Essentials of psychiatric mental health nursing concepts of care in evidence based practice 5th edit
Essentials of Psychiatric Mental Health Nursing Concepts of Care in Evidence Based Practice 5th edition by Mary Townsend 0803623380 9780803623385 pdf download
Director of Content Development: Darlene D. Pedersen
Senior Project Editor: Padraic J. Maroney
Cover Design: Carolyn O’Brien
As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Townsend, Mary C., 1941–
Essentials of psychiatric/mental health nursing : concepts of care in evidence-based practice / Mary C. Townsend. — fifth ed. p. ; cm.
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 $.25 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: 8036-2338-5/11 + $.25.
To my best friend, Jimmy
Lois Angelo, MSN, APRN, BC Assistant Professor
Massachusetts College of Pharmacy and Health Sciences
Boston, Massachusetts
Linda Blair, BSN, RN
Nursing Instructor
Central Carolina Community College Sanford, North Carolina
Debra DeVoe, RN, MSN, NE-BC
Nursing Instructor
Our Lady of Lourdes Camden, New Jersey
Donna A. Enrico, MBS, BSN, RN
Clinical Instructor College of Southern Nevada Las Vegas, Nevada
Elizabeth Fife, MSN, RN, CNS, CPN
Associate Professor
Louisiana Tech University Ruston, Louisiana
Patricia J. Hefner, MSN, RN-BC Faculty; Course Coordinator of Psychiatric Mental Health Nursing
Katherine M. Howard, MS, RN-BC Nursing Instructor
Middlesex County College Nursing Program, Raritan Bay Medical Center Edison, New Jersey
Janet K. Johnson, MBA, MSN, RN
Nursing Coordinator
Fort Berthold Community College
New Town, North Dakota
Rebecca King, RN, MSN, PMHCNS-BC Division Chair for Nursing and Allied Health University of Arkansas, Community College of Batesville Batesville, Arkansas
Jan E. Lawrenz Blasi, MSN, RN Nursing Instructor Chandler School of Nursing and Allied Health, Pratt Community College Pratt, Kansas
Anne Marie Leveille, RN, MSN, MPH Assistant Professor Medgar Evers College Brooklyn, New York
Heritage Valley Sewickley Moon, Pennsylvania
Sharon A. Henle, EdD, ANP, RHIA, CNE
Assistant Professor of Nursing Farmingdale State College Farmingdale, New York
Jennifer E. Herrold, RN, MSN, CRNP Instructor
Thomas Jefferson University Danville, Pennsylvania
Beverly J. Howard, MSN, RN, FNP Instructor
Alvin Community College Alvin, Texas
Tamar Lucas, BSN, MSN, RN, BC Nursing Instructor Itawamba Community College Fulton, Mississippi
Jana S. Martin, MS, RN, CNE Division Chair, Allied Health Services OSU Institute of Technology Okmulgee, Oklahoma
Renee Menkens, RN, MS Assistant Professor
Southwestern Oregon Community College Coos Bay, Oregon
Susan M. Reading-Martin, MS, RN, CS, FNP, ARNP-BC Nursing Faculty
Western Nebraska Community College Scottsbluff, Nebraska
Donna F. Rye, MSN, RN Assistant
Professor
Cox College Springfield, Missouri
Karen B. Silva, RN, MSN, MFN, BC Nursing Faculty
Keiser University Sarasota, Florida
Alexandra Winter, RN, MSN Assistant Director of Nursing Metropolitan Community College Omaha,
Nebraska
A very special thank you to:
Cathy Melfi Curtis, MSN, RN-BC, Psychiatric Mental Health Nursing, Trident Technical College, Charleston, South Carolina, for her outstanding work in preparation of the student and instructor test banks that accompany this textbook, and to Cathy Melfi Curtis and Carol Norton Tuzo, MSN, RN-BC, Psychiatric Mental Health Nursing, Trident Technical College, Charleston, South Carolina, for their collaboration in preparing the PowerPoint presentation to accompany this textbook.
Sincere thanks also go to:
Robert G. Martone, Publisher, Nursing, F. A. Davis Company, for your sense of humor and continuous optimistic outlook about the outcome of this project.
Padraic J. Maroney, Senior Project Editor, Nursing, F. A. Davis Company, for all your help and support in preparing the manuscript for publication.
Linda Kern, Project Manager, Progressive Publishing Alternatives, 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 textbook, and offer suggestions for improvements. Many changes have been made based on your input.
To those individuals who critiqued the manuscript for this edition and shared your ideas, opinions, and suggestions for enhancement. I sincerely appreciate your contributions to the final product.
Mary C. Townsend
TO THE INSTRUCTOR
The fifth edition of Essentials of Psychiatric/Mental Health Nursing is published at a time of continued change and turmoil in the nursing profession. The United States is in the midst of a nursing shortage that is expected to intensify as baby boomers age and the need for health care grows. Compounding this problem is a shortage of nursing faculty. Qualified applicants to nursing schools are being turned away because of insufficient numbers of faculty. In 2005, the U.S. Department of Labor awarded several million dollars in grants to address the nurse faculty shortage. These new faculty members need assistance in transitioning to the role of nursing educator.
The target audience for Essentials 5e includes both associate degree and baccalaureate programs. The duration of most psychiatric nursing rotations is 5 to 10 weeks. This leaves little time for extraneous material, and faculty must concentrate on the “essential” concepts related to nursing of psychiatric clients. This textbook is a presentation of those essential concepts. Because most psychiatric nursing students feel uncomfortable and somewhat insecure with the communication aspects of psychiatric nursing, a new emphasis on therapeutic communication is included in the Essentials 5e. Communication strategies have been expanded within the interventions included in the care plans. These “communication interventions” are identified by the icon
It is our goal to stay on the cutting edge of nursing education. So with this in mind, the topic of Quality and Safety Education for Nurses (QSEN) is addressed in this edition. In February 2007, The Robert Wood Johnson Foundation (RWJF) awarded a grant to the University of North Carolina at Chapel Hill School of Nursing to develop a curriculum on quality and safety for nursing schools. The Institute of Medicine (IOM), in its 2003 report, Health Professions Education: A Bridge to Quality, challenged faculties of medicine, nursing, and other health professions to ensure that their graduates have achieved a core set of competencies in order to meet the needs of the 21st century health-care system. These competencies include providing patientcentered care, working in interdisciplinary teams, employing evidence-based practice, applying quality improvement, and utilizing informatics.
in the curricula of nursing schools. Historically, quality care and patient safety have been core concepts of nursing and nursing education. However, it has been suggested that ideas for teaching quality and safety competencies has been sorely lacking. Under the leadership of Principal Investigator Linda R. Cronenwett, the IOM competencies have been adapted for nursing in the hope that they can serve as guidelines to curricular development, and ultimately to “provide a framework for regulatory bodies that set standards for licensure, certification, and accreditation of nursing education programs.” The work of Cronenwett and her associates, including competency definitions and an outline of required knowledge, skills, and attitudes associated with each, was published in Nursing Outlook, 55(3), and may be found on the website http://www .qsen.org.
Definitions of the quality and safety competencies as they apply to nursing include the following:
1. Patient-centered care. Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Educational associations and accrediting bodies are recommending the inclusion of these competencies
2. Teamwork and collaboration. Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.
3. Evidence-based practice. Integrates best current evidence with clinical expertise and patient/ family preferences and values for delivery of optimal health care.
4. Quality improvement. Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health-care systems.
5. Safety. Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
6. Informatics. Use information and technology to communicate, manage knowledge, mitigate error, and support decision making.
Within selected chapters, this textbook includes a number of boxes entitled “QSEN Teaching Strategy.” These activities arm the instructor and the student
with guidelines for attaining the knowledge, skills, and attitudes necessary for achievement of quality and safety competencies in nursing.
CONTENT AND FEATURES NEW TO THE FIFTH EDITION
All content has been updated to reflect current state of the discipline of nursing.
Updated NANDA terminology based on Nursing Diagnoses: Definitions and Classification 2009–2011 has been used throughout the text.
Homework assignments. At the beginning of each chapter, following the objectives, a new section has been added entitled “Homework Assignment.” It is much easier to teach when students come prepared and have read the text before class. However, many students are reluctant readers. One way to encourage students to read before class is to assign homework due before class based on the day’s topic. Homework questions need to count toward the grade but they don’t have to count a lot. Students are motivated by even a small number of points because they know they can complete homework successfully if they try. Grading criteria should be clear, and to minimize grading time, homework could also be assigned “pass-fail.” Homework questions are straightforward and, because students will not yet have had a chance to ask questions in class on the topic, are written at the knowledge and comprehension levels rather than at the application and analysis levels.
Review questions at the end of each chapter have been updated to reflect the NCLEX format. Summaries now appear as “key points” from the chapter.
The Mental Status Assessment has been expanded to include psychosocial assessment questions to facilitate the assessment process for the student.
Tables entitled “Assigning Nursing Diagnoses to Behaviors Commonly Associated With (specific diagnosis)” have been added to diagnosis chapters.
Sample Case Studies and Care Plans have been included at the end of each of the diagnosis chapters.
The chapter on mood disorders has been divided into two separate chapters:
Psychopharmacology does not appear as a separate chapter in the fifth edition. Overview content has been moved to Chapter 3 “Biological Implications.” Content related to specific medications appears in the diagnosis chapter to which the medication applies. This should facilitate understanding of the medication, as well as the study process for the student. All new medications since publication of the previous edition are included.
There is a new emphasis on communication techniques in the fifth edition.
Communication strategies have been expanded within the interventions included in the care plans. These “communication interventions” are identified by the icon
Boxes entitled “QSEN Teaching Strategy” appear within selected chapters. These activities provide the instructor and the student with guidelines for attaining the knowledge, skills, and attitudes necessary for achievement of quality and safety competencies in nursing.
“Mood Disorders Depression” and “Mood Disorders Bipolar Disorder.”
The neurobiology of ADHD has been added to this edition.
New content on fetal alcohol syndrome and validity therapy is included.
A concept care map for dementia has been added.
FEATURES THAT HAVE BEEN RETAINED IN THE FIFTH EDITION
The concept of holistic nursing is retained in the fifth edition. An attempt has been made to ensure that the physical aspects of psychiatric/mental health nursing are not overlooked. In all relevant situations, the mind-body connection is addressed.
Nursing process is retained in the fifth edition as the tool for delivery of care to the individual with a psychiatric disorder or to assist in the primary prevention or exacerbation of mental illness symptoms. The six steps of the nursing process, as described in the American Nurses Association Standards of Clinical Nursing Practice are used to provide guidelines for the nurse. These standards of care are included for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnoses, as well as the aging individual, the bereaved individual, victims of abuse and neglect, and as examples in several of the therapeutic approaches. The six steps include:
● Assessment: Background assessment data, including a description of symptomatology, provides an extensive knowledge base from which the nurse may draw when performing an assessment. Several assessment tools are also included.
● Diagnosis: Analysis of the data is included, from which nursing diagnoses common to specific psychiatric disorders are derived.
● Outcome Identification: Outcomes are derived from the nursing diagnoses and stated as measurable goals.
● Planning: A plan of care is presented with selected nursing diagnoses for the DSM-IV-TR diagnoses, as well as for the elderly client, the bereaved individual, victims of abuse and neglect, the elderly homebound client, and the primary caregiver of the client with a severe and persistent mental illness. The planning standard also includes tables that list topics for educating clients and families about mental illness. Concept map care plans are included for all major psychiatric diagnoses.
● Implementation: The interventions that have been identified in the plan of care are included along with rationales for each. Case studies at the end of each DSM-IV-TR chapter assist the student in the practical application of theoretical material. Also included as a part of this particular standard is Unit II of the textbook: “Psychiatric/Mental Health Nursing Interventions.” This section of the textbook addresses psychiatric nursing intervention in depth, and frequently speaks to the differentiation in scope of practice between the basic level psychiatric nurse and the advanced practice level psychiatric nurse.
● Evaluation: The evaluation standard includes a set of questions that the nurse may use to assess whether the nursing actions have been successful in achieving the objectives of care.
Other Features
All references have been updated throughout the text. Classical references are distinguished from general references.
Boxes with definitions of core concepts appear throughout the text.
An F. A. Davis/Townsend website that contains additional nursing care plans that do not appear in the text, links to psychotropic medications, concept map care plans, and neurobiological content and illustrations
A Student CD that contains 270 practice test questions, learning activities, concept map care plans, and client teaching guides
Internet references for each DSM-IV-TR diagnosis, with website listings for information related to the disorder
Tables that list topics for client/family education (clinical chapters)
Boxes that include current research studies with implications for evidence-based nursing practice (clinical chapters)
Assigning nursing diagnoses to client behaviors (diagnostic chapters and Appendix C)
Taxonomy and diagnostic criteria from the DSMIV-TR (2000) are used throughout the text.
ADDITIONAL EDUCATIONAL RESOURCES
Faculty may also find the following teaching aids that accompany this textbook helpful: Instructor’s Resource Disk (IRD). This IRD contains:
● Approximately 550 multiple-choice questions (including new format questions reflecting the latest NCLEX blueprint)
● Lecture outlines for all chapters
● Learning activities for all chapters (including answer key)
● Answers to the Critical Thinking Exercises from the textbook
● PowerPoint presentations to accompany all chapters in the textbook
● Answers to the Homework Assignment questions from the textbook
It is hoped that the revisions and additions to this fifth edition continue to satisfy a need within psychiatric/ mental health nursing practice. The mission of this textbook has been, and continues to be, to provide both students and clinicians with up-to-date information about psychiatric/mental health nursing. The user-friendly format and easy-to-understand language, which have been retained in this edition, have made this text particularly appreciated and often preferred over others.
Mary C. Townsend
PSYCHIATRIC MENTAL HEALTH NURSING OF SPECIAL POPULATIONS
Essentials of Psychiatric Mental Health Nursing
CONCEPTS OF CARE IN
EVIDENCE-BASED PRACTICE
FIFTH EDITION
U NIT O NE
INTRODUCTION TO PSYCHIATRIC/ MENTAL HEALTH CONCEPTS
1 C HAPTER
Mental Health and Mental Illness
CHAPTER OUTLINE
OBJECTIVES
HOMEWORK ASSIGNMENT
INTRODUCTION
MENTAL HEALTH
MENTAL ILLNESS
PHYSICAL AND PSYCHOLOGICAL RESPONSES TO STRESS
KEY TERMS
anticipatory grief
bereavement overload
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)
ego defense mechanisms fight or flight syndrome neurosis
psychosis
THE DSM-IV-TR MULTIAXIAL EVALUATION SYSTEM
SUMMARY AND KEY POINTS
REVIEW QUESTIONS
CORE CONCEPTS
anxiety grief
OBJECTIVES
After reading this chapter, the student will be able to:
1. Define mental health and mental illness.
2. Discuss cultural elements that influence attitudes toward mental health and mental illness.
3. Identify physiological responses to stress.
4. Discuss the concepts of anxiety and grief as psychological responses to stress.
5. Describe the DSM-IV-TR multiaxial evaluation system for classification of mental disorders.
HOMEWORK ASSIGNMENT
Please read the chapter and answer the following questions.
1. Explain the concepts of incomprehensibility and cultural relativity.
2. Describe some symptoms of panic anxiety.
3. Jane was involved in an automobile accident in which both her parents were killed. When you ask her about it, she says she has no memory of the accident. What ego defense mechanism is she using?
INTRODUCTION
4. In what stage of the grieving process is the individual with delayed or inhibited grief fixed?
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, whereas others have very little tolerance for behaviors that deviate from the cultural norms. A study of the history of psychiatric care reveals some shocking truths about past treatment of mentally ill individuals. Many were kept in control by means that were cruel and inhumane.
Primitive beliefs regarding mental disturbances took several views. Some thought that an individual with mental illness had been dispossessed of his or her soul and that the only way wellness could be achieved was if the soul returned. Others believed that evil spirits or supernatural or magical powers had entered the body. The “cure” for these individuals involved a ritualistic exorcism, which often consisted of brutal beatings, starvation, or other torturous means, to purge the body of these unwanted forces. Still others considered that the mentally ill individual may have broken a taboo or sinned against another individual or God, for which ritualistic purification was required or various types of retribution were demanded. The correlation of mental illness to demonology or witchcraft led to some mentally ill individuals being burned at the stake.
This chapter defines mental health and mental illness and describes physical and psychological responses to stress. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), multiaxial evaluation system is also presented.
MENTAL HEALTH
A number of theorists have attempted to define the concept of mental health. Many of these concepts deal
with various aspects of individual functioning. Maslow (1970) emphasized an individual’s motivation in the continuous quest for self-actualization. He identified a “hierarchy of needs,” the lower needs requiring fulfillment before those at higher levels can be achieved, with self-actualization being fulfillment of one’s highest potential. An individual’s position within the hierarchy may fluctuate based on life circumstances. For example, an individual facing major surgery who has been working on tasks to achieve self-actualization may become preoccupied, if only temporarily, with the need for physiological safety. A representation of this needs hierarchy is presented in Figure 1–1.
SELFACTUALIZATION
(The individual possesses a feeling of selffulfillment and the realization of his or her highest potential.)
SELF-ESTEEM ESTEEM-OF-OTHERS
(The individual seeks self-respect and respect from others,works to achieve success and recognition in work, anddesires prestige from accomplishments.)
LOVE AND BELONGING
(Needs are for giving and receiving of affection,companionship,satisfactory interpersonal relationships, and identification with a group.)
SAFETY AND SECURITY
(Needs at this level are for avoiding harm,maintaining comfort,order,structure,physical safety,freedom from fear,and protection.)
PHYSIOLOGICAL NEEDS
(Basic fundamental needs include food, water, air, sleep, exercise, elimination, shelter, and sexual expression.)
FIGURE 1–1 Maslow’s hierarchy of needs.
Maslow described self-actualization as the state of being “psychologically healthy, fully human, highly evolved, and fully mature.” He believed that healthy, or self-actualized, individuals possessed the following characteristics:
● An appropriate perception of reality
● The ability to accept oneself, others, and human nature
● The ability to manifest spontaneity
● The capacity for focusing concentration on problemsolving
● A need for detachment and desire for privacy
● Independence, autonomy, and a resistance to enculturation
● An intensity of emotional reaction
● A frequency of “peak” experiences that validate the worthwhileness, richness, and beauty of life
● An identification with humankind
● The ability to achieve satisfactory interpersonal relationships
● A democratic character structure and strong sense of ethics
● Creativeness
● A degree of nonconformance
The American Psychiatric Association (APA) (2003) defines mental health as “a state of being that is relative rather than absolute. The successful performance of mental functions shown by productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity.”
Townsend (2009) defines mental health as “the successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms” (p. 14).
This definition of mental health will be used for purposes of this text.
MENTAL ILLNESS
A universal concept of mental illness is difficult to define because of the cultural factors that influence such a concept. However, certain elements are associated with individuals’ perceptions of mental illness, regardless of cultural origin. Horwitz (2002) identifies two of these elements as incomprehensibility and cultural relativity. Incomprehensibility relates to the inability of the general population to understand the motivation behind the behavior. When observers are unable to find meaning or comprehensibility in behavior, they are likely to label that behavior as mental illness. Horwitz states,
“Observers attribute labels of mental illness when the rules, conventions, and understandings they use to interpret behavior fail to find any intelligible motivation behind an action.”
The element of cultural relativity considers that these rules, conventions, and understandings are conceived within an individual’s own particular culture. Behavior is categorized as “normal” or “abnormal” according to one’s cultural or societal norms. Therefore, a behavior that is recognized as evidence of mental illness in one society may be viewed as normal in another society and vice versa. Horwitz identified a number of cultural aspects of mental illness, which are presented in Box 1–1.
In the DSM-IV-TR (APA, 2000), the APA defines mental illness or a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern
Box 1–1 Cultural Aspects of Mental Illness
1. It is usually members of the lay community rather than a psychiatric professional who initially recognize that an individual’s behavior deviates from the social norms.
2. People who are related to an individual or who are of the same cultural or social group are less likely to label that individual’s behavior as mental illness than someone 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 an explanation for it.
3. Psychiatrists see a person with mental illness most often when the family members can no longer deny the illness and often when the behavior is at its worst. The local or cultural norms define pathological behavior.
4. Individuals in the lowest socioeconomic class usually display the highest amount of mental illness symptoms. However, they tend to tolerate a wider range of behaviors that deviate from societal norms and are less likely to consider these behaviors as indicative of mental illness. Mental illness labels are most often applied by psychiatric professionals.
5. The higher the social class, the greater the recognition of mental illness behaviors (as defined by societal norms). Members of the higher social classes are likely to be self-labeled or labeled by family members or friends. Psychiatric assistance is sought soon after the first signs of emotional disturbance.
6. The more highly educated the person, the greater the recognition of mental illness behaviors. However, even more relevant than amount of education is type of education. Individuals in the more humanistic types of professions (e.g., lawyers, social workers, artists, teachers, nurses) are more likely to seek psychiatric assistance than other professionals such as business executives, computer specialists, accountants, and engineers.
7. In terms of religion, Jewish people are more likely to seek psychiatric assistance than are people who are Catholic or Protestant.
B OX 1–1 Cultural Aspects of Mental Illness—cont’d
8. Women are more likely than men to recognize the symptoms of mental illness and seek assistance.
9. The greater the cultural distance from the mainstream of society (i.e., the fewer the ties with conventional society), the greater the likelihood of a negative response by society to mental illness. For example, immigrants have a greater distance from the mainstream than the native born, ethnic minorities greater than the dominant culture, and “bohemians” more than bourgeoisie. They are more likely to be subjected to coercive treatment, and involuntary psychiatric commitments are more common.
Source: Adapted from Horwitz (2002).
that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning), or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom . . . and is not merely an expectable . . . response to a particular event” (p. xxxi).
Townsend (2009) defines mental illness as “maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms, and interfere with the individual’s social, occupational, and/or physical functioning” (p. 15).
This definition of mental illness will be used for purposes of this text.
PHYSICAL AND PSYCHOLOGICAL RESPONSES TO STRESS
Physical Responses
In 1956, Hans Selye published the results of his research concerning the physiological response of a biological system to a change imposed on it. After the initial publication of his findings, he revised his definition of stress to “the state manifested by a specific syndrome which consists of all the nonspecifically-induced changes within a biologic system” (Selye, 1976, p. 64). This syndrome of symptoms has come to be known as the fight or flight syndrome. Selye called this general reaction of the body to stress the general adaptation syndrome. He described the reaction in three distinct stages:
1. Alarm reaction stage: During this stage, the physiological responses of the fight or flight syndrome are initiated.
2. Stage of resistance: The individual uses the physiological responses of the first stage as a defense in
the attempt to adapt to the stressor. If adaptation occurs, the third stage is prevented or delayed. Physiological symptoms may disappear.
3. Stage of exhaustion: This stage occurs when there is a prolonged exposure to the stressor to which the body has become adjusted. The adaptive energy is depleted, and the individual can no longer draw from the resources for adaptation described in the first two stages. Diseases of adaptation (e.g., headaches, mental disorders, coronary artery disease, ulcers, colitis) may occur. Without intervention for reversal, exhaustion and even death ensues (Selye, 1956, 1974).
Biological responses associated with the fight or flight syndrome include the following:
● The immediate response: The hypothalamus stimulates the sympathetic nervous system, which results in the following physical effects:
• The adrenal medulla releases norepinephrine and epinephrine into the bloodstream.
• The pupils of the eye dilate.
• Secretion from the lacrimal (tear) glands is increased.
• In the lungs, the bronchioles dilate and the respiration rate is increased.
• The force of cardiac contraction increases, as does cardiac output, heart rate, and blood pressure.
• Gastrointestinal motility and secretions decrease, and sphincter contracts.
• In the liver, there is increased glycogenolysis and gluconeogenesis and decreased glycogen synthesis.
• The bladder muscle contracts and the sphincter relaxes; there is increased ureter motility.
• Secretion from the sweat glands is increased.
• Lipolysis occurs in the fat cells.
● The sustained response: When the stress response is not relieved immediately and the individual remains under stress for a long period of time, the hypothalamus stimulates the pituitary gland to release hormones that produce the following effects:
• Adrenocorticotropic hormone (ACTH) stimulates the adrenal cortex to release glucocorticoids and mineralocorticoids, resulting in increased gluconeogenesis and retention of sodium and water and decreased immune and inflammatory responses.
• Vasopressin (antidiuretic hormone) increases fluid retention and also increases blood pressure through constriction of blood vessels.
• Growth hormone has a direct effect on protein, carbohydrate, and lipid metabolism, resulting in increased serum glucose and free fatty acids.
• Thyrotropic hormone stimulates the thyroid gland to increase the basal metabolic rate.
• Gonadotropins cause a decrease in secretion of sex hormones, resulting in decreased libido and impotence.
This fight or flight response undoubtedly served our ancestors well. Those Homo sapiens who had to face the giant grizzly bear or the saber-toothed tiger as a facet of their struggle for survival must have used these adaptive resources to their advantage. The response was elicited in emergencies, used in the preservation of life, and followed by restoration of the compensatory mechanisms to the preemergent condition (homeostasis).
Selye performed his extensive research in a controlled setting with laboratory animals as subjects. He elicited physiological responses with physical stimuli, such as exposure to heat or extreme cold, electric shock, injection of toxic agents, restraint, and surgical injury. Since the publication of Selye’s original research, it has become apparent that the fight or flight syndrome occurs in response to psychological or emotional stimuli, just as it does to physical stimuli. The psychological or emotional stressors are often not resolved as rapidly as some physical stressors; therefore, the body may be depleted of its adaptive energy more readily than it is from physical stressors. The fight or flight response may be inappropriate or even dangerous to the lifestyle of today, wherein stress has been described as a psychosocial state that is pervasive, chronic, and relentless. It is this chronic response that maintains the body in the aroused condition for extended periods that promotes susceptibility to diseases of adaptation.
Psychological Responses
Anxiety and grief have been described as two major, primary psychological response patterns to stress. A variety of thoughts, feelings, and behaviors are associated with each of these response patterns. Adaptation is determined by the degree to which the thoughts, feelings, and behaviors interfere with an individual’s functioning.
CORE CONCEPT
Anxiety
A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.
Anxiety
Feelings of anxiety are so common in our society that they are almost considered universal. Anxiety arises from the chaos and confusion that exists in the world today. Fears of the unknown and conditions of ambiguity offer a perfect breeding ground for anxiety to take root and grow. Low levels of anxiety are adaptive and can provide the motivation required for survival. Anxiety becomes problematic when the individual is unable to prevent the anxiety from escalating to a level that interferes with the ability to meet basic needs.
Peplau (1963) described four levels of anxiety: mild, moderate, severe, and panic. Nurses must be able to recognize the symptoms associated with each level to plan for appropriate intervention with anxious individuals.
● Mild anxiety: This level of anxiety is seldom a problem for the individual. It is associated with the tension experienced in response to the events of day-to-day living. Mild anxiety prepares people for action. It sharpens the senses, increases motivation for productivity, increases the perceptual field, and results in a heightened awareness of the environment. Learning is enhanced, and the individual is able to function at his or her optimal level.
● Moderate anxiety: As the level of anxiety increases, the extent of the perceptual field diminishes. The moderately anxious individual is less alert to events occurring within the environment. The individual’s attention span and ability to concentrate decrease, although he or she may still attend to needs with direction. Assistance with problem-solving may be required. Increased muscular tension and restlessness are evident.
● Severe anxiety: The perceptual field of the severely anxious individual is so greatly diminished that concentration centers on one particular detail only or on many extraneous details. Attention span is extremely limited, and the individual has much difficulty completing even the simplest task. Physical symptoms (e.g., headaches, palpitations, insomnia) and emotional symptoms (e.g., confusion, dread, horror) may be evident. Discomfort is experienced to the degree that virtually all overt behavior is aimed at relieving the anxiety.
● Panic anxiety: In this most intense state of anxiety, the individual is unable to focus on even one detail within the environment. Misperceptions are common, and a loss of contact with reality may occur. The individual may experience hallucinations or delusions. Behavior may be characterized by wild and desperate actions or extreme withdrawal. Human functioning and communication with others are ineffective. Panic anxiety
is associated with a feeling of terror, and individuals may be convinced that they have a life-threatening illness or fear that they are “going crazy,” are losing control, or are emotionally weak (APA, 2000). Prolonged panic anxiety can lead to physical and emotional exhaustion and can be life threatening.
A variety of behavioral adaptation responses occur at each level of anxiety. Figure 1–2 depicts these behavioral responses on a continuum of anxiety ranging from mild to panic.
Mild Anxiety
At the mild level, individuals use any of a number of coping behaviors that satisfy their needs for comfort. Menninger (1963) described the following types of coping mechanisms that individuals use to relieve anxiety in stressful situations:
● Sleeping
● Eating
● Physical exercise
● Smoking
● Crying
● Yawning
● Drinking
● Daydreaming
● Laughing
● Cursing
● Pacing
● Foot swinging
● Fidgeting
● Nail biting
● Finger tapping
● Talking to someone with whom one feels comfortable
Undoubtedly, there are many more responses too numerous to mention here, considering that each individual develops his or her own unique ways to relieve anxiety at the mild level. Some of these behaviors are much more adaptive than others.
Mild to Moderate Anxiety
Sigmund Freud (1961) identified the ego as the reality component of the personality that governs problemsolving and rational thinking. As the level of anxiety
increases, the strength of the ego is tested, and energy is mobilized to confront the threat. Anna Freud (1953) identified a number of defense mechanisms employed by the ego in the face of threat to biological or psychological integrity (Table 1–1). Some of these ego defense mechanisms are more adaptive than others, but all are used either consciously or unconsciously as protective devices for the ego in an effort to relieve mild to moderate anxiety. They become maladaptive when an individual uses them to such a degree that there is interference with the ability to deal with reality, with interpersonal relations, or with occupational performance.
Moderate to Severe Anxiety
Anxiety at the moderate to severe level that remains unresolved over an extended period can contribute to a number of physiological disorders. The DSMIV-TR (APA, 2000) describes these disorders as “the presence of one or more specific psychological or behavioral factors that adversely affect a general medical condition.” The psychological factors may exacerbate symptoms of, delay recovery from, or interfere with treatment of the medical condition. The condition may be initiated or exacerbated by an environmental situation that the individual perceives as stressful. Measurable pathophysiology can be demonstrated. The DSM-IV-TR states:
Psychological and behavioral factors may affect the course of almost every major category of disease, including cardiovascular conditions, dermatological conditions, endocrinological conditions, gastrointestinal conditions, neoplastic conditions, neurological conditions, pulmonary conditions, renal conditions, and rheumatological conditions. (APA, 2000, p. 732)
Severe Anxiety
Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving. Neurosis is no longer a separate category of disorders in the DSM-IV-TR (APA, 2000). However, the term is still used in the literature to further describe the symptomatology of certain disorders. Neuroses are psychiatric disturbances, characterized by excessive anxiety that is expressed directly or altered through defense mechanisms. It appears as a symptom, such as an obsession, a compulsion, a phobia, or a sexual dysfunction (Sadock & Sadock, 2007). The following are common characteristics of people with neuroses:
● They are aware that they are experiencing distress.
● They are aware that their behaviors are maladaptive.
TABLE 1–1 Ego Defense Mechanisms
Defense Mechanism
Compensation
Covering up a real or perceived weakness by emphasizing a trait one considers more desirable
Denial
Refusing to acknowledge the existence of a real situation or the feelings associated with it
Example
A physically handicapped boy is unable to participate in football, so he compensates by becoming a great scholar.
A woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem.
Displacement
The transfer of feelings from one target to another that is considered less threatening or that is neutral
A client is angry at his doctor, does not express it, but becomes verbally abusive with the nurse.
Defense Mechanism Example
Rationalization
Attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors
Reaction Formation
Preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors
Regression
Responding to stress by retreating to an earlier level of development and the comfort measures associated with that level of functioning
IdentificationRepression
An attempt to increase selfworth by acquiring certain attributes and characteristics of an individual one admires
Intellectualization
An attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis
Introjection
Integrating the beliefs and values of another individual into one’s own ego structure
A teenaged boy who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences.
Susan’s husband is being transferred with his job to a city far away from her parents. She hides anxiety by explaining to her parents the advantages associated with the move.
Children integrate their parents’ value system into the process of conscience formation. A child says to friend, “Don’t cheat. It’s wrong.”
Involuntarily blocking unpleasant feelings and experiences from one’s awareness
Sublimation
Rechanneling of drives or impulses that are personally or socially unacceptable into activities that are constructive
Suppression
The voluntary blocking of unpleasant feelings and experiences from one’s awareness
Isolation Undoing
Separating a thought or memory from the feeling tone or emotion associated with it
Projection
Attributing feelings or impulses unacceptable to one’s self to another person
Without showing any emotion, a young woman describes being attacked and raped.
Sue feels a strong sexual attraction to her track coach and tells her friend, “He’s coming on to me!”
Symbolically negating or canceling out an experience that one finds intolerable
John tells the rehab nurse, “I drink because it’s the only way I can deal with my bad marriage and my worse job.”
Jane hates nursing. She attended nursing school to please her parents. During career day, she speaks to prospective students about the excellence of nursing as a career.
When 2-year-old Jay is hospitalized for tonsillitis he will drink only from a bottle, although his mother states he has been drinking from a cup for 6 months.
An accident victim can remember nothing about the accident.
A mother whose son was killed by a drunk driver channels her anger and energy into being the president of the local chapter of Mothers Against Drunk Drivers.
Scarlett O’Hara says, “I don’t want to think about that now. I’ll think about that tomorrow.”
Joe is nervous about his new job and yells at his wife. On his way home, he stops and buys her some flowers.
● They are unaware of any possible psychological causes of the distress.
● They feel helpless to change their situation.
● They experience no loss of contact with reality.
The following disorders are examples of psychoneurotic responses to severe anxiety as they appear in the DSM-IV-TR:
● Anxiety disorders: Disorders in which the characteristic features are symptoms of anxiety and avoidance behavior (e.g., phobias, obsessive-compulsive disorder, panic disorder, generalized anxiety disorder, post-traumatic stress disorder).
● Somatoform disorders: Disorders in which the characteristic features are physical symptoms for which there is no demonstrable organic pathology. Psychological factors are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the symptoms (e.g., hypochondriasis, conversion disorder, somatization disorder, pain disorder).
● Dissociative disorders: Disorders in which the characteristic feature is a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment (e.g., dissociative amnesia, dissociative fugue, dissociative identity disorder, depersonalization disorder).
Panic Anxiety
At this extreme level of anxiety, an individual is not capable of processing what is happening in the environment and may lose contact with reality. Psychosis is defined as a loss of ego boundaries or a gross impairment in reality testing (APA, 2000). Psychoses are serious psychiatric disturbances characterized by the presence of delusions or hallucinations and the impairment of interpersonal functioning and relationship to the external world. The following are common characteristics of people with psychoses:
● They exhibit minimal distress (emotional tone is flat, bland, or inappropriate).
● They are unaware that their behavior is maladaptive.
● They are unaware of any psychological problems.
● They are exhibiting a flight from reality into a less stressful world or into one in which they are attempting to adapt.
Examples of psychotic responses to anxiety include the schizophrenic, schizoaffective, and delusional disorders.
CORE CONCEPT
Grief
A subjective state of emotional, physical, and social responses to the loss of a valued entity.
Grief
Most individuals experience intense emotional anguish in response to a significant personal loss. A loss is anything that is perceived as such by the individual. Losses may be real, in which case it can be substantiated by others (e.g., death of a loved one, loss of personal possessions), or they may be perceived by the individual alone and unable to be shared or identified by others (e.g., loss of the feeling of femininity following a mastectomy). Any situation that creates change for an individual can be identified as a loss. Failure (either real or perceived) can also be viewed as a loss.
The loss, or anticipated loss, of anything of value to an individual can trigger the grief response. This period of characteristic emotions and behaviors is called mourning. The “normal” mourning process is adaptive and is characterized by feelings of sadness, guilt, anger, helplessness, hopelessness, and despair. Indeed, an absence of mourning after a loss may be considered maladaptive.
Stages of Grief
Kübler-Ross (1969), in extensive research with terminally ill patients, identified five stages of feelings and behaviors that individuals experience in response to a real, perceived, or anticipated loss:
● Stage 1 Denial: This is a stage of shock and disbelief. The response may be one of “No, it can’t be true!” The reality of the loss is not acknowledged. Denial is a protective mechanism that allows the individual to cope within an immediate time frame while organizing more effective defense strategies.
● Stage 2 Anger: “Why me?” and “It’s not fair!” are comments often expressed during the anger stage. Envy and resentment toward individuals not affected by the loss are common. Anger may be directed at the self or displaced on loved ones, caregivers, and even God. There may be a preoccupation with an idealized image of the lost entity.
● Stage 3 Bargaining: “If God will help me through this, I promise I will go to church every Sunday and volunteer my time to help others.” During this stage,
which is usually not visible or evident to others, a “bargain” is made with God in an attempt to reverse or postpone the loss. Sometimes the promise is associated with feelings of guilt for not having performed satisfactorily, appropriately, or sufficiently.
● Stage 4 Depression: During this stage, the full impact of the loss is experienced. The sense of loss is intense, and feelings of sadness and depression prevail. This is a time of quiet desperation and disengagement from all association with the lost entity. This stage differs from pathological depression in that it represents advancement toward resolution rather than the fixation in an earlier stage of the grief process.
● Stage 5 Acceptance: The final stage brings a feeling of peace regarding the loss that has occurred. It is a time of quiet expectation and resignation. The focus is on the reality of the loss and its meaning for the individuals affected by it.
Not all individuals experience each of these stages in response to a loss, nor do they necessarily experience them in this order. Some individuals’ grieving behaviors may fluctuate, and even overlap, among the stages.
Anticipatory Grief
When a loss is anticipated, individuals often begin the work of grieving before the actual loss occurs. This is called anticipatory grief. Most people reexperience the grieving behaviors once the loss occurs, but having this time to prepare for the loss can facilitate the process of mourning, actually decreasing the length and intensity of the response. Problems arise, particularly in anticipating the death of a loved one, when family members experience anticipatory grieving and the mourning process is completed prematurely. They disengage emotionally from the dying person, who then may feel rejected by loved ones at a time when this psychological support is so important.
Resolution
The grief response can last from weeks to years. It cannot be hurried, and individuals must be allowed to progress at their own pace. After the loss of a loved one, grief work usually lasts for at least a year, during which the grieving person experiences each significant “anniversary” date for the first time without the loved one present.
Length of the grief process may be prolonged by a number of factors. If the relationship with the lost entity had been marked by ambivalence or if there had been an enduring “love-hate” association, reaction to the loss may be burdened with guilt. Guilt lengthens
the grief reaction by promoting feelings of anger toward the self for having committed a wrongdoing or behaved in an unacceptable manner toward that which is now lost. It may even lead to feeling that one’s behavior has contributed to the loss.
Anticipatory grieving is thought to shorten the grief response in some individuals who are able to work through some of the feelings before the loss occurs. If the loss is sudden and unexpected, mourning may take longer than it would if individuals were able to grieve in anticipation of the loss.
Length of the grieving process is also affected by the number of recent losses experienced by an individual and whether he or she is able to complete one grieving process before another loss occurs. This is particularly true for elderly individuals who may be experiencing numerous losses—such as spouse, friends, other relatives, independent functioning, home, personal possessions, and pets—in a relatively short time. As grief accumulates, a type of bereavement overload occurs, which for some individuals presents an impossible task of grief work.
Resolution of the process of mourning is thought to have occurred when an individual can look back on the relationship with the lost entity and accept both the pleasures and the disappointments (both the positive and the negative aspects) of the association (Bowlby & Parkes, 1970). Disorganization and emotional pain have been experienced and tolerated. Preoccupation with the lost entity has been replaced with energy and the desire to pursue new situations and relationships.
Maladaptive Grief Responses
Maladaptive responses to loss occur when an individual is not able to progress satisfactorily through the stages of grieving to achieve resolution. Usually in such situations, an individual becomes fixed in the denial or anger stage of the grief process. Several types of grief responses have been identified as pathological. They include responses that are prolonged, delayed or inhibited, or distorted. The prolonged response is characterized by an intense preoccupation with memories of the lost entity for many years after the loss has occurred. Behaviors associated with the stages of denial or anger are manifested, and disorganization of functioning and intense emotional pain related to the lost entity are evidenced.
In the delayed or inhibited response, the individual becomes fixed in the denial stage of the grieving process. The emotional pain associated with the loss is not experienced, but anxiety disorders (e.g., phobias, hypochondriasis) or sleeping and eating disorders (e.g., insomnia, anorexia) may be evident. The
individual may remain in denial for many years until the grief response is triggered by a reminder of the loss or even by another, unrelated loss.
The individual who experiences a distorted response is fixed in the anger stage of grieving. In the distorted response, all the normal behaviors associated with grieving, such as helplessness, hopelessness, sadness, anger, and guilt, are exaggerated out of proportion to the situation. The individual turns the anger inward on the self, is consumed with overwhelming despair, and is unable to function in normal activities of daily living. Pathological depression is a distorted grief response.
THE DSM-IV-TR MULTIAXIAL EVALUATION SYSTEM
The APA (2000) endorses case evaluation on a multiaxial system “to facilitate comprehensive and systematic evaluation with attention to the various mental disorders and general medical conditions, psychosocial and environmental problems, and level of functioning that might be overlooked if the focus were on assessing a single presenting problem” (p. 27). Each individual is evaluated on five axes. They are defined by the DSMIV-TR in the following manner:
● Axis I Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention: This includes all mental disorders (except personality disorders and mental retardation).
● Axis II Personality Disorders and Mental Retardation: These disorders usually begin in childhood or adolescence and persist in a stable form into adult life.
● Axis III General Medical Conditions: These include any current general medical condition that is potentially relevant to the understanding or management of the individual’s mental disorder.
● Axis IV Psychosocial and Environmental Problems: These are problems that may affect the diagnosis, treatment, and prognosis of mental disorders named on axes I and II. These include problems related to primary support group, social environment, education, occupation, housing, economics, access to health-care services, interaction with the legal system or crime, and other types of psychosocial and environmental problems.
● Axis V Global Assessment of Functioning: This allows the clinician to rate the individual’s overall functioning on the Global Assessment of Functioning (GAF) Scale. This scale represents in global terms a single measure of the individual’s psychological,
social, and occupational functioning. A copy of the GAF Scale appears in Box 1–2.
Table 1–2 is an example of a psychiatric diagnosis using the multiaxial system. The DSM-IV-TR outline of axes I and II categories and codes is presented in Appendix A.
SUMMARY AND KEY POINTS
■ For purposes of this text, mental health is defined as “the successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age appropriate and congruent with local and cultural norms” (Townsend, 2009).
■ Mental illness is defined as “maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual’s social, occupational, and/or physical functioning” (Townsend, 2009).
■ Most cultures label behavior as mental illness on the basis of incomprehensibility and cultural relativity.
■ When observers are unable to find meaning or comprehensibility in behavior, they are likely to label that behavior as mental illness. The meaning of behaviors is determined within individual cultures.
■ Selye, who has become known as the founding father of stress research, defined stress as “the state manifested by a specific syndrome which consists of all the non-specifically induced changes within a biological system” (Selye, 1976).
■ Selye determined that physical beings respond to stressful stimuli with a predictable set of physiological changes. He described the response in three distinct stages: (1) the alarm reaction stage, (2) the stage of resistance, and (3) the stage of exhaustion. Many illnesses, or diseases of adaptation, have their origin in this aroused state, which is the preparation for fight or flight.
■ Anxiety and grief have been identified as the two major, primary responses to stress.
TABLE
1–2 Example of a Psychiatric Diagnosis
Axis I 300.4Dysthymic Disorder
Axis II301.6Dependent Personality Disorder
Axis III244.9Hypothyroidism
Axis IVUnemployed
Axis VGAF = 65 (current)
B OX 1–2 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 | 91 Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
90 | 81 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 life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
80 | 71 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 in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
70 | 61 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), but generally functioning pretty well, has some meaningful interpersonal relationships.
60 | 51 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, conflicts with peers or coworkers).
50 | 41 Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
40 | 31 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, 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 | 21 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).
20 | 11 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 (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
10 | 1 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 expectation of death.
0 Inadequate information.
Source: American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Text Revision. Washington, DC: American Psychiatric Publishing. With permission.
■ Peplau (1963) defined anxiety by levels of symptom severity: mild, moderate, severe, and panic.
■ Behaviors associated with levels of anxiety include coping mechanisms, ego defense mechanisms, psychophysiological responses, psychoneurotic responses, and psychotic responses.
■ Grief is described as a response to loss of a valued entity.
■ Stages of normal mourning as identified by KüblerRoss (1969) are denial, anger, bargaining, depression, and acceptance.
■ Anticipatory grief is grief work that is begun, and sometimes completed, before the loss occurs.
■ Resolution is thought to occur when an individual is able to remember and accept both the positive and negative aspects associated with the lost entity.
■ Grieving is thought to be maladaptive when the mourning process is prolonged, delayed or inhibited, or becomes distorted and exaggerated out of proportion to the situation.
■ Pathological depression is considered to be a distorted reaction.
■ The DSM-IV-TR multiaxial system of diagnostic classification defines five axes in which each individual case is evaluated.
REVIEW QUESTIONS
Self-Examination/Learning Exercise
Select the answer that is most appropriate for each of the following questions.
1. Three years ago, Anna’s dog Lucky, whom she had had for 16 years, was run over by a car and killed. Anna’s daughter reports that since that time, Anna has lost weight, rarely leaves her home, and just sits and talks about Lucky. Anna’s behavior would be considered maladaptive because:
a. it has been more than 3 years since Lucky died.
b. her grief is too intense just over the 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. Based on the information in Question 1, Anna’s grieving behavior would most likely be considered to be:
a. delayed.
b. inhibited.
c. prolonged.
d. distorted.
3. Anna is diagnosed with Major Depression. She is most likely fixed in which stage of the grief process?
a. Denial
b. Anger
c. Depression
d. Acceptance
4. Anna, who is 72 years old, is of the age at which 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, age 72, has been grieving the death of her dog, Lucky, for 3 years. She is not able to take care of her activities of daily living, and wants only to make daily visits to Lucky’s grave. Her daughter has likely put off seeking help for Anna because:
a. women are less likely to seek help for emotional problems than men are.
b. relatives often try to “normalize” the behavior, rather than label it mental illness.
c. she knows that all older people are expected to be a little depressed.
d. she is afraid that the neighbors “will think her mother is crazy.”
6. Anna’s dog Lucky got away from her 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, “he was the very best dog. He always minded me. He always did everything I told him to do.” This represents the defense mechanism of:
a. sublimation.
b. compensation.
c. reaction formation.
d. undoing.
8. Anna has been a widow for 20 years. Her maladaptive grief response to the loss of her dog may be attributed to which of the following? Select all that apply.
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. Inability to prepare in advance for the loss
9. For what reason would Anna’s 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 “There is nothing wrong with me!”
10. Which of the following statements by Anna might suggest that she is achieving resolution of her grief over Lucky’s death?
a. “I don’t cry anymore when I think about Lucky.”
b. “It’s true. Lucky didn’t always mind me. Sometimes he ignored my commands.”
c. “I remember how it happened now. I should have held tighter to his leash!”
d. “I won’t ever have another dog. It’s just too painful to lose them.”
REFERENCES
American Psychiatric Association (APA). (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Text revision. Washington, DC: American Psychiatric Publishing. American Psychiatric Association (APA). (2003). A psychiatric glossary (8th ed.). Washington, DC: American Psychiatric Publishing. Horwitz, A.V. (2002). The social control of mental illness. Clinton Corners, NY: Percheron Press.
Sadock, B.J., & Sadock, V.A. (2007). Synopsis of psychiatry: Behavioral sciences/clinical psychiatry (10th ed.). Baltimore: Lippincott Williams & Wilkins.
Townsend, M.C. (2009). Psychiatric/mental health nursing: Concepts of care in evidence-based practice (6th ed.). Philadelphia: F.A. Davis.
CLASSICAL REFERENCES
Bowlby, J., & Parkes, C.M. (1970). Separation and loss. In E.J. Anthony & C. Koupernik (Eds.), International yearbook for child psychiatry and allied disciplines: The child and his family (Vol. 1). New York: John Wiley & Sons.
Freud, A. (1953). The ego and mechanisms of defense. New York: International Universities Press.
Freud, S. (1961). The ego and the id. In Standard edition of the complete psychological works of Freud (Vol. XIX). London: Hogarth Press.
Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.
Maslow, A. (1970). Motivation and personality (2nd ed.). New York: Harper & Row.
Menninger, K. (1963). The vital balance. New York: Viking Press. Peplau, H. (1963). A working definition of anxiety. In S. Burd & M. Marshall (Eds.), Some clinical approaches to psychiatric nursing. New York: Macmillan.
Selye, H. (1956). The stress of life. New York: McGraw-Hill.
Selye, H. (1974). Stress without distress. New York: Signet Books. Selye, H. (1976). The stress of life (rev. ed.). New York: McGraw-Hill.
2
C HAPTER
Concepts of Personality Development
OBJECTIVES
HOMEWORK ASSIGNMENT
INTRODUCTION
PSYCHOANALYTIC THEORY
INTERPERSONAL THEORY
CHAPTER OUTLINE
THEORY OF PSYCHOSOCIAL DEVELOPMENT
THEORY OF OBJECT RELATIONS A NURSING MODEL—HILDEGARD E. PEPLAU
After reading this chapter, the student will be able to:
1. Define personality.
2. Identify the relevance of knowledge associated with personality development to nursing in the psychiatric/mental health setting.
3. Discuss the major components of the following developmental theories: a. Psychoanalytic theory—Freud b. Interpersonal theory—Sullivan
c. Theory of psychosocial development— Erikson
d. Theory of object relations development—Mahler
e. A nursing model of interpersonal development—Peplau
HOMEWORK ASSIGNMENT
Please read the chapter and answer the following questions.
1. Which part of the personality as described by Freud is developed as the child internalizes the values and morals set forth by primary caregivers?
2. According to Erikson, what happens when the adolescent does not master the tasks of identity versus role confusion?
3. According to Mahler’s theory, the individual with borderline personality disorder harbors fears of abandonment and underlying rage based on fixation in what stage of development?
INTRODUCTION
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) defines personality traits as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts” (p. 686). Nurses must have a basic knowledge of human personality development to understand maladaptive behavioral responses commonly seen in psychiatric clients. Developmental theories identify behaviors associated with various stages through which individuals pass, thereby specifying what is appropriate or inappropriate at each developmental level.
Specialists in child development believe that infancy and early childhood are the major life periods for the origination and occurrence of developmental change. Specialists in life cycle development believe that people continue to develop and change throughout life, thereby suggesting the possibility for renewal and growth in adults.
Developmental stages are identified by age. Behaviors can then be evaluated for age appropriateness. Ideally, an individual successfully fulfills all the tasks associated with one stage before moving on to the next stage (at the appropriate age). In reality, however, this seldom happens. One reason is related to temperament, the inborn personality characteristics that influence an individual’s manner of reacting to the environment and, ultimately, his or her developmental progression (Chess & Thomas, 1986). The environment may also influence one’s developmental pattern. Individuals who are reared in a dysfunctional family system often have retarded ego development. According to specialists in life-cycle development,
behaviors from an unsuccessfully completed stage can be modified and corrected in a later stage.
Stages overlap, and an individual may be working on tasks associated with several stages at one time. When an individual becomes fixed in a lower level of development, with age-inappropriate behaviors focused on fulfillment of those tasks, psychopathology may become evident. Only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress do they constitute personality disorders (APA, 2000).
PSYCHOANALYTIC THEORY
Sigmund Freud (1961), who has been called the father of psychiatry, is credited as the first to identify development by stages. He considered the first 5 years of a child’s life to be the most important because he believed that an individual’s basic character had been formed by the age of 5.
Freud’s personality theory can be conceptualized according to structure and dynamics of the personality, topography of the mind, and stages of personality development.
CORE CONCEPT
Personality
The combination of character, behavioral, temperamental, emotional, and mental traits that is unique to each specific individual.
Structure of the Personality
Freud organized the structure of the personality into three major components: the id, ego, and superego. They are distinguished by their unique functions and different characteristics.
Id
The id is the locus of instinctual drives—the “pleasure principle.” Present at birth, it endows the infant with instinctual drives that seek to satisfy needs and achieve immediate gratification. Id-driven behaviors are impulsive and may be irrational.
Ego
The ego, also called the rational self or the “reality principle,” begins to develop between the ages of 4 and 6 months. The ego experiences the reality of the external world, adapts to it, and responds to it. As the ego develops and gains strength, it seeks to bring the influences of the external world to bear upon the id, to substitute the reality principle for the pleasure principle (Marmer, 2003). A primary function of the ego is one of mediator, that is, to maintain harmony among the external world, the id, and the superego.
Superego
If the id is identified as the pleasure principle, and the ego the reality principle, the superego might be referred to as the “perfection principle.” The superego, which develops between ages 3 and 6 years, internalizes the values and morals set forth by primary caregivers. Derived from a system of rewards and punishments, the superego is composed of two major components: the ego-ideal and the conscience. When a child is consistently rewarded for “good” behavior, the self-esteem is enhanced, and the behavior becomes part of the ego-ideal; that is, it is internalized as part of his or her value system. The conscience is formed when the child is consistently punished for “bad” behavior. The child learns what is considered morally right or wrong from feedback received from parental figures and from society or culture. When moral and ethical principles or even internalized ideals and values are disregarded, the conscience generates a feeling of guilt within the individual. The superego is important in the socialization of the individual because it assists the ego in the control of id impulses. When the superego becomes rigid and punitive, however, problems with low self-confidence and low self-esteem arise.
For behavioral examples of id, ego, and superego, see Table 2–1.
Topography of the Mind
Freud classified all mental contents and operations into three categories: the conscious, the preconscious, and the unconscious.
● The conscious includes all memories that remain within an individual’s awareness. It is the smallest of the three categories. Events and experiences that are easily remembered or retrieved are considered to be within one’s conscious awareness. Examples include telephone numbers, birthdays of self and significant others, dates of special holidays, and what one had for lunch today. The conscious mind is thought to be under the control of the ego, the rational and logical structure of the personality.
● The preconscious includes all memories that may have been forgotten or are not in present awareness but, with attention, can readily be recalled into consciousness. Examples include telephone numbers or addresses once known but little used and feelings associated with significant life events that may have occurred at some time in the past. The preconscious enhances awareness by helping to suppress unpleasant or nonessential memories from consciousness. It is thought to be partially under the control of the superego, which helps to suppress unacceptable thoughts and behaviors.
● The unconscious includes all memories that one is unable to bring to conscious awareness. It is the
TABLE 2–1 Structure of the Personality
Behavioral Examples
Id Ego
“I found this wallet; I will keep the money.”
“Mom and Dad are gone. Let’s party!!!!!”
“I’ll have sex with whomever I please, whenever I please.”
“I already have money. This money doesn’t belong to me. Maybe the person who owns this wallet doesn’t have any money.”
“Mom and Dad said no friends over while they are away. Too risky.”
“Promiscuity can be very dangerous.”
Superego
“It is never right to take something that doesn’t belong to you.”
