Explore the full ebook collection and download it now at ebookball.

com

Psychiatric Nursing Assessment Care Plans and

Medications 9th Edition by Townsend Mary
9780803643956 0803643950

https://ebookball.com/product/psychiatric-nursing-
assessment-care-plans-and-medications-9th-edition-by-
townsend-mary-9780803643956-0803643950-904/

OR CLICK HERE

DOWLOAD EBOOK

Browse and Get More Ebook Downloads Instantly at https://ebookball.com

Click here to visit ebookball.com and download ebookball now
 Your digital treasures (PDF, ePub, MOBI) await
Download instantly and pick your perfect format...

Read anywhere, anytime, on any device!

Psychiatric Nursing Assessment Care Plans and Medications

9th Edition by Townsend Mary 9780803643956 0803643950

https://ebookball.com/product/psychiatric-nursing-assessment-care-
plans-and-medications-9th-edition-by-townsend-
mary-9780803643956-0803643950-904/

ebookball.com

Nursing Diagnoses in Psychiatric Nursing Care Plans and

Psychotropic Medications 8th Edition by Mary Townsend ISBN
9780803647046 0803647042
https://ebookball.com/product/nursing-diagnoses-in-psychiatric-
nursing-care-plans-and-psychotropic-medications-8th-edition-by-mary-
townsend-isbn-9780803647046-0803647042-642/

ebookball.com

Psychiatric Mental Health Nursing Concepts of Care in

Evidence Based Practice 6th Edition by Mary Townsend
9780803638761 0803638760
https://ebookball.com/product/psychiatric-mental-health-nursing-
concepts-of-care-in-evidence-based-practice-6th-edition-by-mary-
townsend-9780803638761-0803638760-902/

ebookball.com

Essentials of Psychiatric Mental Health Nursing Concepts

of Care in Evidence Based Practice 4th edition by Mary
Townsend 9780803616110 0803616112
https://ebookball.com/product/essentials-of-psychiatric-mental-health-
nursing-concepts-of-care-in-evidence-based-practice-4th-edition-by-
mary-townsend-9780803616110-0803616112-958/

ebookball.com
Essentials of Psychiatric Mental Health Nursing Concepts
of Care in Evidence Based Practice 5th edition by Mary
Townsend 0803623380 9780803623385
https://ebookball.com/product/essentials-of-psychiatric-mental-health-
nursing-concepts-of-care-in-evidence-based-practice-5th-edition-by-
mary-townsend-0803623380-9780803623385-888/

ebookball.com

Nursing Care Plans 8th Edition by Marilynn Doenges,Mary

Frances,Moorhouse,Alice Murr 9780803624269 0803624263

https://ebookball.com/product/nursing-care-plans-8th-edition-by-
marilynn-doenges-mary-frances-moorhouse-alice-
murr-9780803624269-0803624263-842/

ebookball.com

Nursing Care Plans Guidelines for Individualizing Client

Care Across the Life Span 10th Edition by Marilynn
Doenges, Mary Frances Moorhouse, Alice Murr ISBN
9781719642675 1719642672
https://ebookball.com/product/nursing-care-plans-guidelines-for-
individualizing-client-care-across-the-life-span-10th-edition-by-
marilynn-doenges-mary-frances-moorhouse-alice-murr-
isbn-9781719642675-1719642672-6478/
ebookball.com

Nursing Care Plans and Documentation Nursing Diagnoses and

Collaborative Problems 5th Edition by Lynda Juall
Carpenito ISBN 0781770645 9780781770644
https://ebookball.com/product/nursing-care-plans-and-documentation-
nursing-diagnoses-and-collaborative-problems-5th-edition-by-lynda-
juall-carpenito-isbn-0781770645-9780781770644-520/

ebookball.com

Nursing Care Plans and Documentation Nursing Diagnoses and

Collaborative Problems 5th Edition by Lynda Juall
Carpenito ISBN 0781770645 9780781770644
https://ebookball.com/product/nursing-care-plans-and-documentation-
nursing-diagnoses-and-collaborative-problems-5th-edition-by-lynda-
juall-carpenito-isbn-0781770645-9780781770644-538/

ebookball.com
4092_FM_i-xxiv 25/07/14 10:20 AM Page iv
4092_FM_i-xxiv 25/07/14 10:20 AM Page v

Psychiatric Mental
Health Nursing:
Concepts of Care in Evidence-Based
Practice
EIGHTH EDITION

Mary C. Townsend, DSN, PMHCNS-BC

Clinical Specialist/Nurse Consultant
Adult Psychiatric Mental Health Nursing
Former Assistant Professor and
Coordinator, Mental Health Nursing
Kramer School of Nursing
Oklahoma City University
Oklahoma City, Oklahoma
4092_FM_i-xxiv 25/07/14 10:20 AM Page vi

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2015 by F. A. Davis Company

Copyright © 2015 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Publisher, Nursing: Robert G. Martone

Director of Content Development: Darlene D. Pedersen
Content Project Manager: Jacalyn C. Clay
Electronic Project Editor: Katherine E. Crowley
Cover Design: Carolyn O’Brien

As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies
undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord
with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or
for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any
practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the
unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for
changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when
using new or infrequently ordered drugs.

Library of Congress Control Number: 2014944300

ISBN: 978-0-8036-4092-4

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by
F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that
the fee of $.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been
granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional
Reporting Service is: 8036-4092-4/15 0 + $.25.
4092_FM_i-xxiv 25/07/14 10:20 AM Page vii

THIS BOOK IS DEDICATED TO:

FRANCIE

God made sisters for sharing laughter

and wiping tears

4092_FM_i-xxiv 25/07/14 10:20 AM Page viii
4092_FM_i-xxiv 25/07/14 10:20 AM Page ix

Contributors

Lois Angelo, MSN, APRN, BC Karyn I. Morgan, RN, MSN, CNS

ED Care Manager Senior Instructor, Mental Health Nursing
Newton Wellesley Hospital The University of Akron
Newton, Massachusetts Akron, Ohio
and
Cathy Melfi Curtis, MSN, RN-BC CNS, Intensive Outpatient Psychiatry
Nursing Educator Consultant Summa Health System
Charleston, South Carolina Akron, Ohio

Tona Leiker, PhD, APRN-CNS, CNE Carol Norton Tuzo, MSN, RN-BC
Clinical Nurse Specialist Nursing Educator Consultant
Wesley Medical Center Charleston, South Carolina
Wichita, Kansas

ix
4092_FM_i-xxiv 25/07/14 10:20 AM Page x
4092_FM_i-xxiv 25/07/14 10:20 AM Page xi

Reviewers

Theresa Aldelman Ruth Burkhart

Bradley University New Mexico State University/Dona Ana Community
Peoria, Illinois College
Las Cruces, New Mexico
Fredrick Astle
University of South Carolina Annette Cannon
Columbia, South Carolina Platt College
Aurora, Colorado
Carol Backstedt
Baton Rouge Community College Deena Collins
Baton Rouge, Louisiana Huron School of Nursing
Cleveland, Ohio
Elizabeth Bailey
Clinton Community College Martha Colvin
Pittsburgh, New York Georgia College & State University
Milledgeville, Georgia
Sheryl Banak
Baptist Health Schools - Little Rock Mary Jean Croft
Little Rock, Arkansas St. Joseph School of Nursing
Providence, Rhode Island
Joy A. Barham
Northwestern State University Connie Cupples
Shreveport, Louisiana Union University
Germantown, Tennessee
Barbara Barry
Cape Fear Community College Karen Curlis
Wilmington, North Carolina State University of New York Adirondack
Queensbury, New York
Carole Bomba
Harper College Nancy Cyr
Palatine, Illinois North Georgie College and State University
Dahlonega, Georgia
Judy Bourrand
Samford University Carol Danner
Birmingham, Alabama Baptist Health Schools Little Rock - School of Nursing
Little Rock, Arkansas
Susan Bowles
Barton Community College Carolyn DeCicco
Great Bend, Kansas Our Lady of Lourdes School of Nursing
Camden, New Jersey
Wayne Boyer
College of the Desert Leona Dempsey, PhD, APNP (ret.), PMHCS-BC
Palm Desert, California University of Wisconsin Oshkosh
Oshkosh, Wisconsin
Joyce Briggs
Ivy Tech Community College Debra J. DeVoe
Columbus, Indiana Our Lady of Lourdes School of Nursing
Camden, New Jersey
Toni Bromley
Rogue Community College Victoria T. Durkee, PhD, APRN
Grants Pass, Oregon University of Louisiana at Monroe
Monroe, Louisiana
Terrall Bryan
North Carolina A & T State University
Greensboro, North Carolina

xi
4092_FM_i-xxiv 25/07/14 10:20 AM Page xii

xii Reviewers

J. Carol Elliott Ruby Houldson

St. Anselm College Illinois Eastern Community College
Fairfield, California Olney, Illinois

Sandra Farmer Eleanor J. Jefferson

Capital University Community College of Denver
Columbus, Ohio Platt College
Metropolitan St. College
Patricia Freed Denver, Colorado
Saint Louis University
St. Louis, Missouri Dana Johnson
Mesa State College/Grand Junction Regional Center
Diane Gardner Grand Junction, Colorado
University of West Florida
Pensacola, Florida Janet Johnson
Fort Berthold Community College
Maureen Gaynor New Town, North Dakota
Saint Anselm College
Manchester, New Hampshire Nancy Kostin
Madonna University
Denise Glenore Livonia, Michigan
West Coast University
Riverside, California Linda Lamberson
University of Southern Maine
Sheilia R. Goodwin Portland, Maine
Winston Salem State University
Salem, North Carolina Irene Lang
Bristol Community College
Janine Graf-Kirk Fall River, Massachusetts
Trinitas School of Nursing
Elizabeth, New Jersey Rhonda Lansdell
Northeast MS Community College
Susan B. Grubbs Baldwyn, Mississippi
Francis Marion University
Florence, South Carolina Jacqueline Leonard
Franciscan University of Steubenville
Elizabeth Gulledge Steubenville, Ohio
Jacksonville State University
Jacksonville, Alabama Judith Lynch-Sauer
University of Michigan
Kim Gurcan Ann Arbor, Michigan
Columbus Practical School of Nursing
Columbus, Ohio Glenna Mahoney
University of Saint Mary
Patricia Jean Hedrick Young Leavenworth, Kansas
Washington Hospital School of Nursing
Washington, Pennsylvania Jacqueline Mangnall
Jamestown College
Melinda Hermanns Jamestown, North Dakota
University of Texas at Tyler
Tyler, Texas Lori A. Manilla
Hagerstown Community College
Alison Hewig Hagerstown, Maryland
Victoria College
Victoria, Texas Patricia Martin
West Kentucky Community and Technical College
Cheryl Hilgenberg Paducah, Kentucky
Millikin University
Decatur, Illinois Christine Massey
Barton College
Lori Hill Wilson, North Carolina
Gadsden State Community College
Gadsden, Alabama
4092_FM_i-xxiv 25/07/14 10:20 AM Page xiii

Reviewers xiii

Joanne Matthews Lillian Parker

University of Kentucky Clayton State University
Lexington, Kentucky Morrow, Georgia

Joanne McClave JoAnne M. Pearce, MS, RN

Wayne Community College Idaho State University
Goldsboro, North Carolina Pocatello, Idaho

Mary McClay Karen Peterson

Walla Walla University DeSales University
Portland, Oregon Center Valley, Pennsylvania

Susan McCormick Carol Pool

Brazosport College South Texas College
Lake Jackson, Texas McAllen, Texas

Shawn McGill William S. Pope

Clovis Community College Barton College
Clovis, New Mexico Wilson, North Carolina

Margaret McIlwain Karen Pounds

Gordon College Northeastern University
Barnesville, Georgia Boston, Massachusetts

Nancy Miller Konnie Prince

Minneapolis Community and Technical College Victoria College
Minneapolis, Minnesota Victoria, Texas

Vanessa Miller Susan Reeves

California State University Fullerton Tennessee Technological University
Fullerton, California Cookeville, Tennessee

Mary Mitsui Debra Riendeau

Emporia State University Saint Joseph’s College of Maine
Emporia, Kansas Lewiston, Maine

Cheryl Moreland, MS, RN Sharon Romer

Western Nevada College South Texas College
Carson City, Nevada McAllen, Texas

Daniel Nanguang Lisa Romero

El Paso Community College Solano Community College
El Paso, Texas Fairfield, California

Susan Newfield Donna S. Sachse

West Virginia University Union University
Morgantown, West Virginia Germantown, Tennessee

Dorothy Oakley Betty Salas

Jamestown Community College Otero Junior College
Olean, New York La Junta, Colorado

Christie Obritsch Sheryl Samuelson, PhD, RN

University of Mary Millikin University
Bismarck, North Dakota Decatur, Illinois

Sharon Opsahl John D. Schaeffer

Western Technical College San Joaquin Delta College
La Crosse, Wisconsin Stockton, California

Vicki Paris Mindy Schaffner

Jackson State Community College Pacific Lutheran University
Jackson, Tennessee Tacoma, Washington
4092_FM_i-xxiv 25/07/14 10:20 AM Page xiv

xiv Reviewers

Becky Scott Dorothy Varchol

Mercy College of Northwest Ohio Cincinnati State
Toledo, Ohio Cincinnati, Ohio

Janie Shaw Connie M. Wallace

Clayton State University Nebraska Methodist College
Morrow, Georgia Omaha, Nebraska

Lori Shaw Sandra Wardell

Nebraska Methodist College Orange County Community College
Omaha, Nebraska Middletown, New York

Joyce Shea Susan Warmuskerken

Fairfield University West Shore Community College
Fairfield, Connecticut Scottville, Michigan

Judith Shindul-Rothschild Roberta Weseman

Boston College East Central College
Chestnut Hill, Massachusetts Union, Missouri

Audrey Silveri Margaret A. Wheatley

UMass Worcester Graduate School of Nursing Case Western Reserve University, FPB School of
Worcester, Massachusetts Nursing
Cleveland, Ohio
Brenda Smith, MSN, RN
North Georgia College and State University Jeana Wilcox
Dahlonega, Georgia Graceland University
Independence, Missouri
Janet Somlyay
University of Wyoming Jackie E. Williams
Laramie, Wyoming Georgia Perimeter College
Clarkston, Georgia
Charlotte Strahm, DNSc, RN, CNS-PMH
Purdue North Central Rita L. Williams, MSN, RN, CCM
Westville, Indiana Langston University School of Nursing & Health
Professions
Jo Sullivan Langston, Oklahoma
Centralia College
Centralia, Washington Rodney A. White
Lewis and Clark Community College
Kathleen Sullivan Godfrey, Illinois
Boise State University
Boise, Idaho Vita Wolinsky
Dominican College
Judy Traynor Orangeburg, New York
Jefferson Community College
Watertown, New York Marguerite Wordell
Kentucky State University
Claudia Turner Frankfort, Kentucky
Temple College
Temple, Texas Jan Zlotnick
City College of San Francisco
Suzanne C. Urban San Francisco, California
Mansfield University
Mansfield, Pennsylvania
4092_FM_i-xxiv 25/07/14 10:20 AM Page xv

Acknowledgments

Robert G. Martone, Publisher, Nursing, F. A. Davis My daughters, Kerry and Tina, for all the joy you have
Company, for your sense of humor and continuous provided me and all the hope that you instill in me.
optimistic outlook about the outcome of this project. I’m so thankful that I have you.

Jacalyn Clay, Content Project Manager, Nursing, My grandchildren, Meghan, Matthew, and Catherine,
F.A. Davis Company, for all your help and support in for showing me what life is truly all about. I am
preparing the manuscript for publication. blessed by your very presence.

Sharon Lee, Production Manager, F. A. Davis Com- My furry friends, Angel, Max, Riley, and Charlie, for
pany, and Matt Rosenquist, Graphic World Inc, for the pure pleasure you bring into my life every day that
your support and competence in the final editing and you live.
production of the manuscript.
My husband, Jim, who gives meaning to my life in so
The nursing educators, students, and clinicians, who many ways. You are the one whose encouragement
provide critical information about the usability of the keeps me motivated, whose support gives me strength,
textbook, and offer suggestions for improvements. and whose gentleness gives me comfort.
Many changes have been made based on your input.

To those individuals who critiqued the manuscript for

this edition and shared your ideas, opinions, and sug-
gestions for enhancement. I sincerely appreciate your
contributions to the final product.

xv
4092_FM_i-xxiv 25/07/14 10:20 AM Page xvi
4092_FM_i-xxiv 25/07/14 10:20 AM Page xvii

Contents

UNIT 1 Summary and Key Points 74

Review Questions 75
Basic Concepts in Psychiatric/
Mental Health Nursing 1 Chapter 5 Ethical and Legal Issues in
Psychiatric/Mental Health Nursing 78
Chapter 1 The Concept of Stress Adaptation 2 Objectives 78
Objectives 2 Homework Assignment 78
Homework Assignment 2 Ethical Considerations 80
Stress as a Biological Response 3 Legal Considerations 83
Stress as an Environmental Event 5 Summary and Key Points 91
Stress as a Transaction Between the Review Questions 92
Individual and the Environment 7 Chapter 6 Cultural and Spiritual Concepts
Stress Management 8
Summary and Key Points 9 Relevant to Psychiatric/Mental
Review Questions 10 Health Nursing 95
Objectives 95
Chapter 2 Mental Health/Mental Illness: Homework Assignment 95
Historical and Theoretical Concepts 12 Cultural Concepts 96
Objectives 12 How Do Cultures Differ? 96
Homework Assignment 12 Application of the Nursing Process 98
Historical Overview of Psychiatric Care 13 Spiritual Concepts 109
Mental Health 14 Addressing Spiritual and Religious
Mental Illness 15 Needs Through the Nursing Process 112
Psychological Adaptation to Stress 16 Summary and Key Points 117
Mental Health/Mental Illness Continuum 23 Review Questions 118
Summary and Key Points 24
Review Questions 25 UNIT 3
Therapeutic Approaches in
UNIT 2
Psychiatric Nursing Care 121
Foundations for Psychiatric/
Mental Health Nursing 27 Chapter 7 Relationship Development 122
Objectives 122
Chapter 3 Theoretical Models of Personality Homework Assignment 122
Development 28 Role of the Psychiatric Nurse 123
Objectives 28 Dynamics of a Therapeutic Nurse-Client
Homework Assignment 28 Relationship 124
Psychoanalytic Theory 29 Conditions Essential to Development of
Interpersonal Theory 32 a Therapeutic Relationship 127
Theory of Psychosocial Development 33 Phases of a Therapeutic Nurse-Client
Theory of Object Relations 36 Relationship 129
Cognitive Development Theory 38 Boundaries in the Nurse-Client
Theory of Moral Development 39 Relationship 131
A Nursing Model—Hildegard E. Peplau 40 Summary and Key Points 132
Summary and Key Points 43 Review Questions 132
Review Questions 44 Chapter 8 Therapeutic Communication 135
Chapter 4 Concepts of Psychobiology 47 Objectives 135
Objectives 47 Homework Assignment 135
Homework Assignment 47 What Is Communication? 136
The Nervous System: An Anatomical The Impact of Preexisting Conditions 136
Review 48 Nonverbal Communication 138
Neuroendocrinology 59 Therapeutic Communication Techniques 140
Genetics 65 Nontherapeutic Communication
Psychoimmunology 68 Techniques 140
Psychopharmacology 69 Active Listening 144
Implications for Nursing 73
xvii
4092_FM_i-xxiv 25/07/14 10:20 AM Page xviii

xviii Contents

Process Recordings 145 Phases in the Development of a Crisis 218

Feedback 145 Types of Crises 219
Summary and Key Points 147 Crisis Intervention 222
Review Questions 148 Phases of Crisis Intervention: The Role of
the Nurse 222
Chapter 9 The Nursing Process in Psychiatric/ Disaster Nursing 224
Mental Health Nursing 150 Application of the Nursing Process to
Objectives 150 Disaster Nursing 225
Homework Assignment 150 Summary and Key Points 232
The Nursing Process 151 Review Questions 232
Why Nursing Diagnosis? 160
Nursing Case Management 161 Chapter 14 Assertiveness Training 235
Applying the Nursing Process in the Objectives 235
Psychiatric Setting 164 Homework Assignment 235
Concept Mapping 165 Assertive Communication 236
Documentation of the Nursing Process 165 Basic Human Rights 236
Summary and Key Points 170 Response Patterns 236
Review Questions 171 Behavioral Components of Assertive
Behavior 237
Chapter 10 Therapeutic Groups 174 Techniques That Promote Assertive
Objectives 174 Behavior 239
Homework Assignment 174 Thought-Stopping Techniques 240
Functions of a Group 175 Role of the Nurse in Assertiveness
Types of Groups 175 Training 240
Physical Conditions That Influence Group Summary and Key Points 244
Dynamics 176 Review Questions 244
Curative Factors 177
Phases of Group Development 177 Chapter 15 Promoting Self-Esteem 247
Leadership Styles 178 Objectives 247
Member Roles 179 Homework Assignment 247
Psychodrama 179 Components of Self-Concept 248
The Role of the Nurse in Group Therapy 180 Development of Self-Esteem 249
Summary and Key Points 181 Manifestations of Low Self-Esteem 250
Review Questions 182 Boundaries 252
The Nursing Process 253
Chapter 11 Intervention With Families 184 Summary and Key Points 257
Objectives 184 Review Questions 258
Homework Assignment 184
Stages of Family Development 185 Chapter 16 Anger/Aggression Management 261
Major Variations 187 Objectives 261
Family Functioning 189 Homework Assignment 261
Therapeutic Modalities With Families 193 Anger and Aggression, Defined 262
The Nursing Process—A Case Study 199 Predisposing Factors to Anger and
Summary and Key Points 204 Aggression 263
Review Questions 205 The Nursing Process 264
Summary and Key Points 270
Chapter 12 Milieu Therapy—The Therapeutic Review Questions 271
Community 208
Chapter 17 The Suicidal Client 274
Objectives 208
Homework Assignment 208 Objectives 274
Milieu, Defined 209 Homework Assignment 274
Current Status of the Therapeutic Historical Perspectives 275
Community 209 Epidemiological Factors 275
Basic Assumptions 209 Risk Factors 275
Conditions That Promote a Therapeutic Predisposing Factors: Theories of Suicide 277
Community 210 Application of the Nursing Process With
The Program of Therapeutic Community 211 the Suicidal Client 278
The Role of the Nurse in Milieu Therapy 213 Summary and Key Points 286
Summary and Key Points 214 Review Questions 286
Review Questions 215 Chapter 18 Behavior Therapy 289
Chapter 13 Crisis Intervention 217 Objectives 289
Objectives 217 Homework Assignment 289
Homework Assignment 217 Classical Conditioning 290
Characteristics of a Crisis 218 Operant Conditioning 291
4092_FM_i-xxiv 25/07/14 10:20 AM Page xix

Contents xix

Techniques for Modifying Client Behavior 291 Substance-Induced Disorder, Defined 366
Role of the Nurse in Behavior Therapy 293 Classes of Psychoactive Substances 367
Summary and Key Points 295 Predisposing Factors to Substance-Related
Review Questions 296 Disorders 367
The Dynamics of Substance-Related
Chapter 19 Cognitive Therapy 298 Disorders 368
Objectives 298 Application of the Nursing Process 387
Homework Assignment 298 The Chemically-Impaired Nurse 402
Historical Background 299 Codependency 403
Indications for Cognitive Therapy 299 Treatment Modalities for Substance-
Goals and Principles of Cognitive Therapy 299 Related Disorders 404
Basic Concepts 300 Non-Substance Addictions 409
Techniques of Cognitive Therapy 301 Summary and Key Points 412
Role of the Nurse in Cognitive Therapy 304 Review Questions 413
Summary and Key Points 307
Review Questions 307 Chapter 24 Schizophrenia Spectrum and Other
Psychotic Disorders 419
Chapter 20 Electroconvulsive Therapy 310 Objectives 419
Objectives 310 Homework Assignment 419
Homework Assignment 310 Nature of the Disorder 420
Electroconvulsive Therapy, Defined 311 Predisposing Factors 422
Historical Perspectives 311 Types of Schizophrenia and Other
Indications 312 Psychotic Disorders 427
Contraindications 312 Application of the Nursing Process 429
Mechanism of Action 312 Treatment Modalities for Schizophrenia
Side Effects 312 and Other Psychotic Disorders 439
Risks Associated With Electroconvulsive Summary and Key Points 452
Therapy 313 Review Questions 453
The Role of the Nurse in Electroconvulsive
Therapy 313 Chapter 25 Depressive Disorders 458
Summary and Key Points 315 Objectives 458
Review Questions 316 Homework Assignment 458
Historical Perspective 459
Chapter 21 The Recovery Model 319 Epidemiology 459
Objectives 319 Types of Depressive Disorders 461
Homework Assignment 319 Predisposing Factors 464
What is Recovery? 320 Developmental Implications 467
Guiding Principles of Recovery 320 Application of the Nursing Process 472
Models of Recovery 322 Treatment Modalities for Depression 482
Nursing Interventions That Assist With Summary and Key Points 493
Recovery 327 Review Questions 493
Summary and Key Points 328
Review Questions 329 Chapter 26 Bipolar and Related Disorders 498
Objectives 498
UNIT 4 Homework Assignment 498
Nursing Care of Clients With Alterations Historical Perspective 499
Epidemiology 499
in Psychosocial Adaptation 331 Types of Bipolar Disorders 499
Predisposing Factors 502
Chapter 22 Neurocognitive Disorders 332 Developmental Implications 503
Application of the Nursing Process to
Objectives 332
Bipolar Disorder (Mania) 505
Homework Assignment 332
Treatment Modalities for Bipolar Disorder
Delirium 333
(Mania) 512
Neurocognitive Disorders 334
Summary and Key Points 523
Application of the Nursing Process 341
Review Questions 524
Medical Treatment Modalities 352
Summary and Key Points 359 Chapter 27 Anxiety, Obsessive-Compulsive,
Review Questions 359
and Related Disorders 528
Chapter 23 Substance-Related and Addictive Objectives 528
Disorders 365 Homework Assignment 528
Historical Aspects 529
Objectives 365
Epidemiological Statistics 529
Homework Assignment 365
How Much Is Too Much? 531
Substance Use Disorder, Defined 366
4092_FM_i-xxiv 25/07/14 10:20 AM Page xx

xx Contents

Application of the Nursing Process— Application of the Nursing Process 680

Assessment 531 Treatment Modalities 693
Diagnosis/Outcome Identification 540 Summary and Key Points 698
Planning/Implementation 543 Review Questions 698
Evaluation 547
Treatment Modalities 549 UNIT 5
Summary and Key Points 555
Review Questions 556 Psychiatric/Mental Health Nursing
of Special Populations 703
Chapter 28 Trauma- and Stressor-Related
Disorders 559
Chapter 33 Children and Adolescents 704
Objectives 559
Objectives 704
Homework Assignment 559
Homework Assignment 704
Historical and Epidemiological Data 560
Neurodevelopmental Disorders 705
Application of the Nursing Process—
Disruptive Behavior Disorders 728
Trauma-Related Disorders 560
Anxiety Disorders 734
Application of the Nursing Process—
Quality and Safety Education for Nurses
Stressor-Related Disorders 567
(QSEN) 738
Treatment Modalities 572
General Therapeutic Approaches 741
Summary and Key Points 577
Summary and Key Points 742
Review Questions 578
Review Questions 742
Chapter 29 Somatic Symptom and Dissociative Chapter 34 The Aging Individual 747
Disorders 581
Objectives 747
Objectives 581 Homework Assignment 747
Homework Assignment 581 How Old is Old? 748
Historical Aspects 582 Epidemiological Statistics 748
Epidemiological Statistics 582 Theories of Aging 750
Application of the Nursing Process 583 The Normal Aging Process 752
Treatment Modalities 602 Special Concerns of the Elderly
Summary and Key Points 604 Population 759
Review Questions 605 Application of the Nursing Process 764
Summary and Key Points 772
Chapter 30 Issues Related to Human Sexuality Review Questions 774
and Gender Dysphoria 608
Objectives 608 Chapter 35 Survivors of Abuse or Neglect 777
Homework Assignment 608 Objectives 777
Development of Human Sexuality 609 Homework Assignment 777
Sexual Disorders 611 Predisposing Factors 778
Application of the Nursing Process to Application of the Nursing Process 780
Sexual Disorders 620 Treatment Modalities 792
Gender Dysphoria 630 Summary and Key Points 793
Application of the Nursing Process to Review Questions 794
Gender Dysphoria in Children 631
Gender Dysphoria in Adolescents or Chapter 36 Community Mental Health Nursing 798
Adults 634 Objectives 798
Variations in Sexual Orientation 635 Homework Assignment 798
Sexually Transmitted Diseases 637 The Changing Focus of Care 799
Summary and Key Points 641 The Public Health Model 800
Review Questions 641 The Community as Client 801
Summary and Key Points 827
Chapter 31 Eating Disorders 646 Review Questions 827
Objectives 646
Homework Assignment 646 Chapter 37 The Bereaved Individual 830
Epidemiological Factors 647 Objectives 830
Application of the Nursing Process 647 Homework Assignment 830
Treatment Modalities 662 Theoretical Perspectives on Loss and
Summary and Key Points 665 Bereavement 831
Review Questions 666 Length of the Grief Response 835
Anticipatory Grief 835
Chapter 32 Personality Disorders 669 Maladaptive Responses to Loss 836
Objectives 669 Application of the Nursing Process 838
Homework Assignment 669 Additional Assistance 843
Historical Aspects 671 Summary and Key Points 847
Types of Personality Disorders 672 Review Questions 848
4092_FM_i-xxiv 25/07/14 10:20 AM Page xxi

Contents xxi

Chapter 38 Military Families 851 Appendix F Assigning Nursing Diagnoses to Client

Objectives 851 Behaviors 895
Homework Assignment 851 Glossary 897
Historical Aspects 852 Index 917
Epidemiological Statistics 852
Application of the Nursing Process 852
Treatment Modalities 862 *The following content can be found online at
Summary and Key Points 863 www.davisplus.com:
Review Questions 864
• Psychopharmacology

Appendix A Answers to Chapter Review Questions 868 • Relaxation Therapy

Appendix B Examples of Answers to Communication • Complementary Therapies
Exercises 870 • Forensic Nursing
Appendix C Mental Status Assessment 871
• Controlled Drug Categories and Pregnancy Categories
Appendix D DSM-5 Classification 875
Appendix E NANDA Nursing Diagnoses: Taxonomy II 891 • Sample Client Teaching Guides
4092_FM_i-xxiv 25/07/14 10:20 AM Page xxii
4092_FM_i-xxiv 25/07/14 10:20 AM Page xxiii

To the Instructor

Currently in progress, implementation of the recom- Substance Use and Addictive Disorders, Schizophrenia,
mendations set forth by the New Freedom Commis- Depressive Disorders, Personality Disorders, and Sur-
sion on Mental Health has given enhanced priority to vivors of Abuse or Neglect. These exercises portray clin-
mental health care in the United States. Moreover, at ical scenarios that allow the student to practice
the 65th meeting of the World Health Assembly communication skills with clients. Examples of answers
(WHA) in May 2012, India, Switzerland, and the appear in an appendix at the back of the book.
United States cosponsored a resolution requesting New content on factitious disorder, Munchausen
that the World Health Organization, in collaboration syndrome, and hoarding disorder.
with member countries, develop a global mental New chapter on “Trauma- and Stressor-Related
health action plan. This resolution was passed at the Disorders” (to correlate with DSM-5).
66th WHA in May 2013. By their support of this reso- New chapter on “Military Families.”
lution, member countries have expressed their com- New chapter on “The Recovery Model” in the
mitment for “promotion of mental health, prevention Therapeutic Approaches unit of the textbook. Addi-
of mental disorders, and early identification, care, tional content on the Recovery Model in chapters on
support, treatment, and recovery of persons with Schizophrenia and Bipolar Disorder.
mental disorders.” With the passage of this resolution, Updated and new psychotropic drugs approved
mental health services may now be available for mil- since the publication of the seventh edition. These
lions who have been without this type of care. are included in the specific diagnostic chapters to
Many nurse leaders see this period of mental health- which they apply and in the psychopharmacology
care reform as an opportunity for nurses to expand chapter found on davisplus.com.
their roles and assume key positions in education, pre-
vention, assessment, and referral. Nurses are, and will Features That Have Been Retained
continue to be, in key positions to assist individuals to in the Eighth Edition
attain, maintain, or regain optimal emotional wellness.
As it has been with each new edition of Psychiatric The concept of holistic nursing is retained in the
Mental Health Nursing: Concepts of Care in Evidence- eighth edition. An attempt has been made to ensure
Based Nursing, the goal of this eighth edition is to that the physical aspects of psychiatric/mental health
bring to practicing nurses and nursing students the nursing are not overlooked. In all relevant situations,
most up-to-date information related to neurobiology, the mind/body connection is addressed.
psychopharmacology, and evidence-based nursing Nursing process is retained in the eighth edition
interventions. Notable in this edition are changes as- as the tool for delivery of care to the individual with a
sociated with the recently-published fifth edition of psychiatric disorder or to assist in the primary preven-
the American Psychiatric Association’s Diagnostic and tion or exacerbation of mental illness symptoms. The
Statistical Manual of Mental Disorders (DSM-5). six steps of the nursing process, as described in the
American Nurses Association Standards of Clinical Nurs-
Content and Features New to the Eighth ing Practice, are used to provide guidelines for the nurse.
These standards of care are included for the DSM-5
Edition diagnoses, as well as those on the aging individual, the
All content has been updated to reflect the current bereaved individual, survivors of abuse and neglect,
state of the discipline of nursing. and military families, and as examples in several of the
All psychiatric diagnostic content is reflective of therapeutic approaches. The six steps include:
the newly published American Psychiatric Associa- Assessment: Background assessment data, including
tion’s Diagnostic and Statistical Manual of Mental a description of symptomatology, provides an ex-
Disorders, 5th Edition (2013). tensive knowledge base from which the nurse may
All nursing diagnoses are current with the draw when performing an assessment. Several as-
NANDA-I 2012-2014 Nursing Diagnoses Definitions and sessment tools are also included.
Classifications. Diagnosis: Analysis of the data is included, from
Six “Communication Exercises” boxes—one each which nursing diagnoses common to specific psy-
following the chapters on Neurocognitive Disorders, chiatric disorders are derived.
xxiii
4092_FM_i-xxiv 25/07/14 10:20 AM Page xxiv

xxiv To the Instructor

Outcome Identification: Outcomes are derived from the concept map care plans, and neurobiological
nursing diagnoses and stated as measurable goals. content and illustrations, as well as student re-
Planning: A plan of care is presented with selected nurs- sources including practice test questions, learning
ing diagnoses for the DSM-5 diagnoses, as well as for activities, concept map care plans, and client teach-
the elderly client, the bereaved individual, victims of ing guides.
abuse and neglect, military veterans and their fami-
lies, the elderly homebound client, and the primary Additional Educational Resources
caregiver of the client with a chronic mental illness. Faculty may also find the following teaching aids that
The planning standard also includes tables that list accompany this textbook helpful:
topics for educating clients and families about mental Instructor Resources at www.davisplus.com:
illness. Concept map care plans are included for all ■ Multiple choice questions (including new format
major psychiatric diagnoses. questions reflecting the latest NCLEX blueprint).
Implementation: The interventions that have been ■ Lecture outlines for all chapters
identified in the plan of care are included along ■ Learning activities for all chapters (including
with rationales for each. Case studies at the end of answer key)
each DSM-5 chapter assist the student in the practi- ■ Answers to the Critical Thinking Exercises from the
cal application of theoretical material. Also included textbook
as a part of this particular standard is Unit 3 of the ■ PowerPoint Presentation to accompany all chapters
textbook, “Therapeutic Approaches in Psychiatric in the textbook
Nursing Care.” This section of the textbook ad- ■ Answers to the Homework Assignment Questions
dresses psychiatric nursing intervention in depth, from the textbook
and frequently speaks to the differentiation in scope ■ Case studies for use with student teaching
of practice between the basic level psychiatric nurse
Additional chapters on Psychopharmacology, Re-
and the advanced practice level psychiatric nurse.
laxation Therapy, Complementary Therapies, and
Evaluation: The evaluation standard includes a set of
Forensic Nursing are online at www.davisplus.com.
questions that the nurse may use to assess whether
It is hoped that the revisions and additions to this
the nursing actions have been successful in achiev-
eighth edition continue to satisfy a need within psy-
ing the objectives of care.
chiatric/mental health nursing practice. The mission
Other features of this eighth edition: of this textbook has been, and continues to be, to pro-
■ Internet references for each DSM-5 diagnosis, vide both students and clinicians with up-to-date infor-
with website listings for information related to the mation about psychiatric/mental health nursing. The
disorder. user-friendly format and easy-to-understand language,
■ Tables that list topics for client/family education for which we have received many positive comments,
(in the clinical chapters). have been retained in this edition. I hope that this
■ Boxes that include current research studies with eighth edition continues to promote and advance the
implications for evidence-based nursing practice commitment to psychiatric/mental health nursing.
(in the clinical chapters).
■ Assigning nursing diagnoses to client behaviors Mary C. Townsend
(diagnostic chapters and Appendix F).
■ Taxonomy and diagnostic criteria from the DSM-5
(2013). Used throughout the text.
■ All references have been updated throughout the
text. Classical references are distinguished from
general references.
■ Boxes with definitions of core concepts appear
throughout the text.
■ Comprehensive glossary.
■ Answers to end-of-chapter review questions
(Appendix A).
■ Answers to communication exercises (Appendix B).
■ Sample client teaching guides (online at
www.davisplus.com).
■ Website. An F.A. Davis/Townsend website that con-
tains additional nursing care plans that do not ap-
pear in the text, links to psychotropic medications,
4092_Ch01_001-011 23/07/14 11:41 AM Page 1

UNIT 1
Basic Concepts in
Psychiatric/Mental
Health Nursing
4092_Ch01_001-011 23/07/14 11:41 AM Page 2

CORE CONCEPTS
adaptation
1 The Concept of Stress
Adaptation
CHAPTER OUTLINE
Objectives Stress Management
maladaptation Homework Assignment Summary and Key Points
stressor Stress as a Biological Response Review Questions
Stress as an Environmental Event
Stress as a Transaction Between the Individual
and the Environment

K EY T E R M S
“fight or flight” syndrome precipitating event
general adaptation syndrome predisposing factors

O B J EC T I V E S
After reading this chapter, the student will be able to:

1. Define adaptation and maladaptation. 5. Explain the concept of stress as a transac-

2. Identify physiological responses to stress. tion between the individual and the
3. Explain the relationship between stress and environment.
“diseases of adaptation.” 6. Discuss adaptive coping strategies in the
4. Describe the concept of stress as an envi- management of stress.
ronmental event.

HOMEWORK ASSIGNMENT
Please read the chapter and answer the following questions:

1. How are the body’s physiological defenses 3. In their study, what event did Miller and
affected when under sustained stress? Why? Rahe find produced the highest level of
2. In the view of stress as an environmental stress reaction in their subjects?
event, what aspects are missing when 4. What is the initial step in stress
considering an individual’s response to a management?
stressful situation?

Psychologists and others have struggled for many years processes and preserving self-esteem can be viewed as
to establish an effective definition of the term stress. healthy adaptations to stress.
This term is used loosely today and still lacks a defini- Roy (1976) defined an adaptive response as behav-
tive explanation. Stress may be viewed as an individual’s ior that maintains the integrity of the individual.
reaction to any change that requires an adjustment or Adaptation is viewed as positive and is correlated with
response, which can be physical, mental, or emotional. a healthy response. When behavior disrupts the in-
Responses directed at stabilizing internal biological tegrity of the individual, it is perceived as maladaptive.

2
4092_Ch01_001-011 23/07/14 11:41 AM Page 3

CHAPTER 1 ■ The Concept of Stress Adaptation 3

Maladaptive responses by the individual are consid- biological system to a change imposed on it. Since his
ered to be negative or unhealthy. initial publication, he has revised his definition of
Various 20th-century researchers contributed to stress, calling it “the state manifested by a specific syn-
several different concepts of stress. Three of these con- drome which consists of all the nonspecifically-
cepts include stress as a biological response, stress as induced changes within a biologic system” (Selye,
an environmental event, and stress as a transaction be- 1976). This syndrome of symptoms has come to be
tween the individual and the environment. This chap- known as the “fight or flight” syndrome. Schematics
ter includes an explanation of each of these concepts. of these biological responses, both initially and with
sustained stress, are presented in Figures 1-1 and 1-2.
Selye called this general reaction of the body to stress
CORE CONCEPT the general adaptation syndrome. He described three
Stressor distinct stages of the reaction:
A biological, psychological, social, or chemical factor
that causes physical or emotional tension and may be 1. Alarm Reaction Stage. During this stage, the phys-
a factor in the etiology of certain illnesses. iological responses of the “fight or flight” syn-
drome are initiated.
2. Stage of Resistance. The individual uses the phys-
Stress as a Biological Response iological responses of the first stage as a defense in
the attempt to adapt to the stressor. If adaptation
In 1956, Hans Selye published the results of his re- occurs, the third stage is prevented or delayed.
search concerning the physiological response of a Physiological symptoms may disappear.

HYPOTHALAMUS

Stimulates

Sympathetic Nervous System

Innervates

Adrenal Eye Lacrimal Respiratory Cardiovascular GI system Liver Urinary Sweat Fat
medulla glands system system system glands cells

Pupils Bronchioles Gastric and Ureter Lipolysis

dilated dilated intestinal motility
Respiration motility Bladder
rate increased Secretions muscle
Sphincters contracts;
contract sphincter
relaxes

Norepinephrine Secretion Force of cardiac Glycogenolysis Secretion

and epinephrine increased contraction and
released Cardiac output gluconeogenesis
Heart rate Glycogen
Blood pressure synthesis

FIGURE 1–1 The “fight or flight” syndrome: the initial stress response.
4092_Ch01_001-011 23/07/14 11:41 AM Page 4

4 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

HYPOTHALAMUS

Stimulates

Pituitary Gland

Releases

Adrenocorticotropic hormone Vasopressin Growth hormone Thyrotropic hormone Gonadotropins

(ACTH) (ADH)

Stimulates Blood pressure Direct effect on Stimulates (Initially)

through constriction protein, carbohydrate, Sex hormones;
of blood and lipid metabolism, Later, with
Adrenal cortex vessels resulting in Thyroid gland sustained
Fluid increased serum stress:
retention glucose and free Secretion of
Releases fatty acids Basal metabolic sex hormones
rate (BMR)
Glucocorticoids Mineralocorticoids

Libido
Gluconeogenesis Retention Impotence
Immune of sodium
response and water
Inflammatory
response

FIGURE 1–2 The “fight or flight” syndrome: the sustained stress response.

3. Stage of Exhaustion. This stage occurs when there compensatory mechanisms to the pre-emergent con-
is a prolonged exposure to the stressor to which dition (homeostasis).
the body has become adjusted. The adaptive en- Selye performed his extensive research in a con-
ergy is depleted, and the individual can no longer trolled setting with laboratory animals as subjects.
draw from the resources for adaptation described He elicited the physiological responses with physical
in the first two stages. Diseases of adaptation (e.g., stimuli, such as exposure to heat or extreme cold,
headaches, mental disorders, coronary artery dis- electric shock, injection of toxic agents, restraint,
ease, ulcers, colitis) may occur. Without interven- and surgical injury. Since the publication of his orig-
tion for reversal, exhaustion, and in some cases inal research, it has become apparent that the “fight
even death, ensues (Selye, 1956, 1974). or flight” syndrome of symptoms occurs in response
This “fight or flight” response undoubtedly served to psychological or emotional stimuli, just as it does
our ancestors well. Those Homo sapiens who had to face to physical stimuli. The psychological or emotional
the giant grizzly bear or the saber-toothed tiger as part stressors are often not resolved as rapidly as some
of their struggle for survival must have used these physical stressors, and therefore the body may be de-
adaptive resources to their advantage. The response pleted of its adaptive energy more readily than it is
was elicited in emergency situations, used in the from physical stressors. The “fight or flight” re-
preservation of life, and followed by restoration of the sponse may be inappropriate, even dangerous, to
4092_Ch01_001-011 23/07/14 11:41 AM Page 5

CHAPTER 1 ■ The Concept of Stress Adaptation 5

the lifestyle of today, in which stress has been de- Miller and Rahe (1997) have updated the original
scribed as a psychosocial state that is pervasive, Social Readjustment Rating Scale devised by Holmes
chronic, and relentless. It is this chronic response and Rahe in 1967. Just as in the earlier version, numer-
that maintains the body in the aroused condition for ical values are assigned to various events, or changes,
extended periods of time that promotes susceptibil- that are common in people’s lives. The updated version
ity to diseases of adaptation. reflects an increased number of stressors not identified
in the original version. In the new study, Miller and
Rahe found that women react to life stress events at
CORE CONCEPT higher levels than men, and unmarried people gave
Adaptation higher scores than married people for most of the
Adaptation is said to occur when an individual’s physical events. Younger subjects rated more events at a higher
or behavioral response to any change in his or her stress level than older subjects. A high score on the Re-
internal or external environment results in preservation cent Life Changes Questionnaire (RLCQ) places the
of individual integrity or timely return to equilibrium. individual at greater susceptibility to physical or psy-
chological illness. The questionnaire may be com-
pleted considering life stressors within a 6-month or
Stress as an Environmental Event 1-year period. Six-month totals equal to or greater than
300 life change units (LCUs) or 1-year totals equal to
A second concept defines stress as the “thing” or or greater than 500 LCUs are considered indicative of
“event” that triggers the adaptive physiological and a high level of recent life stress, thereby increasing the
psychological responses in an individual. The event risk of illness for the individual. The RLCQ is pre-
creates change in the life pattern of the individual, sented in Table 1-1.
requires significant adjustment in lifestyle, and taxes It is unknown whether stress overload merely
available personal resources. The change can be ei- predisposes a person to illness or actually precipi-
ther positive, such as outstanding personal achieve- tates it, but there does appear to be a causal link
ment, or negative, such as being fired from a job. The (Pelletier, 1992). Life changes questionnaires have
emphasis here is on change from the existing steady been criticized because they do not consider the in-
state of the individual’s life pattern. dividual’s perception of the event. Individuals differ

TA B L E 1–1 The Recent Life Changes Questionnaire

LIFE CHANGE EVENT LCU LIFE CHANGE EVENT LCU

HEALTH HOME AND FAMILY

An injury or illness which: Major change in living conditions 42
Kept you in bed a week or more, 74
or sent you to the hospital Change in residence:
Move within the same town or city 25
Was less serious than above 44 Move to a different town, city, or state 47

Major dental work 26 Change in family get-togethers 25

Major change in eating habits 27 Major change in health or behavior of family 55

member
Major change in sleeping habits 26
Marriage 50
Major change in your usual type/ 28
amount of recreation Pregnancy 67

Miscarriage or abortion 65
WORK
Change to a new type of work 51 Gain of a new family member:
Birth of a child 66
Change in your work hours or conditions 35 Adoption of a child 65
Change in your responsibilities at work: A relative moving in with you 59
More responsibilities 29 Spouse beginning or ending work 46
Fewer responsibilities 21
Promotion 31
Continued
4092_Ch01_001-011 23/07/14 11:41 AM Page 6

6 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

TA B L E 1–1 The Recent Life Changes Questionnaire—cont’d

LIFE CHANGE EVENT LCU LIFE CHANGE EVENT LCU
Demotion 42 Child leaving home:
Transfer 32 To attend college 41
Due to marriage 41
Troubles at work: For other reasons 45
With your boss 29
With coworkers 35 Change in arguments with spouse 50
With persons under your supervision 35
Other work troubles 28 In-law problems 38

Major business adjustment 60 Change in the marital status of your parents:

Divorce 59
Retirement 52 Remarriage 50

Loss of job: Separation from spouse:

Laid off from work 68 Due to work 53
Fired from work 79 Due to marital problems 76

Correspondence course to 18 Divorce 96

help you in your work
Birth of grandchild 43
PERSONAL AND SOCIAL Death of spouse 119
Change in personal habits 26
Death of other family member:
Beginning or ending school or college 38 Child 123
Brother or sister 102
Change of school or college 35 Parent 100
Change in political beliefs 24
FINANCIAL
Change in religious beliefs 29 Major change in finances:
Increased income 38
Change in social activities 27 Decreased income 60
Vacation 24 Investment and/or credit difficulties 56

New, close, personal relationship 37 Loss or damage of personal property 43

Engagement to marry 45 Moderate purchase 20

Girlfriend or boyfriend problems 39 Major purchase 37

Sexual difficulties 44 Foreclosure on a mortgage or loan 58

“Falling out” of a close personal 47

relationship

An accident 48

Minor violation of the law 20

Being held in jail 75

Death of a close friend 70

Major decision regarding your 51

immediate future

Major personal achievement 36

SOURCE: Miller and Rahe (1997), with permission.

4092_Ch01_001-011 23/07/14 11:41 AM Page 7

CHAPTER 1 ■ The Concept of Stress Adaptation 7

in their reactions to life events, and these variations When an event is appraised as challenging, the individ-
are related to the degree to which the change is per- ual focuses on potential for gain or growth, rather
ceived as stressful. These types of instruments also than on risks associated with the event. Challenge
fail to consider the individual’s coping strategies produces stress even though the emotions associated
and available support systems at the time when the with it (eagerness and excitement) are viewed as pos-
life change occurs. Positive coping mechanisms and itive, and coping mechanisms must be called upon to
strong social or familial support can reduce the in- face the new encounter. Challenge and threat may
tensity of the stressful life change and promote a occur together when an individual experiences these
more adaptive response. positive emotions along with fear or anxiety over pos-
sible risks associated with the challenging event.
Stress as a Transaction Between When stress is produced in response to harm/loss,
the Individual and the Environment threat, or challenge, a secondary appraisal is made by
the individual.
This concept of stress emphasizes the relationship be-
Secondary Appraisal
tween the individual and the environment. Personal
characteristics and the nature of the environmental This secondary appraisal is an assessment of skills, re-
event are considered. This illustration parallels the sources, and knowledge that the person possesses to
modern concept of the etiology of disease. No longer deal with the situation. The individual evaluates by
is causation viewed solely as an external entity; considering the following:
whether or not illness occurs depends also on the re- ■ Which coping strategies are available to me?
ceiving organism’s susceptibility. Similarly, to predict ■ Will the option I choose be effective in this situation?
psychological stress as a reaction, the properties of ■ Do I have the ability to use that strategy in an effec-
the person in relation to the environment must be tive manner?
considered. The interaction between the primary appraisal of
the event that has occurred and the secondary ap-
Precipitating Event praisal of available coping strategies determines the
Lazarus and Folkman (1984) define stress as a relation- quality of the individual’s adaptation response to stress.
ship between the person and the environment that is
appraised by the person as taxing or exceeding his or Predisposing Factors
her resources and endangering his or her well-being. A variety of elements influence how an individual per-
A precipitating event is a stimulus arising from the in- ceives and responds to a stressful event. These predis-
ternal or external environment and is perceived by posing factors strongly influence whether the response
the individual in a specific manner. Determination is adaptive or maladaptive. Types of predisposing fac-
that a particular person-environment relationship is tors include genetic influences, past experiences, and
stressful depends on the individual’s cognitive ap- existing conditions.
praisal of the situation. Cognitive appraisal is an indi- Genetic influences are those circumstances of an indi-
vidual’s evaluation of the personal significance of the vidual’s life that are acquired through heredity. Exam-
event or occurrence. The event “precipitates” a re- ples include family history of physical and psychological
sponse on the part of the individual, and the response conditions (strengths and weaknesses) and tempera-
is influenced by the individual’s perception of the ment (behavioral characteristics present at birth that
event. The cognitive response consists of a primary ap- evolve with development).
praisal and a secondary appraisal. Past experiences are occurrences that result in
learned patterns that can influence an individual’s
Individual’s Perception of the Event adaptation response. They include previous expo-
Primary Appraisal sure to the stressor or other stressors, learned coping
Lazarus and Folkman (1984) identify three types of responses, and degree of adaptation to previous
primary appraisal: irrelevant, benign-positive, and stressors.
stressful. An event is judged irrelevant when the out- Existing conditions incorporate vulnerabilities that
come holds no significance for the individual. A influence the adequacy of the individual’s physical,
benign-positive outcome is one that is perceived as pro- psychological, and social resources for dealing with
ducing pleasure for the individual. Stress appraisals in- adaptive demands. Examples include current health
clude harm/loss, threat, and challenge. Harm/loss status, motivation, developmental maturity, severity
appraisals refer to damage or loss already experi- and duration of the stressor, financial and educa-
enced by the individual. Appraisals of a threatening na- tional resources, age, existing coping strategies, and
ture are perceived as anticipated harms or losses. a support system of caring others.
4092_Ch01_001-011 23/07/14 11:41 AM Page 8

8 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

This transactional model of stress/adaptation will Coping strategies are considered maladaptive when
serve as a framework for the process of nursing in this the conflict being experienced goes unresolved or in-
text. A graphic display of the model is presented in tensifies. Energy resources become depleted as the
Figure 1-3. body struggles to compensate for the chronic physio-
logical and psychological arousal being experienced.
The effect is a significant vulnerability to physical
CORE CONCEPT or psychological illness.
Maladaptation
Maladaptation occurs when an individual’s physical or
Adaptive Coping Strategies
behavioral response to any change in his or her internal Awareness
or external environment results in disruption of individual The initial step in managing stress is awareness—to
integrity or in persistent disequilibrium. become aware of the factors that create stress and the
feelings associated with a stressful response. Stress can
be controlled only when one recognizes that it is
Stress Management* being experienced. As one becomes aware of stres-
sors, he or she can omit, avoid, or accept them.
The growth of stress management into a multimillion-
dollar-a-year business attests to its importance in our Relaxation
society. Stress management involves the use of coping Individuals experience relaxation in different ways.
strategies in response to stressful situations. Coping Some individuals relax by engaging in large motor ac-
strategies are adaptive when they protect the individual tivities, such as sports, jogging, and physical exercise.
from harm (or additional harm) or strengthen the in- Still others use techniques such as breathing exercises
dividual’s ability to meet challenging situations. Adap- and progressive relaxation to relieve stress. (A discus-
tive responses help restore homeostasis to the body sion of relaxation therapy may be found online at
and impede the development of diseases of adaptation. www.DavisPlus.com.
Meditation
Precipitating Event Practiced 20 minutes once or twice daily, meditation
has been shown to produce a lasting reduction in
blood pressure and other stress-related symptoms
Predisposing Factors
Genetic Influences
(Davis, Eshelman, & McKay, 2008). Meditation in-
Past Experiences volves assuming a comfortable position, closing the
Existing Conditions
eyes, casting off all other thoughts, and concentrating
on a single word, sound, or phrase that has positive
Cognitive Appraisal
meaning to the individual. The technique is de-
scribed in detail online at www.DavisPlus.com.
* Primary *
Interpersonal Communication With Caring Other
Benign- Stress
As previously mentioned, the strength of one’s available
Irrelevant
positive appraisals support systems is an existing condition that signifi-
No Pleasurable cantly influences the adaptability of coping with stress.
response response
Harm/
Threat
Challenge Sometimes just “talking the problem out” with an indi-
loss
vidual who is empathetic is sufficient to interrupt esca-
* Secondary * lation of the stress response. Writing about one’s
feelings in a journal or diary can also be therapeutic.
Availability of coping strategies
Perceived effectiveness of coping strategies
Perceived ability to use coping strategies effectively
Problem Solving
An extremely adaptive coping strategy is to view the sit-
Quality of Response
uation objectively (or to seek assistance from another
Adaptive Maladaptive individual to accomplish this if the anxiety level is too
high to concentrate). After an objective assessment of
the situation, the problem-solving/decision-making
FIGURE 1–3 Transactional model of stress/adaptation.
model can be instituted as follows:
■ Assess the facts of the situation.
*Techniques of stress management are discussed at greater ■ Formulate goals for resolution of the stressful
length in Unit 3 of this text. situation.
4092_Ch01_001-011 23/07/14 11:41 AM Page 9

CHAPTER 1 ■ The Concept of Stress Adaptation 9

■ Study the alternatives for dealing with the situation. ■ Selye called the general reaction of the body to
■ Determine the risks and benefits of each alternative. stress the “general adaptation syndrome,” which
■ Select an alternative. occurs in three stages: the alarm reaction stage, the
■ Implement the alternative selected. stage of resistance, and the stage of exhaustion.
■ Evaluate the outcome of the alternative ■ When individuals remain in the aroused response
implemented. to stress for an extended period of time, they be-
■ If the first choice is ineffective, select and imple- come susceptible to diseases of adaptation, some
ment a second option. examples of which include headaches, mental
disorders, coronary artery disease, ulcers, and
Pets
colitis.
Studies show that those who care for pets, especially ■ Stress may also be viewed as an environmental
dogs and cats, are better able to cope with the stressors event. This results when a change from the existing
of life (Allen, Blascovich, & Mendes, 2002; Barker, steady state of the individual’s life pattern occurs.
Knisely, McCain, & Best, 2005). The physical act of ■ When an individual experiences a high level of life
stroking or petting a dog or cat can be therapeutic. It change events, he or she becomes susceptible to
gives the animal an intuitive sense of being cared for physical or psychological illness.
and at the same time gives the individual the calming ■ Limitations of the environmental concept of stress
feeling of warmth, affection, and interdependence include failure to consider the individual’s percep-
with a reliable, trusting being. One study showed that tion of the event, coping strategies, and available
among people who had had heart attacks, pet owners support systems at the time when the life change
had one-fifth the death rate of those who did not have occurs.
pets (Friedmann & Thomas, 1995). Another study re- ■ Stress is more appropriately expressed as a transac-
vealed evidence that individuals experienced a statis- tion between the individual and the environment
tically significant drop in blood pressure in response that is appraised by the individual as taxing or ex-
to petting a dog or cat (Whitaker, 2000). ceeding his or her resources and endangering his
Music or her well-being.
It is true that music can “soothe the savage beast.” ■ The individual makes a cognitive appraisal of the
Creating and listening to music stimulate motivation, precipitating event to determine the personal sig-
enjoyment, and relaxation. Music can reduce depres- nificance of the event or occurrence.
sion and bring about measurable changes in mood ■ Primary cognitive appraisals may be irrelevant,
and general activity. benign-positive, or stressful.
■ Secondary cognitive appraisals include assessment
Summary and Key Points and evaluation by the individual of skills, re-
sources, and knowledge to deal with the stressful
■ Stress has become a chronic and pervasive condi- situation.
tion in the United States today. ■ Predisposing factors influence how an individual
■ Adaptive behavior is viewed as behavior that main- perceives and responds to a stressful event. They
tains the integrity of the individual, with a timely include genetic influences, past experiences, and
return to equilibrium. It is viewed as positive and existing conditions.
is correlated with a healthy response. ■ Stress management involves the use of adaptive
■ When behavior disrupts the integrity of the indi- coping strategies in response to stressful situations
vidual or results in persistent disequilibrium, it is in an effort to impede the development of diseases
perceived as maladaptive. Maladaptive responses of adaptation.
by the individual are considered to be negative or ■ Examples of adaptive coping strategies include de-
unhealthy. veloping awareness, relaxation, meditation, interper-
■ A stressor is defined as a biological, psychological, sonal communication with caring other, problem
social, or chemical factor that causes physical or solving, pets, and music.
emotional tension and may be a factor in the etiol-
ogy of certain illnesses.
■ Hans Selye identified the biological changes asso- Additional info available at
ciated with a stressful situation as the “fight or www.davisplus.com
flight” syndrome.
4092_Ch01_001-011 23/07/14 11:41 AM Page 10

10 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

Review Questions
Self-Examination/Learning Exercise
Select the answer that is most appropriate for questions 1 through 5. In question 6, identify the category in which
each example belongs.
1. Sondra, who lives in Maine, hears on the evening news that 25 people were killed in a tornado in south
Texas. Sondra experiences no anxiety upon hearing of this stressful situation. This is most likely because
Sondra:
a. Is selfish and does not care what happens to other people.
b. Appraises the event as irrelevant to her own situation.
c. Assesses that she has the skills to cope with the stressful situation.
d. Uses suppression as her primary defense mechanism.
2. Cindy regularly develops nausea and vomiting when she is faced with a stressful situation. Which of
the following is most likely a predisposing factor to this maladaptive response by Cindy?
a. Cindy inherited her mother’s “nervous” stomach.
b. Cindy is fixed in a lower level of development.
c. Cindy has never been motivated to achieve success.
d. When Cindy was a child, her mother pampered her and kept her home from school when she
was ill.
3. When an individual’s stress response is sustained over a long period, the endocrine system involvement
results in which of the following?
a. Decreased resistance to disease.
b. Increased libido
c. Decreased blood pressure.
d. Increased inflammatory response.
4. Management of stress is extremely important in today’s society because:
a. Evolution has diminished human capability for “fight or flight.”
b. The stressors of today tend to be ongoing, resulting in a sustained response.
c. We have stress disorders that did not exist in the days of our ancestors.
d. One never knows when one will have to face a grizzly bear or saber-toothed tiger in today’s society.
5. Nancy has just received a promotion on her job. She is very happy and excited about moving up in
her company, but she has been experiencing anxiety since receiving the news. Her primary appraisal
is that she most likely views the situation as which of the following?
a. Benign-positive
b. Irrelevant
c. Challenging
d. Threatening
6. Precipitating stressors, past experiences, existing conditions, and genetic influences are components
of the Transactional Model of Stress Adaptation, and influence an individual’s response to stress.
Identify each of these conditions in the following examples.
a. Precipitating stressor
b. Past experience
c. Existing conditions
d. Genetic influences
_____ Mr. T is fixed in a lower level of development.
_____ Mr. T’s father had diabetes mellitus.
_____ Mr. T has been fired from his last five jobs.
_____ Mr. T’s baby was stillborn last month.
4092_Ch01_001-011 23/07/14 11:41 AM Page 11

CHAPTER 1 ■ The Concept of Stress Adaptation 11

References Pelletier, K.R. (1992). Mind as healer, mind as slayer: A holistic

approach to preventing stress disorders. New York, NY: Dell.
Allen, K., Blascovich, J., & Mendes, W.B. (2002). Cardiovascular Whitaker, J. (2000). Pet owners are a healthy breed. Health &
reactivity and the presence of pets, friends, and spouses: The Healing, 10(10), 1–8.
truth about cats and dogs. Psychosomatic Medicine, 64, 727–739.
Barker, S.B., Knisely, J.S., McCain, N.L., & Best, A.M. (2005). Classical References
Measuring stress and immune response in healthcare profes- Holmes, T., & Rahe, R. (1967). The social readjustment rating
sionals following interaction with a therapy dog: A pilot study. scale. Journal of Psychosomatic Research, 11, 213–218.
Psychological Reports, 96, 713–729. Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal and coping.
Davis, M.D., Eshelman, E.R., & McKay, M. (2008). The relaxation New York, NY: Springer Publishing.
and stress reduction workbook (6th ed.). Oakland, CA: New Roy, C. (1976). Introduction to nursing: An adaptation model.
Harbinger Publications. Englewood Cliffs, NJ: Prentice-Hall.
Friedmann, E., & Thomas, S.A. (1995). Pet ownership, social sup- Selye, H. (1956). The stress of life. New York, NY: McGraw-Hill.
port, and one-year survival after acute myocardial infarction Selye, H. (1974). Stress without distress. New York, NY: Signet
in the cardiac arrhythmia suppression trial. American Journal Books.
of Cardiology, 76(17), 1213. Selye, H. (1976). The stress of life (rev. ed.). New York, NY:
Miller, M.A., & Rahe, R.H. (1997). Life changes scaling for the McGraw Hill.
1990s. Journal of Psychosomatic Research, 43(3), 279–292.
4092_Ch02_012-026 24/07/14 5:20 PM Page 12

2
Mental Health/Mental Illness:
Historical and Theoretical
Concepts
CORE CONCEPTS CHAPTER OUTLINE
anxiety Objectives Psychological Adaptation to Stress
grief Homework Assignment Mental Health/Mental Illness Continuum
Historical Overview of Psychiatric Care Summary and Key Points
Mental Health Review Questions
Mental Illness

K EY T E R M S
anticipatory grieving introjection suppression
bereavement overload isolation undoing
defense mechanisms projection humors
compensation rationalization mental health
denial reaction formation mental illness
displacement regression neurosis
identification repression psychosis
intellectualization sublimation “ship of fools”

O B J EC T I V E S
After reading this chapter, the student will be able to:

1. Discuss the history of psychiatric care. 4. Describe psychological adaptation responses

2. Define mental health and mental illness. to stress.
3. Discuss cultural elements that influence at- 5. Identify correlation of adaptive/maladaptive
titudes toward mental health and mental behaviors to the mental health/mental
illness. illness continuum.

HOMEWORK ASSIGNMENT
Please read the chapter and answer the following questions:

1. Explain the concepts of incomprehensibility you ask her about it, she says she has no
and cultural relativity. memory of the accident. What ego defense
2. Describe some symptoms of panic anxiety. mechanism is she using?
3. Jane was involved in an automobile accident 4. In what stage of the grieving process is the in-
in which both her parents were killed. When dividual with delayed or inhibited grief fixed?

The consideration of mental health and mental ill- tolerance for behaviors that deviate from the cul-
ness has its basis in the cultural beliefs of the society tural norms.
in which the behavior takes place. Some cultures are A study of the history of psychiatric care reveals
quite liberal in the range of behaviors that are con- some shocking truths about past treatment of indi-
sidered acceptable, whereas others have very little viduals with mental illness. Many were kept in control

12
4092_Ch02_012-026 24/07/14 5:20 PM Page 13

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 13

by means that today could be considered less than This notion gave rise to the establishment of special
humane. units for clients with mental illness within general
This chapter deals with the evolution of psychiatric hospitals, as well as residential institutions specifi-
care from ancient times to the present. Mental health cally designed for this purpose. They can likely be
and mental illness are defined, and the psychological considered the first asylums for individuals with
adaptation to stress is explained in terms of the two mental illness.
major responses: anxiety and grief. Behavioral re- Colonial Americans tended to reflect the attitudes
sponses and their placement along the mental health/ of the European communities from which they had
mental illness continuum are discussed. emigrated. Particularly in the New England area, in-
dividuals were punished for behavior attributed to
Historical Overview of Psychiatric Care witchcraft. In the 16th and 17th centuries, institutions
for people with mental illness did not exist in the
Primitive beliefs regarding mental disturbances took United States, and care of these individuals became a
several views. Some thought that an individual with family responsibility. Those without family or other
mental illness had been dispossessed of his or her soul resources became the responsibility of the communi-
and that the only way wellness could be achieved was ties in which they lived and were incarcerated in
if the soul returned. Others believed that evil spirits places where they could do no harm to themselves or
or supernatural or magical powers had entered the others.
body. The “cure” for these individuals involved a ritu- The first hospital in America to admit clients with
alistic exorcism to purge the body of these unwanted mental illness was established in Philadelphia in the
forces. This often consisted of brutal beatings, starva- middle of the 18th century. Benjamin Rush, often
tion, or other torturous means. Still others considered called the father of American psychiatry, was a physi-
that the individual with mental illness may have bro- cian at the hospital. He initiated the provision of hu-
ken a taboo or sinned against another individual or manistic treatment and care for clients with mental
God, for which ritualistic purification was required or illness. Although he included kindness, exercise, and
various types of retribution were demanded. The cor- socialization, he also employed harsher methods such
relation of mental illness to demonology or witchcraft as bloodletting, purging, various types of physical re-
led to some individuals with mental illness being straints, and extremes of temperatures, reflecting the
burned at the stake. medical therapies of that era.
The position of these ancient beliefs evolved with in- The 19th century brought the establishment of a
creasing knowledge about mental illness and changes system of state asylums, largely the result of the work
in cultural, religious, and sociopolitical attitudes. The of Dorothea Dix, a former New England school-
work of Hippocrates, about 400 B.C., began the move- teacher, who lobbied tirelessly on behalf of the men-
ment away from belief in the supernatural. Hippocrates tally ill population. She was unfaltering in her belief
associated insanity and mental illness with an irregular- that mental illness was curable and that state hospi-
ity in the interaction of the four body fluids—blood, tals should provide humanistic therapeutic care.
black bile, yellow bile, and phlegm. He called these This system of hospital care for individuals with
body fluids humors, and associated each with a partic- mental illness grew, but the mentally ill population
ular disposition. Disequilibrium among these four hu- grew faster. The institutions became overcrowded
mors was thought to cause mental illness, and it was and understaffed, and conditions deteriorated.
often treated by inducing vomiting and diarrhea with Therapeutic care reverted to custodial care. These
potent cathartic drugs. state hospitals provided the largest resource for in-
During the Middle Ages (A.D. 500 to 1500), the as- dividuals with mental illness until the initiation of
sociation of mental illness with witchcraft and the su- the community health movement of the 1960s (see
pernatural continued to prevail in Europe. During Chapter 36).
this period, many people with severe mental illness The emergence of psychiatric nursing began in
were sent out to sea on sailing boats with little guid- 1873 with the graduation of Linda Richards from
ance to search for their lost rationality. The expres- the nursing program at the New England Hospital
sion “ship of fools” was derived from this operation. for Women and Children in Boston. She has come
During the same period in the Middle Eastern Is- to be known as the first American psychiatric nurse.
lamic countries, however, a change in attitude During her career, Richards was instrumental in
began to occur, from the perception of mental ill- the establishment of a number of psychiatric hos-
ness as the result of witchcraft or the supernatural pitals and the first school of psychiatric nursing at
to the idea that these individuals were actually ill. the McLean Asylum in Waverly, Massachusetts, in
4092_Ch02_012-026 24/07/14 5:20 PM Page 14

14 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

1882. The focus in this school, and those that fol- Maslow described self-actualization as being “psy-
lowed, was “training” in how to provide custodial chologically healthy, fully human, highly evolved,
care for clients in psychiatric asylums—training and fully mature.” He believed that “healthy,” or
that did not include the study of psychological con- “self-actualized,” individuals possessed the following
cepts. Significant change did not occur until 1955, characteristics:
when incorporation of psychiatric nursing into ■ An appropriate perception of reality
their curricula became a requirement for all under- ■ The ability to accept oneself, others, and human
graduate schools of nursing. nature
Nursing curricula emphasized the importance of ■ The ability to manifest spontaneity
the nurse-patient relationship and therapeutic ■ The capacity for focusing concentration on prob-
communication techniques. Nursing intervention lem solving
in the somatic therapies (e.g., insulin and electro- ■ A need for detachment and desire for privacy
convulsive therapy) provided impetus for the incor- ■ Independence, autonomy, and a resistance to
poration of these concepts into nursing’s body of enculturation
knowledge. ■ An intensity of emotional reaction
With the apparently increasing need for psychi- ■ A frequency of “peak” experiences that vali-
atric care in the aftermath of World War II, the gov- dates the worthwhileness, richness, and beauty
ernment passed the National Mental Health Act of of life
1946. This legislation provided funds for the educa- ■ An identification with humankind
tion of psychiatrists, psychologists, social workers, and ■ The ability to achieve satisfactory interpersonal
psychiatric nurses. Graduate-level education in psy- relationships
chiatric nursing was established during this period. ■ A democratic character structure and strong sense
Also significant at this time was the introduction of of ethics
antipsychotic medications, which made it possible for ■ Creativeness
psychotic clients to more readily participate in their ■ A degree of nonconformance
treatment, including nursing therapies.
Jahoda (1958) identified a list of six indicators that
Knowledge of the history of psychiatric/mental
she suggested are a reflection of mental health:
health care contributes to the understanding of the
concepts presented in this chapter and those in 1. A Positive Attitude Toward Self. This includes an
Chapter 3, which describe the theories of personality objective view of self, including knowledge and ac-
development according to various 19th-century and ceptance of strengths and limitations. The individ-
20th-century leaders in the psychiatric/mental health ual feels a strong sense of personal identity and a
movement. Modern American psychiatric care has its security within the environment.
roots in ancient times. A great deal of opportunity 2. Growth, Development, and the Ability to Achieve
exists for continued advancement of this specialty Self-actualization. This indicator correlates with
within the practice of nursing. whether the individual successfully achieves
the tasks associated with each level of develop-
Mental Health ment (see Erikson, Chapter 3). With successful
achievement in each level, the individual gains
A number of theorists have attempted to define the motivation for advancement to his or her highest
concept of mental health. Many of these concepts potential.
deal with various aspects of individual functioning. 3. Integration. The focus here is on maintaining an
Maslow (1970) emphasized an individual’s motivation equilibrium or balance among various life processes.
in the continuous quest for self-actualization. He Integration includes the ability to adaptively respond
identified a “hierarchy of needs,” the lower ones re- to the environment and the development of a phi-
quiring fulfillment before those at higher levels can losophy of life, both of which help the individual
be achieved, with self-actualization being fulfillment maintain anxiety at a manageable level in response
of one’s highest potential. An individual’s position to stressful situations.
within the hierarchy may reverse from a higher level 4. Autonomy. This refers to the individual’s ability to
to a lower level based on life circumstances. For ex- perform in an independent, self-directed manner.
ample, an individual facing major surgery who has The individual makes choices and accepts respon-
been working on tasks to achieve self-actualization sibility for the outcomes.
may become preoccupied, if only temporarily, with 5. Perception of Reality. Accurate reality percep-
the need for physiological safety. A representation of tion is a positive indicator of mental health. This
this needs hierarchy is presented in Figure 2-1. includes perception of the environment without
4092_Ch02_012-026 24/07/14 5:20 PM Page 15

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 15

SELF-
ACTUALIZATION
(The individual
possesses a
feeling of self-
fulfillment and
the realization
of his or her
highest potential.)

SELF-ESTEEM
ESTEEM-OF-OTHERS
(The individual seeks self-respect
and respect from others, works to
achieve success and recognition in
work, and desires prestige from
accomplishments.)

LOVE AND BELONGING

(Needs are for giving and receiving of
affection, companionship, satisfactory
interpersonal relationships, and
identification with a group.)

SAFETY AND SECURITY

(Needs at this level are for avoiding harm, maintaining
comfort, order, structure, physical safety, freedom from
fear, and protection.)

PHYSIOLOGICAL NEEDS
(Basic fundamental needs include food, water, air, sleep, exercise,
elimination, shelter, and sexual expression.)

FIGURE 2–1 Maslow’s hierarchy of needs.

distortion, as well as the capacity for empathy Robinson (1983) has offered the following defini-
and social sensitivity—a respect and concern for tion of mental health:
the wants and needs of others. a dynamic state in which thought, feeling, and behav-
6. Environmental Mastery. This indicator suggests ior that is age-appropriate and congruent with the
that the individual has achieved a satisfactory role local and cultural norms is demonstrated. (p. 74)
within the group, society, or environment. It sug-
gests that he or she is able to love and accept the For purposes of this text, and in keeping with the
love of others. When faced with life situations, the framework of stress/adaptation, a modification of
individual is able to strategize, make decisions, Robinson’s definition of mental health is considered.
change, adjust, and adapt. Life offers satisfaction Thus, mental health is viewed as “the successful adap-
to the individual who has achieved environmental tation to stressors from the internal or external envi-
mastery. ronment, evidenced by thoughts, feelings, and
behaviors that are age-appropriate and congruent
Black and Andreasen (2011) define mental
with local and cultural norms.”
health as:
a state of being that is relative rather than absolute. Mental Illness
The successful performance of mental functions
shown by productive activities, fulfilling relationships A universal concept of mental illness is difficult, be-
with other people, and the ability to adapt to change cause of the cultural factors that influence such a def-
and to cope with adversity. (p. 608) inition. However, certain elements are associated with
4092_Ch02_012-026 24/07/14 5:20 PM Page 16

16 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

individuals’ perceptions of mental illness, regardless or behavior that reflects a dysfunction in the psycholog-
of cultural origin. Horwitz (2002) identifies two ical, biological, or developmental processes underlying
of these elements as (1) incomprehensibility and mental functioning. (p. 20)
(2) cultural relativity. For purposes of this text, and in keeping with the
Incomprehensibility relates to the inability of the gen- framework of stress/adaptation, mental illness will be
eral population to understand the motivation behind characterized as “maladaptive responses to stressors
the behavior. When observers are unable to find from the internal or external environment, evidenced
meaning or comprehensibility in behavior, they are by thoughts, feelings, and behaviors that are incon-
likely to label that behavior as mental illness. Horwitz gruent with the local and cultural norms, and that in-
states, “Observers attribute labels of mental illness terfere with the individual’s social, occupational,
when the rules, conventions, and understandings they and/or physical functioning.”
use to interpret behavior fail to find any intelligible
motivation behind an action” (p. 17). The element of
cultural relativity considers that these rules, conven-
Psychological Adaptation to Stress
tions, and understandings are conceived within an in- All individuals exhibit some characteristics associated
dividual’s own particular culture. Behavior that is with both mental health and mental illness at any
considered “normal” and “abnormal” is defined by given point in time. Chapter 1 described how an in-
one’s cultural or societal norms. Therefore, a behav- dividual’s response to stressful situations is influenced
ior that is recognized as mentally ill in one society may by his or her personal perception of the event and a
be viewed as “normal” in another society, and vice variety of predisposing factors, such as heredity, tem-
versa. Horwitz identified a number of cultural aspects perament, learned response patterns, developmental
of mental illness, which are presented in Box 2-1. maturity, existing coping strategies, and support sys-
The American Psychiatric Association (APA, tems of caring others.
2013), in its Diagnostic and Statistical Manual of Men- Anxiety and grief have been described as two
tal Disorders, Fifth Edition (DSM-5), defines mental major, primary psychological response patterns to
disorder as: stress. A variety of thoughts, feelings, and behaviors
a syndrome characterized by clinically significant distur- are associated with each of these response patterns.
bance in an individual’s cognitions, emotion regulation, Adaptation is determined by the degree to which the

BOX 2-1 Cultural Aspects of Mental Illness

1. Usually members of the lay community, rather than a psy- members or friends. Psychiatric assistance is sought near
chiatric professional, initially recognize that an individual’s the first signs of emotional disturbance.
behavior deviates from the societal norms. 6. The more highly educated the person, the greater the
2. People who are related to an individual or who are of the recognition of mental illness behaviors. However, even
same cultural or social group are less likely to label an in- more relevant than the amount of education is the type
dividual’s behavior as mentally ill than someone who is of education. Individuals in the more humanistic types of
relationally or culturally distant. Relatives (or people of professions (lawyers, social workers, artists, teachers,
the same cultural or social group) try to “normalize” the nurses) are more likely to seek psychiatric assistance than
behavior; that is, they try to find an explanation for the professionals such as business executives, computer spe-
behavior. cialists, accountants, and engineers.
3. Psychiatrists see a person with mental illness most often 7. In terms of religion, Jewish people are more likely to seek
when the family members can no longer deny the illness psychiatric assistance than are Catholics or Protestants.
and often when the behavior is at its worst. The local or 8. Women are more likely than men to recognize the symp-
cultural norms define pathological behavior. toms of mental illness and seek assistance.
4. Individuals in the lowest social class usually display the high- 9. The greater the cultural distance from the mainstream of so-
est amount of mental illness symptoms. However, they ciety (i.e., the fewer the ties with conventional society), the
tend to tolerate a wider range of behaviors that deviate from greater the likelihood of negative response by society to
societal norms and are less likely to consider these behav- mental illness. For example, immigrants have a greater dis-
iors as indicative of mental illness. Mental illness labels are tance from the mainstream than the native born, ethnic mi-
most often applied by psychiatric professionals. norities greater than the dominant culture, and “bohemians”
5. The higher the social class, the greater the recognition of greater than the bourgeoisie. They are more likely to be sub-
mental illness behaviors. Members of the higher social jected to coercive treatment, and involuntary psychiatric
classes are likely to be self-labeled or labeled by family commitments are more common.

Adapted from Horwitz, A.V. (2002). The social control of mental illness. Clinton Corners, NY: Percheron Press.
4092_Ch02_012-026 24/07/14 5:20 PM Page 17

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 17

thoughts, feelings, and behaviors interfere with an in- ■ Panic Anxiety. In this most intense state of anxiety,
dividual’s functioning. the individual is unable to focus on even one detail
in the environment. Misperceptions are common,
and a loss of contact with reality may occur. The in-
CORE CONCEPT dividual may experience hallucinations or delu-
Anxiety sions. Behavior may be characterized by wild and
A diffuse apprehension that is vague in nature and is desperate actions or extreme withdrawal. Human
associated with feelings of uncertainty and helplessness. functioning and communication with others is in-
effective. Panic anxiety is associated with a feeling
of terror, and individuals may be convinced that
Anxiety they have a life-threatening illness or fear that they
Feelings of anxiety are so common in our society that are “going crazy,” are losing control, or are emo-
they are almost considered universal. Anxiety arises tionally weak. Prolonged panic anxiety can lead to
from the chaos and confusion that exists in the world physical and emotional exhaustion and can be a
today. Fears of the unknown and conditions of ambi- life-threatening situation.
guity offer a perfect breeding ground for anxiety to A synopsis of the characteristics associated with each
take root and grow. Low levels of anxiety are adaptive of the four levels of anxiety is presented in Table 2-1.
and can provide the motivation required for survival. Behavioral Adaptation Responses to Anxiety
Anxiety becomes problematic when the individual is
unable to prevent the anxiety from escalating to a level A variety of behavioral adaptation responses occur at
that interferes with the ability to meet basic needs. each level of anxiety. Figure 2-2 depicts these behav-
Peplau (1963) described four levels of anxiety: ioral responses on a continuum of anxiety ranging
mild, moderate, severe, and panic. It is important for from mild to panic.
nurses to be able to recognize the symptoms associ- Mild Anxiety
ated with each level to plan for appropriate interven- At the mild level, individuals employ any of a number
tion with anxious individuals. of coping behaviors that satisfy their needs for com-
■ Mild Anxiety. This level of anxiety is seldom a fort. Menninger (1963) described the following types
problem for the individual. It is associated with the of coping mechanisms that individuals use to relieve
tension experienced in response to the events of anxiety in stressful situations:
day-to-day living. Mild anxiety prepares people for ■ Sleeping ■ Cursing
action. It sharpens the senses, increases motivation ■ Yawning ■ Pacing
for productivity, increases the perceptual field, and ■ Eating ■ Nail biting
results in a heightened awareness of the environ- ■ Drinking ■ Foot swinging
ment. Learning is enhanced and the individual is ■ Physical exercise ■ Finger tapping
able to function at his or her optimal level. ■ Daydreaming ■ Fidgeting
■ Moderate Anxiety. As the level of anxiety increases, ■ Smoking ■ Talking to someone
the extent of the perceptual field diminishes. The ■ Laughing with whom one feels
moderately anxious individual is less alert to events ■ Crying comfortable
occurring in the environment. The individual’s at-
Undoubtedly there are many more responses too
tention span and ability to concentrate decrease,
numerous to mention here, considering that each in-
although he or she may still attend to needs with
dividual develops his or her own unique ways to relieve
direction. Assistance with problem solving may be
anxiety at the mild level. Some of these behaviors are
required. Increased muscular tension and restless-
more adaptive than others.
ness are evident.
■ Severe Anxiety. The perceptual field of the severely Mild-to-Moderate Anxiety
anxious individual is so greatly diminished that Sigmund Freud (1961) identified the ego as the reality
concentration centers on one particular detail only component of the personality that governs problem solv-
or on many extraneous details. Attention span is ing and rational thinking. As the level of anxiety in-
extremely limited, and the individual has much dif- creases, the strength of the ego is tested, and energy is
ficulty completing even the simplest task. Physical mobilized to confront the threat. Anna Freud (1953)
symptoms (e.g., headaches, palpitations, insomnia) identified a number of defense mechanisms employed
and emotional symptoms (e.g., confusion, dread, by the ego in the face of threat to biological or psycho-
horror) may be evident. Discomfort is experienced logical integrity. Some of these ego defense mechanisms
to the degree that virtually all overt behavior is are more adaptive than others, but all are used either
aimed at relieving the anxiety. consciously or unconsciously as a protective device for
4092_Ch02_012-026 24/07/14 5:20 PM Page 18

18 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

TAB LE 2–1 Levels of Anxiety

PERCEPTUAL ABILITY TO PHYSICAL EMOTIONAL/BEHAVIORAL
LEVEL FIELD LEARN CHARACTERISTICS CHARACTERISTICS
Mild Heightened perception Learning is Restlessness May remain superficial
(e.g., noises may enhanced Irritability with others
seem louder; details Rarely experienced as
within the environ- distressful
ment are clearer) Motivation is increased
Increased awareness
Increased alertness

Moderate Reduction in perceptual Learning still Increased restlessness A feeling of discontent

field occurs, but not at Increased heart and May lead to a degree of
Reduced alertness to optimal ability respiration rate impairment in interper-
environmental events Decreased Increased perspiration sonal relationships as
(e.g., someone talking attention span Gastric discomfort individual begins to
may not be heard; Decreased ability Increased muscular focus on self and the
part of the room may to concentrate tension need to relieve personal
not be noticed) Increase in speech rate, discomfort
volume, and pitch

Severe Greatly diminished; Extremely limited Headaches Feelings of dread,

only extraneous attention span Dizziness loathing, horror
details are perceived, Unable to Nausea Total focus on self and
or fixation on a single concentrate or Trembling intense desire to relieve
detail may occur problem-solve Insomnia the anxiety
May not take notice of Effective learning Palpitations
an event even when cannot occur Tachycardia
attention is directed Hyperventilation
by another Urinary frequency
Diarrhea

Panic Unable to focus on Learning cannot Dilated pupils Sense of impending

even one detail within occur Labored breathing doom
the environment Unable to Severe trembling Terror
Misperceptions of the concentrate Sleeplessness Bizarre behavior, including
environment common Unable to compre- Palpitations shouting, screaming,
(e.g., a perceived hend even Diaphoresis and pallor running about wildly,
detail may be elabo- simple directions Muscular clinging to anyone or
rated and out of incoordination anything from which a
proportion) Immobility or purpose- sense of safety and
less hyperactivity security is derived
Incoherence or inability Hallucinations;
to verbalize delusions
Extreme withdrawal into
self

Maladaptive use of defense mechanisms promotes dis-

Mild Moderate Severe Panic
integration of the ego. The major ego defense mecha-
nisms identified by Anna Freud are discussed here and
Coping Ego Psycho- Psycho- Psychotic summarized in Table 2-2.
mechanisms defense physiological neurotic responses
mechanisms responses responses 1. Compensation is the covering up of a real or per-
ceived weakness by emphasizing a trait one consid-
FIGURE 2–2 Adaptation responses on a continuum of anxiety. ers more desirable.
EXAMPLES:
the ego in an effort to relieve mild-to-moderate anxiety. (a) A handicapped boy who is unable to participate in sports
They become maladaptive when they are used by an in- compensates by becoming a great scholar. (b) A young man
dividual to such a degree that there is interference with who is the shortest among members of his peer group views
the ability to deal with reality, with effective interper- this as a deficiency and compensates by being overly aggres-
sonal relations, or with occupational performance. sive and daring.
4092_Ch02_012-026 24/07/14 5:20 PM Page 19

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 19

TAB LE 2–2 Ego Defense Mechanisms

DEFENSE MECHANISM EXAMPLE DEFENSE MECHANISM EXAMPLE

COMPENSATION RATIONALIZATION
Covering up a real or A physically handicapped Attempting to make John tells the rehab nurse,
perceived weakness by boy is unable to partici- excuses or formulate “I drink because it’s the
emphasizing a trait one pate in football, so he logical reasons to only way I can deal with
considers more desirable. compensates by be- justify unacceptable my bad marriage and my
coming a great scholar. feelings or behaviors. worse job.”

DENIAL REACTION FORMATION

Refusing to acknowledge A woman drinks alcohol Preventing unacceptable Jane hates nursing. She
the existence of a real every day and cannot or undesirable attended nursing school to
situation or the feelings stop, failing to ac- thoughts or behaviors please her parents. During
associated with it. knowledge that she from being expressed career day, she speaks to
has a problem. by exaggerating oppo- prospective students about
site thoughts or types the excellence of nursing
of behaviors. as a career.

DISPLACEMENT REGRESSION
The transfer of feelings A client is angry with his Retreating in response to When 2-year-old Jay is hos-
from one target to another physician, does not ex- stress to an earlier level pitalized for tonsillitis he will
that is considered less press it, but becomes of development and drink only from a bottle,
threatening or that is verbally abusive with the comfort measures even though his mom
neutral. the nurse. associated with that states he has been drinking
level of functioning. from a cup for 6 months.

IDENTIFICATION REPRESSION
An attempt to increase A teenager who required Involuntarily blocking An accident victim can
self-worth by acquiring lengthy rehabilitation unpleasant feelings remember nothing about
certain attributes and after an accident and experiences from his accident.
characteristics of an decides to become a one’s awareness.
individual one admires. physical therapist as a
result of his experiences.

INTELLECTUALIZATION SUBLIMATION
An attempt to avoid S’s husband is being Rechanneling of drives A mother whose son was
expressing actual transferred with his job or impulses that are killed by a drunk driver
emotions associated to a city far away from personally or socially channels her anger and
with a stressful situation her parents. She hides unacceptable into energy into being the
by using the intellectual anxiety by explaining to activities that are president of the local
processes of logic, her parents the advan- constructive. chapter of Mothers
reasoning, and analysis. tages associated with Against Drunk Driving.
the move.

INTROJECTION SUPPRESSION
Integrating the beliefs Children integrate their The voluntary blocking of Scarlett O’Hara says, “I
and values of another parents’ value system unpleasant feelings don’t want to think about
individual into one’s into the process of and experiences from that now. I’ll think about
own ego structure. conscience formation. one’s awareness. that tomorrow.”
A child says to a friend,
“Don’t cheat. It’s wrong.”

ISOLATION UNDOING
Separating a thought or A young woman de- Symbolically negating or Joe is nervous about his new
memory from the scribes being attacked canceling out an expe- job and yells at his wife.
feeling, tone, or emotion and raped, without rience that one finds On his way home he stops
associated with it. showing any emotion. intolerable. and buys her some flowers.

PROJECTION
Attributing feelings or Sue feels a strong sexual
impulses unacceptable attraction to her track
to one’s self to another coach and tells her
person. friend, “He’s coming
on to me!”
4092_Ch02_012-026 24/07/14 5:20 PM Page 20

20 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

2. Denial is the refusal to acknowledge the existence literally become a part of the child. The child says to a friend
of a real situation or the feelings associated with it. while playing, “Don’t hit people. It’s not nice!” (b) A psychiatric
client claims to be the Son of God, drapes himself in sheet
EXAMPLES:
and blanket, “performs miracles” on other clients, and refuses
(a) A woman has been told by her family doctor that she to respond unless addressed as Jesus Christ.
has a lump in her breast. An appointment is made for her
with a surgeon; however, she does not keep the appoint- 7. Isolation is the separation of a thought or a mem-
ment and goes about her activities of daily living with no ory from the feeling, tone, or emotions associated
evidence of concern. (b) Individuals continue to smoke with it (sometimes called emotional isolation).
cigarettes even though they have been told of the health
EXAMPLES:
risks involved.
(a) A young woman describes being attacked and raped by
3. Displacement is the transferring of feelings from a street gang. She displays an apathetic expression and no
one target to another that is considered less threat- emotional tone. (b) A physician is able to isolate her feelings
ening or neutral. about the eventual death of a terminally ill cancer client by
EXAMPLES: focusing her attention instead on the chemotherapy that will
be given.
(a) A man who is passed over for promotion on his job says
nothing to his boss but later belittles his son for not making 8. Projection is the attribution of feelings or im-
the basketball team. (b) A boy who is teased and hit by the pulses unacceptable to one’s self to another per-
class bully on the playground comes home after school and son. The individual “passes the blame” for these
kicks his dog. undesirable feelings or impulses to another,
thereby providing relief from the anxiety associ-
4. Identification is an attempt to increase self-worth
ated with them.
by acquiring certain attributes and characteristics
of an individual one admires. EXAMPLES:
EXAMPLES (a) A young soldier who has an extreme fear of participating
(a) A teenage girl emulates the mannerisms and style of in military combat tells his sergeant that the others in his unit
dress of a popular female rock star. (b) The young son of a are “a bunch of cowards.” (b) A businessperson who values
famous civil rights worker adopts his father’s attitudes and punctuality is late for a meeting and states, “Sorry I’m late.
behaviors with the intent of pursuing similar aspirations. My assistant forgot to remind me of the time. It’s so hard to
find good help these days.”
5. Intellectualization is an attempt to avoid express-
ing actual emotions associated with a stressful sit- 9. Rationalization is the attempt to make excuses or
uation by using the intellectual processes of logic, formulate logical reasons to justify unacceptable
reasoning, and analysis. feelings or behaviors.

EXAMPLES: EXAMPLES:
(a) A man whose brother is in a cardiac intensive care unit (a) A self-employed person deliberately neglects to report
following a severe myocardial infarction (MI) spends his al- part of her income to the Internal Revenue Service, and jus-
lotted visiting time in discussion with the nurse, analyzing tifies it to herself by saying, “It’s okay. Everybody does it.”
test results and making a reasonable determination about (b) A young man is unable to afford the sports car he wants
the pathophysiology that may have occurred to induce the so desperately. He tells the salesperson, “I’d buy this car
MI. (b) A young psychology professor receives a letter from but I’ll be getting married soon. This is really not the car for
his fiancée breaking off their engagement. He shows no a family man.”
emotion when discussing this with his best friend. Instead 10. Reaction formation is the prevention of unac-
he analyzes his fiancée’s behavior and tries to reason why ceptable or undesirable thoughts or behaviors
the relationship failed. from being expressed by exaggerating opposite
6. Introjection is the internalization of the beliefs and thoughts or types of behaviors.
values of another individual such that they symbol-
EXAMPLES:
ically become a part of the self to the extent that
the feeling of separateness or distinctness is lost. (a) The young soldier who has an extreme fear of partici-
pating in military combat volunteers for dangerous front-
EXAMPLES: line duty. (b) A secretary is sexually attracted to her boss
(a) A small child develops her conscience by internalizing and feels an intense dislike toward his wife. She treats her
what the parents believe is right and wrong. The parents boss with detachment and aloofness while performing her
4092_Ch02_012-026 24/07/14 5:20 PM Page 21

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 21

secretarial duties and is overly courteous, polite, and flat- Moderate-to-Severe Anxiety
tering to his wife when she comes to the office. Anxiety at the moderate-to-severe level that remains
11. Regression is the retreating to an earlier level of unresolved over an extended period of time can con-
development and the comfort measures associ- tribute to a number of physiological disorders. The
ated with that level of functioning. DSM-5 (APA, 2013) describes these disorders under
the category of “Psychological Factors Affecting
EXAMPLES: Other Medical Conditions.” The psychological factors
(a) When his mother brings his new baby sister home from may exacerbate symptoms of, delay recovery from, or
the hospital, 4-year-old Tommy, who had been toilet trained interfere with treatment of the medical condition.
for more than a year, begins to wet his pants, cry to be held, The condition may be initiated or exacerbated by an
and suck his thumb. (b) A person who is depressed may environmental situation that the individual perceives
withdraw to his or her room, curl up in a fetal position on as stressful. Measurable pathophysiology can be
the bed, and sleep for long periods of time. demonstrated. It is thought that psychological and
behavioral factors may affect the course of almost
12. Repression is the involuntary blocking of unpleas-
every major category of disease, including, but not
ant feelings and experiences from one’s awareness.
limited to, cardiovascular, gastrointestinal, neoplas-
EXAMPLES: tic, neurological, and pulmonary conditions.
(a) A woman cannot remember being sexually assaulted Severe Anxiety
when she was 15 years old. (b) A teenage boy cannot re- Extended periods of repressed severe anxiety can re-
member driving the car that was involved in an accident in sult in psychoneurotic patterns of behaving. Neurosis
which his best friend was killed. is no longer considered a separate category of mental
13. Sublimation is the rechanneling of drives or im- disorder. However, the term sometimes is still used in
pulses that are personally or socially unacceptable the literature to further describe the symptomatology
(e.g., aggressiveness, anger, sexual drives) into ac- of certain disorders and to differentiate from behav-
tivities that are more tolerable and constructive. iors that occur at the more serious level of psychosis.
Neuroses are psychiatric disturbances, characterized
EXAMPLES: by excessive anxiety that is expressed directly or al-
(a) A teenage boy with strong competitive and aggressive tered through defense mechanisms. It appears as a
drives becomes the star football player on his high school symptom, such as an obsession, a compulsion, a pho-
team. (b) A young unmarried woman with a strong desire bia, or a sexual dysfunction (Sadock & Sadock, 2007).
for marriage and a family achieves satisfaction and success The following are common characteristics of people
in establishing and operating a day-care center for preschool with neuroses:
children. ■ They are aware that they are experiencing distress.
■ They are aware that their behaviors are maladaptive.
14. Suppression is the voluntary blocking of un-
■ They are unaware of any possible psychological
pleasant feelings and experiences from one’s
awareness. causes of the distress.
■ They feel helpless to change their situation.
EXAMPLES: ■ They experience no loss of contact with reality.
(a) Scarlett O’Hara says, “I’ll think about that tomorrow.” The following disorders are examples of psy-
(b) A young woman who is depressed about a pending choneurotic responses to anxiety as they appear in
divorce proceeding tells the nurse, “I just don’t want to the DSM-5:
talk about the divorce. There’s nothing I can do about it 1. Anxiety Disorders. Disorders in which the character-
anyway.” istic features are symptoms of anxiety and avoidance
15. Undoing is the act of symbolically negating or behavior (e.g., phobias, panic disorder, generalized
canceling out a previous action or experience anxiety disorder, and separation anxiety disorder).
that one finds intolerable. 2. Somatic Symptom Disorders. Disorders in which
the characteristic features are physical symptoms
EXAMPLES: for which there is no demonstrable organic
(a) A man spills some salt on the table, then sprinkles some pathology. Psychological factors are judged to
over his left shoulder to “prevent bad luck.” (b) A man who play a significant role in the onset, severity, exac-
is anxious about giving a presentation at work yells at his wife erbation, or maintenance of the symptoms (e.g.,
during breakfast. He stops on his way home from work that somatic symptom disorder, illness anxiety disor-
evening to buy her a dozen red roses. der, conversion disorder, and factitious disorder).
4092_Ch02_012-026 24/07/14 5:20 PM Page 22

22 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

3. Dissociative Disorders. Disorders in which the adaptive and is characterized by feelings of sadness,
characteristic feature is a disruption in the usually guilt, anger, helplessness, hopelessness, and despair.
integrated functions of consciousness, memory, Indeed, an absence of mourning after a loss may be
identity, or perception of the environment (e.g., considered maladaptive.
dissociative amnesia, dissociative identity disorder, Stages of Grief
and depersonalization-derealization disorder).
Kübler-Ross (1969), in extensive research with termi-
Panic Anxiety nally ill patients, identified five stages of feelings and
At this extreme level of anxiety, an individual is behaviors that individuals experience in response to
not capable of processing what is happening in a real, perceived, or anticipated loss:
the environment, and may lose contact with reality. Stage 1—Denial. This is a stage of shock and disbe-
Psychosis is defined as “a severe mental disorder lief. The response may be one of “No, it can’t be
characterized by gross impairment in reality testing, true!” The reality of the loss is not acknowl-
typically manifested by delusions, hallucinations, edged. Denial is a protective mechanism that al-
disorganized speech, or disorganized or catatonic be- lows the individual to cope in an immediate time
havior” (Black & Andreasen, 2011, p. 618). The fol- frame while organizing more effective defense
lowing are common characteristics of people with strategies.
psychoses: Stage 2—Anger. “Why me?” and “It’s not fair!” are
■ They exhibit minimal distress (emotional tone is comments often expressed during the anger
flat, bland, or inappropriate). stage. Envy and resentment toward individuals
■ They are unaware that their behavior is maladaptive. not affected by the loss are common. Anger may
■ They are unaware of any psychological problems. be directed at the self or displaced on loved
■ They are exhibiting a flight from reality into a less ones, caregivers, and even God. There may be a
stressful world or into one in which they are attempt- preoccupation with an idealized image of the
ing to adapt. lost entity.
Examples of psychotic responses to anxiety in- Stage 3—Bargaining. During this stage, which is usu-
clude the schizophrenic, schizoaffective, and delu- ally not visible or evident to others, a “bargain” is
sional disorders. made with God in an attempt to reverse or post-
pone the loss: “If God will help me through this, I
promise I will go to church every Sunday and vol-
unteer my time to help others.” Sometimes the
CORE CONCEPT promise is associated with feelings of guilt for not
Grief having performed satisfactorily, appropriately, or
Grief is a subjective state of emotional, physical, and
sufficiently.
social responses to the loss of a valued entity.
Stage 4—Depression. During this stage, the full im-
pact of the loss is experienced. The sense of loss
is intense, and feelings of sadness and depression
Grief prevail. This is a time of quiet desperation and dis-
Most individuals experience intense emotional an- engagement from all association with the lost en-
guish in response to a significant personal loss. A loss tity. It differs from pathological depression, which
is anything that is perceived as such by the individ- occurs when an individual becomes fixed in an
ual. Losses may be real, in which case they can be earlier stage of the grief process. Rather, stage 4
substantiated by others (e.g., death of a loved one, of the grief response represents advancement to-
loss of personal possessions), or they may be per- ward resolution.
ceived by the individual alone, unable to be shared Stage 5—Acceptance. The final stage brings a feeling
or identified by others (e.g., loss of the feeling of of peace regarding the loss that has occurred. It is
femininity following mastectomy). Any situation that a time of quiet expectation and resignation. The
creates change for an individual can be identified as focus is on the reality of the loss and its meaning
a loss. Failure (either real or perceived) also can be for the individuals affected by it.
viewed as a loss. All individuals do not experience each of these
The loss, or anticipated loss, of anything of value stages in response to a loss, nor do they necessarily
to an individual can trigger the grief response. This experience them in this order. Some individuals’
period of characteristic emotions and behaviors is grieving behaviors may fluctuate, and even overlap,
called mourning. The “normal” mourning process is between stages.
4092_Ch02_012-026 24/07/14 5:20 PM Page 23

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 23

Anticipatory Grief on the relationship with the lost entity and accept
When a loss is anticipated, individuals often begin the both the pleasures and the disappointments (both
work of grieving before the actual loss occurs. Most the positive and the negative aspects) of the associa-
people re-experience the grieving behaviors once the tion (Bowlby & Parkes, 1970). Disorganization and
loss occurs, but having this time to prepare for the emotional pain have been experienced and tolerated.
loss can facilitate the process of mourning, actually Preoccupation with the lost entity has been replaced
decreasing the length and intensity of the response. with energy and the desire to pursue new situations
Problems arise, particularly in anticipating the death and relationships.
of a loved one, when family members experience an-
Maladaptive Grief Responses
ticipatory grieving and the mourning process is com-
pleted prematurely. They disengage emotionally from Maladaptive responses to loss occur when an indi-
the dying person, who may then experience feelings vidual is not able to satisfactorily progress through
of rejection by loved ones at a time when this psycho- the stages of grieving to achieve resolution. These
logical support is so necessary. responses usually occur when an individual becomes
fixed in the denial or anger stage of the grief
Resolution process. Several types of grief responses have been
The grief response can last from weeks to years. It can- identified as pathological. They include responses
not be hurried, and individuals must be allowed to that are prolonged, delayed or inhibited, or dis-
progress at their own pace. In the loss of a loved one, torted. The prolonged response is characterized by an
grief work usually lasts for at least a year, during which intense preoccupation with memories of the lost en-
the grieving person experiences each significant “an- tity for many years after the loss has occurred. Behaviors
niversary” date for the first time without the loved one associated with the stages of denial or anger are
present. manifested, and disorganization of functioning and
Length of the grief process may be prolonged by a intense emotional pain related to the lost entity are
number of factors. If the relationship with the lost en- evidenced.
tity had been marked by ambivalence or if there had In the delayed or inhibited response, the individual
been an enduring “love-hate” association, reaction to becomes fixed in the denial stage of the grieving
the loss may be burdened with guilt. Guilt lengthens process. The emotional pain associated with the
the grief reaction by promoting feelings of anger to- loss is not experienced, but anxiety disorders (e.g.,
ward the self for having committed a wrongdoing or phobias, somatic symptom disorders) or sleeping
behaved in an unacceptable manner toward that and eating disorders (e.g., insomnia, anorexia) may
which is now lost, and perhaps the grieving person be evident. The individual may remain in denial for
may even feel that his or her behavior has contributed many years until the grief response is triggered by
to the loss. a reminder of the loss or even by another, unre-
Anticipatory grieving is thought to shorten the lated loss.
grief response in some individuals who are able to The individual who experiences a distorted re-
work through some of the feelings before the loss oc- sponse is fixed in the anger stage of grieving. In the
curs. If the loss is sudden and unexpected, mourning distorted response, all the normal behaviors associ-
may take longer than it would if individuals were able ated with grieving, such as helplessness, hopelessness,
to grieve in anticipation of the loss. sadness, anger, and guilt, are exaggerated out of pro-
Length of the grieving process is also affected by portion to the situation. The individual turns the
the number of recent losses experienced by an in- anger inward on the self, is consumed with over-
dividual and whether he or she is able to complete whelming despair, and is unable to function in nor-
one grieving process before another loss occurs. mal activities of daily living. Pathological depression
This is particularly true for elderly individuals who is a distorted grief response.
may be experiencing numerous losses, such as
spouse, friends, other relatives, independent func- Mental Health/Mental Illness Continuum
tioning, home, personal possessions, and pets, in a
relatively short time. Grief accumulates, and this Anxiety and grief have been described as two major,
represents a type of bereavement overload, which primary responses to stress. In Figure 2-3, both of
for some individuals presents an impossible task of these responses are presented on a continuum ac-
grief work. cording to degree of symptom severity. Disorders as
Resolution of the process of mourning is thought they appear in the DSM-5 are identified at their ap-
to have occurred when an individual can look back propriate placement along the continuum.
4092_Ch02_012-026 24/07/14 5:20 PM Page 24

24 UNIT 1 ■ Basic Concepts in Psychiatric/Mental Health Nursing

Feelings of Dysthymia Major Depression

Sadness Cyclothymic Disorder Bipolar Disorder

Life's Everyday Neurotic Psychotic

Disappointments Responses Responses

Mild Moderate Severe

Grief Grief
Mental Mental
Health Illness
Anxiety Anxiety

Mild Moderate Severe Panic

Coping Ego Defense Psychophysiological Psychoneurotic Psychotic

Mechanisms Mechanisms Responses Responses Responses

Sleeping Compensation Headaches Phobias Schizophrenia

Eating Denial Anorexia Obsessions Schizoaffective
Yawning Displacement Arthritis Compulsions disorder
Drinking Identification Colitis Hypochondriasis Delusional
Exercise Isolation Ulcers Conversion disorders
Smoking Projection Asthma disorder
Crying Rationalization Pain Multiple
Pacing Regression Cancer personalities
Laughing Repression CHD Amnesia
Talking it Sublimation Sexual Fugue
out with Suppression dysfunction
someone Undoing

FIGURE 2–3 Conceptualization of anxiety and grief responses along the mental health/mental illness continuum.

Summary and Key Points are age-appropriate and congruent with local and
cultural norms.”
■ Psychiatric care has its roots in ancient times, when ■ In determining mental illness, individuals are in-
etiology was based in superstition and ideas related fluenced by incomprehensibility of the behavior; that
to the supernatural. is, whether or not they are able to understand the
■ Treatments were often inhumane and included bru- motivation behind the behavior.
tal beatings, starvation, or other torturous means. ■ Another consideration is cultural relativity. The
■ Hippocrates associated insanity and mental illness “normality” of behavior is determined by cultural
with an irregularity in the interaction of the four and societal norms.
body fluids (humors)—blood, black bile, yellow ■ For purposes of this text, the definition of mental ill-
bile, and phlegm. ness is viewed as “maladaptive responses to stressors
■ Conditions for care of the mentally ill have im- from the internal or external environment, evi-
proved, largely because of the influence of leaders denced by thoughts, feelings, and behaviors that are
such as Benjamin Rush, Dorothea Dix, and Linda incongruent with the local and cultural norms, and
Richards, whose endeavors provided a model for that interfere with the individual’s social, occupa-
more humanistic treatment. tional, and/or physical functioning.”
■ Maslow identified a “hierarchy of needs” that indi- ■ Anxiety and grief have been described as two
viduals seek to fulfill on their quest to self-actual- major, primary psychological response patterns
ization (one’s highest potential). to stress.
■ For purposes of this text, the definition of mental ■ Peplau defined anxiety by levels of symptom sever-
health is viewed as “the successful adaptation to stres- ity: mild, moderate, severe, and panic.
sors from the internal or external environment, ev- ■ Behaviors associated with levels of anxiety include
idenced by thoughts, feelings, and behaviors that coping mechanisms, ego defense mechanisms,
4092_Ch02_012-026 24/07/14 5:20 PM Page 25

CHAPTER 2 ■ Mental Health/Mental Illness: Historical and Theoretical Concepts 25

psychophysiological responses, psychoneurotic re- ■ Resolution is thought to occur when an individual

sponses, and psychotic responses. is able to remember and accept both the positive
■ Grief is described as a response to loss of a valued and negative aspects associated with the lost entity.
entity. Loss is anything that is perceived as such by ■ Grieving is thought to be maladaptive when the
the individual. mourning process is prolonged, delayed or inhib-
■ Kübler-Ross, in extensive research with terminally ited, or becomes distorted and exaggerated out of
ill patients, identified five stages of feelings and be- proportion to the situation. Pathological depres-
haviors that individuals experience in response to sion is considered to be a distorted reaction.
a real, perceived, or anticipated loss: denial, anger,
bargaining, depression, and acceptance.
■ Anticipatory grief is grief work that is begun, and Additional info available at
sometimes completed, before the loss occurs. www.davisplus.com

Review Questions
Self-Examination/Learning Exercise
Select the answer that is most appropriate for each of the following questions.
1. Three years ago, Anna’s dog, Lucky, whom she had had for 16 years, was hit by a car and killed. Anna’s
daughter reports that since that time, Anna has lost weight, rarely leaves her home, and just sits and
talks about Lucky. Anna’s behavior would be considered maladaptive because:
a. It has been more than three years since Lucky died.
b. Her grief is too intense just over the loss of a dog.
c. Her grief is interfering with her functioning.
d. People in this culture would not comprehend such behavior over loss of a pet.
2. Based on the information in Question 1, Anna’s grieving behavior would most likely be considered to be:
a. Delayed
b. Inhibited
c. Prolonged
d. Distorted
3. Anna is diagnosed with major depressive disorder. She is most likely fixed in which stage of the grief
process?
a. Denial
b. Anger
c. Depression
d. Acceptance
4. Anna, who is 72 years old, is of the age when she may have experienced many losses coming close to-
gether. What is this called?
a. Bereavement overload
b. Normal mourning
c. Isolation
d. Cultural relativity
5. Anna, age 72, has been grieving the death of her dog, Lucky, for 3 years. She is not able to take care
of her activities of daily living, and wants only to make daily visits to Lucky’s grave. Her daughter has
likely put off seeking help for Anna because:
a. Women are less likely to seek help for emotional problems than men.
b. Relatives often try to “normalize” the behavior, rather than label it mental illness.
c. She knows that all older people are expected to be a little depressed.
d. She is afraid that the neighbors “will think her mother is crazy.”

Continued
Another Random Scribd Document
with Unrelated Content
uniquement de l’objet, mes jugemens ne me tromperoient jamais, puisqu’il n’est
jamais faux que je sente ce que je sens.
‘Pourquoi donc est-ce que je me trompe sur le rapport de ces deux bâtons, sur-
tout s’ils ne sont pas parallèles? Pourquoi, dis-je, par exemple, que le petit bâton
est le tiers du grand, tandis qu’il n’en est que le quart? Pourquoi l’image, qui est la
sensation, n’est elle pas conforme à son modèle, qui est l’objet? C’est que je suis
actif quand je juge, que l’opération qui compare est fautive, et que mon
entendement, qui juge les rapports, mêle ses erreurs à la vérité des sensations qui
ne montrent que les objets.
‘Ajoutez à cela une réflexion qui vous frappera, je m’assure, quand vous y
aurez pensé; c’est que si nous étions purement passifs dans l’usage de nos sens, il
n’y auroit entr’eux aucun communication; il nous seroit impossible de connoître
que le corps que nous touchons, et l’objet que nous voyons sont le même. Ou nous
ne sentirions jamais rien hors de nous, ou il y auroit pour nous cinq substances
sensibles, donc nous n’aurions nul moyen d’appercevoir l’identité.
‘Qu’on donne tel ou tel nom à cette force de mon esprit qui rapproche et
compare mes sensations; qu’on l’appelle attention, méditation, réflexion, ou
comme on voudra; toujours est-il vrai qu’elle est en moi et non dans les choses, que
c’est moi seul qui la produis, quoique je ne la produise qu’à l’occasion de
l’impression que font sur moi les objets. Sans être maître de sentir ou de ne pas
sentir, je le suis d’examiner plus ou moins ce que je sens.
‘Je ne suis donc pas simplement un être sensitif et passif, mais un être actif et
intelligent, et quoi qu’en dise la philosophie, j’oserai prétendre à l’honneur de
penser, &c.’—Emile, beginning of the third, or end of the second volume.

97. I here speak of association as distinct from imagination or the effects of

novelty.

98. See preface to Butler’s Sermons.

99. As far as the love of good or happiness operates as a general principle of

action, it is in this way. I have supposed this principle to be at the bottom of all our
actions, because I did not desire to enter into the question. If I should ever finish
the plan which I have begun, I shall endeavour to shew that the love of happiness
even in the most general sense does not account for the passions of men. The love
of truth, and the love of power are I think distinct principles of action, and mix
with, and modify all our pursuits. See Butler as quoted above.
 TRANSCRIBER’S NOTES
1. P. 60, changed "limited, not does" to "limited,
nor does".
2. P. 292, changed “outrè” to “outré”.
3. P. 372, changed “ma premiere connaissance” to
“ma première connaissance”.
4. Did not correct “it’s” used in the possessive
sense.
5. P. 410, changed “affections particuliéres celles”
to “affections particulières celles”.
6. P. 416, added footnote number to the footnote on
this page.
7. P. 455, changed “sont pas paralleles” to “sont pas
parallèles”.
8. Silently corrected typographical errors and also
variations in spelling.
9. Retained anachronistic, non-standard, and
uncertain spellings as printed.
*** END OF THE PROJECT GUTENBERG EBOOK THE COLLECTED
WORKS OF WILLIAM HAZLITT, VOL. 07 (OF 12) ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States
copyright in these works, so the Foundation (and you!) can copy
and distribute it in the United States without permission and
without paying copyright royalties. Special rules, set forth in the
General Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the

free distribution of electronic works, by using or distributing this
work (or any other work associated in any way with the phrase
“Project Gutenberg”), you agree to comply with all the terms of
the Full Project Gutenberg™ License available with this file or
online at www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand,
agree to and accept all the terms of this license and intellectual
property (trademark/copyright) agreement. If you do not agree
to abide by all the terms of this agreement, you must cease
using and return or destroy all copies of Project Gutenberg™
electronic works in your possession. If you paid a fee for
obtaining a copy of or access to a Project Gutenberg™
electronic work and you do not agree to be bound by the terms
of this agreement, you may obtain a refund from the person or
entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only

be used on or associated in any way with an electronic work by
people who agree to be bound by the terms of this agreement.
There are a few things that you can do with most Project
Gutenberg™ electronic works even without complying with the
full terms of this agreement. See paragraph 1.C below. There
are a lot of things you can do with Project Gutenberg™
electronic works if you follow the terms of this agreement and
help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright
law in the United States and you are located in the United
States, we do not claim a right to prevent you from copying,
distributing, performing, displaying or creating derivative works
based on the work as long as all references to Project
Gutenberg are removed. Of course, we hope that you will
support the Project Gutenberg™ mission of promoting free
access to electronic works by freely sharing Project Gutenberg™
works in compliance with the terms of this agreement for
keeping the Project Gutenberg™ name associated with the
work. You can easily comply with the terms of this agreement
by keeping this work in the same format with its attached full
Project Gutenberg™ License when you share it without charge
with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside
the United States, check the laws of your country in addition to
the terms of this agreement before downloading, copying,
displaying, performing, distributing or creating derivative works
based on this work or any other Project Gutenberg™ work. The
Foundation makes no representations concerning the copyright
status of any work in any country other than the United States.

1.E. Unless you have removed all references to Project

Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project
Gutenberg™ work (any work on which the phrase “Project
Gutenberg” appears, or with which the phrase “Project
Gutenberg” is associated) is accessed, displayed, performed,
viewed, copied or distributed:

This eBook is for the use of anyone anywhere in the United

States and most other parts of the world at no cost and
with almost no restrictions whatsoever. You may copy it,
give it away or re-use it under the terms of the Project
Gutenberg License included with this eBook or online at
www.gutenberg.org. If you are not located in the United
States, you will have to check the laws of the country
where you are located before using this eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is

derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of
the copyright holder), the work can be copied and distributed to
anyone in the United States without paying any fees or charges.
If you are redistributing or providing access to a work with the
phrase “Project Gutenberg” associated with or appearing on the
work, you must comply either with the requirements of
paragraphs 1.E.1 through 1.E.7 or obtain permission for the use
of the work and the Project Gutenberg™ trademark as set forth
in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is

posted with the permission of the copyright holder, your use and
distribution must comply with both paragraphs 1.E.1 through
1.E.7 and any additional terms imposed by the copyright holder.
Additional terms will be linked to the Project Gutenberg™
License for all works posted with the permission of the copyright
holder found at the beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files
 containing a part of this work or any other work associated with
Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute

this electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1
with active links or immediate access to the full terms of the
Project Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if
you provide access to or distribute copies of a Project
Gutenberg™ work in a format other than “Plain Vanilla ASCII” or
other format used in the official version posted on the official
Project Gutenberg™ website (www.gutenberg.org), you must,
at no additional cost, fee or expense to the user, provide a copy,
a means of exporting a copy, or a means of obtaining a copy
upon request, of the work in its original “Plain Vanilla ASCII” or
other form. Any alternate format must include the full Project
Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™
works unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or

providing access to or distributing Project Gutenberg™
electronic works provided that:

• You pay a royalty fee of 20% of the gross profits you derive
from the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
 payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt
that s/he does not agree to the terms of the full Project
Gutenberg™ License. You must require such a user to return or
destroy all copies of the works possessed in a physical medium
and discontinue all use of and all access to other copies of
Project Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project

Gutenberg™ electronic work or group of works on different
terms than are set forth in this agreement, you must obtain
permission in writing from the Project Gutenberg Literary
Archive Foundation, the manager of the Project Gutenberg™
trademark. Contact the Foundation as set forth in Section 3
below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on,
transcribe and proofread works not protected by U.S. copyright
law in creating the Project Gutenberg™ collection. Despite these
efforts, Project Gutenberg™ electronic works, and the medium
on which they may be stored, may contain “Defects,” such as,
but not limited to, incomplete, inaccurate or corrupt data,
transcription errors, a copyright or other intellectual property
infringement, a defective or damaged disk or other medium, a
computer virus, or computer codes that damage or cannot be
read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except

for the “Right of Replacement or Refund” described in
paragraph 1.F.3, the Project Gutenberg Literary Archive
Foundation, the owner of the Project Gutenberg™ trademark,
and any other party distributing a Project Gutenberg™ electronic
work under this agreement, disclaim all liability to you for
damages, costs and expenses, including legal fees. YOU AGREE
THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT
EXCEPT THOSE PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE
THAT THE FOUNDATION, THE TRADEMARK OWNER, AND ANY
DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE
TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL,
PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE
NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you

discover a defect in this electronic work within 90 days of
receiving it, you can receive a refund of the money (if any) you
paid for it by sending a written explanation to the person you
received the work from. If you received the work on a physical
medium, you must return the medium with your written
explanation. The person or entity that provided you with the
defective work may elect to provide a replacement copy in lieu
of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund.
If the second copy is also defective, you may demand a refund
in writing without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set

forth in paragraph 1.F.3, this work is provided to you ‘AS-IS’,
WITH NO OTHER WARRANTIES OF ANY KIND, EXPRESS OR
IMPLIED, INCLUDING BUT NOT LIMITED TO WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this
agreement violates the law of the state applicable to this
agreement, the agreement shall be interpreted to make the
maximum disclaimer or limitation permitted by the applicable
state law. The invalidity or unenforceability of any provision of
this agreement shall not void the remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the

Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and
distribution of Project Gutenberg™ electronic works, harmless
from all liability, costs and expenses, including legal fees, that
arise directly or indirectly from any of the following which you
do or cause to occur: (a) distribution of this or any Project
Gutenberg™ work, (b) alteration, modification, or additions or
deletions to any Project Gutenberg™ work, and (c) any Defect
you cause.

Section 2. Information about the Mission

of Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new
computers. It exists because of the efforts of hundreds of
volunteers and donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project
Gutenberg™’s goals and ensuring that the Project Gutenberg™
collection will remain freely available for generations to come. In
2001, the Project Gutenberg Literary Archive Foundation was
created to provide a secure and permanent future for Project
Gutenberg™ and future generations. To learn more about the
Project Gutenberg Literary Archive Foundation and how your
efforts and donations can help, see Sections 3 and 4 and the
Foundation information page at www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation
The Project Gutenberg Literary Archive Foundation is a non-
profit 501(c)(3) educational corporation organized under the
laws of the state of Mississippi and granted tax exempt status
by the Internal Revenue Service. The Foundation’s EIN or
federal tax identification number is 64-6221541. Contributions
to the Project Gutenberg Literary Archive Foundation are tax
deductible to the full extent permitted by U.S. federal laws and
your state’s laws.

The Foundation’s business office is located at 809 North 1500

West, Salt Lake City, UT 84116, (801) 596-1887. Email contact
links and up to date contact information can be found at the
Foundation’s website and official page at
www.gutenberg.org/contact
 Section 4. Information about Donations to
the Project Gutenberg Literary Archive
Foundation
Project Gutenberg™ depends upon and cannot survive without
widespread public support and donations to carry out its mission
of increasing the number of public domain and licensed works
that can be freely distributed in machine-readable form
accessible by the widest array of equipment including outdated
equipment. Many small donations ($1 to $5,000) are particularly
important to maintaining tax exempt status with the IRS.

The Foundation is committed to complying with the laws

regulating charities and charitable donations in all 50 states of
the United States. Compliance requirements are not uniform
and it takes a considerable effort, much paperwork and many
fees to meet and keep up with these requirements. We do not
solicit donations in locations where we have not received written
confirmation of compliance. To SEND DONATIONS or determine
the status of compliance for any particular state visit
www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states

where we have not met the solicitation requirements, we know
of no prohibition against accepting unsolicited donations from
donors in such states who approach us with offers to donate.

International donations are gratefully accepted, but we cannot

make any statements concerning tax treatment of donations
received from outside the United States. U.S. laws alone swamp
our small staff.

Please check the Project Gutenberg web pages for current

donation methods and addresses. Donations are accepted in a
number of other ways including checks, online payments and
credit card donations. To donate, please visit:
www.gutenberg.org/donate.

Section 5. General Information About

Project Gutenberg™ electronic works
Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could
be freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose
network of volunteer support.

Project Gutenberg™ eBooks are often created from several

printed editions, all of which are confirmed as not protected by
copyright in the U.S. unless a copyright notice is included. Thus,
we do not necessarily keep eBooks in compliance with any
particular paper edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,

including how to make donations to the Project Gutenberg
Literary Archive Foundation, how to help produce our new
eBooks, and how to subscribe to our email newsletter to hear
about new eBooks.
Welcome to Our Bookstore - The Ultimate Destination for Book Lovers
Are you passionate about books and eager to explore new worlds of
knowledge? At our website, we offer a vast collection of books that
cater to every interest and age group. From classic literature to
specialized publications, self-help books, and children’s stories, we
have it all! Each book is a gateway to new adventures, helping you
expand your knowledge and nourish your soul
Experience Convenient and Enjoyable Book Shopping Our website is more
than just an online bookstore—it’s a bridge connecting readers to the
timeless values of culture and wisdom. With a sleek and user-friendly
interface and a smart search system, you can find your favorite books
quickly and easily. Enjoy special promotions, fast home delivery, and
a seamless shopping experience that saves you time and enhances your
love for reading.
Let us accompany you on the journey of exploring knowledge and
personal growth!

ebookball.com