MODULE 1

Foundation of Psychiatric Nursing

Lesson 1 - Terminologies in Psychiatric Nursing
Mental Health - is a state of balance between the individual and the surrounding world,
a state of harmony between oneself and others, and a co- existence between the reality
of the self and that of the others.

Mental Illness - are clinically significant conditions characterized by alterations in

thinking, mood (emotions), behavior associated with personal distress and impaired
functioning.

Psychiatry - It is a branch of medicine that deals with the diagnosis, treatment and
prevention of mental illness.

Psychiatric Nursing - It is a specialized area of nursing practice, employing theories of

human behavior as it is a science, and the purposeful use of self as it is an art , in the
diagnosis and treatment of human responses to actual or potential mental health
problems .

Perception - is the meaningful organization of sensory data and their interpretation in

the light of one’s past experience.

Hyper aesthesia - Increased intensity of sensations, seen in intense emotions and

hypochondriacally (chronic anxiety) personalities. In hyper aesthesia sounds appear
louder, colors brighter, and pain unbearable.

Illusions - Misperceptions or misinterpretations of real external sensory stimuli: e.g.

Shadows may be misperceived as frightening figures. In a fading light rope is
misperceived as a snake.

Hallucinations - Perception in the absence of real external stimuli; experienced as true

perception coming from the external world (not within the mind). E.g. Hearing a voice of
someone when actually nobody is speaking within the hearing distance. (Causes:
Intense emotions, Suggestion, Disorders of sense organs, Sensory deprivation,
Disorders of CNS - epilepsy, Psychiatric disorders)

Auditory hallucinations (Voice, sound, noise) - is a form of hallucination that

involves perceiving sounds without auditory stimulus seen in Psychosis. Three types:
Elementary – noises, bells or undifferentiated whispers; in organic states: Partly
organized- music and completely organized- hallucinatory voices schizophrenia-
persecutory in nature

Types of auditory hallucination:

Second-person hallucinations - voice speaking to the person addressing him as
“you”.

Third-person hallucinations - voice talking about the person as “he” or “she”.

Thought echo - hearing one’s own thoughts being spoken aloud; the voice may come
from inside or outside the head.

Visual hallucination - is the seeing of things that are not there. (Elementary- flashes of
light:

Partly organized- patterns - Completely organized- people, animals, objects.)

Olfactory hallucinations - is the phenomenon of smelling odors that are not really
present. The most common odors are unpleasant smells such as rotting flesh, vomit,
urine, faces, smoke, etc.

Gustatory hallucination - is the perception of taste without a stimulus. Seen in

depression

Tactile hallucinations - Hallucination of touch or surface sensation. Three types:

superficial, kinesthetic (movement of body parts) and visceral (severe pain of separation
of internal organ, twitching etc.).

Formication (type of tactile hallucination) - is the sensation of insects crawling

underneath the skin and is frequently associated with prolonged cocaine use.

Somatic Hallucination - False sensation of things occurring / moving in or to the body,

most often visceral in origin.

Imperative hallucination - Voices giving instructions to patients, who may or may not
feel obliged to carry them out.

Command / commentary hallucinations - The subject hears voices that comment on,
command, or describe the subject's actions or behavior. The person feels obliged to
obey.

Lilliputian hallucinations - A type of visual hallucination. Commonly seen in certain

neurological diseases. Here the object appears either smaller or larger than they
actually are. (micropsia, macropsia). It is seen in Alice in wonderland syndrome.

Scenic hallucinations - hallucinations in which whole scenes are hallucinated like a

cinema film; more common in psychiatric disorders associated with epilepsy. Type of
visual hallucination.
Autoscopy (phantom mirror image) - The person sees himself and knows that it is he.
Sometimes seen in normal subjects when they are depressed or emotionally disturbed.
Commonly seen in borderline disorders and psychosis.

Negative Autoscopy - the patient looks in the mirror and sees no image; in organic
states. Although the sufferer's image may be seen by others, he or she claims not to
see it.

Internal Autoscopy - the subject sees his own internal organs.

Extracampine hallucinations - a hallucination which is outside the limits of the sensory

field. They are hallucinations beyond the possible sensory field. e.g., 'seeing' somebody
standing behind you.

Hypnagogic hallucinations - hallucinations when falling asleep. Hypnopompic

hallucinations: hallucinations when waking from sleep. It can be any type such as
auditory, visual etc.

Mood congruent hallucination - Hallucination in which content is consistent with either

a depressed or manic mood.

Mood incongruent hallucination - Hallucination in which content is not consistent with

either a depressed or manic mood. eg. Depressed voices in depression, self-inflated
worth or power in mania.

Pseudo hallucination - seen in Attention seeking personalities, hysteria.

Derealisation - A subjective sense that the environment is strange and unreal.

Depersonalization - a person’s subjective sense of being unreal, strange and

unfamiliar.

Abnormalities of Possession of thought. (Source of water)

Abnormalities in the stream of thought. (Flow of river)

Abnormalities in the content of thought. (Water, mud etc.)

Abnormalities of Form of thought. (Liquid form of water)

Obsessions - Repetitive ideas, images, feelings or urges insistently entering person’s

mind despite resistance. They are unwanted, distressful and recognized as senseless
and irrational. Obsessions are frequently followed by compelling actions (compulsions).
Common obsessional Contents - dirt/ contamination / cleaning, orderliness,
doubts/checking/counting, aggressive impulses/inappropriate acts, Ruminations:
internal debates in which arguments for and against even the simplest everyday actions
.
Thought alienation - Thoughts are under the control of outside forces and are
participating in it. The types of alienation are;

Thought Insertion - Delusion that some of person’s thoughts being put into the mind by
an external force (other people, certain agency) and these thoughts are recognized as
foreign.

Thought Withdrawal - Delusion that some of person’s thoughts being taken out of the
mind against his will by outside forces. Usually associated with thought blocking. The
experience is passive.

Thought Broadcasting - Delusion that others can read or hear the person’s thoughts,
as they are broadcast over the air, radio or some other unusual way. The experience is
passive.

Dysmorphophobia - A type of overvalued idea where the patient believes one aspect
of his body is abnormal/deformed or imperfect. It is also called as Body dysmorphic
disorder (BDD)

Volubility - abundant or pressured talking. Seen in mania (tachylogia (excessive

speech), verbomania (use of more words)

Flight of ideas -The thoughts follow each other rapidly and there is no general direction
of thinking, seen in mania /excited schizophrenics. Flight of ideas describes excessive
speech at a rapid rate that involves fragmented or unrelated ideas. It is common in
mania. It has also been described in schizophrenia and ADHD.

Pressure of thoughts - Rapid abundant varying thoughts associated with pressure of

speech and flight of ideas.

Poverty of thoughts - Few, slow, unvaried thoughts associated with poverty of speech.
Thought block: Sudden cessation of thought flow with complete emptying of the mind
not caused by an external influence.

Circumstantiality - A pattern of thinking and communication that is demonstrated by

the speaker’s inclusion of many irrelevant and unnecessary details in his speech before
he is able to come to the point. Seen in epileptic personality, obsessional personality
and dementia.

Derailment - Direction of thought is lost and the thought goes away from the intended
theme.
 Tangentiality - It is a form of derailment. Replying to a question in an oblique,
tangential or even irrelevant manner. Wandering from the topic and never returning to it
or providing the information requested. E.g. In answer to the question "Where are you
from?” a response "My dog is from England. They have good fish and chips there. Fish
breathe through gills. “

Thought blocking (thought derivation, snapping off) - sudden arrest of train of

thoughts leaving a “blank”. A new thought may begin after the pause. With no recall of
what was being said or going to be said. Seen in F-20, also in anxious or exhausted
states.

Preservation - It is the repetition of a particular response (such as a word, phrase, or

gesture) regardless of the absence or cessation of a stimulus. It is usually caused by a
brain injury or other organic disorder.

Overvalued Ideas - abnormal beliefs, unique to the individual which dominates his life.
Worry- subjective sense of tension or uneasiness.

Phobias - persistent, pathological, unrealistic fear of an object, situation

Somatic symptoms - bodily complains which are varied in anatomical location and are
usually are not associated with any pathology

Religious preoccupation - seen in OCD

Excessive day dreaming - Schizotypal personality (odd and eccentric people with less
relationship)

Homicidal Ideas-F-20, ASP (Anti-social personality)

Philosophical and Magical ideas

Depressive cognition - ideas of worthlessness, helplessness, hopelessness

Suicidal ideas DSH (Deliberate self-harm)

Inflated self-esteem - mania, narcissistic personality (excessive self-admiration,

disregard for others' feelings etc.)

Delusions - Fixed false beliefs which are not shared by others, are out of keeping with
one’s educational, social and cultural background and are unshakable in the face of
evidence to the contrary.

Primary Delusion - (Autochthonous Delusion) - That which appear suddenly and with
full conviction, but without any previous events leading up to it. Seen in Schizophrenia.
Secondary Delusions - Derived from preceding morbid experience.

Delusional Mood - The experience of change of mood often with anxiety prior to
delusion.

Delusional Perception - in the initial stage of delusion the person make new
perceptions with familiar stimuli such as doubting familiar situations.

Grandiose delusion - Delusion of exaggerated self-importance, power or identity.

Persecutory (paranoid) delusion - Delusion of being persecuted (cheated, mistreated,

etc.)

Delusion of Control/influence - The thoughts, feelings of the patient is controlled by

external forces.

Delusion of jealousy/infidelity - Delusion that a loved person (wife/husband) is

unfaithful (infidelity delusion)

Delusion of Guilt/self-accusation - belief that one is sinner and responsible for the
ruin of family of someone else.

Somatic Delusion - Belief involving functioning of the body. E.g. my brain is melting.

Nihilistic delusion - Delusion of nonexistence of self, part of the body, belongings,

others or the world. Seen in major depression.

Delusion of reference - Delusion that some events and others behavior refer to
oneself.

Delusions of love (‘fantasy lover’, ‘erotomania’) - Delusion that someone, (usually

inaccessible, high social class person) is deeply in love with the patient.
Somatic Passivity: Passive recipient of bodily sensations imposed from outside forces.

Passivity phenomena - also may occur as part of delusions such as our impulses,
actions and feelings are controlled by some external force. Connected with somatic
hallucination.

Delusions of Replacement (Capgras Syndrome) - a belief that important people in

one's life have been replaced by impostors.

Mood-Congruent Delusion - Delusional content has association to mood: - in

depressed mood: delusion of self - accusation.

Mood-Incongruent Delusions - Delusional content has no association to mood, e.g.

patient with elevated mood has delusion of thought insertion.
Systematized Delusion - Delusion united by a single event or theme e.g. delusion of
jealousy/thematically well connected with each other.

Bizarre Delusion - Totally odd and strange delusional belief, e.g. delusion that person’s
acts are controlled by stars.

Loosening of Association - (Loose Association) a thought disorder in which series of

ideas are presented with loosely connected. A manifestation of a thought disorder
whereby the patient's responses to the interviewer's questions are not logically
connected to those that occur before or after. Example: I sang out for my mother ……
for this to hell I went…how long road…is

Neologism - Use of newly coined term, word, or phrase that has not yet been accepted
into mainstream language. E.g. what do you know about him?

Autistic thinking - Thinking not in accordance with consensus reality and emphasizes
preoccupation with inner experience.

Verbigeration - senseless repetition of some words or phrases over and over again.
Peter paid plenty for piping. Plenty for piping paid Peter.”

Word Salad - Meaningless and incoherent mixture of words of phrases. Eg. “It was
shockingly not of the best quality I have known all such evildoers coming out of doors
with the best of intentions!”

Feeling - A positive or negative reaction to some experience

Emotion - A stirred up state due to physiological changes which occurs as a response

to some event and which tends to maintain or abolish the causative event.

Mood - The pervasive feeling tone which is sustained (lasts for a length of time) and
colors the total experience of the person.

Affect - The outward objective expression of the immediate cross sectional emotion at a
given time.

Euthymia - A normal mood state, neither depressed nor manic.

Perplexity - A state of puzzled bewilderment.

Anxiety - Feeling of apprehension accompanied by autonomic symptoms (such as

muscles tension, perspiration and tachycardia), caused by anticipation of danger.

Free-floating anxiety - Diffuse, unfocused anxiety, not attached to a specific danger.

Fear - Anxiety caused by realistic consciously recognized danger.

Panic - Acute, self-limiting, episodic intense attack of anxiety associated with

overwhelming dread and autonomic symptoms.

Phobia - irrational exaggerated fear and avoidance of a specific object, situation or

activity.

Agoraphobia - patients rigidly avoids situations in which it would be difficult to obtain

help.

Social phobia - Intense and excessive fear of being observed by other people E.g:
eating or drinking in public or talking to the other member of sex.

Specific phobia - irrational fear of a specific object or stimulus.

Acrophobia - fear of heights.

Arachnophobia - fear of spiders.

Claustrophobia - fear of closed spaces.

Gamophobia - fear of marriage.

Hemophobia / Haematophobia - fear of blood.

Zoophobia - fear of animals.

Insectophobia - Fear of insects.

Hydrophobia - fear of water.

Astraphobia - fear of thunderstorms.

Agitation - severe feeling of inner tension associated with motor restlessness.

Irritable mood - easily annoyed and provoked to anger.

Dysphoria - mixture feelings of sadness and apprehension.

Depressed mood - feeling of sadness, pessimism and a sense of loneliness.

Anhedonia - lack of pleasure in acts which are normally pleasurable. Eg. Games,
watching movies etc.
Diurnal variation - a variation in the severity of symptoms (mood) depending on the
time of the day.

Grief - Subjective feeling of loss. Sadness appropriate to a real loss (e.g. death of a
relative)

Guilt - unpleasant emotion secondary to doing what is perceived as wrong.

Shame: unpleasant emotion secondary to failure to live up to self-expectations.

Ambivalent Mood - coexistence of two opposing emotional tones towards the same
object in the same person at the same time.

Alexithymia - inability to, or difficulty in, expressing one’s own emotions.

Elevated Mood - a mood more cheerful than usual. The types are as follows;

Euphoria (Stage I) - mild elevation in which feeling of elevated mood with optimism and
self-satisfaction not keeping with ongoing events. Usually seen in hypomania.

Elation (stage II) - (Moderate elevation) – a feeling of confidence and enjoyment, along
with increased Positive mental attitude (PMA). –a feature of manic illness.

Exaltation (stage III) - (severe elevation): intense elation with delusions of grandeur,
seen in severe mania.

Ecstasy (Stage IV) - (very severe elevation): a sense of extreme well-being associated
with a feeling of rapture, bliss and grace. Typically seen in delirious and stuporous
mania.

Expansive Mood - expression of euphoria with an overestimation of self-importance.

Grandiosity - feeling and thinking of great importance (in identity or ability).

Constricted Affect - significant reduction in the normal emotional responses.

Flat affect - absence of emotional expression.

Apathy - lack of emotion, interest or concern, associated with detachment.

Labile Affect - rapid, abrupt changes in emotions in the same setting, unrelated to
external stimuli.

La Belle Indifference - A condition in which the person is unconcerned with symptoms

caused by a conversion disorder. Lack of emotion or concern for the perceptions by
others of one's disability, usually seen in persons with conversion disorder.
Inappropriate Affect - disharmony between emotions and the idea, thought, or speech,
accompanying it.

Cyclothymia - There is cyclical mood variation to a lesser degree than in bipolar

disorder.

Dysthymia - Mild chronic depression.

Echolalia - Meaningless imitation of words or phrases made by others.

Verbigeration - Repetition of words of phases while unable to articulate the next word
in the sentence. Similar to preservation but no significance of stimuli.

Pressure of Speech - rapid, uninterrupted speech that is increased in amount.

Tendency to speak rapidly and frenziedly.

Mutism - inability to speak.

Elective Mutism - refusal to speak in certain circumstances.

Poverty of Speech - restricted amount of speech.

Stuttering (Stammering) - frequent repetition or prolongation of a sound or syllable,

leading to markedly impaired speech fluency.

Cluttering - dysrhythmic rapid and jerky speech.

Clang Associations (Rhyming) - association of word similar in sound but not in

meaning (e.g. That boat hope floats” or “The train brain rained on me.)

Word Salad - incoherent mixture of words and phrases.

Dysphasia - impairment in producing or understanding speech.

Dysarthria - difficulty in articulation (production of appropriate sound) and speech

production.

Sensory Aphasia - nonsensical fluent speech due to damage to Wernicke’s area (a

part of cerebral cortex that deals with sensory speech processing such as
comprehension).

Motor Aphasia - impairment in the ability to formulate fluent speech due to lesion
affecting Broca’s area (a part of cerebral cortex that deals with motor speech
processing).
Coprolalia - forced vocalization/repetition of obscene words or phrases.

Palilalia - is characterized by the repetition of a word or phrase; i.e., the subject

continues to repeat a word or phrase after once having said. It is a perseveratory
phenomenon.

Alogia - lack of speech output.

Psychomotor Retardation - Slowed mental and motor activities.

Stupor - A state in which a person does not react to the surroundings: (mute, immobile
and unresponsive).

Catatonic Stupor - Stupor with rigid posturing.

Psychomotor Agitation - Restlessness with psychological tension. (Patient is not fully

aware of restlessness.)

Catatonic Excitement - Marked agitation, impulsivity and aggression without external

provocation.

Chorea - sudden involuntary movement of several muscle groups with the resultant
action appearing like part of voluntary movement.

Aggression - Verbal or physical hostile behavior, with rage and anger.

Akathisia - Inability to keep sitting still, due to a compelling subjective feeling of

restlessness.

Dyskinesia - Restless movement of group of muscles (face, neck, hands).

Dystonia - Painful severe muscle spasm.

Torticollis - Contraction of neck muscles.

Tics - Sudden repeated involuntary muscle twisting. E.g. repeated blinking, grimacing.

Compulsions - Compelling repeated irrational action associated with obsessions. E.g.

repeated hand washing.

Echopraxia - Imitative repetition of movement of somebody.

Stereotypies - Purposeless repetitive involuntary movements. E.g. Foot tapping, thigh

rocking.
Mannerism - Odd goal-directed movements. E.g. repeated hand movement resembling
a military salute.

Waxy Flexibility - Patient’s limbs may be moved like wax, holding position for long
period of time before returning to previous position. People allowing themselves to be
placed in postures by others, and then maintaining those postures for long periods even
if they are obviously uncomfortable. This occurs in catatonic schizophrenia.

Automatic obedience - the patient carries out every instruction regardless of the
consequences. Perseveration: is a senseless repetition of a goal-directed action, a
particular response, such as a word, phrase, or gesture which has already served its
purpose (beyond their relevance).

Dyspraxia - inability to carryout complex motor tasks, although the component motor
movements are preserved.

Ambitendency - a motor symptom of schizophrenia in which there is an alternating

mixture of automatic obedience and negativism.

Trichotillomania - a condition characterized by an overwhelming urge to pluck out

specific hairs.

Pyromania - is an impulse control disorder in which individuals repeatedly fail to resist

impulses to deliberately start fires, in order to relieve tension or for instant gratification.

Dipsomania - uncontrollable craving for alcohol or compulsive drinking of alcohol.

Kleptomania - a disorder in which the individual impulsively steals things other than
personal use or financial gain.

Negativism - an apparently motiveless resistance to all commands and attempts to be

moved or doing just the opposite.

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LESSON 2 - History of Psychiatry and Psychiatric Nursing
Psychiatry - is a branch of medicine that deals with the diagnosis, treatment and
prevention mental illness

Psychiatric Nursing - is a specialized area of nursing practice employing theories of

human behavior, as a science and the purposeful use of self as an art in the diagnosis
and response to actual or potential mental health problems (American Nurses
Association 1994)

Psychiatric nursing deals with the promotion of mental health, prevention of mental
illness, care and rehabilitation of mentally ill individuals both in hospital and community.

History of Psychiatry Primitive beliefs regarding mental illness:

Individual had been dispossessed of his/her soul Mgt: Returning the soul to the client
Broken a taboo or sinned against another individual or god Mgt: Ritualistic purification

Evil spirits or super natural/magical powers entered the body

Mgt: Exorcism (prayer, noise making)Brutal beating, starvation, Burning, amputated and
tortured Oral preparation of a purgative made from sheep dung and wine Trephining (A
circular opening made on the skull by means of crude stone instruments to let out evil
spirits)

Development of Psychiatry

Pythagoras (BC): developed the concept that the brain is the seat of intellectual activity

Hippocrates (BC): described mental illness as hysteria, mania and depression Plato (
BC) identified the relationship between mind and body. Asclepiades, who is referred to
as the father of psychiatry, made use of simple hygienic measures, diet bath, massage
in place of mechanical restraints.

Aristotle, a Greek philosopher, emphasized on the release of repressed emotions for

the effective treatment of mental illness. He suggested catharsis and music therapy for
the patient with melancholia St. Augustine who believed that although God acted
directly in human affairs, people were responsible for their own actions

Renaissance in Europe (AD): it was believed that demons were the cause of
hallucinations, delusions and sexual activity Mgt: Torture and even death

Important Milestones 1773: The first mental hospital in the US was built in
Williamsburg, Virginia1793: Philip Pinel removed the chains from mentally ill patients
confined in Bicetre, a hospital outside Paris i.e. the first revolution in psychiatry1812:
The first American text book in psychiatry was written by Benjamin Rush, who is
referred to as the father of American Psychiatry

1812: Clifford Beers, an ex- patient of mental hospital wrote the book, “The Mind That
found Itself” based on his bitter experiences in the hospital1912: Eugene Bleuler, a
Swiss psychiatrist coined the term Schizophrenia The Indian Lunacy Act passed1927:
Insulin shock treatment was introduced for schizophrenia1936: frontal lobotomy was
advocated for the management of psychiatric disorders

1938: Electro Convulsive Therapy (ECT) was used for the treatment of psychoses

1939: development of psychoanalytical theory by Sigmund Freud led to new concepts in

the treatment of mental illness.1946: The Bhore committee presented the situation with
regard to mental health services. Based on the recommendations 5 hospitals were set
up at Amirtsar, Hyderabad, Srinagar, Jamnagar and New Delhi

1949: Lithium was first used for the treatment of mania

1952: Chlorpromazine was introduced which brought about a revolution in psycho-

pharmacology1963: The community Mental Health centres Act was passed1978: The
Alma –Ata declaration of ‘Health for all by 2000 AD’ posed a major challenge to Indian
mental health professionals.

1981: Community psychiatric centres were setup experiment with primary mental health
approach at Raipur Rani, Chandigarh and Sakalwara, Bangalore.1982: The Central
Council of India accepted the national Mental Health Policy and brought out the National
Mental Health programme in India.1987: The Indian Mental Health Act was passed

1990: The Govt.of India formed an Action Group at Delhi to pool the opinions of mental
health experts about the National Mental health program NIMHANS Bangalore has
taken up the leadership in orienting heath care professionals about the mental health
programs of our country

Development of Modern Psychiatric Nursing

1872: First training school for nurses based on the Nightingale system was established
by the New England Hospital for women and children, Linda Richards the first Nurse to
graduate from the one-year course, developed 12 training schools in the USA

1882: first school to prepare nurses to care for the mentally ill was opened at Mc Lean
Hospital in Waverly Two-year program was started but few psychological skills were
addressed and much importance was given to custodial care such as personal hygiene,
nutrition, medication etc1913: John Hopkins became the first school of nursing to
include a fully developed course for psychiatry nursing in the curriculum
1943: Psy. Nsg course was started for male nurses

1946: Health survey committee’s report recommended preparation of nursing personnel

in Psy. Nsg also. The existing institutions like mental hospitals in Bangalore and Ranchi
should start training

1952: Dr.Hildegard Peplau defined the therapeutic roles that nurses might play in the
mental health setting. She described the skills and roles of the psy. Nurse in her book
“interpersonal relations in Nursing” . It was the first systematic and theoretical frame
work developed for Psy. Nsg.

1953: Maxwell Jones introduced therapeutic community.

1956: one-year post certificate course in psy. nsg was started at NIMHANS,
Bangalore1960: The focus began to shift to primary prevention and implementing care
and consultation in the communityThe name psychiatric nursing changed in to mental
health nursing. 1970’s when it was known as psychosocial nursing.

1963: Journal of Psy. Nsg and Mental Health services was published.

1964: Mudaliar committee felt the need for preparing large number of Psy. Nurses and
recommended inclusion of Psychiatry in the nursing curriculum.1965: The Indian
Nursing Council included psy. Nsg as a compulsory course in B.Sc. Nsg program 1973:
Standards of psychiatric and mental health nursing practice were enunciated to provide
a means of improving the quality care

1975: Psy. Nsg was offered as an elective subject in M.Sc. Nursing at the RAK College
of Nsg, New Delhi.

1980: Scientific advances in the area of psychobiology, brain imaging techniques,

knowledge about neurotransmitters and neuronal receptors, molecular genetics related
psychiatry etc. emerged. These contributed to the shift from psychodynamic models to
more balanced psychobiological models of psychiatric care.

1986: The Indian Nursing Council made psy. nsg a component of General nursing and
Midwifery course1990: During these years’ integration of neuro sciences into holistic
biopsychosocial practice of psychiatric nursing occurred1994: The above mentioned
changes led to the revision of standards of psychiatric and mental health nsg.

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LESSON 3 – Evolution of Mental Health Psychiatric Nursing
Complimentary therapies - unconventional therapies that encompasses a spectrum of
practices and beliefs, including herbs, visual imagery, acupunctures, and massage
therapy.

Decade of brain - proclamation by the state Congress that explains mental illness as a
disease of the brain. It underscores the significance of technological advances in
neurobiology and genetics and their impact on understanding mental illness.

Deinstitutionalization - caring for people outside the hospital who have been
previously hospitalized for an extended period, caring for people in the community
rather than in a state facility.

Mental Health Movement - a movement that begun more than 25 years ago that
focuses on humane treatment of the mentally ill, initially advocating their release from
state institutions to community mental health centers.

Moral treatment - humane treatment of the mentally ill; for example, releasing clients
from mechanical restraints and improving physical care.

Psychotropic - various pharmacologic agents, such as antidepressants and

antipsychotic, ant manic and antianxiety agents used to affect behavior, mood and
feelings.

Neurobiology - biology of the nervous system, particularly the brain.

Neuroscience - the science and study of the central nervous system.

Insanity - was associated with demonic possession.

Healers - extract unseen spirits through rituals using herbs, ointments and precious
stones.

Mental illness - was perceived as incurable, and treatment of the insane was
sometimes inhumane and brutal.

Mentally ill people:

Often imprisoned or forced to live in streets and beg for food.

For more humane treatment, they depend on charity of religious groups, who dispenses
alms or food or other donations to the needy or poor and ran almshouses and general
hospitals.
First mental asylum: St. Mary of Bethlehem

Built in London, England during the 14th Century.

Conceived as a sanctuary or refuge for the destitute and afflicted.

Model for similar institutions elsewhere.

Continued skepticism about the curability of mental illness.

Asylums became the repositories for prolonged enclosure of the mentally ill.

Insane people were treated more like animals than humans.

Inhabitants were poorly clothed and fed; often chained and caged, and deprived of heat
and sunlight.

The insane was no longer treated as less than human.

The concept of asylum developed from the humane efforts of Pinel and Tuke.

Emphasized the need for pleasant surroundings and diversional and moral treatment of
the mentally ill.

Treatment include (considered controversial): bloodletting and the administration of cold

and hot baths, harsh purgatives, and emetics.

Considers inducement of fright or shock would cause the mentally ill to regain their
insanity.

Invented the tranquilizer chair and the Gyrator.

Tranquilizer chair- the mentally ill’s extremities is strapped down and this reduces motor
and pulse rates; thought to produce calming effect.

Gyrator- a form of shock therapy consisting of a rotating, swinging platform onto which
the person was strapped and moved at high speed; Thought to increase cerebral
circulation.

Author of the first American treatise on Psychiatry: Medical Inquiries and Observations
upon the Disease of the Mind.

Advocated kindness and moral treatment.

Greatest impact came after he was placed in charge of Bicerte Hospital.

Proved that releasing the insane from chains and providing moral treatment improved
their prospect.

William Tuke (1732-1822)

Began a 4-yaer dynasty that advocated humane treatment of the mentally ill.

Franz Anton Mesmer (1734- 1815)

Renewed the art of suggestive healing that stemmed from the ancient use of trances,
which became the basis of hypnosis.

U.S. and other European Countries began a movement that championed reformation of
ideas in establishing state hospitals.

1772 - First psychiatric hospital in America in Williamsburg, Virginia.

1817 - Mclean Asylum in Massachusetts became the first US institution to provide

humane treatment for the mentally ill.

Humane treatment- emphasized an environment of understanding and promoted a

sense of contentment and mental and physical health.

Increased concerns and sensitivity to the needs of the mentally ill generated a need for
better-educated attendants to care for severely disturbed clients.

A retired school teacher from Massachusetts.

Led crusade that brought attention of these conditions to the public and legislature.

The result is an improvement in standards of care for the mentally ill which led to
proliferation of state hospitals.

The first American Psychiatric Nurse

Graduate of New England Hospital for Women

Developed nursing care in state hospitals and also directed a school of psychiatric
Nursing in Mclean Psychiatric Asylum in 1880.

Her efforts resulted to the development of school for nurses in more than 30 asylums

Exploration of the reasons for mental disease accelerated with contributions from
numerous theorists and researchers who laid the foundation for understanding and
demystifying mental illness.
Initiated psychobiological theory and dynamic concept of psychiatric care.

Theory centered on treatment rather than disease and integrated biochemical, genetic,
psycho social, and environmental stresses on mental illness.

Had been treated for mental illness.

Contributed to preventive care though his classic work, A Mind That Found Itself,
published in 1908.

Played a major role in establishing Mental Health Movement in New Haven,

Connecticut, in 1908 and promoting the early detection of mental illness.

Devised a classification of mental disorders.

Shifted from an emphasis on research in the path biological laboratory to the

observation and research in conditions known as praecox dementia and mania.

Coined the term schizophrenia and included its characteristics the four as: apathy,
associative looseness, autism, and ambivalence.

Development of psychoanalysis, psychosexual theories, and neurosis.

Psychoanalysis- a method that serves as the basis for treatment and a theory for
personality development.

Founded analytic psychology.

Proposed and originated the concepts extroverted and introverted personality.

Integrated spiritual concepts, reasoning, ancestral emotional trends, and mysticism, and
the creative notion of human beings.

Objected to Freud’s notions that neurosis and personality development were based on
biological drives.

Her theory suggested that neuroses stem from cultural factors and impaired
interpersonal relationships.

Postulated the Hypothesis of interpersonal theory and the development of

multidisciplinary approaches to psychiatric and milieu therapy.

He surmised that anxiety could be reduced through a meaningful interpersonal

relationship that stresses the process of effective communication.

A deliberate shift from institutional care in state hospitals to community facilities.

Community mental health centers: provides less restrictive treatment located closer to
homes, families and friends.

Declared by the US Congress as the Decade of the Brain Increase in brain research;
increased interest in biologic explanations for mental disorders. Significant changes in
public awareness which enabled clinicians to address relatively complex topics with
patients and families. Nursing responded by significant augmentation of psychobiologic
content in academic nursing programs and a torrent of continuing education programs.

“Nursing Mental Diseases” Written by Harriet Bailey in 1920 in 1937, psychiatric nursing
became a part of the curriculum of general nursing programs.

Hildegard Peplau Developed a model for psychiatric nursing practice wrote the book
“Interpersonal Relationship in Nursing” (1952), heavily influenced by Harry Stack
Sullivan. Emphasizes the interpersonal dimension of practice. Wrote a history of
psychiatric nursing Single most important figure in psychiatric nursing

The Diagnostic and Statistical Manual of Mental Disorders (DSM): outlines the signs
and symptoms required in order for clinicians to assign a specific diagnosis to a patient.
Has been published in six editions since its inception in 1952

Axis I: Clinical disorders (e.g., schizophrenia, major depression, bipolar disorder) Axis
II: Personality or developmental disorders (e.g., paranoid and borderline personality
disorders, mental retardation) Axis III: General medical conditions that relate to axis I
or II or have bearing on treatment (e.g., neoplasms, endocrine disorders) Axis IV:
Severity of psychosocial stressors (e.g., divorce, housing, educational issues) Axis V:
Global assessment of functioning, on a scale of 0 to 100 (e.g., score of 30 means that
the patient’s behavior is highly influenced by delusions and hallucinations)

Was established thru Public Works Act 3258

Was first known as Insular Psychopathic Hospital, situated on a hilly piece of land in
Barrio Mauway, Mandaluyong, Rizal and was formally opened on December 17, 1928.

Later known as National Mental Hospital

November 12, 1986: was given its present name National Center for Mental Health thru
Memorandum Circular No. 48 of the Office of the President.

January 30, 1987: categorized as Special Research Training Center and Hospital
under the DOH

Today: Bed capacity: 4,200

Daily average in-patients: 3, 400 ◦ 46.7 hectares ◦ 35 pavilions/ cottages ◦ 52 wards

Personnel: 1,993 ◦ Doctors: 116 ◦ Nurses: 375 ◦ Administrative staff: 651 ◦ Medical

Ancillary Personnel: 196

A special training and research hospital mandated to render a comprehensive

(preventive, promotive, curative and rehabilitative) range of quality mental health
services nationwide. Gives and creates venues for quality mental health education,
training and research geared towards hospital and community mental health services
nationwide.

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practice
 MODULE 2
Concepts of Mental Health and
Mental Illness
Lesson 1 – Mental Health
MENTAL HEALTH is defined as a state of complete physical, mental and social
wellbeing and not merely the absence of disease or infirmity.

WHO DEFINITION
The positive dimension of mental health is stressed in whose definition of health as
contained in its constitution.

FEW FACTS
Depression is characterized by sustained sadness and loss of interest along with
psychological, behavioral and physical symptoms. It is ranked as the leading cause of
disability worldwide

About half of mental disorders begin before the age of 14. Around 20% of the world's
children and adolescents are estimated to have mental disorders or problems, with
similar types of disorders being reported across cultures.

MENTAL HEALTH
Mental health is not just the absence of mental disorder. It is defined as a state of well-
being in which every individual realizes his or her own potential, can cope with the
normal stresses of life, can work productively and fruitfully, and is able to make a
contribution to her or his community.

HISTORY
Mentally ill were considered to be possessed by devils.  Patients were locked up in tall
jail like buildings, far removed from the center of population, alienated from the rest of
society. During the 20th century, psychiatry began to make scientific advance.

Mental health is thus the balanced develop- meant of the individual’s personality and
emotional attitude which enables him to live harmoniously with his fellow men.  Mental
health is not exclusively a matter of relation between persons. It is also a matter of
relation of the individual towards the community he lives in, towards the society of which
the community is a part.

PROBLEM STATEMENT
WORLD:
Mental and behavioral disorders are found in people of all regions, all countries and all
societies.

An analysis done by WHO shows that neuro psychiatric conditions, which included a
selection of these disorders had an aggregate point prevalence of 10% for adults.
INDIA
Survey in India suggest morbidity rate of not less than 18 – 20 per 1000,and the types
of illness and their prevalence are very much the same as in other parts of the world.
The number of specialized hospitals for mental disorder patients in the country are 47
with total number of beds about 10329.

WHO DAY 2001 THEME

MENTAL HEALTH: STOP EXCLUSION – DARE TO CARE

INDIA: NEW OPD CASES IN 2004 IN MENTAL HOSPITALS

PSYCHOTIC SUBSTANCE - 6737
SCHIZOPHRENIA – 55869
MOOD DISORDER - 31555
NEUROTIC – 38482
BEHAVIOUR SYNDROME – 3417
PERSONALITY DISORDER – 906
MENTAL RETARDATION - 4256
CHILDHOOD DISORDER – 885
PSYCHOLOGICAL DISORDER – 1151
ORGANIC DISORDER – 4577
UNSPECIFIED DISORDERS - 2904

CHARACTERISTICS OF A MENTALLY HEALTHY PERSON

 He feels comfortable about himself, he feels reasonably secure and adequate.
He neither underestimates his own ability.
 The mentally healthy person feels right towards others. This means that he is
able to be interested in others and to love them. He is able to like and trust
others.
 The mentally healthy person is able to meet the demands of life. He is not
bowled over by his own emotions of fear, anger, love or guilt.

WARNING SIGNALS OF POOR MENTAL HEALTH

1. Are you always worrying?
2. Are you unable to concentrate because of unrecognized reasons?
3. Are you continually unhappy without justified cause?
4. Do you lose temper easily and often?
5. Are you troubled by regular insomnia?
6. Do you have wide fluctuations in your mood?
7. Do you continually dislike to be with people?
8. Are you upset if the routine of your life is disturbed?
9. Do your children consistently get on your nerves?
10. Are you ‘browned off’ and constantly bitter
11.Are you afraid without real cause?
12. Are you always right and the other person always wrong?
13. Do you have numerous aches and pains for which no doctor can find a physical
cause?

TYPES OF MENTAL ILLNESS

 Organic disorders – eg. dementia in Alzheimer’s disease.
 Mental and behavioral disorders due to psychoactive substance use – eg.
Alcohol, opioid dependence syndrome.
 Schizophrenia and delusional disorders – eg. Paranoid schizophrenia, delusional
disorder, acute and transient psychotic disorder.
 Mood (affective) disorders – eg. Bipolar affective disorder, depressive episode.

TYPES OF MENTAL ILLNESS

 Neurotic, stress related disorders – eg. Generalized anxiety disorder, obsessive

– compulsive disorders.
 Behavioral syndromes – eg. Eating disorder, non-organic sleep disorders.
 Disorder of adult personality and behavior eg. Paranoid personality disorder.
 Mental retardation.

TYPES OF MENTAL ILLNESS

 Disorders of psychological development – eg. Specific reading disorders,

childhood autism.
 Behavioral and emotional disorders with onset in childhood – eg. Hyperkinetic
disorders, tic disorders, conduct disorders.
 Unspecified mental disorder.

MAJOR MENTAL ILLNESSES:

 SCHIZOPHRENIA OR SPLIT PERSONALITY

 MANIC DEPRESSIVE PSYCHOSIS
 PARANOIA

MINOR MENTAL ILLNESSES:

 NEUROSIS OR PSYCHONEUROSIS
 PERSONALITY AND CHARACTER DISORDERS

CAUSES OF MENTAL ILLHEALTH

ORGANIC CONDITIONS:
1. Cerebral arteriosclerosis
2. Neoplasms
3. Metabolic diseases
4. Neurological diseases
5. Endocrine diseases
6. Epilepsy, TB, Leprosy etc.

HEREDITY:
Child of 2 schizophrenic parents is 40 times more likely to develop schizophrenia.

SOCIAL PATHOLOGICAL CAUSES:

Social and environmental factors associated with mental ill health comprise: Worries,
anxieties, emotional stress, tension, frustration, unhappy marriages, broken homes,
poverty, industrialization, urbanization, changing family structure, population mobility,
economic insecurity, cruelty, rejection, neglect.

ENVIRONMENTAL FACTORS

 Toxic substances: carbon disulphide, mercury, manganese, tin, lead

compounds.
 Psychotropic drugs: barbiturates, alcohol, griesofulvin.
 Nutritional factors: thiamine and pyridoxine deficiency.
 Minerals: deficiency of iodine.
 Infective agents: infectious diseases e.g. measles, rubella during prenatal,
perinatal, and postnatal period of life have adverse effect on brains development.
 Traumatic factors: Road and occupational accidents.
 Radiation: CNS is most sensitive to radiation during the period of neural
development.

CRUCIAL POINTS IN LIFE OF HUMAN BEINGS

 Prenatal period: Pregnancy is a stressful period for some women.

 First 5 years of life: Roots of mental health are in early childhood. Broken
homes are likely to produce behavior disorders in children.
 School child: Everything that happens in school affects the mental health of
child.
 Adolescence: The transition from adolescence to manhood is often a stormy
one and fraught with dangers to mental health manifested in form of mental ill
health among the young.
 Old age: Causes are organic conditions of brain, economic insecurity, lack of
home, poor status and insecurity.

NEEDS OF MAN / WOMAN

1. The need for affection.

2. The need for belonging.
3. The need for independence.
4. The need for achievement.
5. The need for recognition.
6. The need for sense of personal worth.
7. The need for self-actualization.

PREVENTIVE ASPECTS

 PRIMARY PREVENTION: Improving the social environment, promotion of social,

emotional and physical wellbeing of all people. Working for better living
conditions/health.

 SECONDARY PREVENTION: Early diagnosis of mental illness and of social and

emotional disturbances through screening programmes in schools, university,
industry and provision of treatment facilities. Family based health services have
much role to play. Family counseling is also a method for helping the ill.

 TERTIARY PREVENTION: It aims to reduce the duration of mental illness and

thus reduce the stress they create for the family and the community. The goal at
this level is to prevent further break down and disruption.

MENTAL HEALTH SERVICES

 Early diagnosis and treatment.

 Rehabilitation.
 Group and individual psychotherapy.
 Mental health education.
 Use of modern psychoactive drugs.
 After care services.

COMMUNITY MENTAL HEALTH PROGRAMME

 Inpatient services
 Outpatient services
 Partial hospitalization
 Emergency services
 Diagnostic services
 Pre and after care services
 Education services
 Training, research and evaluation

HUMAN RIGHTS OF MENTALLY ILL

“ALL PERSONS WITH A MENTAL ILLNESS OR WHO ARE BEING TREATED AS
SUCH PERSONS ,SHALL BE TREATED WITH HUMANITY AND RESPECT FOR THE
INHERENT DIGNITY OF THE HUMAN PERSON … THERE SHALL BE NO
DISCRIMINATION ON THE GROUNDS OF MENTAL ILLNESS …” UN 1991
ALCOHOLISM AND DRUG DEPENDENCE

 DEFINITION: Drug is defined as any substance that when taken into living
organism, may modify one or more of its functions (WHO).

 DRUG ABUSE: Self administration of a drug for non-medical reasons, in

quantities and frequencies which may impair an individual’s ability to function
effectively, and which may result in social, physical or emotional harm.

DRUG DEPENDENCE

A state of psychic, sometimes also physical, resulting from the interaction

between a living organism and a drug, characterized by behavioral and other responses
that always include a compulsion to take the drug on a continuous or periodic basis in
order to experience its psychic effects and sometimes to avoid the discomfort of its
absence.

THE PROBLEM

 The non-medical use of alcohol and other psychoactive drugs has become a
matter of serious concern in many countries.
 An estimated 12 – 20 million people smoke marijuana in US.
 Experience in Sweden indicates drug dependence reached a peak in the age
group 12 – 20 years and the problem is less among girls.
 The problem of drug dependence has reached an epidemic proportions in many
countries.

AGENT FACTORS

DEPENDENCE PRODUCING DRUGS:

1. Alcohol
2. Opioids
3. Cannabinoids
4. Sedatives or hypnotics
5. Cocaine
6. Other stimulants including caffeine
7. Hallucinogens
8. Tobacco
9. Volatile solvents
10. Other psychoactive substances

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Lesson 2 - Mental Health Care Delivery System
MENTAL HEALTH PROGRAM

Description

Mental health and well-being is a concern of all. Addressing concerns related to MNS
contributes to the attainment of the SDGs. Through a comprehensive mental health
program that includes a wide range of promotive, preventive, treatment and
rehabilitative services; that is for all individuals across the life course especially those at
risk of and suffering from MNS disorders; integrated in various treatment settings from
community to facility that is implemented from the national to the barangay level; and
backed with institutional support mechanisms from different government agencies and
CSOs, we hope to attain the highest possible level of health for the nation because
there is no Universal Health Care without mental health

Vision

A society that promotes the well-being of all Filipinos, supported by transformative multi-
sectoral partnerships, comprehensive mental health policies and programs, and a
responsive service delivery network

Mission

To promote over-all wellness of all Filipinos, prevent mental, psychosocial, and

neurologic disorders, substance abuse and other forms of addiction, and reduce burden
of disease by improving access to quality care and recovery in order to attain the
highest possible level of health to participate fully in society.

Objectives

1. To promote participatory governance and leadership in mental health

2. To strengthen coverage of mental health services through multi-sectoral
partnership to provide high quality service aiming at best patient experience
in a responsive service delivery network
3. To harness capacities of LGUs and organized groups to implement
promotive and preventive interventions on mental health
4. To leverage quality data and research evidence for mental health
5. To set standards for compliance in different aspects of services

Program Components

1. Wellness of Daily Living

  All health/social/poverty reduction/safety and security programs and the
like are protective factors in general for the entire population
 Promotion of Healthy Lifestyle, Prevention and Control of Diseases,
Family wellness programs, etc
 School and workplace health and wellness programs

2. Extreme Life Experience

 Provision of mental health and psychosocial support (MHPSS) during

personal and community wide disasters

3. Mental Disorder
4. Neurologic Disorders
5. Substance Abuse and other Forms of Addiction

 Provision of services for mental, neurologic and substance use disorders

at the primary level from assessment, treatment and management to
referral; and provision of psychotropic drugs which are provided for free.
 Enhancement of mental health facilities under HFEP

Partner Institutions

NGAs ( DOLE, DSWD, DepEd, Tesda, CHED, DILG)

NGOs (WHO, PPA, PAP, PNA, PLAE, AWIT Foundation, WAPR, NGF)

Policies and Laws

DOH Administrative Order No. 8 series of 2001 The National Mental Health Policy
DOH Administrative Order No. 2016-0039 Revised Operational Framework for a
Comprehensive National Mental Health Program
Republic Act No. 11036 Mental Health Act

Strategies, Action Points and Timeline

 Governance
 Service coverage
 Advocacy
 Evidence
 Regulation

Program Accomplishments/Status

1. Passage of the Republic Act No. 11036 dated June 20, 2018 "An Act
Establishing a National Mental Health Policy for the Purpose of Enhancing the
Delivery of Integrated Mental Health Services, Promoting and Protecting the
 Rights of Persons Utilizing Psychiatric, Neurologic and Psychosocial Health
Services, Appropriating Funds Therefore and for Other Purposes"
2. DOH Administrative Order No. 2016-0039 dated October 28, 2016 " Revised
Operational Framework for a Comprehensive National Mental Health Program"
3. National Mental Health Program Strategic Plan 2018-2022
4. Harmonized MHPPS Training Manual
5. Development of the Implementing Rules and Regulation of the RA No. 11036
also known as The Mental Health Act
6. Conduct of the Advocacy Activities such as 2nd Public Health Convention on
Mental Health, Observance of the World Health Day, World Suicide Prevention
Day, National Mental Health Week and Mental Health Fairs
7. Training on Mental Health Gap Action Programme
8. Conduct of The National Prevalence Survey on Mental Health
9. Establishment of the Medicine Access Program for Mental Health

Calendar of Activities

September 10 - World Suicide Prevention Day

October 10 -World Mental Health Day
2nd Week of Ocotber - National Mental Week

Statistics

The World Health Organization (WHO) estimates that

a. 154 million people suffer from depression

b. million from schizophrenia
c. 877,000 people die by suicide every year
d. 50 million people suffer from epilepsy
e. 24 million from Alzheimer’s disease and other dementias
f. 15.3 million persons with drug use disorders

In the Philippines

1. 2004 WHO study, up to 60% of people attending primary care clinics daily in the
country are estimated to have one or more MNS disorders.
2. 2000 Census of Population and Housing showed that mental illness and mental
retardation rank 3rd and 4th respectively among the types of disabilities in the
country (88/100,000
3. Data from the Philippine General Hospital in 2014 show that epilepsy accounts
for 33.44% of adult and 66.20% of pediatric neurologic out-patient visits per
year.
4. Drug use prevalence among Filipinos aged 10 to 69 years old is at 2.3%, or an
estimated 1.8 million users according to the DDB 2015 Nationwide Survey on the
Nature and Extent of Drug Abuse in the Philippines
5. 2011 WHO Global School-Based Health Survey has shown that in the
Philippines, 16% of students between 13-15 years old have ever seriously
considered attempting suicide while 13% have actually attempted suicide one or
more times during the past year.
6. The incidence of suicide in males increased from 0.23 to 3.59 per 100,000
between 1984 and 2005 while rates rose from 0.12 to 1.09 per 100,000 in
females (Redaniel, Dalida and Gunnell, 2011).
7. Intentional self-harm is the 9th leading cause of death among the 20-24 years old
(DOH, 2003).
8. A study conducted among government employees in Metro Manila revealed that
32% out of 327 respondents have experienced a mental health problem in their
lifetime (DOH 2006).
9. Based on Global Epidemiology on Kaplan and Sadock’s Synopsis of
Psychiatry, 2015 and Kaufman’s Clinical Neurology for Psychiatrists, 7th
edition, 2013
A. Schizophrenia ---1% ….1 Million
B. Bipolar ---1% …. 1 Million
C. Major Depressive Disorder ---17% …. 17 M
D. Dementia --- 5% (of older than 65) ….
E. Epilepsy ---0.06% …. 600,000
Lesson 3 - Guiding Principles in Psychiatric Nursing
Principles of Psychiatric Nursing

The basic principles in Psychiatric Nursing are as follows:

1. Accepting patients as exactly as they are

2. Maintaining contact with reality
3. Seeking validation from patient
4. Self-understanding used as a therapeutic tool
5. Nurse’s personal contribution
6. Influence of expectations of behavior
7. Consistency and patient security
8. Reassurance
9. Changes in patient behavior through emotional experience
10. Avoiding increased patient anxiety
11. Consideration of reason for behavior
12. Necessity of Motor and Sensory stimulation
13. Realistic nurse patient relationship

1. Accepting patients as exactly as they are:

• The goal is to convey to the patient as a respect for him/ her as an
individual human being who possesses worth and dignity.

Acceptance is conveyed through many avenues of approach such as:

1. Non-judgmental and non-punitive relationship with patient.
• A patient's behavior is no more right or wrong, good or bad.
• You can feel shocked from his or her behavior but do not make the patient
feel that he has insulted and must be punished.

A non-punitive approach:
Do not punish neither directly nor indirectly for his expressions of behavior.

The means of punishment consists of measures such as:

a. avoiding a patient except when something must be done for him.
b. Telling him something un-pleasant
c. calling attention to his defects by talking to him.
d. Reducing him to a diagnosis.
e. Failing to explain what is being done to him.
f. Laughing at his fears.
g. Expecting him to know and behave as though hospital routine were more important
than him.
h. Demanding that he respects doctors and nurses, and showing him annoyance and
disapproval face.
Showing interest in the patient as a person and not as a case or clinical problem.
• Reading patient's chart by the nurse
• Studying textbooks for increased understanding of the development of the
behavior pattern
• Using time spent with him on those things which he is interested
• Nurses awareness of patient's likes and dislikes
• Attain patient's requests and if not explain to them the reason for not
meeting it
• Listen carefully to client’s complaints and expressions
• Accept patient's fears as a real to him

Recognizing the feelings patients do express:

• The nurse must focus his/her attention upon understanding what the
feeling means to the patients E.g. “I’d like to break someone's neck,
means that he is angry.
• Use of open-end question. It does not direct the patient's answer in any
specific direction. E.g. "Would you care to tell me about it?"

Talking provides a means of keeping acceptance of patients.

• The conversation should center on the patient, on his needs, wants and
on his interests, not on the nurse's
• Nurse can use Understanding approach, reflection and open-end
questions

Listening to Patients
• Listening requires hearing, proper interpretation and selective
responsiveness.
• Nurse can encouraging patients to talk through non-directive comments
and through interests in what the patient is saying.

Permitting patients to express emotions

• Anxiety, fear, hostility, hate and anger should be expected, tolerated and
allowed expression but without physiologic or physical danger to
themselves and others.

2. Maintaining contact with reality

• Clients tend to see reality as they want it to be rather than what it is.
• There must not be support for the unrealistic ideas, assumptions or
behavior. Reality must be called to the patient's attention.

3. Seeking Validation from patient

• It is the meaning of feelings and behavior from the patient’s point of view
thus the nurse has to check against the nurse's interpretation of how he
sees things.
4. Self- understanding used as a therapeutic tool
• The nurse should feel some security about her ability to respond
appropriately to patient behavior by understanding her behavior and
attitude towards mental illness first
• The nurse can participate in group conferences about patient care.

5. Nurse's personal contribution

• Self-understanding of how nurse really feels is so important and
stereotyped behavior response to situations and patients is potentially
dangerous.
• The inconsistency between feelings and actions lessens the nurse's
effectiveness in a relationship

6. Influence of expectations of behavior

• It is important to see the potential for growth in every patient this makes the
nurse to be active as a resources person.

7. Consistency and patient security

• The nurse has to be consistent in attitude, behavior, and feelings and routine in
the psychiatric hospital to help the patient to reduce the number of decisions he
is called upon to make

8. Reassurance

Reassurance can best be given to patient by:

• Attention to matters that are important to him/her.
• Allowing patient to be as sick as he needs to be
• complete awareness and acceptance of how the patient actually feels.
• Doing things without asking anything of the patient in return, such as improved
behavior or a show of appreciation.

9. Changes in patient behavior through emotional experience

• Help patient to go through experience and develop their own feelings toward
subject
• This involves the use of acceptance, discriminating listening, focus of
relationships upon the patient, and involvement with the patient.

10. Avoiding increased patient anxiety

• Demands upon the patient that he obviously cannot meet. e.g. to insist that a
depressed patient cheer-up, that an over active patient sits down and keeps
quiet. Failure causes anxiety to patient
• Careless conversations
• Focusing attention on patient's defects, failing abilities
• Insincerity
• Threats, by sharp commands
• Avoid topics/situations that increase patient's anxiety
 • Avoid exposing the patient's failing ability
• Avoid focusing attention on patient's weaknesses

11. Consideration of reason for behavior

• Viewing patient's behavior objectively is important in understanding why the
patient behaves in a specific way.
• Objectivity is the ability to evaluate a situation of the patient's behavior, on the
basis of what is actually happening rather than on the basis of one's personal
feelings

12. Necessity of Motor and Sensory Stimulation

• Opportunity must be given to psychiatric patients on exercises, games or mental

tasks to increase the sense of achievement

13. Realistic nurse patient relationship

• It has to be therapeutic relationship and limitations within the relationships
• It is to protect the patient from demanding more than possibly he can receive
• It has a beginning, it develops once a relationship is established and it has an
end. A relationship based on mutual respect and trust will tolerate mistakes and
the strains and stresses of termination.

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Psychiatric Nursing
• Psychiatry - is a branch of medicine that deals with the
diagnosis, treatment and prevention of mental illness

• Psychiatric Nursing - is a specialized area of nursing

practice employing theories of human behavior, as a
science and the purposeful use of self as an art in the
diagnosis and response to actual or potential mental
health problems (American Nurses Association 1994)
 History of Psychiatry Primitive beliefs regarding mental illness:
Individual had been dispossessed of his/her soul

Evil spirits or super natural/magical powers entered the

body
……….
Pythagoras (BC): developed the concept that the brain is the
seat of intellectual activity

Hippocrates (BC): described mental illness as hysteria, mania

and depression
• Plato ( BC) identified the relationship between mind
and body.

• Asclepiades, who is referred to as the father of

psychiatry, made use of simple hygienic measures, diet
bath, massage in place of mechanical restraints.

• Aristotle, a Greek philosopher, emphasized on the

release of repressed emotions for the effective
treatment of mental illness
• Renaissance in Europe (AD): it was
believed that demons were the cause of
hallucinations, delusions and sexual activity
Mgt: Torture and even death

• Important Milestones 1773: The first mental

hospital in the US was built in Williamsburg,
Virginia1793: Philip Pinel removed the chains
from mentally ill patients
• 1812: Clifford Beers, an ex- patient of mental hospital wrote the book,
“The Mind That found Itself” based on his bitter experiences in the
hospital1912:

• Eugene Bleuler, a Swiss psychiatrist coined the term Schizophrenia The

Indian Lunacy Act passed1927: Insulin shock treatment was
introduced for schizophrenia1936: frontal lobotomy was advocated for
the management of psychiatric disorders

• 1938: Electro Convulsive Therapy (ECT) was used for the treatment of
psychoses
• 1939: development of psychoanalytical theory by
Sigmund Freud led to new concepts in the
treatment of mental illness.

• 1949: Lithium was first used for the treatment of

mania

• 1952: Chlorpromazine was introduced which

brought about a revolution in psycho-
pharmacology1963.
• 1981: Community psychiatric centres were setup experiment with
primary mental health approach

• 1990: The Govt.of India formed an Action Group at Delhi to pool

the opinions of mental health experts about the National Mental
health program
• 1872: First training school for nurses based on the Nightingale
system was established by the New England Hospital for
women and children,

• Linda Richards the first Nurse to graduate from the one-year

course, developed 12 training schools in the USA
• 1882: first school to prepare nurses to care for the
mentally ill was opened at Mc Lean Hospital in
Waverly

• 1943: Psy. Nsg course was started for male nurses

• 1946: Health survey committee’s report recommended

preparation of nursing personnel in Psy. Nsg

• 1952: Dr. Hildegard Peplau defined the therapeutic

roles that nurses might play in the mental health
setting.
• 1953: Maxwell Jones introduced therapeutic community.

• 1956: one-year post certificate course in psy. nsg was started at

NIMHANS, Bangalore1960:

• 1963: Journal of Psy. Nsg and Mental Health services was published.

• 1964: Mudaliar committee felt the need for preparing large number of Psy.
Nurses and recommended inclusion of Psychiatry in the nursing
curriculum.1965:
•
1975: Psy. Nsg was offered as an elective subject in M.Sc. Nursing at the
RAK College of Nsg, New Delhi.
• 1980: Scientific advances in the area of
psychobiology, brain imaging techniques,
knowledge about neurotransmitters and
neuronal receptors, molecular genetics related
psychiatry etc. emerged.

• 1986: The Indian Nursing Council made psy. nsg a

component of General nursing and Midwifery
course1990:
Psychiatric Nursing
• Mental health is not just the absence of
mental disorder. It is defined as a state of well-
being in which every individual realizes his or
her own potential, can cope with the normal
stresses of life, can work productively and
fruitfully, and is able to make a contribution to
her or his community.
MAJOR MENTAL ILLNESSES:
• SCHIZOPHRENIA OR SPLIT PERSONALITY
• MANIC DEPRESSIVE PSYCHOSIS
• PARANOIA
MINOR MENTAL ILLNESSES:

• NEUROSIS OR PSYCHONEUROSIS
• PERSONALITY AND CHARACTER DISORDERS
CAUSES OF MENTAL ILLHEALTH

ORGANIC CONDITIONS:
1. Cerebral arteriosclerosis
2. Neoplasms
3. Metabolic diseases
4. Neurological diseases
5. Endocrine diseases
6. Epilepsy, TB, Leprosy etc.
HEREDITY:
• Child of 2 schizophrenic parents is 40 times more likely
to
develop schizophrenia.
SOCIAL PATHOLOGICAL CAUSES:
• Social and environmental factors associated with mental
ill health comprise: Worries, anxieties, emotional stress,
tension, frustration, unhappy marriages, broken homes,
poverty, industrialization, urbanization, changing family
structure, population mobility, economic insecurity, cruelty,
rejection, neglect.
ENVIRONMENTAL FACTORS
Toxic substances: carbon disulphide, mercury, manganese, tin, lead
compounds.
Psychotropic drugs: barbiturates, alcohol, griesofulvin.
Nutritional factors: thiamine and pyridoxine deficiency.
Minerals: deficiency of iodine.
Infective agents: infectious diseases e.g. measles, rubella during prenatal,
perinatal, and postnatal period of life have adverse effect on brains
development.
Traumatic factors: Road and occupational accidents.
Radiation: CNS is most sensitive to radiation during the period of neural
development.
CRUCIAL POINTS IN LIFE OF HUMAN BEINGS
Prenatal period: Pregnancy is a stressful period for some women.
First 5 years of life: Roots of mental health are in early childhood.
Broken homes are likely to produce behavior disorders in children.
School child: Everything that happens in school affects the mental
health of child.
Adolescence: The transition from adolescence to manhood is often
a stormy one and fraught with dangers to mental health manifested
in form of mental ill health among the young.
Old age: Causes are organic conditions of brain, economic
insecurity, lack of home, poor status and insecurity.
NEEDS OF MAN / WOMAN
1. The need for affection.
2. The need for belonging.
3. The need for independence.
4. The need for achievement.
5. The need for recognition.
6. The need for sense of personal worth.
7. The need for self-actualization.
PREVENTIVE ASPECTS

PRIMARY PREVENTION: Improving the social environment, promotion of social,

emotional and physical wellbeing of all people. Working for better living
conditions/health.
SECONDARY PREVENTION: Early diagnosis of mental illness and of social and
emotional disturbances through screening programmes in schools, university,
industry and provision of treatment facilities. Family based health services have
much role to play. Family counseling is also a method for helping the ill.
TERTIARY PREVENTION: It aims to reduce the duration of mental illness and thus
reduce the stress they create for the family and the community. The goal at this
level is to prevent further break down and disruption.
MENTAL HEALTH SERVICES
• Early diagnosis and treatment.
• Rehabilitation.
• Group and individual psychotherapy.
• Mental health education.
• Use of modern psychoactive drugs.
• After care services.
 MODULE 3
Conceptual Framework and Theories
Lesson 1: Theories of human behavior and practices

What is a theory?

• A set of concepts, definitions, relationships, and assumptions that project a systematic

view of a phenomena
• It may consist of one or more relatively specific and concrete concepts and
propositions that purport to account for, or organize some phenomenon (Barnum, 1988)

What are the components of a theory?

• Concepts – ideas and mental images that help to describe phenomena (Alligood and
Marriner-Tomey, 2002)
• Definitions – convey the general meaning of the concepts
• Assumptions – statements that describe concepts
• Phenomenon – aspect of reality that can be consciously sensed or experienced
(Meleis, 1997).

What is a paradigm?

• A model that explains the linkages of science, philosophy, and theory accepted and
applied by the discipline (Alligood and Marriner – Tomey, 2002)

What is a domain?

• The view or perspective of the discipline

• It contains the subject, central concepts, values and beliefs, phenomena of interest,
and the central problems of the discipline

How does domain relate to nursing theory?

• Nursing has identified its domain in a paradigm that includes four linkages:
1) Person/client
2) Health
3) Environment
4) Nursing

Purposes of nursing theory

What are the purposes of nursing theory?

• It guides nursing practice and generates knowledge
• It helps to describe or explain nursing
• Enables nurses to know WHY they are doing WHAT they are doing
Types of nursing theories
• Grand theories – broad and complex
• Middle-range theories- address specific phenomena and reflect practice
• Descriptive theories – first level of theory development
• Prescriptive theories – address nursing interventions and predict their consequences

Why on earth do we study nursing theory?

• Everyday practice enriches theory
• Both practice and theory are guided by values and beliefs
• Theory helps to reframe our thinking about nursing
• Theory guides use of ideas and techniques
• Theory can close the gap between theory and research
• To envision potentialities (Gordon, Parker, & Jester, 2001)

“The study and use of nursing theory in nursing practice must have roots in the
everyday practice of nurses (Gordon, Parker, and Jester, 2001).

So how do nurses use theory in everyday practice?

• Organize patient data
• Understand patient data
• Analyze patient data
• Make decisions about nursing interventions
• Plan patient care
• Predict outcomes of care
• Evaluate patient outcomes (Alligood, 2001)

How do student nurses begin to use nursing theory?

• By asking yourself two very important questions…..

Student nurse questions

• What is the nature of knowledge needed for the practice of nursing?
• What does it mean to me to practice nursing?

Nursing also utilizes non-nursing theories

Commonly used non-nursing theories

• Systems theory
• Basic Human Needs theory
• Health and Wellness Models
• Stress and Adaptation
• Developmental Theories
• Psychosocial Theories

What is the link between nursing theory and the research process?
• Theory provides direction for nursing research
• Relationships of components in a theory help to drive the research questions for
understanding nursing
• Chinn and Kramer (2004), indicate a spiral relationship between the two

Current trends that influence nursing theory

• Medical science
• Nursing education
• Professional nursing organizations
• Evolving research approaches
• Global concerns
• Consumer demands
• Technologies

“Practicing nurses who despise theory are condemned to performing a series of tasks -
either at the command of a physician or in response to routines and policies.” Leah
Curtin, RN, MS, FAAN (1989) Former Editor, Nursing Management

Human Behavior Model; General Theory of Human Behavior

Beyond All Doubt (The Explanation of Human Behavior)

12 Words Say It All

All human behavior is an attempt to remove doubt from our lives

Doubt Is the Constant in Human Behavior

1. Doubt is the engine that drives behavior

2. Doubt removal is the equivalent of gravity
3. Trying to remove doubt from our lives is the equivalent of gravity trying to pull
everything to the center of the earth
The Behavior Process
1. We consider all of the possibilities that we can see available to us at any one
moment 8
2. We consider all of the possibilities that we can see available to us at any one
moment We choose the one we have the least amount of doubt in and we act
that out 9
3. We consider all of the possibilities that we can see available to us at any one
moment We choose the one we have the least amount of doubt in and we act
that out This is all we do, we do this over and over and over again, constantly
4. We consider all of the possibilities that we can see available to us at any one
 The Behavior Cycle

The cycle has four stages

I Want I Act I Think I Judge

We start by wanting something

Do I want it? Should I want it? Can I do it/Can I get it? What’s the best plan to get what I
want? We evaluate our options; we make a judgment (decide which one we have the
least amount of doubt in) We act

Four Elements of Behavior

1. Belief Systems
2. Energy
3. Opportunity
4. Trigger

If any of these four are lacking, or are lacking sufficient quantity or quality the
specific behavior cannot take place This will become more obvious when we look
at the elements individually and look at a picture of how it all comes together, so
let’s do that now

Belief Systems

You need to believe that it’s humanly possible You need to believe that you can do it
You need to believe that you should do it If you don’t believe all three of these things,
the instance of behavior cannot take place

Energy

You need enough energy You need the right kind of energy (your mood has to match)
Some other person or thing will also need to have enough of and the right kind of
energy, if the behavior involves other people or things

Opportunity

You have to have the opportunity to engage in the behavior If you don’t have the
opportunity the behavior can’t take place If you don’t believe you have the opportunity
(even if you really do) then the behavior can’t take place

Trigger

There has to be a trigger to initiate the process It could be a physical, mental or

emotional trigger Quite often all three exist There’s always a trigger
Any specific behavior only occurs when the four elements combine in that precise way
 • Change any of the four elements and the behavior will not occur If the behavior is
already taking place the four elements need to remain stable for the behavior to
continue

• Change any of the four elements and that behavior will stop and a new behavior
based on the new configuration of the elements will begin Let’s look at it in picture form
Lesson 3: Models of Mental Health & Illness
W.H.O.s definition of Health:

"A state of complete physical, mental and social well-being and not merely the absence
of disease or infirmity."

Mental Health is defined as

“A state of well-being in which every individual realizes his or her own potential, can
cope with the normal stresses of life, can work productively and fruitfully, and is able to
make a contribution to his or her community.”

Mental Illness is defined as

“Mental illness can be seen in purely sociological terms, as a deviation from socially
approved standards of interpersonal behaviour, or as an inability to perform one’s
sanctioned social roles. In social science literature it is generally agreed that the mental
illness refers to dysfunctional interpersonal behaviour, judged to be dysfunctional in
terms of the norms and values held by the observer” (International Encyclopedia of
Psychiatry, Psychology, Psychoanalysis & Neurology, 1992).

“An illness with psychological or behavioral manifestation and/or impairment in

functioning, due to social, psychological, genetic, physical or biological disturbances”
(American Psychiatric Association).

“Mentally ill person means a person who is in need of treatment by reason of any
mental disorder other than mental retardation‖(Indian Mental Health Act, 1987).”

Mental health, Mental Ill-health and Mental Illness

 It is a commonplace to view the relationship between health and illness — and,
therefore, mental health and mental illness — as two ends of the same
 Trent (1992),
 The Canadian Ministry of National Health and Welfare (MNHW),1988
 Downie et al (1990)
 Groder, (1977)

History

 In the mid-19th century, William Sweetzer was the first to clearly define the term
"mental hygiene", which can be seen as the precursor to contemporary
approaches to work on promoting positive mental health
 An important figure to "mental hygiene", would be Dorothea Dix (1802–1887), a
school teacher, who had campaigned her whole life in order to help those
suffering of a mental illness, and to bring to light the deplorable conditions which
they were put it in. This was known as the "mental hygiene movement".
  At the beginning of the 20th century, Clifford Beers founded the National
Committee for Mental Hygiene and opened the first outpatient mental health
clinic in the United States of America.

Significance

 Evidence from the World Health Organization suggests that nearly half the
world’s population is affected by mental illness with an impact on their self-
esteem, relationships and ability to function in everyday life.
 There is growing evidence that is showing emotional abilities are associated with
prosocial behaviors such as stress management and physical health‖ (Richards,
Campania, & Muse-Burke (2010).
 The importance of maintaining good mental health is crucial to living a long and
healthy life.

Perspectives

 Sense of Responsibility
 Sense of Self-reliance
 Sense of Direction
 A Set of Personal Values
 Sense of Individuality
 Mental Well-Being
 Lack of a mental disorder
 Cultural and religious considerations

Maria Jahoda (1963) proposed the following six characteristics of the mentally healthy
individual
 Environmental mastery
 Undistorted perception of reality
 Integration Autonomy
 Growth, self-development and self-actualization
 Attitude towards Self

Models of Mental Illness

 Spiritual Model
 Moral Character Model
 The Statistical Model
 The Disease/ Medical/ Biological Model
-Genetics
-Neuroimaging
-Neurobiology
 Psychological Models
-Psychodynamic Model
-The Behavioural Model
 The Cognitive-behavioural Model
-Existential / Humanistic Model
 The Social Model
 Psychosocial Model
-The Social Learning Model
 Family Therapy Model
 Biopsychosocial Model

Spiritual Model
The first and oldest explanatory system for mental illness is spiritual. From a
traditional spiritual perspective, consciousness is seen as resulting from or deeply
connected to some supernatural force. Usually, there is a religious narrative that
explains that there are good and bad forces in the world, and that suffering is a function
of either being possessed by the bad, or through the idea that the afflicted have fallen
out of favor with the good. This generally occurs because of sin or related concept of
immoral behavior that leads to some form of badness or contamination.

Moral Character Model

The second explanatory system for mental illness is moral character. In a
nutshell, the position of moral character is that there are virtues which one must learn,
such as courage and fortitude, honesty and integrity, compassion and grace that enable
on to live the admirable life.

The Statistical Model

Derived more from mathematics than from psychology, the statistical model
concentrates on the definition of abnormality. According to this approach, abnormality is
any substantial deviation from a statistically calculated average. Those who fall within
the Golden mean‖ i.e. in short, those who do what most people do, are normal, while
those whose behaviour differs from those of the majority are abnormal.

The Medical Model

The medical model attributes mental abnormalities to physiological, biochemical,
or genetic causes and attempts to treat these abnormalities by way of medically
grounded procedures such as psychopharmacology (drug therapy), electroconvulsive
therapy (ECT), or psychosurgery (brain surgery).

Genetic
Genetic models of mental disorder suggest that psychopathology is inherited
from parents, and there is certainly evidence for the familial transmission of many
disorders.

Neuroimaging
This system explains causation of mental illness in terms of structural changes in
different parts of brain. It suggests that in various mental illness certain ventricular
atrophy, volumetric changes, reduction in cortical volume can be seen which may be
one of the various contributory factors behind the causation of illness.
Neurobiology

Here the belief is that the human is an organism that consists of natural functions
designed by nature (i.e., natural selection operating on genetics) and mental illness is
the breakdown of such functions. Thus, just as a heart attack is a biological disease
characterized by the breakdown of the functioning of the circulatory system, mental
illness stems from malfunctioning neurophysiological processes.

Psychological Models
An important explanatory system for mental illness is psychological in nature.
The general model here is that the individual develops along a path and attempts to
adapt to their environment. However, if the individual fails to learn certain crucial
elements or learns the wrong responses to new situations or adopts short term solutions
that have long term maladaptive consequences, then suffering and dysfunction result.
 Psychodynamic Model
 The Behavioural Model
 The Cognitive-behavioural Model
 Humanistic / Existential Model

Psychodynamic Model
The core assumption of this approach is that the roots of mental disorders are
psychological. They lie in the unconscious mind and are the result the failure of defense
mechanisms to protect the self (or ego) from anxiety. Problems are determined by the
history of a person’s prior emotional experiences, especially the childhood ones or to be
more specific, the negative childhood experiences.

The Behavioural Model

This system believes that, only the study of directly observable behavior, the stimuli and
reinforcing conditions that control it could serve as a basis for understanding human,
behaviour, normal or abnormal. The behavioural perspective is organized around a
central theme: the role of learning in human behaviour.

The Cognitive-behavioural Model

The cognitive model understands mental disorder as being a result of errors or
biases in thinking. It explains how thoughts and information processing can become
distorted and leads to maladaptive emotions and behaviour. Our view of the world is
determined by our thinking, and dysfunctional thinking can lead to mental disorder.
Therefore, to correct mental disorder, what is necessary is a change in thinking.

Humanistic / Existential Model

The humanistic model sees mental health problems as a signal that an individual
is failing to reach his or her potential and that psychological growth has stopped. The
humanistic perspective views human nature as ―basically good‖. It emphasizes
present conscious processes – paying less attention to unconscious processes and
past causes – and places strong emphasis on each person’s inherent capacity for
responsible self-direction. Its emphasis is thus on growth and self-actualizing rather
than on curing diseases or alleviating disorders. The humanistic model does not believe
in labeling people by diagnosing them as having specific mental disorders.

The Social Model

The social model suggests that the ways in which societies are organized, not
just biological and psychological characteristics of individuals, must be considered as
causal factors in mental illness. It does not argue that people should not be held
responsible for their behaviour because they are victims of ―society‖, but they do
suggest that social structure imposes restrictions on behaviour as surely as biological
inheritance and that the effects of social conditions on mental illness need to be
understood, to explain both individual distress and how that distress might be related to
larger forces. The social model regards social forces as the most important
determinants of mental disorder.

Psychosocial Model
This model explains the causation of mental illness due to the effect of interaction
of psychological and social factors. Psychosocial factors are those developmental
influences that may handicap a person psychologically, making him or her less
resourceful in coping with social events.

There are four basic categories of psychosocial causal factors:

 Early deprivation or trauma
 Inadequate parenting styles
 Marital discord and divorce
 Maladaptive peer relationship
 The Social Learning Model:

Family Therapy Model

Laing & Esterson (1964) were among the first British writers to express the view that
individuals with mental illness were the victims of a pathological family process. Family
therapy usually begins by an approach that encourages all members of the family to
work together in resolving the conflict. The process is designed to identify and change
relationships where necessary. Attention is paid to family interactions, especially to
alignments and discord and the engagement and disengagement of the different group
members.
 Double Bind
 Schisms and Skewed Families
 Pseudomutual and Pseudohostile Families
 Expressed Emotion

Biopsychosocial Model

Integration of:
 Biological
 Social
  Psychological (Esp. cognitive & behavioral)

Abnormality caused by:

 Interaction of these factors – no one cause
 Relative importance of each factor depends on individual and environment

Explanations of mental illness:

 Diathesis / Stress
 Physiological, sociocultural or genetic predisposition to develop disorder
 Stressor that triggers manifestation of disorder
Conclusion
 Current trends in delivery of care emphasize a collaborative team approach
 The diverse explanations provide a range of models that influence and direct
current approaches in the treatment and management of people with mental
health problems. The dominance of the biomedical model is increasingly being
challenged by other professional groups.
https://www2.slideshare.net/SudarshanaDasgupta/models-of-mental-health-illness
Psychiatric Nursing
 Models of Mental Illness
• Psychological Models
• Spiritual Model • -Psychodynamic Model
• Moral Character Model • -The Behavioural Model
• The Cognitive-behavioural
• The Statistical Model Model
• -Existential / Humanistic
• The Disease/ Medical/ Model
Biological Model • The Social Model
• -Genetics • Psychosocial Model
• -The Social Learning Model
• -Neuroimaging • Family Therapy Model
• -Neurobiology • Biopsychosocial Model
 Spiritual Model
• The first and oldest explanatory system for mental
illness is spiritual. From a traditional spiritual
perspective, consciousness is seen as resulting from or
deeply connected to some supernatural force. Usually,
there is a religious narrative that explains that there
are good and bad forces in the world, and that
suffering is a function of either being possessed by the
bad, or through the idea that the afflicted have fallen
out of favor with the good. This generally occurs
because of sin or related concept of immoral behavior
that leads to some form of badness or contamination.
 Spiritual Model
• The first and oldest explanatory system for mental
illness is spiritual. From a traditional spiritual
perspective, consciousness is seen as resulting from or
deeply connected to some supernatural force. Usually,
there is a religious narrative that explains that there
are good and bad forces in the world, and that
suffering is a function of either being possessed by the
bad, or through the idea that the afflicted have fallen
out of favor with the good. This generally occurs
because of sin or related concept of immoral behavior
that leads to some form of badness or contamination.
Moral Character Model
• The second explanatory system for mental
illness is moral character. In a nutshell, the
position of moral character is that there are
virtues which one must learn, such as courage
and fortitude, honesty and integrity,
compassion and grace that enable on to live
the admirable life.
The Statistical Model
• Derived more from mathematics than from
psychology, the statistical model concentrates on
the definition of abnormality. According to this
approach, abnormality is any substantial
deviation from a statistically calculated average.
Those who fall within the Golden mean‖ i.e. in
short, those who do what most people do, are
normal, while those whose behaviour differs
from those of the majority are abnormal.
The Medical Model
• The medical model attributes mental
abnormalities to physiological, biochemical, or
genetic causes and attempts to treat these
abnormalities by way of medically grounded
procedures such as psychopharmacology (drug
therapy), electroconvulsive therapy (ECT), or
psychosurgery (brain surgery).
Psychological Models
• An important explanatory system for mental illness is
psychological in nature. The general model here is that
the individual develops along a path and attempts to
adapt to their environment. However, if the individual
fails to learn certain crucial elements or learns the
wrong responses to new situations or adopts short
term solutions that have long term maladaptive
consequences, then suffering and dysfunction result.
Psychodynamic Model
• The core assumption of this approach is that the roots
of mental disorders are psychological. They lie in the
unconscious mind and are the result the failure of
defense mechanisms to protect the self (or ego) from
anxiety. Problems are determined by the history of a
person’s prior emotional experiences, especially the
childhood ones or to be more specific, the negative
childhood experiences.
The Behavioural Model
• This system believes that, only the study of
directly observable behavior, the stimuli and
reinforcing conditions that control it could serve
as a basis for understanding human, behaviour,
normal or abnormal. The behavioural perspective
is organized around a central theme: the role of
learning in human behaviour.
The Cognitive-behavioural Model
• The cognitive model understands mental disorder as being a result of errors or
biases in thinking. It explains how thoughts and information processing can
become distorted and leads to maladaptive emotions and behaviour. Our view of
the world is determined by our thinking, and dysfunctional thinking can lead to
mental disorder. Therefore, to correct mental disorder, what is necessary is a
change in thinking.

Humanistic / Existential Model

• The humanistic model sees mental health problems as a signal that an individual
is failing to reach his or her potential and that psychological growth has stopped.
The humanistic perspective views human nature as ―basically good‖. It
emphasizes present conscious processes – paying less attention to unconscious
processes and past causes – and places strong emphasis on each person’s inherent
capacity for responsible self-direction. Its emphasis is thus on growth and self-
actualizing rather than on curing diseases or alleviating disorders. The humanistic
model does not believe in labeling people by diagnosing them as having specific
mental disorders.
The Social Model
• The social model suggests that the ways in which societies are
organized, not just biological and psychological characteristics of
individuals, must be considered as causal factors in mental illness.
It does not argue that people should not be held responsible for
their behaviour because they are victims of ―society‖, but they
do suggest that social structure imposes restrictions on behaviour
as surely as biological inheritance and that the effects of social
conditions on mental illness need to be understood, to explain
both individual distress and how that distress might be related to
larger forces. The social model regards social forces as the most
important determinants of mental disorder.
Psychosocial Model
• This model explains the causation of mental
illness due to the effect of interaction of
psychological and social factors. Psychosocial
factors are those developmental influences
that may handicap a person psychologically,
making him or her less resourceful in coping
with social events.
Family Therapy Model
• Laing & Esterson (1964) were among the first British
writers to express the view that individuals with mental
illness were the victims of a pathological family process.
Family therapy usually begins by an approach that
encourages all members of the family to work together in
resolving the conflict. The process is designed to identify
and change relationships where necessary. Attention is
paid to family interactions, especially to alignments and
discord and the engagement and disengagement of the
different group members.