the plan of care are included along with Approximately 500 multiple choice questions (in- rationale for each. Case studies at the end of each cluding new format questions reflecting the latest DSM-IV-TR chapter assist the student in the practi- NCLEX blueprint) cal application of theoretical material. Also included Lecture outlines for all chapters as a part of this particular standard is Unit Two of Learning activities for all chapters (including an- the textbook: Psychiatric/Mental Health Nursing swer key) Interventions. This section of the textbook ad- Answers to the Critical Thinking Exercises from dresses psychiatric nursing intervention in depth, the textbook and frequently speaks to the differentiation in scope PowerPoint Presentation to accompany all chap- of practice between the basic level psychiatric nurse ters in the textbook and the advanced practice level psychiatric nurse. It is my hope that the revisions and additions to this Advanced practice nurses with prescriptive authority fourth edition continue to satisfy a need within psychi- will find the extensive chapter on psychopharmacol- atric/mental health nursing practice. The mission of ogy particularly helpful. this textbook has been, and continues to be, to provide Evaluation: The evaluation standard includes a set both students and clinicians with up-to-date informa- of questions that the nurse may use to assess whether tion about psychiatric/mental health nursing. Many of the nursing actions have been successful in achieving the changes reflect feedback that I have received from the objectives of care. users of the previous editions. To those individuals I ex- Internet references with web site listings for infor- press a heartfelt thanks. I welcome comments in an ef- mation related to DSM-IV-TR diagnoses and other fort to retain what some have called the “user mental health topics. friendliness” of the text. I hope that this fourth edition Tables that list topics for client education. (Clinical continues to promote and advance the commitment to chapters). psychiatric/mental health nursing. Boxes that include current research studies with im- plications for evidence based nursing practice. (Clini- MARY C. TOWNSEND cal chapters). Townsend(F)-FM 7/3/07 12:30 PM Page xiv Copyright © 2008 by F. A. Davis. This page has been left intentionally blank. Townsend(F)-FM 7/24/07 3:13 PM Page xv Copyright © 2008 by F. A. Davis. C O N T E N T S Unit One Phase III: Separation-Individuation I NTRODUCTION TO P SYCHIATRIC / (5 to 36 Months) 24 Relevance of Object Relations Theory to Nursing M ENTAL H EALTH C ONCEPTS Practice 25 Chapter 1 A Nursing Model—Hildegard E. Peplau 25 Mental Health and Mental Illness 3 Peplau’s Stages of Personality Development 26 Introduction 4 Learning to Count on Others 26 Learning to Delay Satisfaction 26 Mental Health 4 Identifying Oneself 27 Mental Illness 5 Developing Skills in Participation 27 Relevance of Peplau’s Model to Nursing Physical and Psychological Responses to Stress 5 Practice 28 Physical Responses 5 Psychological Responses 6 Summary 28 The DSM-IV-TR Multiaxial Evaluation System 11 Chapter 3 Summary 12 Biological Implications 31 Chapter 2 Introduction 32 Concepts of Personality Development 15 Neurophysiological Influences 32 Introduction 16 The Nervous System 32 The Neuroendocrine System 39 Psychoanalytic Theory 16 Structure of the Personality 16 Implications for Psychiatric Illness 43 Topography of the Mind 17 Schizophrenia 43 Dynamics of the Personality 17 Mood Disorders 43 Freud’s Stages of Personality Development 18 Anxiety Disorders 44 Relevance of Psychoanalytic Theory to Nursing Anorexia Nervosa 44 Practice 19 Alzheimer’s Disease 45 Interpersonal Theory 19 Diagnostic Procedures Used to Detect Altered Sullivan’s Stages of Personality Development 20 Brain Function 45 Relevance of Interpersonal Theory to Nursing Electroencephalography 45 Practice 20 Computerized EEG Mapping 46 Computed Tomographic Scan 46 Theory of Psychosocial Development 21 Magnetic Resonance Imaging 46 Erikson’s Stages of Personality Development 21 Positron Emission Tomography 46 Relevance of Psychosocial Development Theory to Single Photon Emission Computed Nursing Practice 23 Tomography 46 Theory of Object Relations 23 Implications for Nursing 46 Phase I: The Autistic Phase (Birth to 1 Month) 23 Phase II: The Symbiotic Phase (1 to 5 Months) 24 Summary 47 xv Townsend(F)-FM 7/3/07 12:30 PM Page xvi Copyright © 2008 by F. A. Davis. xvi CONTENTS Chapter 4 Unit Two Ethical and Legal Issues 50 P SYCHIATRIC /M ENTAL H EALTH N URSING I NTERVENTIONS Introduction 51 Ethical Considerations 51 Chapter 6 Theoretical Perspectives 51 Relationship Development Ethical Egoism 52 and Therapeutic Communication 95 Ethical Dilemmas 52 Introduction 96 Ethical Principles 53 A Model for Making Ethical Decisions 54 The Therapeutic Nurse-Client Relationship 96 Ethical Issues in Psychiatric/Mental Therapeutic Use of Self 97 Health Nursing 54 Conditions Essential to Development of a Legal Considerations 55 Therapeutic Relationship 97 Nurse Practice Acts 56 Rapport 97 Types of Law 56 Trust 97 Classifications Within Statutory Respect 98 and Common Law 56 Genuineness 98 Legal Issues in Psychiatric/Mental Empathy 98 Health Nursing 57 Phases of a Therapeutic Nurse-Client Summary 62 Relationship 99 The Preinteraction Phase 99 Chapter 5 The Orientation (Introductory) Phase 100 Cultural and Spiritual Concepts The Working Phase 100 Relevant to Psychiatric/Mental The Termination Phase 101 Health Nursing 66 Boundaries in the Nurse-Client Relationship 101 Cultural Concepts 67 Interpersonal Communication 102 How do Cultures Differ? 68 The Impact of Pre-existing Conditions 102 Communication 68 Nonverbal Communication 104 Space 68 Therapeutic Communication Techniques 106 Social Organization 68 Nontherapeutic Communication Techniques 106 Time 69 Process Recordings 106 Environmental Control 69 Active Listening 106 Biological Variations 69 Feedback 108 Application of the Nursing Process 69 Summary 112 Background Assessment Data 69 Culture-Bound Syndromes 76 Chapter 7 Diagnosis Outcome Identification 79 The Nursing Process in Psychiatric/ Planning/Implementation 79 Mental Health Nursing 115 Evaluation 81 Introduction 116 Spiritual Concepts 81 The Nursing Process 116 Spiritual Needs 82 Definition 116 Religion 84 Standards of Care 116 Assessment of Spiritual and Religious Standard I. Assessment 116 Needs 84 Standard II. Diagnosis 117 Diagnoses/Outcome Identification/ Standard III. Outcome Identification 117 Evaluation 86 Standard IV. Planning 117 Planning/Implementation 86 Standard V. Implementation 126 Summary 86 Standard VI. Evaluation 127 Townsend(F)-FM 7/3/07 12:30 PM Page xvii Copyright © 2008 by F. A. Davis. CONTENTS xvii Why Nursing Diagnosis? 127 Phases of Group Development 153 Phase I. Initial or Orientation Phase 153 Nursing Case Management 129 Phase II. Middle or Working Phase 153 Critical Pathways of Care 129 Phase III. Final or Termination Phase 153 Applying the Nursing Process in the Leadership Styles 154 Psychiatric Setting 131 Autocratic 154 Concept Mapping 132 Democratic 154 Laissez-Faire 154 Documentation of the Nursing Process 134 Problem-Oriented Recording 134 Member Roles 154 Focus Charting 134 Psychodrama 155 The PIE Method 135 Electronic Documentation 136 The Family as a Group 156 Summary 137 The Role of the Nurse in Group Interventions 157 Chapter 8 Summary 157 Milieu Therapy—The Therapeutic Community 140 Chapter 10 Introduction 141 Intervening in Crises 162 Milieu, Defined 141 Introduction 163 Current Status of the Therapeutic Characteristics of a Crisis 163 Community 141 Basic Assumptions 141 Phases in the Development of a Crisis 163 Conditions that Promote a Therapeutic Types of Crises 164 Community 142 Class 1: Dispositional Crises 164 Class 2: Crises of Anticipated Life Transitions 165 The Program of the Therapeutic Class 3: Crises Resulting from Traumatic Community 143 Stress 165 The Role of the Nurse 143 Class 4: Maturational/Developmental Crises 165 Class 5: Crises Reflecting Psychopathology 166 Summary 146 Class 6: Psychiatric Emergencies 166 Chapter 9 Crisis Intervention 166 Intervention in Groups 149 Phases of Crisis Intervention: The Role of the Introduction 150 Nurse 167 Phase 1. Assessment 167 Functions of a Group 150 Phase 2. Planning of Therapeutic Intervention 168 Types of Groups 150 Phase 3. Intervention 168 Task Groups 150 Phase 4. Evaluation of Crisis Resolution and Teaching Groups 150 Anticipatory Planning 168 Supportive/Therapeutic Groups 151 Crisis on the Inpatient Unit: Anger/Aggression Self-Help Groups 151 Management 169 Physical Conditions that Influence Assessment 169 Group Dynamics 151 Diagnosis/Outcome Identification 170 Seating 151 Outcome Criteria 170 Size 151 Planning/Implementation 170 Membership 152 Evaluation 170 Curative Factors 152 Disaster Nursing 170 Townsend(F)-FM 7/3/07 12:30 PM Page xviii Copyright © 2008 by F. A. Davis. xviii CONTENTS Application of the Nursing Process Unit Three to Disaster Nursing 173 C ARE OF C LIENTS WITH P SYCHIATRIC Background Assessment Data 173 D ISORDERS Nursing Diagnoses/Outcome Identification 173 Chapter 13 Planning/Implementation 174 Delirium, Dementia, and Amnestic Evaluation 174 Disorders 237 Summary 174 Introduction 238 Chapter 11 Delirium 238 Etiological Implications 239 Psychopharmacology 182 Dementia 239 Introduction 183 Etiological Implications 241 Historical Perspectives 183 Amnestic Disorders 245 How do Psychotropics Work? 183 Etiological Implications 246 Applying the Nursing Process in Application of the Nursing Process 247 Psychopharmacological Therapy 186 Assessment 247 Antianxiety Agents 186 The Client History 247 Antidepressants 189 Physical Assessment 247 Mood-Stabilizing Agents 195 Diagnostic Laboratory Evaluations 247 Antipsychotic Agents 200 Diagnosis/Outcome Identification 251 Sedative-Hypnotics 205 Planning/Implementation 251 Agents for Attention-Deficit/Hyperactivity Client/Family Education 253 Disorder (ADHD) 206 Evaluation 253 Summary 208 Medical Treatment Modalities 253 Delirium 253 Chapter 12 Dementia 253 Complementary and Psychosocial Cognitive Impairment 254 Therapies 212 Agitation, Aggression, Hallucinations, Thought Disturbances, and Wandering 255 Complementary Therapies 213 Depression 255 Introduction 213 Anxiety 256 Sleep Disturbances 256 Commonalities and Contrasts 214 Summary 256 Types of Complementary Therapies 215 Herbal Medicine 215 Chapter 14 Acupressure and Acupuncture 216 Substance-Related Disorders 262 Diet and Nutrition 216 Chiropractic Medicine 224 Introduction 263 Therapeutic Touch 224 Substance-Use Disorders 263 Massage 225 Substance Abuse 263 Yoga 225 Substance Dependence 264 Pet Therapy 225 Substance-Induced Disorders 264 Psychosocial Therapies 226 Substance Intoxication 264 Individual Psychotherapies 226 Substance Withdrawal 265 Relaxation Therapy 228 Assertiveness Training 229 Classes of Psychoactive Substances 265 Cognitive Therapy 230 Etiological Implications 265 Summary 231 Biological Factors 265 Townsend(F)-FM 7/3/07 12:30 PM Page xix Copyright © 2008 by F. A. Davis. CONTENTS xix Psychological Factors 266 Undifferentiated Schizophrenia 311 Sociocultural Factors 266 Residual Schizophrenia 311 Schizoaffective Disorder 311 The Dynamics of Substance-Related Brief Psychotic Disorder 311 Disorders 267 Schizophreniform Disorder 312 Alcohol Abuse and Dependence 267 Delusional Disorder 312 Sedative, Hypnotic, or Anxiolytic Abuse Shared Psychotic Disorder 312 and Dependence 271 Psychotic Disorder Due to a General Medical CNS Stimulant Abuse and Dependence 274 Condition 313 Inhalant Abuse and Dependence 277 Substance-Induced Psychotic Disorder 313 Opioid Abuse and Dependence 278 Opioid Intoxication 280 Application of the Nursing Process 313 Hallucinogen Abuse and Dependence 281 Background Assessment Data 313 Cannabis Abuse and Dependence 283 Positive and Negative Symptoms 316 Diagnosis/Outcome Identification 316 Application of the Nursing Process 285 Planning/Implementation 317 Assessment 285 Client/Family Education 321 Dual Diagnosis 288 Evaluation 321 Diagnosis/Outcome Identification 289 Planning/Implementation 292 Treatment Modalities for Schizophrenia Evaluation 294 and Other Psychotic Disorders 321 Psychological Treatments 321 Treatment Modalities for Substance-Related Social Treatment 324 Disorders 294 Organic Treatment 325 Alcoholics Anonymous 294 Pharmacotherapy 296 Summary 327 Counseling 297 Group Therapy 297 Chapter 16 Psychopharmacology for Substance Mood Disorders 332 Intoxication and Substance Withdrawal 298 Introduction 333 Summary 299 Historical Perspective 333 Chapter 15 Epidemiology 334 Gender 334 Schizophrenia and Other Psychotic Age 334 Disorders 304 Social Class 334 Introduction 305 Race and Culture 334 Marital Status 335 Nature of the Disorder 305 Seasonality 335 Prognosis 307 Types of Mood Disorders 335 Etiological Implications 307 Depressive Disorders 335 Biological Influences 307 Bipolar Disorders 336 Genetics 307 Other Mood Disorders 338 Physiological Influences 309 Psychological Influences 309 Depressive Disorders 339 Environmental Influences 310 Etiological Implications 339 Theoretical Integration 310 Developmental Implications 342 Types of Schizophrenia and Other Psychotic Application of the Nursing Process to Depressive Disorders 310 Disorders 345 Disorganized Schizophrenia 310 Background Assessment Data 345 Catatonic Schizophrenia 310 Diagnosis/Outcome Identification 347 Paranoid Schizophrenia 311 Planning/Implementation 348 Townsend(F)-FM 7/3/07 12:30 PM Page xx Copyright © 2008 by F. A. Davis. xx CONTENTS Client/Family Education 352 Behavior Therapy 406 Evaluation of Care for the Depressed Client 352 Group/Family Therapy 407 Psychopharmacology 407 Bipolar Disorder (Mania) 352 Etiological Implications 352 Summary 409 Developmental Implications 353 Chapter 18 Application of the Nursing Process to Bipolar Disorder (Mania) 355 Anxiety-Related Disorders 413 Background Assessment Data 355 Introduction 414 Diagnosis/Outcome Identification 356 Planning/Implementation 357 Historical Aspects 414 Client/Family Education 358 Epidemiological Statistics 415 Evaluation of Care for the Manic Client 358 Application of the Nursing Process 416 Background Assessment Data—Types of Treatment Modalities for Mood Psychophysiological Disorders 416 Disorders 360 Diagnosis/Outcome Identification 422 Psychological Treatments 360 Planning/Implementation 423 Organic Treatments 362 Client Family Education 423 Suicide 366 Evaluation 423 Epidemiological Factors 366 Background Assessment Data—Types of Somatoform Disorders 426 Application of the Nursing Process with Diagnosis/Outcome Identification 428 the Suicidal Client 366 Planning/Implementation 429 Assessment 366 Evaluation 434 Diagnosis/Outcome Identification 369 Treatment Modalities for Somatoform Planning/Implementation 369 Disorders 434 Evaluation 372 Background Assessment Data—Types of Dissociative Summary 372 Disorders 434 Diagnosis/Outcome Identification 437 Chapter 17 Planning/Implementation 438 Anxiety Disorders 379 Evaluation 438 Treatment Modalities for Dissociative Introduction 380 Disorders 438 Historical Aspects 380 Summary 443 Epidemiological Statistics 380 Chapter 19 How Much is Too Much? 381 Disorders of Human Sexuality 448 Application of the Nursing Process 381 Introduction 449 Panic Disorder 381 Panic Disorder with Agoraphobia 382 Development of Human Sexuality 449 Generalized Anxiety Disorder 382 Birth Through Age 12 449 Phobias 387 Adolescence 450 Obsessive-Compulsive Disorder 391 Adulthood 450 Posttraumatic Stress Disorder 398 The “Middle” Years—40 to 65 451 Anxiety Disorder Due to a General Medical Sexual Disorders 451 Condition 404 Paraphilias 451 Substance-Induced Anxiety Disorder 404 Sexual Dysfunctions 455 Treatment Modalities 404 Application of the Nursing Process to Sexual Individual Psychotherapy 404 Disorders 459 Cognitive Therapy 405 Treatment Modalities for Sexual Dysfunctions 462 Townsend(F)-FM 7/3/07 12:30 PM Page xxi Copyright © 2008 by F. A. Davis. CONTENTS xxi Variations in Sexual Orientation 467 Application of the Nursing Process 504 Homosexuality 467 Borderline Personality Disorder 504 Transsexualism 469 Antisocial Personality Disorder 509 Bisexuality 469 Treatment Modalities 513 Sexually Transmitted Diseases 470 Interpersonal Psychotherapy 513 Summary 470 Psychoanalytical Psychotherapy 516 Milieu or Group Therapy 516 Chapter 20 Cognitive/Behavioral Therapy 516 Eating Disorders 476 Psychopharmacology 516 Introduction 477 Summary 518 Epidemiological Factors 477 Unit Four Application of the Nursing Process 478 Background Assessment Data P SYCHIATRIC /M ENTAL H EALTH (Anorexia Nervosa) 478 N URSING OF S PECIAL P OPULATIONS Background Assessment Data (Bulimia Nervosa) 478 Chapter 22 Etiological Implications for Anorexia Children and Adolescents 525 Nervosa and Bulimia Nervosa 479 Background Assessment Data (Obesity) 480 Introduction 526 Etiological Implications for Obesity 481 Mental Retardation 526 Diagnosis/Outcome Identification 482 Etiological Implications 526 Planning/Implementation 482 Application of the Nursing Process to Mental Client/Family Education 482 Retardation 527 Evaluation 482 Diagnosis/Outcome Identification 528 Treatment Modalities 488 Planning/Implementation 528 Behavior Modification 488 Evaluation 528 Individual Therapy 488 Autistic Disorder 530 Family Therapy 489 Etiological Implications 530 Psychopharmacology 489 Application of the Nursing Process to Autistic Summary 490 Disorder 530 Chapter 21 Attention-Deficit/Hyperactivity Disorder 531 Etiological Implications 533 Personality Disorders 495 Application of the Nursing Process Introduction 496 to ADHD 534 Historical Aspects 496 Conduct Disorder 540 Types of Personality Disorders 497 Etiological Implications 540 Paranoid Personality Disorder 497 Application of the Nursing Process to Conduct Schizoid Personality Disorder 498 Disorder 541 Schizotypal Personality Disorder 499 Oppositional Defiant Disorder 542 Antisocial Personality Disorder 499 Etiological Implications 542 Borderline Personality Disorder 500 Application of the Nursing Process to Oppositional Histrionic Personality Disorder 500 Defiant Disorder 544 Narcissistic Personality Disorder 501 Avoidant Personality Disorder 501 Tourette’s Disorder 545 Dependent Personality Disorder 502 Etiological Implications 547 Obsessive-Compulsive Personality Disorder 503 Application of the Nursing Process to Tourette’s Passive-Aggressive Personality Disorder 503 Disorder 547 Townsend(F)-FM 7/3/07 12:30 PM Page xxii Copyright © 2008 by F. A. Davis. xxii CONTENTS Separation Anxiety Disorder 550 Sociocultural Aspects of Aging 590 Etiological Implications 550 Sexual Aspects of Aging 591 Application of the Nursing Process to Separation Special Concerns of the Elderly Population 592 Anxiety Disorder 551 Retirement 592 General Therapeutic Approaches 553 Long-Term Care 594 Behavior Therapy 553 Elder Abuse 595 Family Therapy 553 Suicide 597 Group Therapy 553 Application of the Nursing Process 598 Psychopharmacology 555 Assessment 598 Summary 555 Diagnosis/Outcome Identification 599 Planning/Implementation 600 Chapter 23 Evaluation 600 Victims of Abuse or Neglect 561 Summary 605 Introduction 562 Historical Perspectives 562 Chapter 25 Community Mental Health Nursing 611 Etiological Implications 563 Biological Theories 563 Introduction 612 Psychological Theories 563 The Changing Focus of Care 612 Sociocultural Theories 563 The Public Health Model 613 Application of the Nursing Process 565 Background Assessment Data 565 The Community as Client 614 Diagnosis/Outcome Identification 571 Primary Prevention 614 Planning/Implementation 572 Secondary Prevention 620 Evaluation 572 Tertiary Prevention 623 Treatment Modalities 572 The Homeless Population 629 Crisis Intervention 572 Historical and Epidemiological Aspects 629 Summary 576 Community Resources for the Homeless 635 The Homeless Client and the Nursing Chapter 24 Process 636 The Aging Individual 581 Summary 638 Introduction 582 Chapter 26 How Old is Old? 582 The Bereaved Individual 642 Epidemiological Statistics 583 The Population 583 Introduction 643 Marital Status 583 Theoretical Perspectives on Loss Living Arrangements 583 and Bereavement 643 Economic Status 583 Stages of Grief 643 Employment 583 Health Status 584 Length of the Grief Process 646 Theories of Aging 584 Anticipatory Grief 647 Biological Theories 584 Maladaptive Responses to Loss 647 Psychosocial Theories 585 Delayed or Inhibited Grief 647 The Normal Aging Process 586 Distorted (Exaggerated) Grief Response 648 Biological Aspects of Aging 586 Chronic or Prolonged Grieving 648 Psychological Aspects of Aging 588 Normal versus Maladaptive Grieving 648 Townsend(F)-FM 7/24/07 3:13 PM Page xxiii Copyright © 2008 by F. A. Davis. CONTENTS xxiii Application of the Nursing Process 648 Domain 4: Activity/Rest 671 Background Assessment Data: Concepts Domain 5: Perception/Cognition 671 of Death—Developmental Issues 648 Background Assessment Data: Concepts Domain 6: Self-Perception 671 of Death—Cultural Issues 650 Domain 7: Role Relationships 672 Nursing Diagnosis/Outcome Identification 652 Planning/Implementation 652 Domain 8: Sexuality 672 Evaluation 652 Domain 9: Coping/Stress Tolerance 672 Additional Assistance 654 Domain 10: Life Principles 672 Hospice 654 Advance Directives 657 Domain 11: Safety/Protection 673 Summary 657 Domain 12: Comfort 673 Appendix A Domain 13: Growth/Development 673 DSM-IV-TR Classification: Appendix C Axes I and II Categories and Codes 663 Assigning Nursing Diagnoses Disorders Usually First Diagnosed in Infancy, to Client Behaviors 674 Childhood, or Adolescence 663 Delirium, Dementia, and Amnestic and Other Appendix D Cognitive Disorders 664 Mental Status Assessment 676 Mental Disorders Due to a General Medical Identifying Data 676 Condition Not Elsewhere Classified 664 General Description 676 Substance-Related Disorders 664 Emotions 676 Schizophrenia and Other Psychotic Thought Processes 677 Disorders 666 Perceptual Disturbances 677 Mood Disorders 667 Sensorium and Cognitive Ability 677 Somatoform Disorders 667 Impulse Control 677 Factitious Disorders 667 Judgment and Insight 677 Dissociative Disorders 667 Sexual and Gender Identity Disorders 667 Appendix E Eating Disorders 668 Glossary 678 Sleep Disorders 668 Appendix F Other Conditions That May Be a Focus of Clinical Answers to Review Questions 699 Attention 669 Chapter 1. Mental Health and Mental Additional Codes 669 Illness 699 Chapter 2. Concepts of Personality Appendix B Development 699 NANDA Nursing Diagnoses: Taxonomy II Domains, Classes, and Diagnoses 670 Chapter 3. Biological Implications 699 Chapter 4. Ethical and Legal Issues 699 Domain 1: Health Promotion 670 Chapter 5. Cultural and Spiritual Concepts Domain 2: Nutrition 670 Relevant to Psychiatric/Mental Health Domain 3: Elimination and Exchange 670 Nursing 699 Townsend(F)-FM 7/3/07 12:30 PM Page xxiv Copyright © 2008 by F. A. Davis. xxiv CONTENTS Chapter 6. Relationship Development and Chapter 16. Mood Disorders 700 Therapeutic Communication 699 Chapter 17. Anxiety Disorders 700 Chapter 7. The Nursing Process in Chapter 18. Anxiety-Related Disorders 700 Psychiatric/Mental Health Nursing 699 Chapter 19. Disorders of Human Sexuality 700 Chapter 8. Milieu Therapy—The Therapeutic Community 700 Chapter 20. Eating Disorders 700 Chapter 9. Intervention in Groups 700 Chapter 21. Personality Disorders 700 Chapter 10. Intervening in Crises 700 Chapter 22. Children and Adolescents 700 Chapter 11. Psychopharmacology 700 Chapter 23. Victims of Abuse or Neglect 701 Chapter 12. Complementary and Psychosocial Chapter 24. The Aging Individual 701 Therapies 700 Chapter 25. Community Mental Health Chapter 13. Delirium, Dementia, and Amnestic Nursing 701 Disorders 700 Chapter 26. The Bereaved Individual 701 Chapter 14. Substance-Related Disorders 700 Index 703 Chapter 15. Schizophrenia and Other Psychotic Disorders 700 Townsend(F)-01 6/28/07 2:57 PM Page 1 Copyright © 2008 by F. A. Davis. UNIT ONE Introduction to Psychiatric/ Mental Health Concepts Townsend(F)-01 6/28/07 2:57 PM Page 2 Copyright © 2008 by F. A. Davis. This page has been left intentionally blank. Townsend(F)-01 6/28/07 2:57 PM Page 3 Copyright © 2008 by F. A. Davis. 1 C H A P T E R Mental Health and Mental Illness CHAPTER OUTLINE OBJECTIVES THE DSM-IV-TR MULTIAXIAL INTRODUCTION EVALUATION SYSTEM MENTAL HEALTH SUMMARY MENTAL ILLNESS REVIEW QUESTIONS PHYSICAL AND PSYCHOLOGICAL RESPONSES TO STRESS KEY TERMS anticipatory grief ego defense mechanisms neurosis bereavement overload fight-or-flight syndrome psychosis Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM- IV-TR) CORE CONCEPTS anxiety grief OBJECTIVES After reading this chapter, the student will be able to: 1. Define mental health and mental illness. 4. Discuss the concepts of anxiety and grief as psy- 2. Discuss cultural elements that influence atti- chological responses to stress. tudes toward mental health and mental illness. 5. Describe the DSM-IV-TR multiaxial evaluation 3. Identify physiological responses to stress. system for classification of mental disorders. 3 Townsend(F)-01 6/28/07 2:57 PM Page 4 Copyright © 2008 by F. A. Davis. 4 UNIT I INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS INTRODUCTION The concepts of mental health and mental illness are culturally defined. Some cultures are quite liberal in the range of behaviors that are considered acceptable, SELF- ACTUALIZATION whereas others have very little tolerance for behaviors (The individual possesses a that deviate from the cultural norms. A study of the his- feeling of self- fulfillment and tory of psychiatric care reveals some shocking truths the realization of his or her highest potential.) about past treatment of mentally ill individuals. Many were kept in control by means that could be considered SELF-ESTEEM ESTEEM-OF-OTHERS (The individual seeks self-respect less than humane. and respect from others, works to achieve success and recognition in Primitive beliefs regarding mental disturbances took work, and desires prestige from accomplishments.) several views. Some thought that an individual with mental illness had been dispossessed of his or her soul LOVE AND BELONGING (Needs are for giving and receiving of and that the only way wellness could be achieved was if affection, companionship, satisfactory interpersonal relationships, and the soul returned. Others believed that evil spirits or identification with a group.) supernatural or magical powers had entered the body. SAFETY AND SECURITY The “cure” for these individuals involved a ritualistic (Needs at this level are for avoiding harm, maintaining comfort, order, structure, physical safety, freedom from exorcism to purge the body of these unwanted forces fear, and protection.) that often consisted of brutal beatings, starvation, or PHYSIOLOGICAL NEEDS other torturous means. Still others considered that the (Basic fundamental needs include food, water, air, sleep, exercise, elimination, shelter, and sexual expression.) mentally ill individual may have broken a taboo or sinned against another individual or God, for which rit- FIGURE 1–1 Maslow’s hierarchy of needs. ualistic purification was required or various types of retribution were demanded. The correlation of mental evolved, and fully mature.” He believed that healthy, illness to demonology or witchcraft led to some men- or self-actualized, individuals possessed the following tally ill individuals being burned at the stake. characteristics: This chapter defines mental health and mental ill- An appropriate perception of reality ness and describes physical and psychological responses The ability to accept oneself, others, and human to stress. The Diagnostic and Statistical Manual of Men- tal Disorders, 4th Edition, Text Revision (DSM-IV-TR), nature The ability to manifest spontaneity multiaxial evaluation system is also presented. The capacity for focusing concentration on problem- solving A need for detachment and desire for privacy MENTAL HEALTH Independence, autonomy, and a resistance to encul- A number of theorists have attempted to define the turation An intensity of emotional reaction concept of mental health, which in many cases deals A frequency of “peak” experiences that validate the with various aspects of individual functioning. Maslow (1970) emphasized an individual’s motivation in the worthwhileness, richness, and beauty of life An identification with humankind continuous quest for self-actualization. He identified a The ability to achieve satisfactory interpersonal re- “hierarchy of needs,” the lower ones requiring fulfill- ment before those at higher levels can be achieved, with lationships A democratic character structure and strong sense self-actualization being fulfillment of one’s highest po- tential. An individual’s position within the hierarchy of ethics Creativity may fluctuate based on life circumstances. For exam- A degree of nonconformance ple, an individual facing major surgery who has been working on tasks to achieve self-actualization may be- The American Psychiatric Association (APA, 2003) come preoccupied, if only temporarily, with the need defines mental health as “A state of being that is rela- for physiological safety. A representation of the needs tive rather than absolute. The successful performance hierarchy is provided in Figure 1–1. of mental functions shown by productive activities, ful- Maslow described self-actualization as the state of filling relationships with other people, and the ability to being “psychologically healthy, fully human, highly adapt to change and to cope with adversity.” Townsend(F)-01 6/28/07 2:57 PM Page 5 Copyright © 2008 by F. A. Davis. CHAPTER 1 MENTAL HEALTH AND MENTAL ILLNESS 5 Townsend (2006) defines mental health as “The suc- BOX 1–1 Cultural Aspects of Mental Illness cessful adaptation to stressors from the internal or ex- ternal environment, evidenced by thoughts, feelings, 1. It is usually members of the lay community rather than and behaviors that are age-appropriate and congruent a psychiatric professional who initially recognize that an individual’s behavior deviates from the social norms. with local and cultural norms.” (p.16) 2. People who are related to an individual or who are of This definition of mental health is used for purposes the same cultural or social group are less likely to label of this text. that individual’s behavior as mental illness than some- one who is relationally or culturally distant. Family members (or people of the same cultural or social group) try to “normalize” the behavior and try to find MENTAL ILLNESS an explanation for the behavior. 3. Psychiatrists see a person with mental illness most A universal concept of mental illness is difficult to de- often when the family members can no longer deny the fine because of the cultural factors that influence such a illness and often when the behavior is at its worst. The concept. However, certain elements are associated with local or cultural norms define pathological behavior. 4. Individuals in the lowest socioeconomic class usually individuals’ perceptions of mental illness, regardless of display the highest amount of mental illness symptoms. cultural origin. Horwitz (2002) identifies two of these However, they tend to tolerate a wider range of be- elements as incomprehensibility and cultural relativity. haviors that deviate from societal norms and are less Incomprehensibility relates to the inability of the gen- likely to consider these behaviors as indicative of men- eral population to understand the motivation behind a tal illness. Mental illness labels are most often applied by psychiatric professionals. behavior. When observers are unable to find meaning 5. The higher the social class, the greater the recognition or comprehensibility in behavior, they are likely to label of mental illness behaviors (as defined by societal that behavior as mental illness. Horwitz states, “Ob- norms). Members of the higher socioeconomic classes servers attribute labels of mental illness when the rules, are likely to be self-labeled or labeled by family mem- conventions, and understandings they use to interpret bers or friends. Psychiatric assistance is sought soon after the first signs of emotional disturbance. behavior fail to find any intelligible motivation behind 6. The more highly educated the person, the greater the an action.” recognition of mental illness behaviors. However, even The element of cultural relativity considers that these more relevant than amount of education is type of edu- rules, conventions, and understandings are conceived cation. Individuals in the more humanistic types of pro- within an individual’s own particular culture. Behavior fessions (e.g., lawyers, social workers, artists, teachers, nurses) are more likely to seek psychiatric assistance is categorized as “normal” or “abnormal” according to than other professionals such as business executives, one’s cultural or societal norms. Therefore, a behavior computer specialists, accountants, and engineers. that is recognized as evidence of mental illness in one 7. In terms of religion, Jewish people are more likely to society may be viewed as normal in another society, and seek psychiatric assistance than are people who are vice versa. Horwitz identified a number of cultural as- Catholic or Protestant. 8. Women are more likely than men are to recognize the pects of mental illness, which are presented in Box 1–1. symptoms of mental illness and seek assistance. In the DSM-IV-TR (APA, 2000), the APA defines 9. The greater the cultural distance from the mainstream mental illness or a mental disorder as: “A clinically sig- of society (i.e., the fewer the ties with conventional so- nificant behavioral or psychological syndrome or pat- ciety), the greater the likelihood of a negative response tern that occurs in an individual and that is associated by society to mental illness. For example, immigrants have a greater distance from the mainstream than the with present distress (e.g., a painful symptom) or dis- native born, blacks more than whites, and “bohemians” ability (i.e., impairment in one or more important areas more than bourgeoisie. They are more likely to be sub- of functioning), or with a significantly increased risk of jected to coercive treatment, and involuntary psychi- suffering death, pain, disability, or an important loss of atric commitments are more common. freedom…and is not merely an expectable… response Source: Adapted from Horwitz (2002). to a particular event.” (p. xxxi) Townsend (2006) defines mental illness as: “Mal- adaptive responses to stressors from the internal or ex- PHYSICAL AND PSYCHOLOGICAL ternal environment, evidenced by thoughts, feelings, RESPONSES TO STRESS and behaviors that are incongruent with the local and cultural norms, and interfere with the individual’s so- cial, occupational, and/or physical functioning.” (p. 17) Physical Responses This definition of mental illness is used for purposes In 1956, Hans Selye published the results of his research of this text. concerning the physiological response of a biological Townsend(F)-01 6/28/07 2:57 PM Page 6 Copyright © 2008 by F. A. Davis. 6 UNIT I INTRODUCTION TO PSYCHIATRIC/MENTAL HEALTH CONCEPTS system to a change imposed on it. After the initial pub- the hypothalamus stimulates the pituitary gland to lication of his findings, he revised his definition of stress release hormones that produce the following effects: to “the state manifested by a specific syndrome which Adrenocorticotropic hormone (ACTH) stimulates consists of all the nonspecifically-induced changes the adrenal cortex to release glucocorticoids and within a biologic system” (Selye, 1976, p. 64). This syn- mineralocorticoids, resulting in increased gluco- drome of symptoms has come to be known as the fight- neogenesis and retention of sodium and water and or-flight syndrome. Selye called this general decreased immune and inflammatory responses. reaction of the body to stress the general adaptation syn- Vasopressin (antidiuretic hormone) increases drome. He described the reaction in three distinct stages: fluid retention and also increases blood pressure through constriction of blood vessels. 1. Alarm reaction stage. During this stage, the phys- Growth hormone has a direct effect on protein, iological responses of the fight or flight syndrome carbohydrate, and lipid metabolism, resulting in are initiated. increased serum glucose and free fatty acids. 2. Stage of resistance. The individual uses the phys- Thyrotropic hormone stimulates the thyroid iological responses of the first stage as a defense in gland to increase the basal metabolic rate. the attempt to adapt to the stressor. If adaptation oc- Gonadotropins cause a decrease in secretion of sex curs, the third stage is prevented or delayed. Physi- hormones, resulting in decreased libido and im- ological symptoms may disappear. potence. 3. Stage of exhaustion. This stage occurs when there is a p

Essentials of Psychiatric Mental Health Nursing (4th Edition) PDF

Document Details

Tags

Related

Summary

Full Transcript

Upgrade to continue