Terms to Remember in Process Recording and Mental Status Assessment

(Psychiatric Nursing)

Process Recording(Parts)

I. Personal Data:a. Name of Patientb. Addressc. Aged. Gendere. Date/ Place of Birthf. Religiong. Place where the patient spent the last 15 yrs. of life

II. Objectivesa. Client Centered Objectives- focus on client’s benefitsb. Nurse Centered Objectives- focus on nurse’s benefits

III. Description of Settinga. Describe the set-up/ environmentb. Describe the nature, behavior, affect and mood of the client

IV. Process Recording- Include all therapeutic communications and different theories related to

analysis of the given therapeutic communications.

Different Therapeutic Communications

1. Offering Self

making self-available and showing interest and concern. “I will walk with you”

2. Active listening

paying close attention to what the patient is saying by observing both verbal and non-verbal cues.

Maintaining eye contact and making verbal remarks to clarify and encourage further communication.

3. Exploring

“Tell me more about your son”

4. Giving broad openings

What do you want to talk about today?

5. Silence

Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.

6. Stating the observed

verbalizing what is observed in the patient to, for validation and to encourage discussion

“You sound angry”

7. Encouraging comparisons

asking to describe similarities and differences among feelings, behaviors, and events.

“Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”

8. Identifying themes

asking to identify recurring thoughts, feelings, and behaviors. “When do you always feel the need to check the locks and doors?”

9. Summarizing

reviewing the main points of discussions and making appropriate conclusions. “During this meeting, we discussed about what you will do when you feel the

urge to hurt your self again and this include…”

10. Placing the event in time or sequence

asking for relationship among events. “When do you begin to experience this ticks? Before or after you entered grade

school?”

11. Voicing doubt

voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.

“I find it hard to believe…”

12. Encouraging descriptions of perceptions

asking the patients to describe feelings, perceptions and views of their situations. “What are these voices telling you to do?”

13. Presenting reality or confronting

stating what is real and what is not without arguing with the patient. “I know you hear these voices but I do not hear them”. “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.

14. Seeking clarification

asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear.

“I am not familiar with your work, can you describe it further for me”. “I don’t think I understand what you are saying”.

15. Verbalizing the implied

rephrasing patient’s words to highlight an underlying message to clarify statements.

Patient: I wont be bothering you anymore soon. Nurse: Are you thinking of killing yourself?

16. Reflecting

throwing back the patient’s statement in a form of question helps the patient identify feelings.

Patient: I think I should leave now. Nurse: Do you think you should leave now?

17. Restating

repeating the exact words of patients to remind them of what they said and to let them know they are heard.

Patient: I can’t sleep. I stay awake all night. Nurse: You can’t sleep at night?

18. General leads

using neutral expressions to encourage patients to continue talking. “Go on…” “You were saying…”

19. Asking question

using open-ended questions to achieve relevance and depth in discussion. “How did you feel when the doctor told you that you are ready for discharge

soon?”

20. Empathy

recognizing and acknowledging patient’s feelings. “It’s hard to begin to live alone when you have been married for more than thirty

years”.

21. Focusing

pursuing a topic until its meaning or importance is clear. “Let us talk more about your best friend in college” “You were saying…”

22. Interpreting

providing a view of the meaning or importance of something. Patient: I always take this towel wherever I go. Nurse: That towel must always be with you.

23. Encouraging evaluation

asking for patients views of the meaning or importance of something. “What do you think led the court to commit you here?”

“Can you tell me the reasons you don’t want to be discharged?

24. Suggesting collaboration

offering to help patients solve problems. “Perhaps you can discuss this with your children so they will know how you feel

and what you want”.

25. Encouraging goal setting

asking patient to decide on the type of change needed. “What do you think about the things you have to change in your self?”

26. Encouraging formulation of a plan of action

probing for step by step actions that will be needed. “If you decide to leave home when your husband beat you again what will you do

next?”

27. Encouraging decisions

asking patients to make a choice among options. “Given all these choices, what would you prefer to do.

28. Encouraging consideration of options

asking patients to consider the pros and cons of possible options. “Have you thought of the possible effects of your decision to you and your

family?”

29. Giving information

providing information that will help patients make better choices. “Nobody deserves to be beaten and there are people who can help and places to

go when you do not feel safe at home anymore”.

30. Limit setting

discouraging nonproductive feelings and behaviors, and encouraging productive ones.

“Please stop now. If you don’t, I will ask you to leave the group and go to your room.

31. Supportive confrontation

acknowledging the difficulty in changing, but pushing for action. “I understand. You feel rejected when your children sent you here but if you look

at this way…”

32. Role playing

practicing behaviors for specific situations, both the nurse and patient play particular role.

“I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.

33. Rehearsing

asking the patient for a verbal description of what will be said or done in a particular situation.

“Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?”.

34. Feedback

pointing out specific behaviors and giving impressions of reactions. “I see you combed your hair today”.

35. Encouraging evaluation

asking patients to evaluate their actions and their outcomes. “What did you feel after participating in the group therapy?”.

36. Reinforcement

giving feedback on positive behaviors. “Everyone was able to give their options when we talked one by one and each of

waited patiently for our turn to speak”.

Avoid pitfalls:

1. Giving advise 2. Talking about your self 3. Telling client is wrong 4. Entering into hallucinations and delusions of client 5. False reassurance 6. Cliché 7. Giving approval 8. Asking WHY? 9. Changing subject 10. Defending doctors and other health team members.

Non Therapeutic Communications

1. Overloading

talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.

“What’s your name? I see you like sports. Where do you live?”

2. Value Judgments

giving one’s own opinion, evaluating, moralizing or implying one’s values by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.

“You shouldn’t do that, its wrong”.

3. Incongruence

sending verbal and non-verbal messages that contradict one another. The nurse tells the patient “I’d like to spend time with you” and then walks away.

4. Underloading

remaining silent and unresponsive, not picking up cues, and failing to give feedback.

The patient ask the nurse, simply walks away.

5. False reassurance/ agreement

Using cliché to reassure client. “It’s going to be alright”.

6. Invalidation

Ignoring or denying another’s presence, thought’s or feelings. Client: How are you? Nurse responds: I can’t talk now. I’m too busy.

7. Focusing on self

responding in a way that focuses attention to the nurse instead of the client. “This sunshine is good for my roses. I have beautiful rose garden”.

8. Changing the subject

introducing new topic inappropriately, a pattern that may indicate anxiety. The client is crying, when the nurse asks “How many children do you have?”

9. Giving advice

telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility.

“If I were you… Or it would be better if you do it this way…”

10. Internal validation

making an assumption about the meaning of someone else’s behavior that is not validated by the other person (jumping into conclusion).

The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.

Other ineffective behaviors and responses:

1. Defending – Your doctor is very good. 2. Requesting an explanation – Why did you do that? 3. Reflecting – You are not suppose to talk like that! 4. Literal responses – If you feel empty then you should eat more. 5. Looking too busy. 6. Appearing uncomfortable in silence. 7. Being opinionated. 8. Avoiding sensitive topics 9. Arguing and telling the client is wrong 10. Having a closed posture-crossing arms on chest 11. Making false promises – I’ll make sure to call you when you get home.

12. Ignoring the patient – I can’t talk to you right now 13. Making sarcastic remarks 14. Laughing nervously 15. Showing disapproval – You should not do those things.

Different Theories related to Psychiatric Nursing

Florence Nightingales’s Environmental Theory

Defined Nursing: “The act of utilizing the environment of the patient to assist him in his recovery.”

Focuses on changing and manipulating the environment in order to put the patient in the best possible conditions for nature to act.

Identified 5 environmental factors: fresh air, pure water, efficient drainage, cleanliness/sanitation and light/direct sunlight.

Considered a clean, well-ventilated, quiet environment essential for recovery. Deficiencies in these 5 factors produce illness or lack of health, but with a

nurturing environment, the body could repair itself.

Dorothea Orem’s Self-Care Theory

Defined Nursing: “The act of assisting others in the provision and management of self-care to maintain/improve human functioning at home level of effectiveness.”

Focuses on activities that adult individuals perform on their own behalf to maintain life, health and well-being.

Has a strong health promotion and maintenance focus. Identified 3 related concepts:

1. Self-care – activities an Individual performs independently throughout life to promote and maintain personal well-being.

2. Self-care deficit – results when self-care agency (Individual’s ability) is not adequate to meet the known self-care needs.

3. Nursing System – nursing interventions needed when Individual is unable to perform the necessary self-care activities:

1. Wholly compensatory – nurse provides entire self-care for the client.

Example: care of a new born, care of client recovering from surgery in a post-anesthesia care unit

2. Partial compensatory – nurse and client perform care, client can perform selected self-care activities, but also accepts care done by the nurse for needs the client cannot meet independently.

Example: Nurse can assist post operative client to ambulate, Nurse can bring a meal tray for client who can feed himself

3. Supportive-educative – nurse’s actions are to help the client develop/learn their own self-care abilities through knowledge, support and encouragement.

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Example: Nurse guides a mother how to breastfeed her

baby, Counseling a psychiatric client on more adaptive coping strategies.

Virginia Henderson’s Definition of the Unique Function of Nursing

Defined Nursing: “Assisting the individual, sick or well, in the performance of those activities contributing to health or it’s recovery (or to peaceful death) that an individual would perform unaided if he had the necessary strength, will or knowledge”.

Identified 14 basic needs : 1. Breathing normally 2. Eating and drinking adequately 3. Eliminating body wastes 4. Moving and maintaining desirable position 5. Sleeping and resting 6. Selecting suitable clothes 7. Maintaining body temperature within normal range 8. Keeping the body clean and well-groomed 9. Avoiding dangers in the environment 10. Communicating with others 11. Worshipping according to one’s faith 12. Working in such a way that one feels a sense of accomplishment 13. Playing/participating in various forms of recreation 14. Learning, discovering or satisfying the curiosity that leads to normal

development and health and using available health facilities.

Madeleine Leininger’s Transcultural Care Theory and Ethnonursing

Nursing is a learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well being (or health) in culturally meaningful and beneficial ways, or to help people face handicaps or death.

Transcultural nursing as a learned subfield or branch of nursing which focuses upon the comparative study and analysis of cultures with respect to nursing and health-illness caring practices, beliefs and values with the goal to provide meaningful and efficacious nursing care services to people according to their cultural values and health-illness context.

Focuses on the fact that different cultures have different caring behaviors and different health and illness values, beliefs, and patterns of behaviors.

Awareness of the differences allows the nurse to design culture-specific nursing interventions.

Callista Roy’s Adaptation Theory

Viewed humans as Biopsychosocial beings constantly interacting with a changing environment and who cope with their environment through Biopsychosocial adaptation mechanisms.

Focuses on the ability of Individuals., families, groups, communities, or societies to adapt to change.

The degree of internal or external environmental change and the person’s ability to cope with that change is likely to determine the person’s health status.

Nursing interventions are aimed at promoting physiologic, psychologic, and social functioning or adaptation.

Martha Roger’s Concept of Science of Unitary Human Beings, and Principles of Homeodynamics

Nursing is an art and science that is humanistic and humanitarian. It is directed toward the unitary human and is concerned with the nature and direction of human development. The goal of nurses is to participate in the process of change..

Nursing interventions seek to promote harmonious interaction between persons and their environment, strengthen the wholeness of the Individual and redirect human and environmental patterns or organization to achieve maximum health.

5 basic assumptions:

1.1. The human being is a unified whole, possessing individual integrity and

manifesting characteristics that are more than and different from the sum of parts.

2. The individual and the environment are continuously exchanging matter and energy with each other

3. The life processes of human beings evolve irreversibly and unidirectionally along a space-time continuum

4. Patterns identify human being and reflect their innovative wholeness 5. The individual is characterized by the capacity for abstraction and

imagery, language and thought, sensation and emotion

Hildegard Peplau’s Interpersonal Relations Theory

Defined Nursing: “An interpersonal process of therapeutic interactions between an Individual who is sick or in need of health services and a nurse especially educated to recognize, respond to the need for help.

Nursing is a  “maturing force and an educative instrument” Identified 4 phases of the Nurse – Patient relationship:

1. Orientation – individual/family has a “felt need” and seeks professional assistance from a nurse (who is a stranger). This is the problem identification phase.

2. Identification – where the patient begins to have feelings of belongingness and a capacity for dealing with the problem, creating an optimistic attitude from which inner strength ensues. Here happens the selection of appropriate professional assistance.

3. Exploitation – the nurse uses communication tools to offer services to the patient, who is expected to take advantage of all services.

4. Resolution – where patient’s needs have already been met by the collaborative efforts between the patient and the nurse. Therapeutic relationship is terminated and the links are dissolved, as patient drifts away from identifying with the nurse as the helping person.

Lydia Hall’s Key Concepts of Three Interlocking Circles Theory

Nursing is participation in care, core and cure aspects of patient care, where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other members of the health team.

The major purpose of care is to achieve an interpersonal relationship with the individual that will facilitate the development of the core.

Dorothy Johnson’s Key Concepts of Behavioral System

Each individual has patterned, purposeful, repetitive ways of acting that comprises a behavioral system specific to that individual.

Faye Glenn Abdellah’s Concept of Twenty One Nursing Problems

Nursing is broadly grouped into 21 problem areas to guide care and promote the use of nursing judgement.

Nursing is a comprehensive service that is based on the art and science and aims to help people, sick or well, cope with their health needs.

21 Nursing Problems

1. To maintain good hygiene. 2. To promote optimal activity; exercise, rest and sleep. 3. To promote safety. 4. To maintain good body mechanics 5. To facilitate the maintenance of a supply of oxygen 6. To facilitate maintenance of nutrition 7. To facilitate maintenance of elimination 8. To facilitate the maintenance of fluid and electrolyte balance 9. To recognize the physiologic response of the body to disease conditions 10. To facilitate the maintenance of regulatory mechanisms and functions 11. To facilitate the maintenance of sensory functions 12. To identify and accept positive and negative expressions, feelings and reactions 13. To identify and accept the interrelatedness of emotions and illness. 14. To facilitate the maintenance of effective verbal and non-verbal communication 15. To promote the development of productive interpersonal relationship 16. To facilitate progress toward achievement of personal spiritual goals 17. To create and maintain a therapeutic environment 18. To facilitate awareness of self as an individual with varying needs. 19. To accept the optimum possible goals 20. To use community resources as an aid in resolving problems arising from illness. 21. To understand the role of social problems as influencing factors

Imogene King’s Goal Attainment Theory

Nursing is a process of action, reaction, and interaction whereby nurse and client share information about their perception in the nursing situation

Jean Watson’s The Philosophy and Science of Caring

Nursing is concerned with promotion health, preventing illness, caring for the sick, and restoring health.

Nursing is a human science of persons and human health-illness experiences that are mediated by professional, personal, scientific, esthetic and ethical human care transactions

She defined caring as a nurturant way or responding to a valued client towards whom the nurse feels a personal sense of commitment and responsibility. It is only demonstrated interpersonally that results in the satisfaction of certain human needs. Caring accepts the person as what he/she may become in a caring environment

Carative Factors:

1.1. The promotion of a humanistic-altruistic system of values 2. Instillation of faith-hope 3. The cultivation of sensitivity to one’s self and others 4. The development and acceptance of the expression of positive and

negative feelings.

5. The systemic use of the scientific problem-solving method for decision making

6. The promotion of interpersonal teaching-learning 7. The provision for supportive, protective and corrective mental, physical,

socio-cultural and spiritual environment 8. Assistance with the gratification of human needs 9. The allowance for existential phenomenological forces

Rosemarie Rizzo Parse’s Theory of Human Becoming

Nursing is a scientific discipline, the practice of which is a performing art Three assumption about Human Becoming

1. Human becoming is freely choosing personal meaning in situation in the intersubjective process of relating value priorities

2. Human becoming is co-creating rhythmic patterns or relating in mutual process in the universe

3. Human becoming is co-transcending multidimensionally with emerging possibilities.

Patricia Benner - From Novice to Expert

Described 5 levels of nursing experience and developed exemplars and paradigm cases to illustrate each level

1. Novice 2. Advanced beginner 3. Competent 4. Proficient 5. Expert

Levels reflect: o movement from reliance on past abstract principles to the use of past

concrete experience as paradigms o change in perception of situation as a complete whole in which certain

parts are relevant

Importance of Theoretical Frameworks

Foundation of any profession is the development of a specialized body of knowledge. Theories should be developed in nursing, not borrow theories form other disciplines

Responsibility of nurses to know and understand theorists Critically analyze theoretical frameworks

Betty Neuman - Health Care Systems Model

The person is a complete system, with interrelated parts maintains balance and harmony between internal and external environment by

adjusting to stress and defending against tension-producing stimuli Focuses on stress and stress reduction Primarily concerned with effects of stress on health

Stressors are any forces that alter the system’s stability Flexible lines of resistance - Surround basic core Internal factors that help defend against stressors Normal line of resistance -  Normal adaptation state Flexible line of defense - Protective barrier, changing, affected by variables Wellness is equilibrium

Nursing interventions are activates to:

strengthen flexible lines of defense strengthen resistance to stressors maintain adaptation

V.1 Theme Identificationa. Content Themeb. Interaction Themec. Mood Theme

V.2 Nursing Diagnosis

VI. Nursing Interventions based on theories

VII. Summary and Evaluation (including therapy) VII. Reference

Mental Status Assessment(Parts)

Page 1: Including Client’s Name, Age and Ward

Orientation: PersonPlaceDateTime Situation

*All pages of this MSA have its own interpretation and analysis*

Page 2: Defense Mechanisms

Vaillant's categorization of defence mechanisms

Level 1 - Pathological

The mechanisms on this level, when predominating, almost always are severely pathological. These four defences, in conjunction, permit one to effectively rearrange external experiences to eliminate the need to cope with reality. The pathological users of these mechanisms frequently appear irrational or insane to others. These are the "psychotic" defences, common in overt psychosis. However, they are found in dreams and throughout childhood as well.

They include:

Delusional Projection : Grossly frank delusions about external reality, usually of a persecutory nature.

Denial : Refusal to accept external reality because it is too threatening; arguing against an anxiety-provoking stimulus by stating it doesn't exist; resolution of emotional conflict and reduction of anxiety by refusing to perceive or consciously acknowledge the more unpleasant aspects of external reality.

Distortion : A gross reshaping of external reality to meet internal needs. Splitting : A primitive defence. Negative and positive impulses are split off and

unintegrated. Fundamental example: An individual views other people as either innately good or innately evil, rather than a whole continuous being.

Extreme projection: The blatant denial of a moral or psychological deficiency, which is perceived as a deficiency in another individual or group.

Level 2 - Immature

These mechanisms are often present in adults and more commonly present in adolescents. These mechanisms lessen distress and anxiety provoked by threatening people or by uncomfortable reality. People who excessively use such defences are seen as socially undesirable in that they are immature, difficult to deal with and seriously out of touch with reality. These are the so-called "immature" defences and overuse almost always leads to serious problems in a person's ability to cope effectively. These defences are often seen in severe depression and personality disorders. In adolescence, the occurrence of all of these defences is normal.

They include:

Acting out : Direct expression of an unconscious wish or impulse in action, without conscious awareness of the emotion that drives that expressive behavior.

Fantasy : Tendency to retreat into fantasy in order to resolve inner and outer conflicts.

Idealization : Unconsciously choosing to perceive another individual as having more positive qualities than he or she may actually have.[14]

Passive aggression : Aggression towards others expressed indirectly or passively such as using procrastination.

Projection : Projection is a primitive form of paranoia. Projection also reduces anxiety by allowing the expression of the undesirable impulses or desires without becoming consciously aware of them; attributing one's own unacknowledged unacceptable/unwanted thoughts and emotions to another; includes severe prejudice, severe jealousy, hyper vigilance to external danger, and "injustice collecting". It is shifting one's unacceptable thoughts, feelings and impulses within oneself onto someone else, such that those same thoughts, feelings, beliefs and motivations are perceived as being possessed by the other.

Projective identification : The object of projection invokes in that person precisely the thoughts, feelings or behaviors projected.

Somatization : The transformation of negative feelings towards others into negative feelings toward self, pain, illness, and anxiety.

They have been associated with impaired sexual function in females.[15]

Level 3 - Neurotic

These mechanisms are considered neurotic, but fairly common in adults. Such defences have short-term advantages in coping, but can often cause long-term problems in relationships, work and in enjoying life when used as one's primary style of coping with the world.

They include:

Displacement : Defence mechanism that shifts sexual or aggressive impulses to a more acceptable or less threatening target; redirecting emotion to a safer outlet; separation of emotion from its real object and redirection of the intense emotion toward someone or something that is less offensive or threatening in order to avoid dealing directly with what is frightening or threatening. For example, a mother may yell at her child because she is angry with her husband.

Dissociation : Temporary drastic modification of one's personal identity or character to avoid emotional distress; separation or postponement of a feeling that normally would accompany a situation or thought.

Hypochondriasis : An excessive preoccupation or worry about having a serious illness.

Intellectualization : A form of isolation; concentrating on the intellectual components of a situation so as to distance oneself from the associated anxiety-provoking emotions; separation of emotion from ideas; thinking about wishes in formal, affectively bland terms and not acting on them; avoiding unacceptable emotions by focusing on the intellectual aspects (e.g. Isolation, Rationalization, Ritual, Undoing, Compensation, Magical thinking).

Isolation : Separation of feelings from ideas and events, for example, describing a murder with graphic details with no emotional response.

Rationalization (making excuses) : Where a person convinces him or herself that no wrong was done and that all is or was all right through faulty and false reasoning. An indicator of this defence mechanism can be seen socially as the formulation of convenient excuses - making excuses.

Reaction formation : Converting unconscious wishes or impulses that are perceived to be dangerous into their opposites; behavior that is completely the opposite of what one really wants or feels; taking the opposite belief because the true belief causes anxiety. This defence can work effectively for coping in the short term, but will eventually break down.

Regression : Temporary reversion of the ego to an earlier stage of development rather than handling unacceptable impulses in a more adult way.

Repression : the process of attempting to repel desires towards pleasurable instincts, caused by a threat of suffering if the desire is satisfied; the desire is moved to the unconscious in the attempt to prevent it from entering consciousness;[16] seemingly unexplainable naivety, memory lapse or lack of awareness of one's own situation and condition; the emotion is conscious, but the idea behind it is absent.[citation needed]

Undoing : A person tries to 'undo' an unhealthy, destructive or otherwise threatening thought by engaging in contrary behaviour.

Level 4 - Mature

These are commonly found among emotionally healthy adults and are considered mature, even though many have their origins in an immature stage of development. They have been adapted through the years in order to optimize success in life and relationships. The use of these defences enhances pleasure and feelings of control. These defences help us integrate conflicting emotions and thoughts, while still remaining effective. Those who use these mechanisms are usually considered virtuous.

They include:

Altruism : Constructive service to others that brings pleasure and personal satisfaction.

Anticipation : Realistic planning for future discomfort. Humour : Overt expression of ideas and feelings (especially those that are

unpleasant to focus on or too terrible to talk about) that gives pleasure to others.

Humor, which explores the absurdity inherent in any event, enables someone to "call a spade a spade", while "wit" is a form of displacement (see above under Level 3). Wit refers to the serious or distressing in a humorous way, rather than disarming it; the thoughts remain distressing, but they are "skirted round" by witticism.

Identification : The unconscious modeling of one's self upon another person's character and behavior.

Introjection : Identifying with some idea or object so deeply that it becomes a part of that person.

Sublimation : Transformation of negative emotions or instincts into positive actions, behavior, or emotion.

Thought suppression : The conscious process of pushing thoughts into the preconscious; the conscious decision to delay paying attention to an emotion or need in order to cope with the present reality; making it possible to later access uncomfortable or distressing emotions while accepting them.

Page 3: Extra pyramidal Symptoms-Pseudo Parkinsonism

1. Mask like face2. No swinging of arms3. Hesitancy of speech4. Decreased muscle strength5. Shuffling gait6. Drooling7. Fine intention tremors

-Acute Dystonic Reaction1. Acute spasm of jaw, tongue, neck, eyes2. Laryngeal spasm

-Akathisia1. Restlessness2. Tenseness3. Inability to sit still4. Rocking back and forth on feet5. Crossing leg frequently6. Inability to relax

- Tardive Dyskinesia1. Involuntary movements of mouth, face, may extend to fingers, arms and trunk.

Page 4: Thinking and Communication

-Loose of association1. Neologism- is a newly coined word or phrase that may be in the process of

entering common use, but has not yet been accepted into mainstream language.2. Work Salad- Speech that is unintelligible because, though the individual words

are real words, the manner in which they are strung together results in incoherent gibberish, e.g. the question "Why do people comb their hair?" elicits a response like "Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons. Hello, beautiful."

3. Echolalia- the automatic repetition of vocalizations made by another person.4. Echopraxia- the automatic repetition of movements made by another person.

5. Clang association- the mental connection between dissociated ideas made because of similarity in the sounds of the words used to describe the ideas. The phenomenon occurs frequently in schizophrenia.E.g. "I'm not trying to make noise. I'm trying to make sense. If you can't make sense out of nonsense, well, have fun." "I heard the bell. Well, hell, I heard the bell."

6. Illogical thinking- Conclusions are reached that do not follow logically (non-sequiturs or faulty inferences). e.g. "Do you think this will fit in the box?" draws a reply like "Well duh; it's brown isn't it?"

- Alogia- Complete lack of speech, as in profound mental retardation or advanced dementia. Alogia is synonymous in this sense with aphasia.- Concrete thinking- Lack of insight- Aphasia- is an acquired language disorder in which there is an impairment of any language modality. This may include difficulty in producing or comprehending spoken or written language.- Apraxia- is a disorder caused by damage to specific areas of the cerebrum, characterized by loss of the ability to execute or carry out learned purposeful movements

despite having the desire and the physical ability to perform the movements.- Agnosia- is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss.- Flight of Ideas- A sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea. To the listener, the ideas seem unrelated and do not seem to repeat. Often pressured speech is also present. e.g. "I own is five cigars. I've been to Havana. She rose out of the water, in a bikini."

Others: Thought is revealed through speech. Thus, observation of patterns of thought naturally involves close observation of the speech of the individual being considered. Although it is normal to exhibit some of the following during times of extreme stress(e.g. a cataclysmic event or the middle of a war) it is the degree, frequency, and the resulting functional impairment that leads to the conclusion that the person being observed has a thought disorder.

Blocking - Interruption of train of speech before completion. e.g. "Am I early?", "No, you're just about on-" This is commonly seen when a joke is being told and the speaker forgets the punchline. At an extreme degree, after blocking occurs, the speaker does not recall the topic he or she was discussing. True blocking is a common sign of schizophrenia.

Circumferential speech - Speech that is very delayed at reaching its goal. Speaking about many concepts related to the point of the conversation before eventually returning to the point and concluding the thought. Excessive long-windedness. e.g. "What is your name?" "Well, sometimes when people ask me that I have to think about whether or not I will answer because some people think it's an odd name even though I don't really because my mom gave it to me and I think my dad helped but it's as good a name as any in my opinion but yeah it's Tom."

Clanging - Sounds, rather than meaningful relationships, appear to govern words or topics. Excessive rhyming. e.g. "I'm not trying to make noise. I'm trying to make sense. If you can't make sense out of nonsense, well, have fun." "I heard the bell. Well, hell, I heard the bell."

Derailment (also Loose Association and Knight's Move thinking) - Ideas slip off the topic's track on to another which is obliquely related or unrelated. e.g. "The

next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California."

Distractible speech - During mid speech, the subject is changed in response to a stimulus. e.g. "Then I left San Francisco and moved to... where did you get that tie?"

Echolalia - Echoing of one's or other people's speech that may only be committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner's sentences. This can be a symptom of Tourette's Syndrome. e.g. "What would you like for dinner?", "That's a good question. That's a good question. That's a good question. That's a good question."

Evasive Interaction - Attempts to annunciate ideas and/or feelings about another individual comes out as evasive or in a diluted form, e.g.: "I... er ah... you are uh... I think you have... uh-- acceptable erm... uh... hair."[citation needed]

Flight of Ideas - A sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea. To the listener, the ideas seem unrelated and do not seem to repeat. Often pressured speech is also present. e.g. "I own is five cigars. I've been to Havana. She rose out of the water, in a bikini."

Illogicality - Conclusions are reached that do not follow logically (non-sequiturs or faulty inferences). e.g. "Do you think this will fit in the box?" draws a reply like "Well duh; it's brown isn't it?"

Incoherence (word salad) - Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish, e.g. the question "Why do people comb their hair?" elicits a response like "Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons. Hello, beautiful."

Loss of goal - Failure to show a train of thought to a natural conclusion. e.g. "Why does my computer keep crashing?", "Well, you live in a stucco house, so the pair of scissors needs to be in another drawer."

Neologisms - New word formations. These may also involve elisions of two words that are similar in meaning or in sound. e.g. "I got so angry I picked up a dish and threw it at the geshinker."

Perseveration - Persistent repetition of words or ideas. e.g. "It's great to be here in Nevada, Nevada, Nevada, Nevada, Nevada." This may also involve repeatedly giving the same answer to different questions. e.g. "Is your name Mary? Yes. Are you in the hospital? Yes. Are you a table? Yes."

Phonemic paraphasia - Mispronunciation; syllables out of sequence. e.g. "I slipped on the lice and broke my arm."

Pressure of speech - An increase in the amount of spontaneous speech compared to what is considered customary. This may also include an increase in the rate of speech. Alternatively it may be difficult to interrupt the speaker; the speaker may continue speaking even when a direct question is asked.

Self-reference - Patient repeatedly and inappropriately refers back to self. e.g. "What's the time?", "It's 7 o'clock. That's my problem."

Semantic paraphasia - Substitution of inappropriate word. e.g. "I slipped on the coat, on the ice I mean, and broke my book."

Stilted speech - Speech excessively stilted and formal. e.g. "The attorney comported himself indecorously."

Tangentiality - Replying to questions in an oblique, tangential or irrelevant manner. e.g.:

Q: "What city are you from?" A: "Well, that's a hard question. I'm from Iowa. I really don't know where my relatives came from, so I don't know if I'm Irish or French."

Word approximations - Old words used in a new and unconventional way. e.g. "His boss was a seeover."

Page 5: Perceiving and Interpreting

- Delusions1. Reference- The person falsely believes that insignificant remarks, events, or

objects in one's environment have personal meaning or significance. For instance, a person may believe they are receiving special messages from newspaper headlines.

2. Prosecution- These are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals. Sometimes the delusion is isolated and fragmented (such as the false belief that co-workers are harassing), but sometimes are well-organized belief systems involving a complex set of delusions ("systematized delusions"). People with a set of persecutory delusions may believe, for example, they are being followed by government organizations because the "persecuted" person has been falsely identified as a spy. These systems of beliefs can be so broad and complex that they can explain everything that happens to the person.

3. External influence4. Somatic- A delusion whose content pertains to bodily functioning, bodily

sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or changed—for example, infested with parasites.

5. Grandiose- An individual is convinced they have special powers, talents, or abilities. Sometimes, the individual may actually believe they are a famous person or character (for example, a rock star). More commonly, a person with this delusion may believe they have accomplished some great achievement for which they have not received sufficient recognition (for example, the discovery of a new scientific theory). Often, this type of person believes they have uncovered an obvious "truth" that has escaped the entire history of humankind.

Other types:

Delusions are categorized into four different groups:

Bizarre delusion: A delusion that is very strange and completely implausible; an example of a bizarre delusion would be that aliens have removed the affected person's brain.

Non-bizarre delusion: A delusion whose content is definitely mistaken, but is at least possible; an example may be that the affected person mistakenly believes he or she is under constant police surveillance.

Mood-congruent delusion: Any delusion whose content is consistent with either a depressive or manic state; for example, a depressed person may believe that

news anchors on television highly disapprove of him or her, or a person in a manic state might believe that he or she is a powerful deity.

Mood-neutral delusion: A delusion that does not relate to the sufferer's emotional state; for example, a belief that an extra limb is growing out of the back of one's head is neutral to either depression or mania.[6]

In addition to these categories, delusions often manifest according to a consistent theme. Although delusions can have any theme, certain themes are more common. Some of the more common delusion themes are [6]:

Delusion of control: This is a false belief that another person, group of people, or external force controls one's thoughts, feelings, impulses, or behavior. A person may describe, for instance, the experience that aliens actually make him or her move in certain ways and that the person affected has no control over the bodily movements. Thought broadcasting (the false belief that the affected person's thoughts are heard aloud), thought insertion, and thought withdrawal (the belief that an outside force, person, or group of people is removing or extracting a person's thoughts) are also examples of delusions of control.

Nihilistic delusion: A delusion whose theme centres on the nonexistence of self or parts of self, others, or the world. A person with this type of delusion may have the false belief that the world is ending.

Delusional jealousy (or delusion of infidelity): A person with this delusion falsely believes their spouse or lover is having an affair. This delusion stems from pathological jealousy, and the person often gathers "evidence" and confronts the spouse about the nonexistent affair.

Delusion of guilt or sin (or delusion of self-accusation): This is a false feeling of remorse or guilt of delusional intensity. A person may, for example, believe he has committed some horrible crime and should be punished severely. Another example is a person who is convinced he is responsible for some disaster (such as fire, flood, or earthquake) with which there can be no possible connection.

Delusion of mind being read: The false belief that other people can know one's thoughts. This is different from thought broadcasting in that the person does not believe that his or her thoughts are heard aloud.

Delusion of reference: The person falsely believes that insignificant remarks, events, or objects in one's environment have personal meaning or significance. For instance, a person may believe they are receiving special messages from newspaper headlines.

Erotomania is a delusion in which one believes that another person is in love with him or her. They believe that this other person was the first to declare his or her affection, often by special glances, signals, telepathy, or messages through the media.

Grandiose delusion: An individual is convinced they have special powers, talents, or abilities. Sometimes, the individual may actually believe they are a famous person or character (for example, a rock star). More commonly, a person with this delusion may believe they have accomplished some great achievement for which they have not received sufficient recognition (for example, the discovery of a new scientific theory). Often, this type of person believes they have uncovered an obvious "truth" that has escaped the entire history of humankind.

Persecutory delusion: These are the most common type of delusions and involve the theme of being followed, harassed, cheated, poisoned or drugged, conspired against, spied on, attacked, or obstructed in the pursuit of goals. Sometimes the delusion is isolated and fragmented (such as the false belief that co-workers are harassing), but sometimes are well-organized belief systems involving a complex set of delusions ("systematized delusions"). People with a set of persecutory delusions may believe, for example, they are being followed by government organizations because the "persecuted" person has been falsely identified as a spy.

These systems of beliefs can be so broad and complex that they can explain everything that happens to the person.

Religious delusion: Any delusion with a religious or spiritual content. These may be combined with other delusions, such as grandiose delusions (the belief that the affected person is God, or chosen to act as a God, for example).

Somatic delusion: A delusion whose content pertains to bodily functioning, bodily sensations, or physical appearance. Usually the false belief is that the body is somehow diseased, abnormal, or changed—for example, infested with parasites.

Delusions of parasitosis (DOP) or delusional parasitosis: The person believes that they are infested with an insect, bacteria, mite, spiders, lice, fleas, worms, or other organisms. They may also report being repeatedly bitten. In some cases, entomologists are asked to investigate cases of mysterious bites. Sometimes physical manifestations may occur including skin lesions

- Hallucinations- A profound distortion in a person's perception of reality, typically accompanied by a powerful sense of reality. An hallucination may be a sensory

experience in which a person can see, hear, smell, taste, or feel something that is not there.

The types of hallucinations include:

← An auditory hallucination- is an hallucination involving the sense of hearing. Called also paracusia and paracusis.

← A gustatory hallucination- is an hallucination involving the sense of taste. ← A hypnagogic hallucination- is a vivid dreamlike hallucination at the onset of

sleep. ← Hypnopompic hallucination- is a vivid dreamlike hallucination on awakening. ← Kinesthetic hallucination- is an hallucination involving the sense of bodily

movement. ← Lilliputian hallucination- is an hallucination in which things, people, or animals

seem smaller than they would be in reality. ← Olfactory hallucination -is an hallucination involving the sense of smell. ← Somatic hallucination- is an hallucination involving the perception of a physical

experience occurring with the body. ← Tactile hallucination- is an hallucination involving the sense of touch. ← Visual hallucination -is an hallucination involving the sense of sight.

- Illusions- Depersonalization- Attending to irrelevant stimuli- Poor reality testing

Page 6: Feeling and Affect- Flat- Blunted- Inappropriate- Lability

Page 7: Behaving and Interacting- Withdrawal- Motor hyperactivity- Motor hypoactivity

- Ambivalence- state of having simultaneous, conflicting feelings toward a person or thing- Anhedonia- is an inability to experience pleasurable emotions from normally pleasurable life events such as eating, exercise, social interaction or sexual activities.- Avolition- a psychological state characterized by general lack of desire, drive, or motivation to pursue meaningful goals.- Poor personal hygiene- Impulsive- a personality trait characterized by the inclination of an individual to initiate behavior without adequate forethought as to the consequences of their actions, acting on the spur of the moment.- Paranoia

Page 8: Negative Cognition- Overgeneralization- All or nothing thinking- Should statements- Labeling- Mind reading- Fortune Telling

Page 9: Others- Amnesia- Fugue- Depersonalization- Phobias- Memory

1. Remote (long term)2. Recent (early am) 3. Recent part (current events)4. Immediate memory (short term)5. Immediate recall

Prepared by:Leomar Gonzales

BPSU Nursing Student (2007-2011)