AKA Erik Homburger Erikson

Born: June 15, 1902 Birthplace: Frankfurt am Main, Germany Died: May 12, 1994 Location of death: Harwich, MA Cause of death: unspecified Religion: Jewish Race or Ethnicity: White Occupation: Psychologist Nationality: United States Executive summary: Eight Stages of Childhood Psychosocial development as articulated by Erik Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future.

Psychosocial Development Stages Summary Important Events Outcome Feeding Children develop a sense of trust when caregivers provide reliabilty, care, and affection. A lack of this will lead to mistrust. Autonomy vs. Toilet Training Children need to develop a sense of Early personal control over physical skills Childhood (2 to Shame and Doubt and a sense of independence. 3 years) Success leads to feelings of autonomy, failure results in feelings of shame and doubt. Exploration Children need to begin asserting Preschool (3 to Initiative vs. Guilt control and power over the 5 years) environment. Success in this stage leads to a sense of purpose. Children who try to exert too much power experience disapproval, resulting in a sense of guilt. Industry vs. School Children need to cope with new School Age (6 to Inferiority social and academic demands. 11 years) Success leads to a sense of competence, while failure results in feelings of inferiority. Stage Infancy (birth to 18 months) Basic Conflict Trust vs. Mistrust

Adolescence (12 to 18 years)

Identity vs. Role Confusion

Young Adulthood (19 to 40 years)

Intimacy vs. Isolation

Middle Adulthood (40 to 65 years)

Generativity vs. Stagnation

Maturity(65 to death)

Ego Integrity vs. Despair

Teens needs to develop a sense of self and personal identity. Success leads to an ability to stay true to yourself, while failure leads to role confusion and a weak sense of self. Relationships Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. Work and Adults need to create or nurture Parenthood things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world. Reflection on Life Older adults need to look back on life and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in regret, bitterness, and despair.

Social Relationships

Psychosocial Development Stages

Infancy (Birth -18 months)

Psychosocial Crisis: Trust vs. Mistrust

Developing trust is the first task of the ego, and it is never complete. The child will let its mother out of sight without anxiety and rage because she has become an inner certainty as well as an outer predictability. The balance of trust with mistrust depends largely on the quality of the maternal relationship.

Main question asked: Is my environment trustworthy or not? Central Task: Receiving care Positive Outcome: Trust in people and the environment Ego Quality: Hope Definition: Enduring belief that one can attain ones deep and essential wishes Developmental Task: Social attachment; Maturation of sensory, perceptual, and motor functions; Primitive causality. Significant Relations: Maternal parent

Erikson proposed that the concept of trust versus mistrust is present throughout an individuals entire life. Therefore if the concept is not addressed, taught and handled properly during infancy (when it is first introduced), an individual may be negatively affected and never fully immerse themselves in the world. For example, a person may hide themselves from the outside world and be unable to form healthy and long-lasting relationships with others, or even themselves. If an individual does not learn to trust themselves, others and the world they may lose the virtue of hope, which is directly linked to this concept. If a person loses their belief in hope they will struggle with overcoming hard times and failures in their lives, and may never fully recover from them. This would prevent them from learning and maturing into a fully-developed person if the concept of trust versus mistrust was improperly learned, understood and used in all aspects of their lives. Younger Years (1 1/2 - 3 Years)

Psychosocial Crisis: Autonomy vs. Shame & doubt

If denied independence, the child will turn against his/her urges to manipulate and discriminate. Shame develops with the child's self-consciousness. Doubt has to do with having a front and back -- a "behind" subject to its own rules. Left over doubt may become paranoia. The sense of autonomy fostered in the child and modified as life progresses serves the preservation in economic and political life of a sense of justice.

Main question asked: Do I need help from others or not?

Early Childhood (3-6 Years)

Psychosocial Crisis: Initiative vs. Guilt

Initiative adds to autonomy the quality of undertaking, planning, and attacking a task for the sake of being active and on the move. The child is learning to master the world around them, learning basic skills and principles of physics; things fall to the ground, not up; round things roll, how to zip and tie, count and speak with ease. At this stage the child wants to begin and complete their own actions for a purpose. Guilt is a new emotion and is confusing to the child; she may feel guilty over things which are not logically guilt producing, and she will feel guilt when her initiative does not produce the desired results.

Main question asked: How moral am I?

Middle Childhood (7-12 Years)

Psychosocial Crisis: Industry vs. Inferiority

To bring a productive situation to completion is an aim which gradually supersedes the whims and wishes of play. The fundamentals of technology are developed. To lose the hope of such "industrious" association may pull the child back to the more isolated, less conscious familial rivalry of the oedipal time.

Main question asked: Am I good at what I do?

Adolescence (12-18 Years)

Psychosocial Crisis: Identity vs. Role Confusion

The adolescent is newly concerned with how they appear to others. Ego identity is the accrued confidence that the inner sameness and continuity prepared in the past are matched by the sameness and continuity of one's meaning for others, as evidenced in the promise of a career. The inability to settle on a school or occupational identity is disturbing.

Main question asked: "Who am I, and what is my goal in life?"

Early Adulthood (19-34 years)

Psychosocial Crisis: Intimacy vs. Isolation

Body and ego must be masters of organ modes and of the other nuclear conflicts in order to face the fear of ego loss in situations which call for self-abandon. The avoidance of these experiences leads to openness and self-absorption. Middle Adulthood (35-60 Years)

Psychosocial Crisis: Generativity vs. Stagnation

Generativity is the concern of establishing and guiding the next generation. Simply having or wanting children doesn't achieve generativity. Socially-valued work and disciplines are also expressions of generativity.

Main question asked: Will I ever accomplish anything useful?...

Later Adulthood (60 years - Death)

Psychosocial Crisis: Ego integrity vs. despair

Ego integrity is the ego's accumulated assurance of its capacity for order and meaning. Despair is signified by a fear of one's own death, as well as the loss of self-sufficiency, and of loved partners and friends. Gestalt therapy Gestalt therapy is a form of psychotherapy, based on the experiential ideal of here and now, and relationships with others and the world. It is an existential or experiential form of psychotherapy that emphasizes personal responsibility. Gestalt therapy is used often to increase a clients self-awareness by putting the past to rest and focus on the present.

History
Gestalt therapy was originally developed by Frederick Fritz Perls, Laura Perls, and Paul Goodman in the 1940s. Perls believed that self-awareness leads to self-acceptance and responsibility for ones thoughts and feelings. Gestalt therapy rose from its beginnings in the middle of the 20th century to rapid and widespread popularity during the decade of the 1960s and early 1970s. During the 70s and 80s Gestalt therapy training centers spread globally, but they were, for the most part, not aligned with formal academic settings.

Focus of the therapy

The therapy focuses upon the individuals experience in the present moment, the therapist-client relationship, the environmental and social contexts of a persons life, and the self-regulating adjustments people make as a result of their overall situation.

Goals that are encouraged to achieved by the patient during Gestalt Therapy
1. Identifying the persons action or becoming aware of what they are doing. 2. Becoming aware of how they are doing a certain behavior. 3. Learning how to change the behaviors that keeps him or her from achieving life goals. 4. Accepting and valuing him or herself as a person.

5. Emphasizes of what is being done, thought and felt at the present time rather than what might have been, should have been, was or might be. It FOCUSES on what is happening instead of on the subject being discussed.

Gestalt Techniques
1. Increasing the awareness of body language and of negative internal messages. 2. Making a client speak continually in the present tense and in the first person to emphasize self-awareness. 3. Creation of episodes by the therapist and diversions that clearly demonstrate a point rather that explaining in words. 4. Asking the client to concentrate on a part of his or her personality or one emotion. The therapist would then ask the client to address it as if it were sitting by itself in the clients chair. 5. To increase self-awareness the therapist often use this therapy by having then write and read letters, keep journals and perform other activities designed to put the past tp rest and focus on the present.

Group therapy is a form of psychotherapy which as small, carefully selected group of individuals meets regularly with a therapist. The client participates in sessions with a group of people. These individuals share a common purpose and are expected to contribute to the group to benefit from others in return.
In group therapy approximately 6-10 individuals meet face-to-face with a trained group therapist. During the group meeting time, members decide what they want to talk about. Members are encouraged to give feedback to others. Feedback includes expressing your own feelings about what someone says or does. Group rules are established that all members must observe. These set of rules vary according to the type of group.

Purpose of a Group Therapy

1. 2. 3. 4. It helps an individual gain new information or learning It helps an individual gain inspiration or hope. The group also allows a person to develop new ways of relating to people. During group therapy, people begin to see that they are not alone and that there is hope and help. It is comforting to hear that other people have a similar difficulty, or have already worked through a problem that deeply disturbs another group member. 5. In a group, a person feels accepted. 6. Group therapy sessions allow an individual to interact freely with other members that shares the same past or present difficulties and problems. The individual then, becomes aware that he is not alone and that others share the same problem.

7. A person gains insight into ones problem and behaviors and how they affect to others. 8. Altruistic behavior is practiced. Altruism is the giving of oneself for the benefit of others. As the group members begin to feel more comfortable, they will be able to speak freely. The psychological safety of the group will allow the expression of those feelings which are often difficult to express outside of group. The client will begin to ask for the support he or she needs.

Types of Group Therapy

1. Psychotherapy Groups 2. Family therapy 3. Education groups
5.Self-help groups

4. Support groups

Jean Piagets Theory of Cognitive Development

Born: Aug 9, 1896 Birthplace: Neuchtel, Switzerland Died: September 17, 1980 Location of death: Geneva, Switzerland Cause of death: unspecified Gender: Male Race or Ethnicity: White Occupation: Psychologist Nationality: Switzerland Executive summary: Elaborated the stages of childhood Cognitive development refers to how a person perceives, thinks, and gains understanding of his or her world through the interaction of genetic and learned factors. Among the areas of cognitive development are information processing, intelligence, reasoning, language development, and memory.

Cognitive Stages of Development

Sensorimotor (0-2 years) Pre-operational (2-7 years)

Concrete Operation (7-11 years) Formal Operation (11 yearsadulthood)

Development proceeds from reflex activity to representation and sensorimotor solutions to problems Problems solved through representation; language development; (2-4 years); thoughts and language both egocentric; cannot solve conservation problems. Reversibility attained; can solve conservation problems; Logical operation developed and applied to concrete problems; cannot solve complex verbal problems. Logically solves all types of problems; thinks scientifically; solves complex problems; cognitive structures mature.

Sensorimotor stage (infancy): In this period, which has six sub-stages, intelligence is demonstrated through motor activity without the use of symbols. Knowledge of the world is limited, but developing, because it is based on physical interactions and experiences. Children acquire object permanence at about seven months of age (memory). Physical development (mobility) allows the child to begin developing new intellectual abilities. Some symbolic (language) abilities are developed at the end of this stage. Pre-operational stage (toddlerhood and early childhood): In this period, which has two sub stages, intelligence is demonstrated through the use of symbols, language use matures, and memory and imagination are developed, but thinking is done in a non-logical, non-reversible manner. Egocentric thinking predominates. Concrete operational stage (elementary and early adolescence): In this stage, characterized by seven types of conservation (number, length, liquid, mass, weight, area, and volume), intelligence is demonstrated through logical and systematic manipulation of symbols related to concrete objects. Operational thinking develops (mental actions that are reversible). Egocentric thought diminishes. Formal operational stage (adolescence and adulthood): In this stage, intelligence is demonstrated through the logical use of symbols related to abstract concepts. Early in the period there is a return to egocentric thought. Only 35 percent of high school graduates in industrialized countries obtain formal operations; many people do not think formally during adulthood.

As a nurse, dealing with physically and/or mentally ill patients requires a great deal of patience and understanding. However, before a person can understand and empathize with others, he or she must first know himself or herself. The process of knowing ones own principle, beliefs, feelings, personality, strengths, weaknesses, preconceptions, attitudes and responses in different situations is called self awareness. Discerning

ones own capabilities and limitations allow a nurse to consider, observe and pay attention to the bizarre or subtle reactions of clients.

Self-awareness gives the nurse a skill in establishing relationships with clients of different values, beliefs, attitudes and principles. This is achieved by the nurses utilization of aspects in his or her personality, values, feelings and coping skills commonly known as the therapeutic use of self. Johari window is a psychological tool used to develop self-awareness and promote better relationshipsamong people. It was created by two American Psychologists Joseph Luft and Harry Ingham in 1955. The word JOHARI comes from the first names of its developers Joseph and Harry (Joharry). It is also known as disclosure or feedback model of self awareness. Utilizing this tool creates a portrait of someone; this is done by giving the person a psychosocial exercise. A list of 56 adjectives is given to the subject and he or she is instructed to choose five or six words that best describe him or her. The same list is given to the subjects peers, friends and colleagues. These people will also choose 5 or 6 adjectives that best describe the subject. After the test, the answers are mapped, compared and categorized in four areas. The four areas are as follows: Quadrant 1: Open Arena or Public self

These pertain to the qualities known to others and the subject himself. If quadrant 1 is the longest, it means that the subject is open to others and has gained self-awareness. If this area is the shortest, the subject shares little about him or her.

Area or Quadrant 2: Blind spot or Blind Area

These refer to the subjects attributes that are unknown to him but are known by his or her peers.

Area or Quadrant 3: Hidden or Private self

The things that the subject knows about himself.

Area or Quadrant 4: Unknown

An empty quadrant which symbolizes the qualities undiscovered by the neither the subject nor others.

The success of the test depends on the honesty of the opinions given. A person is represented with little insight if quadrants 1 and 3 have the smallest adjective listed. The main goal the subject is to work towards moving the qualities from quadrants 2, 3, and 4 to the first area. Korsakoffs syndrome is a condition that mainly affects chronic alcoholics. It is also called Korsakovs syndrome, Korsakoffs psychosis or amnesic-confabulatory syndrome. It is a brain or neurological disorder caused by thiamine or Vitamin B1 deficiency. The syndrome is named after Sergie Korsakoff, a neuropsychiatrist who popularized the theory.

Causes
1. Chronic Alcoholism. This syndrome is due to the direct effects of alcohol or to the severe nutritional deficiencies that are associated with chronic alcoholism. A lack of Vitamin B1 is common in people with alcoholism thus, Vitamin B deficiency is noted. In chronic alcoholism the condition usually occurs following delirium tremens. 2. Malabsorption. It is also common in persons whose bodies do not absorb food properly (malabsorption). 3. Other severe brain disturbances. The syndrome also occurs in other severe brain disturbances such as paralysis, dementia, brain damage, infections and poisonings. 4. Dietary deficiencies 5. Prolonged vomiting 6. Eating disorders 7. Effects of chemotherapy 8. Hyperemesis gravidarum 9. Severe malnutrition. Alcoholism may be an indicator of poor nutrition, which in addition to inflammation of the stomach lining causes thiamine deficiency.

Disease Process
A deficiency of thiamine or Vitamin B causes damage to the medial thalamus and to the mammillary bodies of the hypothalamus. As a result, generalized cerebral atrophy may occur. In cases where Wernickes encephalopathy, a neurological disorder that causes brain damage in lower parts of the brain called the thalamus and hypothalamus, accompanies Korsakoffs syndrome the disorder is called Wernicke-Korsakoff syndrome. In most cases, Korsakoff syndrome, or Korsakoff psychosis, tends to develop as Wernickes symptoms go away. It results from damage to areas of the brain involved with memory, thus, Korsakoffs syndrome involves:

Neuronal loss or damage to neurons Gliosis, which is a result of injury to the supporting cells of the central nervous system. Hemorrhage or bleeding of the mammilary bodies.

Signs and Symptoms

1. 2. 3. 4. 5. Anterograde amnesia or the inability to form new memories Retrograde amnesia or the loss of memory (can be severe) Confabulation or the reciting of imaginary experiences. Lack of insight Apathy or the absence of interest in or concern about emotional, social, or physical life 6. Hallucinations or seeing and hearing things are not really present 7. Delirium 8. Anxiety 9. Fear 10. Depression 11. Confusion 12. Delusions and insomnia 13. Painful extremities

Treatment
1. Thiamine by injection into a vein or a muscle or by mouth. Usually, thiamine does not improve loss of memory and intellect that occur with Korsakoffs psychosis. However it may improve symptoms such as delirium or confusion. 2. Stopping alcohol use to prevent additional loss of brain function and damage to the nerves.

3. Eating a well balanced and nourishing diet with increase intake of foods containing Vitamin B1. KUBLER-ROSS STAGE OF DYING 4.

Precipitating Factors of Grief

Death in family Separation Divorce Physical Illness Work failure disappointments

1. Denial

Initial response to protect the self from anxiety. No not me, Its not true, Its not impossible May continue to make impractical/unrealistic plans May comment that a mistake has been made about the diagnosis of terminal illness May appear normal and can continued ADL as if nothing is wrong May not conform with the advised treatment regimen Adaptive response crying, verbal denial Maladptive response absence or reaction such as crying.

2. Anger

Individual feel that they are victims of incompetence or a vengeful God (they did something wrong so they are being punished), fate (karma), circumstances (wrong place and wrong time). Why me, What did I do to deserve this? They seek for reasons, answers and explanations May express anger overtly being irritable, impatient, critical verbally abusive.

May express anger covertly by neglecting self, not eating, nor going to check ups, committing suicide, drinking alcohol. Adaptive response verbal expression Maladaptive persistent guilt or low self esteem, aggression, self destructive ideation or behavior.

3. Bargaining

The person try to inhibit good behavior, make up for perceived wrong doings or other engage in behaviors that would please GOD so he will be given more timean extension of life or granted recovery. Yes, me but If I live until Christmas or until my childs graduation ( So many ifs), I will do this Adaptive response bargains for treatment control, express wish to be alive for specific events in the near future. Maladaptive response bargains for unrealistic activities or events in the distant future.

4. Depression

Occurs when the reality of loss or impending loss cannot be ignored anymore and the person grieves for himself and those he will leave behind, for the things that he can no longer accomplish or experience. Yes, Im dying Withdrawn, has no energy and interest to interact. Cries Makes few demands Adaptive response crying, withdrawing from interaction Maladaptive response self destructive actions, despair.

5. Acceptance

Occurs when the person has come to peace with himself and others Yes, I am ready Stage of affective void not happy nor sad Only persons who are highly significant to him stimulates a reaction. Others are merely tolerated. Makes realistic preparation Adaptive response may wish to be alone, limit conversation, complete personal and family business.

Nursing Interventions:

Assess; specific loss, meaning of loss, coping skills, support persons. Accept the client; do not respond personally to the client.

Support adaptive responses; allow to express feelings Support defense mechanism reassure client that denial and wanting to be alone is normal. Help find constructive outlets of anger. Do not take clients hostility personally. Do no retaliate. Monitor for self destructive behaviors Help express feelings: Ask how they feel Meet needs Allow as much decision making as possible to maintain dignity by giving choices and alternatives. MAJOR DEPRESSIVE DISORDER

A mood disorder may include symptoms of depressed mood, feelings or hopelessness and helpless ss, decreased interest in usual activities, disinterest in relationship with others or cycles of depression and mania.

Depression is often concurrent with other psychiatric diagnoses. Almost have of clients with major depressive disorders have histories of non-mood psychiatric disorders. A high incidence exists for persons with chronic illness or prolonges hospitalization or institutional care.

Risk Factors
1. 2. 3. 4. 5. 6. Biological factors brainchemicals Family genetics parent with depression, child 10-13% risk of depression. Gender higher rate for women Age often less than 40 when begins Marital status more frequently single, widowed Season of year Seasonal Affective Disorder (SAD) occurs when client experiences recurrent depression that occurs annually at the same time. 7. Psychological influences low self-esteem, unresolved grief. 8. Environmental factors lack of social support, stressful life events. 9. Medical co-morbidity clients with chronic or terminal illness, postpartum, and current substance abuse are especially prone to becoming depresses.

Signs and Symptoms

1. Sexual disinterest 2. Suicidal and homicidal ideations 3. Decrease in personal hygiene

4. Tearfulness, crying, and melancholy 5. Altered thought process; difficulty concentrating, self-destructive behavior. 6. Loss of energy or restlessness 7. Anhedonia or loss of pleasure 8. Gain or loss of weight 9. Anger, self-directed 10. Psychomotor retardation or agitation 11. Insomnia or hypersomnia 12. Feelings of hopelessness, worthlessness, and helplessness.

Nursing Diagnoses

Risk for violence, self-directed or directed at others Impaired verbal communication Decisional conflict Altered role performance Hopelessness Deficit in diversional activity Fatigue Sel-care deficit Altered thought processes Self-esteem Anxiety

Therapeutic Nursing Management

1. Safe environment 2. Psychological treatment o Individual psychotherapy long term therapeutic approach or short term solution-oriented, may focus on in-depth exploration, specific stress situations, or problem solving. o Behavioral therapy modifying behavior to assist in reducing depressive symptoms and increasing coping skills. o Behavioral contacts focus on specific client problems and need to help the client resolve them. 3. Social treatment o Milieu therapy incorporates day to day living experiences in a therapeutic environment to expect changes in perception and behavior. o Family therapy aimed at assisting the family cope with the clients illness and supporting the client in therapeutic ways. o Group therapy focuses on assisting clients with interpersonal communication, coping, and problem-solving skills. 4. Psychopharmacologic and Somatic treatments

o o o

Administer antidepressant medications Continued assessment by monitoring clients mental health status is critical, particularly interms of agitation and suicidal ideation. Electroconvulsive therapy

Nursing Interventions
1. Priority for care is always the clients safety. 2. Use of behavioral contacts. Use this technique to meet outcomes relating to no self-harm or no suicidal ideation or plan. 3. Assess regularly for suicidal ideation or plan. 4. Observe client for distorted, negative thinking. 5. Assist client to learn and use problem solving and stress management skills. 6. Avoid doing too much for the client, as this will only increase clients dependence and decrease self-esteem. 7. The nurses role in the physical care of the client experiencing major depressive disorder is to provide assessment and interventions related to appropriate nutrition, fluids, sleep, exercise, and hygieme, and to provide health education. 8. Explore meaningful losses in the clients life. 9. Help the client and family to identify the internal and external indicators of major depressive disorder. Obsessive Compulsive Disorder (OCD) is characterized by persistent thought and urges to perform repeated acts or rituals, usually as a means of releasing tension or anxiety. The frequency and intensity of the ritualistic behaviors, such as handwashing, ordering, or checking, are time consuming (taking more than one hour per day) and cause marked distress, significant impairment, or interfere with daily living. 1. Obsession o The person experiences recurrent and persistent thoughts, impulses, images that are intrusive, disturbing, inappropriate, and usually triggered by anxiety. o The thoughts, images, and impulses are not simply excessive worries about real life problems. o The person recognizes the thoughts, images, and impulses are from within own mind. 2. Compulsion o Repetitive behaviors or mental acts that a person feels driven to perform, which usually adhere to a rigid and specifically defined routine. o The behaviors and ideations are typically aimed at reducing anxiety or preventing some dreaded situation from occurring.

Specific Biological Factors

There is some evidence that indicates OCD is linked to a deficiency in serotonin. Clients have also been shown to have abnormalities in frontal lobes and basal ganglia; it is unclear what the implications are for clinical care.

Signs and Symptoms

Obsessions recurrent, persistent ideas, thoughts or impulses, involuntarily coming to awareness. Ruminations forced preoccupation with thoughts about a particular topic, associated with brooding and inconclusive speculation. Cognitive rituals elaborate series of mental acts the client feels compelled to complete. Compulsive motor rituals elaborate rituals of everyday functioning such as grooming, dressing, eating, washing or checking doors or appliances. Other symptoms chronic anxiety, low self-esteem, difficulty expressing positive feelings and depressed mood.

Nursing Diagnoses

Anxiety Powerlessness Ineffective verbal communication Self-esteem disturbance Impaired social interaction Risk for injury Sleep pattern disturbances Ineffective breathing pattern

Nursing Interventions
1. Limit, but do not interrupt, the compulsive acts. 2. Teach the client to use alternate coping methods to decrease anxiety. 3. Clients behavior maybe frustrating to staff and family. Power struggles often result. Consistency to the approach to care is critical. 4. Assess the clients needs carefully. 5. Provide an environment that has structure and predictability as a strategy to decrease anxiety. 6. Risk associated with the use of alcohol and drug abuse. The American Psychiatric Associations Diagnostic and Statistical Manual, Fourth Edition (DSM IV), defines oppositional defiant disorder (ODD) as a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that

persists for at least 6 months. ODD is a condition in which a child displays an ongoing pattern of uncooperative, defiant, hostile, and annoying behavior toward people in authority. The childs behavior often disrupts the childs normal daily activities, including activities within the family and at school.

Causes and Risk Factors

The causative factors can be divided into categories, namely:

Biological Factor. Aggressive behavior may be caused by alterations in the neurotransmitter activity of the brain. Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals are out of balance or not working properly, messages may not make it through the brain correctly, leading to symptoms of ODD, and other mental illnesses. Also, some studies suggest that defects in or injuries to certain areas of the brain can lead to serious behavioral problems in children. Familial Factor. Familial influences on child development may be genetically linked, attributed to conflict in the family home or based on parent-child interactions. Additionally, a parents prior aggressive behavior (in childhood) has been shown to manifest itself in their child at the same age. Genetics. Many children and teens with ODD have close family members with mental illnesses, including mood disorders, anxiety disorders, and personality disorders. This suggests that a vulnerability to develop ODD may be inherited. Environmental. Factors such as a dysfunctional family life, a family history of mental illnesses and/or substance abuse and inconsistent discipline by parents may contribute to the development of behavior disorders.

Clinical Manifestations

Actively does not follow adults requests Angry and resentful of others Argues with adults Blames others for own mistakes Has few or no friends or has lost friends Is in constant trouble in school Loses temper Spiteful or seeks revenge Touchy or easily annoyed

Diagnosis
To fit this diagnosis, the pattern must last for at least 6 months and must be characterized by the frequent occurrence of at least four of the following behaviors: losing temper, arguing with adults, actively defying or refusing to comply with the requests or rules of adults, deliberately doing things that will annoy other people, blaming others for his or her own mistakes or misbehavior, being touchy or easily annoyed by others, being angry and resentful, or being spiteful or vindictive.

Management of Children with ODD

Behavior management techniques. Use behavior contracts. Be fair but be firm, give respect to get respect. Using a consistent approach to discipline and following through with positive reinforcement of appropriate behaviors. Apply effective contingencies that are consistent responses to the childs behavior, following through with appropriate rewards and consequences when these are needed.

Paraphilias are complex psychiatric disorders that are manifested as unusual sexual behavior. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IVTR) defined it as a recurrent, intensely sexually arousing fantasies, sexual urges, or behaviors generally involving:

Inanimate objects (non-human objects) Suffering or humiliation of oneself or partner Children Nonconsenting person

Diagnosis
The criteria for diagnosing this disorder are: Criterion A: the unusual sexual behavior should occur over a period of 6 months Criterion B: the sexual behavior caused a clinically significant distress or impairment in social, occupational or other important areas of functioning. Criterion B differs in for some disorders.

For pedophilia, voyeurism, exhibitionism and frotteurism, the diagnosis is formulated if acting out on these urges or if the urge itself caused a significant distress or interpersonal difficulty.

For sadism, a diagnosis is made if these urges are done to a nonconsenting person. For the other paraphilias, a diagnosis created when the sexual behavior, urges or fantasies caused a clinically significant distress or impairment in social, occupational or other important areas of functioning.

Eight specific disorders of paraphilia

1. Exhibitionism the repeated urge or behavior of exposing ones genitals to strangers or masturbating in public areas. 2. Exhibitionism this is characterized by the use of inanimate objects (fetish) to achieve orgasm or gain sexual excitement. Common fetishes are womens undergarments (brassiere, lingerie, and panty), shoes and other apparels. An individual with this disorder masturbates while holding or rubbing the object to them. 3. Frotteurism persistent urges of touching or rubbing against a nonconsenting person in a place where a person with this disorder can make a quick escape (e.g. crowded places, public transportation, shopping mall or a crowded sidewalk). The person rubs his hands against a victims breasts or genitalia or he can rub his genitals against the victims thigh or buttocks. 4. Pedophilia a sexual activity done with a child 13 years younger is a characteristic of this disorder. The pedophile should be at least 16 years old or at least 5 years older than the victim. 5. Sexual masochism the intense and persistent sexual urge involving acts of suffering (beaten or bound) and being humiliated. 6. Sexual sadism sexual urge involving acts in which the pain, suffering or humiliation of a partner is arousing a person. 7. Transvestic fetishism sexual fantasies, urge and behaviors involving crossdressing by a heterosexual male. 8. Voyeurism sexual arousal by observing an unsuspecting person who is naked, in the process of undressing or engaging in sexual activity. Personality disorder is defined as the totality of a persons unique biopsychosocial and spiritual traits that consistently influence behavior. The following traits are likely in individuals with a personality disorder: 1. Interpersonal relations that ranges from distant to overprotective.
Contents 1. 1 Definition 2. 2 Diagnosis 1. 2.1 Cluster A: Personality Disorders ( The Eccentric and Mad group)

2. 2.2 Cluster B: Personality Disorders ( The Erratic and Bad group) 3. 2.3 Cluster C: Personality Disorders ( The anxious and Sad group) 3. 3 Signs and Symptoms 4. 4 Nursing Diagnoses 5. 5 Nursing Interventions

2. 3. 4. 5. 6.

Suspiciousness Social anxiety Failure to conform to social norms. Self-destructive behaviors Manipulation and splitting.

Prognosis is poor, and clients experience long term disability and may have other psychiatric disorders.

Diagnosis
A personality disorder is diagnosed when a person exhibits deviation on the following areas: 1. Cognition ways a person interprets and perceives him or herself, other people and events. 2. Affect ranges, lability and appropriateness of emotional response 3. Impulse control ability to control impulses or express behavior at the appropriate time and place.
Cluster A: Personality Disorders ( The Eccentric and Mad group)

1. Paranoid Personality disorder- People with a paranoid personality disorder are characterized by an overly suspicious and mistrustful behavior. Clinical Manifestations: 1. 2. 3. 4. Aloof and withdrawn Appear guarded and hypervigilant Have a restricted affect Unable to demonstrate a warm and empathetic emotional responses

5. Shows constant mistrust and suspicion 6. Frequently see malevolence in the actions when none exists

7. Spends disproportionate time examining and analyzing the behavior and motive of others to discover hidden and threatening meanings 8. Often feel attacked by others 9. Devises plans or fantasies for protection 10. Uses the defense mechanism of projection (blaming other people, institution or events for their own difficulties) 2. Schizoid Personality Disorder- People who are showing a pervasive pattern of social relationship detachment and a limited range of emotional expression in the interpersonal settings falls under this type of personality disorder. Clinical Manifestations: 1. 2. 3. 4. 5. Displays restricted affect Shows little emotion Aloof, emotionally cold and uncaring Have rich and extensive fantasy life Accomplished intellectually and often involved with computers or electronics in hobbies or job 6. Spends long hours solving puzzles and mathematical problems 7. Indecisive 8. Lacks future goals or direction 9. Impaired insight 10. Self-absorbed and loners 11. Lacks desire for involvement with others 12. No disordered or delusional thought processes present 3. Schizotypal Personality Disorder- Schizoid and schizotypal personality disorder are both characterized by pervasive pattern of social and interpersonal deficits, however, the latter is noted with cognitive and perceptual distortions and behavioral eccentricities. Clinical Manifestations: 1. 2. 3. 4. 5. 6. 7. Odd appearance (stained or dirty clothes, unkempt and disheveled) Wander aimlessly Loose, bizarre or vague speech Restricted range of emotions Ideas or reference and magical thinking is noted Expresses ideas of suspicions regarding the motives of others Experiences anxiety with people

Cluster B: Personality Disorders ( The Erratic and Bad group)

1. Antisocial Personality Disorder- Antisocial Personality disorder is characterized by a persistent pattern of violation and disregard for the rights of others, deceit and manipulation

Clinical Manifestations: 1. Violation of the rights of others 2. Lack of remorse for behaviors 3. Shallow emotions 4. Lying 5. Rationalization of own behavior 6. Poor judgment 7. Impulsivity 8. Irritability and aggressiveness 9. Lack of insight 10. Thrill seeking behaviors 11. Exploitation of people in relationships 12. Poor work history 13. Consistent irresponsibility 2. Borderline Personality Disorder- Borderline personality disorder is the most common personality disorder found in clinical settings. This disorder is characterized by a persistent pattern of unstable relationships, self image, affect and has marked impulsivity. It is more common in females than in males. Self-mutilation injuries such as cutting or burning are noted in this type of personality disorder. Clinical manifestations: 1. Fear of abandonment (real or perceived) 2. Unstable and intense relationship 3. Unstable self-image 4. Impulsivity or recklessness 5. Recurrent self-mutilating behavior or suicidal threats or gestures 6. Chronic feelings of emptiness and boredom 7. Labile mood 8. Irritability 9. Splitting 10. Impaired judgment 11. Lack of insight 12. Transient psychotic symptoms such as hallucinations demanding self-harm 3. Narcissistic Personality Disorder- A person with a narcissistic personality disorder shows a persistent pattern of grandiosity either in fantasy or behavior, a need for admiration and a lack of empathy. Clinical Manifestations: 1. Arrogant and haughty attitude 2. Lack the ability to recognize or to empathize with the feelings of others 3. Express envy and begrudge others of any recognition of material success (they believe it rightfully should be theirs) 4. Belittle or disparage others feelings

5. Expresses grandiosity overtly 6. Expect to be recognized for their perceived greatness 7. Preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love 8. Compares themselves with famous or privileged people 9. Poor or limited insight 10. Fragile and vulnerable self-esteem 11. Ambitious and confident 12. Exploit relationships to elevate their own status 4. Histrionic Personality disorder- Excessive emotionality and attention-seeking behaviors are pervasive patterns noted in people with a histrionic personality disorder. Clinical manifestations: 1. 2. 3. 4. 5. 6. 7. 8. 9. Exaggerate closeness of relationships or intimacy Uses colorful speech Tends to overdress Concerned with impressing others Emotionally expressive Experiences rapid mood and emotion shifts Self-absorbed Highly suggestible and will agree with almost anyone to gain attention Always want to be the center of attraction

Cluster C: Personality Disorders ( The anxious and Sad group)

1. Avoidant Personality Disorder Avoidant personality disorder is characterized by a persistent pattern of: 1. Social uneasiness and reticence 2. Low self-esteem 3. Hypersensitivity to negative reaction Clinical Manifestations 1. 2. 3. 4. 5. 6. Shy Unusually fearful of rejection, criticism, shame or disapproval Socially awkward Easily devastated by real or perceived criticism Have a very low self-esteem Believes that they are inferior

2. Dependent Personality Disorder- People who are noted to excessively need someone to take care of them that lead to their persistent clingy and submissive behavior have a dependent personality disorder. These individuals have fear of being

separated from the person whom they cling on to. The behavior elicits caretaking from others. Clinical Manifestations 1. 2. 3. 4. Pessimistic Self-critical Can be easily be hurt by other people Frequently reports feeling unhappy or depressed ( due to actual or perceived loss of support from a person) 5. Preoccupied with unrealistic fears of being alone and left alone to take care for themselves 6. Has difficulty deciding on their own even how simple the problem is 7. Constantly seeks advice from others and repeated assurances about all types of decisions 8. Lacks confidence 9. Uncomfortable and helpless when alone 10. Has difficulty initiating or completing simple daily tasks on their own 3. Obsessive Compulsive Personality Disorder- Individuals who are preoccupied with perfectionism, mental and interpersonal control and orderliness have an obsessive compulsive personality disorder. Persons with an obsessive compulsive personality are serious and formal and answer questions with precision and much detail. These people often seek treatment because of their recognition that life has no pleasure or because they are experiencing problems at work and in their relationships. Clinical Manifestations 1. Formal and serious 2. Precise and detail-oriented 3. Perfectionist 4. Constricted emotional range (has difficulty expressing emotions) 5. Stubborn and reluctant to relinquish control 6. Restricted affect 7. Preoccupation to orderliness 8. Have low self-esteem 9. Harsh 10. Have difficulty in relationships

Signs and Symptoms

1. 2. 3. 4. 5. Inappropriate response to stress and inflexible approach to problem solving. Long term difficulties in relating to others, in school and in work situations. Demanding and manipulative. Ability to cause others to react with extreme annoyance or irritability. Poor interpersonal skills.

6. Anxiety 7. Depression 8. Anger and aggression 9. Difficulty with adherence to treatment. 10. Harm to self or others.

Nursing Diagnoses

Ineffective individual coping Social isolation Impaired social interaction High risk for violence to self or others Anxiety

Nursing Interventions
1. Work with the client to increase coping skills and identify need for improvement coping. 2. Respond to the clients specific symptoms and needs. 3. Keep communication clear and consistent. 4. Client may require physical restraints, seclusion/observation room, one to one supervision. 5. Keep the client involved in treatment planning. 6. Avoid becoming victim to the clients involvement in appropriate self-help groups. 7. Require the client take responsibility for his/her own behavior and the consequences for actions. 8. Discuss with the client and family the possible environment and situational causes, contributing factors, and triggers.

A phobia is an anxiety disorder characterized by obsessive, irrational, and intense fear of a specific object an activity, or a physical situation. The fear, which is out of proportion to reality, usually results from early painful or unpleasant experiences involving a particular object or situation. A phobia may arise from displacing an unconscious conflict on an object that is symbolically related.

Types of Phobias
1. Agoraphobia o Fear of being in places or situations from which escape may be difficult or help may not be readily available.

2. Social Phobia o Also called Social Anxiety Disorder o Characterized by persistent fear of appearing shameful, stupid or inept in the presence of others. 3. Specific Phobia o Also called Simple Phobia o A persistent fear of a specific object or situation, other than of two phobias mentioned above. o Sub-categories: 1. Injury-blood-injection 2. Situational 3. Natural environment 4. Animals 5. Other (fear of costumed character, space, etc)

Risk Factors
1. Learning theory o The belief that phobias are learned and become conditioned responses when the client needs to escape an uncomfortable situation. 2. Cognitive theory o Phobias are produced by anxiety-inducing self-instructions of faulty cognitions. 3. Life experiences o Certain life experiences, such as traumatic events, may set the sage for phobias later in life.

Signs and Symptoms

1. 2. 3. 4. 5. Withdrawal High levels of anxiety Inability to function and meet self-care needs Inappropriate behavior used to avoid the feared situation, object or activity Dysfunctional social interactions and relationships

Nursing Diagnoses
1. 2. 3. 4. 5. Anxiety Powerless Ineffective individual coping Impaired verbal communication Altered thought processes

6. Self-esteem disturbance 7. Impaired social interaction 8. Risk for injury

Therapeutic Nursing Management

1. Systematic desensitization o This process of gradual exposure to phobic object or situation aimed at decreasing the fear and increasing the ability to function in the presence of phobic stimulus.

Accuracy in assessment determines whether the following steps of the nursing process will produce accurate nursing diagnoses, palnning, and intervention. Psychiatric-mental health assessment is the gathering, organizing, and documenting of data about the psychiatric and mental health needs of the client and family.

Assessment

The first step of the nursing process.

Interview

The degree to which the interview is therapeutic, or helpful, to the client may determine the extent and honesty of the information shared by the client. Clients expect the interviewer to be an expert who is confident in the professional role, maintains confidentiality, demonstrates warmth and genuineness, is nonjudgmental toward them and their past or current behavior, and recognizes that clients are experts on themselves and their behavior.

Assessment Data
1. Subjective o Clients current problem and reason for seeking help. o Past mental illness and treatment o Family history and mental illness o Medical history o Allergies to medications, foods, and other substances o Past and present medications and their effects

Past and present abuse Substance abuse history Educational and/or vocational history Health habits Safety issues Cultural beliefs and practices 2. Objective o Behavior o Communication o Physical assessment o Laboratory or testing data o Mental status
o o o o o o

Appearance

Hygiene, grooming, appropriateness of clothing, posture, and gestures.

Behavior

Eye contact, motor behavior, body language, behavioral responses to others and environment, volume and speed of speech, tone of voice, flow of words.

Affect and Mood

Happy, sad, anxious, sullen, hostile, inappropriate for situation, silly, and range of emotions.

Orientation

To person, place, time, situation, relationship with others.

Memory

Immediate recall, recent and remote memory.

Sensorium or Attention

Ability to concentrate on a task or conversation, perception of stimuli.

Intellectual functioning

General fund of knowledge about the world, cognitive abilities such as a simple arithmetic. Ability to think abstractly or symbolically.

Judgement

Decision making ability, especially regarding delay of gratification.

Insight

Awareness of ones responsibility for and analysis of current problem, understanding of how client arrived in current situation.

Thought Content

Recurrent topics of conversation, themes.

Thought process

Processing of events in the situation, awareness of ones thoughts, logic of thought.

Perception

Awareness of reality vs. fantasy, hallucinations, delusions, illusions, suicidal or homicidal ideation or plans.

Reality therapy is devised by William Glaser in 1965 which focuses on the persons behavior and how that behavior keeps him or her from achieving life goals. The approach was developed while Glaser is working with persons with delinquent behavior, unsuccessful school performance and emotional problems. This therapy is considered a cognitive-behavioral approach to treatment.

Approach of Reality Therapy

William Glaser believed that people who are unsuccessful often blame their problems on other people, the system or the society. It is Glasers belief that these types of people can only find their own identities through a responsible behavior. The focus of approach of counseling and problem solving in reality therapy focuses on the here-and-now of the client and how to create a better future. In this therapy, the individual is challenged to examine himself for ways in which his own behavior obstructs his attempts of achieving his life goal. The focus of Reality Therapy is to help counselees take ownership of their behavior and responsibility for the direction their lives take. With reality therapy, whatever happened in our lives or what has been done in the past, the person can still choose behavior that will help him meet his needs more effectively in the future. It is believed that these needs that a person has to effectively meet are the following: 1. Power this includes a persons achievement and feeling worthwhile. Winning is also included here. 2. Love and belonging this includes families, loved ones, relatives and groups.

3. Freedom independence, autonomy, personal space 4. Fun pleasure and enjoyment 5. Survival nourishment, shelter

Process Involved in Reality Therapy

In practicing reality therapy, two major components should be considered:

A trusting environment should be created. Therapeutic techniques should be utilized to help a person discover what they really WANT, reflect on their current activities and behavior and devise a new plan to fulfill that WANT effectively in the future.

The processes taking place in reality therapy are: 1. Developing a good RAPPORT with the client. To make the entire process effective, trust and rapport should be built at the beginning. 2. The current behavior (not the previous one) should be examined and evaluated by the client with the help of a psychotherapist. The therapist will ask the client to make a value judgment about his current behavior. 3. Help the client plan a new behavior that can be possibly done that works better than the current one. 4. The participant must make a commitment to carry out the plan. 5. There should be no punishment to be implemented. The therapist however, should stress to the client that there are no excuses and to never give up.

Summary of Facts about Reality Therapy

Focus of Reality Therapy: Help counselees take ownership of their behavior and responsibility for the direction their lives take. Basic Premise of Reality Therapy: Regardless of what has happened to us in our lives, or what we have done in the past, we are living and making choices here and now. Restraint application is a technique of physically restricting a persons freedom of movement, physical activity or normal access to his body. A physical restraint is a piece of equipment or device that restricts a patients ability to move. It is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to ones body.

The definition of restraint is based not on the equipment or device but rather on the functional status of the client. If the client cannot release himself from the device physically, then the said device is considered a restraint.

Purpose of Restraint Application

Restraints are used to control a patient who is at risk of harming him or her self and/or others. In some cases, restraints are also used for children who are not capable of remaining still when they are frightened or in pain during administration of medication or performing other procedures. However, using restraints in any health care facility should be used as the last option in dealing with patients. When to use restraints? Physical restraint should be used only when other, less restrictive, measures prove ineffective in protecting the patient and others from harm.

Types of Restraints
1. Soft restraints. This type of physical restraint device is used to limit movement of patients who are confused, disoriented or combative. The main goal of using this restraint is to prevent the patient from injuring him or her self and/or others. 2. Vest and Belt Restraints. In using this device full movement of arms and legs are permitted. This is used to prevent the patient from falling from bed or a chair. 3. Limb Restraints. Patients who are removing supportive equipments such as I.V. lines, indwelling catheters, NGTs and etc. are placed on limb restraints. This device allows only slight limb motion. 4. Mitts. This device prevents the patient from removing supportive equipment, scratching rashes or sores and injuring him or herself and/or others. 5. 5. Body restraints. When patients become combative and hysterical they can be controlled by applying body restraints. This immobilizes almost all of the body. 6. 6. Leather Restraints. This restraint is only used when soft restraints are not sufficient to control the patient and when sedation is either dangerous to the patient or ineffective.

Precautions of Restraint Application

1. Before applying restraints it is important to try other methods of promoting patient safety. Alternative methods that might be effective are reorientation of the patient to the physical surroundings, moving the patients room near to the staff members, teaching relaxation techniques in order to decrease anxiety and fear and decrease overstimulation. 2. Documentation of any alternative method used is extremely important. Restraint application should be documented thoroughly.\

Situations that Requires Restraint Application

1. Confused client tries to endanger him or herself 2. Confused client attempts to remove supportive equipments such as necessary tubes, IV lines or protective dressings. 3. The client is at risk for falls. 4. The client is suicidal. 5. The client poses harm or threat of inflicting harm to health care staff, other clients and/or visitors. 6. A child is unable to remain still during a minor surgical procedure.

Equipments
Soft restraints

Vest restraint Limb restraint Mitt restraint Belt restraint Body restraint as needed Padding if needed (large gauze pads can be used) Restrain flow sheet (washcloth can be used)

Leather restraints

Two wrist and two ankle leather restraints Four straps Key Large gauze pads this is used to cushion each extremity Restraint flow sheet (washcloth can be used)

Restraint Application Key Steps 1. Make sure that the restraints are correct size for the patients build and weight.

2. Explain the need for restraint to the patient. Assure him or her that they are used to protect him from injury rather than to punish him. It is necessary to inform the patient of the conditions necessary to release him or her from restraints. 3. Restraints are ONLY used when all other methods have failed to keep the patient from harming himself or others. Restraints used should be least restrictive to the patient. 4. Obtain adequate assistance to manually restrain the patient. 5. After an hour of placing a restraint, the patient should be evaluated by a licensed independent practitioner and an order must be written for restraints. 6. The order must ne time limited: 4 hours for adults; 2 hours for patients ages 9 to 17 years old; 1 hour for patients younger than 9 years old. 7. The original order expires in 24 hours. Thus, the same order cannot be used the following day. 8. To promote safety and ensure the patient is not harmed with restraint application, the patient should be assessed every 2 hours or according to the facility policy. 9. In cases where the client consented to have his family informed of his care, the family should be notified of the use of restraints.

TYPES OF SCHIZOPHRENIA:
The diagnosis is made according to the clients predominant symptoms:

Schizophrenia, paranoid type is characterized by persecutory (feeling victimized or spied on) or grandiose delusions, hallucinations, and occasionally, excessively religiosity (delusional focus) or hostile and aggressive behavior. Schizophrenia, disorganized type is characterized by grossly inappropriate or flat affect, incoherence, loose associations, and extremely disorganized behavior. Schizophrenia, catatonic type is characterized by marked psychomotor disturbance, either motionless or excessive motor activity. Motor immobility may be manifested by catalepsy (waxy flexibility) or stupor. Schizophrenia, undifferentiated type is characterized by mixed schizophrenic symptoms (of other types) along with disturbances of thought, affect, and behavior. Schizophrenia, residual type is characterized by at least one previous, though not a current, episode, social withdrawal, flat affect and looseness of associations.