1762  |  wileyonlinelibrary.com/journal/jan J Adv Nurs. 2021;77:1762–1771.© 2020 John Wiley & Sons Ltd

Received: 12 August 2020  |  Revised: 28 October 2020  |  Accepted: 24 November 2020
DOI: 10.1111/jan.14715

O R I G I N A L R E S E A R C H :
E M P I R I C A L R E S E A R C H – Q U A N T I T A T I V E

Examining the association between evidence-based practice
and the nurse-patient therapeutic relationship in mental health
units: A cross-sectional study

Antonio R. Moreno-Poyato1,2  | Georgina Casanova-Garrigos3  | Juan F. Roldán-
Merino4  | Óscar Rodríguez-Nogueira5 | MiRTCIME.CAT working group

1Department of Public Health, Mental
Health and Maternal and Child Health
Nursing, Nursing School, Universitat de
Barcelona, Ĺ Hospitalet de Llobregat,
Barcelona, Spain
2IMIM (Hospital del Mar Medical Research
Institute), Barcelona, Spain
3School of Nursing, Universitat Rovira i
Virgili, Tarragona, Spain
4Campus Docent Sant Joan de Déu Fundació
Privada. School of Nursing, University of
Barcelona, Barcelona, Spain
5Nursing and Physical Therapy Department,
SALBIS Research Group, Health Sciences
School, Universidad de León, Ponferrada,
León, Spain

Correspondence
Juan F. Roldán-Merino, Campus Docent Sant
Joan de Déu Fundació Privada. School of
Nursing, University of Barcelona, Spain.
Email: [email protected]

Abstract
Aims: To examine the relationship between the dimensions of evidence-based prac-
tice and the therapeutic relationship and to predict the quality of the therapeutic
relationship from these dimensions among nurses working in mental health units.
Design: A cross-sectional design.
Methods: Data were collected between February–April 2018 via an online form com-
pleted by nurses working at 18 mental health units. Multiple linear regressions were
used to examine the relationship between the dimensions of evidence-based prac-
tice and therapeutic relationship. Questionnaires were completed by 198 nurses.
Results: Higher levels of evidence-based practice were a significant predictor of a
higher-quality therapeutic relationship (β: 2.276; 95% CI: 1.30–3.25). The evidence-
based practice factor which most influenced an improved therapeutic relationship
was the nurses’ attitude (β: 2.047; 95% CI: 0.88–3.21). The therapeutic relationship
dimension which was most conditioned by evidence-based practice dimensions was
agreement on tasks, which was most favourable with a better attitude (β: 0.625;
95% CI: 0.09–1.16) and greater knowledge and skills for evidence-based practice (β:
0.500; 95% CI: 0.08–0.93).
Conclusion: In mental health settings, the therapeutic nurse–patient relationship is
positively enhanced by evidenced-based practice and the nurse’s level of experience,
with a great influence on shared decision-making.
Impact: This research sought to examine the relationship between the evidence-
based practice and the therapeutic relationship in mental health nursing. This study
demonstrates that an improved attitude and knowledge of evidence-based practices
of mental health nurses increases shared decision-making with patients, which is a
basic requirement for person-centred care. Because the therapeutic relationship is
considered the backbone of nursing practice in mental health units, this research will
have an impact on both mental health nurses and mental health unit managers.

K E Y W O R D S

evidence-based practice, mental health, nurse–patient relationships, practice nursing,
quantitative approaches

     |  1763MORENO-POYATO ET Al.

1   |   I N T R O D U C T I O N

The international literature recognizes that the therapeutic re-
lationship is an essential component of mental health nursing
(Moreno-Poyato et al., 2016; Peplau, 1988; Vahidi et al., 2018) im-
proving person-centred care and shared decision-making (Hamovitch
et al., 2018). Furthermore, it is known that evidence-based practice
enables the best clinical decisions to be made about patient care,
considering factors such as nurses’ experience and users’ expecta-
tions (DiCenso et al., 1998). In this regard, it seems clear that nurses
with greater competence in evidence-based practice should estab-
lish a better therapeutic relationship with patients.

1.1 | Background

Via the therapeutic relationship, nurses are able to positively make
an impact on the health of people with mental health problems
(McAndrew et al., 2014; Moreno-Poyato et al., 2019). Furthermore,
the establishment of an appropriate therapeutic relationship has
been empirically demonstrated to be associated with improved
health outcomes for patients (Kelley et al., 2014). Furthermore, the
therapeutic relationship also increases the effectiveness of any clini-
cal practice intervention performed by nurses in acute mental health
units (McAndrew et al., 2014). In terms of therapeutic value, via their
interactions, nurses can provide a safe place, allowing the patient to
overcome emotional resistance and move toward deep self-knowl-
edge that often results in change (McAndrew et al., 2014). Along
these lines, it was Peplau (1988) in the 1950s who referred to the
role of the nurse as a leader who should help the patient to take on
tasks through a relationship of cooperation and active participation,
thus representing a true therapeutic alliance (Bordin, 1979). In turn,
Bordin (1979) pointed out that the main components of the thera-
peutic alliance are the agreement between the therapist and the
patient on the treatment objectives, the tasks to be carried out and,
finally, the affective bond that is established between the patient and
the therapist. To build effective interpersonal relationships, Peplau
(1988, 1997) described nursing care as an interpersonal process of
therapeutic nature. Concretely, Peplau (1988, 1997) described nurs-
ing care as a human relationship between a sick person or a person
in need of help and a nurse who is properly trained to recognize and
respond to the person’s need for help. The therapeutic interpersonal
relationship described by Peplau (1988) is based on three phases:
orientation, working and termination. During the orientation phase,
the individual perceives a need and seeks professional assistance.
In this case, the nurse helps the patient to recognize, understand
and assess his or her problem and situation. Subsequently, the work-
ing phase represents most of the time that the nurse spends with
the patient, where the nurse facilitates the exploration of feelings
to help the patient cope with the illness and to be able to move on
to the last phase, the resolution phase, which marks the satisfac-
tion of old needs and the emergence of new needs to be fulfilled
(Peplau, 1988).

Multiple studies provide evidence of the attributes required for
the therapeutic relationship and their meaning (Felton et al., 2018;
Harris & Panozzo, 2019; Hartley et al., 2019; McAllister et al., 2019;
Moreno-Poyato et al., 2016). However, there is evidence of underuse
of the same by mental health nurses (Hamaideh, 2017; Youssef
et al., 2018). Clearly, it follows that knowledge and implementation
of evidence-based empirical and theoretical precepts of the thera-
peutic relationship should facilitate and improve the implementation
of therapeutic relationship in clinical practice in mental health units.

Evidence-based practice has been defined as the organized use
of the best available evidence (DiCenso et al., 1998). Some authors
consider this as being an essential element in the provision of opti-
mal high-quality care (Ramos-Morcillo et al., 2015; Stevens, 2013).
Indeed, the implementation of EBP has been associated with im-
proved health outcomes, decreased healthcare expenditure and
increased nursing staff satisfaction (Moore, 2017; Ramos-Morcillo
et al., 2015). Over recent years, certain difficulties have been ob-
served in the implementation of this empirical knowledge in the
complex clinical reality of health services (Correa et al., 2020). Thus,
limitations have been identified for its use both at the individual
level and by organizations at large. For professionals, lack of time, a
heavy workload and lack of knowledge represent major difficulties
(Correa et al., 2020; Stevens, 2013). Furthermore, the lack of human
and material support and insufficient leadership resources are
the main organizational limitations identified (Correa et al., 2020;
Warren et al., 2016). In this regard, it should be noted that mental
health nurses must overcome certain barriers that they encounter
on a daily basis to implement EBP (Yadav & Fealy, 2012; Youssef
et al., 2018). According to Alzayyat (2014), these barriers are due to
the nature of the evidence, the contribution of mental health nurses
involved in research, the personal characteristics of these nurses
and organizational factors.

In the field of mental health, nursing studies have shown that
the incorporation of evidence-based practice in clinical practice in-
creases the empathy of nurses and improves the factors that con-
tribute towards establishing a therapeutic alliance with patients
(Moreno-Poyato et al., 2018), and increasing the nurses’ self-confi-
dence, allowing them to reflect on their practice, present ideas and
acquire new knowledge (Moreno-Poyato et al., 2019). However,
these studies have not specifically evaluated the contribution be-
tween the EBP and its dimensions and the therapeutic relation-
ship from a quantitative point of view (Moreno-Poyato et al., 2019;
Moreno-Poyato et al., 2018).

Considering the impact of EBP on the therapeutic relationship in
nursing practice in general and understanding the therapeutic rela-
tionship as the essence of nursing practice in mental health (Felton
et al., 2018; Moreno-Poyato et al., 2016), it is imperative to study
the impact of EBP on this relationship in mental health units. Further
knowledge is clearly necessary, considering that the work performed
by mental health nurses in the context of the therapeutic relation-
ship must be translated into practice following the established
guidelines of empirical-theoretical precepts based on EBP. No stud-
ies to date have evaluated the relationship between both constructs.

1764  |     MORENO-POYATO ET Al.

It is therefore essential to research the association between the dif-
ferent dimensions of EBP and the therapeutic relationship and its
factors, while considering the relationship between EBP and the
socio-demographic and professional characteristics of nurses, to
develop strategies to improve the quality of the nurse–patient ther-
apeutic relationship in mental health units.

2   |   T H E S T U DY

2.1 | Aims

The aims of this study were to examine the relationship between the
dimensions of evidence-based practice and the therapeutic relation-
ship and to predict the quality of the therapeutic relationship from
these dimensions among nurses working in mental health units.

2.2 | Design

This cross-sectional, correlational study sought to explore the asso-
ciation between dimensions for EBP and the level of the therapeutic
relationship among mental health unit nurses. The data collected for
this study were part of the first phase of a mixed-method project
entitled MiTRCIME.CAT, which aimed to improve the therapeutic re-
lationship by implementing evidence-based practice in acute mental
health units in Catalonia (Spain).

2.3 | Sample/Participants

The 21 mental health hospitalization units forming part of the
Catalonian Network of Mental Health were informed of this study,
of which 18 units agreed to participate. All the nurses employed
at the collaborating units were invited to participate in the study
(n = 235). Resident nurses who were on clinical placements were
excluded from the study. Finally, 198 nurses participated in the
study. Considering that, to perform a multiple linear regression, it is
recommended to introduce one variable for every 10–15 individuals
(Austin & Steyerberg, 2015; Green, 1991) and that in our study, nine
variables were collected for each individual, the final sample size was
considered appropriate.

2.4 | Data collection

First, the director of each institution, plus the research team, selected
a nurse coordinator for each centre who fulfilled the conditions of
leadership and credibility and agreed to participate voluntarily in the
study. Thereafter, to recruit participants from each unit, the principal
investigator presented the research project and its aims to each cen-
tre via informational sessions with nurses. Thereafter, the nurse coor-
dinators were placed in charge of recruiting the participating nurses

and gathering the informed consent forms and email addresses to
provide them with a confidential participant code, together with a
link to the electronic form via the google forms platform to gather
the data during the first phase of the study. The data collection for
this part of the study took place between February and April 2018.
The electronic form included a questionnaire which gathered nurses’
socio-demographic and professional data and measurement tools,
including the Work Alliance Inventory – Short (WAI-S: Horvath &
Greenberg, 1989) and the Evidence-Based Practice Questionnaire
(EBPQ-19: Upton & Upton, 2006).

2.5 | Ethical considerations

This study was approved by the Research Ethics Committees of all
the participating hospitals and participating nurses signed a con-
sent form. The consent forms and the completed questionnaire
were given to participants as separate forms and data were treated
confidentially.

2.6 | Data analysis

The quantitative variables were expressed as the mean and the
standard deviation. The categorical variables were expressed as the
number and percentage. In the bivariate analysis, the association be-
tween the quantitative variables was evaluated using the Pearson’s
correlation coefficient. The relationship between quantitative and
categorical variables was determined using the Student’s t-test.
Finally, multiple linear regression models were used for the analy-
sis of the therapeutic relationship according to the EBPQ and by in-
troducing the socio-demographic profile and professional variables
of nurses as covariates. The choice of covariates was made based
on possible theoretical associations between the main factor (EBP)
and these variables. The socio-demographic and professional vari-
ables introduced in each of the models were gender, years of mental
health experience, mental health specialty and highest education.
Age was not included to avoid redundancy and multicollinearity.
Statistically significant results were established with a p-value of
<.05. The statistical analyses were calculated using the SPSS V 22.0
statistical package (SPSS Inc., Chicago, IL).

2.7 | Validity and reliability

The level of the therapeutic relationship was measured using the
Working Alliance Inventory-Short (WAI-S). The short version of
this scale contains 12 items, and each item is assessed by the health
professional based on a scale ranging from 1 (never) to 7 (always).
The scoring range of the overall WAI-S is 12–84 points. The higher
the score, the higher the therapeutic relationship. This question-
naire has three dimensions: (a) bond: the bond between patient
and nurse, which includes aspects such as empathy, mutual trust

     |  1765MORENO-POYATO ET Al.

T
A

B
L

E
1

 
R

el
at

io
ns

hi
p

of
n

ur
se

s’
s

oc
io

-d
em

og
ra

ph
ic

a
nd

p
ro

fe
ss

io
na

l v
ar

ia
bl

es
w

it
h

th
e

EB
P

Q
a

nd
W

A
I-

S

V
ar

ia
bl

es
n

P
ra

ct
ic

e
A

tt
it

ud
e

K
no

w
le

dg
e/

Sk
ill

s
EB

P
Q

W
A

I-
S

C
or

re
la

ti
on

co

ef
fi

ci
en

t
(r

)
M

ea
n

(S
D

)
p

C
or

re
la

ti
on

co

ef
fi

ci
en

t
(r

)
M

ea
n

(S
D

)
p

C
or

re
la

ti
on

co

ef
fi

ci
en

t
(r

)
M

ea
n

(S
D

)
p

C
or

re
la

ti
on

co

ef
fi

ci
en

t
(r

)
M

ea
n

(S
D

)
p

C
or

re
la

ti
on

co

ef
fi

ci
en

t
(r

)
M

ea
n

(S
D

)
p

A
ge

(y
ea

rs
)

19
8

−
0.

02
4

.7
42

a  
0.

02
9

.6
8

4a
 

−
0.

0
85

.2
35

a  
−

0.
0

4
0

.5
77

a  
0.

14
3

.0
4

4

Ye
ar

s
of

M
H

ex

pe
ri

en
ce

19
8

−
0.

01
5

0
83

6a
 

–
0.

02
3

.7
50

a  
−

0.
01

3
.8

61
a  

−
0.

02
0

.7
82

a  
0.

22
1

.0
02

Se
x Fe

m
al

e
14

2
4.

5
(1

.2
)

.5
25

b  
5.

7
(0

.7
)

.7
63

b  
4.

5
(1

.0
)

.3
6

4b
 

4.
9

(0
.8

)
.9

79
b  

62
.4

(5

.9
)

.4
85

M
al

e
56

4.
4

(1
.2

)
5.

7
(0

.7
)

4.
7

(0
.9

)
4.

9
(0

.8
)

61
.7

(5

.5
)

H
ig

he
st

e
du

ca
ti

on

B
ac

he
lo

r’s

de
gr

ee
13

2
4.

4
(1

.2
)

.1
0

4b
 

5.
6

(0
.7

)
.2

58
b  

4.
4

(1
.0

)
<

.0
01

b  
4.

8
(0

.8
)

.0
03

b  
61

.6

(6
.0

)
0.

02
7b

 

P
hD

o
r

m
as

te
r’s

de

gr
ee

66
4.

7
(1

.2
)

5.
8

(0
.7

)
5.

0
(0

.9
)

5.
2

(0
.8

)
63

.5

(5
.1

)

M
H

S
pe

ci
al

ty

Ye
s

39
4.

6
(1

.2
)

.7
53

b  
5.

7
(0

.7
)

.9
03

b  
4.

4
(1

.2
)

.1
71

b  
4.

9
(0

.9
)

.6
97

b  
62

.5

(5
.9

)
0.

72
0

b  

N
o

15
9

4.
5

(1
.2

)
5.

7
(0

.7
)

4.
6

(1
.0

)
4.

9
(0

.8
)

62
.1

(5

.8
)

N
ot

e:
E

B
P

Q
, E

vi
de

nc
e-

B
as

ed
P

ra
ct

ic
e

Q
ue

st
io

nn
ai

re
; M

H
, m

en
ta

l h
ea

lt
h;

S
D

, S
ta

nd
ar

d
de

vi
at

io
n;

W
A

I-
S,

W
or

ki
ng

A
lli

an
ce

In
ve

nt
or

y
Sh

or
t.

a P
ea

rs
on

’ c
or

re
la

ti
on

c
oe

ff
ic

ie
nt

b S

tu
de

nt
‘s

t
t

es
t

1766  |     MORENO-POYATO ET Al.

and acceptance; (b) objectives: the agreement between patient and
nurse on the goals of therapy (i.e., mutual acceptance of what the in-
tervention aims to achieve); and (c) tasks or activities: the agreement
between patient and nurse on the tasks or activities to be carried
out. The Spanish version of the WAI-S has good reliability and valid-
ity, with a Cronbach alpha of 0.93 (Andrade-González & Fernández-
Liria, 2015). In the case of our sample, the Cronbach’s alpha value
for the total scale was 0.71, the subscales for tasks and bonding pre-
sented internal consistencies of 0.73 and 0.56, respectively, whereas
the subscale objectives had a lower internal consistency of 0.31.

Evidence-based practice was measured using the Evidence-
Based Practice Questionnaire (EBPQ-19) developed by Upton and
Upton (2006). The EBPQ-19 Questionnaire consists of 19 items,
structured in three dimensions: (a) practice, which includes six
items (e.g. ‘Formulated a clearly answerable question as the begin-
ning of the process towards filling this gap or ‘Tracked down the
relevant evidence once you have formulated the question’); (b) atti-
tude with three items (e.g., ‘I welcome questions on my practice’ or
‘Evidence-based practice is fundamental to professional practice’);
and (c) professional knowledge and skills for evidence-based prac-
tice with 10 items (e.g., ‘Knowledge of how to retrieve evidence’ or
‘Ability to critically analyze evidence against set standards’). Each
item scores from 1–7, with 1 being the least favourable value and
7 the most favourable in terms of competence in the application of
EBP. The scale ranges from 19–133 points. We used the Spanish
adaptation of this questionnaire validated by Pedro Gómez
et al. (2009) with Cronbach’s alpha values of 0.89, 0.72 and 0.92
for each of the factors. In our sample, the Cronbach’s alpha values
were 0.92 for the total scale and 0.88, 0.50 and 0.92 for each of
the factors.

3   |   R E S U LT S

Of the 235 nurses who were invited to participate, 198 nurses
agreed to participate in the study and answered the form. The aver-
age age of participants was 33.8 years (SD 9.23). Only 27.5% were
male and almost 80% of the nurses lacked the official qualification
of mental health nurse. One third of the nurses (33.2%) had offi-
cial postgraduate training (Masters or PhD studies). The mean num-
ber of years’ experience in mental health was 7.9 years (SD 7.45).
Regarding the relationship between the nurses’ socio-demographic
and professional variables and the EBPQ and WAI, experience in
mental health was associated with a greater therapeutic alliance
(r = 0.221, p = .002) whereas no association was found with a greater
EBPQ. Furthermore, associations between higher academic level
and greater competence for EBP were found (t = -2.957, p = .003).

T A B L E 2   Relationship between the EBPQ and the level of
therapeutic relationship of nurses

Variable Practice Attitude
Knowledge/
Skills EBPQ

Bond 0.194** 0.273*** 0.244*** 0.287***

Objectives 0.089 0.189** 0.058 0.127

Tasks 0.250*** 0.265*** 0.308*** 0.340***

WAI-S 0.233*** 0.317*** 0.264*** 0.328***

Note: EBPQ, Evidence-Based Practice Questionnaire; WAI-S, Working
Alliance Inventory Short.
*p < .05,
**p < .01,
***p < .001.

Variable β

Model 1
(Adj R2 = 0.161)

P-value β

Model 2
(Adj R2 = 0.175)

P-value95% CI 95% CI

Gender
(female)

1.135 −0.554-2.823 .187 1.142 −0.538-2.822 .181

Years of MH
experience

0.222 0.107-0.336 <.0001 0.224 0.111-0.338 <.0001

Highest
education
(PhD or
master’s
degree)

1.355 −0.277-2.987 .103 1.427 −0.225-3.079 .090

MH Nursing
Specialty
(no)

1.430 −0.698-3.557 .187 1.473 −0.658-3.604 .174

EBPQ 2.276 1.303-3.250 <.0001

Practice 0.285 −0.484-1.054 .465

Attitude 2.047 0.876-3.217 .001

Knowledge/
Skills

0.619 −0.312-1.550 .191

Note: Abbreviations:EBPQ, Evidence-Based Practice Questionnaire; CI, confidence interval; MH,
mental health

T A B L E 3   Multiple linear regression
examining the association between the
EBPQ and the therapeutic relationship
(N = 198)

     |  1767MORENO-POYATO ET Al.

Likewise, higher academic level was associated with greater thera-
peutic alliance (t = -2.222, p = .027). In contrast, specific training as a
mental health nurse specialist was not related with either EBP or the
therapeutic alliance (Table 1).

A bivariate analysis was conducted to study the association be-
tween the dimensions of the EBP competence of nurses and the
therapeutic alliance and associated factors. A significant positive
correlation was observed between most dimensions and the total
scores of both scales. Particularly noteworthy were the positive as-
sociations between competence for EBP and the relationship of the
same with the level of the therapeutic alliance, specifically regarding
the factor for agreement on tasks (Table 2).

To determine whether the level of therapeutic alliance could be
explained, firstly, by the competence for EBP and the socio-profes-
sional factors of the nurses and secondly, incorporating the dimen-
sions of competence for EBP and the socio-professional factors, two
linear regressions were calculated (Table 3). Model 1 was significant
(F (5, 192) = 8.568, p < .0001), with the variables incorporated into
the model representing 16.1% of the variation in the level of nurses’
therapeutic alliance. It should be noted that competence for EBP was
the most influential variable in this first model (β = 2,276, p < .0001).
The second model (F (7, 190) = 6,972, p < .0001) revealed that the
most influential dimension for therapeutic alliance was the attitude
towards EBP (β = 2,047, p = .001). This model explained 17.5% of the
variation of the level of the therapeutic relationship.

Subsequently, we examined the influence of the competence
dimensions for EBP and each of the factors of the therapeutic al-
liance. For this purpose, linear regressions were calculated once
again, adjusted for nurses’ socio-professional variables. The models
that emerged from examining the influence of EBP on the bond and
the agreement on therapy goals between nurses and their patients,
were also significant, although they only explained 10% and 5% of
the changes in the bond (F (7, 190) = 4.034, p < .0001) and in the

agreement on therapy goals (F (7, 190) = 2.558, p = 0,015). In both
models, the only influential dimension was attitude towards EBP, with
β = 0.686 (p = .005) and β = 0.735 (p = .014) respectively. However,
when examining the influence of EBP dimensions on task agreement,
once again a model was obtained which explained over 16% of the
changes in the agreement on tasks (F (7, 190) = 6.610, p < .0001). In
this model, experience (β = 0.096, p < .0001) and gender (β = 0.872,
p = .027) were significant socio-professional variables for nurses.
In addition, in this model it is noteworthy that attitude (β = 0.625,
p = .023) and knowledge/skills for EBP (β = 0.500, p = .022) were
predictor variables (Table 4).

4   |   D I S C U S S I O N

The aim of this study was to examine the relationship between the
dimensions of EBP among mental health nurses and the therapeutic
relationship they establish with their patients. According to our find-
ings, it is worth highlighting that a greater EBP improves the thera-
peutic relationship established by nurses in mental health units.
Although this relationship appears to be evident from a theoretical-
conceptual point of view, since therapeutic relationship has tradi-
tionally been considered as the axis of care in mental health nursing
(Felton et al., 2018; Harris & Panozzo, 2019; Peplau, 1988), this find-
ing enables us to confirm the association between both constructs,
from a quantitative point of view. This reinforces the statement that
the therapeutic relationship is not only based on an experiential con-
struction of a relationship between nurse and patient (McAndrew
et al., 2014), rather it also improves when the nurse shows greater
competence for EBP.

In terms of the specific characteristics of nurses, it should be
noted that, unlike other studies, the nurses who showed the great-
est competence for EBP were those with the highest educational

T A B L E 4   Association between nurses’ characteristics and EBPQ’s subscales with WAI’s subscales (N = 198)

Dependent
variables

Bond
(Adj R2 = 0.097)

Goals
(Adj R2 = 0.052)

Tasks
(Adj R2 = 0.166)

Independent
variables β 95% CI

P-
value β 95% CI P-value β 95% CI P-value

Gender (female) 0.240 −0.452 to 0.931 .495 0.031 −0.808 to 0.870 .943 0.872 0.099 to 1.645 .027

Years of MH
experience

0.050 0.003 to 0.097 .037 0.079 0.022 to 0.135 .007 0.096 0.044 to 0.148 <.001

Highest
education (PhD
or master’s
degree)

0.529 −0.151 to 1.209 .126 0.564 −0.261 to 1.389 .179 0.333 −0.426 to 1.093 .388

MH Nursing
Specialty (no)

0.383 −0.495 to 1.260 .391 0.112 −0.952 to 1.176 .836 0.978 −0.002 to 1.958 .05

Practice 0.058 −0.258 to 0.375 .718 0.071 −0.313 to 0.455 .715 0.156 −0.198 to 0.510 .385

Attitude 0.686 0.204 to 1.168 .005 0.735 0.151 to 1.320 .014 0.625 0.087 to 1.164 .023

Knowledge/
Skills

0.267 −0.117 to 0.650 .172 −0.147 −0.612 to 0.318 .533 0.500 0.072 to 0.928 .022

Note: Abbreviation:EBPQ, Evidence-Based Practice Questionnaire; WAI, Working Alliance Inventory; CI, confidence interval; MH, mental health

1768  |     MORENO-POYATO ET Al.

level (Wonder et al., 2017; Moore, 2017; Rojjanasrirat & Rice, 2017).
However, in line with other previous studies, the nurses’ experi-
ence was not associated with improved EBP (Wonder et al., 2017;
Moore, 2017; Rojjanasrirat & Rice, 2017). This fact is remarkable
given that experience is a factor associated with EBP from a the-
oretical point of view (DiCenso et al., 1998) and some studies have
also confirmed this association (Hamaideh, 2017; Zhou et al., 2016).
Likewise, no differences were found regarding whether the nurses
had training in the specialty of mental health nursing. We were un-
able to compare this finding with other studies due to a lack of liter-
ature in this area, however, it raises the question of whether training
for mental health specialists in our context is including content on
EBP.

Regarding the association between EBP dimensions and the
therapeutic relationship, the dimension which most influenced
the overall therapeutic relationship was the attitude of nurses to-
wards EBP. In fact, the attitude towards EBP is often the highest
rated factor by nurses in most settings and specialties (Cavazos-
Rehg et al., 2014; Wonder et al., 2017; Moore, 2017; Ramos-
Morcillo et al., 2015; Zhou et al., 2016). In addition, nurses’ beliefs
and attitudes about the importance and value of EBP have been
identified as one of the most important attributes for implement-
ing EBP (Schaefer & Welton, 2018). When nurses have positive
attitudes on this topic, it is easier for them to implement changes
in their daily practice (Saunders & Vehviläinen-Julkunenb, 2016).
The attitude of the nurse towards the recipient of their care is
an inherent part of the profession, which must be focused on pa-
tients’ needs, as negative attitudes prevent the establishment of
a quality therapeutic relationship (Wahl & Aroesty-Cohen, 2010).
Teaching future professionals should not reinforce certain nega-
tive attitudes but rather create strategies in the studies that help
generate attitudes of greater acceptance and understanding of the
person. However, neither practice nor knowledge explained im-
provements in the overall therapeutic relationship. Indeed, both
knowledge and practice of EBP were the dimensions that scored
the lower mean scores by the nurses. These results could be due
to the difficulties described in the literature affecting EBP in men-
tal health nursing such as lack of training, lack of time and lack of
resources for EBP, factors that directly affect both nurses’ knowl-
edge and the use of evidence in clinical practice (Alzayyat, 2014;
Hamaideh, 2017; Yadav & Fealy, 2012).

The analysis of the association between EBP dimensions and
each of the dimensions of the therapeutic relationship, revealed
a significant association between the attitude towards EBP and
experience and each of the dimensions of the therapeutic relation-
ship. The results indicate that a better attitude towards EBP al-
lows the establishment of a greater bond of trust with the patient
in the context of the therapeutic relationship, an element with a
strong attitudinal component (Bordin, 1979) and basic in the first
phase of the therapeutic relationship (Peplau, 1997). In this sense,
a higher score in the attitude towards EBP represents nurses who
are open to dialogue and change, who do not judge others when
they criticize their actions and who try to integrate opinions and

knowledge as part of a possible improvement. In short, a nurse
who accepts comments and does not judge these, who adopts the
patients’ perspective and accepts it, strengthening the link formed
in the nurse–patient therapeutic relationship (Moreno-Poyato &
Rodríguez-Nogueira, 2020). However, the nurses’ experience
had more weight in explaining the improvements in factors such
as agreement on goals and tasks. It should also be noted that a
better agreement on the tasks was influenced by attitude and by
a greater knowledge and skills for EBP. Consequently, a higher
level of knowledge and skills of EBP nurses is more relevant in
the working phase during the therapeutic relationship process
(Peplau, 1997). This finding is particularly relevant as it confirms
that knowledge and skills for EBP are necessary for person-cen-
tred care and shared decision-making. These are aspects that
positively condition the therapeutic relationship and are directly
related to the trend in current mental health care that focuses on
the paradigm of autonomy and the recovery model which recog-
nizes the importance of person-centred care. The main elements
of the recovery model include a greater involvement of the service
users, a vision of the person beyond his or her illness and the fa-
cilitating treatment selection. In short, the recovery model aims
to reverse the role of the service user from being a follower to
another where they can lead, change and direct their own care
(Newman et al., 2015; Smith & Williams, 2016).

4.1 | Limitations

This study has several limitations. First, the cross-sectional de-
sign did not allow us to detect changes in nurses’ perceptions
over time, nor make causal inferences. Second, it is important to
consider that the therapeutic relationship was assessed as a gen-
eral measure and, this was related with nurses’ overall percep-
tions of the therapeutic relationship, which could have differed
from those of their patients. Finally, although the purpose of the
study was not to validate the scales used, it should be noted that
the internal consistency of the objectives subscale of the WAI-S
in our study was low. In contrast, one of the study strengths was
the rate of participation among nurses in the participating institu-
tions. Therefore, the results can be generalized to the nurses of
mental health units in Spain. It is likely that the results can be ex-
trapolated to other countries where the training plans for nurses
and the care settings in mental health units are similar to those
of this study. Furthermore, we identified specific relationships
between the dimensions of EBP and the therapeutic relationship
and, although the degree of influence from the predictive point
of view was not high, it should be considered that taking into ac-
count that the therapeutic relationship is a multifaceted construct,
the amount of explained variance is significant and could be con-
sidered to be high. These findings suggest the need to perform
further in-depth studies of the factors that influence the quality of
the therapeutic relationship. In addition, it would be advisable to
replicate the study on an international level to confirm the results

     |  1769MORENO-POYATO ET Al.

and to elaborate strategies to improve EBP and, consequently, im-
prove the quality of the therapeutic relationship.

5   |   C O N C L U S I O N

The results of our study contribute to a greater understanding of the
relationship between the dimensions of evidence-based practice and
therapeutic relationship in nurses working in mental health units. The
results confirm that increased evidence-based practice improves the
establishment of the nurse–patient therapeutic relationship in mental
health units. In general, the association of nurses’ attitudes with their
experience in therapeutic relationship is noteworthy. Specifically, an
improved nurse attitude and knowledge of evidence-based practice
increases shared decision-making with patients, which is basic to per-
son-centred care. An improved attitude towards EBP is likely to help
nurses working in mental health units to apply the knowledge acquired
in daily clinical practice, improving care through new evidence-based
practices.

A C K N O W L E D G M E N T S
We would like to acknowledge all the participants of MiRTCIME.
CAT project and the College of Nurses of Barcelona for financial
support (PR-218/2017). We also thank Dr. Xavier Duran from the
Methodological and Biostatistical Advisory Service of the IMIM,
Barcelona, for his cooperation.

C O N F L I C T O F I N T E R E S T
No conflict of interest has been declared by the authors.

A U T H O R C O N T R I B U T I O N S
ARMP, JFRM and GCG made substantial contributions to the con-
ception or design of the work; or the acquisition, analysis or inter-
pretation of data for the work. JFRM contributed the main part of
the data analysis. ARMP, JFRM, GCG and ORN helped in drafting
the work or revising it critically for important intellectual content.
ARMP, JFRM, GCG and ORN contributed to final approval of the
version to be published. Agreement to be accountable for all aspects
of the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and
resolved by ARMP.

F U N D I N G I N F O R M AT I O N
College of Nurses of Barcelona (PR-218/2017).

P E E R R E V I E W
The peer review history for this article is available at https://publo
ns.com/publo n/10.1111/jan.14715.

O R C I D
Antonio R. Moreno-Poyato https://orcid.org/0000-0002-5700-4315
Georgina Casanova-Garrigos https://orcid.org/0000-0002-3652-9745
Juan F. Roldán-Merino https://orcid.org/0000-0002-7895-6083

R E F E R E N C E S
Alzayyat, A. S. (2014). Barriers to evidence-based practice utilization in

psychiatric/mental health nursing. Issues in Mental Health Nursing,
35(2), 134–143. https://doi.org/10.3109/01612 840.2013.848385

Andrade-González, N., & Fernández-Liria, A. (2015). Spanish adaptation
of the working alliance inventory-short (WAI-S). Current Psychology,
35(1), 169–177. https://doi.org/10.1007/s1214 4-015-9365-3

Austin, P. C., & Steyerberg, E. W. (2015). The number of subjects per
variable required in linear regression analyses. Journal of Clinical
Epidemiology, 68(6), 627–636. https://doi.org/10.1016/j.jclin
epi.2014.12.014

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept
of the working alliance. Psychotherapy: Theory, Research & Practice,
16(3), 252–260. https://doi.org/10.1037/h0085885

Cavazos-Rehg, P. A., Breslau, N., Hatsukami, D., Krauss, M. J., Spitznagel,
E. L., Grucza, R. A., Salyer, P., Hartz, S. M., & Bierut, L. J. (2014).
Smoking cessation is associated with lower rates of mood/anxiety
and alcohol use disorders. Psychological Medicine, 44(12), 2523–
2535. https://doi.org/10.1017/S0033 29171 3003206

Correa, V. C., Lugo-Agudelo, L. H., Aguirre-Acevedo, D. C., Contreras, J.
A. P., Borrero, A. M. P., Patiño-Lugo, D. F., & Valencia, D. A. C. (2020).
Individual, health system and contextual barriers and facilitators for
the implementation of clinical practice guidelines: A systematic me-
tareview. Health Research Policy and Systems, 18(1), 74. https://doi.
org/10.1186/s1296 1-020-00588 -8

de Pedro Gómez, J., Morales Asencio, J. M., Sesé Abad, A., Bennasar
Veny, M., Ruiz Roman, M. J., & Muñoz Ronda, F. J. (2009). Validación
de la versión española del cuestionario sobre la práctica basada en
la evidencia en enfermeras. Revista Española De Salud Pública, 83(4),
577–586.

DiCenso, A., Cullum, N., & Ciliska, D. (1998). Implementing evi-
dence-based nursing: Some misconceptions. Evidence-Based Nursing,
1(2), 36–37. https://doi.org/10.1136/ebn.1.2.38

Felton, A., Repper, J., & Avis, M. (2018). Therapeutic relationships, risk
and mental health practice. International Journal of Mental Health
Nursing, 27(3), 1137–1148. https://doi.org/10.1111/inm.12430

Green, S. B. (1991). How many subjects does it take to do a regression
analysis. Multivariate Behavioral Research, 26(3), 499–510. https://doi.
org/10.1207/s1532 7906m br2603_7

Hagedorn Wonder, A., McNelis, A. M., Spurlock, D., Ironside, P. M.,
Lancaster, S., Davis, C. R., Gainey, M., & Verwers, N. (2017).
Comparison of nurses’ self-reported and objectively measured ev-
idence-based practice knowledge. Journal of Continuing Education
in Nursing, 48(2), 65–70. https://doi.org/10.3928/00220 124-20170
119-06

Hamaideh, S. H. (2017). Sources of knowledge and barriers of imple-
menting evidence-based practice among mental health nurses in
Saudi Arabia. Perspectives in Psychiatric Care, 53(3), 190–198. https://
doi.org/10.1111/ppc.12156

Hamovitch, E. K., Choy-Brown, M., & Stanhope, V. (2018). Person-
centered care and the therapeutic alliance. Community Mental Health
Journal, 54(7), 951–958. https://doi.org/10.1007/s1059 7-018-0295-z

Harris, B. A., & Panozzo, G. (2019). Therapeutic alliance, relationship
building and communication strategies-for the schizophrenia pop-
ulation: An integrative review. Archives of Psychiatric Nursing, 33(1),
104–111. https://doi.org/10.1016/j.apnu.2018.08.003

Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2019). Effective nurse-patient
relationships in mental health care: A systematic review of interven-
tions to improve the therapeutic alliance. International Journal of Nursing
Studies, 102, 103490. https://doi.org/10.1016/j.ijnur stu.2019.103490

Horvath, A. O., & Greenberg, L. S. (1989). Development and validation
of the Working Alliance Inventory. Journal of Counseling Psychology,
36(2), 223–233. https://doi.org/10.1037/0022-0167.36.2.223

Kelley, J. M., Kraft-Todd, G., Schapira, L., Kossowsky, J., & Riess, H. (2014).
The influence of the patient-clinician relationship on healthcare

1770  |     MORENO-POYATO ET Al.

outcomes: A systematic review and meta-analysis of randomized
controlled trials. PLoS One, 9(4), e94207. https://doi.org/10.1371/
journ al.pone.0094207

McAllister, S., Robert, G., Tsianakas, V., & McCrae, N. (2019).
Conceptualising nurse-patient therapeutic engagement on acute
mental health wards: An integrative review. International Journal
of Nursing Studies, 93, 106–118. https://doi.org/10.1016/j.ijnur
stu.2019.02.013

McAndrew, S., Chambers, M., Nolan, F., Thomas, B., & Watts, P. (2014).
Measuring the evidence: Reviewing the literature of the measure-
ment of therapeutic engagement in acute mental health inpatient
wards. International Journal of Mental Health Nursing, 23(3), 212–220.
https://doi.org/10.1111/inm.12044

Moore, L. (2017). Effectiveness of an online educational module in
improving evidence-based practice skills of practicing registered
nurses. Worldviews on Evidence-Based Nursing, 14(5), 358–366.
https://doi.org/10.1111/wvn.12214

Moreno-Poyato, A. R., Delgado-Hito, P., Leyva-Moral, J. M., Casanova-
Garrigós, G., & Montesó-Curto, P. (2019). Implementing evi-
dence-based practices on the therapeutic relationship in inpatient
psychiatric care: A participatory action research. Journal of Clinical
Nursing, 28(9–10), 1614–1622. https://doi.org/10.1111/jocn.14759

Moreno-Poyato, A. R., Delgado-Hito, P., Suárez-Pérez, R., Lluch-Canut,
T., Roldán-Merino, J. F., & Montesó-Curto, P. (2018). Improving the
therapeutic relationship in inpatient psychiatric care: Assessment
of the therapeutic alliance and empathy after implementing ev-
idence-based practices resulting from participatory action re-
search. Perspectives in Psychiatric Care, 54(2), 300–308. https://doi.
org/10.1111/ppc.12238

Moreno-Poyato, A. R., Montesó-Curto, P., Delgado-Hito, P., Suárez-
Pérez, R., Aceña-Domínguez, R., Carreras-Salvador, R., Leyva-Moral,
J. M., Lluch-Canut, T., & Roldán-Merino, J. F. (2016). The therapeutic
relationship in inpatient psychiatric care: A narrative review of the
perspective of nurses and patients. Archives of Psychiatric Nursing,
30(6), 782–787. https://doi.org/10.1016/j.apnu.2016.03.001

Moreno-Poyato, A. R., & Rodríguez-Nogueira, Ó. (2020). The association
between empathy and the nurse–patient therapeutic relationship in
mental health units: A cross-sectional study. Journal of Psychiatric and
Mental Health Nursing. https://doi.org/10.1111/jpm.12675

Newman, D., O’Reilly, P., Lee, S. H., & Kennedy, C. (2015). Mental health
service users’ experiences of mental health care: An integrative liter-
ature review. Journal of Psychiatric and Mental Health Nursing, 22(3),
171–182. https://doi.org/10.1111/jpm.12202

Peplau, H. E. (1988). Interpersonal relations in nursing : A conceptual frame
of reference for psychodynamic nursing. Macmillan.

Peplau, H. E. (1997). Peplau’s theory of interpersonal relations. Nursing
Science Quarterly, 10(4), 162–167. https://doi.org/10.1177/08943
18497 01000407

Ramos-Morcillo, A. J., Fernández-Salazar, S., Ruzafa-Martínez, M.,
& Del-Pino-Casado, R. (2015). Effectiveness of a brief, basic ev-
idence-based practice course for clinical nurses. Worldviews on
Evidence-Based Nursing / Sigma Theta Tau International, Honor Society
of Nursing, 12(4), 199–207. https://doi.org/10.1111/wvn.12103

Rojjanasrirat, W., & Rice, J. (2017). Evidence-based practice knowledge, atti-
tudes and practice of online graduate nursing students. Nurse Education
Today, 53, 48–53. https://doi.org/10.1016/j.nedt.2017.04.005

Saunders, H., & Vehviläinen-Julkunenb, K. (2016). The state of readiness
for evidence-based practice among nurses: An integrative review.
International Journal of Nursing Studies, 56, 128–140. https://doi.
org/10.1016/j.ijnur stu.2015.10.018

Schaefer, J. D., & Welton, J. M. (2018). Evidence based practice readi-
ness: A concept analysis. Journal of Nursing Management, 26(6), 621–
629. https://doi.org/10.1111/jonm.12599

Smith, G. P., & Williams, T. M. (2016). From providing a service to being
of service: Advances in person-centred care in mental health. Current
Opinion in Psychiatry, 29(5), 292–297. https://doi.org/10.1097/
YCO.00000 00000 000264

Stevens, K. R. (2013). The impact of evidence-based practice in nursing
and the next big ideas. Online Journal of Issues in Nursing, 18(2), 4.
https://doi.org/10.3912/OJIN.Vol18 No02M an04

Upton, D., & Upton, P. (2006). Development of an evidence-based prac-
tice questionnaire for nurses. Journal of Advanced Nursing, 53(4),
454–458. https://doi.org/10.1111/j.1365-2648.2006.03739.x

Vahidi, M., Ebrahimi, H., Areshtanab, H. N., Jafarabadi, M. A., Lees,
D., Foong, A., & Cleary, M. (2018). Therapeutic relationships and
safety of care in Iranian psychiatric inpatient units. Issues in Mental
Health Nursing, 39(11), 967–976. https://doi.org/10.1080/01612
840.2018.1485795

Wahl, O., & Aroesty-Cohen, E. (2010). Attitudes of mental health profes-
sionals about mental illness: A review of the recent literature. Journal
of Community Psychology, 38(1), 49–62. https://doi.org/10.1002/
jcop.20351

Warren, J. I., Mclaughlin, M., Bardsley, J., Eich, J., Esche, C. A., Kropkowski,
L., & Risch, S. (2016). The strengths and challenges of implementing
EBP in healthcare systems. Worldviews on Evidence-Based Nursing,
13(1), 15–24. https://doi.org/10.1111/wvn.12149

Yadav, B. L., & Fealy, G. M. (2012). Irish psychiatric nurses’ self-reported
barriers, facilitators and skills for developing evidence-based prac-
tice. Journal of Psychiatric and Mental Health Nursing, 19(2), 116–122.
https://doi.org/10.1111/j.1365-2850.2011.01763.x

Youssef, N. F. A., Alshraifeen, A., Alnuaimi, K., & Upton, P. (2018). Egyptian
and Jordanian nurse educators’ perception of barriers preventing
the implementation of evidence-based practice: A cross-sectional
study. Nurse Education Today, 64, 33–41. https://doi.org/10.1016/j.
nedt.2018.01.035

Zhou, F., Hao, Y., Guo, H., & Liu, H. (2016). Attitude, knowledge and practice
on Evidence-Based Nursing among Registered Nurses in Traditional
Chinese Medicine Hospitals: A multiple Center Cross-Sectional
Survey in China. Evidence-Based Complementary and Alternative
Medicine, 2016, 1–8. https://doi.org/10.1155/2016/5478086

How to cite this article: Moreno-Poyato AR, Casanova-
Garrigos G, Roldán-Merino JF, Rodríguez-Nogueira Ó;
MiRTCIME.CAT working group. Examining the association
between evidence-based practice and the nurse-patient
therapeutic relationship in mental health units: A cross-
sectional study. J Adv Nurs. 2021;77:1762–1771. https://doi.
org/10.1111/jan.14715

     |  1771MORENO-POYATO ET Al.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of evidence-based
nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance and with potential to advance
knowledge for practice, education, management or policy. JAN publishes research reviews, original research reports and methodological and
theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:
• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1.998 – ranked 12/114 in the 2016 ISI Journal Citation

Reports © (Nursing (Social Science)).
• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries worldwide

(including over 3,500 in developing countries with free or low cost access).
• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
• Positive publishing experience: rapid double-blind peer review with constructive feedback.
• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.
• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley Online Library,

as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

6054_IFC 20/07/17 11:58 AM Page 2

Everything you need to succeed…
in class, in clinical, on exams and on the NCLEX®

YOUR GUIDE TO

Psychiatric Mental
Health NursingLE

A
R

N
IN

G APP
LY

IN
G

A

SSESSING

LEARNING APPLYING ASSESSING
Your text provides the foundational

knowledge you need to know.
DavisPlus features interactive

clinical scenarios that show you
how theory applies to practice.

Davis Edge is the online Q&A
review platform that evaluates

your mastery of the material and
builds your test-taking skills.

Your text works together with DavisPlus and Davis Edge to make
this often intimidating, but must-know content easier to master.

Don’t miss everything that’s waiting online to make learning less
stressful…and save you time. Follow the instructions on the inside
front cover to use the access code to unlock your resources today.

Your journey to success
BEGINS HERE!

6054_IFC 20/07/17 11:58 AM Page 3

LEARNING

STEP #1
Build a solid foundation.

Movie Connections list films that demonstrate the conditions
and behaviors you may not encounter in clinical.

Quality and Safety Education for
Nurses (QSEN) Activities help you attain
the knowledge, skills, and attitudes
required to fulfill the initiative’s quality
and safety competencies.

Communication Exercises let you
practice your communication skills
with vignettes and questions that
prepare you for clinical and practice.

NEW! “Real People. Real Stories”
features interviews with patients
to bring their experiences to life.

C H A P T E R 4 ■ Psychopharmacology 59

One of the Quality and Safety in Nursing Educa-
tion (QSEN) criteria identified by the Institute of
Medicine (IOM) (2003) stresses that the patient

must be at the center of decisions about treatment
(patient-centered care), and this type of assessment tool
provides an opportunity to actively engage the patient in
describing what medications have been effective or inef-
fective and identifying side effects that may impact will-
ingness to adhere to a medication regimen.

Antianxiety Agents
Background Assessment Data
Indications
Antianxiety drugs are also called anxiolytics and his-
torically were referred to as minor tranquilizers. They
are used in the treatment of anxiety disorders, anxiety
symptoms, acute alcohol withdrawal, skeletal muscle
spasms, convulsive disorders, status epilepticus, and
preoperative sedation. They are most appropriate for

BOX 4-1 Medication Assessment Tool

Date __________________________ Client’s Name __________________________________ Age ______________________
Marital Status ____________________ Children __________________________ Occupation ___________________________
Presenting Symptoms (subjective & objective) _______________________________________________________________
_____________________________________________________________________________________________________
Diagnosis (DSM-5) _____________________________________________________________________________________
Current Vital Signs: Blood Pressure: Sitting ________/________ ; Standing __________/__________; Pulse____________ ;
Respirations ____________ Height ___________________ Weight _______________________

CURRENT/PAST USE OF PRESCRIPTION DRUGS (Indicate with “c” or “p” beside name of drug whether current or past use):

Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results
____________ ____________ _______________ _______________ _____________ ___________________
____________ ____________ _______________ _______________ _____________ ___________________
____________ ____________ _______________ _______________ _____________ ___________________

Name Dosage How Long Used Why Prescribed By Whom Side Effects/Results
____________ ____________ _______________ _______________ _____________ ___________________
____________ ____________ _______________ _______________ _____________ ___________________
____________ ____________ _______________ _______________ _____________ ___________________

CURRENT/PAST USE OF STREET DRUGS, ALCOHOL, NICOTINE, AND/OR CAFFEINE (Indicate with “c” or “p” beside
name of drug):
Name Amount Used How Often Used When Last Used Effects Produced
_______________ _______________ _______________ _______________ ______________________
_______________ _______________ _______________ _______________ ______________________
_______________ _______________ _______________ _______________ ______________________

Any allergies to food or drugs?____________________________________________________________________________

Any special diet considerations?___________________________________________________________________________

TA B L E 4 – 2 Effects of Psychotropic Medications on Neurotransmitters—cont’d
ACTION ON NEUROTRANSMITTER

EXAMPLE OF MEDICATION AND/OR RECEPTOR DESIRED EFFECTS SIDE EFFECTS

5-HT1A agonist
D2 agonist
D2 antagonist

Relieves anxiety Nausea, headache, dizziness
Restlessness

Antianxiety: buspirone

5-HT, 5-hydroxytryptamine (serotonin); ACh, acetylcholine; ADHD, attention deficit-hyperactivity disorder; BZ, benzodiazepine; D,
dopamine; EPS, extrapyramidal symptoms; GABA, gamma-aminobutyric acid; H, histamine; MAO, monoamine oxidase; MAO-A,
monoamine oxidase A; MAOI, monoamine oxidase inhibitor; NE, norepinephrine; SNRI, serotonin-norepinephrine reuptake inhibitor;
SSRI, selective serotonin reuptake inhibitor.

AU: Ok to
add here?

Continued

6054_Ch04_054-085 17/05/17 6:16 pm Page 59

6054_FM_i-xx 20/07/17 12:18 PM Page i

Therapeutic Communication Icon
identifies helpful interventions
and guidance on how to speak
with your patients. Look for this
icon in Care Plan sections.

A FREE ebook version of your text is available with
each new printed book to make studying and reviewing
easier. Use the access code on the inside front cover.

APPLYING

STEP #2
Practice in a
safe environment.

Clinical Scenarios on www.DavisPlus.com walk you
through the nursing process with client summaries,
multiple-choice questions with rationales, drag- and
drop activities, and so much more.

6054_FM_i-xx 20/07/17 12:18 PM Page ii

ASSESSING
ASS

ESSING

STEP #3
Study smarter, not harder.

Davis Edge is the interactive,
online Q&A review platform
that provides the practice
you need to master course
content and to improve your
scores on classroom exams.
Access it from a laptop,
tablet, or mobile device for
review and study on the go.

Assignments are made by
your instructor. Or, create
your own practice quizzes
to review before an exam.

6054_FM_i-xx 20/07/17 12:18 PM Page iii

Comprehensive rationales explain
why your responses are correct or
incorrect. Page-specific references
direct you to the relevant content in
Psychiatric Mental Health Nursing.

The Success Center offers a
snapshot of your progress
and identifies your strengths
and weaknesses.

The Feedback Report drills down to
show your performance in individual
content areas. It’s easy to create new
practice quizzes that focus on your
areas of weakness or to select the
topics or concepts you want to study.

6054_FM_i-xx 16/08/17 2:42 pm Page iv

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

NINTH EDITION

Mary C. Townsend, DSN, PMHCNS-BC
Clinical Specialist/Nurse Consultant
Adult Psychiatric Mental Health Nursing

Former Assistant Professor and
Coordinator, Mental Health Nursing
Kramer School of Nursing
Oklahoma City University
Oklahoma City, Oklahoma

Karyn I. Morgan, RN, MSN, CNS
Psychiatric Clinical Nurse Specialist
Professor of Instruction, Mental Health Nursing
The University of Akron
Akron, OH

6054_FM_i-xx 16/08/17 2:42 pm Page v

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

Copyright © 2018 by F. A. Davis Company

Copyright © 2018 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without written permission from the publisher.

Printed in the United States of America

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

Senior Acquisitions Editor: Susan R. Rhyner
Content Project Manager II: Amy M. Romano
Electronic Project Editor: Samantha Olin
Cover Design: Carolyn O’Brien

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

Library of Congress Control Number: 2014944300
ISBN: 978-0-8036-6054-0

Library of Congress Cataloging-in-Publication Data

Names: Townsend, Mary C., 1941- author. | Morgan, Karyn I., author.
Title: Psychiatric mental health nursing : concepts of care in evidence-based

practice / Mary C. Townsend, Karyn I. Morgan.
Description: Ninth edition. | Philadelphia, PA : F. A. Davis Company, [2018]

| Includes bibliographical references (p. ) and index.
Identifiers: LCCN 2017009564| ISBN 9780803660540 | ISBN 0803660545
Subjects: | MESH: Psychiatric Nursing—methods | Mental Disorders—nursing |

Evidence-Based Nursing
Classification: LCC RC440 | NLM WY 160 | DDC 616.89/0231—dc23 LC record available at https://lccn.loc.gov/2017009564

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis
Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of
$.25 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a
photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting
Service is: 978-8036-6054-0/18 0 + $.25.

6054_FM_i-xx 16/08/17 2:42 pm Page vi

THIS BOOK IS DEDICATED TO:

FRANCIE

God made sisters for sharing laughter

and wiping tears

–Mary Townsend

To my friend and mentor, Chaplain (Colonel) Thomas W. Elsey

He was dearly loved and will be deeply missed

October 26, 1942–November 10, 2015

–Karyn Morgan

6054_FM_i-xx 16/08/17 2:42 pm Page vii

Theresa Aldelman
Bradley University
Peoria, Illinois

Fredrick Astle
University of South Carolina
Columbia, South Carolina

Carol Backstedt
Baton Rouge Community College
Baton Rouge, Louisiana

Elizabeth Bailey
Clinton Community College
Pittsburgh, New York

Sheryl Banak
Baptist Health Schools – Little Rock
Little Rock, Arkansas

Joy A. Barham
Northwestern State University
Shreveport, Louisiana

Barbara Barry
Cape Fear Community College
Wilmington, North Carolina

Carole Bomba
Harper College
Palatine, Illinois

Judy Bourrand
Samford University
Birmingham, Alabama

Susan Bowles
Barton Community College
Great Bend, Kansas

Wayne Boyer
College of the Desert
Palm Desert, California

Joyce Briggs
Ivy Tech Community College
Columbus, Indiana

Toni Bromley
Rogue Community College
Grants Pass, Oregon

Terrall Bryan
North Carolina A & T State University
Greensboro, North Carolina

Ruth Burkhart
New Mexico State University/Dona Ana Community

College
Las Cruces, New Mexico

Annette Cannon
Platt College
Aurora, Colorado

Deena Collins
Huron School of Nursing
Cleveland, Ohio

Martha Colvin
Georgia College & State University
Milledgeville, Georgia

Mary Jean Croft
St. Joseph School of Nursing
Providence, Rhode Island

Connie Cupples
Union University
Germantown, Tennessee

Karen Curlis
State University of New York Adirondack
Queensbury, New York

Nancy Cyr
North Georgia College and State University
Dahlonega, Georgia

Carol Danner
Baptist Health Schools Little Rock – School of Nursing
Little Rock, Arkansas

Carolyn DeCicco
Our Lady of Lourdes School of Nursing
Camden, New Jersey

Leona Dempsey, PhD, APNP (ret.), PMHCS-BC
University of Wisconsin Oshkosh
Oshkosh, Wisconsin

Debra J. DeVoe
Our Lady of Lourdes School of Nursing
Camden, New Jersey

Victoria T. Durkee, PhD, APRN
University of Louisiana at Monroe
Monroe, Louisiana

J. Carol Elliott
St. Anselm College
Fairfield, California

viii

Reviewers

6054_FM_i-xx 16/08/17 2:42 pm Page viii

Reviewers ix

Sandra Farmer
Capital University
Columbus, Ohio

Patricia Freed
Saint Louis University
St. Louis, Missouri

Diane Gardner
University of West Florida
Pensacola, Florida

Maureen Gaynor
Saint Anselm College
Manchester, New Hampshire

Denise Glenore
West Coast University
Riverside, California

Sheilia R. Goodwin
Winston Salem State University
Salem, North Carolina

Janine Graf-Kirk
Trinitas School of Nursing
Elizabeth, New Jersey

Susan B. Grubbs
Francis Marion University
Florence, South Carolina

Elizabeth Gulledge
Jacksonville State University
Jacksonville, Alabama

Kim Gurcan
Columbus Practical School of Nursing
Columbus, Ohio

Patricia Jean Hedrick Young
Washington Hospital School of Nursing
Washington, Pennsylvania

Melinda Hermanns
University of Texas at Tyler
Tyler, Texas

Alison Hewig
Victoria College
Victoria, Texas

Cheryl Hilgenberg
Millikin University
Decatur, Illinois

Lori Hill
Gadsden State Community College
Gadsden, Alabama

Ruby Houldson
Illinois Eastern Community College
Olney, Illinois

Eleanor J. Jefferson
Community College of Denver
Platt College
Metropolitan St. College
Denver, Colorado

Dana Johnson
Mesa State College/Grand Junction Regional Center
Grand Junction, Colorado

Janet Johnson
Fort Berthold Community College
New Town, North Dakota

Nancy Kostin
Madonna University
Livonia, Michigan

Linda Lamberson
University of Southern Maine
Portland, Maine

Irene Lang
Bristol Community College
Fall River, Massachusetts

Rhonda Lansdell
Northeast MS Community College
Baldwyn, Mississippi

Jacqueline Leonard
Franciscan University of Steubenville
Steubenville, Ohio

Judith Lynch-Sauer
University of Michigan
Ann Arbor, Michigan

Glenna Mahoney
University of Saint Mary
Leavenworth, Kansas

Jacqueline Mangnall
Jamestown College
Jamestown, North Dakota

Lori A. Manilla
Hagerstown Community College
Hagerstown, Maryland

Patricia Martin
West Kentucky Community and Technical College
Paducah, Kentucky

Christine Massey
Barton College
Wilson, North Carolina

Joanne Matthews
University of Kentucky
Lexington, Kentucky

6054_FM_i-xx 16/08/17 2:42 pm Page ix

Joanne McClave
Wayne Community College
Goldsboro, North Carolina

Mary McClay
Walla Walla University
Portland, Oregon

Susan McCormick
Brazosport College
Lake Jackson, Texas

Shawn McGill
Clovis Community College
Clovis, New Mexico

Margaret McIlwain
Gordon College
Barnesville, Georgia

Nancy Miller
Minneapolis Community and Technical College
Minneapolis, Minnesota

Vanessa Miller
California State University Fullerton
Fullerton, California

Mary Mitsui
Emporia State University
Emporia, Kansas

Cheryl Moreland, MS, RN
Western Nevada College
Carson City, Nevada

Daniel Nanguang
El Paso Community College
El Paso, Texas

Susan Newfield
West Virginia University
Morgantown, West Virginia

Dorothy Oakley
Jamestown Community College
Olean, New York

Christie Obritsch
University of Mary
Bismarck, North Dakota

Sharon Opsahl
Western Technical College
La Crosse, Wisconsin

Vicki Paris
Jackson State Community College
Jackson, Tennessee

Lillian Parker
Clayton State University
Morrow, Georgia

JoAnne M. Pearce, MS, RN
Idaho State University
Pocatello, Idaho

Karen Peterson
DeSales University
Center Valley, Pennsylvania

Carol Pool
South Texas College
McAllen, Texas

William S. Pope
Barton College
Wilson, North Carolina

Karen Pounds
Northeastern University
Boston, Massachusetts

Konnie Prince
Victoria College
Victoria, Texas

Cheryl Puntil
Hawaii Community College
Hilo, Hawaii

Larry Purnell
University of Delaware
Newark, Delaware

Susan Reeves
Tennessee Technological University
Cookeville, Tennessee

Debra Riendeau
Saint Joseph’s College of Maine
Lewiston, Maine

Sharon Romer
South Texas College
McAllen, Texas

Lisa Romero
Solano Community College
Fairfield, California

Donna S. Sachse
Union University
Germantown, Tennessee

Betty Salas
Otero Junior College
La Junta, Colorado

Sheryl Samuelson, PhD, RN
Millikin University
Decatur, Illinois

John D. Schaeffer
San Joaquin Delta College
Stockton, California

x Reviewers

6054_FM_i-xx 16/08/17 2:42 pm Page x

Reviewers xi

Mindy Schaffner
Pacific Lutheran University
Tacoma, Washington

Becky Scott
Mercy College of Northwest Ohio
Toledo, Ohio

Janie Shaw
Clayton State University
Morrow, Georgia

Lori Shaw
Nebraska Methodist College
Omaha, Nebraska

Joyce Shea
Fairfield University
Fairfield, Connecticut

Judith Shindul-Rothschild
Boston College
Chestnut Hill, Massachusetts

Audrey Silveri
UMass Worcester Graduate School of Nursing
Worcester, Massachusetts

Brenda Smith, MSN, RN
North Georgia College and State University
Dahlonega, Georgia

Janet Somlyay
University of Wyoming
Laramie, Wyoming

Charlotte Strahm, DNSc, RN, CNS-PMH
Purdue North Central
Westville, Indiana

Jo Sullivan
Centralia College
Centralia, Washington

Kathleen Sullivan
Boise State University
Boise, Idaho

Judy Traynor
Jefferson Community College
Watertown, New York

Claudia Turner
Temple College
Temple, Texas

Suzanne C. Urban
Mansfield University
Mansfield, Pennsylvania

Dorothy Varchol
Cincinnati State
Cincinnati, Ohio

Connie M. Wallace
Nebraska Methodist College
Omaha, Nebraska

Sandra Wardell
Orange County Community College
Middletown, New York

Susan Warmuskerken
West Shore Community College
Scottville, Michigan

Roberta Weseman
East Central College
Union, Missouri

Margaret A. Wheatley
Case Western Reserve University, FPB School

of Nursing
Cleveland, Ohio

Jeana Wilcox
Graceland University
Independence, Missouri

Jackie E. Williams
Georgia Perimeter College
Clarkston, Georgia

Rita L. Williams, MSN, RN, CCM
Langston University School of Nursing & Health

Professions
Langston, Oklahoma

Rodney A. White
Lewis and Clark Community College
Godfrey, Illinois

Vita Wolinsky
Dominican College
Orangeburg, New York

Marguerite Wordell
Kentucky State University
Frankfort, Kentucky

Jan Zlotnick
City College of San Francisco
San Francisco, California

6054_FM_i-xx 16/08/17 2:42 pm Page xi

xii

Acknowledgments

Amy M. Romano, Content Project Manager, Nursing,
F.A. Davis Company, for all your help and support in
preparing the manuscript for publication.

Sharon Y. Lee, Production Editor, for your support
and competence in the final editing and production
of the manuscript.

The nursing educators, students, and clinicians, who
provide critical information about the usability of the
textbook and offer suggestions for improvements.
Many changes have been made on the basis of your
input.

To those individuals who critiqued the manuscript for
this edition and shared your ideas, opinions, and sug-
gestions for enhancement. I sincerely appreciate your
contributions to the final product.

My husband, Jim, and children and grandchildren,
Kerry and Ryan, Tina and Jonathan, Meghan,
Matthew, and Catherine for showing me what life is
truly all about.

Mary C. Townsend

First of all, sincere thanks to Mary Townsend for hav-
ing the confidence in me to be included in authoring
this exceptional text. I have the utmost respect for
what you have created and for your foresight in rec-
ognizing the most relevant issues in the changing face
of psychiatric mental health nursing care.

My thanks also to Susan Rhyner for the encourage-
ment, humor, and passion that have made this work
enjoyable. Thanks to Amy Romano, Andrea Miller,
and Christine Becker for your expertise and accessi-
bility in preparing the manuscript. I, too, appreciate
all the reviewers who have offered feedback and their
unique expertise. Thanks to Jennifer Feldman, MLIS,
AHIP, for sharing your skills and research assistance.
I have learned just how true it is that it “takes a village”
and I am grateful for each of you.

Special thanks to Erin Barnard, Alan Brunner, Fred
Frese, Emmy Strong, and the others who coura-
geously allowed their stories to be told. Your contri-
butions to student learning and to breaking down the
barriers of stigmatization are immeasurable.

I appreciate each of you more than I can say.

Karyn I. Morgan

6054_FM_i-xx 16/08/17 2:42 pm Page xii

xiii

Contents

UNIT 1
Basic Concepts in Psychiatric-Mental
Health Nursing 1

Chapter 1 The Concept of Stress Adaptation 2
Objectives 2
Homework Assignment 2
Stress as a Biological Response 3
Stress as an Environmental Event 5
Stress as a Transaction Between the

Individual and the Environment 7
Stress Management 8
Summary and Key Points 9
Review Questions 10

Chapter 2 Mental Health and Mental Illness:
Historical and Theoretical Concepts 12
Objectives 12
Homework Assignment 12
Historical Overview of Psychiatric Care 13
Mental Health 14
Mental Illness 15
Psychological Adaptation to Stress 16
Mental Health/Mental Illness

Continuum 22
Summary and Key Points 23
Review Questions 23

UNIT 2
Foundations for Psychiatric-Mental
Health Nursing 27

Chapter 3 Concepts of Psychobiology 28
Objectives 28
Homework Assignment 28
The Nervous System: An Anatomical

Review 29
Neuroendocrinology 39
Genetics 45
Psychoneuroimmunology 48
Psychopharmacology and the Brain 49
Implications for Nursing 49
Summary and Key Points 50
Review Questions 51

Chapter 4 Psychopharmacology 54
Objectives 54
Homework Assignment 54
Historical Perspectives 55
The Role of the Nurse in

Psychopharmacology 55
How Do Psychotropics Work? 57
Applying the Nursing Process in

Psychopharmacological Therapy 57

Summary and Key Points 82
Review Questions 83

Chapter 5 Ethical and Legal Issues 86
Objectives 86
Homework Assignment 86
Ethical Considerations 88
Legal Considerations 92
Summary and Key Points 101
Review Questions 102

Chapter 6 Cultural and Spiritual Concepts
Relevant to Psychiatric-Mental
Health Nursing 105
Objectives 105
Homework Assignment 105
Cultural Concepts 106
How Do Cultures Differ? 106
Application of the Nursing Process 108
Spiritual Concepts 120
Addressing Spiritual and Religious Needs

Through the Nursing Process 123
Summary and Key Points 128
Review Questions 129

UNIT 3
Therapeutic Approaches in Psychiatric
Nursing Care 133

Chapter 7 Relationship Development 134
Objectives 134
Homework Assignment 134
Role of the Psychiatric Nurse 135
Dynamics of a Therapeutic Nurse-Client

Relationship 136
Conditions Essential to Development

of a Therapeutic Relationship 139
Phases of a Therapeutic Nurse-Client

Relationship 141
Boundaries in the Nurse-Client

Relationship 143
Summary and Key Points 144
Review Questions 145

Chapter 8 Therapeutic Communication 147
Objectives 147
Homework Assignment 147
What Is Communication? 148
The Impact of Preexisting Conditions 148
Nonverbal Communication 150
Therapeutic Communication Techniques 152
Nontherapeutic Communication Techniques 154
Active Listening 154
Motivational Interviewing 156
Process Recordings 157
Feedback 160

6054_FM_i-xx 16/08/17 2:42 pm Page xiii

Summary and Key Points 160
Review Questions 161

Chapter 9 The Nursing Process in
Psychiatric-Mental Health Nursing 164
Objectives 164
Homework Assignment 164
The Nursing Process 165
Why Nursing Diagnosis? 175
Nursing Case Management 176
Applying the Nursing Process in

the Psychiatric Setting 178
Concept Mapping 179
Documentation of the Nursing Process 179
Summary and Key Points 185
Review Questions 185

Chapter 10 Therapeutic Groups 188
Objectives 188
Homework Assignment 188
Functions of a Group 189
Types of Groups 189
Physical Conditions That Influence Group

Dynamics 190
Therapeutic Factors 191
Phases of Group Development 191
Leadership Styles 192
Member Roles 193
Psychodrama 193
The Role of the Nurse in Therapeutic Groups 194
Summary and Key Points 195
Review Questions 196

Chapter 11 Intervention With Families 199
Objectives 199
Homework Assignment 199
Stages of Family Development 200
Major Variations 202
Family Functioning 204
Therapeutic Modalities With Families 208
The Nursing Process—A Case Study 214
Summary and Key Points 219
Review Questions 220

Chapter 12 Milieu Therapy—The Therapeutic
Community 223
Objectives 223
Homework Assignment 223
Milieu, Defined 224
Current Status of the Therapeutic

Community 224
Basic Assumptions 224
Conditions That Promote a Therapeutic

Community 225
The Program of Therapeutic Community 226
The Role of the Nurse in Milieu Therapy 229
Summary and Key Points 230
Review Questions 231

Chapter 13 Crisis Intervention 234
Objectives 234
Homework Assignment 234
Characteristics of a Crisis 235
Phases in the Development of a Crisis 235
Types of Crises 237
Crisis Intervention 239

Phases of Crisis Intervention: The Role
of the Nurse 239

Disaster Nursing 241
Application of the Nursing Process to

Disaster Nursing 242
Summary and Key Points 249
Review Questions 250

Chapter 14 Assertiveness Training 253
Objectives 253
Homework Assignment 253
Assertive Communication 254
Basic Human Rights 254
Response Patterns 254
Behavioral Components of Assertive

Behavior 256
Techniques That Promote Assertive

Behavior 257
Thought-Stopping Techniques 258
Role of the Nurse in Assertiveness

Training 259
Summary and Key Points 262
Review Questions 263

Chapter 15 Promoting Self-Esteem 266
Objectives 266
Homework Assignment 266
Components of Self-Concept 267
Development of Self-Esteem 268
Manifestations of Low Self-Esteem 270
Boundaries 271
The Nursing Process 273
Summary and Key Points 277
Review Questions 277

Chapter 16 Anger and Aggression Management 280
Objectives 280
Homework Assignment 280
Anger and Aggression, Defined 281
Predisposing Factors to Anger and

Aggression 281
The Nursing Process 283
Summary and Key Points 289
Review Questions 290

Chapter 17 Suicide Prevention 293
Objectives 293
Homework Assignment 293
Historical Perspectives 294
Epidemiological Factors 294
Risk Factors 296
Predisposing Factors: Theories of Suicide 298
Application of the Nursing Process

With the Suicidal Client 299
Summary and Key Points 312
Review Questions 313

Chapter 18 Behavior Therapy 318
Objectives 318
Homework Assignment 318
Classical Conditioning 319
Operant Conditioning 320
Techniques for Modifying Client Behavior 320
Role of the Nurse in Behavior Therapy 322
Summary and Key Points 324
Review Questions 325

xiv Contents

6054_FM_i-xx 16/08/17 2:42 pm Page xiv

Chapter 19 Cognitive Therapy 327
Objectives 327
Homework Assignment 327
Historical Background 328
Indications for Cognitive Therapy 328
Goals and Principles of Cognitive Therapy 328
Basic Concepts 329
Techniques of Cognitive Therapy 331
Role of the Nurse in Cognitive Therapy 333
Summary and Key Points 336
Review Questions 337

Chapter 20 Electroconvulsive Therapy 340
Objectives 340
Homework Assignment 340
Electroconvulsive Therapy, Defined 341
Historical Perspectives 341
Indications 342
Contraindications 342
Mechanism of Action 343
Side Effects 343
Risks Associated With Electroconvulsive

Therapy 343
The Role of the Nurse in Electroconvulsive

Therapy 344
Summary and Key Points 346
Review Questions 347

Chapter 21 The Recovery Model 350
Objectives 350
Homework Assignment 350
What Is Recovery? 351
Guiding Principles of Recovery 351
Models of Recovery 353
Nursing Interventions That Assist

With Recovery 359
Summary and Key Points 360
Review Questions 361

UNIT 4
Nursing Care of Clients With Alterations
in Psychosocial Adaptation 363

Chapter 22 Neurocognitive Disorders 364
Objectives 364
Homework Assignment 364
Delirium 365
Neurocognitive Disorder 366
Application of the Nursing Process 374
Medical Treatment Modalities 386
Summary and Key Points 393
Review Questions 394

Chapter 23 Substance-Related and
Addictive Disorders 399
Objectives 399
Homework Assignment 400
Substance Use Disorder, Defined 400
Substance-Induced Disorders, Defined 401
Predisposing Factors to Substance-

Related Disorders 401
The Dynamics of Substance-Related

Disorders 403
Application of the Nursing Process 425

The Chemically Impaired Nurse 440
Codependency 441
Treatment Modalities for Substance-Related

Disorders 442
Non-Substance Addictions 447
Summary and Key Points 450
Review Questions 451

Chapter 24 Schizophrenia Spectrum and Other
Psychotic Disorders 456
Objectives 456
Homework Assignment 456
Nature of the Disorder 457
Predisposing Factors 458
Other Schizophrenia Spectrum

and Psychotic Disorders 463
Application of the Nursing Process 467
Treatment Modalities for Schizophrenia

and Other Psychotic Disorders 479
Summary and Key Points 488
Review Questions 489

Chapter 25 Depressive Disorders 494
Objectives 494
Homework Assignment 494
Historical Perspective 495
Epidemiology 495
Types of Depressive Disorders 497
Predisposing Factors 500
Developmental Implications 504
Application of the Nursing Process 509
Treatment Modalities for Depression 519
Summary and Key Points 527
Review Questions 527

Chapter 26 Bipolar and Related Disorders 533
Objectives 533
Homework Assignment 533
Historical Perspective 534
Epidemiology 534
Types of Bipolar Disorders 534
Predisposing Factors 537
Developmental Implications 538
Application of the Nursing Process

to Bipolar Disorder (Mania) 540
Treatment Modalities for Bipolar

Disorder (Mania) 547
Summary and Key Points 555
Review Questions 555

Chapter 27 Anxiety, Obsessive-Compulsive,
and Related Disorders 559
Objectives 559
Homework Assignment 559
Historical Aspects 560
Epidemiological Statistics 560
How Much Is Too Much? 562
Application of the Nursing Process—

Assessment 562
Diagnosis and Outcome Identification 571
Planning and Implementation 574
Evaluation 578
Treatment Modalities 580
Summary and Key Points 586
Review Questions 587

Contents xv

6054_FM_i-xx 16/08/17 2:42 pm Page xv

Chapter 28 Trauma- and Stressor-Related
Disorders 591
Objectives 591
Homework Assignment 591
Historical and Epidemiological Data 592
Application of the Nursing Process—

Trauma-Related Disorders 592
Application of the Nursing Process—

Stressor-Related Disorders 600
Treatment Modalities 606
Summary and Key Points 610
Review Questions 611

Chapter 29 Somatic Symptom and Dissociative
Disorders 614
Objectives 614
Homework Assignment 614
Historical Aspects 615
Epidemiological Statistics 616
Application of the Nursing Process 616
Treatment Modalities 632
Summary and Key Points 637
Review Questions 638

Chapter 30 Issues Related to Human
Sexuality and Gender Dysphoria 641
Objectives 641
Homework Assignment 641
Development of Human Sexuality 642
Variations in Sexual Orientation 644
Gender Dysphoria 646
Application of the Nursing Process

to Gender Dysphoria in Children 647
Gender Dysphoria in Adolescents

and Adults 650
Sexual Disorders 652
Application of the Nursing Process

to Sexual Disorders 659
Summary and Key Points 668
Review Questions 668

Chapter 31 Eating Disorders 673
Objectives 673
Homework Assignment 673
Epidemiological Factors 674
Application of the Nursing Process 676
Treatment Modalities 690
Summary and Key Points 693
Review Questions 693

Chapter 32 Personality Disorders 697
Objectives 697
Homework Assignment 697
Historical Aspects 699
Types of Personality Disorders 700
Application of the Nursing Process 707
Treatment Modalities 721
Summary and Key Points 725
Review Questions 726

UNIT 5
Psychiatric Mental Health Nursing
of Special Populations 731

Chapter 33 Children and Adolescents 732
Objectives 732
Homework Assignment 732
Neurodevelopmental Disorders 733
Disruptive Behavior Disorders 754
Anxiety Disorders 763
Quality and Safety Education for

Nurses (QSEN) 765
General Therapeutic Approaches 767
Summary and Key Points 768
Review Questions 769

Chapter 34 The Aging Individual 773
Objectives 773
Homework Assignment 773
How Old is Old? 774
Epidemiological Statistics 775
Theories of Aging 776
The Normal Aging Process 779
Special Concerns of the Elderly Population 785
Application of the Nursing Process 791
Summary and Key Points 798
Review Questions 801

Chapter 35 Survivors of Abuse or Neglect 806
Objectives 806
Homework Assignment 806
Predisposing Factors 807
Application of the Nursing Process 809
Treatment Modalities 822
Summary and Key Points 824
Review Questions 825

Chapter 36 Community Mental Health Nursing 831
Objectives 831
Homework Assignment 831
The Changing Focus of Care 832
The Public Health Model 833
The Community as Client 834
Summary and Key Points 858
Review Questions 858

Chapter 37 The Bereaved Individual 862
Objectives 862
Homework Assignment 862
Theoretical Perspectives on Loss and

Bereavement 863
Length of the Grief Response 867
Anticipatory Grief 867
Maladaptive Responses to Loss 868
Application of the Nursing Process 869
Additional Assistance 875
Summary and Key Points 878
Review Questions 879

xvi Contents

6054_FM_i-xx 16/08/17 2:42 pm Page xvi

Chapter 38 Military Families 883
Objectives 883
Homework Assignment 883
Historical Aspects 884
Epidemiological Statistics 884
Application of the Nursing Process 884
Treatment Modalities 894
Summary and Key Points 897
Review Questions 898

Appendix A Answers to Chapter Review
Questions Appendix-1

Appendix B Examples of Answers to
Communication Exercises Appendix-3

Appendix C Mental Status Assessment Appendix-6
Appendix D DSM-5 Classification: Categories

and Codes Appendix-10

Appendix E Assigning NANDA International
Nursing Diagnoses to Client
Behaviors Appendix-26

Glossary Glossary-1
Index Index-1

Ebook Bonus Chapters

Chapter 39 Complementary and Psychosocial
Therapies 903

Chapter 40 Relaxation Therapy 929
Chapter 41 Theoretical Models of Personality

Development 940
Chapter 42 Forensic Nursing 959

Contents xvii

6054_FM_i-xx 16/08/17 2:42 pm Page xvii

Currently in progress, implementation of the recom-
mendations set forth by the New Freedom Commis-
sion on Mental Health has given enhanced priority
to mental health care in the United States. Moreover,
at the 65th meeting of the World Health Assembly
(WHA) in May 2012, India, Switzerland, and the
United States cosponsored a resolution requesting
that the World Health Organization, in collaboration
with member countries, develop a global mental
health action plan. This resolution was passed at the
66th WHA in May 2013. By their support of this res-
olution, member countries have expressed their
commitment for “promotion of mental health, pre-
vention of mental disorders, and early identification,
care, support, treatment, and recovery of persons
with mental disorders.” With the passage of this res-
olution, mental health services may now be available
for millions who have been without this type of care.
More recently, national initiatives have sought to
address the growing crises of deaths related to sui-
cide and opiate overdoses. Mental health and mental
illness continue to gain attention globally in the wake
of these and other critical issues but much still needs
to be done to reduce stigmatization and premature
loss of life in this population.

Many nurse leaders see this period of mental health-
care reform as an opportunity for nurses to expand
their roles and assume key positions in education, pre-
vention, assessment, and referral. Nurses are, and will
continue to be, in key positions to assist individuals to
attain, maintain, or regain optimal emotional wellness.

As it has been with each new edition of Psychiatric
Mental Health Nursing: Concepts of Care in Evidence-Based
Nursing, the goal of this ninth edition is to bring to prac-
ticing nurses and nursing students the most up-to-date
information related to neurobiology, psychopharmacol-
ogy, and evidence-based nursing interventions. This edi-
tion includes changes associated with the latest( fifth)
edition of the American Psychiatric Association’s Diag-
nostic and Statistical Manual of Mental Disorders (DSM-5).

Content and Features New to the Ninth
Edition

All content has been updated to reflect the current
state of the discipline of nursing.

All nursing diagnoses are current with the
NANDA-I 2015–2017 Nursing Diagnoses Definitions
and Classifications.

Communication Exercises are included in Chapters
13, Crisis Intervention; 17, Suicide Prevention; 21, The
Recovery Model; 22, Neurocognitive Disorders; 23, Sub-
stance Use and Addictive Disorders; 24, Schizophrenia
Spectrum and Other Psychotic Disorders; 25, Depres-
sive Disorders; 26, Bipolar and Related Disorders; 27,
Anxiety, Obsessive-Compulsive, and Related Disor-
ders; 30, Issues Related to Human Sexuality; 31, Eating
Disorders; 32, Personality Disorders; 35, Survivors of
Abuse or Neglect; and 37, The Bereaved Individual.
These exercises portray clinical scenarios that allow the
student to practice communication skills with clients.
Examples of answers appear in an appendix at the back
of the book.

A new feature, “Real People, Real Stories,” in-
cludes interviews conducted by one of the authors,
Karyn Morgan, in which individuals discuss their
experience of living with a mental illness and their
thoughts on important information for nurses to
know. These discussions can be used with students
to explore communication issues and interventions
to combat stigmatization and to build empathy
through understanding individuals’ unique experi-
ences. “Real People, Real Stories” interviews are in
Chapters 8, Therapeutic Communication; 17, Sui-
cide Prevention; 23, Substance Use and Addictive
Disorders; 24, Schizophrenia Spectrum and Other
Psychotic Disorders; 25, Depressive Disorders; 30, Issues
Related to Human Sexuality and Gender Dysphoria;
and 38, Military Families.

New QSEN icons (in addition to the existing QSEN
Teaching Strategy boxes) have been added selectively
throughout chapters to highlight content that reflects
application of one or more of the six QSEN compe-
tencies (patient-centered care, evidence-based prac-
tice, teamwork and collaboration, maintaining safety,
quality improvement, and informatics).

Chapter 4, Psychopharmacology, has been moved
from DavisPlus to the textbook. While each class of
psychoactive substances is discussed in this chapter,
lists of commonly used agents have been retained in
the chapters that discuss specific disorders. For exam-
ple, a list of commonly used antipsychotic agents
(along with dosage ranges, half-life, and pregnancy
categories) appears in Chapter 24, Schizophrenia
Spectrum and Other Psychotic Disorders. These lists
also appear online at DavisPlus.

New content on motivational interviewing appears
in Chapters 8 and 23.

xviii

To the Instructor

6054_FM_i-xx 16/08/17 2:42 pm Page xviii

To the Instructor xix

New content describing the concept of emotional
intelligence is included in Chapter 14, Assertiveness
Training.

New content on RAISE (Recovery After an Initial
Schizophrenia Episode), based on the NIMH initia-
tive is included in Chapter 24.

New content on gender dysphoria and transgender
issues appears in Chapter 21.

Updated and new psychotropic drugs approved
since the publication of the eighth edition are included
in the specific diagnostic chapters to which they apply.

Features That Have Been Retained
in the Ninth Edition

The concept of holistic nursing is retained in the
ninth edition. An attempt has been made to ensure
that the physical aspects of psychiatric-mental health
nursing are not overlooked. In all relevant situations,
the mind/body connection is addressed.

Nursing process is retained in the ninth edition as
the tool for delivery of care to the individual with a psy-
chiatric disorder or to assist in the primary prevention
or exacerbation of mental illness symptoms. The six
steps of the nursing process, as described in the
American Nurses Association Standards of Clinical Nurs-
ing Practice, are used to provide guidelines for the nurse.
These standards of care are included for the DSM-5
diagnoses, as well as those on the aging individual, the
bereaved individual, survivors of abuse and neglect, and
military families, and as examples in several of the ther-
apeutic approaches. The six steps include:

Assessment: Background assessment data, including
a description of symptomatology, provides an ex-
tensive knowledge base from which the nurse may
draw when performing an assessment. Several
assessment tools are also included.

Diagnosis: Nursing diagnoses common to specific
psychiatric disorders are derived from analysis of
assessment data.

Outcome Identification: Outcomes are derived from
the nursing diagnoses and stated as measurable
goals.

Planning: A plan of care is presented with selected
nursing diagnoses for the DSM-5 diagnoses, as well
as for the elderly client, the bereaved individual,
victims of abuse and neglect, military veterans and
their families, the elderly homebound client, and
the primary caregiver of the client with a chronic
mental illness. The planning standard also includes
tables that list topics for educating clients and fam-
ilies about mental illness. Concept map care plans
are included for all major psychiatric diagnoses.

Implementation: The interventions that have been
identified in the plan of care are included along with

rationales for each. Case studies at the end of each
DSM-5 chapter assist the student in the practical
application of theoretical material. Also included as
a part of this particular standard is Unit 3, Therapeu-
tic Approaches in Psychiatric Nursing Care. This
section of the textbook addresses psychiatric nursing
intervention in depth and frequently speaks to the
differentiation in scope of practice between the basic-
level psychiatric nurse and the advanced practice–
level psychiatric nurse.

Evaluation: The evaluation standard includes a set of
questions that the nurse may use to assess whether
the nursing actions have been successful in achiev-
ing the objectives of care.

Following are additional features of this ninth
edition:

■ Internet references for each DSM-5 diagnosis, with
website listings for information related to the
disorder.

■ Tables that list topics for client/family education
(in the clinical chapters).

■ Boxes that include current research studies with
implications for evidence-based nursing practice
(in the clinical chapters).

■ Assigning nursing diagnoses to client behaviors
(diagnostic chapters).

■ Taxonomy and diagnostic criteria from the DSM-5
(2013). Used throughout the text.

■ All references have been updated throughout the
text. Classical references are distinguished from
general references.

■ Boxes with definitions of core concepts appear
throughout the text.

■ Comprehensive glossary.
■ Answers to end-of-chapter review questions

(Appendix A).
■ Answers to communication exercises (Appendix B).
■ Sample client teaching guides (online at www

.davisplus.com).
■ Website. An F.A. Davis/Townsend website that con-

tains additional nursing care plans that do not ap-
pear in the text, links to psychotropic medications,
concept map care plans, and neurobiological con-
tent and illustrations, as well as student resources
including practice test questions, learning activities,
concept map care plans, and client teaching guides.

Additional Educational Resources
Faculty may also find the teaching aids that accompany
this textbook helpful. These Instructor Resources are
located at www.davisplus.com:

■ Multiple choice questions (including new format
questions reflecting the latest NCLEX blueprint).

■ Lecture outlines for all chapters

6054_FM_i-xx 16/08/17 2:42 pm Page xix

■ Learning activities for all chapters (including
answer key)

■ Answers to the Critical Thinking Exercises from the
textbook

■ PowerPoint Presentation to accompany all chapters
in the textbook

■ Answers to the Homework Assignment Questions
from the textbook

■ Case studies for use with student teaching

Additional chapters on Theories of Personality
Development, Relaxation Therapy, Complementary
and Psychosocial Therapies, and Forensic Nursing are
presented online at www.davisplus.com.

It is hoped that the revisions and additions to
this ninth edition continue to satisfy a need within
psychiatric-mental health nursing practice. The mis-
sion of this textbook has been, and continues to be, to
provide both students and clinicians with up-to-date
information about psychiatric-mental health nursing.
The user-friendly format and easy-to-understand lan-
guage, for which we have received many positive com-
ments, have been retained in this edition. We hope that
this ninth edition continues to promote and advance
the commitment to psychiatric/mental health nursing.

Mary C. Townsend
Karyn I. Morgan

xx To the Instructor

6054_FM_i-xx 16/08/17 2:42 pm Page xx

U N I T 1
Basic Concepts in
Psychiatric-Mental

Health Nursing

6054_Ch01_001-011 27/07/17 5:24 PM Page 1

1The Concept of Stress Adaptation
C H A P T E R O U T L I N E

Objectives

Homework Assignment

Stress as a Biological Response

Stress as an Environmental Event

Stress as a Transaction Between the Individual
and the Environment

Stress Management

Summary and Key Points

Review Questions

K EY T E R M S

adaptive responses

fight-or-flight syndrome

general adaptation syndrome

maladaptive responses

precipitating event

predisposing factors

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

1. Define adaptation and maladaptation.
2. Identify physiological responses to stress.
3. Explain the relationship between stress and

“diseases of adaptation.”
4. Describe the concept of stress as an environ-

mental event.

5. Explain the concept of stress as a transaction
between the individual and the environment.

6. Discuss adaptive coping strategies in the
management of stress.

H O M E W O R K A S S I G N M E N T
Please read the chapter and answer the following questions:

1. How are the body’s physiological defenses
affected when under sustained stress? Why?

2. In the view of stress as an environmental
event, what aspects are missing when
considering an individual’s response to a
stressful situation?

3. In their study, what event did Miller and
Rahe (1997) find produced the highest
level of stress reaction in their participants?

4. What is the initial step in stress
management?

CORE CONCEPTS
Adaptation
Maladaptation
Stressor

2

Psychologists and others have struggled for many
years to establish an effective definition of the term
stress. This term is used loosely today and still lacks
a definitive explanation. Stress may be viewed as an
individual’s reaction to any change that requires an
adjustment or response, which can be physical, men-
tal, or emotional. Responses directed at stabilizing

internal biological processes and preserving self-
esteem can be viewed as healthy adaptations to
stress.

Roy (1976), a nursing theorist, defined an adaptive
response as behavior that maintains the integrity of
the individual. Adaptation is viewed as positive and is
correlated with a healthy response. When behavior

6054_Ch01_001-011 27/07/17 5:24 PM Page 2

disrupts the integrity of the individual, it is perceived
as maladaptive. Maladaptive responses by the individ-
ual are considered to be negative or unhealthy.

Various 20th-century researchers contributed to
several different concepts of stress. Three of these
concepts include stress as a biological response,
stress as an environmental event, and stress as a
transaction between the individual and the environ-
ment. This chapter includes an explanation of each
of these concepts.

Stress as a Biological Response

In 1956, Hans Selye published the results of his re-
search on the physiological response of a biological
system to an imposed change on the system. Since his
initial publication, his definition of stress has evolved
to “the state manifested by a specific syndrome which
consists of all the nonspecifically induced changes
within a biologic system” (Selye, 1976). This combi-
nation of symptoms has come to be known as the
fight-or-flight syndrome. Schematics of these biologi-
cal responses, both initially and with sustained stress,
are presented in Figures 1–1 and 1–2. Selye called this
phenomenon the general adaptation syndrome. He
described three distinct stages of the reaction:

1. Alarm reaction stage: During this stage, the physi-
ological responses of the fight-or-flight syndrome
are initiated.

C H A P T E R 1 ■ The Concept of Stress Adaptation 3

CORE CONCEPT
Stressor
A biological, psychological, social, or chemical factor
that causes physical or emotional tension and may con-
tribute to the development of certain illnesses.

HYPOTHALAMUS

Stimulates

Sympathetic Nervous System

Innervates

Adrenal
medulla

Eye Cardiovascular
system

Lacrimal
glands

Respiratory
system

GI system Liver Urinary
system

Fat
cells

Sweat
glands

Pupils
dilated

Bronchioles
dilated

Respiration
rate increased

Gastric and
intestinal
motility

Secretions
Sphincters

contract

Ureter
motility
Bladder
muscle

contracts
Sphincter
relaxes

Lipolysis

Norepinephrine
and epinephrine

released

Secretion
increased

Force of cardiac
contraction

Cardiac output
Heart rate

Blood pressure

Glycogenolysis
and

gluconeogenesis
Glycogen
synthesis

Secretion

FIGURE 1–1 The fight-or-flight syndrome: The initial stress response.

6054_Ch01_001-011 27/07/17 5:24 PM Page 3

2. Stage of resistance: The individual uses the physi-
ological responses of the first stage as a defense in
the attempt to adapt to the stressor. If adaptation
occurs, the third stage is prevented or delayed.
Physiological symptoms may disappear.

3. Stage of exhaustion: This stage occurs when the
body responds to prolonged exposure to a stressor.
The adaptive energy is depleted, and the individual
can no longer draw from the resources for adapta-
tion described in the first two stages. Diseases of
adaptation (e.g., headaches, mental disorders, coro-
nary artery disease, ulcers, colitis) may occur. With-
out intervention for reversal, exhaustion and, in
some cases, even death, ensues (Selye, 1956, 1974).

The fight-or-flight response undoubtedly served
our ancestors well. Those Homo sapiens who had to
face the giant grizzly bear or the saber-toothed tiger
as part of their struggle for survival must have used

these adaptive resources to their advantage. The
response was elicited in emergency situations, used in
the preservation of life, and followed by restoration
of the compensatory mechanisms to the preemergent
condition (homeostasis).

Selye performed his extensive research in a con-
trolled setting with laboratory animals as subjects. He
elicited the physiological responses with physical stim-
uli, such as exposure to heat or extreme cold, electric
shock, injection of toxic agents, restraint, and surgical
injury. Since the publication of his original research,
it has become apparent that the fight-or-flight syn-
drome of symptoms occurs in response to psycholog-
ical or emotional stimuli just as it does to physical
stimuli. Psychological or emotional stressors are
often not resolved as rapidly as physical stressors,
so the body may be depleted of its adaptive energy
more readily than it is from physical stressors. The
fight-or-flight response may be inappropriate or even

4 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

HYPOTHALAMUS

Stimulates

Pituitary Gland

Releases

Adrenocorticotropic hormone
(ACTH)

Growth hormoneVasopressin
(ADH)

Thyrotropic hormone
(TSH)

Gonadotropins

(Initially)
Sex hormones;
later, with
sustained
stress:
Secretion of
sex hormones

Direct effect on
protein, carbohydrate,
and lipid metabolism,
resulting in
increased serum
glucose and free
fatty acids

StimulatesStimulates

Releases

Adrenal cortex

Basal metabolic
rate

Thyroid gland

Glucocorticoids Mineralocorticoids

Gluconeogenesis
Immune
response
Inflammatory
response

Retention
of sodium
and water

Blood pressure
through constriction
of blood
vessels
Fluid
retention

Libido
Impotence

FIGURE 1–2 The fight-or-flight syndrome: The sustained stress response.

6054_Ch01_001-011 27/07/17 5:24 PM Page 4

dangerous in our modern lifestyle in which stress
has been described as a pervasive, chronic, and relent-
less psychosocial state. When the stress response
becomes chronic, the body’s existence in the aroused
condition for extended time periods promotes
susceptibility to disease.

Miller and Rahe (1997) have updated the original
Social Readjustment Rating Scale devised by Holmes
and Rahe in 1967 to reflect an increased number of
modern stressors. Just as in the earlier version, numer-
ical values are assigned to various common life events
based on the stress these events create. In their
research, Miller and Rahe found that women react
to life stress events at higher levels than do men, and
unmarried people gave higher scores than married
people for most of the events. Younger participants
rated more events at a higher stress level than did
older participants. A high score on the Recent Life
Changes Questionnaire (RLCQ) places the individual
at greater susceptibility to physical or psychological
illness. The questionnaire may be completed consid-
ering life stressors within a 6-month or 1-year period.
Six-month totals equal to or greater than 300 life
change units (LCUs) or 1-year totals equal to or
greater than 500 LCUs are considered indicative of a
high level of recent life stress, thereby increasing the
individual’s risk of illness. The RLCQ is presented in
Table 1–1.

It is unknown whether stress overload merely pre-
disposes a person to illness or actually precipitates it,
but there does appear to be a link (Amirkhan, 2012).
Individuals differ in their reactions to life events, and
these variations are related to the degree to which
the change is perceived as stressful. Life changes

C H A P T E R 1 ■ The Concept of Stress Adaptation 5

TA B L E 1– 1 The Recent Life Changes Questionnaire
LIFE CHANGE EVENT LCU LIFE CHANGE EVENT LCU

HEALTH
An injury or illness which: 74

Kept you in bed a week or more, or sent
you to the hospital

Was less serious than above 44

Major dental work 26

Major change in eating habits 27

Major change in sleeping habits 26

Major change in your usual type/amount 28
of recreation

WORK
Change to a new type of work 51

Change in your work hours or conditions 35

Change in your responsibilities at work:
More responsibilities 29
Fewer responsibilities 21
Promotion 31
Demotion 42
Transfer 32

Troubles at work:
With your boss 29
With coworkers 35
With persons under your supervision 35
Other work troubles 28

Major business adjustment 60

Retirement 52

Loss of job:
Laid off from work 68
Fired from work 79

Correspondence course to help you in your work 18

PERSONAL AND SOCIAL
Change in personal habits 26

Beginning or ending school or college 38

Change of school or college 35

Change in political beliefs 24

Change in religious beliefs 29

CORE CONCEPT
Adaptation
Adaptation is said to occur when an individual’s physical
or behavioral response to any change in his or her in-
ternal or external environment results in preservation of
individual integrity or timely return to equilibrium.

Stress as an Environmental Event

A second concept defines stress as an “event” that trig-
gers an individual’s adaptive physiological and
psychological responses. The event creates change in
the life pattern of the individual, requires significant
adjustment in lifestyle, and taxes available personal
resources. The change can be either positive, such as
outstanding personal achievement, or negative, such
as being fired from a job. The emphasis here is on
change from the existing steady state of the individ-
ual’s life pattern.

Continued

6054_Ch01_001-011 27/07/17 5:24 PM Page 5

6 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

TA B L E 1– 1 The Recent Life Changes Questionnaire—cont’d
LIFE CHANGE EVENT LCU LIFE CHANGE EVENT LCU

Spouse beginning or ending work 46

Child leaving home:
To attend college 41
Due to marriage 41
For other reasons 45

Change in arguments with spouse 50

In-law problems 38

Change in the marital status of your parents:
Divorce 59
Remarriage 50

Separation from spouse:
Due to work 53
Due to marital problems 76

Divorce 96

Birth of grandchild 43

Death of spouse 119

Death of other family member:
Child 123
Brother or sister 102
Parent 100

FINANCIAL
Major change in finances:

Increased income 38
Decreased income 60
Investment and/or credit difficulties 56

Loss or damage of personal property 43

Moderate purchase 20

Major purchase 37

Foreclosure on a mortgage or loan 58

Change in social activities 27

Vacation 24

New, close, personal relationship 37

Engagement to marry 45

Girlfriend or boyfriend problems 39

Sexual difficulties 44

“Falling out” of a close personal relationship 47

An accident 48

Minor violation of the law 20

Being held in jail 75

Death of a close friend 70

Major decision regarding your immediate future 51

Major personal achievement 36

HOME AND FAMILY
Major change in living conditions 42

Change in residence:
Move within the same town or city 25
Move to a different town, city, or state 47

Change in family get-togethers 25

Major change in health or behavior of family 55
member

Marriage 50

Pregnancy 67

Miscarriage or abortion 65

Gain of a new family member:
Birth of a child 66
Adoption of a child 65
A relative moving in with you 59

LCU, life change unit.

SOURCE: Miller, M.A., & Rahe, R.H. (1997). Life changes scaling for the 1990s. Journal of Psychosomatic Research, 43(3), 279-292,
with permission.

questionnaires have been criticized because they do
not consider the individual’s perception of the event.
These types of instruments also fail to consider cul-
tural variations, the individual’s coping strategies,
and available support systems at the time when the
life change occurs. Amirkhan (2012) developed a
tool to assess stress overload that attempts to correct
for these limitations by asking a series of 30 questions

that all begin with “In the past week have you
felt . . .” followed by choices such as calm, inade-
quate, depressed, and others. The emphasis in this
tool is on the individual’s perception of events rather
than on the events themselves. Although the ap-
proaches to assessing for stress and vulnerability vary,
it is clear that positive coping mechanisms and strong
social or familial support can reduce the intensity of

6054_Ch01_001-011 27/07/17 5:24 PM Page 6

stressful life changes and promote a more adaptive
response.

Stress as a Transaction Between
the Individual and the Environment

The concept of stress as a transaction between the
individual and the environment emphasizes the
relationship between internal variables (within an indi-
vidual) and external variables (within the environ-
ment). This concept parallels the modern concept
of disease etiology. No longer is causation viewed
solely as an external entity; whether or not illness
occurs depends also on the receiving organism’s sus-
ceptibility. Similarly, to predict psychological stress as
a reaction, the internal characteristics of the person
in relation to the environment must be considered.

Precipitating Event
Lazarus and Folkman’s seminal theory (1984) defines
stress (and potentially illness) as a psychological
phenomenon in which the relationship between the
person and the environment is appraised by the per-
son as taxing or exceeding his or her resources and
endangering his or her well-being. A precipitating
event is a stimulus arising from the internal or exter-
nal environment and perceived by the individual in a
specific manner. Determination of an event as stress-
ful depends on the individual’s cognitive appraisal
of the situation. Cognitive appraisal is an individual’s
evaluation of the personal significance of the event
or occurrence. The event “precipitates” a response on
the part of the individual, and the response is influ-
enced by the individual’s perception of the event. The
cognitive response consists of a primary appraisal and a
secondary appraisal.

Individual’s Perception of the Event
Primary Appraisal
Lazarus and Folkman (1984) identify three types of
primary appraisal: irrelevant, benign-positive, and
stressful. An event is judged irrelevant when the
outcome holds no significance for the individual. A
benign-positive outcome is one that is perceived as pro-
ducing pleasure for the individual. Stress appraisals
include harm or loss, threat, and challenge. Harm
or loss appraisals refer to damage or loss already
experienced by the individual. Appraisals of a threat-
ening nature are perceived as anticipated harms or
losses. When an event is appraised as challenging, the
individual focuses on potential for gain or growth
rather than on risks associated with the event. Chal-
lenge produces stress even though the emotions
associated with it (eagerness and excitement) are
viewed as positive, and coping mechanisms must be

called upon to face the new encounter. Challenge
and threat may occur together when an individual ex-
periences these positive emotions along with fear or
anxiety over possible risks associated with the chal-
lenging event.

When stress is produced in response to harm or
loss, threat, or challenge, a secondary appraisal is
made by the individual.

Secondary Appraisal
The secondary appraisal is an assessment of skills, re-
sources, and knowledge that the person possesses to
deal with the situation. The individual evaluates by
considering the following:

■ Which coping strategies are available to me?
■ Will the option I choose be effective in this situation?
■ Do I have the ability to use that strategy in an effec-

tive manner?

The interaction between the primary appraisal of the
event that has occurred and the secondary appraisal of
available coping strategies determines the quality of the
individual’s adaptation response to stress.

Predisposing Factors
A variety of elements influence how an individual
perceives and responds to a stressful event. These
predisposing factors strongly influence whether the
response is adaptive or maladaptive. Types of predis-
posing factors include genetic influences, past expe-
riences, and existing conditions.

Genetic influences are those circumstances of an
individual’s life that are acquired through heredity.
Examples include family history of physical and psy-
chological conditions (strengths and weaknesses) and
temperament (behavioral characteristics present at
birth that evolve with development).

Past experiences are occurrences that result in
learned patterns that can influence an individual’s
adaptation response. They include previous expo-
sure to the stressor or other stressors, learned coping
responses, and degree of adaptation to previous
stressors.

Existing conditions incorporate vulnerabilities that
influence the adequacy of the individual’s physical,
psychological, and social resources for dealing with
adaptive demands. Examples include current health
status, motivation, developmental maturity, severity
and duration of the stressor, financial and educa-
tional resources, age, existing coping strategies, and
a caring support system. Hobfoll’s conservation of
resources theory (Hobfoll 1989; Hobfoll, Schwarzer,
& Chon, 1998) adds that as existing conditions (loss
or lack of resources) exceed the person’s perception
of adaptive capabilities, the person not only experi-
ence stress in the present but also becomes more

C H A P T E R 1 ■ The Concept of Stress Adaptation 7

6054_Ch01_001-011 27/07/17 5:24 PM Page 7

vulnerable to the effects of stress in the future due to
a “weaker resource reservoir to call on to meet future
demand” (Hobfoll et al., 1998, p. 191). All of the pre-
ceding concepts and theories are foundational to the
transactional model of stress and adaptation that
serves as the framework for the process of nursing in
this text. A graphic display of the model is presented
in Figure 1–3.

protect the individual from harm (or additional
harm) or strengthen the individual’s ability to meet
challenging situations. Adaptive responses help
restore homeostasis to the body and impede the
development of diseases of adaptation. Positive
adaptation, particularly in response to adversity, has
also been referred to as resilience.

Responses are considered maladaptive when
the conflict goes unresolved or intensifies. Energy
resources become depleted as the body struggles
to compensate for the chronic physiological and psy-
chological arousal experienced in response to the
stressful event. The effect is a significant vulnerability
to physical or psychological illness. One key to stress
management is to identify factors and practices that
contribute to adaptive coping and resilience.

Adaptive Coping Strategies
Awareness
The initial step in managing stress is awareness—to
become aware of the factors that create stress and the
feelings associated with a stressful response. Stress can
be controlled only when one recognizes the signs that
it is occurring. As an individual becomes aware of
stressors, he or she can choose to omit, avoid, or
accept them.

Relaxation
Individuals experience relaxation in different ways.
Some people relax by engaging in large motor activi-
ties, such as sports, jogging, and physical exercise.
Others use techniques such as breathing exercises
and progressive relaxation. A discussion of relaxation
therapy may be found online at DavisPlus.

Meditation
Meditation has been shown to produce a lasting
reduction in blood pressure and other stress-related
symptoms when practiced for 20 minutes once or
twice a day (Scott, 2016). The practice of mindfulness
meditation is foundational to many psychosocial in-
terventions aimed at reducing anxiety and improving
engagement in problem-solving. Meditation involves
assuming a comfortable position, closing the eyes,
casting off all other thoughts, and concentrating on
a single word, sound, or phrase that has positive
meaning to the individual. It may also involve concen-
trating on one’s breathing or other mindfulness prac-
tices. The technique of meditation is described in
detail online at DavisPlus.

Interpersonal Communication
As previously mentioned, the strength of an individ-
ual’s available support system is an existing condition
that significantly influences his or her adaptation when
coping with stress. Sometimes just “talking the problem
out” with an empathetic individual can interrupt

8 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

Precipitating Event

Predisposing Factors
Genetic Influences
Past Experiences
Existing Conditions

Cognitive Appraisal

* Primary *

Irrelevant

No
response

Benign
positive

Pleasurable
response

Stress
appraisals

Harm/
loss Threat

Challenge

* Secondary *

Availability of coping strategies
Perceived effectiveness of coping strategies
Perceived ability to use coping strategies effectively

Quality of Response

Adaptive Maladaptive

FIGURE 1–3 Transactional model of stress and adaptation.

CORE CONCEPT
Maladaptation
Maladaptation occurs when an individual’s physical or
behavioral response to any change in his or her internal
or external environment results in disruption of individual
integrity or in persistent disequilibrium.

Stress Management*

The growth of stress management into a multimillion-
dollar-a-year industry unto itself attests to its impor-
tance in our society. Stress management involves the
use of coping strategies in response to stressful situ-
ations. Coping strategies are adaptive when they

*Some stress management techniques are discussed at greater
length in Unit 3 of this text and in the Complementary and Psy-
chosocial Therapies chapter available online at www.DavisPlus.com.

6054_Ch01_001-011 27/07/17 5:24 PM Page 8

escalation of the stress response. Writing about one’s
feelings in a journal or diary can also be therapeutic.

Problem-Solving
Problem-solving is an adaptive coping strategy in
which the individual is able to view the situation ob-
jectively (or to seek assistance from another individual
to accomplish this if the anxiety level is too high to
concentrate) and then apply a problem-solving and
decision-making model such as the following:

■ Assess the facts of the situation.
■ Formulate goals for resolution of the stressful

situation.
■ Study the alternatives for dealing with the situation.
■ Determine the risks and benefits of each alternative.
■ Select an alternative.
■ Implement the alternative selected.
■ Evaluate the outcome of the alternative imple-

mented.
■ If the first choice is ineffective, select and imple-

ment a second option.

Pets
Studies show that those who care for pets, especially
dogs and cats, are better able to cope with the stres-
sors of life (Mayo Clinic, 2015). The physical act
of stroking a dog’s or cat’s fur can be therapeutic,
giving the animal an intuitive sense of being cared
for and providing the individual the calming feeling
of warmth, affection, and interdependence with a re-
liable, trusting being. Studies have also shown that
individuals with companion pets demonstrate im-
provements in heart health, allergies, anxiety, and
mental illnesses such as depression (Casciotti &
Zuckerman, 2016, Donehy, 2015).

Music
It is true that music can “soothe the savage beast.”
Studies have shown multiple benefits of listening to
music, including relieving pain, improving motivation
and performance, improving sleep, enhancing blood
vessel function, reducing stress, relieving symptoms
of depression, improving cognition, and easing recov-
ery in stroke patients (Christ, 2013).

Summary and Key Points

■ Stress has become a chronic and pervasive condi-
tion in the United States.

■ Adaptive behavior is a stress response that main-
tains the integrity of the individual with a timely
return to equilibrium. It is viewed as positive and
is correlated with a healthy response.

■ When behavior disrupts the integrity of the indi-
vidual or results in persistent disequilibrium, it is
perceived as maladaptive. Maladaptive responses
by the individual are unhealthy.

■ A stressor is defined as a biological, psychological,
social, or chemical factor that causes physical or
emotional tension and may be a factor in the etiol-
ogy of certain illnesses.

■ Hans Selye identified the biological changes asso-
ciated with a stressful situation as the fight-or-flight
syndrome.

■ Selye called the general reaction of the body to
stress the “general adaptation syndrome,” which
occurs in three stages: the alarm reaction stage, the
stage of resistance, and the stage of exhaustion.

■ When individuals remain in the aroused response
to stress for an extended period of time, they be-
come susceptible to diseases, including headaches,
mental disorders, coronary artery disease, ulcers,
and colitis.

■ Stress may also be viewed as an environmental event,
which results when a change from the existing
steady state of the individual’s life pattern occurs.

■ When an individual experiences a high level of life
change events, he or she becomes susceptible to
physical or psychological illness.

■ Limitations of the environmental concept of stress
include failure to consider the individual’s percep-
tion of the event, coping strategies, and available
support systems at the time when the life change
occurs.

■ Stress is more appropriately expressed as a transac-
tion between the individual and the environment
that is appraised by the individual as taxing or ex-
ceeding his or her resources and endangering his
or her well-being.

■ The individual makes a cognitive appraisal of the
precipitating event to determine the personal
significance of the event or occurrence.

■ Primary cognitive appraisals may be irrelevant,
benign-positive, or stressful.

■ Secondary cognitive appraisals include assessment
and evaluation by the individual of skills, resources,
and knowledge to deal with the stressful situation.

■ Predisposing factors influence how an individual
perceives and responds to a stressful event. They
include genetic influences, past experiences, and
existing conditions.

■ Stress management involves the use of adaptive
coping strategies in response to stressful situations
in an effort to impede the development of diseases
of adaptation.

■ Examples of adaptive coping strategies include
developing awareness, relaxation, meditation,
interpersonal communication with caring other,
problem-solving, pets, and music.

C H A P T E R 1 ■ The Concept of Stress Adaptation 9

Additional info available
at www.davisplus.com

6054_Ch01_001-011 27/07/17 5:24 PM Page 9

10 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

Review Questions
Self-Examination/Learning Exercise

Select the answer that is most appropriate for each of the following questions.

1. Sondra, who lives in Maine, hears on the evening news that 25 people were killed in a tornado in south
Texas. Sondra experiences no anxiety upon hearing of this stressful situation. What is the most likely
reason that Sondra experiences no anxiety?
a. She is selfish and does not care what happens to other people.
b. She appraises the event as irrelevant to her own situation.
c. She assesses that she has the skills to cope with the stressful situation.
d. She uses suppression as her primary defense mechanism.

2. Cindy regularly develops nausea and vomiting when she is faced with a stressful situation. Which of
the following is most likely a predisposing factor to this maladaptive response by Cindy?
a. Cindy inherited her mother’s “nervous” stomach.
b. Cindy is fixed in a lower level of development.
c. Cindy has never been motivated to achieve success.
d. When Cindy was a child, her mother pampered her and kept her home from school when she

was ill.

3. When an individual’s stress response is sustained over a long period, the endocrine system involvement
results in which of the following?
a. Decreased resistance to disease
b. Increased libido
c. Decreased blood pressure
d. Increased inflammatory response

4. Why is stress management extremely important in today’s society?
a. Evolution has diminished the human capability for fight-or-flight responses.
b. The stressors of today tend to be ongoing, resulting in a sustained response.
c. We have stress disorders that did not exist in the days of our ancestors.
d. One never knows when one will have to face a grizzly bear or saber-toothed tiger in today’s society.

5. Elena has just received a promotion on her job. She is very happy and excited about moving up in her
company, but she has been experiencing anxiety since receiving the news. Her primary appraisal is
that she most likely views the situation as which of the following?
a. Benign-positive
b. Irrelevant
c. Challenging
d. Threatening

6. John comes to the mental health clinic with reports of anxiety and depression. According to the trans-
actional model of stress and adaptation, which of the following are important to consider when assess-
ing John’s complaints? (Select all that apply.)
a. John’s perception of precipitating events
b. Past stressors and degree of positive coping abilities
c. Existing social supports
d. Physical strength
e. Pupillary adaptation to light

6054_Ch01_001-011 27/07/17 5:24 PM Page 10

References
Amirkhan, J.H. (2012). Stress overload: A new approach to

the assessment of stress. American Journal of Community
Psychology, 49(1-2), 55-71. doi:10.1007/s10464-011-
9438-x

Casciotti, D., & Zuckerman, D. (2016). The benefits of pets for
human health. Retrieved from http://center4research.org/
healthy-living-prevention/pets-and-health-the-impact-of-
companion-animals

Christ, S. (2013). 20 surprising science-backed health benefits of
music. Retrieved from www.usatoday.com/story/news/health/
2013/12/17/health-benefits-music/4053401

Donehy, K. (2015). Pets for depression and health. Retrieved
from www.webmd.com/depression/features/pets-
depression

Mayo Clinic. (2015). Pet therapy: Man’s best friend as healer.
Retrieved from www.mayoclinic.org/healthy-lifestyle/
consumer-health/in-depth/pet-therapy/art-20046342

Scott, E. (2016). Meditation research and benefits. Retrieved
from www.verywell.com/meditation-research-and-benefits-
3144996

Classical References
Hobfoll, S. (1989). Conservation of resources: A new attempt at

conceptualizing stress. American Psychologist 44(3), 513-524.
doi:http://dx.doi.org/10.1037/0003-066X.44.3.513

Hobfoll, S., Schwarzer, R., & Chon, K. (1998). Disentangling the
stress labyrinth: Interpreting the meaning of stress as it is
studied in the health context. Anxiety, Stress, and Coping, 11(3),
181-212. doi:http://dx.doi.org/10.1080/10615809808248311

Holmes, T., & Rahe, R. (1967). The social readjustment rating
scale. Journal of Psychosomatic Research, 11(2), 213-218.
doi:http://dx.doi.org/10.1016/0022-3999(67)90010-4

Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal and coping.
New York: Springer Publishing.

Miller, M.A., & Rahe, R.H. (1997). Life changes scaling for
the 1990s. Journal of Psychosomatic Research, 43(3), 279-292.
doi:10.1016/S0022-3999(97)00118-9

Roy, C. (1976). Introduction to nursing: An adaptation model.
Englewood Cliffs, NJ: Prentice-Hall.

Selye, H. (1956). The stress of life. New York: McGraw-Hill.
Selye, H. (1974). Stress without distress. New York: Signet Books.
Selye, H. (1976). The stress of life (rev. ed.). New York: McGraw Hill.

C H A P T E R 1 ■ The Concept of Stress Adaptation 11

6054_Ch01_001-011 27/07/17 5:24 PM Page 11

2 Mental Health and Mental Illness: Historical and Theoretical Concepts
C H A P T E R O U T L I N E

Objectives

Homework Assignment

Historical Overview of Psychiatric Care

Mental Health

Mental Illness

Psychological Adaptation to Stress

Mental Health/Mental Illness Continuum

Summary and Key Points

Review Questions

K EY T E R M S

anticipatory grieving

bereavement overload

defense mechanisms

compensation

denial

displacement

identification

intellectualization

introjection

isolation

projection

rationalization

reaction formation

regression

repression

sublimation

suppression

undoing

humors

mental health

mental illness

neurosis

psychosis

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

1. Discuss the history of psychiatric care.
2. Define mental health and mental illness.
3. Discuss cultural elements that influence

attitudes toward mental health and mental
illness.

4. Describe psychological adaptation responses
to stress.

5. Correlate adaptive and maladaptive
responses to the mental health/mental
illness continuum.

H O M E W O R K A S S I G N M E N T
Please read the chapter and answer the following questions:

1. Explain the concepts of incomprehensibility
and cultural relativity.

2. Describe some symptoms of panic anxiety.
3. Jane was involved in an automobile accident

in which both her parents were killed. When

you ask her about it, she says she has no
memory of the accident. What ego defense
mechanism is she using?

4. In what stage of the grieving process is the
individual with delayed or inhibited grief fixed?

CORE CONCEPTS
Anxiety
Grief

12

The consideration of mental health and mental ill-
ness has its basis in the cultural beliefs of the society
in which the behavior takes place. Some cultures
are quite liberal in the range of behaviors that are
considered acceptable, whereas others have very little

tolerance for behaviors that deviate from the cultural
norms.

A study of the history of psychiatric care reveals
some shocking truths about past treatment of indi-
viduals with mental illness. Many were kept in control

6054_Ch02_012-026 01/09/17 10:42 am Page 12

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 13

by means that today could be considered less than
humane.

This chapter deals with the evolution of psychiatric
care from ancient times to the present. Mental health
and mental illness are defined, and the psychological
adaptation to stress is explained in terms of the two
major responses: anxiety and grief. Behavioral re-
sponses are conceptualized along the mental health/
mental illness continuum.

Historical Overview of Psychiatric Care

Primitive beliefs regarding mental disturbances took
several views. Some cultures thought that an individual
with mental illness had been dispossessed of his or her
soul and wellness could be achieved only if the soul was
returned. Others believed that evil spirits or supernat-
ural or magical powers had entered the body. The
“cure” for these individuals involved a ritualistic exor-
cism to purge the body of these unwanted forces. This
purging often consisted of brutal beatings, starvation,
or other torturous means. Still other cultures consid-
ered that the individual with mental illness may have
broken a taboo or sinned against another individual
or God, for which ritualistic purification was required
or various types of retribution were demanded. The
correlation of mental illness to demonology led to
some individuals with mental illness being burned at
the stake.

These ancient beliefs evolved with increasing
knowledge about mental illness and changes in cul-
tural, religious, and sociopolitical attitudes. Around
400 BC, the work of Hippocrates was the first to place
mental illness in a physical rather than supernatural
context. Hippocrates theorized that mental illness
was caused by irregularity in the interaction of the
four body fluids: blood, black bile, yellow bile, and
phlegm. He called these body fluids humors and
associated each with a particular disposition. Disequi-
librium among these four humors was often treated
by inducing vomiting and diarrhea with potent cathar-
tic drugs.

During the Middle Ages (AD 500 to 1500), the
association of mental illness with witchcraft and the
supernatural continued to prevail in Europe. During
this period, many people with mental illness were set
to sea alone in sailing boats with little guidance to
search for their lost rationality, a practice from which
the expression “ship of fools” was derived. But in
Middle Eastern countries, a change in attitude began
to occur that led to the perception of mental illness
as a medical problem rather than a result of supernat-
ural forces. This notion gave rise to the establishment
of special units for clients with mental illness within

general hospitals as well as residential institutions
specifically designed for this purpose. They can likely
be considered the first asylums for individuals with
mental illness.

Colonial Americans tended to reflect the attitudes
of the European communities from which they had
emigrated. Particularly in the New England area, in-
dividuals were punished for behavior attributed to
witchcraft. In the 16th and 17th centuries, institutions
for people with mental illness did not exist in the
United States, and care of these individuals became a
family responsibility. Those without family or other
resources became the responsibility of the communi-
ties in which they lived and were incarcerated in
places where they could do no harm to themselves
or others.

The first hospital in America to admit clients
with mental illness was established in Philadelphia
in the middle of the 18th century. Benjamin Rush,
often called the father of American psychiatry,
was a physician at the hospital. He initiated the pro-
vision of humanistic treatment and care for clients
with mental illness. But although he included kind-
ness, exercise, and socialization in his care, he also
employed harsh methods such as bloodletting,
purging, various types of physical restraints, and
extremes of temperatures, reflecting the medical
therapies of that era.

The 19th century brought the establishment of a
system of state asylums, largely the result of the work
of Dorothea Dix, a former New England school-
teacher who lobbied tirelessly on behalf of the men-
tally ill population. She was unfaltering in her belief
that mental illness was curable and that state hospitals
should provide humanistic therapeutic care. This sys-
tem of hospital care for individuals with mental
illness grew, but the mentally ill population grew
faster. The institutions became overcrowded and
understaffed, and conditions deteriorated. Therapeutic
care reverted to custodial care in state hospitals,
which provided the largest resource for individuals
with mental illness until the initiation of the commu-
nity health movement of the 1960s (see Chapter 36,
Community Mental Health Nursing).

The emergence of psychiatric nursing began in
1873 with the graduation of Linda Richards from
the nursing program at the New England Hospital
for Women and Children in Boston. She has come
to be known as the first American psychiatric nurse.
During her career, Richards was instrumental in the
establishment of a number of psychiatric hospitals
and the first school of psychiatric nursing at the
McLean Asylum in Waverly, Massachusetts, in 1882.
This school and others like it provided training in

6054_Ch02_012-026 01/09/17 10:42 am Page 13

custodial care for clients in psychiatric asylums—
training that did not include the study of psychological
concepts. Significant change in psychiatric nursing
education did not occur until 1955, when incorpo-
ration of psychiatric nursing into the curricula be-
came a requirement for all undergraduate schools
of nursing. This new curricula emphasized the impor-
tance of the nurse–patient relationship and therapeu-
tic communication techniques. Nursing intervention
in the somatic therapies (e.g., insulin and electrocon-
vulsive therapy) provided impetus for the incorpora-
tion of these concepts into the profession’s body of
knowledge.

With the increasing need for psychiatric care in
the aftermath of World War II, the government
passed the National Mental Health Act of 1946. This
legislation provided funds for the education of psy-
chiatrists, psychologists, social workers, and psychi-
atric nurses. Graduate-level education in psychiatric
nursing was established during this period. Around
the same time, the introduction of antipsychotic
medications made it possible for clients with psy-
choses to more readily participate in their treatment,
including nursing therapies.

Knowledge of the history of psychiatric-mental
health care contributes to the understanding of
the concepts presented in this chapter and those
in the online chapter (available at www.DavisPlus
.com), which describe the theoretical models of per-
sonality development according to various 19th- and
20th-century leaders in the mental health movement.
Modern American psychiatric care has its roots in
ancient times. A great deal of opportunity exists for
continued advancement of this specialty within the
practice of nursing.

Mental Health

A number of theorists have attempted to define the
concept of mental health. Many of these concepts deal
with various aspects of individual functioning. Maslow
(1970) emphasized an individual’s motivation in the
continuous quest for self-actualization. He identified
a “hierarchy of needs,” with the most basic needs
requiring fulfillment before those at higher levels can
be achieved and with self-actualization defined as ful-
fillment of one’s highest potential. An individual’s
position within the hierarchy may revert from a higher
level to a lower level based on life circumstances.
For example, an individual facing major surgery who
has been working to achieve self-actualization may
become preoccupied, if only temporarily, with the
need for physiological safety. A representation of this
needs hierarchy is presented in Figure 2–1.

Maslow described self-actualization as being “psy-
chologically healthy, fully human, highly evolved, and
fully mature.” He believed that self-actualized individ-
uals possess the following characteristics:

■ An appropriate perception of reality
■ The ability to accept oneself, others, and human

nature
■ The ability to manifest spontaneity
■ The capacity for focusing concentration on problem-

solving
■ A need for detachment and desire for privacy
■ Independence, autonomy, and a resistance to

enculturation
■ An intensity of emotional reaction
■ A frequency of “peak” experiences that validate the

worthwhileness, richness, and beauty of life
■ An identification with humankind
■ The ability to achieve satisfactory interpersonal

relationships
■ A democratic character structure and strong sense

of ethics
■ Creativeness
■ A degree of nonconformance

Jahoda (1958) identified a list of six indicators that
are a reflection of mental health:

1. A positive attitude toward self: This indicator
refers to an objective view of self, including
knowledge and acceptance of strengths and lim-
itations. The individual feels a strong sense of
personal identity and security within his or her
environment.

2. Growth, development, and the ability to achieve
self-actualization: This indicator correlates with
whether the individual successfully achieves the
tasks associated with each level of development
(see Erikson, in the online chapter Theoretical
Models of Personality Development). With success-
ful achievement in each level, the individual gains
motivation for advancement to his or her highest
potential.

3. Integration: The focus of this indicator is on
maintaining equilibrium or balance among vari-
ous life processes. Integration includes the ability
to adaptively respond to the environment and the
development of a philosophy of life, both of
which help the individual maintain a manageable
anxiety level in response to stressful situations.

4. Autonomy: This indicator refers to the individual’s
ability to perform in an independent, self-directed
manner. He or she makes choices and accepts
responsibility for the outcomes.

5. Perception of reality: Accurate reality perception
is a positive indicator of mental health. It includes

14 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

6054_Ch02_012-026 01/09/17 10:42 am Page 14

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 15

perception of the environment without distor-
tion as well as the capacity for empathy and social
sensitivity—a respect and concern for the wants
and needs of others.

6. Environmental mastery: This indicator suggests
that the individual has achieved a satisfactory role
within the group, society, or environment and is
able to love and accept the love of others. When
faced with life situations, the individual is able to
strategize, make decisions, change, adjust, and
adapt. Life offers satisfaction to the individual who
has achieved environmental mastery.

Black and Andreasen (2014) describe mental
health as a state of being that is relative rather than
absolute but marked by the successful performance
of mental functions such as adapting to change, cop-
ing with stressors, fulfilling relationships with others,
and the accomplishing productive activities.

Robinson (1983) offers the following definition of
mental health:

A dynamic state in which thought, feeling, and behav-
ior that is age-appropriate and congruent with the
local and cultural norms is demonstrated. (p. 74)

For purposes of this text, and in keeping with the
framework of stress and adaptation, a modification
of Robinson’s definition of mental health is consid-
ered. Thus, mental health is viewed as “the successful
adaptation to stressors from the internal or external
environment, evidenced by thoughts, feelings, and
behaviors that are age-appropriate and congruent
with local and cultural norms.”

Mental Illness

Arriving at a universal concept of mental illness is dif-
ficult because of the cultural factors that influence such

(The individual
possesses a
feeling of self-
f u l f i l l m e n t a n d
t h e r e a l i z a t i o n
of his or her
highest potential.)

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

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

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

SELF-
ACTUALIZATION

SELF-ESTEEM
RESPECT OF OTHERS

LOVE AND BELONGING

SAFETY AND SECURITY

PHYSIOLOGICAL NEEDS
(Basic fundamental needs include food, water, air, sleep, exercise,

elimination, shelter, and sexual expression.)

FIGURE 2–1 Maslow’s hierarchy of needs.

6054_Ch02_012-026 01/09/17 10:42 am Page 15

a definition. However, certain elements are associated
with individuals’ perceptions of mental illness, regard-
less of cultural origin. Horwitz (2010) identifies two of
these elements as (1) incomprehensibility and (2) cul-
tural relativity.

Incomprehensibility relates to the inability of the gen-
eral population to understand the motivation behind
an individual’s behavior. When observers are unable
to find meaning or comprehensibility in behavior,
they are likely to label that behavior as mental illness.
Horwitz states, “Observers attribute labels of mental
illness when the rules, conventions, and understand-
ings they use to interpret behavior fail to find any in-
telligible motivation behind an action” (p. 17). The
element of cultural relativity considers that these rules,
conventions, and understandings are conceived within
an individual’s own particular culture. Behavior that
is considered “normal” and “abnormal” is defined by
one’s cultural or societal norms. Horwitz identified a
number of cultural aspects of mental illness, which are
presented in Box 2–1.

The American Psychiatric Association (2013), in its
Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5), defines mental disorder as

a syndrome characterized by clinically significant
disturbance in an individual’s cognitions, emotion
regulation, or behavior that reflects a dysfunction

in the psychological, biological, or developmental
processes underlying mental functioning. Mental dis-
orders are usually associated with significant distress
or disability in social, occupational, or other impor-
tant activities. An expected or culturally approved
response to a common stressor or loss such as the
death of a loved one is not a mental disorder. (p. 20)

For purposes of this text, and in keeping with the
transactional model of stress and adaptation, mental
illness is characterized as “maladaptive responses to
stressors from the internal or external environment,
evidenced by thoughts, feelings, and behaviors that
are incongruent with the local and cultural norms
and that interfere with the individual’s social, occu-
pational, and/or physical functioning.”

Psychological Adaptation to Stress

All individuals exhibit characteristics associated with
both mental health and mental illness at any given
point in time. Chapter 1, The Concept of Stress Adap-
tation, describes how an individual’s response to stress-
ful situations is influenced by physiological factors, his
or her personal perception of the event, and a variety
of predisposing factors such as heredity, temperament,
learned response patterns, developmental maturity,
existing coping strategies, and support systems of caring
others.

16 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

BOX 2–1 Cultural Aspects of Mental Illness

1. Usually, members of the community, not a psychiatric pro-
fessional, initially recognizes that an individual’s behavior
deviates from societal norms.

2. People who are related to an individual or who are of
the same cultural or social group are less likely to label an
individual’s behavior as mentally ill than are people who
are relationally or culturally distant. Relatives and those
who share a culture try to normalize the behavior by look-
ing for an explanation.

3. Often, psychiatrists see a person with mental illness only
when the family members can no longer deny the illness.
Recognition or acknowledgment of possible mental illness
typically occurs when behavior is at its worst as defined
by local or cultural norms.

4. Individuals in lower socio-economic classes usually display
more mental illness symptoms than do people in higher
socio-economic classes. However, they tend to tolerate a
wider range of behaviors that deviate from societal norms
and are less likely to consider these behaviors as indicative
of mental illness. Mental illness labels are most often ap-
plied by psychiatric professionals.

5. The higher the social class, the greater the recognition of
mental illness behaviors. Members of the higher social

classes are likely to be self-labeled or labeled by family
members or friends. Psychiatric assistance is sought near
the first signs of emotional disturbance.

6. The more highly educated the person, the greater the
recognition of mental illness behaviors. However, even
more relevant than the amount of education is the type
of education. Individuals in the more humanistic profes-
sions (lawyers, social workers, artists, teachers, nurses) are
more likely to seek psychiatric assistance than are profes-
sionals such as business executives, computer specialists,
accountants, and engineers.

7. Women are more likely than men to recognize the symp-
toms of mental illness and seek assistance.

8. The greater the cultural distance from the mainstream
of society (i.e., the fewer the ties with conventional
society), the greater the likelihood of negative societal
response to mental illness. For example, immigrants
have a greater distance from the mainstream than the
native born, ethnic minorities greater than the dominant
culture, and “bohemians” greater than the bourgeoisie.
These groups are more likely to be subjected to coercive
treatment, and involuntary psychiatric commitments are
more common.

Adapted from Horwitz, A.V. (2010). The social control of mental illness. Clinton Corners, NY: Percheron Press.

6054_Ch02_012-026 01/09/17 10:42 am Page 16

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 17

Anxiety and grief have been described as two
primary psychological response patterns to stress. A
variety of thoughts, feelings, and behaviors are associ-
ated with each of these response patterns. Adaptation
is determined by the degree to which the thoughts,
feelings, and behaviors interfere with an individual’s
functioning.

Anxiety
Feelings of anxiety are so common in our society that
they are almost considered universal. Anxiety arises
from the chaos and confusion that exists in the world.
Fear of the unknown and conditions of ambiguity
offer a perfect breeding ground for anxiety to take
root and grow. Low levels of anxiety are adaptive and
can provide the motivation required for survival. Anx-
iety becomes problematic when the individual is un-
able to prevent his or her response from escalating to
a level that interferes with the ability to meet basic
needs.

Peplau (1963) described four levels of anxiety: mild,
moderate, severe, and panic. It is important for nurses
to be able to recognize the symptoms associated with
each level to plan for appropriate intervention with
anxious individuals.

■ Mild anxiety: This level of anxiety is seldom a prob-
lem for the individual. It is associated with the
tension experienced in response to the events of
day-to-day living. Mild anxiety prepares people for
action. It sharpens the senses, increases motivation
for productivity, increases the perceptual field, and
results in a heightened awareness of the environ-
ment. Learning is enhanced, and the individual is
able to function at his or her optimal level.

■ Moderate anxiety: As the level of anxiety increases,
the extent of the perceptual field diminishes. The
moderately anxious individual is less alert to events
occurring in the environment. The individual’s
attention span and ability to concentrate decrease,
although he or she may still attend to needs with
direction. Assistance with problem-solving may be
required. Increased muscular tension and restless-
ness are evident.

■ Severe anxiety: The perceptual field of the severely
anxious individual is so greatly diminished that
concentration centers on one particular detail only
or on many extraneous details. Attention span is

extremely limited, and the individual has difficulty
completing even the simplest task. Physical symp-
toms (e.g., headaches, palpitations, insomnia) and
emotional symptoms (e.g., confusion, dread, hor-
ror) may be evident. Discomfort is experienced to
the degree that virtually all overt behavior is aimed
at relieving the anxiety.

■ Panic anxiety: In this most intense state of anxiety, the
individual is unable to focus on even one detail in the
environment. Misperceptions are common, and a loss
of contact with reality may occur. The individual may
experience hallucinations or delusions. Behavior may
be characterized by wild and desperate actions or
extreme withdrawal. Human functioning and com-
munication with others is ineffective. Panic anxiety is
associated with a feeling of terror, and individuals may
be convinced that they have a life-threatening illness
or fear that they are “going crazy,” are losing control,
or are emotionally weak. Prolonged panic anxiety can
lead to physical and emotional exhaustion and can
be a life-threatening situation.

A synopsis of the characteristics associated with each
of the four levels of anxiety is presented in Table 2–1.

Behavioral Adaptation Responses to Anxiety
A variety of behavioral adaptation responses occur at
each level of anxiety. Figure 2–2 depicts these behav-
ioral responses on a continuum of anxiety ranging
from mild to panic.

Mild Anxiety
At the mild level, individuals employ any of a number
of coping behaviors that satisfy their needs for com-
fort. Menninger (1963) described the following types
of coping mechanisms that individuals use to relieve
anxiety in stressful situations:

CORE CONCEPT
Anxiety
A diffuse, vague apprehension that is associated with
feelings of uncertainty and helplessness.

■ Sleeping
■ Yawning
■ Eating
■ Drinking
■ Physical exercise
■ Daydreaming
■ Smoking
■ Laughing
■ Crying

■ Cursing
■ Pacing
■ Nail biting
■ Foot swinging
■ Finger tapping
■ Fidgeting
■ Talking to someone

with whom one feels
comfortable

Undoubtedly, there are many more responses too
numerous to mention here, considering that each
individual develops his or her own unique ways to
relieve mild anxiety. Some of these behaviors are
more adaptive than others.

Mild-to-Moderate Anxiety
Sigmund Freud (1961) identified the ego as the
reality component of the personality, governing

6054_Ch02_012-026 01/09/17 10:42 am Page 17

threat to biological or psychological integrity. Some
of these ego defense mechanisms are more adaptive
than others, but all are used either consciously or
unconsciously as protective devices for the ego in
an effort to relieve mild-to-moderate anxiety. The
mechanisms become maladaptive when used by an
individual to such a degree that there is interfer-
ence with the ability to deal with reality, effective in-
terpersonal relations, or occupational performance.
Maladaptive use of defense mechanisms promotes
disintegration of the ego. The major ego defense
mechanisms identified by Anna Freud are summa-
rized in Table 2–2.

18 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

TA B L E 2 – 1 Levels of Anxiety
PHYSICAL EMOTIONAL AND BEHAVIORAL

LEVEL PERCEPTUAL FIELD ABILITY TO LEARN CHARACTERISTICS CHARACTERISTICS

Mild

Moderate

Severe

Panic

Heightened perception
(e.g., noises may
seem louder; details
within the environ-
ment are clearer)

Increased awareness
Increased alertness

Reduction in perceptual
field

Reduced alertness to
environmental events
(e.g., someone talk-
ing may not be
heard; part of the
room may not be
noticed)

Greatly diminished; only
extraneous details are
perceived, or fixation
on a single detail may
occur

May not take notice of
an event even when
attention is directed
by another

Unable to focus on
even one detail within
the environment

Misperceptions of
the environment
common (e.g., a
perceived detail may
be elaborated and
out of proportion)

Learning is
enhanced

Learning still occurs
but not at optimal
ability

Decreased attention
span

Decreased ability to
concentrate

Extremely limited
attention span

Unable to concen-
trate or problem-
solve

Effective learning
cannot occur

Learning cannot
occur

Unable to concen-
trate

Unable to compre-
hend even simple
directions

Restlessness
Irritability

Increased restlessness
Increased heart and

respiration rates
Increased perspiration
Gastric discomfort
Increased muscular

tension
Increase in speech rate,

volume, and pitch

Headaches
Dizziness
Nausea
Trembling
Insomnia
Palpitations
Tachycardia
Hyperventilation
Urinary frequency
Diarrhea

Dilated pupils
Labored breathing
Severe trembling
Sleeplessness
Palpitations
Diaphoresis and pallor
Muscular incoordination
Immobility or purpose-

less hyperactivity
Incoherence or inability

to verbalize

May remain superficial
with others

Rarely experienced
as distressful

Motivation is increased

A feeling of discontent
May lead to a degree of

impairment in interper-
sonal relationships as
individual begins to
focus on self and the
need to relieve
personal discomfort

Feelings of dread, loathing,
horror

Total focus on self and
intense desire to relieve
the anxiety

Sense of impending
doom

Terror
Bizarre behavior, including

shouting, screaming,
running about wildly,
clinging to anyone or
anything from which a
sense of safety and
security is derived

Hallucinations, delusions
Extreme withdrawal

into self

Mild Moderate Severe Panic

Coping
mechanisms

Ego
defense

mechanisms

Psycho-
neurotic

responses

Psychotic
responses

Psycho-
physiological
responses

FIGURE 2–2 Adaptation responses on a continuum of anxiety.

problem-solving and rational thinking. As the level
of anxiety increases, the strength of the ego is tested,
and energy is mobilized to confront the threat.
Anna Freud (1953) identified a number of defense
mechanisms employed by the ego in the face of

6054_Ch02_012-026 01/09/17 10:42 am Page 18

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 19

TA B L E 2 – 2 Ego Defense Mechanisms
DEFENSE MECHANISM EXAMPLE DEFENSE MECHANISM EXAMPLE

COMPENSATION
Covering up a real or
perceived weakness by
emphasizing a trait one
considers more desirable

DENIAL
Refusing to acknowledge
the existence of a real
situation or the feelings
associated with it

DISPLACEMENT
The transfer of feelings
from one target to another
that is considered less
threatening or that is
neutral

IDENTIFICATION
An attempt to increase
self-worth by acquiring
certain attributes and
characteristics of an
individual one admires

INTELLECTUALIZATION
An attempt to avoid
expressing actual
emotions associated
with a stressful situation
by using the intellectual
processes of logic,
reasoning, and analysis

INTROJECTION
Integrating the beliefs
and values of another
individual into one’s
own ego structure

ISOLATION
Separating a thought
or memory from the
feeling, tone, or emotion
associated with it

PROJECTION
Attributing feelings or

impulses unacceptable
to one’s self to another
person

A physically handicapped
boy is unable to partici-
pate in football, so he
compensates by becom-
ing a great scholar.

A woman drinks alcohol
every day and cannot
stop, failing to acknowl-
edge that she has a
problem.

A client is angry with his
physician, does not ex-
press it, but becomes
verbally abusive with the
nurse.

A teenager who required
lengthy rehabilitation
after an accident decides
to become a physical
therapist as a result of his
experiences.

Sarah’s husband is being
transferred with his job to
a city far away from her
parents. She hides anxiety
by explaining to her par-
ents the advantages asso-
ciated with the move.

Children integrate their
parents’ value system
into the process of con-
science formation. A child
says to a friend, “Don’t
cheat. It’s wrong.”

A young woman de-
scribes being attacked
and raped without
showing any emotion.

Sue feels a strong sexual
attraction to her track
coach and tells her friend,
“He’s coming on to me!”

RATIONALIZATION
Attempting to make
excuses or formulate
logical reasons to justify
unacceptable feelings or
behaviors

REACTION FORMATION
Preventing unacceptable
or undesirable thoughts
or behaviors from being
expressed by exaggerat-
ing opposite thoughts or
types of behaviors

REGRESSION
Retreating in response
to stress to an earlier
level of development
and the comfort mea –
sures associated with
that level of functioning

REPRESSION
Involuntarily blocking
unpleasant feelings and
experiences from one’s
awareness

SUBLIMATION
Rechanneling of drives
or impulses that are
personally or socially
unacceptable into
activities that are
constructive

SUPPRESSION
The voluntary blocking
of unpleasant feelings
and experiences from
one’s awareness

UNDOING
Symbolically negating
or canceling out an
experience that one
finds intolerable

John tells the rehab
nurse, “I drink because
it’s the only way I can
deal with my bad mar-
riage and my worse job.”

Jane hates nursing. She
attended nursing school to
please her parents. During
career day, she speaks
to prospective students
about the excellence of
nursing as a career.

When 2-year-old Jay is
hospitalized for tonsillitis
he will drink only from a
bottle, even though his
mother states he has
been drinking from a
cup for 6 months.

An accident victim can
remember nothing about
his accident.

A mother whose son was
killed by a drunk driver
channels her anger and
energy into being the
president of the local
chapter of Mothers
Against Drunk Driving.

Scarlett says, “I don’t
want to think about that
now. I’ll think about that
tomorrow.”

Joe is nervous about his
new job and yells at his
wife. On his way home
he stops and buys her
some flowers.

6054_Ch02_012-026 01/09/17 10:42 am Page 19

Moderate-to-Severe Anxiety
Anxiety at the moderate-to-severe level that remains
unresolved over an extended period of time can
contribute to a number of physiological disorders.
The DSM-5 (APA, 2013) describes these disorders
under the category “Psychological Factors Affecting
Other Medical Conditions.” The psychological factors
may exacerbate symptoms of, delay recovery from, or
interfere with treatment of the medical condition.
The condition may be initiated or exacerbated by
an environmental situation that the individual per-
ceives as stressful. Measurable pathophysiology can be
demonstrated. It is thought that psychological and
behavioral factors may affect the course of almost
every major category of disease, including but not
limited to cardiovascular, gastrointestinal, neoplastic,
neurological, and pulmonary conditions.

Severe Anxiety
Extended periods of repressed severe anxiety can re-
sult in psychoneurotic behavior patterns. Neurosis is
no longer considered a separate category of mental
disorder. However, the term is still used in the literature
to further describe the symptomatology of certain
disorders and to differentiate from behaviors that
occur at the more serious level of psychosis. Neuroses
are psychiatric disturbances characterized by excessive
anxiety that is expressed directly or altered through de-
fense mechanisms. It appears as a symptom such as an
obsession, a compulsion, a phobia, or a sexual dysfunc-
tion (Sadock, Sadock, & Ruiz, 2015). The following are
common characteristics of people with neuroses:

■ They are aware that they are experiencing distress.
■ They are aware that their behaviors are maladaptive.
■ They are unaware of any possible psychological

causes of the distress.
■ They feel helpless to change their situation.
■ They experience no loss of contact with reality.

The following disorders are examples of psychoneu-
rotic responses to anxiety as they appear in the DSM-5:

■ Anxiety disorders: Disorders in which the character-
istic features are symptoms of anxiety and avoidance
behavior (e.g., phobias, panic disorder, generalized
anxiety disorder, and separation anxiety disorder).

■ Somatic symptom disorders: Disorders in which the
characteristic features are physical symptoms for
which there is no demonstrable organic pathology.
Psychological factors are judged to play a significant
role in the onset, severity, exacerbation, or mainte-
nance of the symptoms (e.g., somatic symptom dis-
order, illness anxiety disorder, conversion disorder,
and factitious disorder).

■ Dissociative disorders: Disorders in which the
characteristic feature is a disruption in the usually
integrated functions of consciousness, memory,

identity, or perception of the environment (e.g.,
dissociative amnesia, dissociative identity disorder,
and depersonalization-derealization disorder).

Panic Anxiety
At this extreme level of anxiety, an individual is not
capable of processing what is happening in the envi-
ronment and may lose contact with reality. Psychosis
is defined as a significant thought disturbance in
which reality testing is impaired, resulting in delu-
sions, hallucinations, disorganized speech, or catatonic
behavior (Black & Andreasen, 2014). The following are
common characteristics of people with psychoses:

■ They exhibit minimal distress (emotional tone is
flat, bland, or inappropriate).

■ They are unaware that their behavior is maladaptive.
■ They are unaware of any psychological problems

(anosognosia).
■ They are exhibiting a flight from reality into a less

stressful world or one in which they are attempting
to adapt.

Examples of psychotic responses to anxiety include
schizophrenic, schizoaffective, and delusional disorders.

20 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

CORE CONCEPT
Grief
Grief is a subjective state of emotional, physical, and
social responses to the loss of a valued entity.

Grief
Most individuals experience intense emotional an-
guish in response to a significant personal loss. A loss
is anything that is perceived as such by the individual.
Losses may be real, in which case they can be substan-
tiated by others (e.g., death of a loved one, loss of per-
sonal possessions), or they may be perceived by the
individual alone, unable to be shared or identified by
others (e.g., loss of the feeling of femininity following
mastectomy). Any situation that creates change for an
individual can be identified as a loss. Failure (either
real or perceived) also can be viewed as a loss.

The loss or anticipated loss of anything of value
to an individual can trigger the grief response. This
period of characteristic emotions and behaviors is
called mourning. The “normal” mourning process is
adaptive and is characterized by feelings of sadness,
guilt, anger, helplessness, hopelessness, and despair.
An absence of mourning after a loss may be consid-
ered maladaptive.

Stages of Grief
Kübler-Ross (1969), in extensive research with termi-
nally ill patients, identified five stages of feelings and

6054_Ch02_012-026 01/09/17 10:42 am Page 20

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 21

behaviors that individuals experience in response to
a real, perceived, or anticipated loss:

Stage 1—Denial: This is a stage of shock and dis –
belief. The response may be one of “No, it can’t
be true!” The reality of the loss is not acknowl-
edged. Denial is a protective mechanism that al-
lows the individual to cope in an immediate time
frame while organizing more effective defense
strategies.

Stage 2—Anger: “Why me?” and “It’s not fair!” are
comments often expressed during the anger
stage. Envy and resentment toward individuals
not affected by the loss are common. Anger may
be directed at the self or displaced on loved ones,
caregivers, and even God. There may be a pre –
occupation with an idealized image of the lost
entity.

Stage 3—Bargaining: During this stage, which is usu-
ally not visible or evident to others, a “bargain” is
made with God in an attempt to reverse or post-
pone the loss: “If God will help me through this, I
promise I will go to church every Sunday and
volunteer my time to help others.” Sometimes the
promise is associated with feelings of guilt for not
having performed satisfactorily, appropriately, or
sufficiently.

Stage 4—Depression: During this stage, the full im-
pact of the loss is experienced. The sense of loss is
intense, and feelings of sadness and depression
prevail. This is a time of quiet desperation and
disengagement from all association with the lost
entity. It differs from pathological depression, which
occurs when an individual becomes fixed in an
earlier stage of the grief process. Rather, stage 4 of
the grief response represents advancement toward
resolution.

Stage 5—Acceptance: The final stage brings a feeling
of peace regarding the loss that has occurred. It is
a time of quiet expectation and resignation. The
focus is on the reality of the loss and its meaning
for the individuals affected by it.

Not all individuals experience each of these stages
in response to a loss, nor do they necessarily experi-
ence them in this order. Some individuals’ grieving
behaviors may fluctuate and even overlap between
stages.

Anticipatory Grief
When a loss is anticipated, individuals often begin
the work of grieving before the actual loss occurs.
Most people reexperience the grieving behaviors
once the loss occurs, but preparing for the loss in
advance can facilitate the process of mourning,
actually decreasing the length and intensity of the
response. Problems arise, particularly in anticipating

the death of a loved one, when family members
experience anticipatory grieving and complete the
mourning process prematurely. They disengage
emotionally from the dying person, who may then
experience feelings of rejection by loved ones at a
time when this psychological support is so necessary.

Resolution
The grief response can last from weeks to years. It
cannot be hurried, and individuals must be allowed
to progress at their own pace. In the loss of a loved
one, grief work usually lasts for at least a year, during
which the grieving person experiences each signifi-
cant anniversary or holiday for the first time without
the loved one present.

Length of the grief process may be prolonged by a
number of factors. If the relationship with the lost
entity was marked by ambivalence or if there had
been an enduring love–hate association, reaction to
the loss may be burdened with guilt. Guilt lengthens
the grief reaction by promoting feelings of anger
toward oneself for having committed a wrongdoing
or behaved in an unacceptable manner toward a lost
loved one. He or she may even feel that the negative
behavior contributed to the loss.

Anticipatory grieving may shorten the grief response
in individuals who are able to work through some of
the feelings before the loss occurs. If the loss is sudden
and unexpected, mourning may take longer than it
would if individuals were able to grieve in anticipation
of the loss.

Length of the grieving process is also affected
by the number of recent losses experienced by
an individual and whether he or she is able to
complete one grieving process before another
loss occurs. This is particularly true for elderly indi-
viduals who may experience numerous losses in
a span of a few years, including spouse, friends,
other relatives, independent functioning, home,
personal possessions, and pets. Grief accumulates
into a bereavement overload, which for some indi-
viduals is perceived as difficult or even impossible
to overcome.

The process of mourning may be considered
resolved when an individual is able to regain a sense
of organization, redefine his or her life in the ab-
sence of the lost person or object, and pursue new
interests and relationships. Disorganization and
emotional pain have been experienced and toler-
ated. Preoccupation with the lost entity has been
replaced with a renewed energy and new resolve
about ways to keep the memory of the lost one alive.
Most grief, however, does not permanently disap-
pear but will reemerge from time to time in re-
sponse to triggers such as anniversary dates (Sadock
et al., 2015).

6054_Ch02_012-026 01/09/17 10:42 am Page 21

Maladaptive Grief Responses
Maladaptive responses to loss occur when an individual
is not able to satisfactorily progress through the stages
of grieving to achieve resolution. These responses
usually occur when an individual becomes fixed in the
denial or anger stage of the grief process. Several types
of grief responses have been identified as pathological,
including those that are prolonged, delayed, inhibited,
or distorted. The prolonged response is characterized
by an intense preoccupation with memories of the lost
entity for many years after the loss has occurred. Behaviors
associated with the stages of denial or anger are mani-
fested, and disorganization of functioning and intense
emotional pain related to the lost entity are evidenced.

In the delayed or inhibited response, the individual
becomes fixed in the denial stage of the grieving
process. The emotional pain associated with the loss
is not experienced, but anxiety disorders (e.g., pho-
bias, somatic symptom disorders) or sleeping and
eating disorders (e.g., insomnia, anorexia) may be

evident. The individual may remain in denial for
many years until the grief response is triggered by a
reminder of the loss or even by an unrelated loss.

The individual who experiences a distorted response
is fixed in the anger stage of grieving. In the distorted
response, all the normal behaviors associated with griev-
ing, such as helplessness, hopelessness, sadness, anger,
and guilt, are exaggerated out of proportion to the
situation. The individual turns the anger inward on the
self, is consumed with overwhelming despair, and is
unable to function in normal activities of daily living.
Pathological depression is a distorted grief response.

Mental Health/Mental Illness Continuum

Anxiety and grief have been described as two primary
responses to stress. In Figure 2–3, both of these re-
sponses are presented on a continuum according to
degree of symptom severity. Disorders as they appear
in the DSM-5 are identified at their appropriate place-
ment along the continuum.

22 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

Feelings of
Sadness

Dysthymia
Cyclothymic Disorder

Major Depression
Bipolar Disorder

Life’s Everyday
Disappointments

Neurotic
Responses

Psychotic
Responses

Mild Moderate Severe

Grief Grief

Anxiety Anxiety

Panic

Coping
Mechanisms

Ego Defense
Mechanisms

Psychoneurotic
Responses

Psychotic
Responses

Sleeping
Eating
Yawning
Drinking
Exercise
Smoking
Crying
Pacing
Laughing
Talking it
out with
someone

Compensation
Denial
Displacement
Identification
Isolation
Projection
Rationalization
Regression
Repression
Sublimation
Suppression
Undoing

Headaches
Anorexia
Arthritis
Colitis
Ulcers
Asthma
Pain
Cancer
CHD
Sexual
dysfunction

Phobias
Obsessions
Compulsions
Hypochondriasis
Conversion
disorder
Multiple
personalities
Amnesia
Fugue

Schizophrenia
Schizoaffective
disorder
Delusional
disorders

Mild Moderate Severe

Mental
Health

Mental
Illness

Psychophysiological
Responses

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

6054_Ch02_012-026 01/09/17 10:42 am Page 22

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 23

Summary and Key Points

■ Psychiatric care has its roots in ancient times, when
etiology was based in superstition and ideas related
to the supernatural.

■ Treatments were often inhumane and included
brutal beatings, starvation, or torture.

■ Hippocrates associated insanity and mental illness
with an irregularity in the interaction of the four
body fluids (humors): blood, black bile, yellow bile,
and phlegm.

■ Conditions for care of the mentally ill have im-
proved, largely because of the influence of leaders
such as Benjamin Rush, Dorothea Dix, and Linda
Richards, whose endeavors provided a model for
more humanistic treatment.

■ Maslow identified a hierarchy of needs that individ-
uals seek to fulfill in their quest to self-actualization
(one’s highest potential).

■ For purposes of this text, the definition of mental
health is “the successful adaptation to stressors from
the internal or external environment, evidenced by
thoughts, feelings, and behaviors that are age-
appropriate and congruent with local and cultural
norms.”

■ Most cultures label behavior as mental illness on the
basis of incomprehensibility and cultural relativity.

■ When observers are unable to find meaning or
comprehensibility in behavior, they are likely to
label that behavior as mental illness. The meaning
of behaviors is determined within individual cul-
tures. For purposes of this text, the definition of
mental illness is viewed as “maladaptive responses to
stressors from the internal or external environment,

evidenced by thoughts, feelings, and behaviors that
are incongruent with the local and cultural norms,
and that interfere with the individual’s social, occu-
pational, and/or physical functioning.”

■ Anxiety and grief have been described as two pri-
mary psychological response patterns to stress.

■ Peplau defined anxiety by levels of symptom sever-
ity: mild, moderate, severe, and panic.

■ Behaviors associated with levels of anxiety include
coping mechanisms, ego defense mechanisms,
psychophysiological responses, psychoneurotic
responses, and psychotic responses.

■ Grief is described as a response to loss of a valued
entity. Loss is anything that is perceived as such by
the individual.

■ Kübler-Ross, in extensive research with terminally
ill patients, identified five stages of feelings and
behaviors that individuals experience in response
to a real, perceived, or anticipated loss: denial,
anger, bargaining, depression, and acceptance.

■ Anticipatory grief is grief work that begins and
sometimes ends before the loss occurs.

■ Resolution is thought to occur when an individual
is able to remember and accept both the positive
and negative aspects associated with the lost entity.

■ Grieving is thought to be maladaptive when the
mourning process is prolonged, delayed or inhib-
ited, or becomes distorted and exaggerated out of
proportion to the situation. Pathological depres-
sion is considered to be a distorted reaction.

Additional info available
at www.davisplus.com

Review Questions
Self-Examination/Learning Exercise

Select the answer that is most appropriate for each of the following questions.

1. Anna’s dog, Lucky, her pet for 16 years, was killed by a car 3 years ago. Since that time, Anna has lost
weight, rarely leaves her home, and talks excessively about Lucky. Why would Anna’s behavior be
considered maladaptive?
a. It has been more than 3 years since Lucky died.
b. Her grief is too intense over the loss of a dog.
c. Her grief is interfering with her functioning.
d. Cultural norms typically do not comprehend grief over the loss of a pet.

Continued

6054_Ch02_012-026 01/09/17 10:42 am Page 23

24 U N I T 1 ■ Basic Concepts in Psychiatric-Mental Health Nursing

Review Questions—cont’d
Self-Examination/Learning Exercise

2. Anna states that Lucky was her closest friend, and since his death, there is no one who could ever
replace the relationship they had. According to Maslow’s hierarchy of needs, which level of need is
not being met?
a. Physiological needs
b. Self-esteem needs
c. Safety and security needs
d. Love and belonging needs

3. Anna’s daughter notices that Anna appears to be listening to another voice when just the two of them
are in a room together. When questioned, Anna admits that she hears someone telling her that she
was a horrible caretaker for Lucky and did not deserve to ever have a pet. Which of the following best
describes what Anna is experiencing?
a. Neurosis
b. Psychosis
c. Depression
d. Bereavement

4. Anna, who is 72 years old, is of the age when she may have experienced several losses in a short time.
What is this called?
a. Bereavement overload
b. Normal mourning
c. Isolation
d. Cultural relativity

5. Anna has been grieving the death of Lucky for 3 years. She is unable to take care of her normal activities
because she insists on visiting Lucky’s grave daily. What is the most likely reason that Anna’s daughter
has put off seeking help for Anna?
a. Women are less likely than men to seek help for emotional problems.
b. Relatives often try to normalize behavior rather than label it mental illness.
c. She knows that all older people are expected to be a little depressed.
d. She is afraid that the neighbors will think her mother is “crazy.”

6. Lucky’s accident occurred when he got away from Anna while they were taking a walk. He ran into the
street and was hit by a car. Anna cannot remember the circumstances of his death. This is an example
of what defense mechanism?
a. Rationalization
b. Suppression
c. Denial
d. Repression

7. Lucky sometimes refused to obey Anna’s commands to come back to her, including when he ran into
the street on the day of the accident. But Anna continues to insist, “He was the very best dog. He always
minded me. He always did everything I told him to do.” Which defense mechanism is Anna exhibiting?
a. Sublimation
b. Compensation
c. Reaction formation
d. Undoing

8. Anna has been a widow for 20 years. Her maladaptive grief response to the loss of her dog may be
attributed to which of the following? (Select all that apply.)
a. Unresolved grief over loss of her husband
b. Loss of several relatives and friends over the last few years
c. Repressed feelings of guilt over the way Lucky died
d. Inability to prepare in advance for the loss

6054_Ch02_012-026 01/09/17 10:43 am Page 24

C H A P T E R 2 ■ Mental Health and Mental Illness: Historical and Theoretical Concepts 25

Review Questions—cont’d
Self-Examination/Learning Exercise

9. For what reason would Anna’s illness be considered a neurosis rather than a psychosis?
a. She is unaware that her behavior is maladaptive.
b. She exhibits inappropriate affect (emotional tone).
c. She experiences no loss of contact with reality.
d. She tells the nurse, “There is nothing wrong with me!”

10. Which of the following statements by Anna might suggest that she is achieving resolution of her grief
over Lucky’s death?
a. “I don’t cry anymore when I think about Lucky.”
b. “It’s true. Lucky didn’t always mind me. Sometimes he ignored my commands.”
c. “I remember how it happened now. I should have held tighter to his leash!”
d. “I won’t ever have another dog. It’s just too painful to lose them.”

References
American Psychiatric Association. (2013). Diagnostic and statistical

manual of mental disorders (5th ed.). Washington, DC: American
Psychiatric Publishing.

Black, D.W., & Andreasen, N.C. (2014). Introductory textbook of
psychiatry (6th ed.). Washington, DC: American Psychiatric
Publishing.

Horwitz, A.V. (2010). The social control of mental illness. Clinton
Corners, NY: Percheron Press.

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia:
Lippincott Williams & Wilkins.

Classical References
Freud, A. (1953). The ego and mechanisms of defense. New York:

International Universities Press.

Freud, S. (1961). The ego and the id. In Standard edition of the
complete psychological works of Freud (Vol. XIX). London:
Hogarth Press.

Jahoda, M. (1958). Current concepts of positive mental health.
New York: Basic Books.

Kübler-Ross, E. (1969). On death and dying. New York: Macmillan.
Maslow, A. (1970). Motivation and personality (2nd ed.). New York:

Harper & Row.
Menninger, K. (1963). The vital balance. New York: Viking Press.
Peplau, H. (1963). A working definition of anxiety. In S. Burd &

M. Marshall (Eds.), Some clinical approaches to psychiatric
nursing. New York: Macmillan.

Robinson, L. (1983). Psychiatric nursing as a human experience
(3rd ed.). Philadelphia: WB Saunders.

6054_Ch02_012-026 01/09/17 10:43 am Page 25

6054_Ch02_012-026 01/09/17 10:43 am Page 26

U N I T 2
Foundations for

Psychiatric-Mental
Health Nursing

6054_Ch03_027-053 27/07/17 5:22 PM Page 27

3 Concepts of Psychobiology
C H A P T E R O U T L I N E

Objectives

Homework Assignment

The Nervous System: An Anatomical Review

Neuroendocrinology

Genetics

Psychoneuroimmunology

Psychopharmacology and the Brain

Implications for Nursing

Summary and Key Points

Review Questions

K EY T E R M S

axon

cell body

circadian rhythms

dendrites

genotype

limbic system

neuron

neurotransmitter

phenotype

receptor sites

synapse

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

1. Identify gross anatomical structures of the
brain and describe their functions.

2. Discuss the physiology of neurotransmission
in the central nervous system.

3. Describe the role of neurotransmitters in
human behavior.

4. Discuss the association of endocrine func-
tioning to the development of psychiatric
disorders.

5. Describe the role of genetics in the develop-
ment of psychiatric disorders.

6. Discuss the correlation of altered brain
function to various psychiatric disorders.

7. Identify diagnostic procedures used to detect
alteration in biological functioning that may
contribute to psychiatric disorders.

8. Discuss the influence of psychological
factors on the immune system.

9. Describe the biological mechanisms of
psychoactive drugs at neural synapses.

10. Recognize theorized influences in the devel-
opment of psychiatric disorders, including
brain physiology, genetics, endocrine func-
tion, immune system, and psychosocial
and environmental factors.

11. Discuss the implications of psychobiological
concepts for the practice of psychiatric-
mental health nursing.

H O M E W O R K A S S I G N M E N T
Please read the chapter and answer the following questions:

1. A dramatic reduction in which neurotransmit-
ter is most closely associated with Alzheimer’s
disease?

2. Anorexia nervosa has been associated with
a primary dysfunction of which structure of
the brain?

3. Many psychotropic medications work by
blocking the reuptake of neurotransmitters.
Describe the process of reuptake.

4. What psychiatric disorder may be linked to
chronic hypothyroidism?

CORE CONCEPTS
Genetics
Neuroendocrinology
Psychobiology
Psychoneuroimmunology
Psychopharmacology

28

6054_Ch03_027-053 27/07/17 5:22 PM Page 28

In recent years, increased emphasis has been placed
on the organic basis for psychiatric illness. This “neu-
roscientific revolution” studies the biological basis of
behavior, and several mental illnesses are now consid-
ered physical disorders resulting from malfunctions
and/or malformations of the brain. That some psychi-
atric illnesses and associated behaviors can be traced
to biological factors does not imply that psychosocial
and sociocultural influences are totally discounted.
For example, there is evidence that psychological inter-
ventions have an influence on brain activity that is
similar to that of psychopharmacological intervention
(Flor, 2014; Furmark et al., 2002). Other evidence in-
dicates that lifestyle choices such as marijuana use
can precipitate mental illness (psychosis) in individuals
with genetic vulnerability (National Institutes of
Health, 2017). Ongoing research will build a better
understanding of the complex interplay of neural
activities within the brain and interaction with one’s
environment.

The systems of biology, psychology, and sociology
are not mutually exclusive—they are interacting sys-
tems. This interaction is clearly indicated by the fact
that individuals experience biological changes in
response to environmental events. One or several of
these systems may at various times explain behavioral
phenomena.

This chapter focuses on the role of neurophysiolog-
ical, neurochemical, genetic, and endocrine influences
on psychiatric illness. An introduction to psychophar-
macology is included (discussed in more detail in
Chapter 4, Psychopharmacology), and various diagnos-
tic procedures used to detect alteration in biological
function that may contribute to psychiatric illness are

identified. The implications for psychiatric-mental
health nursing are discussed.

The Nervous System: An Anatomical Review

The Brain
The brain has three major divisions, subdivided into
six major parts:

l. Forebrain
a. Cerebrum
b. Diencephalon

2. Midbrain
a. Mesencephalon

3. Hindbrain
a. Pons
b. Medulla
c. Cerebellum
Each of these structures is discussed individually.

A summary is presented in Table 3–1.

Cerebrum
The cerebrum consists of a right and left hemisphere
and constitutes the largest part of the human brain.
The two hemispheres are separated by a deep groove
and connected to each other by a band of 200 million
axons (nerve fibers) called the corpus callosum. Because

C H A P T E R 3 ■ Concepts of Psychobiology 29

CORE CONCEPT
Psychobiology
The study of the biological foundations of cognitive,
emotional, and behavioral processes.

TA B L E 3 – 1 Structure and Function of the Brain
STRUCTURE PRIMARY FUNCTION

I. FOREBRAIN
A. Cerebrum

1. Frontal lobes

2. Parietal lobes

3. Temporal lobes

4. Occipital lobes

Composed of two hemispheres connected by a band of nerve tissue that houses a band of
200 million axons called the corpus callosum. The outer layer is called the cerebral cortex.
It is extensively folded and consists of billions of neurons. The left hemisphere appears to
deal with logic and solving problems. The right hemisphere may be called the “creative” brain
and is associated with affect, behavior, and spatial-perceptual functions. Each hemisphere is
divided into four lobes

Voluntary body movement, including movements that permit speaking, thinking and judgment
formation, and expression of feelings

Perception and interpretation of most sensory information (including touch, pain, taste, and
body position)

Hearing, short-term memory, and sense of smell; expression of emotions through connection
with limbic system

Visual reception and interpretation
Continued

6054_Ch03_027-053 27/07/17 5:22 PM Page 29

each hemisphere controls different functions, infor-
mation is processed through the corpus callosum
so that each hemisphere is aware of the activity of
the other.

The surface of the cerebrum consists of gray matter
and is called the cerebral cortex. The gray matter is com-
posed of neuron cell bodies that appear gray to the
eye. These cell bodies are thought to be the actual
“thinking” structures of the brain. The basal ganglia,
four subcortical nuclei of gray matter (the striatum,
the pallidum, the substantia nigra, and the subthalamic
nucleus), are found deep within the cerebral hemi-
spheres. They are responsible for certain subconscious
aspects of voluntary movement, such as swinging the
arms when walking, gesturing while speaking, and reg-
ulating muscle tone (Scanlon & Sanders, 2015).

The cerebral cortex is identified by numerous folds
called gyri and deep grooves between the folds called
sulci. This extensive folding extends the surface area
of the cerebral cortex to permit the presence of mil-
lions more neurons than could not be accommodated
without the folds (as is the case in the brains of some
animals, such as dogs and cats). Each hemisphere of
the cerebral cortex is divided into the frontal lobe,
parietal lobe, temporal lobe, and occipital lobe. These
lobes, which are named for the overlying bones in the
cranium, are identified in Figure 3–1.

The Frontal Lobes
Voluntary body movement is controlled by impulses
through the frontal lobes. The right frontal lobe

controls motor activity on the left side of the body,
and the left frontal lobe controls motor activity on
the right side of the body. The frontal lobe may also
play a role in the emotional experience, as evidenced
by changes in mood and character after damage to
this area. The prefrontal cortex (the front part of
the frontal lobe) plays an essential role in the regu-
lation and adaptation of our emotions to new situa-
tions and may have implications for moral and
spiritual responses (Sadock, Sadock, & Ruiz, 2015).
Neuroimaging tests suggest there may be decreased
activity in the frontal lobes of people with schizo-
phrenia (Butler et al., 2012).

The Parietal Lobes
The parietal lobes manage somatosensory input,
including touch, pain, pressure, taste, temperature,
perception of joint and body position, and visceral
sensations. The parietal lobes also contain association
fibers linked to the primary sensory areas through
which interpretation of sensory-perceptual informa-
tion is made. Language interpretation is associated
with the left hemisphere of the parietal lobe.

The Temporal Lobes
The upper anterior temporal lobe is concerned with
auditory functions, and the lower part is dedicated to
short-term memory. The sense of smell has a connec-
tion to the temporal lobes, as the impulses carried by
the olfactory nerves end in this area of the brain. The
temporal lobes also play a role in the expression of

30 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

TA B L E 3 – 1 Structure and Function of the Brain—cont’d
STRUCTURE PRIMARY FUNCTION

B. Diencephalon
1. Thalamus

2. Hypothalamus

3. Limbic system

II. MIDBRAIN
A. Mesencephalon

III. HINDBRAIN
A. Pons

B. Medulla

C. Cerebellum

Connects cerebrum with lower brain structures
Integrates all sensory input (except smell) on way to cortex; some involvement with emotions
and mood

Regulates anterior and posterior lobes of pituitary gland; exerts control over actions of the auto-
nomic nervous system; regulates appetite and temperature

Consists of medially placed cortical and subcortical structures and the fiber tracts connecting
them with one another and with the hypothalamus. It is sometimes called the “emotional
brain”—associated with feelings of fear and anxiety; anger and aggression; love, joy, and hope;
and with sexuality and social behavior

Responsible for visual, auditory, and balance (“righting”) reflexes

Regulation of respiration and skeletal muscle tone; ascending and descending tracts connect
brainstem with cerebellum and cortex

Pathway for all ascending and descending fiber tracts; contains vital centers that regulate heart rate,
blood pressure, and respiration; reflex centers for swallowing, sneezing, coughing, and vomiting

Regulates muscle tone and coordination and maintains posture and equilibrium

6054_Ch03_027-053 27/07/17 5:22 PM Page 30

emotions through an interconnection with the limbic
system. The left temporal lobe and the left parietal
lobe are involved in language interpretation.

The Occipital Lobes
The occipital lobes are the primary area of visual
reception and interpretation. Visual perception, the
ability to judge spatial relationships such as distance
and to see in three dimensions, is also processed in
this area. Language interpretation is affected by the
visual processing that occurs in the occipital lobes.

Diencephalon
The second part of the forebrain is the diencephalon,
which connects the cerebrum with lower structures of
the brain. The major components of the diencephalon
include the thalamus and the hypothalamus, which are
part of a neuroanatomical loop of structures known as
the limbic system. These structures are identified in
Figures 3–1 and 3–2.

Thalamus
The thalamus integrates all sensory input (except
smell) on its way to the cortex. This integration al-
lows for rapid interpretation of the whole rather than
individual perception of each sensation. The thala-
mus is also involved in temporarily blocking minor
sensations so that an individual can concentrate on

one important event when necessary. For example,
an individual who is studying for an examination may
be unaware of the clock ticking in the room or another
person entering because the thalamus has temporarily
blocked these incoming sensations from the cortex.
The impact of dopamine in the thalamus is associ-
ated with several neuropsychiatric disorders.

Hypothalamus
The hypothalamus is located just below the thalamus
and just above the pituitary gland. It has a number of
diverse functions.

1. Regulation of the pituitary gland: The pituitary
gland consists of two lobes—the posterior lobe and
the anterior lobe.
a. The posterior lobe of the pituitary gland is actually

extended tissue from the hypothalamus. The
posterior lobe stores antidiuretic hormone (which
helps to maintain blood pressure through regu-
lation of water retention) and oxytocin (the
hormone responsible for stimulation of the
uterus during labor and the release of milk from
the mammary glands). Both of these hormones
are produced in the hypothalamus. When the
hypothalamus detects the body’s need for these
hormones, it sends nerve impulses to the poste-
rior pituitary for their release.

C H A P T E R 3 ■ Concepts of Psychobiology 31

Frontal lobe

Premotor area
Motor area

General sensory area

Sensory association
area

Parietal lobe

Occipital lobe

Visual area

Auditory area

Temporal lobe

Auditory
association
area

Visual association
area

Motor speech area

Cerebellum

Pons Medulla

FIGURE 3–1 Left cerebral hemisphere showing some of the functional areas that have been mapped. (Adapted from Scanlon, V.C., & Sanders, T.
[2015]. Essentials of anatomy and physiology [7th ed.]. Philadelphia: F.A. Davis Company, with permission.)

6054_Ch03_027-053 27/07/17 5:23 PM Page 31

b. The anterior lobe of the pituitary gland consists
of glandular tissue that produces a number of
hormones used by the body. These hormones
are regulated by releasing factors from the hypo-
thalamus. When the hormones are required by
the body, the releasing factors stimulate the re-
lease of the hormone from the anterior pitu-
itary, and the hormone in turn stimulates its
target organ to carry out its specific functions.

2. Direct neural control over the actions of the auto-
nomic nervous system: The hypothalamus regulates
the appropriate visceral responses during various
emotional states. The actions of the autonomic
nervous system are described later in this chapter.

3. Regulation of appetite, temperature, blood pres-
sure, thirst, and circadian rhythms: Appetite is reg-
ulated through response to blood nutrient levels.

4. Regulation of temperature: The hypothalamus
senses internal temperature changes in the blood
that flows through the brain. It receives information

through sensory input from the skin about external
temperature changes and uses this information to
promote certain types of responses (e.g., sweating
or shivering) that help maintain body temperature
within the normal range.

Limbic System
The part of the brain known as the limbic system con-
sists of portions of the cerebrum and the dien-
cephalon. Its major components include the medially
placed cortical and subcortical structures and the
fiber tracts connecting them with one another and
with the hypothalamus. The limbic system is a group
of structures including the amygdala, mammillary
body, olfactory tract, hypothalamus, cingulate gyrus,
septum pellucidum, thalamus, hippocampus, and
fornix. This system has been called the “emotional
brain” and is associated with feelings of fear and
anxiety; anger, rage, and aggression; love, joy, and hope;
and sexuality and social behavior. The amygdala seems

32 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

Septum
pellucidum

Thalamus
Fornix

HippocampusMammillary body
Pituitary gland

Amygdala

Olfactory
tract

Hypothalamus

Cingulate
gyrus

FIGURE 3–2 Structures of the limbic system. (From Scanlon, V.C., & Sanders, T. [2011]. Essentials of anatomy and physiology [6th ed.]. Philadelphia:
F.A. Davis Company, with permission.)

6054_Ch03_027-053 27/07/17 5:23 PM Page 32

to be a primary gateway for processing emotional
stimuli, particularly responses to fear, anxiety, and
panic.

Mesencephalon
Structures of major importance in the mesencephalon,
or midbrain, include nuclei and fiber tracts. The
mesencephalon extends from the pons to the hypo-
thalamus and is responsible for integration of various
reflexes, including visual reflexes (e.g., automatically
turning away from a dangerous object when it comes
into view), auditory reflexes (e.g., automatically turn-
ing toward a sound that is heard), and righting reflexes
(e.g., automatically keeping the head upright and
maintaining balance).

Pons
The pons is a bulbous structure that lies between the
midbrain and the medulla as part of the brainstem
(Fig. 3–1). It is composed of large bundles of fibers
and forms a major connection between the cerebel-
lum and the brainstem. The pons is a relay station
that transmits messages between various parts of the
nervous system, including the cerebrum and cerebel-
lum. It contains the central connections of cranial
nerves V through VIII and centers for respiration and
skeletal muscle tone. The pons is also associated with
sleep and dreaming.

Medulla
The medulla is the connecting structure between the
spinal cord and the pons, and all of the ascending
and descending fiber tracts pass through it. The vital
centers are contained in the medulla, and it is respon-
sible for regulation of heart rate, blood pressure, and
respiration. The medulla contains reflex centers for
swallowing, sneezing, coughing, and vomiting, as
well as nuclei for cranial nerves IX through XII. The
medulla, pons, and midbrain form the structure
known as the brainstem.

Cerebellum
The cerebellum is separated from the brainstem by
the fourth ventricle but is connected to it through
bundles of fiber tracts (Fig. 3–1). The cerebellum is
associated with involuntary aspects of movement such
as coordination, muscle tone, and the maintenance
of posture and equilibrium.

Nerve Tissue
The tissue of the central nervous system (CNS) con-
sists of nerve cells called neurons that generate and
transmit electrochemical impulses. The structure of
a neuron is composed of a cell body, an axon, and
dendrites. The cell body contains the nucleus and is
essential for the continued life of the neuron. The

dendrites are processes that transmit impulses toward
the cell body, and the axon transmits impulses away
from the cell body. The axons and dendrites are cov-
ered by layers of cells called neuroglia that form a coat-
ing, or “sheath,” of myelin. Myelin is a phospholipid
that provides insulation against short-circuiting of the
neurons during their electrical activity and increases
the velocity of the impulse. The white matter of the
brain and spinal cord is so called because of the
whitish appearance of the myelin sheath over the axons
and dendrites. The gray matter is composed of cell
bodies that contain no myelin.

The three classes of neurons include afferent (sen-
sory), efferent (motor), and interneurons. The affer-
ent neurons carry impulses from receptors in the
internal and external periphery to the CNS, where
they are then interpreted into various sensations. The
efferent neurons carry impulses from the CNS to effectors
in the periphery, such as muscles (that respond by
contracting) and glands (that respond by secreting).

Interneurons exist entirely within the CNS, and
99 percent of all nerve cells belong to this group. They
may carry only sensory or motor impulses, or they may
serve as integrators in the pathways between afferent
and efferent neurons. They account in large part for
thinking, feelings, learning, language, and memory.

Synapses
Information is transmitted through the body from
one neuron to another. Some messages may be
processed through only a few neurons, whereas
others may require thousands of neuronal connec-
tions. The neurons that transmit the impulses do not
actually touch each other. The junction between two
neurons is called a synapse. The small space between
the axon terminals of one neuron and the cell body
or dendrites of another is called the synaptic cleft.
Neurons conducting impulses toward the synapse
are called presynaptic neurons, and those conducting
impulses away are called postsynaptic neurons.

Chemicals that act as neurotransmitters are stored
in the axon terminals of the presynaptic neuron. An
electrical impulse through the neuron causes the
release of this neurotransmitter into the synaptic cleft.
The neurotransmitter then diffuses across the synap-
tic cleft and combines with receptor sites that are
situated on the cell membrane of the postsynaptic
neuron. The type of combination determines whether
or not another electrical impulse is generated. If an
electrical impulse is generated, the result is called an
excitatory response and the electrical impulse moves on
to the next synapse, where the same process recurs.
If an electrical impulse is not generated by the neu-
rotransmitter-receptor site combination, the result is
called an inhibitory response, and synaptic transmission

C H A P T E R 3 ■ Concepts of Psychobiology 33

6054_Ch03_027-053 27/07/17 5:23 PM Page 33

is terminated. Activity at the neural synapse is relevant
in the study of psychiatric disorders because excessive
or deficient activity of neurotransmitters influences a
variety of cognitive and emotional symptoms. The
synapse is also believed to be the primary site of activ-
ity for psychotropic drugs.

The cell body of the postsynaptic neuron also con-
tains a chemical inactivator that is specific to the neuro-
transmitter released by the presynaptic neuron. When
the synaptic transmission has been completed, the
chemical inactivator quickly inactivates the neurotrans-
mitter to prevent unwanted, continuous impulses until
a new impulse from the presynaptic neuron releases
more of the neurotransmitter. Continuous impulses
can result in excessive activity of neurotransmitters
such as dopamine, which is believed to be responsible
for symptoms such as hallucinations and delusions
seen in people with schizophrenia. A schematic repre-
sentation of a synapse is presented in Figure 3–3.

Autonomic Nervous System
The autonomic nervous system (ANS) is considered
part of the peripheral nervous system. Its regulation
is modulated by the hypothalamus, and emotions
exert a great deal of influence over its functioning. For

this reason, the ANS has been implicated in the etiol-
ogy of a number of psychophysiological disorders.

The ANS has two divisions: the sympathetic and
the parasympathetic. The sympathetic division is
dominant in stressful situations and prepares the
body for the fight-or-flight response (discussed in
Chapter 1, The Concept of Stress Adaptation). The
neuronal cell bodies of the sympathetic division orig-
inate in the thoracolumbar region of the spinal cord.
Their axons extend to the chains of sympathetic
ganglia where they synapse with other neurons that
subsequently innervate the visceral effectors. This
results in an increase in heart rate and respiration
and a decrease in digestive secretions and peristalsis.
Blood is shunted to the vital organs and skeletal mus-
cles to ensure adequate oxygenation.

The neuronal cell bodies of the parasympathetic
division originate in the brainstem and the sacral
segments of the spinal cord and extend to the
parasympathetic ganglia where the synapse takes
place either very close to or actually in the visceral
organ being innervated. In this way, a very localized
response is possible. The parasympathetic division
dominates when an individual is in a relaxed, non-
stressful condition. The heart and respirations are

34 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

Na+

Na+

Na+

Axon of presynaptic
neuron

Vesicles of neurotransmitter Receptor site

Inactivator
(cholinesterase)

Dendrite of
postsynaptic

neuron

Inactivated
neurotransmitter

Neurotransmitter
(acetylcholine)

Mitochondrion

FIGURE 3–3 Impulse transmission at a synapse. The arrow indicates the direction of electrical impulses. (From Scanlon, V.C., & Sanders, T. [2015].
Essentials of anatomy and physiology [7th ed.]. Philadelphia: F.A. Davis Company, with permission.)

6054_Ch03_027-053 27/07/17 5:23 PM Page 34

maintained at a normal rate, and secretions and
peristalsis increase for normal digestion. Elimination
functions are promoted. A schematic representation
of the ANS is presented in Figure 3–4.

Neurotransmitters
Although neurotransmitters were described during
the explanation of synaptic activity, they are discussed
here separately and in detail because of the essential
function they perform in the role of human emotion

and behavior. Neurotransmitters are also central to the
therapeutic action of many psychotropic medications.

Neurotransmitters are chemicals that convey infor-
mation across synaptic clefts to neighboring target cells.
They are stored in small vesicles in the axon terminals
of neurons. When the action potential, or electrical
impulse, reaches this point, the neurotransmitters
are released from the vesicles. They cross the synaptic
cleft and bind with receptor sites on the cell body or
dendrites of the adjacent neuron to allow the impulse

C H A P T E R 3 ■ Concepts of Psychobiology 35

FIGURE 3–4 The autonomic nervous system. The sympathetic division is shown on the left, and the parasympathetic division is shown on the
right (both divisions are bilateral). (From Scanlon, V.C., & Sanders, T. [2015]. Essentials of anatomy and physiology [7th ed.]. Philadelphia: F.A. Davis Com-
pany, with permission.)

Sympathetic
Eye Ciliary ganglion

Parasympathetic

Salivary
glands

Pons

Otic
ganglion

Vagus nerve

Pterygopalatine
ganglion

Submandibular
ganglion

Midbrain
III

Medulla

VII

IX

Trachea

Preganglionic
neuron

Preganglionic neurons

Postganglionic
neuron

Postganglionic
neurons

Celiac ganglion

Adrenal gland

Chain of
sympathetic
ganglia

Inferior
mesenteric
ganglion

Kidney

Pancreas

Superior
mesenteric
ganglion

Large
intestine

Lung

Heart

Stomach

Small
intestine

Colon

Rectum

Reproductive
organs

T1
T2
T3
T4
T5
T6
T7
T8

T9
T10

T11

T12

L1

L2

S2
S3
S4

X

Bladder

6054_Ch03_027-053 27/07/17 5:23 PM Page 35

to continue its course or to prevent the impulse from
continuing. After the neurotransmitter has performed
its function in the synapse, it either returns to the vesi-
cles to be stored and used again or is inactivated and
dissolved by enzymes. The process of being stored for
reuse is called reuptake, a function that holds signifi-
cance for understanding the mechanism of action of
certain psychotropic medications.

Many neurotransmitters exist in the central and
peripheral nervous systems, but only a limited number

have implications for psychiatry. Major categories
include cholinergics, monoamines, amino acids, and
neuropeptides. Each of these is discussed separately
and summarized in Table 3–2.

Cholinergics
Acetylcholine
Acetylcholine was the first chemical to be identified
as and proven to be a neurotransmitter. It is a major
effector chemical in the ANS, producing activity

36 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

TA B L E 3 – 2 Neurotransmitters in the Central Nervous System
POSSIBLE IMPLICATIONS FOR MENTAL

NEUROTRANSMITTER LOCATION AND FUNCTION ILLNESS

I. CHOLINERGICS
A. Acetylcholine

II. MONOAMINES
A. Norepinephrine

B. Dopamine

C. Serotonin

D. Histamine

III. AMINO ACIDS
A. Gamma-aminobutyric

acid

B. Glycine

C. Glutamate and aspartate

ANS: Sympathetic and parasympathetic presynaptic
nerve terminals; parasympathetic postsynaptic
nerve terminals

CNS: Cerebral cortex, hippocampus, limbic
structures, and basal ganglia

Functions: Sleep, arousal, pain perception,
movement, memory

ANS: Sympathetic postsynaptic nerve terminals
CNS: Thalamus, hypothalamus, limbic system,

hippocampus, cerebellum, cerebral cortex
Functions: Mood, cognition, perception, locomotion,

cardiovascular functioning, and sleep and arousal

Frontal cortex, limbic system, basal ganglia, thalamus,
posterior pituitary, spinal cord

Functions: Movement and coordination, emotions,
voluntary judgment, release of prolactin

Hypothalamus, thalamus, limbic system, cerebral
cortex, cerebellum, spinal cord

Functions: Sleep and arousal, libido, appetite,
mood, aggression, pain perception, coordination,
judgment

Hypothalamus
Functions: Wakefulness; pain sensation, inflammatory

response

Hypothalamus, hippocampus, cortex, cerebellum,
basal ganglia, spinal cord, retina

Functions: Slowdown of body activity

Spinal cord, brainstem
Functions: Recurrent inhibition of motor neurons

Pyramidal cells of the cortex, cerebellum, and the
primary sensory afferent systems; hippocampus,
thalamus, hypothalamus, spinal cord

Functions: Relay of sensory information and in the
regulation of various motor and spinal reflexes

Glutamate also has a role in memory and learning.

Increased levels: Depression
Decreased levels: Alzheimer’s

disease, Huntington’s disease,
Parkinson’s disease

Decreased levels: Depression
Increased levels: Mania, anxiety

states, schizophrenia

Decreased levels: Parkinson’s
disease and depression

Increased levels: Mania and
schizophrenia

Decreased levels: Depression
Increased levels: Anxiety states

Decreased levels: Depression

Decreased levels: Huntington’s
disease, anxiety disorders,
schizophrenia, and various
forms of epilepsy

Toxic levels: Glycine
encephalopathy

Decreased levels: Correlated
with spastic motor movements

Increased levels: Huntington’s
disease, temporal lobe epilepsy,
spinal cerebellar degeneration,
anxiety disorders, depressive
disorders

Decreased levels: Schizophrenia

6054_Ch03_027-053 27/07/17 5:23 PM Page 36

C H A P T E R 3 ■ Concepts of Psychobiology 37

TA B L E 3 – 2 Neurotransmitters in the Central Nervous System—cont’d
POSSIBLE IMPLICATIONS FOR MENTAL

NEUROTRANSMITTER LOCATION AND FUNCTION ILLNESS

D. D-Serine

IV. NEUROPEPTIDES
A. Endorphins and

enkephalins

B. Substance P

C. Somatostatin

ANS, autonomic nervous system, CNS, central nervous system, NMDA, N-methyl D-aspartate.

Cerebral cortex, forebrain, hippocampus, cerebellum
striatum, thalamus

Functions: Binds at NMDA receptors and, with
glutamate, is a coagonist whose functions include
mediating NMDA receptor transmission, synaptic
plasticity, neurotoxicity

Hypothalamus, thalamus, limbic structures, midbrain,
brainstem; enkephalins are also found in the
gastrointestinal tract

Functions: Modulation of pain and reduced peristalsis
(enkephalins)

Hypothalamus, limbic structures, midbrain, brain-
stem, thalamus, basal ganglia, spinal cord; also
found in gastrointestinal tract and salivary glands

Function: Regulation of pain

Cerebral cortex, hippocampus, thalamus, basal
ganglia, brainstem, spinal cord

Function: Depending on part of the brain affected,
stimulates release of dopamine, serotonin, norep-
inephrine, and acetylcholine, and inhibits release
of norepinephrine, histamine, and glutamate;
also acts as a neuromodulator for serotonin
in the hypothalamus

Decreased levels: Schizophrenia

Modulation of dopamine activity
by opioid peptides may
indicate some link to the
symptoms of schizophrenia

Decreased levels: Huntington’s
disease, Alzheimer’s disease

Increased levels: Depression

Decreased levels: Alzheimer’s
disease

Increased levels: Huntington’s
disease

at all sympathetic and parasympathetic presynaptic
nerve terminals and all parasympathetic postsynap-
tic nerve terminals. It is highly significant in the
neurotransmission that occurs at the junctions
of nerves and muscles. Acetylcholinesterase is the
enzyme that destroys acetylcholine or inhibits its
activity.

In the CNS, acetylcholine neurons innervate the
cerebral cortex, hippocampus, and limbic structures.
The pathways are especially dense through the area
of the basal ganglia in the brain.

Functions of acetylcholine are manifold and include
sleep, arousal, pain perception, the modulation and
coordination of movement, and memory acquisition
and retention. Cholinergic mechanisms may have
some role in certain disorders of motor behavior and
memory, such as Parkinson’s disease, Huntington’s
disease, and Alzheimer’s disease.

Monoamines
Norepinephrine
Norepinephrine is the neurotransmitter that produces
activity at the sympathetic postsynaptic nerve terminals
in the ANS, resulting in fight-or-flight responses in the
effector organs. In the CNS, norepinephrine pathways
originate in the pons and medulla and innervate the

thalamus, dorsal hypothalamus, limbic system, hip-
pocampus, cerebellum, and cerebral cortex. When
norepinephrine is not returned for storage in the
vesicles of the axon terminals, it is metabolized and in-
activated by the enzymes monoamine oxidase (MAO)
and catechol-O-methyl-transferase (COMT).

The functions of norepinephrine include the regu-
lation of mood, cognition, perception, locomotion,
cardiovascular functioning, and sleep and arousal. The
activity of norepinephrine also has been implicated in
certain mood disorders such as depression and mania,
in anxiety states, and in schizophrenia (Sadock et al.,
2015).

Dopamine
Dopamine pathways arise from the midbrain and hypo-
thalamus and terminate in the frontal cortex, limbic
system, basal ganglia, and thalamus. As with norepi-
nephrine, the inactivating enzymes for dopamine are
MAO and COMT.

Dopamine functions include regulation of move-
ments and coordination, emotions, and voluntary
decision-making ability. Because of its influence on
the pituitary gland, it inhibits the release of prolactin
(Sadock et al., 2015). Increased levels of dopamine
are associated with mania and schizophrenia.

6054_Ch03_027-053 27/07/17 5:23 PM Page 37

Serotonin
Serotonin pathways originate from cell bodies located
in the pons and medulla and project to areas includ-
ing the hypothalamus, thalamus, limbic system, cere-
bral cortex, cerebellum, and spinal cord. Serotonin
that is not returned to be stored in the axon terminal
vesicles is catabolized by the enzyme MAO.

Serotonin may play a role in sleep and arousal,
libido, appetite, mood, aggression, and pain percep-
tion. The serotoninergic system has been implicated
in the etiology of certain psychopathological condi-
tions including anxiety states, mood disorders, and
schizophrenia (Sadock et al., 2015).

Histamine
The role of histamine in mediating allergic and inflam-
matory reactions has been well documented. Its role
in the CNS as a neurotransmitter has only recently
been confirmed, and the availability of information
on this function is limited. The highest concentrations
of histamine are found within various regions of the
hypothalamus. Histaminic neurons in the posterior
hypothalamus are associated with sustaining wakeful-
ness. The enzyme that catabolizes histamine is MAO.
Although the exact processes mediated by histamine
in the CNS are uncertain, some data suggest that his-
tamine may play a role in depressive illness.

Amino Acids
Inhibitory Amino Acids
Gamma-Aminobutyric Acid Gamma-aminobutyric acid
(GABA) has a widespread distribution in the CNS,
with high concentrations in the hypothalamus, hip-
pocampus, cortex, cerebellum, and basal ganglia of
the brain; in the gray matter of the dorsal horn of the
spinal cord; and in the retina. GABA is catabolized by
the enzyme GABA transaminase.

Inhibitory neurotransmitters such as GABA prevent
postsynaptic excitation, interrupting the progression
of the electrical impulse at the synaptic junction. This
function is significant when slowdown of body activity
is advantageous. Enhancement of the GABA system is
the mechanism of action by which the benzodiazepines
produce their calming effect.

Alterations in the GABA system have been impli-
cated in the etiology of anxiety disorders, movement
disorders (e.g., Huntington’s disease), and various
forms of epilepsy.

Glycine The highest concentrations of glycine in the
CNS are found in the spinal cord and brainstem. Little
is known about the possible enzymatic metabolism of
glycine.

Glycine appears to be the neurotransmitter of
recurrent inhibition of motor neurons within the
spinal cord and is possibly involved in the regulation

of spinal and brainstem reflexes. It has been impli-
cated in the pathogenesis of certain types of spastic
disorders and in glycine encephalopathy, which is known
to occur with toxic accumulation of the neurotrans-
mitter in the brain and cerebrospinal fluid (Van
Hove, Coughlin, & Sharer, 2013).

Excitatory Amino Acids
Glutamate and Aspartate Glutamate and aspartate
appear to be primary excitatory neurotransmitters in
the pyramidal cells of the cortex, the cerebellum, and
the primary sensory afferent systems. They are also
found in the hippocampus, thalamus, hypothalamus,
and spinal cord. Glutamate and aspartate are inacti-
vated by uptake into the tissues and through assimi-
lation in various metabolic pathways.

Glutamate and aspartate function in the relay
of sensory information and in the regulation of
various motor and spinal reflexes. Alteration in
these systems has been implicated in the etiology of
certain neurodegenerative disorders, such as Hunting-
ton’s disease, temporal lobe epilepsy, and spinal cere-
bellar degeneration. Recent studies have implicated
increased levels of glutamate in anxiety and depres-
sive disorders and decreased levels in schizophrenia
(Ouellet-Plamondon & George, 2012). Glutamate also
plays a role in memory and learning. Another amino
acid, D-serine, has been identified as a neurotrans-
mitter that, with glutamate, may act as a coagonist
at NMDA (N-methyl D-aspartate) receptors. Hypofunc-
tion of these neurotransmitters may be associated with
schizophrenia (Balu et al., 2013; Wolosker et al., 2008).

Neuropeptides
Neuropeptides act as signaling molecules in the CNS.
Their activities include regulating processes related to
sex, sleep, stress and pain, emotion, and social cogni-
tion. They may contribute to symptoms and behaviors
associated with psychosis, mood disorders, dementia,
and autism spectrum disorders (Sadock et al., 2015).
Hormonal neuropeptides are discussed in the section
of this chapter on neuroendocrinology.

Opioid Peptides
Opioid peptides, which include the endorphins and
enkephalins, have been widely studied. They are
found in various concentrations in the hypothalamus,
thalamus, limbic structures, midbrain, and brainstem.
Enkephalins are also found in the gastrointestinal tract.
Opioid peptides have natural morphine-like properties
and are thought to have a role in pain modulation.
Released in response to painful stimuli, they may be
responsible for producing the analgesic effect that
results from acupuncture. Opioid peptides alter the
release of dopamine and affect the spontaneous activ-
ity of the dopaminergic neurons. These findings may

38 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

6054_Ch03_027-053 27/07/17 5:23 PM Page 38

have some implication for opioid peptide-dopamine
interaction in the etiology of schizophrenia.

Substance P
Substance P, the first neuropeptide to be discovered, is
present in high concentrations in the hypothalamus,
limbic structures, midbrain, and brainstem. It is also
found in the thalamus, basal ganglia, and spinal cord.
Substance P plays a role in sensory transmission, partic-
ularly in the regulation of pain. Recent studies demon-
strated that people with depression and posttraumatic
stress disorder (PTSD) had elevated levels of substance
P in cerebral spinal fluid (Sadock et al., 2015).

Somatostatin
Somatostatin (also called growth hormone–inhibiting
hormone [GHIH]) is found in the cerebral cortex,
hippocampus, thalamus, basal ganglia, brainstem,
and spinal cord, and has multiple effects on the
CNS. In its function as a neurotransmitter, somato-
statin exerts both stimulatory and inhibitory effects.
Depending on the part of the brain affected, it has
been shown to stimulate dopamine, serotonin, nor-
epinephrine, and acetylcholine and to inhibit norep-
inephrine, histamine, and glutamate. It also acts as a
neuromodulator for serotonin in the hypothalamus,
thereby regulating its release. Somatostatin may serve
this function for other neurotransmitters as well. High
concentrations of somatostatin have been reported in
brain specimens of clients with Huntington’s disease,
and low concentrations have been found in those
with Alzheimer’s disease.

the hormones subject to hypothalamus-pituitary reg-
ulation may have implications for behavioral function-
ing. Discussion of these hormones is summarized in
Table 3–3.

Pituitary Gland
The Posterior Pituitary (Neurohypophysis)
The hypothalamus has direct control over the poste-
rior pituitary through efferent neural pathways. Two
hormones are found in the posterior pituitary: vaso-
pressin (antidiuretic hormone) and oxytocin. They
are actually produced by the hypothalamus and stored
in the posterior pituitary. Their release is mediated by
neural impulses from the hypothalamus (Fig. 3–6).

Antidiuretic Hormone
The main function of antidiuretic hormone (ADH)
is to conserve body water and maintain normal blood
pressure. The release of ADH is stimulated by pain,
emotional stress, dehydration, increased plasma con-
centration, and decreases in blood volume. An alter-
ation in the secretion of this hormone is related to
the polydipsia seen in patients with diabetes. This may
be one of many factors contributing to the polydipsia
and water intoxication (a state of hyperhydration re-
lated to excessive consumption of water) observed in
about 10 to 20 percent of patients with severe mental
illness, particularly those with schizophrenia. Other
factors correlated with this behavior include adverse
effects of psychotropic medications and features of
the behavioral disorder itself. Many factors may influ-
ence excessive intake of water in patients with severe
psychiatric illness. Severe water intoxication can result
in electrolyte imbalance and death (Kohli, Shishir, &
Sharma, 2011). ADH also may play a role in learning
and memory, alteration of the pain response, and
modification of sleep patterns.

Oxytocin
Oxytocin causes contraction of the uterus at the end
of pregnancy and stimulates release of milk from the
mammary glands (Scanlon & Sanders, 2015). It is also
released in response to stress and during sexual
arousal. Oxytocin may promote bonding between
sexes and has been used experimentally with autistic
children to increase socialization (Sadock et al.,
2015). Its role in behavioral functioning is unclear,
although it is possible that oxytocin may stimulate the
release of adrenocorticotropic hormone (ACTH) in
certain situations, thereby playing a key role in the
overall hormonal response to stress.

The Anterior Pituitary (Adenohypophysis)
The hypothalamus produces releasing hormones
that pass through capillaries and veins of the hy-
pophyseal portal system to capillaries in the anterior

C H A P T E R 3 ■ Concepts of Psychobiology 39

CORE CONCEPTS
Neuroendocrinology
The study of the interaction between the nervous system
and the endocrine system and the effects of various
hormones on cognitive, emotional, and behavioral
functioning.

Neuroendocrinology

Human endocrine functioning has a strong founda-
tion in the CNS under the direction of the hypothala-
mus, which has direct control over the pituitary gland.
The pituitary gland has two major lobes—the interior
lobe (also called the adenohypophysis) and the posterior
lobe (also called the neurohypophysis). The pituitary gland
is only about the size of a pea, but despite its size and
because of the powerful control it exerts over en-
docrine functioning in humans, it is sometimes called
the “master gland.” Figure 3–5 shows the hormones of
the pituitary gland and their target organs. Many of

6054_Ch03_027-053 27/07/17 5:23 PM Page 39

40 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

Hypothalamus

Kidneys

Posterior pituitary

Uterus

Ovaries
Testes

Thyroid

Breasts

Adrenal
cortex

Bones, organs

Anterior pituitary hormones

Anterior pituitary

Posterior pituitary hormones

A
D

H

Oxytocin

Prolactin

LHFSH

TSH

ACTH
G

H

FIGURE 3–5 Hormones of the pituitary gland and their target organs. (From Scanlon, V.C., & Sanders, T. [2015]. Essentials of anatomy and physiology
[7th ed.]. Philadelphia: F.A. Davis Company, with permission.)

TA B L E 3 – 3 Hormones of the Neuroendocrine System
POSSIBLE BEHAVIORAL

LOCATION AND CORRELATION TO ALTERED
HORMONE STIMULATION OF RELEASE TARGET ORGAN FUNCTION SECRETION

Antidiuretic
hormone (ADH)

Oxytocin

Posterior pituitary; release
stimulated by dehydration,
pain, stress

Posterior pituitary; release
stimulated by end of preg-
nancy; stress; during sexual
arousal

Kidney (causes
increased
reabsorption)

Uterus; breasts

Conservation of body
water; maintenance
of blood pressure

Contraction of the
uterus for labor; re-
lease of breast milk

Polydipsia; altered pain
response; modified
sleep pattern

May perform role in
stress response by
stimulation of ACTH

6054_Ch03_027-053 27/07/17 5:23 PM Page 40

C H A P T E R 3 ■ Concepts of Psychobiology 41

TA B L E 3 – 3 Hormones of the Neuroendocrine System—cont’d
POSSIBLE BEHAVIORAL

LOCATION AND CORRELATION TO ALTERED
HORMONE STIMULATION OF RELEASE TARGET ORGAN FUNCTION SECRETION

Growth
hormone (GH)

Thyroid-stimulating
hormone (TSH)

Adrenocorticotropic
hormone (ACTH)

Prolactin

Gonadotropic
hormones

Melanocyte-
stimulating
hormone (MSH)

Anterior pituitary; release
stimulated by growth
hormone–releasing hor-
mone from hypothalamus

Anterior pituitary; release
stimulated by thyrotropin-
releasing hormone from
hypothalamus

Anterior pituitary; release
stimulated by corticotropin-
releasing hormone from
hypothalamus

Anterior pituitary; release
stimulated by prolactin-
releasing hormone from
hypothalamus

Anterior pituitary;
release stimulated
by gonadotropin-
releasing hormone
from hypothalamus

Anterior pituitary; release
stimulated by onset of
darkness

Bones and
tissues

Thyroid gland

Adrenal cortex

Breasts

Ovaries and
testes

Pineal gland

Growth in children;
protein synthesis in
adults

Stimulation of
secretion of needed
thyroid hormones for
metabolism of food
and regulation of
temperature

Stimulation of secre-
tion of cortisol, which
performs a role in
response to stress

Stimulation of milk
production

Stimulation of
secretion of estro-
gen, progesterone,
and testosterone;
role in ovulation and
sperm production

Stimulation of secre-
tion of melatonin

Anorexia nervosa

Increased levels of
thyroid hormones
(decreased secretion
of TSH): Insomnia,
anxiety, emotional
lability

Decreased levels of
thyroid hormones
(increased secretion
of TSH): Fatigue,
depression

Increased levels: Mood
disorders, psychosis

Decreased levels:
Depression, apathy,
fatigue

Increased levels:
Depression, anxiety,
decreased libido,
irritability

Decreased levels:
Depression, anorexia
nervosa

Increased testosterone:
Increased sexual
behavior and
aggressiveness

Increased levels:
Depression

pituitary, where they stimulate secretion of special-
ized hormones. The hormones of the anterior pituitary
gland regulate multiple body functions and include
growth hormone, thyroid-stimulating hormone, ACTH,
prolactin, gonadotropin-stimulating hormone, and
melanocyte-stimulating hormone. Most of these hor-
mones are regulated by a negative feedback mechanism.
Once the hormone has exerted its effects, the infor-
mation is “fed back” to the anterior pituitary, which
inhibits the release and ultimately decreases the effects
of the stimulating hormones.

Growth Hormone
The release of growth hormone (GH), also called soma-
totropin, is stimulated by growth hormone–releasing

hormone (GHRH) from the hypothalamus. Its release
is inhibited by GHIH, or somatostatin, also from the
hypothalamus. It is responsible for growth in children
and continued protein synthesis throughout life. Dur-
ing periods of fasting, it stimulates the release of fat
from the adipose tissue to increase energy. The release
of GHIH is stimulated in response to periods of hyper-
glycemia. GHRH is stimulated in response to hypo-
glycemia and to stressful situations. During prolonged
stress, GH has a direct effect on protein, carbohydrate,
and lipid metabolism, resulting in increased serum glu-
cose and free fatty acids to be used for increased energy.
GH deficiency has been noted in many patients with
major depressive disorder, and several GH abnormali-
ties have been noted in patients with anorexia nervosa.

6054_Ch03_027-053 27/07/17 5:23 PM Page 41

Thyroid-Stimulating Hormone
Thyrotropin-releasing hormone (TRH) from the hypo-
thalamus stimulates the release of thyroid-stimulating
hormone (TSH), or thyrotropin, from the anterior
pituitary. TSH stimulates the thyroid gland to secrete
triiodothyronine (T3) and thyroxine (T4). Thyroid
hormones are integral to the metabolism of food and
the regulation of temperature.

A correlation between thyroid dysfunction and
altered behavioral functioning has been well docu-
mented. Common symptoms of hyperthyroidism
include irritability, insomnia, anxiety, restlessness,
weight loss, and emotional lability, in some instances
progressing to delirium or psychosis. Symptoms of
fatigue, decreased libido, memory impairment, depres-
sion, and suicidal ideation have been associated with
chronic hypothyroidism. Studies have correlated vari-
ous forms of thyroid dysfunction with mood disorders,
anxiety, eating disorders, schizophrenia, and dementia.

Adrenocorticotropic Hormone
Corticotropin-releasing hormone (CRH) from the
hypothalamus stimulates the release of ACTH from the
anterior pituitary. ACTH stimulates the adrenal cortex
to secrete cortisol. CRH, ACTH, and cortisol levels all
rise in response to stress. Disorders of the adrenal cor-
tex have been associated with mood disorders, PTSD,
Alzheimer’s dementia, and substance use disorders.

Addison’s disease is the result of hyposecretion
of the hormones of the adrenal cortex. Behavioral
symptoms of hyposecretion include mood changes with
apathy, social withdrawal, impaired sleep, decreased

concentration, and fatigue. Hypersecretion of cortisol
results in Cushing’s disease and is associated with
behaviors that include depression, mania, psychosis,
and suicidal ideation. Cognitive impairments also
have been observed.

Prolactin
Prolactin is mainly involved in reproductive functions
and milk production in the mammary glands during
pregnancy. First-generation antipsychotic medications
increase prolactin levels and may be responsible for
the undesired side effect of lactation. High prolactin
levels are also associated with depression, decreased
libido, anxiety, irritability, and the negative symptoms
of schizophrenia. Prolactin levels in psychotic patients
have been positively correlated with severity of tardive
dyskinesia (Sadock et al., 2015).

Gonadotropic Hormones
The gonadotropic hormones are so called because they
produce an effect on the gonads—the ovaries and the
testes. The gonadotropins include follicle-stimulating
hormone (FSH) and luteinizing hormone (LH). In
women, FSH initiates maturation of ovarian follicles
into ova and stimulates their secretion of estrogen. LH
is responsible for ovulation and the secretion of pro –
gesterone from the corpus luteum. In men, FSH initi-
ates sperm production in the testes, and LH increases
secretion of testosterone by the interstitial cells of the
testes (Scanlon & Sanders, 2015).

Limited evidence exists to correlate gonadotropins
to behavioral functioning, although some observations

42 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

Hypothalamus

Hypothalamic-hypophyseal tract

Posterior pituitary

Inferior hypophyseal
artery

Hormones of
posterior
pituitary

Posterior lobe vein

Optic chiasma

Hypothalamus

Releasing hormones

Capillaries in hypothalamus

Hypophyseal portal veins

Capillaries in
anterior pituitary

Hormones of
anterior pituitary

Lateral hypophyseal vein

Superior hypophyseal
arteries

Optic chiasma

FIGURE 3–6 Structural relationships of hypothalamus and pituitary gland. (A) Posterior pituitary stores hormones produced in the hypothalamus.
(B) Releasing hormones of the hypothalamus circulate directly to the anterior pituitary and influence its secretions. Notice the two networks of
capillaries. (From Scanlon, V.C., & Sanders, T. [2015]. Essentials of anatomy and physiology [7th ed.]. Philadelphia: F.A. Davis Company, with permission.)

A B

6054_Ch03_027-053 27/07/17 5:23 PM Page 42

have been made that warrant hypothetical considera-
tion. Studies have indicated decreased levels of testos-
terone, LH, and FSH in men who have depression.
Increased sexual behavior and aggressiveness have been
linked to elevated testosterone levels in both men and
women. Decreased plasma levels of LH and FSH com-
monly occur in patients with anorexia nervosa. Supple-
mental estrogen therapy has resulted in improved
mentation and mood in some depressed women.

Melanocyte-Stimulating Hormone
Melanocyte-stimulating hormone (MSH) from the
hypothalamus stimulates the pineal gland to secrete
melatonin. The release of melatonin appears to
depend on the onset of darkness and is suppressed
by light. Studies of this hormone have indicated that
environmental light can affect neuronal activity and
influence circadian rhythms. Correlation between
abnormal secretion of melatonin and symptoms of
depression has led to the implication of melatonin
in the etiology of seasonal affective disorder, in which
individuals become depressed only during the fall and
winter months when the amount of daylight decreases.

Circadian Rhythms
Human biological rhythms are largely determined by
genetic coding, with input from the external environ-
ment influencing the cyclic effects. Circadian rhythms
in humans follow a near-24-hour cycle and may influ-
ence a variety of regulatory functions, including the
sleep–wakefulness cycle, body temperature regulation,
patterns of activity such as eating and drinking, and
hormone secretion. The 24-hour rhythms in humans
are affected to a large degree by the cycles of lightness
and darkness. This occurs because of a “pacemaker”
in the brain that sends messages to other systems in
the body and maintains the 24-hour rhythm. This
endogenous pacemaker appears to be the suprachias-
matic nuclei of the hypothalamus. These nuclei receive
projections of light through the retina and in turn
stimulate electrical impulses to various other systems
in the body, mediating the release of neurotransmit-
ters or hormones that regulate bodily functioning.

Most of the biological rhythms of the body operate
over a period of about 24 hours, but cycles of longer
lengths have been studied. For example, women of
menstruating age show monthly cycles of proges-
terone levels in the saliva, of skin temperature over
the breasts, and of prolactin levels in the plasma of
the blood (Hughes, 1993).

Some rhythms may even last as long as a year.
These circannual rhythms are particularly relevant
to certain medications, such as cyclosporine, which
appears to be more effective at some times than others
during a period of about 12 months (Hughes, 1993).
Clinical studies have shown that administration of

chemotherapy during the appropriate circadian phase
and at the appropriate time of day can significantly
increase the efficacy and decrease the toxic effects of
certain cytotoxic agents (Garlapow, 2016; Lis et al.,
2003).

The Role of Circadian Rhythms in Psychopathology
Circadian rhythms may play a role in psychopathology.
Abnormal circadian rhythms have been associated
with a variety of mental illnesses including depres-
sion, bipolar disorder, and seasonal affective disorder.
Because many hormones have been implicated in
behavioral functioning, it is reasonable to believe that
peak secretion times could be influential in predicting
certain behaviors. The association of depression with
increased secretion of melatonin during darkness hours
has already been discussed. External manipulation of
the light–dark cycle and removal of external time cues
often have beneficial effects on mood disorders.

Symptoms that occur in the premenstrual cycle
have been linked to disruptions in biological rhythms.
A number of the symptoms associated with premen-
strual dysphoric disorder (PMDD) strongly resemble
those attributed to depression, and hormonal changes
have been implicated in the etiology. Some of these
changes include progesterone–estrogen imbalance,
increase in prolactin and mineralocorticoids, high level
of prostaglandins, decrease in endogenous opiates,
changes in metabolism of biogenic amines (serotonin,
dopamine, norepinephrine, acetylcholine), and varia-
tions in secretion of glucocorticoids or melatonin.

Because the sleep–wakefulness cycle is probably
the most fundamental of biological rhythms, and
sleep disturbances are common in both depression
and PMDD, it will be discussed in greater detail. A rep-
resentation of bodily functions affected by 24-hour
biological rhythms is presented in Figure 3–7.

Sleep
The sleep–wakefulness cycle is genetically determined
rather than learned and is established some time after
birth. Even when environmental cues such as the abil-
ity to detect light and darkness are removed, the
human sleep–wakefulness cycle generally develops
about a 25-hour periodicity, which is close to the
24-hour normal circadian rhythm.

Sleep can be measured by the types of brain waves
that occur during various stages of sleep activity.
Dreaming episodes are characterized by rapid eye
movement (REM) and are called REM sleep. The
sleep–wakefulness cycle is represented by six distinct
stages.

Stage 0—Alpha rhythm: This stage of the sleep–
wakefulness cycle is characterized by a relaxed,
waking state with eyes closed. The alpha brain wave
rhythm has a frequency of 8 to 12 cycles per second.

C H A P T E R 3 ■ Concepts of Psychobiology 43

6054_Ch03_027-053 27/07/17 5:23 PM Page 43

Stage 1—Beta rhythm: Stage 1 characterizes the transi-
tion into sleep, a period of dozing in which thoughts
wander and the person drifts in and out of sleep.
Beta brain wave rhythm has a frequency of 18 to
25 cycles per second.

Stage 2—Theta rhythm: This stage comprises about
half of time spent sleeping. Eye movement and
muscular activity are minimal. Theta brain wave
rhythm has a frequency of 4 to 7 cycles per second.

Stage 3—Delta rhythm: This is a period of deep and
restful sleep. Muscles are relaxed, heart rate and

blood pressure fall, and breathing slows. No eye
movement occurs. Delta brain wave rhythm has a
frequency of 1.5 to 3 cycles per second.

Stage 4—Delta rhythm: This is the stage of deepest
sleep. Individuals who suffer from insomnia or
other sleep disorders often do not experience this
stage of sleep. Eye movement and muscular activity
are minimal. Delta waves predominate.

REM sleep—Beta rhythm: The dream cycle occurs
during REM sleep. Eyes dart about beneath closed
eyelids, moving more rapidly than when awake.

44 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

— — — — — — — — — — — —

0800 1000 1200 1400 1600 1800 2000 2200 2400 0200 0400 0600

(Darkness)

Body
temperature

Pulse
rate

Blood
pressure

Growth
hormone

Cortisol

Thyroid
hormones

Prolactin

Melatonin

Testosterone (males)

Progesterone
(females)**
Estrogen

(Daylight)

▼

▲

▼

▲

▲

▼
▲

▼
▲

▼
▲

▼
▲

▼
▲

▼

▼

▲

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

▼

▼ ▲

▲

Days

(Clock Hours)

* ▼ indicates low point and ▲ indicates peak time of these biological factors within a 24-hour circadian rhythm.
** The female hormones are presented on a monthly rhythm because of their influence on the reproductive cycle.
Daily rhythms of female gonadotropins are difficult to assay and are probably less significant than monthly.

FIGURE 3–7 Circadian biological rhythms.

6054_Ch03_027-053 27/07/17 5:23 PM Page 44

The brain wave pattern is similar to that of stage 1
sleep. Heart and respiration rates increase, and
blood pressure may increase or decrease. Muscles
are hypotonic during REM sleep.

Stages 2 through REM repeat themselves through-
out the cycle of sleep. One is more likely to experience
longer periods of stages 3 and 4 sleep early in the cycle
and longer periods of REM sleep later in the sleep
cycle. Most people experience REM sleep about four
to five times during the night. The amount of REM
sleep and deep sleep decreases with age, and the time
spent in drowsy wakefulness and dozing increases.

Neurochemical Influences
A number of neurochemicals have been shown to
influence the sleep–wakefulness cycle. Several studies
have revealed information about the sleep-inducing
characteristics of serotonin. L-Tryptophan, the amino
acid precursor to serotonin, has been used for many
years as an effective sedative-hypnotic to induce sleep
in individuals with sleep-onset disorder. Serotonin
and norepinephrine both appear to be most active
during non-REM sleep, whereas the neurotransmitter
acetylcholine is activated during REM sleep (Skudaev,
2009). The exact role of GABA in sleep facilitation is
unclear, although the sedative effects of drugs that
enhance GABA transmission, such as benzodiazepines,
suggest that this neurotransmitter plays an important
role in regulation of sleep and arousal. Some studies
have suggested that acetylcholine induces and pro-
longs REM sleep, whereas histamine appears to have
an inhibitory effect. Neuroendocrine mechanisms
seem to be more closely tied to circadian rhythms
than to the sleep–wakefulness cycle. One exception
is growth hormone secretion, which increases during
the stage 3 sleep period and may be associated with
slow-wave sleep (Van Cauter & Plat, 1996).

particular genotype are designated by characteristics
that specify a phenotype. Examples of phenotypes
include eye color, height, blood type, sound of voice,
and hair type. As evident by the examples presented,
phenotypes are not only genetic but may also be
acquired (i.e., influenced by the environment) or a
combination of both. It is likely that many psychiatric
disorders are the result of a combination of genetics
and environmental influences.

Investigators who study the etiological implications
for psychiatric illness may explore several risk factors.
Studies to determine if an illness is familial compare
the percentage of family members with the illness to
those in the general population or within a control
group of unrelated individuals. These studies estimate
the prevalence of psychopathology among relatives
and make predictions about the predisposition to an
illness based on familial risk factors. Schizophrenia,
bipolar disorder, major depressive disorder, anorexia
nervosa, panic disorder, somatic symptom disorder,
antisocial personality disorder, and alcoholism are
examples of psychiatric illness in which familial ten-
dencies have been indicated.

Studies that are purely genetic search for a specific
gene that causes a particular illness. A number of dis-
orders exist in which the mutation of a specific gene or
change in the number or structure of chromosomes has
been associated with the etiology. Examples include
Huntington’s disease, cystic fibrosis, phenylketonuria,
Duchenne’s muscular dystrophy, and Down syndrome.

The search for pure genetic links to certain psychi-
atric disorders continues. Risk factors for early-onset
Alzheimer’s disease have been linked to mutations
on chromosomes 21, 14, and 1 (National Institute
on Aging, 2015). Other studies have linked a gene
in the region of chromosome 19 that produces
apolipoprotein E (ApoE) with late-onset Alzheimer’s
disease. One large study (National Institute of Mental
Health, 2013) found similar genetic variations in pa-
tients with five mental disorders that were previously
considered completely distinct. Autism, attention-
deficit/hyperactivity disorder (ADHD), bipolar disor-
der, major depression, and schizophrenia all showed
some common gene variations, including differences
in two genes that regulate the flow of calcium into cells.
Although these findings are intriguing, they do not
clearly explain all the genetic risks for mental illness,
the nongenetic risks, or the interaction between the
two. Future research will continue to search for an-
swers with the ultimate goal of improving diagnosis
and treatment and perhaps uncovering keys to pre-
vention of mental illness. In addition to familial and
purely genetic investigations, other types of studies
have been conducted to estimate the existence and
degree of genetic and environmental contributions
to the etiology of certain psychiatric disorders. Twin

C H A P T E R 3 ■ Concepts of Psychobiology 45

CORE CONCEPT
Genetics
The study of the biological transmission of certain physical
and/or behavioral characteristics from parent to offspring.

Genetics

Human behavioral genetics seeks to understand both
the genetic and environmental contributions to indi-
vidual variations in human behavior. This type of
study is complicated by the fact that behaviors, like all
complex traits, involve multiple genes.

The term genotype refers to the total set of genes
present in an individual and coded in the DNA at the
time of conception. The physical manifestations of a

6054_Ch03_027-053 27/07/17 5:23 PM Page 45

studies and adoption studies have been successfully
employed for this purpose.

Twin studies examine the frequency of a disorder in
monozygotic (genetically identical) and dizygotic (not
genetically identical) twins. Twins are called concordant
when both members suffer from the disorder in ques-
tion. Concordance in monozygotic twins is considered
stronger evidence of genetic involvement than it is in
dizygotic (fraternal) twins. Twin studies have supported
genetic vulnerability in the etiology of several mental
illnesses, including adjustment disorders, PTSD, sub-
stance abuse, schizophrenia, bipolar disorder, major
depression, obsessive compulsive disorder, risk for
suicide, and others (Sadock et al., 2015).

Adoption studies allow researchers to compare the
influence of genetics versus environment on the de-
velopment of a psychiatric disorder. Knowles (2003)
describes the four types of adoption studies that have
been conducted:

1. The study of adopted children whose biological
parent(s) had a psychiatric disorder but whose
adoptive parent(s) did not.

2. The study of adopted children whose adoptive
parent(s) had a psychiatric disorder but whose
biological parent(s) did not.

3. The study of adoptive and biological relatives
of adopted children who developed a psychiatric
disorder.

4. The study of monozygotic twins reared apart by
different adoptive parents.

Disorders in which adoption studies have suggested
a possible genetic link include alcoholism, schizophre-
nia, major depression, bipolar disorder, suicide risk,
ADHD, and antisocial personality disorder (Sadock
et al., 2015).

A summary of various psychiatric disorders and the
possible biological influences discussed in this chapter
is presented in Table 3–4. Various diagnostic proce-
dures used to detect alteration in biological function-
ing that may contribute to psychiatric disorders are
presented in Table 3–5.

46 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

CORE CONCEPT
Psychoneuroimmunology
The study of the relationship between the immune sys-
tem, the nervous system, and psychological processes
such as thinking and behavior.

TA B L E 3 – 4 Biological Implications of Psychiatric Disorders
ANATOMICAL BRAIN NEUROTRANSMITTER POSSIBLE ENDOCRINE IMPLICATIONS OF
STRUCTURES INVOLVED HYPOTHESIS CORRELATION CIRCADIAN RHYTHMS POSSIBLE GENETIC LINK

SCHIZOPHRENIA
Frontal cortex,
temporal lobes,
limbic system

DEPRESSIVE
DISORDERS
Frontal lobes,
limbic system,
temporal lobes

BIPOLAR DISORDER
Frontal lobes, limbic
system, temporal
lobes

PANIC DISORDER
Limbic system,
midbrain

Dopamine hyperac-
tivity; decreased
glutamate

Decreased levels
of norepinephrine,
dopamine, and
serotonin; increased
glutamate

Increased levels of
norepinephrine and
dopamine in acute
mania

Increased levels of
norepinephrine;
decreased GABA
activity

Decreased prolactin
levels

Increased cortisol
levels; thyroid hor-
mone hyposecre-
tion; increased
melatonin

Some indication of
elevated thyroid
hormones in acute
mania

Elevated levels of
thyroid hormones

May correlate
antipsychotic
medication adminis-
tration to times
of lowest level

DST* used to predict
effectiveness
of antidepressants;
melatonin linked to
depression during
periods of darkness

Abnormal circadian
rhythms have been
associated with
bipolar disorder

May have some
application for
times of medication
administration

Twin, familial, and
adoption studies
suggest genetic link

Twin, familial, and
adoption studies
suggest a genetic link

Twin, familial, and
adoption studies
suggest a genetic link

Twin and familial
studies suggest a
genetic link

6054_Ch03_027-053 27/07/17 5:23 PM Page 46

C H A P T E R 3 ■ Concepts of Psychobiology 47

TA B L E 3 – 4 Biological Implications of Psychiatric Disorders—cont’d
ANATOMICAL BRAIN NEUROTRANSMITTER POSSIBLE ENDOCRINE IMPLICATIONS OF
STRUCTURES INVOLVED HYPOTHESIS CORRELATION CIRCADIAN RHYTHMS POSSIBLE GENETIC LINK

ANOREXIA NERVOSA
Limbic system,
particularly the
hypothalamus

OBSESSIVE-
COMPULSIVE
DISORDER
Limbic system,
basal ganglia
(specifically
caudate nucleus)

ALZHEIMER’S
DISEASE
Temporal, parietal,

and occipital
regions of cerebral
cortex; hippocampus

*DST, dexamethasone suppression test. Dexamethasone is a synthetic glucocorticoid that suppresses cortisol secretion via the feed-
back mechanism. In this test, 1 mg of dexamethasone is administered at 11:30 p.m., and blood samples are drawn at 8:00 a.m.,
4:00 p.m., and 11:00 p.m. on the following day. A plasma value greater than 5 mcg/dL suggests that the individual is not suppressing
cortisol in response to the dose of dexamethasone. This is a positive result for depression and may have implications for other disor-
ders as well.
GABA, gamma-aminobutyric acid.

Decreased levels
of norepinephrine,
serotonin, and
dopamine

Decreased levels
of serotonin

Decreased levels
of acetylcholine,
norepinephrine,
serotonin, and
somatostatin

Decreased levels of
gonadotropins and
growth hormone;
increased cortisol
levels

Increased cortisol
levels

Decreased
corticotropin-
releasing hormone

DST often shows
same results as
in depression

DST often shows
same results as
in depression

Decreased levels of
acetylcholine and
serotonin may
inhibit hypothalamic-
pituitary axis and
interfere with hor-
monal releasing
factors

Twin and familial
studies suggest a
genetic link

Twin studies suggest a
possible genetic link

Familial studies
suggest a genetic
predisposition; late-
onset disorder linked
to marker on chromo-
some 19; early-onset
to chromosomes 21,
14, and 1

TA B L E 3 – 5 Diagnostic Procedures Used to Detect Altered Brain Functioning
EXAMINATION TECHNIQUE USED PURPOSE AND POSSIBLE FINDINGS

Electroencephalography
(EEG)

Computerized EEG
mapping

Computed tomographic
(CT) scan

Electrodes are placed on the scalp in a
standardized position. Amplitude and
frequency of beta, alpha, theta, and delta
brain waves are graphically recorded on
paper by ink markers for multiple areas
of the brain surface.

EEG tracings are summarized by computer-
assisted systems in which various regions
of the brain are identified and functioning is
interpreted by color coding or gray shading.

CT scan may be used with or without
contrast medium. X-rays are taken of
various transverse planes of the brain while
a computerized analysis produces a precise
reconstructed image of each segment.

Measures brain electrical activity; identifies
dysrhythmias, asymmetries, or suppression
of brain rhythms; used in the diagnosis of
epilepsy, neoplasm, stroke, metabolic, or
degenerative disease.

Measures brain electrical activity; used
largely in research to represent statistical
relationships between individuals and
groups or between two populations of
subjects (e.g., patients with schizophrenia
vs. control subjects).

Measures accuracy of brain structure
to detect possible lesions, abscesses,
areas of infarction, or aneurysm. CT has
also identified various anatomical differ-
ences in patients with schizophrenia,
organic mental disorders, and bipolar
disorder.

Continued

6054_Ch03_027-053 27/07/17 5:23 PM Page 47

Psychoneuroimmunology

Normal Immune Response
Cells responsible for nonspecific immune reactions
include neutrophils, monocytes, and macrophages.
They work to destroy the invasive organism and initi-
ate and facilitate the healing of damaged tissue. If
these cells do not accomplish a satisfactory healing
response, specific immune mechanisms take over.

Cytokines are one such mechanism. These mole-
cules, which regulate immune and inflammatory re-
sponses, become active when an individual is fighting
an infection and the resultant inflammatory processes.
Recent research has also demonstrated that cytokines
are active in mood disorders such as depression and
bipolar disorder. Current research focuses on the
impact of cytokines as part of an essential and com-
plex system of responses that are crucial for reducing
inflammation and bolstering the immune response.
Studies are also attempting to identify what happens
when inflammation is not resolved and cytokines
remain active or cross the blood-brain barrier. There is
evidence that these maladaptations may be implicated
in a multitude of illnesses (Ratnayake et al., 2013).

Implications of the Immune System in Psychiatric
Illness
Studies of the biological response to stress have hy-
pothesized that individuals become more susceptible
to physical illness following exposure to a stressful
stimulus or life event (see Chapter 1). This response
is thought to be caused by increased glucocorticoid

release from the adrenal cortex following stimulation
from the hypothalamic-pituitary-adrenal axis during
stressful situations. The result is a suppression in
lymphocyte proliferation and function.

Studies have shown that nerve endings exist in tis-
sues of the immune system. The CNS has connections
in both bone marrow and the thymus, where immune
system cells are produced, and in the spleen and
lymph nodes, where those cells are stored.

GH, which may be released in response to certain
stressors, may enhance immune functioning, whereas
testosterone is thought to inhibit immune functioning.
Increased production of epinephrine and norepineph-
rine occurs in response to stress and may decrease
immunity. Serotonin has been described as an im-
munomodulator because it has demonstrated both
enhancing and inhibitory effects on inflammation
and immunity (Arreola et al., 2015).

Studies have correlated a decrease in lymphocyte
function with periods of grief, bereavement, and
depression, associating the degree of altered immu-
nity with severity of the depression. A number of re-
search studies have attempted to correlate the onset
of schizophrenia to abnormalities of the immune
system. These studies have considered autoimmune
responses, viral infections, and immunogenetics
(Sadock et al., 2015). The role of these factors in the
onset and course of schizophrenia remains unclear.
Attempts to identify a neurotoxic virus that triggers
the manifestations of schizophrenia have not been
successful; however, there is clear evidence of higher
incidence of schizophrenia following viral epidemics.

48 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

TA B L E 3 – 5 Diagnostic Procedures Used to Detect Altered Brain Functioning—cont’d
EXAMINATION TECHNIQUE USED PURPOSE AND POSSIBLE FINDINGS

Magnetic resonance
imaging (MRI)

Positron emission
tomography (PET)

Single photon emission
computed tomography
(SPECT)

Within a strong magnetic field, the nuclei
of hydrogen atoms absorb and reemit
electromagnetic energy that is computer-
ized and transformed into image informa-
tion. No radiation or contrast medium
is used.

The patient receives an intravenous (IV)
injection of a radioactive substance (type
depends on brain activity to be visualized).
The head is surrounded by detectors that
relay data to a computer that interprets
the signals and produces the image.

The technique is similar to PET, but longer-
acting radioactive substance must be used
to allow time for a gamma-camera to rotate
about the head and gather the data, which
are then computer assembled into a brain
image.

Measures anatomical and biochemical sta-
tus of various segments of the brain; detects
brain edema, ischemia, infection, neoplasm,
trauma, and other changes such as demyeli-
nation. Morphological differences have been
noted in brains of patients with schizophre-
nia as compared with control subjects.

Measures specific brain functioning, such
as glucose metabolism, oxygen utilization,
blood flow, and, of particular interest in
psychiatry, neurotransmitter-receptor
interaction.

Measures various aspects of brain function-
ing, as with PET; has also been used to
image activity of cerebrospinal fluid
circulation.

6054_Ch03_027-053 27/07/17 5:23 PM Page 48

Immunological abnormalities have also been inves-
tigated in a number of other psychiatric illnesses,
including alcoholism, autism spectrum disorder, and
neurocognitive disorder.

Evidence exists to support a correlation between
psychosocial stress and the onset of illness. Research
is still required to determine the specific processes
involved in stress-induced modulation of the immune
system.

Psychopharmacology and the Brain

Understanding the brain and the biological processes
involved in thoughts, feelings, and behavior has pos-
itive ramifications beyond better understanding of
psychopharmacological treatment options. As men-
tioned earlier, future research may continue to demon-
strate the impact of psychological interventions on
brain activity and neurotransmitters, which would
open opportunities to hone psychological treatments
and avoid the troubling side effects that accompany
many medications. Furthermore, continued research
in areas such as psychoneuroimmunology may reveal
causes of mental illness, which would provide the
opportunity for primary prevention.

In spite of these opportunities, psychopharmacol-
ogy remains a primary treatment modality for mental
disorders. Understanding, as best we can with cur-
rent evidence, the biological mechanisms at work in
psychoactive drugs is essential to nursing practice.
Figure 3–8 shows the biological mechanism of psy-
choactive drugs at the neural synapse. Psychophar-
macology, the classes of psychoactive drugs, and
relevant nursing implications are discussed in detail
in Chapter 4.

Implications for Nursing

The discipline of psychiatric-mental health nursing
has always championed its role in holistic health care,
but historical review reveals that emphasis has been
placed on treatment approaches that focus on psy-
chological and social factors. Psychiatric nurses must
integrate knowledge of the biological sciences into
their practices if they are to ensure safe and effective
care to people with mental illness. In the hallmark
Surgeon General’s Report on Mental Health (U.S.
Department of Health and Human Services, 1999),
Dr. David Satcher wrote:

The mental health field is far from a complete un-
derstanding of the biological, psychological, and so-
ciocultural bases of development, but development
clearly involves interplay among these influences.
Understanding the process of development requires
knowledge, ranging from the most fundamental

level—that of gene expression and interactions be-
tween molecules and cells—all the way up to the
highest levels of cognition, memory, emotion, and
language. The challenge requires integration of
concepts from many different disciplines. A fuller
understanding of development is not only impor-
tant in its own right, but it is expected to pave the
way for our ultimate understanding of mental
health and mental illness and how different factors
shape their expression at different stages of the life
span. (pp. 61–62)

To ensure a smooth transition from a strictly psy-
chosocial focus to one of biopsychosocial emphasis,
nurses must have a clear understanding of the
following:

■ Neuroanatomy and neurophysiology: The struc-
ture and functioning of the various parts of the
brain and their correlation to human behavior
and psychopathology

■ Neuronal processes: The various functions of the
nerve cells, including the role of neurotransmit-
ters, receptors, synaptic activity, and information
pathways

■ Neuroendocrinology: The interaction of the en-
docrine and nervous systems and the role that the
endocrine glands and their respective hormones
play in behavioral functioning

■ Circadian rhythms: The regulation of biochemical
functioning over periods of rhythmic cycles and its
influence in predicting certain behaviors

■ Genetic influences: The hereditary factors that pre-
dispose individuals to certain psychiatric disorders

■ Psychoneuroimmunology: The influence of stress
on the immune system and its role in the suscepti-
bility to illness

■ Psychopharmacology: The increasing use of psy-
chotropic drugs in the treatment of mental illness,
demanding greater knowledge of psychopharma-
cological principles and nursing interventions
necessary for safe and effective management

■ Diagnostic technology: The importance of keeping
informed about the latest in technological proce-
dures for diagnosing alterations in brain structure
and function

Why are these concepts important to the practice
of psychiatric-mental health nursing? The interrela-
tionship between psychosocial adaptation and phys-
ical functioning has been established. Integrating
biological and behavioral concepts into psychiatric
nursing practice is essential for nurses to meet the
complex needs of clients with mental illness. Psy-
chobiological perspectives must be incorporated
into nursing practice, education, and research to at-
tain the evidence-based outcomes necessary for the
delivery of competent care.

C H A P T E R 3 ■ Concepts of Psychobiology 49

6054_Ch03_027-053 27/07/17 5:23 PM Page 49

50 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

Receptors

Neurotransmitter
in the synaptic cleft

Neurotransmitter
in vesicles

Mitochondria

Neurotransmitter
transporter

Neurotransmitter
transporter

FIGURE 3–8 Area of synaptic transmission that is altered by drugs.
The transmission of electrical impulses from the axon terminal of one neuron to the dendrite of another is achieved by the controlled
release of neurotransmitters into the synaptic cleft. Neurotransmitters include serotonin, norepinephrine, acetylcholine, dopamine,
glutamate, gamma-aminobutyric acid (GABA), and histamine, among others. Prior to its release, the neurotransmitter is concentrated
into specialized synaptic vesicles. Once fired, the neurotransmitter is released into the synaptic cleft where it encounters receptors on
the postsynaptic membrane. Each neurotransmitter has receptors specific to it alone. Some neurotransmitters are considered to be
excitatory, whereas others are inhibitory, a feature that determines whether another action potential will occur. In the synaptic cleft,
the neurotransmitter rapidly diffuses, is catabolized by enzymatic action, or is taken up by the neurotransmitter transporters and
returned to vesicles inside the axon terminal to await another action potential.

Psychotropic medications exert their effects in various ways in this area of synaptic transmission. Reuptake inhibitors block
reuptake of the neurotransmitters by the transporter proteins, resulting in elevated levels of extracellular neurotransmitter. Drugs
that inhibit catabolic enzymes promote excess buildup of the neurotransmitter at the synaptic site.

Some drugs cause receptor blockade, resulting in a reduction in transmission and decreased neurotransmitter activity. These drugs
are called antagonists. Drugs that increase neurotransmitter activity by direct stimulation of the specific receptors are called agonists.

Summary and Key Points

■ It is important for nurses to understand the interac-
tion between biological and behavioral factors in the
development and management of mental illness.

■ Psychobiology is the study of the biological foun-
dations of cognitive, emotional, and behavioral
processes.

■ The limbic system has been called the “emotional
brain.” It is associated with feelings of fear and
anxiety; anger, rage, and aggression; love, joy, and
hope; and with sexuality and social behavior.

■ The three classes of neurons include afferent
(sensory), efferent (motor), and interneurons.
The junction between two neurons is called a
synapse.

■ Neurotransmitters are chemicals that convey infor-
mation across synaptic clefts to neighboring target
cells. Many neurotransmitters have implications in
the etiology of emotional disorders and in the
pharmacological treatment of those disorders.

■ Major categories of neurotransmitters include
cholinergics, monoamines, amino acids, and
neuropeptides.

6054_Ch03_027-053 27/07/17 5:23 PM Page 50

C H A P T E R 3 ■ Concepts of Psychobiology 51

Additional info available
at www.davisplus.com

■ The endocrine system plays an important role in
human behavior through the hypothalamic-pituitary
axis.

■ Hormones and their circadian rhythms of regula-
tion significantly influence a number of physiologi-
cal and psychological life cycle phenomena, such as
moods, sleep and arousal, stress response, appetite,
libido, and fertility.

■ Research continues to validate the role of genetics
in psychiatric illness.

■ Familial, twin, and adoption studies suggest that
genetics may be implicated in the etiology of schiz-
ophrenia, bipolar disorder, depressive disorder,
panic disorder, anorexia nervosa, alcoholism, and
obsessive-compulsive disorder. Genetic studies,
however, fail to entirely explain the complex fac-
tors involved in the development of these illnesses.

■ Psychoneuroimmunology examines the relation-
ship between psychological factors, the immune
system, and the nervous system.

■ Evidence exists to support a link between psy-
chosocial stressors and suppression of the immune
response.

■ Technologies such as magnetic resonance imagery,
computed tomographic scan, positron emission to-
mography, and electroencephalography are used
as diagnostic tools for detecting alterations in psy-
chobiological functioning.

■ Psychotropic medications act at the neural synapse
to affect neurotransmitter activity and have been
associated with improvement in symptoms of many
mental disorders.

■ Integrating knowledge of the expanding biological
focus into psychiatric nursing is essential if nurses are
to meet the changing needs of today’s psychiatric
clients.

Review Questions
Self-Examination/Learning Exercise

Select the answer that is most appropriate for each of the following questions:

1. Which of the following parts of the brain is associated with multiple feelings and behaviors and is
sometimes referred to as the “emotional brain”?
a. Frontal lobe
b. Thalamus
c. Hypothalamus
d. Limbic system

2. Which of the following parts of the brain is concerned with visual reception and interpretation?
a. Frontal lobe
b. Parietal lobe
c. Temporal lobe
d. Occipital lobe

3. Which of the following parts of the brain is associated with voluntary body movement, thinking and
judgment, and expression of feeling?
a. Frontal lobe
b. Parietal lobe
c. Temporal lobe
d. Occipital lobe

4. Which of the following parts of the brain integrates all sensory input (except smell) on the way to the
cortex?
a. Temporal lobe
b. Thalamus
c. Limbic system
d. Hypothalamus

Continued

6054_Ch03_027-053 27/07/17 5:23 PM Page 51

52 U N I T 2 ■ Foundations for Psychiatric-Mental Health Nursing

Review Questions—cont’d
Self-Examination/Learning Exercise

5. Which of the following parts of the brain deals with sensory perception and interpretation?
a. Hypothalamus
b. Cerebellum
c. Parietal lobe
d. Hippocampus

6. Which of the following parts of the brain is concerned with hearing, short-term memory, and sense
of smell?
a. Temporal lobe
b. Parietal lobe
c. Cerebellum
d. Hypothalamus

7. Which of the following parts of the brain has control over the pituitary gland and autonomic nervous
system, as well as regulation of appetite and temperature?
a. Temporal lobe
b. Parietal lobe
c. Cerebellum
d. Hypothalamus

8. At a synapse, the determination of further impulse transmission is accomplished by means of which
of the following?
a. Potassium ions
b. Interneurons
c. Neurotransmitters
d. The myelin sheath

9. A decrease in which of the following neurotransmitters has been implicated in depression?
a. Gamma-aminobutyric acid, acetylcholine, and aspartate
b. Norepinephrine, serotonin, and dopamine
c. Somatostatin, substance P, and glycine
d. Glutamate, histamine, and opioid peptides

10. Which of the following hormones has been implicated in the etiology of mood disorder with seasonal
pattern?
a. Increased levels of melatonin
b. Decreased levels of oxytocin
c. Decreased levels of prolactin
d. Increased levels of thyrotropin

11. Psychotropic medications may act at the neural synapse to accomplish which of the following? (Select
all that apply)
a. Inhibit the reuptake of certain neurotransmitters, creating more availability
b. Inhibit catabolic enzymes, promoting more availability of a neurotransmitter
c. Block receptors, resulting in less neurotransmitter activity
d. Add synthetic neurotransmitters found in the drug

12. Psychoneuroimmunology is a branch of science that involves which of the following? (Select all that
apply.)
a. The impact of psychoactive medications at the neural synapse
b. The relationships between the immune system, the nervous system, and psychological processes

including mental illness
c. The correlation between psychosocial stress and the onset of illness
d. The potential role of viruses in the onset of schizophrenia
e. The genetic factors that influence prevention of mental illness

6054_Ch03_027-053 27/07/17 5:23 PM Page 52

References
Arreola, R., Becerril-Villanueva, E., Cruz-Fuentes, C., Velasco-

Velázquez, M.A., Garcés-Alvarez, M.E., Hurtado-Alvarado, G., . . .
Pavón, L. (2015). Immunomodulatory effects mediated by
serotonin. Journal of Immunology Research. doi:http://dx.doi
.org/10.1155/2015/354957

Balu, D.T., Li, Y., Puhl, M.D., Benneyworth, M.A., Basu, A.C,
Takagi, S., . . . Coyle, J.T. (2013). Multiple risk pathways for
schizophrenia converge in serine racemase knockout mice, a
mouse model of NMDA receptor hypofunction. Proceedings of
the National Academy of Sciences of the United States of America,
110(26), E2400-2409. doi:10.1073/pnas.1304308110

Butler, T., Weisholtz, D., Isenberg, N., Harding, E., Epstein, J.,
Stern, E., & Silbersweig, D. (2012). Neuroimaging of frontal-
limbic dysfunction in schizophrenia and epilepsy-related
psychosis: Toward a convergent neurobiology. Epilepsy
Behavior, 23(2), 113-122. doi:10.1016/j.yebeh.2011.11.004

Flor, H. (2014). Psychological pain interventions and neurophysi-
ology: Implications for a mechanism-based approach. American
Psychologist, 69(2), 188-196. doi:http://dx.doi.org/10.1037/
a0035254

Furmark, T., Tilfors, M., Martiensdottir, I., Fischer, H., Pissiota, A.,
Långström, B., & Fredrikson, M. (2002). Common changes in
cerebral blood flow in patients with social phobia treated with
citalopram or cognitive behavior therapy. Archives of General
Psychiatry, 59(5), 425-430. doi:10.1001/archpsyc.59.5.425

Garlapow, M. (2016). Timing chemotherapy administration to
circadian rhythm improves drug effectiveness. Oncology Nurse
Advisor. Retrieved from www.oncologynurseadvisor.com/
side-effect-management/chemotherapy-more-effective-
when-synced-with-circadian-rhythm/article/504455

Hughes, M. (1993). Body clock: The effects of time on human health.
New York: Facts on File.

Knowles, J.A. (2003). Genetics. In R.E. Hales & S.C. Yudofsky
(Eds.), Textbook of psychiatry (2th ed.). Washington, DC:
American Psychiatric Publishing.

Kohli, A., Shishir, V., & Sharma, A. (2011). Psychogenic polydip-
sia. Indian Journal of Psychiatry, 53(2),166-167. doi:10.4103/
0019-5545.82554

Lis, C.G., Grutsch, J.F., Wood, P., You, M., Rich, I., & Hrushesky,
W.J. (2003). Circadian timing in cancer treatment: The biolog-
ical foundation for an integrative approach. Integrative Cancer
Therapies, 2(2), 105-111. doi:10.1177/1534735403253766

National Institutes of Health (NIH). (2017). Is there a link
between marijuana use and mental illness? Retrieved from
www.drugabuse.gov/publications/research-reports/
marijuana/there-link-between-marijuana-use-mental-illness

National Institute of Mental Health (NIMH). (2013). Five major
mental disorders share genetic roots. Retrieved from
www.nimh.nih.gov/news/science-news/2013/five-major-
mental-disorders-share-genetic-roots.shtml

National Institute on Aging. (2015). Alzheimer’s disease genetics.
The Alzheimer’s Disease Education and Referral Center.
Retrieved from www.nia.nih.gov/alzheimers/publication/
alzheimers-disease-genetics-fact-sheet

Ouellet-Plamondon, C., & George, T.P. (2012). Glutamate and
psychiatry in 2012—Up, up and away! Psychiatric Times,
29(12), 1-5. doi:10.3389/fphar.2012.00195

Ratnayake, U., Quinn, T., Walker, D.W., & Dickinson, H. (2013).
Cytokines and the neurodevelopmental basis of mental illness.
Frontiers of Neuroscience, 7. doi:10.3389/fnins.2013.00180

Sadock, B.J., Sadock, V.A., & Ruiz, P.(2015). Synopsis of psychiatry:
Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia:
Lippincott Williams & Wilkens.

Scanlon, V.C., & Sanders, T. (2015). Essentials of anatomy and
physiology (7th ed.). Philadelphia: F.A. Davis.

Skudaev, S. (2009). The neurophysiology and neurochemistry of
sleep. Retrieved from www.healthstairs.com/sleep3.php

Van Cauter, E., & Plat, L. (1996). Physiology of growth hormone
secretion during sleep. Journal of Pediatrics,128(5), 32-37.
doi:10.1016/S0022-3476(96)70008-2

Van Hove, J., Coughlin, C., & Sharer, G. (2013). Glycine en-
cephalopathy. GeneReviews. National Library of Medicine.
Retrieved from www.ncbi.nlm.nih.gov/books/NBK1357

Wolosker, H., Dumin, E., Balan, L., & Foltyn, V.N. (2008). D-Amino
acids in the brain: D-serine in neurotransmission and neurode-
generation. The FEBS Journal, 275(14), 3514-3526. doi:10.1111/
j.1742-4658.2008.06515.x

Classical References
Sage, D.L. (Producer) (1984). The Brain: Madness. [Television

Broadcast] Washington, DC: Public Broadcasting Company.
U.S. Department of Health and Human Services. (1999). Mental

health: A report of the Surgeon General—Executive summary.
Rockville, MD: U.S. Department of Health and Human
Services.

C H A P T E R 3 ■ Concepts of Psychobiology 53

6054_Ch03_027-053 27/07/17 5:23 PM Page 53