Defense Mechanism

Defense Mechanism

Denial Refuses to accept a painful reality,

pretending as if it doesnt exist.
Diabetic eating chocolate candy
Spending money freely when broke
Waiting 3 days to seek help for severe
abdominal pain

Compensation Overachievement in one area to offset real

or perceived deficiencies in another area
Napoleon complex: diminutive man becoming emperor
Nurse with low self-esteem works double shifts so her
supervisor will like her.

Displacement Directing anger toward someone or

onto another, less threatening (safer) substitute.
A person who is mad at the boss yells at his or
her spouse.
A child who is harassed by a bully at school
mistreats a younger sibling.

Dissociation Dealing with emotional conflict by a

temporary alteration in consciousness or identity
Amnesia that prevents recall of yesterdays auto
accident
An adult remembers nothing of childhood sexual abuse.

Identification Taking on attributes and

characteristics of someone admired.
Nursing student becoming a critical care nurse
because this is the specialty of an instructor
she admires.

Fixation Immobilization of a portion of the personality

resulting from unsuccessful completion of
tasks in a developmental stage.
Never learning to delay gratification
Lack of a clear sense of identity as an adult

Intellectualization Excessive focus on logic and

reason to avoid the feelings associated with a
situation.
Person shows no emotional expression when
discussing serious car accident.

Conversion Expression of an emotional conflict through

the development of a physical symptom, usually
sensorimotor in nature
A teenager forbidden to see X-rated movies is tempted
to do so by friends and develops
blindness, and the teenager is unconcerned about the
loss of sight.

Projection Attributing to others feelings

unacceptable to self.
Man who has thought about same-gender
sexual relationship but never had one, beats a
man who is gay.
A person with many prejudices loudly identifies
others as bigots.

Introjection Unconscious blaming of unacceptable

inclinations or thoughts on an external object
A person who dislikes guns becomes an avid hunter, just
like a best friend.

Reaction Formation Expressing an opposite feeling

from what is actually felt and is considered
undesirable.
Student blames failure on teacher being mean.
Man says he beats his wife because she doesnt
listen to him.

Rationalization Acting the opposite of what one thinks or

feels
Woman who never wanted to have children becomes a
super-mom.
Person who despises the boss tells everyone what a
great boss she is.

Sublimation Redirecting unacceptable feelings or

drives into an acceptable channel.
Person who has quit smoking sucks on hard
candy when the urge to smoke arises.
Person goes for a 15-minute walk when
tempted to eat junk food.

Substitution Replacing the desired gratification with one

that is more readily available
Woman who would like to have her own children opens
a day care center.

Undoing Ritualistically negating or undoing

intolerable feelings/thoughts.
A person who cheats on a spouse brings the
spouse a bouquet of roses.
A man who is ruthless in business donates
large amounts of money to charity.
Regression Moving back to a previous
developmental stage in order to feel safe or have
needs met
Five-year-old asks for a bottle when new baby
brother is being fed.

Suppression Conscious exclusion of unacceptable

thoughts and feelings from conscious awareness
A student decides not to think about a parents illness in
order to study for a test.
A woman tells a friend she cannot think about her sons
death right now.
Repression Excluding emotionally painful or anxietyprovoking thoughts and feelings from conscious
awareness
Woman has no memory of the mugging she suffered
yesterday.

PSYCHIATRIC NURSING | 1

 Man pouts like a four-year-old if he is not the

center of his girlfriends attention.
Resistance Overt or covert antagonism toward
remembering or processing anxiety-producing
information
Nurse is too busy with tasks to spend time
talking to a dying patient.
Person attends court-ordered treatment for
alcoholism but refuses to participate.

Woman has no memory before age 7 when she was

removed from abusive parents.

Therapeutic communication

Stages of Personality Development

FREUD'S PSYCHOSEXUAL DEVELOPMENT

Age

Stage

0 18 mo
18 mo 3 yr
3 6 yr
6 12 yr
13 20 yr

Oral
Anal
Phallic
Latency
Genital

Task
Oral gratification
Independence and control (voluntary sphincter control)
Genital focus
Repressed sexuality; channeled sexual drives (sports)
Puberty with sexual interest

SULLIVAN'S INTERPERSONAL THEORY

Age

Stage

0 18 mo

Infancy
Childhood
Juvenile
Preadolescence
Early adolescence

18 mo 6yr
6 9 yr
9 12 yr
12 14 yr
14 - 21 yr
chosexual Development

Late adolescence

Task
Anxiety reduction via oral gratification
Delay in gratification
Satisfying peer relationships
Satisfying same-sex relationships
Satisfying opposite-sex relationships
Lasting intimate oppositesex relationship

ERICKSON'S PSYCHOSOCIAL THEORY

Age
0 18 mo
18 mo 3 yr
3 6 yr
6 12 yr
12 20 yr
20 - 30 yr
30 - 65yr
65yr - death

Stage
Trust vs. mistrust
Autonomy vs.
shame/doubt
Initiative vs. guilt
Inductry vs. inferiority
Identity vs. role
confusion
Intimacy vs. isolation
Generativity vs
stagnation
Ego integrity vs.
despair

Task
Basic trust in mother figure & generalizes
Self control/independence
Initiate and direct own activities
Self confidence through successful performance and recognition
Task integration from previous stages; secure sense of self
Form a lasting relationship or commitment
Achieve life's goals; consider future generations
Life review with meaning from both positives and negatives;
positive self worth

MAHLER'S THEORY OF OBJECT RELATIONS

Age
0 1 mo

Phase(subphase)
1. Normal autism

Task
Basic needs fulfillment (for survival)

PSYCHIATRIC NURSING | 2

1 mo 5mo

5 10mo
10 16 mo
16 24 mo

2. Symbiosis
3. Separation
-individuation
- Differentiation
- Practicing
-Rapprochement

24 - 36 mo

- Consolidation

Awareness of external fulfillment source

Commencement of separateness from mother figure

Locomotor independence; awareness of separateness of self
Acute separateness wareness; seeks emotional refueling from
mother figure
Established sense of separateness; internalizes sustained image
of loved person/object when out of sight; separation anxiety
resolution

PEPLAU'S INTERPERSONAL THEORY

Age
Infant

Stage
Depending on others

Toddler
Early Childhood

Delaying satisfaction
Self identification

Late Childhood

Participation skills

Task
Learning ways to communicate with primary caregiver for
meeting comfort needs
Some delay in self gratificaqtion to please others
Acquisition of appropriate roles and behaviors through
perception of others expectations of self
Competition, compromise, cooperation skills acquisition; sense
of one's place in the world

AUTONOMIC NERVOUS SYSTEM

SYMPATHETIC AND PARASYMPATHETIC EFFECTS

Eye (pupil)
Nasal mucosa
Salivary Gland
Heart
Arteries
Lung
Gastrointestinal tract
Liver

STRUCTURE

SYMPATHETIC
Dilation
Mucus reduction
Saliva reduction
Rate increased
Constriction
Bronchial muscle relaxation
Decreased motility
Conversion of glycogen to glucose

PARASYMPATHETIC
Constriction
Mucus increased
Saliva increased
Rate decreased
Dilation
Bronchial muscle contraction
Increased motility
Glycogen synthesis

Kidney
Bladder
Sweat Glands

increased
Decreased urine
Contraction of sphincter
Increased sweating

Increased urine
Relaxation of sphincter
No change

NEUROTRANSMITTERS
NEUROTRANSMITTER
Dopamine

FUNCTION
Inhibitory

EFFECT
Fine movement, emotional behavior.
Implicated in schizophrenia and

Serotonin

Inhibitory

parkinson's
Sleep, mood, eating behavior.

Gamma-aminobutyric acid (GABA)

Acetylcholine

Inhibitory
Excitatory

Implicated in anxiety and addiction.

Anxiety states.
Arousal, attention, movement.
Increase - spasms
Decrease - paralysis

Geriatric Depression Rating Scale (GDS)

Short Version
Choose the best answer for how you have felt over the past week (circle yes or no):
1. Are you basically satisfied with your life? YES/NO
2. Have you dropped many of your activities and interests? YES/NO
3. Do you feel that your life is empty? YES/NO
4. Do you often get bored? YES/NO

PSYCHIATRIC NURSING | 3

5. Are you in good spirits most of the time? YES/NO

6. Are you afraid that something bad is going to happen to you? YES/NO
7. Do you feel happy most of the time? YES/NO
8. Do you often feel helpless? YES/NO
9. Do you prefer to stay at home, rather than going out and doing new things? YES/NO
10. Do you feel you have more problems with memory than most? YES/NO
11. Do you think it is wonderful to be alive now? YES/NO
12. Do you feel pretty worthless the way you are now? YES/NO
13. Do you feel full of energy? YES/NO
14. Do you feel that your situation is hopeless? YES/NO
15. Do you think that most people are better off than you are? YES/NO
Total Score _
Bold answers _ depression.
GDS Scoring:
1215 Severe depression
811 Moderate depression
58 Mild depression
04 Normal

CULTURALLY MEDIATED BELIEFS AND PRACTICES

Dying/Birth

Role Differences

Religion

Communication

AfricanAmerican

Reluctant to donate
organs

Varies by education
level/socio-economic level

Baptist/other
Protestant/Muslim

Arab-American

Colostrum is believed
harmful to the infant

Men make most decision

and women are
responsible for daily needs

Muslim (usually Sunni)

/Protestant/Greek/Orthodo
x/other Christian

Asian-American

May use
incense/spiritual;
need extra time with
deceased members
Full family
involvement
throughout life cycle

Father/eldest son primary

decision maker

Primarily buddhism and

Catholicism

Varies tribe to tribe

Traditional Native
American or Christian

MexicanAmericans

Family support during

labor; very
expressive during
bereavement

Equal decision making with

all family members

Roman Catholic primarily

RussianAmerican

Father mey not

attend birth; usually
closest family female
does

Men and women share

decision making

Eastern Orthodox and

Judaism; remember
recent oppression

Native
Americans

Eye Contact: demonstrates

respect/trust
Other: Silence may indicate
distrust
Eye Contact:Females may avoid
eye contact with
males/strangers
Other: Supportive family
members may need a break
from caregiving
Eye Contact:Direct eye contact
may be viewed as disrespectful
Other:use interpreters
whenever possible
Eye Contact:eye contact
sustained
Other: American Indian may be
term preferred by older adults
Eye contact: may be avoided
with authority figures
Other: silence may indicate
disagreement with proposed
plan of care
Eye Contact: direct eye contact
acceptable/nodding means
approval
Other: use interpreters
whenever possible

PERCEPTION OF MENTAL HEALTH SERVICES - ETHNOCULTURAL DIFFERENCES

PSYCHIATRIC NURSING | 4

African-Americans
Often distrustful of therapy and mental health services. May seek therapy because of child-focused concerns.
Seek help and support through the church, which provides a sense of belonging and community (social activities/choir). Therapy is
for crazy people
Mexican-Americans
Understanding the migration of the family is important, including who has been left behind. The church in the barrio often provides
community support.
Curanderos (folk healers) may be consulted for problems such as: mal de ojo (evil eye) and susto (fright)
Puerto Ricans
Nominally Catholic, most value the spirit and soul. Many believe in spirits that protect or harm and the value of incense and candles
to ward off the evil eye.
Often underutilize mental health services, and therapist needsto understand that expectations about outcome may differ.
Asian-American
Many Asian-American families are transitioning from the extended family to the nuclear unit and struggling to hold on to old ways
while developing new skills.
Six predictors of mental health problems are:
1) employment/ financial status,
2) gender (women more vulnerable),
3) old age,
4) social isolation,
5) recent immigration, and
6) refugee premigration experiences and postmigration adjustment

Stages of Death and Dying (Kbler-Ross)

1. Denial and Isolation usually temporary state of being unable to accept the possibility of ones death or that of a loved one.
2. Anger replacement of temporary stage one with the reality that death is possible/going to happen. This is the realization that
the future (plans/hopes) will have an end; a realization of the finality of the self. May fight/argue with health care workers/push
family/friends away.
3. Bargaining seeks one last hope or possibility. Enters an agreement or pact with God for one last time or event to take place
before death. (Let me live to see my grandchild born or my child graduate from college.)
4. Depression after time, loss, pain, the person realizes the situation and course of illness will not improve. Necessary stage to reach
acceptance.
5. Acceptance after working/passing through the previous stages, the person finally accepts what is going to happen. This is not
resignation (giving up) or denying and fighting to the very end. It is a stage that allows for peace and dignity. (Kbler-Ross 1997)
Four Levels of Anxiety
Mild Anxiety This is the anxiety that can positively motivate someone to perform at a high level. It helps a person to focus on the
situation at hand. For instance, this kind of anxiety is often experienced by performers before entering the stage.
Moderate Anxiety Anxiety now moves up a notch with narrowing of the perceptual field. The person has trouble attending to
his/her surroundings, although he/she can follow commands/direction.
Severe Anxiety Increasing anxiety brings the person to yet another level, resulting in an inability to attend to his/her
surroundings, except for maybe a detail. Physical symptoms may develop, such as sweating and palpitations (pounding heart).
Anxiety relief is the goal.
Panic Anxiety The level reached is now one of terror where the only concern is to escape. Communication impossible at this point. (Peplau 1963)

PSYCHIATRIC DISORDERS
Dementia Characterized by intellectual decline and usually progressive deficits not only in memory but also in language,
perception, learning, and other areas. Dementia of the Alzheimers type (AD) is the most common dementia, followed by vascular
dementia (ischemic vascular dementia).
Other causes: Infections: HIV, encephalitis, Creutzfeldt-Jackob disease; drugs and alcohol (Wernicke-Korsakoffs syndrome [thiamine
deficiency]); inherited such as Parkinsons disease and Huntingtons disease. Some dementias (AD) are essentially irreversible and
others potentially reversible (drug toxicities, folate deficiency).
Delirium An organic brain syndrome resulting in a disturbance in consciousness and cognition that happens within a short period
of time with a variable course.
Amnestic Disorder Disturbance in memory and impaired ability to learn new information or recall previously learned
information.
Pseudodementia Cognitive difficulty that is actually caused by depression, but may be mistaken for dementia. Need to consider
and rule out in the elderly who may appear to have dementia when actually suffering from depression, which is a treatable disease.
Could be depressed with cognitive deficits as well.
CLINICAL PEARL AD is a progressive and irreversible dementia with a gradually declining course, whereas ischemic vascular
dementia (mini-strokes and transient ischemic attacks) often presents in a stepwise fashion with an acute decline in cognitive
function.
It is important to distinguish between dementia and delirium because delirium can be life threatening and should be viewed as an
emergency.
Delirium can be differentiated from dementia by its rapid onset, fluctuating in and out of a confusional state, and difficulty in
attending to surroundings.

PSYCHIATRIC NURSING | 5

Delirium is usually caused by a physical condition, such as infection, and so the underlying cause needs to be treated. Keep in mind
that a person with dementia may also become delirious.
Dementia with Lewy Bodies
Clients with dementia with Lewy bodies usually present with visual hallucinations, and, unlike AD, the course is usually a rapid one.
ALERT: Important to differentiate AD from dementia with Lewy bodies. Clients with Lewy bodies dementia are very sensitive to
antipsychotics and, because of their psychosis (visual hallucinations), are often treated with an antipsychotic. Such treatment often
results in EPS. Selegiline may slow disease progression.
DEMENTIA OF ALZHEIMER'S TYPE (AD)
Signs &s symptoms

Memory impairment
Inability to learn new
material
Language deterioration
(naming objects)
Inability to execute
typical tasks
(cook/dress self)
Executive functioning
disturbances
(planning/abstract
thinking/new tasks)
Paranoia
Progressive from mild
forgetfullness to
middle and late
dementia (requiring
total ADL)
Course: 19mo - 27 yr
[avg. 10 - 12 yr]

Causes

o Idiopathic
o Many theories
(viral/trauma)
o Pathology shows
neuritic plaques and
neurofibrillary
tangles also amyloid
protein
o Familial AD (presenilin 1
gene)
o Apo-lipoprotein
Egenotype (kukuli
2002)

Rule Outs

Ischemic vascular
dementia
Dementia with lewy
bodies
Alcoholic dementia
(wernicke-karsakoff
[ thiamine
deficiency]; pellagra
[niacin deficiency];
hepatic encephalitis)
Delirium
Depression
Medical disorder (HIV),
syphillis)
Other substance abuse
Psychosis

Labs/Tests/Exam

Mental status exam

Folstein mini mental

state exam

Neuropsychological

testing (boston
naming; wisconsin

card sorting test)

Beck depression

inventory (R/O

depression)

Geriatric depression

scale (R/O depression)

CBC, blood chemistry
(renal,

metabolic/hepatic).
sed rate, T4/TSH, B12,
folate, UA, FTA-Abs,
CTscan/ MRI; HIV titer

Interventions

early diagnosis
symptom treatment
(aggression/agitation)
behavioral management
communication
techniques
environmental safety
checks
antipsychotics
antidepressant
sedatives
antianxiety agents
nutritional
supplemewnts
anti-alzheimer's agents
(e.g., DONEPEZIL
[ARICEPT];
MEMANTINE
[NAMENDA]

Medications to Treat Dementia of the Alzheimers Type

Medications used to treat mild to moderate AD include: tacrine [Cognex], donepezil [Aricept], and galantamine [Reminyl].
A relatively new drug, memantine (Namenda), which is an NMDA receptor antagonist, is the first drug approved for moderate to
severe AD.

POSITIVE AND NEGATIVE SYMPTOMS OF SCHIZOPHRENIA

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