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Learning Module
Mental Health and
Psychiatric
Nursing
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 Contents

Mental Health and Psychiatric Nursing Learning Module...............................................................3

Preface.............................................................................................................................................4
Acknowledgements..........................................................................................................................5
Foreword..........................................................................................................................................6
Unit: 1Introduction to mental health and Psychiatric Nursing........................................................7
Unit 2: Psychiatric Nursing Skills....................................................................................................24

Unit3: Classification and Management of Psychiatric Disorders....................................................66

Unit4: Condition not attributed to mental disorders that are a focus of attention and
treatment..................................................................................................................................219

Unit 5: Management of a client with Psychiatric emergency.......................................................227

Unit 6: Forensic Psychiatry..........................................................................................................242

Unit 7: Community Psychiatry.....................................................................................................251

Unit 8: Advocacy in Psychiatry....................................................................................................262

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Mental Health and Psychiatric Nursing Learning Module

All rights reserved. This publication can be obtained from Lusaka Institute of Applied. Requests
for permission to reproduce or translate this module should be addressed to the Director, Lusaka
Institute of Applies Sciences (LIAS), 9 miles Off Great North Road, Private Bag, E15, Lusaka.

Efforts have been made to confirm the accuracy of the information presented in this module. The
authors are not responsible for shortcomings errors or omissions or for any consequences from
application of the information in this learning module and make no warranty, expressed or
implied with respect to the completeness, or accuracy of the contents. However, all reasonable
precautions have been taken to verify the information contained in this module. The
responsibility for the interpretation and use of the material lies with the reader.

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Preface

This manual is designed to nurses with learning and their day to day work.

The purpose of the module is to assist nurses` learning and as a reference to qualified nurses to:

1. Identify clinical manifestations of a mental disorder.

2. To manage a person living with a mental disorder within the general health care.
3. Assist the reintegration of people with mental disorders into all aspects of community
life, thus improving their overall quality of life.

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Acknowledgements

The Mental Health and Psychiatric Nursing learning module was produced as an initiative of
Lusaka Institute of Applies Sciences (LIAS)

We designate true authorship of this work and credit to distinguished people.

We take cognisance of the following persons who contributed to proof reading of the module:

1. Isabel Nyahoda (Lecturer- Lusaka Nursing institute)

2. Evans Mwale (Lecturer- Lusaka Nursing institute)

3. Mary Miti (Nursing Education Manager- Lusaka Nursing Institute)

Like any other educational literature, there maybe some weaknesses in our module arising from
our stretch to incorporate as much as we can, while trying to embrace what can be ideally done
to give meaning. We entirely take responsibility of all errors that may be noted and promise to
make every effort to correct such in the future editions.

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Unit1: Introduction to mental Health and Psychiatry Nursing

Psychiatry is a branch of medicine which deals with the study and treatment of mental
diseases. It deals with the mind, emotions and behaviour of man precisely; the least
understood portion of the human being.

Psychiatric illness is characterized by a breakdown in the normal pattern of thought,

emotion and behaviour. Psychiatric symptoms, problems and illness of all kinds are very
common throughout life. Psychiatric nursing is a specialized branch of nursing in which
the nurse utilizes personal knowledge of psychiatric theory and the available
environment to effect therapeutic changes in the patients’ thoughts, feelings and behaviour.
The nurse’s ability to effect these changes varies according to the nurse’s experience and
education. The therapeutic role of the psychiatric nurse cannot be described only in
terms of attitudes, feelings, relationship and understanding. What the nurse brings as a
person to the treatment situation is directly related to her therapeutic effectiveness.

Psychiatric nursing is concerned with the identification, promotion, prevention and care of
patients suffering from mental disorders (Keltner, Schwecke & Bostrom, 2007). Thus,
psychiatric nursing is the process whereby the nurse assists persons, individuals or groups
in developing a more positive self-concept, a more harmonious pattern of interpersonal
relationships and a more productive role in the society.

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Definition of common terminologies used in mental health and psychiatric nursing

TERM DEFINITION
Psychiatry A specialized or branch of medicine that deal in the diagnosis and
management of mental disorders.
Agraphia An inability to write occurring in general dysphasia also called apraxia
Mental health defines mental health as being happy, efficient, lack of anxiety, maturity,
able to adjust, practicing autonomy and self-esteem is high
Health A state of well being, but not merely the absence of disease or infirmity
Communication Interaction between people and their environment based on stimuli and
responses.
Language This is a method by which thoughts and activities are made available to
conscious awareness. It can be vocal, written or sign represented.
DISORDERS OF PERCEPTION

Illusion Misinterpretation of stimuli.

DISORDERS OF THINKING
Flight of ideas Too much ideas flowing together
Retardation of thought No thinking in place such as seen in depression
Circumstantial thinkingA talk that does not go directly to the topic but takes time for that
individual to state the point or simply beating about the bush
Fragmented thinking disjointed ideas
Delusion false belief based on no founded fact(s) or evidence- based
research and is not related to an individual’s educational
background, religion, race or culture
Obsession These are repetitive ideas coming into your mind frequently
DISORDERS OF ORIENTATION

Disorientation Inability to recognize place, time, date, year and person (all the
spheres are forgotten).
DISORDERS OF SPEECH

Incoherent speech senseless speech

Echolalia patient repeating what the interviewer says
Echopraxia Patient repeating the movements made by the interviewer
Neologism Formation of own new words with meaning known by the patient
him/herself
Word salads mixing of words that only make sense to the owner
Mutism When someone can’t talk, as seen in severe depression
DISODERS OF MOTOR ACTIVITY

Stereotyped activity copying what someone else is doing

Negativism Doing exactly the opposite of what one is are taught or told to do
Compulsion an act due to a repeated ideas coming into your mind
Waxy flexibility maintaining of awkward or a sustained posture

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TERM DEFINITION
DISORDERS OF MOOD OR AFFECT

Euphoria/elation excessive happiness

Depression reduced emotional out put or feelings/affects
Incongruent affect unexpected behaviour or affect
Flat affect un-aroused affect or blunt feeling
Ambivalence Existence of two conflicting ideas at the same time
DISORDERS OF MEMORY

Amnesia forgetting things that happened

Retrograde amnesia Amnesia of events that happened after the accident or injury
Anterograde Amnesia of events that happened before the accident
amnesia
Confabulation creating own ideas to cover up what you have forgotten
Erotomania An individual normally un-married woman who believes that she is
loved by a person of high social status. She engages in writing letters,
sending gifts, telephoning or attempt visits
Grandiose delusion an individual believes he/she possess a recognized talent or in sight
such as that of religious leader and seek for position of power
Folie ᾰ duex shared paranoid disorder which develops as a result of close
relationship with a person who already experience persecutory
delusion
Déjà vu A patient seeing a strange person and believing that he/she has seen
that person before, psychopathology familiarity

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HISTORY OF MENTAL HEALTH AND PSYCHIATRY IN ZAMBIA

There were no mental health services in Zambia, then Northern [Link] were being
transferred to Ingusheni hospital in Southern Rhodesia (now Zimbabwe) for mental services.

The lunacy ordinance was enacted in 1921.

• The Mental Disorders Ordinance in 1951.

• In June 1962, Chainama Hills Hospital was opened. Provided guidance on mental health
policy issues.

• In 1974, Ministry of Health took over the hospital.

• In 1978, the Mental Health Coordinating Group was established to set priorities for mental
health services in [Link] led to the establishment of the Mental Health Unit –Technical
input for policy.

• Training of Medical Assistants Psychiatry (Clinical Officers) started in 1964.

• Training of Enrolled Psychiatric Nursing started in 1966.

Mental health services and primary health care

• Primary health care concept was mooted in 1981.

• The structure of mental health services was established:

 Village level

 Health centre level

 District level

 Provincial level

 Specialised level

• However, gaps were noticed in service provision e.g financial problems, staff related
problems.

• Globally, mental health problems are responsible for 12.5 percent of the disease burden.

• Zambian hospital based figures show a prevalence rate of 3.61 and 1.8 per 10 000
population for acute states and schizophrenia respectively.

• Ten percent of admissions for acute states are due to alcohol and drug misuse.

• More men are reported to abuse alcohol than women.

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Health reforms

• The government introduced health reforms in 1991.

• The burden of disease was calculated using the Disability Adjusted Life Years (DALYs)
concept.

• As a result, mental health ranked 17th on the table of priority illnesses.

• Therefore it was not among the six health thrusts short-listed.

• And left out of the first (1995-1998) and second (1998-2000) National Health Strategic Plans
Mental health was also left out of the Basic Health Care Package.

• The health care vision is to provide all Zambians with equity of access to cost- effective,
quality health care as close to the family as possible.

• What does this mean for mental health services?

• How close to the family are mental health services getting?

• What are the implications?

Current situation

At the moment, the situation is critical. There is shortage of staff. Shortage of essential psychotropic
drugs.

 Inadequate funding for various needs.

 Community mental health services are non-existent.
 This scenario has adversely affected the quality care being provided.
 With extensive consultations, mental health is part of the National health strategic
plan.
 There are 560 beds for psychiatric patients across the country.
 200 0f which are at Chainama Hospital and the rest are shared among the seven
provincial psychiatric units.
 Clinical Guidelines on Mental Health have been developed.
 There is little collaboration with traditional health practitioners.
 The effectiveness of alternative and complimentary healing methods.
 Links with the police and prisons are inadequate.
 Mental Health Information System is not available. Information on mental health is
not fully integrated into Health Information System.
 Existing infrastructure in mental health institutions is in a deplorable state.
 There is little access to basic psychotropic medication almost at all levels of care.

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Aetiology of Mental Disorders

Introduction
When the lay public is asked to prioritize their causal beliefs for a vignette depicting either
schizophrenia or depression, psychosocial causes are most popular for depression, but a large
proportion of respondents prefer biological causes for schizophrenia. It therefore follows that
knowing about the lay public's causal beliefs about mental diseases before knowing about the
scientist’s, is a prerequisite for providing adequate information and education to both patients
and the public. Jorm's review on mental health literacy (2000) stated that the public for instance
regards depression and schizophrenia most often to be caused by the social environment,
particularly recent stressors. A review of population studies concluded that while this holds true
for both depression and schizophrenia when using an unlabeled case vignette as a stimulus (e.g.
Lauber et al., 2003; Magliano et al., 2004), the picture is unclear in studies explicitly referring to
the diagnosis of schizophrenia.

What Really Causes Mental Disorders?

Mental disorder is complex and as such, it is difficult to state what the causes are. The influences
that potentially contribute to mental disorder are numerous, and competing theoretical models
have disputed the emphasis to be given to individual and social influences, nature versus
nurture, and biological or psychological factors. What is most important to reiterate is that the
causes of health and disease are generally viewed as a product of the interplay or interaction
between biological, psychological, and sociocultural factors. This is true for all health and illness,
including mental health and mental disorder. For instance, diabetes and schizophrenia alike are
viewed as the result of interactions between biological, psychological, and sociocultural
influences. With these disorders, a biological predisposition is necessary but not sufficient to
explain their occurrence (Barondes, 1993). For other disorders, a psychological or sociocultural
cause may be necessary, but again not sufficient.

There are however some practitioners that have spoken boldly about the biological model
leaving other models. As a comprehensive model of the causes and effects of mental disorder
and its treatment, the bio-medical tradition has been found increasingly wanting. Sociologically-
based explanatory models have been advanced which have gone beyond the quite strict confines
of disease detection and looked to personal and cultural reactions to disease for a greater
understanding of mental disorder. Epidemiologists and public health professionals have stressed
the significance of deprivation, poor housing and unemployment as causal factors. Whatever the
make-up, the complexity and multiplicity of potential causal factors sets the mental health
practitioner to approach aetiology of mental disorders cautiously. However experts generally say
that mental disorders are caused by several factors and that in most instances the causes
interact. Below we list some of the notable ones.

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Genetics (heredity) and The Environment

Many mental disorders tend to run in families, suggesting that people who have a family
member with a mental disorder are more likely to develop a mental disorder. Mental disorders
do occur in people who have a first-degree relative with the disorder, such as a parent, brother,
or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with
the disease may also develop mental disorder more often than the general population. The risk is
highest for an identical twin of a person with mental disorder. He or she has a 40 to 65 percent
chance of developing the disorder.

Susceptibility is passed on in families through genes. Experts believe many mental disorders are
linked to abnormalities in many genes and not just one. That is why a person inherits a
susceptibility to a mental disorder and doesn't necessarily develop the illness. Mental disorder
itself occurs from the interaction of multiple genes and other factors such as stress, abuse, or a
traumatic event like death of a loved one which can influence, or trigger, an illness in a person
who has an inherited susceptibility to it.

Studies suggest that mental disorder may result in part when a certain gene that is a key to
making important brain chemicals malfunctions. This problem may affect the part of the brain
involved in developing higher functioning skills.

In addition, it probably takes more than genes to cause the disorder. Scientists think interactions
between genes and the environment are necessary for mental disorder to develop. Many
environmental factors may be involved, such as exposure to viruses or malnutrition before birth,
problems during birth, and other not yet known psychosocial factors.

Different Brain Chemistry and Structure

Some mental disorders have been linked to an abnormal balance of special chemicals in the brain
called neurotransmitters1 like dopamine and glutamate, and possibly others. Chemical
abnormalities are known to play a role in some mental disorders like schizophrenia.
Neurotransmitters help nerve cells in the brain communicate with each other. If these chemicals
are out of balance or are not working properly, messages may not make it through the brain
correctly, leading to symptoms of mental disorder. In addition, defects in or injury to certain
areas of the brain have also been linked to chemical abnormalities and some mental conditions.

Also, in small ways the brains of people with mental disorder look different than those of healthy
people. For example, fluid-filled cavities at the centre of the brain, called ventricles, are larger in
some people with mental disorder. The brains of people with the illness also tend to have less
gray matter, and some areas of the brain may have less or more activity and in either case, one
may have chemical pathology.

Infections and Brain Damage

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Certain infections have been linked to brain damage and the development of mental
disorder or the worsening of its symptoms. For example, a condition known as paediatric
autoimmune neuropsychiatric disorder (PANDA) associated with some species of
streptococcus has been linked to the development of obsessive-compulsive disorder and
other mental disorders in

children (Garvey et al., 1998). There are a number of mental disorders that have been linked with
microbial pathogens (Pearce, 2003). There have been links between infection by the
parasite Toxoplasma gondii , HIV, cryptococcus among others and mental disorders, with the
direction of causality presented invariably (Thomas et al., 2004; Alvarado-Esquivel, 2006; Vyas et
al., 2007). A number of diseases of the white matter can cause symptoms of mental disorders
(Walterfang et al., 2005). The current research on Lyme's Disease caused by a deer tick, and
related toxins, is expanding the link between bacterial infections and The current research on
Lyme's Disease caused by a deer tick, and related toxins, is expanding the link between bacterial
infections and mental disorders.

5.1.4 Brain Defects Or Injury

Defects in or injury to certain areas of the brain has also been linked to some mental disorders.

Prenatal Damage

Some evidence suggests that a disruption of early fatal brain development or trauma that occurs
at the time of birth -- for example, loss of oxygen to the brain -- may be a factor in the
development of certain conditions, such as autism.

Higher rates of mood, psychotic, and alcohol and substance abuse disorders have been found
following traumatic brain injury (TBI). Findings on the relationship between TBI severity and
prevalence of subsequent mental disorders have been inconsistent, and occurrence has been
linked to prior mental health problems as well as direct neurophysiological effects, in a complex
interaction with personality and attitude and social influences (Fann et al., 2004).

Alcohol and substance abuse

Long-term alcohol and substance abuse, in particular, has been linked to anxiety, depression, and
paranoia. 

Psychological Factors

A great many psychological factors have been identified and linked to mental disorders and the
notable ones include:
 Severe psychological trauma suffered as a child, such as emotional, physical, or sexual
abuse
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  An important early loss, such as the loss of a parent
 Neglect
 Poor ability to relate to others

Environmental Factors

Certain stressors within the environment can trigger a mental disorder in a susceptible person.
These stressors may include:
 Death or divorce.
 A dysfunctional family life.
 Living in poverty.
 Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness.
 Changing jobs or schools....
 Social or cultural expectations (For example, a society that associates beauty with
thinness can be a factor in the development of eating disorders.)
 Alcohol and substance abuse by the person or the person's parents.
 Neighbourhoods, society and culture. Problems in communities or cultures, including
poverty, unemployment or underemployment, lack of social cohesion, and migration
(especially among refugees), have been implicated in the development of mental
disorders (Pilgrim et al., 2005; Glahn et al., 2007). Stresses and strains related to
socioeconomic position (socioeconomic status (SES) or social class) have been linked to
the occurrence of major mental disorders , with a lower or more insecure educational,
occupational, economic or social position generally linked to more mental disorders
(Muntaner et al., 2004). There have been mixed findings on the nature of the links and on
the extent to which pre-existing personal characteristics influence the links. Both personal
resources and community factors have been implicated, as well as interactions between
individual-level and regional-level income levels (Lorant et al., 2003). The causal role of
different socioeconomic factors may vary by country (Araya et al., 2003). Socioeconomic
deprivation in neighbourhoods can cause worse mental health, even after accounting for
genetic factors (Caspi et al., 2000). In addition, minority ethnic groups, including first or
second-generation immigrants, have been found to be at greater risk for
developing mental disorders, which has been attributed to various kinds of life
insecurities and disadvantages, including racism (Chakraborty and McKenzie, 2002). The
direction of causality is sometimes unclear, and alternative hypotheses such as the Drift
Hypothesis sometimes need to be discounted.
 Mental disorder has also been linked to the overarching social, economic and cultural
system (Ihsan, 1995; Bergin and Richards, 2000; Fee, 2000 Krause, 2006).  A value system
that promotes individualism, weakens social ties, and creates ambivalence towards
children, is being spread or imposed via globalization, yet could adversely affect
children's mental health.
 Life events, stresses and relationships. Maltreatment in childhood and in adulthood,
including abuse, physical, emotional abuse, domestic violence and bullying, has been
linked to the development of mental disorder, through a complex interaction of societal,
family, psychological and biological factors (Maughan and McCarthy,1997;Spataro et al.,
2004; Teicher et al., 2006). Negative or stressful life events more generally have been
implicated in the development of a range of mental disorders, including mood and

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 anxiety disorders. The main risks appear to be from a cumulative combination of such
experiences over time, although exposure to a single major trauma can sometimes lead
to psychopathology, including PTSD. Resilience to such experiences varies, and a person
may be resistant to some forms of experience but susceptible to others. Features
associated with variations in resilience include genetic vulnerability, temperamental
characteristics, cognitive set, coping patterns, and other experiences (Rutter, 2000).

Other factors

Poor nutrition and exposure to pollutants, such as lead may play a role in the development of
mental disorders. Poor general health has been found among individuals with severe mental
disorders thought to be due to direct factors including diet, substance use, effects of medication
and social economic disadvantages.

Relationship issues have consistently been linked to development of mental disorders, with
continued debate of the school, work and home environmental being of relative importance and
not forgetting the peer group. Parenting skills, parental depression, divorce have been known to
play a role in the aetiology of mental disorders. Early social privation or lack of ongoing
harmonious secure committed relationships has been implicated both in childhood (including
institutional care) and also through life span relationships. This is very evident during
adolescence (Marano, 2003; Heinrich and Gullone, 2006).

Summary of causes of mental disorders

“What causes mental disorder?”

 General Principles

Aetiology of individual disorders will be dealt with as they are covered

 Some competing aetiological theories

 The bio-psycho-social model
 Predisposing, precipitating, perpetuating
 Other concepts
 Life events, risk/resilience, systemic approach

Aetiological Theories

 Witchcraft
 Demonic possession
 Result of moral (e.g. sexual) laxity
 Various physical processes
 Hippocrates – 4 “humors”(Yellow bile, Black bile, Blood and Phlegm)
 Hysteria “wandering womb”

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  Mental illness as a “myth” – social control

Our current theory

 Most psychiatric disorders have MULTIFACTORIAL aetiology

 “The BIO-PSYCH-SOCIAL approach”
 Biological, Psychological and Social factors
 Predisposing, Precipitating and Perpetuating (maintaining) factors

Aetiology
Precipitatin
g factors

Mental
Disorde
Predisposing Recovery
r
factors

Perpetuatin
g
Factors

Multiple Causation

Multiple Causation

Predisposingcauses
A mount of Stress

High
ress

in placebeforeonset Disorder

manifested
makeperson susceptible
inherited characteristics
Disorder
learned beliefs not
sociocultural beliefs Low
manifested
LowLow High
Predispositionfor the illness

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 Multiple Causation

 Precipitatingcauses High

A m o uonftstress
Disorder
 immediateeventsthat bring
manifested
onthedisorder (stress)
 loss(e.g., loved one, job)
 perceived threat Disorder
 when predisposition high, not
precipitatingevent may be manifested
small
Low
Low High
Predispositionfor thedisorder

Biological
Aetiological Factors (1)

 Genetic
 Chromosomal abnormality e.g. Trisomy 21
 Single Gene e.g. Huntington’s Disease
 Polygenic e.g Schizophrenia
 Sex

Remember: Genes and Environment Interact

Biological: Aetiological Factors (2)

Neuro-developmental

 Intrauterine e.g. Alcohol, Stress, Infection

 Peri-delivery – birth trauma
 Brain changes with age, e.g.
 Schizophrenia in late teenage
 Dementia in old age

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Biological: Aetiological Factors (3)

 Hormonal e.g. Puerperal Psychosis

 Infectious e.g. Cerebral Malaria, HIV
 Trauma e.g. Head injury
 Substance misuse, E.g. Cannabis in Schizophrenia
 Iatrogenic e.g. Steroids
 Chronic Physical Illness
Summary on Biological
Mental disorders as physical diseases
Brain abnormalities
Chemical imbalances
Birth difficulties
Heritability
Psychological: Aetiological Factors
 Temperament
 Early Childhood experience
 Attachment theory: Abuse/Neglect/Loss
 Previous experiences/relationships e.g. Personality characteristic patterns of
thinking, free coping style, e.g.
o worrier
o “depressive cognitions”
o emotional instability
o recklessness
 The personal meaning attached to life events
 High Expressed Emotion (EE) – associated with ñrisk of SZ relapse
 ling and behaving.

Other perspectives on Aetiology

Psychodynamic Perspective
 Sigmund Freud
 Unconscious conflicts and drives
 Early childhood trauma
 therapy helps person become aware of underlying conflicts

Perspectives on Mental Disorders

Cognitive Perspective
 conscious thoughts
 learned maladaptive thought patterns cause mental disorder
Behavioral Perspective
 learned maladaptive patterns of behavior cause mental disorder

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 Social Aetiological Factors

Poverty (absolute and relative)

Poverty

Less education
Reduced access to health care
Less job opportunities
Stress
Decreased social networks
Malnutrition
Poorer physical health
Poor physical health
More risky behaviour
More risky behaviour
Increased rates substance
misuse Increased rates substance misuse

Mental illness

 Relationships, e.g.
o Marital status
o Confiding relationship
o Domestic violence
 Social Network e.g.
o Perpetuating factor in alcohol/drug dependence
o Supportive factor in recovery from depression
 Gender
o Different social roles and expectations
 Employment, e.g.

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 o Unemployment associated with suicide
o Depression/anxiety associated with work stress
o Alcohol use in certain occupational groups
 Culture
 Stigma

Culture and Mental Disorder

Culture influences:
• Value placed by society on mental health
• Presentation of symptoms
• Illness behaviour
• Access to services
• Way individuals and families manage illness
• Way community responds to illness
• Degree of acceptance and support
• Degree of stigma and discrimination

Biological Sociological

Predisposing
Precipitating
Perpetuating

Psychological

3 important concepts
 Life Events
 Risk/Resilience
 Systemic approach

Life Events (1)

 Death of a parent, spouse, child, relative
 Accident
 Physical Illness
 Marriage
 Birth of a child
 Unemployment
 Promotion
All life events (positive and negative) can precipitate mental illness. They can also
predispose to future mental illness or setback recovery (perpetuate). It is not just the
event but the person’s interpretation of it. E.g.
 threat, helplessness
 catastrophisation

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Risk/Resilience
Some factors increase our risk of having mental disorder (RISK factors).Other factors reduce
our risk (resilience or protective factors), e.g. Temperament, social skills, confiding
relationship, social support, Intelligence, abilities, opportunities.

A systemic approach
No man is an island

A systemic approach
“Noman Wider
isanisland” society,
Culture

School,
Work

Family,
friends

Individual

PRINCIPLES OF PSYCHIATRIC NURSING

 Allow a client an opportunity to set own pace in working with problems.

 Nursing interventions should centre on the client as a person, not on control of
symptoms. Symptoms are important, but not as important as the person having
them.
 Recognize your own feelings towards clients and deal with them.
 Go to the client who needs help the most.
 Do not allow a situation to develop or continue in which a client becomes the focus
of attention in a negative manner.
 If client’s behaviour is bizarre, base your decision to intervene on whether the client
is endangering self or others.
 Ask for help-do not try to be a hero when dealing with a client who is out of control.
 Avoid a highly competitive activity that is having one winner and a room full of
losers.
 Make frequent contact with clients- it lets them know they are worth your time and
effort.

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  Remember to assess the physical needs of your client.
 Have patience, move at the client’s pace and ability.
 Suggesting, requesting, or asking works better than commanding.
 Therapeutic thinking is not thinking about or for, but with the client.
 Be honest so the client can rely on you.
 Make reality interesting enough that the client prefers it to his or her fantasy.
 Compliment, reassure and model appropriate behavior.

 This is a basic and brief illustration on the legal principles and sources of law which
have enhanced the delivery of mental health and sound psychiatric nursing practice
in Zambia and other common wealth countries internationally.

Sources: law affecting Psychiatric Nursing in Zambia

The Zambian constitution

You may be aware that the Zambian constitution has outlines that guide how psychiatric patients
should be handled when they commit an offence that would be deemed criminal but such a patient
should be admitted to mental unit so that an evaluation could be made to ascertain whether the
patient is or is not fit to stand trial in a court of law. Patients’ of such nature may get admitted to a
prison station via His Excellence Pleasure, the President also called [Link].

Mental health policy of Zambia

The Mental Health Services Bill, (2006) provides clear guidelines for handling and care of psychiatric
patients at any level of health care for instance the health centre, there should be at least two beds
where such a patient may be admitted before transfer to a district hospital where five beds strictly
reserved for mental patients.

The Ministry of Health – Zambia

The ministry of Zambia is the core custodian for mental health care implementation and
employment of mental health [Link] keeps and facilitates all legal issues related to mental health
[Link] information regarding legal implications for mental health care could be accessed through
the ministry of health and currently the ministry of health is working on the draft document for
mental health in Zambia which is only awaiting parliament approval.

Mental Health Laws In Zambia

Mental disorder in Zambia is defined by an act of parliament called the mental disorders Act Chapter
305 of the laws of Zambia. The law was enacted by the federal government and contains terms that
are deemed as derogatory to the mentally ill. Such terms refers to the mentally ill as idiots, imbecile.
Mental health activists are fighting for this law to be repealed. The government has currently made
tremendous progress in repealing this outdated law.

According to this law, a mentally disordered or defective person means any person who, in
consequence of mental disorder or disease or permanent defect of reason of mind. Congenital or
acquired:

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Is incapable of managing himself or his affairs;

Or is a danger to himself or others; or is unable to conform to the ordinary usages of the society in
which he moves; or requires supervision, treatment or control; or (if a child) appears by reason of
such defect to be incapable of receiving proper benefit from the instruction in ordinary schools;

THE LEGAL ASPECTS OF PSYCHIATRIC-MENTAL HEALTH NURSING

There are many legal aspects in psychiatry for instance a patient suspected of suffering from mental
illness should be admitted to a mental unit under certain legal procedures for example a patient
shall be admitted Under Detention orders endorsed by a magistrate or in the subordinate [Link]
are therefore referred to the Laws of Zambia Vol.17 of the Zambian Constitution.

MENTAL HEALTH POLICIES IN ZAMBIA

The Government of Zambia has been trying to recognize the importance of mental health in the
country. In order to provide coordinated and well structured mental health services, the government
has offered policy direction as regarding care of the mentally ill. The care is in different forms i.e.
institutional care, community care as well as prevention aspects.

A complete document on mental health policies in Zambia’s is available and can be obtained from
Government printers. You are encouraged to access this document.

MENTAL HEALTH ASSOCIATION OF ZAMBIA

Mental Health Association of Zambia (MHAZ) is a nongovernmental organization that looks into the
welfare of the mentally challenged. The association collaborates with the government to ensure that
mental health services are well provided to the community at large. MHAZ plays a key role in
sensitizing the community on the prevention of mental illnesses. It also highlights the challenges that
the mentally ill go through. The association has also been fighting stigma against the mentally ill.

Membership is open to all that are interested in mental health issues

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Unit 2: Psychiatric Nursing Skills

Communication skills

Definition of that communication is the reciprocal exchange of information, ideas, beliefs,

feelings and attitudes between 2 people or among groups of people. It is a skill that is
practiced when making the different nursing interventions in nursing practice.

Methods of communication
There are various methods used for communicating with clients in mental health. These
include:
 verbal
 non verbal
 written communication skills

Verbal communication or the spoken word

Verbal communication occurs through words that are spoken or written. As a nurse you
need to be prepared to communicate effectively with patients that speak a different
language from your own. You may therefore also need to learn or adapt to your client’s
language because certain phrases or ways of expression are better done in the mother
tongue or local dialect.
As a nurse you start communicating with a patient with opening remarks that build rapport
and encourage clients to open up. Then when the patient opens up, as a nurse you need to
listen. Don’t “interrogate patients’ or shower them with questions all at one instant, thereby
making them feel judged.

Non verbal communication or body language

These are messages received via facial expression, voice tone, pitch, physical postures and
gestures. Body language is always present during communication, without which we cannot
communicate. The body language of both the patient and ourselves as nurses (the patient
also sees our body language). For instance, if you are quick and sharp as a nurse the patient
may view such body language as rudeness and an “I don’t care” attitude. On the other hand
if you as a nurse is unhurried, smiles, warm and friendly, it conveys acceptance and patients
may turn to you for help, or disclose personal feelings to you.
Tips for Understanding Non-Verbal Communication
Recognise that people communicate on many levels. Watch their facial expressions, eye
contact, posture, hand and feet movements, and their appearance. When interviewing
people, watch how they sit and wait. As you watch clients, take note of negative gestures
and personal space.
Negative Gestures
Feet dragging: lethargic, don’t care
Head down: timidity, shyness
Shoulders Drooped: weariness, lethargy
Shifty eyes: nervousness
Hands in pockets: something to hide
Weak handshake: meek, ineffectual
Personal space

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‘proper’ space 2-4 feet
Violation of personal space is seen as a threat and an aggressive gesture by both the client
and yourself as a nurse alike.

The Importance of Listening to Clients

The first rule of a therapeutic relationship is to listen to the patient. It is the foundation on
which all other therapeutic skills (assertiveness, counselling, social, nurse patient
therapeutic relationship) are built. Real listening is difficult. It is an active, not a passive,
process. As nurses, we should suspend thinking of personal experiences and problems and
making personal judgements of the patient.

Mnemonic “SOLER”. Summarizes

What does SOLER stand for?

It stands for:
S – Sit squarely
O – Open posture
L – Lean forward
E – Eye contact
R – Relax as you listen

COUNSELLING SKILLS

Definition of counselling

Counseling is a method of relieving distress undertaken by means of a dialogue between 2 people.

The aim is to help the client find their own solutions to problems, while being supported and being
guided by appropriate advice.

Nurses who care for clients with mental problems must be ready at all times to take on the role of a
counselor. A counselor must have certain qualities if clients are to confide in him or her.

Qualities of a Counsellor

 Being genuine means that a counselor cares for the client and behave toward the client as they
really feel. It is similar to congruence.
 Being accepting means that counselor should appreciate clients for who they are, despite the
things that they may have done. Counselor does not have to agree with clients, but they must
accept them. It is the same as unconditional positive regard.

 Being empathic means that the counselor understands the client’s feelings and experiences and
conveys this understanding back to the client. Empathetic understanding can be demonstrated
through reflection of feelings, and clarification.

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Basic Counseling Skills

There are 8 basic skills of counseling that a nurse needs to learn. These skills are used by the nurse
when counseling and are necessary for forming a working relationship with the patient.

The skills are:

 Attending
 Listening
 Clarifying
 Reflecting
 Paraphrasing
 Asking questions / probing
 Summarizing
 Challenging

Attending

Patients in distress are acutely aware of the attention/inattention of the attending nurse, and are
sensitive to both verbal/non-verbal cues. . A nurse or counselor must show through their body
position and facial expression that they are paying attention—for example, by directly facing the
client and making good eye contact. Attending involves ‘SOLER’ behaviours which we discussed
earlier in this unit.

Listening

Listening includes hearing what the patient has to say, gathering and processing information, and
observation of non-verbal cues. It requires more than a physical relationship, but should involve
personal contact during consultation. Active listening demonstrates empathy—letting clients know
that they are being fully listened to and understood.

Clarifying

Clarifying is an attempt to understand a client’s statements. Asking clients to give examples to clarify
what they mean can help you understand better. Other strategies used to clarify something the
client has said include summarizing, at the beginning, during and at the end of a session.

Reflecting

Reflecting involves the nurse acting as a sounding board for the patient by reflecting back what she
or he is saying or feeling. The nurse does this by repeating the client’s verbal and non verbal
message. Reflection conveys back to the speaker their thoughts and feelings.

Paraphrasing

The nurse determines the basic message in a patient’s statement, and then rephrases it, or restates
the sentence in similar words used by the patient. It gives an opportunity to test your understanding
of what is being communicated.

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Asking questions / Probing

Probing is a counselor’s use of a question or statement to direct the client’s attention inward to
explore his/her situation in more depth. A probing question, sometimes called an “open-ended
question”, requires more than a one word (yes, no) answer from the client. When phrased as a
statement, the probe contains a strong element of direction by the counselor; e.g. “Tell me more
about your relationship with your parents,” or “Suppose we explore a little bit more your ideas
about what an alcoholic is.”

Summarizing

To summarize is to select the key points or basic meanings from the client’s verbal content and
feelings and tie them together. This should not include the assumption of the counselor.
Summarizing then, is a review of the main points already discussed in the session to ensure
continuity in a focused direction.

Challenging

The counselor invites the client to examine thoughts and observable behaviour that is self defeating
and change such thoughts and behaviour for the better.e.g. She / he might ask this question to
challenge a belief: “What is your evidence for this belief?” or challenge clients to explore behavioural
consequences.

ASSERTIVE SKILL

ASSERTIVE: having or showing a confident and forceful personality.

SKILL: is the ability to do something well.
ASSERTIVENESS- Is the ability to state positively and constructively your rights or needs
without violating the rights of others. When you use direct, open and honest
communication in relationships to meet your personal needs, you feel more confident, gain
respect from others and live a happier, fulfilled life.
ASSERTIVENESS COMMUNICATION: Assertive behaviour helps us feel good about ourselves
and increases our self-esteem. It helps us feel good about other people and increases our
ability to develop satisfying relationships with others. This is accompanied out of honesty
directness, appropriateness and respecting one’s own basic rights as well as the rights of
others. Honest is basic to assertive behaviour. Assertive honest is not an out spoken
declaration of everything that is on one’s mind. It is instead an accurate representation of
feelings opinions or preferences expressed in a manner that promotes self- respect and
respect for others. Direct communication is starting what one to convey with clarity. Hitting
and beating around the bush are direct forms of communication, communication must
occur in an appropriate context to be considered assertive. The location and timing as well
as the manner (tone of voice, non-verbal gestures)in which the communication is presented

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must be correct in de situation. These are ten basic assertive human rights adapted from
aggregation of resources.
 The right to say no without feeling guilty.
 The right to express feelings opinions and beliefs.
 The right to make mistakes and accept responsibility for them.
 The right to put yourself first sometimes.
 The right to ask for what you want.
 The right to change your mind.
 The right to be listened to and taken seriously.
 The right to set your priorities.
 The right to refuse justification for your feelings or behavior.
 The right to be treated with respect.

RESPONSE PATTERNS
Individuals develop patterns of responding to others, some of these patterns include;
 Watching other people (role modelling)
 Being positively reinforced or punished for a certain response.
 Inventing in response
 Not developing the proper skills for a better response.
 Not being able to think of a better way to respond.
 Consciously choosing a response pattern.
The following are the 4 response pattern that a nurse must be able to recognize when
responding.
Assertive behaviour.
Sometimes called passive, seek to please others at the expense of denying their own human
rights, they sudden let their true feelings show and often feel hate and anxious because they
allow others to choose for them. They seldom achieve their own goals.
Assertive behaviour. Individuals stand on their own rights while protecting the rights of
others. Feelings are expressed openly and honestly. They assume responsibility for their
own choices and allow others to choose for themselves. they maintain self-respect for
others by treating everyone equal.
Aggressive behaviour. These defend their own basic rights violating basic rights of others
feelings are often expressed dishonestly and inappropriately they say what is on their mind
often at the expense of others .Aggressive behaviour common resulting in a putdown of a
receiver right denied, the receiver feels hurt.

PASSIVE AGGRESSIVE BEHAVIOUR.

Individuals defend their own rights by expressing resistance to social and occupational
demand sometimes called indirect aggression.

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BEHAVIOURAL COMPONENTS OF ASSERTIVE BEHAVIOUR.
Alberti and Emons (2001) have identified several defining characteristics of assertive
behavior.

EYE CONTACT
Eye contact is considered appropriate when it is intermittent like looking direct at the
person to whom you are speaking to but looking away now and then. Indirect he or she
feels uncomfortable when someone stares at them continuously.
BODY POSTURE
Sitting or leaning slightly towards the other person in a conversation which suggests an
active interest in what is being said. Emphasis on assertive stance can be achieved by
standing with an erect posture, squarely facing the other person. A slumped posture
conveys passivity or non assertiveness.
DISTANCE (Physical contact)
The distance between two individuals in an interaction or the physical contact between
them is a strong culture influence.
GESTURES
Non- verbal gestures may also culturally related, gesturing and add emphasis, warmth,
depth or power to the spoken words.
FACIAL EXPPRESSIONS
Various facial expressions convey different massages eg(frown ,smile, surprise ,anger and
fear) and is difficult to fake these expressions.

VOICE
The voice conveys the message by its loudness, softness, degree and placement of emphasis
and evidence of true tone.
FLUENCY
Being able to discuss a subject with easy and with obvious knowledge convey assertiveness
and self-control.
TIMING
Assertive responses are most effective when they are spontaneous and immediate.
LISTENING
Assertive listening means giving the other individual full attention by making eye contact,
nodding to indicate acceptance of what is being said.
THOUGHTS
Cognitive process affects ones behaviour.
CONTENTS
Many times individuals do not respond to unpleasant situations.
TECHNIQUES THAT PROMOTE ASSERTIVE BEHAVIOUR
Standing up for one’s basic human rights.
Assuming responsibility for one’s own statement.

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Responding as a broken record (persistanly repeating in calm voice what is wanted)
Agreeing assertively, assertively accepting negative aspect about oneself, admitting when an
error has been made.
Enquiring assertively, seeking additional information about critical statement.
Shifting from content to process, changing their focus of communication from discussing the
topic at hand to analyzing what is actually going on in the interaction.
Clouding/fogging conquering with the critic argument without being defensive and without
agreeing to change.
Defusing, putting off further discussions with an angry individual until he/she is calmer.
Delaying assertively, putting off discussions with another individual until one is calmer.
Responding assertively with ironing

Self awareness skill

In specific to mental health knowing thyself is a basic principle of psychiatric nursing. The
process of self awareness is important because nurses; psychological state influence the
way patients information is analysed. The process of personal introspection adds
dimensions to the nurse-client relationship are pertinent to understanding client responses
thus enabling the nurse to explore these issues with their client. Self awareness is to know
about oneself, who you are? It is important for nurses their own attitude, behaviour and
values because they are always in interaction with people who are unique and not
necessarily have some characteristics.

Rungapachachy (1999) goes so far as to say that becoming self aware one should be
compulsory in the health profession and that it comprises of three related aspects these
are; cognitive, affective, and behavioural. These aspects may also be described as thinking,
feeling and acting for example, if I am aware that a potential situation could make me feel
anxious, then this could block affective communication because my anxiety makes me
unable to speak or make myself understand affectively.

SELF-AWARENESS: This is a process, objective examination of oneself and it is one of the

important components in nursing which improves the nurse and client relationship.

SKILLS: is the ability learned to carry out a task with predetermined results often within a
given amount of time, energy or both.

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 psychiatric nursing experience and the nurses goal is to achieve authentic open and
personal communication. The nurse must be able to examine personal feelings, actions and
reactions. A good understanding and acceptance of self allow the nurse to acknowledge a
patient difference and uniqueness (Eckroth Burcher 2001).

Campbell (1980) has identified a holistic nursing model of self-awareness that consists of
four interconnected skills namely; psychological, physical, environmental and philosophical.
1.
Psychological

This kind of skill includes knowledge of emotions, motivations, self concept and personality
PHYSICAL
This is the knowledge of personal and general physiology as well as of bodily sensation,
body image and physical potential.

ENVIRONMENT

This consists of social cultural environment, relationship with others and knowledge of the
relationship between tumours and nature.

PHILOSOPHICAL

This is the sense of life having meaning. A philosophy of life and death may not include
spiritual being but it does take into account responsibility to the world and ethics of
behavior. In
increasing self awareness johari window came up with a strategy which is divided into
four quadrants namely;

Quadrant 1; Is the open quadrant, it includes behavour, feelings and thoughts known to
the individual and others.

Quadrant 2; This is the blind quadrant it includes all the things that others know about you
and you are not aware about them.

Quadrant 3; this is the hidden quadrant, it includes things about one self that only the
individual knows.

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Quadrant 4 ; this is the unknown quadrant containing aspects of one self, there are unknown to
individual and to others. Taken together these quadrants represent the total self function

1. Known to self and 2. Known only to other

other

3. Known to self only 4. Known neither to self nor other

The following three principles help explain self function;

 A change in one quadrant affects other quadrants.

 The small quadrant 1 the poorer the communication.

 Inner personal learning means that a change has taken place, so quadrant 1 is larger
and one or more of the other quadrants is small.

The goal of increasing self awareness is to enlarge the area of quadrant 1 while reducing the
size of other three quadrants .To increase self knowledge it is necessary to;

LISTEN TO YOURSELF; this means an individual allow genuine emotions to be experienced,

identifies and accepts personal needs and ways moves the body in joyful, free and
spontaneous. It includes personal thoughts ,feelings and impulses.

LISTENING TO AND LEARNING FROM OTHERS; this is the next step in reducing the size of
quadrant2 and knowledge of self is not possible alone .As we relate to others, we broaden
our perception of self, but such learning requires active listening and openness to the
feedback others provide.

SELF DISCLOSING/REVEALING; this is the final step which involves reducing the size of
quadrant 3; it involves revealing to others the important aspects of self. Self disclosure is
both a sign of personality health and a means of achieving health.

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SOCIAL SKILLS
Definition of Social Skills

It is the knowledge and skills people need to have to live in the community. Examples of social skills
include:

 Holding conversations
 Establishing and maintaining friendships
 Dating
 Managing medications
 Grooming
 Numerous other activities that are a part of leading a happy, successful life

How to Conduct Social Skills Training

In social skills training we teach the patient a structured (step by step) way of examining and
modifying their own thoughts and behaviour. The clinician or nurses teaching involvement is
reduced as the patient becomes more skilful at managing difficult situations.

Like assertive training, social skills training is conducted in a group setting so that clients can learn to
interact with both the staff training them and other clients within the same group. From this group
they develop confidence to generalize behaviour learned to other settings such as home when they
get discharged or shops when they go shopping. Just like assertiveness training, , social skills’
training is conducted in a similar manner. In fact assertiveness is a social behaviour.

Importance of Social Skills Training

Social skills’ training is important for the following reasons:

 People with abnormal behaviours; do not interact with others because their social skills are
poor.
 Other people may avoid people with mental disorders because of their self absorption,
pessimism or elation.
 When someone has had mental illness for a long time, they tend to loose their social skills.
Clients with mental illness lose their social skills due to chronic or long illnesses or
admissions. As nurses we have to train them so that they can regain the lost social skills, to
avoid social isolation and stigmatization.

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OBSERVATION SKILLS

Observations are an integral part of nursing as a whole, as you can recall from your lessons
in Fundamentals of Nursing. In mental health, Observations are cardinal to the safety of all,
and when carried out correctly, they ensure a safe environment for clients and staff alike.
This is because many patients lack insight into their illness and may pose a danger to
themselves and others when measures are not put in place to watch them carefully.

Meaning of the word “Observe”

To observe is to watch carefully the way something happens or the way someone does
something. To notice or see something. Patients with mental disorders can be
unpredictable, for example, violent, risk to self and others, suicidal, homicidal, arsonists,
destructive to property.

As a nurse, you should therefore use all your senses to observe the patient by using your
ears, touch, taste, smell & instincts. Observations are therefore carried out continuously
around the clock by nurses on duty because a nurse is the only staff who is with the patient
on a 24hour continuous basis.

Importance of Observations t in Psychiatric Nursing

Observations are important for the following reasons:

 Physical condition of patient is affected by mental disorder

 People with mental disorder are not able to tell you what is wrong with them physically

 Observations include general condition, mental state examination, appearance, vital

signs, fluid balance, sleep patterns, nutritional status, side effects of psycho tropics, look
out for absconding etc

When nursing patients, we should always record all our observations using the correct
charts, sheets and case notes.

Importance of Recordkeeping

Record keeping is very important for the following reasons:

 When your observations are in writing they will facilitate treatment and
interventions by other professionals (psychiatrists, psychologists, sociologists, courts
of law) that may not be present with the patient on a 24 hour basis.

 It may protect you in courts of law.

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  It helps you to report abnormal findings to psychiatrist.

NURSES’ NOTES

The nurses’ notes of observations of their patients are a large part of their value as long as
they are accurate and complete records of their findings are kept. Nursing notes are already
in use in many psychiatric hospitals and provide information of great value without in any
way interfering with the nurses’ other duties.

The following are the purposes of such notes:

1. To give the psychiatrist information about the 24hour behavior of the patient.

2. To indicate the patient’s relationships with other significant people.

3. To pass on useful information to other nurses.

4. To serve as part of the official record of the patientt, nurses’ notes may be of great
importance in planning current treatment, in subsequent research and may in some
circumstances be a significant legal document.

5. To assist the trainee nurse by stimulating her interest in the particular problem
under consideration and to provoke her/his additional reading.

6. To provide psychiatrists and senior nursing staff with a basis for teaching, the notes
may be used in group discussions to help trainees to evaluate situations in an
objective way and to analyze the factors which affect the nurse pt relationship.

The following 10 principles should be observed in the preparation of nursing notes

1. Care must be taken to convey accurate meaning intended; description of behavior

and conversation must be accurate.

2. Statements should be as objective as possible.

3. Notes should be brief – the quality not the quantity is important

4. Information should be concrete – generalizations are usually valueless

5. Simple descriptive English should always be used in preference to technical terms.

6. Direct quotation can be most valuable, especially in reporting delusions and

hallucinations

7. The form of the notes should be flexible, depending on the type of pt being studied.
Depending on hospital policy, some places use the SOAPIER format to write nurses’
notes.

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 8. Notes should be written at least once a week, with special incidents being described
as they occur.

9. Notes must be dated and signed, they are valueless if they lack a proper time
sequence and if the writer cannot be identified

10. Any relevant material produced by the patient himself should be included – for
example, writings, sketches, and paintings.

Things to note on the patient when writing a progress report

Activities of daily living such as the sleeping pattern, resting, eating habits/ appetite,
interaction among fellow patients and members of staff, personal hygiene, speech, mood,
participation in ward activities, such as sweeping, bed making, washing plates, insight of the
illness, hallucinations or delusions, weight, vital signs, elimination and toilet habits, hobbies.

Observations are necessary when caring for clients with mental illness because may not
always tell you what is troubling them. It is always important to keep a record of your
observations in patients’ charts and notes.

STRESS MANAGEMENT SKILLS

Stress Management skills are means and ways of dealing with, or solving problems that we
daily encounter in everyday living.

Definition of s Stress

Stress may be viewed as an individual’s reaction to any change that requires an adjustment
or response.

Stress management

Stress management involves the use of coping strategies, ways or methods that protect the
individual from harm in response to stressful situations or stressors.

Importance of Stress Management for People with Mental Disorders

To prevent people with vulnerability to mental illness falling sick, they can be taught how to
manage the stress. Stress is a precipitating factor in a person with an already existing
vulnerability (such as, genetic inheritance, early childhood traumatic experiences).

Coping Strategies

There are a various coping strategies that we can teach our patients to help them manage
stress. These include:

36
  Awareness of stressors– Become aware of stressors, then omit, avoid, or accept
them.
 Relaxation – Through physical exercises, breathing exercises and muscle relaxation.
 Meditation.
 Seeking support and talking to others if anxiety is too much.
 Problem solving technique of counseling can be used, during which catharsis
(ventilation of feelings) is allowed to take place.
 Good social support networks that are able to offer material, informational and
emotional support.
 Prayer
 Music
 Pets
 Good nutrition
 Balance your life. Avoid too much of one thing.

BEHAVIOUR MODIFICATION SKILLS

Behavior modification is to change behavior. People with mental health problems have
disordered thinking that leads to abnormal behaviours. These abnormal behaviours can be
changed into good or acceptable behavior using behavior modification skills.

A nurse intervens to change behavior during the implementation phase of the nursing
process. Behavior modification skills utilize the principles of classical and operant
conditioning, and social learning covered in Psychology in Nursing.

Definition of behaviour modification

Behavior modification is a practice that treats behavioural problems. It is based on operant,

classical conditioning and social learning.

It is based on the premise that all behaviours are learned and can therefore also be
unlearned. In this approach, bad behaviours are unlearned while good behaviours are
learned using the principles of classical and operant conditioning and social learning.

DIFFERENT WAYS OF CHANGING ABNORMAL BEHAVIOUR

Classical conditioning

 Many of our feelings e.g. violent emotions, are probably conditioned responses to a
face, or voice that we associate with previous childhood bad experiences, such as
being scolded, beaten, or mistreatment.

 Since such emotional responses (fear, anger, poor self esteem) are learned, perhaps
they can be unlearned.

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 This change (to unlearn) of disturbing emotional responses by classical conditioning
is called behaviour modification.

 For example patients with aggressive behaviour can be trained in anger

management skills which include assertiveness that we earlier looked at, relaxation
and deep breathing technique, all which are behavioural methods.

 In operant conditioning, if a response to a stimulus produces positive consequences

for the individual it will tend to be repeated, while if it is followed by negative
consequences it will tend not to be repeated. For instance patients who manipulate
others by for instance by making fun of them should not have such behaviour
reinforced.

o This means that the bad behaviour should be ignored and good things that
they like should be withdrawn from them. For instance, when it is time to go
out for a social outing, explain to them that they cannot go out because they
are unpleasant to other people. They will only be able to go out when they
stop treating other people unkindly.

 Positive reinforcement – Adding a rewarding stimulus as a consequence of a

behaviour, thus increasing the probability that it will occur again. When patients
display good behaviour like being helpful, being good to others, they can be
positively reinforced by giving them something they like in the form of food,
makeup, a social outing and so on.

 Extinction – When positive reinforcement for a particular response (behaviour) is

withdrawn, the behaviour usually stops. This means that when you ignore and do
not laugh at a patient’s unkind jokes that targets vulnerable patients, the unkind
jesting will soon stop.

 Social learning / observation (e.g. assertive skills & social skills) Is a strategy used to
form new behaviour patterns, increase existing skills, or reduce avoidance behaviour
(such as phobias and panic attacks (systemic desensitisation) The behaviour to be
learned is broken down into a series of separate stages that are ranked in order of
difficulty or distress, with the first stage being the least anxiety provoking.

 The person then acquires the new behaviour by observing a person modelling the
behaviour in a controlled environment. The person then imitates the model’s
behaviour.

 Social learning or modelling can be displayed by nurses as they interact with patients
in the ward environment. As a nurse you can model behaviours like greeting,
politeness to say ‘thank you’ and ‘please’. You can also model grooming, holding
conversation, maintaining personal space and good table manners, through involving

38
 themselves in the activities of daily leaving in the unit. The nurse is a role model for
clients. They watch and imitate your behaviour. So remember your self awareness
skills while in the unit with your patients.

THERAPEUTIC NURSING INTERVENTION SKILLS

You may remember that we defined the terms ‘therapeutic’ and ‘interventions’ in one of our earlier
lessons.

Definition of ‘therapeutic’ and ‘interventions’

Therapeutic nursing interventions are actions that nurses take to help, treat or deliver nursing care
to clients so that they may recover or get well. Giving nursing care or therapeutic nurse
interventions to clients with abnormal behaviors and disordered thought patterns is more effective
when clients’ trust has been built up within a nurse patient therapeutic relationship. In fact, the
psychiatric nursing skills are nursing interventions and therefore delivered within a nurse patient
therapeutic relationship.

THE NURSE PATIENT THERAPEUTIC RELATIONSHIP

The nurse patient therapeutic relationship can be defined as an interaction between two people
(usually a caregiver and a care receiver) in which input from both parties contributes to a climate of
healing, growth promotion, and illness prevention.

THE IMPORTANCE OF A NURSE PATIENT THERAPEUTIC RELATIONSHIP

The nurse-client relationship is the foundation upon which psychiatric nursing is established. This
means all nursing interventions are most effective within a nurse patient relationship. It is a
relationship in which both participants learn from one another (Peplau 1991). Like other areas of
nursing practice, psychiatric mental health nursing works within nursing models (Hildegard Peplau,
Dorothea Orem) utilizing nursing care plans, and seeks to care for the whole person.

The emphasis of mental health nursing is on the development of a therapeutic relationship (healing
or beneficial to patient) or alliance. In practice this means the nurse seeks to engage with the client
in a positive collaborative manner that empowers them to draw on their inner resources in addition
to other treatment they may be receiving.

A therapeutic or “helping” relationship is established through use of basic counseling skills as seen
earlier during our lesson on counseling skills.

ADVANTAGES OF A NURSE PATIENT RELATIONSHIP

 Through establishment of a nurse-pt relationship, clients learn to transfer their relationship

with the nurse to relationships with significant others because the nurse acts as a role
model.

39
  Therapeutic relationships are goal oriented. The nurse and client decide together what the
goal of the relationship will be.
 The goal of a therapeutic relationship may be based on a problem solving model.
 Therapeutic use of self is whereby the nurse uses her personal qualities to establish the
relation and to give care to the patient. To use oneself in a therapeutic way one needs to
have a great deal of self awareness skills. Eg. Don’t use the patient to direct your feelings for
someone in your life.
 The relationship is the means by which the nursing process is implemented. Through the
relationship problems are identified and resolution is sought.

PHASES OF A NURSE PATIENT RELATIONSHIP

The relationship is divided into 4 phases:

Pre interaction

The nurse and patient first meet during this phase.

The nurse’s primary concern is to find out why the patient sought help, & together with patient
formulate objectives on what should be achieved in the relationship

Tasks:

 Establish a climate of trust, understanding, acceptance, and open communication.

 Formulate a contract with the patient

Orientation (Introduction)

 Elements of a Nurse-Patient Contract:

 Names of individuals
 Roles of nurse and patient
 Responsibilities of nurse and patient
 Expectations of nurse and patients
 Purpose of the relationship
 Meeting location and time
 Conditions for termination
 Confidentiality

Working

 Most of the therapeutic work is carried out in this phase.

 Problems (reasons patient sought for help) are dealt with using problem solving approach.
 Actual behavioural change is the focus of this phase.
 The psychiatric nursing skills are used to bring about this behavioural change.

40
Termination

 Prepare the patient for termination by decreasing visits, incorporating others into meetings,
or changing location of meetings.
 Clarify reason for such changes so pt does not interpret it as rejection by the nurse.
 Mutually explore feelings of rejection, loss sadness and anger etc.
 Review progress of therapy and attainment of goals.
Therapeutic Nursing Interventions are composed of nursing care directed towards the patient with
the aim of helping him or her recover. Such interventions are best made within the nurse patient
relationship utilizing the nursing process.

PHYSICAL ASSESSMENT OF A PSYCHIATRIC PATIENT

A physical assessment is an examination that is conducted the first time a patient comes to
the health facility with a complaint. It may also be conducted upon admission. Psychiatric
patients may not tell you what physical problems they are having, so you have to be very
observant and skilful in the way that you conduct your examination.

Physical assessment of a psychiatric patient starts with history taking, is followed by vital
signs, and then a physical examination. Examination may either be head to toe or may be
system by system. After the physical examination, laboratory, x-ray and other investigations
may be carried out and will depend on findings of the physical examination and any
complaints from the patient.

Timing of physical assessment: Its art of the admission procedure. If there is a delay in
examining due to an unstable mental state, reasons of delay should be recorded clearly. A
physical assessment comprises of Subjective and objective data. Have a chaperone in
attendance when conducting a physical examination on patient of opposite to avert
accusations of sexual harassment guard against risk of violence by aggressive patients.

PURPOSE OF PHYSICAL EXAMINATION IN PSYCHIATRIC PATIENTS.

 To identify physical illnesses that may have been overlooked and then refer the
patient to appropriate specialists.
 To assess impact of mental illness on the physical wellbeing of the patient such as
nutritional status and symptoms of dehydration in conditions like major depression,
anorexia nervosa and mania.
 To identify side effects of neuroleptic (drugs used to treat mental illness) drugs.
 To assess for signs of neglect and ill treatment such as disheveled hair, unkempt
appearance; injuries due to unrecommended methods of restraint that lead to skin
abrasions on the wrists and ankles and swellings on the body due to being beaten.
BENEFITS OF PHYSICAL EXAMINATION IN PSYCHIATRIC PATIENTS

41
  Physical disease is more prevalent in people with mental disorder than in the general
population. It is important for psychiatrists to maintain skills in physical examination
to ensure that physical illnesses are diagnosed and treated appropriately. Annual
death rates from all causes among psychiatric patients are 2-4 times higher than in
the general population with higher rates of physical disorder across the entire range
of mental disorder.

 Patients who are mentally disturbed may be unable to give a clear account of their
symptoms, even in the presence of a life threatening disorder. Studies have also
shown that in many cases, physical diseases will not be diagnosed and treated when
a patient is admitted to a psychiatric unit.

 An important aspect of psychiatric evaluation is differentiating organic disease from

‘functional’ psychiatric disorders.

 A competent assessment of patient’s physical health also helps to tailor drug use
and reduce the risk of side effects.

 Physical assessment gives a clear baseline for comparison, should a patient’s physical
state change, thus informing the clinician of the severity of the effect of a drug and
of the need for action.

For safety reasons do not only be the two of you-Patient and Health worker in the room.

ADMISSION OF PSYCHIATRIC PATIENTS

Daniel Chisholm (1996) looks at the nature of mental disorder as being heterogeneous and
uncertain as well as chronic. He observes that one of the inherent characteristics of mental
disorder is its heterogeneity, in terms of its aetiology and the behavioural symptoms manifested
by sufferers. There is a consequent unpredictability and uncertainty surrounding decisions
regarding the diagnosis, prognosis and treatment of a person with mental health problems that,
if not unique in health care, is far in excess of all but a few somatic disorders. Put another way,
whilst there is as much uncertainty in mental health as there is in other health sectors with
regard to when illness will occur, the mental health professional — or society in general — faces
an unusually high level of intrinsic uncertainty with regard to how a mental disorder is to be
defined, assessed and managed. In terms of chronicity, mental disorder tends to be of a more
long-standing, chronic nature than all but a few somatic disorders. Episodes of mental disorder
can last many months or even years before symptoms diminish, and periods of illness and
relapse may be repeated over a lifetime. For instance, people who are depressed and who have
experienced two or more episodes in the preceding five years have a 70 to 80 per cent chance of
experiencing a further two or more episodes during the subsequent five years (Angst, 1992).
Over time, therefore, mental disorder presents a different profile of resource allocation and
consumption to many somatic disorders. This long-term, comprehensive view of the costs of
illness is most pertinent, and the virtues of prevention or early intervention most apparent, in
child psychiatry: the future costs of delinquency may far outweigh the costs of treatment at an
early age.
42
Someone with a ―healthy mind has clear thoughts, the ability to solve the problems of daily life,
enjoys good relationships with friends, family, and work colleagues, is spiritually at ease, and can
bring happiness to others. Mental disorder then can be defined as any illness experienced by a
person which cause severe disturbances in life often resulting in an inability to cope with the
ordinary demands of life. A person is affected in his emotions, feelings, and relating with others,
thoughts or behaviour, is out of keeping with their cultural beliefs and personality, and produces
a negative effect on their lives or the lives of their families. Symptoms of illness can appear in the
form of persistent changes in mood, perception of reality, or capacity to organize or maintain
thoughts. Such changes will interfere with the per-son‘s usual beliefs, personality or social
function.

These symptoms cause great distress to the person affected. Symptoms vary, and every
individual is unique. But all persons with mental disorder have some of the thought, feeling, or
behavioural characteristics listed below. While a single symptom or isolated event is not
necessarily a sign of mental disorder, professional help should be sought if symptoms increase or
persist. Often the symptoms of mental disorder are cyclic, varying in severity from time to time.
The duration of an episode also varies; some persons are affected for a few weeks or months
while for others the illness may last many years or a lifetime.

 Social withdrawal: Sitting and doing nothing; friendlessness; abnormal self centeredness;
dropping out of activities; decline in academic or athletic performance.
 Depression: coming out of nowhere, unrelated to events or circumstances; loss of
interest in once pleasurable activities; expressions of hopelessness; excessive fatigue and
sleepiness; inability to sleep; pessimism; perceiving the world as “dead”; thinking or
talking about suicide.
 Thought disorders: Inability to concentrate or cope with minor problems; irrational
statements; peculiar use of words or language structure; excessive fears or
suspiciousness.
 Expression of feelings: hostility from one formerly passive and compliant; indifference,
even in highly important situations; inability to cry; excessive crying; inability to express
joy; inappropriate laughter.
 Behaviour: hyperactivity or inactivity, or alternating between the two; deterioration in
personal hygiene. Noticeable and rapid weight loss; drug or alcohol abuse; forgetfulness
and loss of valuable possessions; attempts to escape through geographic change;
frequent moves or hitchhiking trips; bizarre behaviour (staring, strange posturing);
unusual sensitivity to noise, light, clothing.

Metal State Examination

The Psychiatric History

Mental illness frequently arouses resentment, fear, guilt, shame, and anxiety in patients and
relatives. These may manifest themselves by attitudes of defensiveness, anger, or by
bewilderment. The health worker should be aware of this and attempt to make each history

43
taking an exercise in psychotherapy. In addition, to obtaining much information from family
members, the interviews should orient the family members, allay some of their anxiety and give
them a better understanding of the causes of emotional illness. The members of the family
should be encouraged through their interest in the patient to share as much information as
possible. They can also be told in general terms about some of the problems the patient is facing.
With better understanding on the part of the relatives, they will be able to be more cooperative
in following through recommendations for further care or hospitalization, changes in the home,
and attitudes toward the patient.

Discussions with the relatives should avoid the extremes of alarmism or undue optimism. In
speaking to them, language should be used which is understandable in terms of their own
culture pattern. Special care should be exercised to protect the patient's interests and not give
information to the relatives that could be used against him or that could be misinterpreted by
the family. After the initial interview, the family should be seen whenever necessary or at their
request. They should be kept informed of the patient's progress. Any communication with the
family members or with others concerned with the patient's welfare should be undertaken with
the full knowledge of the patient. There must be no question in the patient's mind about the
confidentiality of what transpires between him and his health worker.

Therefore , the psychiatric history is used to identify the existence of psychological distress and
symptoms of illness. Information obtained can be used to guide the healthcare provider‘s
impressions and therapeutic interventions. Psychological distress and mental disorder may be
influenced by past and present experiences and circumstances. A psychiatric history is a
description of the habits, activities, relationships, and physical conditions that have shaped the
way one feels, thinks, and behaves. The psychiatric history is obtained by interviewing the
individual or asking a series of questions associated with their psychological function. In taking a
psychiatric history and assessing the mental state, it is crucial both to establish and maintain
rapport and to be systematic in obtaining the necessary information. The outline below is
intended as a schema for written documentation. Greater flexibility is clearly required during the
interview.

The history begins with an introduction noting the patient’s name, age, marital status,
occupation, ethnic origin, religion and circumstances of referral. Then follows the Chief
complaint (a concise statement of the patient‘s psychiatric problem in his or her own words) and
the history of the present illness (current circumstances in which current psychiatric symptoms
have occurred covering; duration, precipitating factors, effect on interpersonal relationships,
working capacity and details of treatment to date). In the family history, note parents’/siblings’
ages, occupations, physical and mental health and relationships with the patient. If a relative is
deceased, note the cause of death and the patient’s age at the time of death. Enquiry is made
into any blood relatives with history of psychiatric symptoms, like nervous breakdowns’ suicide,
drug/alcohol abuse and forensic encounters, treatment, or psychiatric hospitalizations.

The personal history begins with the patient’s early life and development including details of the
pregnancy (? planned) and birth (especially complications). Any serious illnesses, separations in
childhood or delays in development are noted. History of alcohol or substance abuse or
dependence – length or period of abuse/dependence; date and amount of last use; history of
drug treatment or rehabilitation programs. The childhood home environment is described

44
(geographical situation, atmosphere) as are details of school (academic achievements,
relationships with peers, teachers). The occupational history should list jobs, reasons for change,
work satisfaction, relationships with colleagues. Document details of sexual practices
(past/present abuse, sexual orientation, difficulties, satisfaction), relationships, marriage
(duration, details of partner, children) and, in the case of women, menstrual pattern,
contraception, miscarriages, stillbirths and terminations of pregnancy.

Previous psychiatric history. An inquiry is made of any prior psychiatric symptoms, treatment
(therapy or medication); prior psychiatric hospitalizations (dates of illnesses, symptoms,
diagnoses, treatments, hospitalizations) and past medical and surgical history are obtained. The
medical history should address significant medical conditions, treatments/surgeries; current
medications; history of allergies to medications or other agents; history of head injuries; seizures;
loss of consciousness or other neurological disorders.

Social history – place of birth; description of family members; marital status; education obtained;
occupations past and present. The patient’s alcohol, drug (prescribed and recreational) and
tobacco consumption and any forensic history are recorded. The patient’s attitude to and
practice of religion, politics and hobbies are noted.

The premorbid personality (e.g. character, social relations) and finally, details of the present
circumstances (accommodation, occupation, financial details), are described.

Mental State Examination (MSE)

A record of the patient's mental status is part of every completely recorded history of illness. In
the form here suggested, it follows the record of the Physical Examination. How much of the
complete MSE is administered and at what point or points in the total relationship with the
patient this is done, depends on each individual case. In many instances, as will be elaborated
below, much necessary minimum information can be elicited in the course of taking the patient's
history and during the physical examination. This may be sufficient to give adequate data for an
estimate of the status of the patient's mental functioning and may provide adequate material for
a useful record. In instances where no further formal examination may be necessary a number of
areas of mental functioning will have been found to be grossly intact in the course of history-
taking and other initial contacts with the patient. These might include the formal headings of:

 Appearance and Behaviour

 Speech
 Mood
 Thought Content
 Perception
 Orientation as to time space and person

It should be remembered that a patient may be too ill to be subjected to a prolonged MSE. Here
again, many pertinent data can be obtained during the necessary initial contact with the patient
and more formal examination, if deemed indicated, may be postponed. The fact of the patient's
refusal to cooperate in some of the more specific areas of the MSE is not in itself a
contraindication to pursuing the examination further. Such refusal needs to be understood on its

45
own terms and may be an important datum towards establishing, for instance, the presence of a
sensorial defect. The patient in this case may be reacting to his anxiety about the presence of
such a defeat by refusal to participate in its demonstration. The skillful examiner then seeks
other avenues through his developing relationship to the patient to obtain the needed
confirmation. When, early in the course of examination of the patient, defects are detected in
some of the areas mentioned above (or in others elaborated below), more formal and detailed
examination is in order. This is also almost always the case in any patient whose complaints
when first seen are primarily in the area of mental functioning.

A written record of the MSE should always be made regardless of factors limiting the extent of
the examination itself. No matter how scattered the sources from which the information has
been gathered in the course of the total contact with the patient, the accumulated data should
be recorded in an organized fashion. One possible form of organizing them is suggested below.

The Technique of Performing the Mental Status Examination

Much of the success and validity of this examination will depend on the way the examiner
approaches the patient. All aspects of the patient's behaviour are data, including his reaction to
the examination itself. Much depends on the examiner's attitude towards this part of the total
examination of the patient. The patient senses quickly if the examiner considers his task in this
area a routine, which has to be performed for the sake of "completeness" of the record.
Perfunctoriness on the part of the examiner, lack of understanding of the purpose of the
examination, defensiveness about administering various parts of the examination - all these are
reflected in the test results and their validity. As many as possible of the items enumerated
below should be obtained during the course of general history taking. Those parts of the MSE,
which require specific questioning, should be done with thorough knowledge of their purpose.
This should be done in the same matter-of-fact manner as one examines those areas of the body
which often are invested with special significance by the patient, but the thorough examination
of which are usually accepted by the patient as a matter of necessity. By the time MSE is begun,
after initial history taking, certain background facts about the patient will be known which will, to
some extent, determine the choice of some of the specific items in the examination (e.g., in the
area of "general information"). These background facts include education, occupation,
socioeconomic status, age, sex and marital status.

Conditions, at the time of examination, also have a great potential influence on the results and
their validity. These conditions should be established and later recorded (e.g., patient's
experiences with regard to drugs, alcohol, recent sleep disturbances, acuteness of present
illness, time of day of the examination , and the physical surroundings in which it was given--on
the hospital division, in the physician's office, etc.).

So what see is that the mental status examination is an organized systematic framework for
noting observations that are made while interviewing individuals. In general, it involves
categorizing observations in terms of behaviour and appearance; thought, feelings, judgment,
insight, and other functions such as memory and concentration. The elements making up a
complete mental status examination are outlined below.

46
Elements of the Mental Status Examination (MSE)

1. Assessment of The patient’s Initial Appearance and Behaviour e.g. gait; grooming;
posture, including general health, demeanour, manner, rapport, eye contact, degree of
cooperation, cleanliness, clothing, self-care, facial expression, posture, motor activity,
which may be excessive (agitation) or decreased (retardation), abnormal movements
(tics, chorea, tremor), stereotypy (purposeless), mannerisms (goal-directed,
understandable), gait abnormality or striking physical features are documented.
2. Assessment of Motoric behaviour –e.g. physical agitation or retardation; tremors;
anxiety.
3. Assessment of Speech is described in terms of rate slow; rapid; loud; soft/inaudible;
stuttering; slurring; paucity; over-inclusive, quantity. (When increased = pressure [often
with associated ‘flight of ideas’]; decreased = poverty), and pattern (spontaneity,
coherence, rationality, directness [to the point or discursive] and perseveration
[repeating words or topics]). Abnormal words (neologisms), puns or rhymes should be
noted, giving verbatim examples if abnormal. Abnormal form of thought may be
deduced, for example where connections between statements are difficult to follow
(‘loosening of associations’). The patient’s subjective experience of thought may be
abnormal as in thought block (thoughts disappear: ‘my mind goes blank’) slow; rapid;
loud; soft/inaudible; stuttering; slurring; paucity; over-inclusive.
4. Assessment of Attitude –e.g. cooperative; irritable; angry; aggressive; defensive; guarded;
apathetic.
5. Assessment of Changes in mood and affect are the commonest symptoms of psychiatric
disorder, but also occur in physical illness and in healthy people at times of adversity.
Mood refers to subjective emotion as experienced by the individual. Abnormal mood
states include: sadness, happiness, irritability, depression, elation, euphoria (unconcerned
contentment), anxiety and anger. It should be noted whether mood is consistent with
thoughts and actions, or ‘incongruous’, while affect is the observed (and often more
transient) external manifestation of that emotion. Mood has been compared to climate,
and affect to weather. Abnormalities of affect include blunting, lability, perplexity and
suspiciousness.
6. Assessment of Disorders of thought content and processing include non-psychotic
phenomena such as obsessional ideas (recurrent thoughts, feelings, images or impulses
which are intrusive, persistent, senseless, unwelcome but recognized as the patient’s own
[in contrast to delusions which are persistent beliefs that is inconsistent with reality] and
phobias (fear/anxiety which is out of proportion to the situation, cannot be reasoned or
explained away and leads to avoidance behaviour). Suicidal or homicidal ideation
(thoughts) and intent (plans) are crucial.
7. Assessment of Abnormalities of perception include illusions (distortions of perception of
an external stimulus, e.g. interpreting a curtain cord as a snake); hallucinations
(perceptions in the absence of an external stimulus which are experienced both as true
and coming from the outside world); and pseudo-hallucinations (internal perceptions
with preserved insight). Hallucinations can occur in any sensory modality, although
auditory and visual are commonest. Some auditory hallucinations occur in normal
individuals, when falling asleep (hypnagogic) or on waking (hypnopompic). Hallucinations
may be auditory, visual, tactile, or olfactory hallucinations.

47
8. Assessment of Judgment – ability to understand relationships between facts and to draw
appropriate conclusions.
9. An assessment of the patient’s insight (degree of correct understanding a patient has of
his/her condition and its cause as well as his/her willingness to accept treatment) is
made, after which the examiner notes his/her reaction to the patient. Is the patient able
or willing to understand his or her condition.
10. Assessment of Cognition:
 Level of consciousness – alert; cloudy; confused.
 Orientation. Within the cognitive assessment, the following are noted: level of
consciousness, memory (long- and short-term, immediate recall), orientation in
time (day, date, time), place, person, attention and concentration, general
knowledge and intelligence. Educational background must be taken into account.
 Memory – long-term (events of the past such as place of birth; date of marriage or
graduations); recent (events of yesterday or last week); short-term (test recall of 3
items after a period of 5 minutes).
 Concentration or attention (You may do a serial 5 test – start at 100 and count
backwards by 5).
 Executive function or ability to reason – abstraction – how are an apple and
banana similar? Interpretation of a proverb appropriate to culture; test naming or
word finding skill (e.g. can the individual name different parts of a watch/time-
piece).
 visual-motor coordination, in basic terms, may be defined as the brain‘s ability to
coordinate information perceived by a sensory organ (the eyes) with complex
motor functions (such as writing). Visual-motor coordination is tested by asking
the individual to draw an object or figure visualized. For example, draw a circle
that is connected to a rectangle and ask the individual to copy the figure. An
inability to copy the figure accurately may be an indication of conditions such as
brain damage due to medical disease or drug abuse (e.g. Alzheimer‘s disease;
alcohol dementia;), schizophrenia, or mental retardation.

11. Assessment of Abnormal beliefs include overvalued ideas (abnormal beliefs or intense
preoccupations, firmly held but comprehensible in the light of the subject’s past
experience and culturally shared belief systems). An example of this would be an intense
but non-delusional feeling of guilty responsibility following bereavement. Ideas of
reference are when the patient feels that other people look at or talk about him/her
because they notice things about him/her, but insight (see below) is retained. Delusions
(fixed, false, firmly held beliefs out of keeping with the patient’s culture, unaltered by
evidence to the contrary, and for which the patient has no insight) may be primary (no
discernible connection with any previous experience or mood; autochthonous) or
secondary (e.g. to mood). Passivity feelings are when the patient experiences outside
control of or interference with his/her actions, feelings, perceptions and thoughts
(thought interference). The latter may involve thought insertion or withdrawal (thoughts
being put into and taken out of the person’s mind) and thought broadcast (the
experience that others can hear or read the individual’s mind/thoughts).

48
 PHYSICAL
Appearance Motor Activity
Behavior

EMOTIONAL
Attitude Mood and Affect
COGNITIVE
Orientation Attention and Concentration
Memory Speech and Language
Thought (Form and Content) Perception
Insight and Judgment Intelligence and Abstraction

Summary of a MSE

In order to assist a health worker conduct a MSE in a busy outpatient department, a Mini-Mental
State Examination (MMSE) template is provided below.

A mini MSE

Patient’s Name...............................................................................: Date:................................................

Instructions: Ask the questions in the order listed. Score one point for each correct response within each
question or activity.

Maximum Patient’s Questions

Score Score
5 “What is the year? Season? Date? Day of the week? Month?”
5 “Where are we now: Province? Town/city? Hospital/Centre? Ward/OPD? Room?”
The examiner names three unrelated objects clearly and slowly, then asks the patient to
3 name all three of them. The patient’s response is used for scoring. The examiner repeats
them until patient learns all of them, if possible. Number of
trials:................................................
5 “I would like you to count backward from 100 by fives.” (90, 85, 80, 75, 70, …) Stop after
five answers. Alternative: “Spell ZAMBIA backwards.” (A-I-B-M-A-Z) Score 1 point for
each correct answer
3 “Earlier I told you the names of three things. Can you tell me what those were?”
2 Show the patient two simple objects, such as a wristwatch and a pencil, and ask the
patient to name them. Score 1 point for each correct answer
1 “Repeat the phrase: ‘No ifs, ands, or buts.’”1 point for correct repetition of phrase.
3 Instruct the individual to follow the commands to a) pick up a piece of paper with the

49
 right hand (score 1 point if performed correctly), b) fold the paper in half (score 1 point
performed correctly), and c) place the paper on the floor (score 1 point if performed
correctly). Maximum of 3 points.
1 “Please read this and do what it says.” (Written instruction is “Close your eyes.”) Score 1
point for correct response.
“Please copy this picture.” (The examiner gives the patient a blank piece of paper and
asks him/her to draw the symbol below. All 10 angles must be present and two must
intersect.) Score 1 point for the correct drawing of the design.
1

30 Total

(Adapted from Rovner and Folstein, 1987)

Instructions for administration and scoring of the MMSE

Orientation (10 points):

 Ask for the date. Then specifically ask for parts omitted (e.g., "Can you also tell me what
month it is?"). One point for each correct answer.
 Ask in turn, "Can you tell me the name of this hospital (town, ward, etc.)?" One point for
each correct answer.

Registration (3 points):

 Say the names of three unrelated objects clearly and slowly, allowing approximately one
second for each. After you have said all three, ask the patient to repeat them. The
number of objects the patient names correctly upon the first repetition determines the
score (0-3). If the patient does not repeat all three objects the first time, continue saying
the names until the patient is able to repeat all three items, up to six trials. Record the
number of trials it takes for the patient to learn the words. If the patient does not
eventually learn all three, recall cannot be meaningfully tested.
 After completing this task, tell the patient, "Try to remember the words, as I will ask for
them in a little while."

Attention and Calculation (5 points):

 Ask the patient to begin with 100 and count backward by fives. Stop after five
subtractions (90, 85, 80, 75, 70,) Score the total number of correct answers.
 If the patient cannot or will not perform the subtraction task, ask the patient to spell the
word "Zambia" backwards. The score is the number of letters in correct order (e.g., A-I-B-
M-A-Z =5, I-B-A-M-A-Z =3).

50
Recall (3 points):

 Ask the patient if he or she can recall the three words you previously asked him or her to
remember. Score the total number of correct answers (0-3).

Language and Praxis (9 points):

 Naming: Show the patient a wrist watch and ask the patient what it is. Repeat with a say a
pen or a toy. Score one point for each correct naming (0-2).
 Repetition: Ask the patient to repeat the sentence after you ("No ifs, ands, or buts.").
Allow only one trial. Score 0 or 1.
 3-Stage Command: Give the patient a piece of blank paper and say, "Take this paper in
your right hand, fold it in half, and put it on the floor." Score one point for each part of
the command correctly executed.
 Reading: On a blank piece of paper print the sentence, "Close your eyes," in letters large
enough for the patient to see clearly. Ask the patient to read the sentence and ask him to
do what it says. Score one point only if the patient actually closes his or her eyes. This is
not a test of memory, so you may prompt the patient to "do what it says" after the
patient reads the sentence.
 Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for
you. Do not dictate a sentence; it should be written spontaneously. The sentence must
contain a subject and a verb and make sense. Correct grammar and punctuation are not
necessary.
 Copying: Show the patient the picture of two intersecting pentagons and ask the patient
to copy the figure exactly as it is. All ten angles must be present and two must intersect to
score one point. Ignore tremor and rotation.

Physical Examination

The physical examination should focus on identifying (or excluding) conditions of which a
suspicion has been raised in the history and MSE and/or with a known association with
psychiatric illness. In presenting a case, the history and MSE should be followed by a justified
statement of diagnosis (or differential diagnosis), and concluded by a summary of possible
aetiological factors (predisposing, precipitating and maintaining) and a plan for further
investigation and management.

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PSYCHIATRIC INTERVIEW, HISTORY, AND MENTAL STATUS EXAMINATION

Introduction

The purpose of a psychiatric diagnostic interview is to gather information that will enable
the examiner to make a diagnosis, prescribe treatment and determine the prognosis. Unlike
most disciplines of physical medicine, however, psychiatry has no external validating
criteria, no laboratory tests to confirm or refute diagnostic impressions. Therefore the
diagnosis is dependant on the skills and knowledge of the individual examiner and can never
be better than the judgment made by individual clinicians. Because of the absence of
external validating criteria or biologic markers, diagnostic reliability is a fundamental
problem in clinical psychiatry.

PSYCHIATRIC EVALUATION

The psychiatric evaluation comprises two sections. The first section consists of the following:
 Histories (e.g., psychiatric, medical, family) includes the patient's description of how
symptoms of the current episode have evolved
 Review of past episodes and treatments.
 Description of current and past medical conditions
 A summary of family members' psychiatric problems and treatments
 Patient’s personal history which reveals interpersonal and adaptive functioning over
time.
Information for the history will come from the patient but may be supplemented by
collateral information from family members, social referral agencies, previous treating
physicians, and old hospital records.

The second section of the psychiatric evaluation is the mental status examination which
systematically reviews emotional and cognitive functioning of the patient at the time the
interview is conducted.

PSYCHIATRIC HISTORY
Identification The identification establishes the basic demographics of the patient. It
includes age, sex, racial or ethnic, religious affiliation, social, occupational, and educational
information for example military service.

This is the first psychiatric hospital admission for Mr. A., a 21-year-old heterosexual male
employed part-time as a veterinarian's assistant. He currently lives with his gilrfriend and
has never been married.

Chief Complaint The chief complaint is a verbatim recording of the patient's reason for
seeking treatment or evaluation. Putting the chief complaint in the patient's own words,
even if doubtful or illogical, conveys valuable information about the person's capacity for
insight and self-observation.

“I took an overdose of some pills but I'm fine now.”

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History of the Present Illness This section is a chronological description of how symptoms in
the current episode have unfolded over time. It provides not only the nature of symptoms,
but also when they emerged and how they have progressed. The characteristics of
symptoms should be described in detail; small distinctions may be diagnostically useful.
Attention should be paid to significant negatives as well as significant positives. Whether
the patient has been on treatment ask the type of treatment and compliance. If
noncompliant ask why. Alcohol or other substance use should be described, including
amounts, frequency, and last use. It is also useful to ask why the person came for treatment
at this time, and what the patient believes to be causing the present symptoms.

Mr. A currently drinks alcohol once or twice each week, A usual amount of alcohol for him
consists of two vodka and eight or nine beers. Often, he drinks until he blacks out. He used
Marijuana this past New Year's Eve. He denies any history of intravenous drug use. He
remembers always speaking and thinking very quickly, because he was always “so bright
and talented and good looking and smart.” In addition, he has needed little sleep since age
15. The racing thoughts, pressured speech, and decreased need for sleep have become more
pronounced since September, when he started feeling “very up.” Since then he has been
getting at most 5 hours of sleep each night without feeling tired. He says he can be very
influential, but that he has no special powers. He reports that he gets angry quickly and that
his mood can change very easily. Since September he's also felt more depressed and
physically restless. He considers suicide frequently, “just to escape the boredom of life.” He
has lost 6 Kg in the last 2 months. There is no history of hallucinations or of delusional
thought.

Past Psychiatric History The past psychiatric history describes all previous episodes and
symptoms whether treated or not. The history should begin with the first onset of
symptoms and progress chronologically to the current episode. If a person has taken
psychiatric medication before, it is essential to determine not only which drug, but the
dosage and length of treatment, to distinguish nonresponsive from a sub therapeutic drug
trial also therapeutic benefits and adverse effects should be noted.

Throughout his childhood, he got into fights with other children and would even attack
family members and teachers. In grade 7, he threw a chair at a teacher. Once he attacked
his older brother and kicked him in the head repeatedly until he lost consciousness and
required medical attention. During his secondary school years, the patient was forced to see
the school nurse because of a heated argument with a teacher. The teacher claimed that the
patient tried to hit him, and though the patient denied this, he was expelled.
There is a history of one previous suicide attempt 2 years ago, precipitated by the infidelity
of his first girlfriend. The patient fashioned a rope and began to hang himself. When he
began to feel pain, he stopped. He never told anyone about this attempt and never sought or
received treatment. Psychotropic medication has never been prescribed.

Medical History The occurrence of major illness or surgery is likely to be of considerable

significance in a person's life and may be the precipitant of psychiatric disturbance. For
example, in response to having a heart attack, a middle-aged man might develop anxiety,

53
depression, and a fear of sex. The presence of underlying medical conditions will inform
treatment decisions:
.
The patient has had streptococcal pharyngitis five times in the past 4 years. At age 15, he
fractured his right wrist in a fight. He denies any other medical conditions. He takes no
medications and has no known drug allergies. He has never been hospitalized or undergone
any surgical procedures.

Family History Many psychiatric disorders are familial, and many of those appear to have a
genetic component to the cause. Knowing who is in the patient's family and which, if any,
psychiatric disorders have been diagnosed may help in diagnosis and treatment planning.
Caution is urged however against over interpretation of such data.
On the other hand, the family history can clearly show level of family support.

The patient's immediate family consists of his father (age 51), his mother (age 49), one older
brother (age 26), and one younger sister (age 19). His father suffers from alcohol
dependence. Family history is otherwise negative for psychiatric disorders, medical disease,
dementia, addiction, suicide attempts, and violence.

Personal History: is intended to describe events of major significance throughout a person's

life, to highlight those that may be etiologically significant, and to describe functioning
overtime. Important elements of the personal history vary from patient to patient. The
information presented in the personal history will be shaped by other information from the
interview.

The health care provider makes ongoing clinical judgments about what is important and
what is not. Major items commonly include the following:
 early childhood friendships
 education and any changes in school performance
 romantic involvements
 Work history, military or jail experiences, and leisure activities
 developmental history ( complications during pregnancy and delivery, full term
pregnancy, use drugs or alcohol during the pregnancy, prenatal complications)
 Milestones of development in infancy and childhood (walking, talking, and bowel
bladder control)
 Social development in childhood is revealed through information about friendships,
schooling, and extracurricular activities, onset of puberty, age of menarche.
 The growth of pubic and axillary hair signals the onset of puberty for boys, late-
onset puberty often has significant emotional and social consequences for boys: they
are often less confident, more self conscious, and less likely to be widely popular or
leaders in school.
 Experiences in dating, first sexual experiences, and any confusion or discomfort
about sexual orientation are all important aspects of adolescent development.
Adolescence is also often a time of first drug experimentation.
 Drug and alcohol use (type of drugs, how much, how often, and under what
circumstances should be obtained as well as changing patterns of drug or alcohol
use.

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  The development of career goals (advanced education, starting a first job, entering
the military, and establishing a partnership including marriage) all signify the
transition from adolescence to adulthood.
 Development continues through an individual's lifetime, developmental milestones
of childhood or adolescence (the achievement of career and family goals will
predominate.
 Current relationships, whether the patient is currently married and has ever been
married before. Qualitative descriptions of interpersonal relations are important in
diagnosing personality disorders and assessing suitability for some kinds of
psychotherapy.
 Work history, jobs held, the length of time in each, and the reasons for leaving.
 Activities in their free time, vocational, recreational, and humanitarian pursuits are
important in the lives of many adults, and their absence may be diagnostically
significant. For some people, military or prison history is important.
As adults grow older, new issues such as:
 Children leaving home,
 Death of one's parents,
 Retirement
 loss of friends
A solid knowledge of psychopathology shapes the interview as it progresses. It is difficult to
justify the time and expense of obtaining a detailed developmental history for a person
with, for example, a simple phobia, obsessive-compulsive disorder, or panic disorder. Such
information is necessary neither for establishing the diagnosis, nor for prescribing and
implementing effective treatment.

SIGNIFICANCE OF PERSONAL HISTORY

The personal history may contain information helpful in making a prognosis as well as
diagnosis. For example, a good premorbid adjustment reflected in school and work history
indicates a good prognosis in patients diagnosed with schizoaffective disorder.

Deteriorating school performance, an irregular work history with failure to progress to

higher levels of responsibility, premature discharge from the military, an inability to sustain
friendships or romantic involvements for any period of time, may all have diagnostic and
prognostic significance. The personal history also helps identify key events that may have
helped precipitate current symptoms: divorce, loss of work, death of a family member,
serious financial setbacks. However, with the exception of posttraumatic stress disorder,
identification of a precipitating event is not required to make a diagnosis. It may be useful
although not necessary. Sexual functioning should be reviewed in the personal history.

Whether there has been a change in sexual functioning, and the extent to which sex is
pleasurable. If sexual difficulties emerge, more detailed questions can follow. When
complaints of sexual disturbances do occur, the information is likely to be more appropriate
for the history of the present illness than for the personal history.

Sample of report arising from personal assessment History

55
The patient grew up in a medium-size city. His relationships with family members have
always been difficult. While he often got into physical fights with his brother and his father,
there is no history of physical, verbal, or sexual abuse. In school, he had difficulty controlling
his behavior, getting into fights and cursing a great deal.
He was a good student when he worked; receiving good grades in subjects in grade 9 he
failed all of his classes in the sophomore (second year of secondary school) year and needed
to repeat the year. He attributed this to ignoring school and playing too much. During his
last year of high school, he attended a special arts school, studying drama and music. He
graduated from high school after 5 years.
He had trouble making friends. He had a girlfriend for 2½ years in high school, but they
broke up because they argued too much. He met his first girlfriend at age 17, but this girl
friend cheated on him, precipitating the previous suicide attempt. In the past 2 or 3 years,
the patient has found himself primarily attracted to older women.
After high school, he lived with his parents for almost 2 years. During that time, he played
drums in a local Kalindula music band and held part-time jobs as a sales clerk. These jobs
never lasted more than a few months, usually ending in verbal fights with his employer. He
applied to music school but was not accepted because of his poor grade 12 results. He
moved to
a Kitwe from Mansa to live with his uncle, hoping to take classes without credit. Lack of
financial resources required him to work instead. He worked for 24 hours each week, off the
books, as a shop keeper. He felt that his uncle was too controlling and domineering and
moved from his uncle to live with a friend later during that year. In the same year he moved
to live with a friend, he met his current girlfriend, at a bar. A week and a half later, he moved
into the girlfriend's house in the suburbs. Miss. B. reports that her relationship with the
patient has been characterized by extreme suspiciousness and hardship. The patient has
recurrent thoughts that his girlfriend doesn't care about him and is cheating on him, even
though there is no evidence. The patient has no savings and is supported by his girlfriend.
His parents have severe financial difficulties and are unable to help him. Contact with family
members is presently limited to his mother and his aunt because he doesn't get along with
any other family members.

The patient has had about 25 different sexual partners, about half very old females and the
other half relatively older ones. He does not always practice safe sex and has engaged in
high-risk behaviors such as anal sex without using a condom. Because of this, he has been
tested for human immunodeficiency virus (HIV) infection four times. The result was negative
each time, most recently 2 months before admission. There is a significant history of
substance abuse. During his second and third years in high school, he smoked marijuana two
to three times each week. He stopped after graduation and has since smoked marijuana only
two or three times. He has smoked cigarettes since age 13, ranging from half a pack to 2½
packs a day. He stopped smoking for 9 months 3 years ago but resumed and currently
smokes half a pack a day.

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MENTAL STATUS EXAMINATION

Introduction

The mental status examination of psychiatric patients is equivalent to the physical

examination in physical medicine. It provides a format for the systematic observation and
recording of information about a person's thinking, emotions, and behaviour. These data
combined with information from the history are the basis for formulating a differential
diagnosis, treatment and prognosis. A mental status examination is objective in nature. It
only records those findings present at the time of interview. Historical information is
excluded. A patient may report having had auditory hallucinations the day before, but
unless they are present when the examination is conducted, hallucinations are not recorded
in the mental status examination. Observed data are always more reliable than inferred
data.

ORGANIZATION OF THE MENTAL STATUS EXAMINATION

The specific format matters less than ensuring that the observations are complete and
logically organized to facilitate diagnosis. However, the outline presented here widely used.

Appearance
A brief description is given of the patient's appearance, behaviour, and manner of relating
to the examiner, with particular attention paid to abnormalities.

Observe the patient for overdress or under dress, wearing of excessive, garish make-up. Pay
attention to grooming, dishevelled or unkempt. Note the level of
cooperation, oppositional, hostilities, seductive, impassiveness and unusual movements
such as making smacking or chewing motions, tremors and pacing.

Although a comprehensive psychiatric assessment always includes a physical examination,

obvious signs of physical illness (e.g., pallor, jaundice, laboured breathing, or dilated pupils)
are also mentioned under “appearance.”

Illustrated report on Appearance

The patient is a muscular young man appearing his stated age, wearing jeans, a white shirt,
and sneakers. He wears several rings on his fingers and bracelets on both wrists. There is a
healing cut on his upper lip, which is slightly swollen. He is unshaven, but has an overall neat
appearance and adequate hygiene. Although he maintained good eye contact, he was
fidgeting throughout the interview sitting with his arms crossed.

Speech: Describes the physical production of speech, not the ideas being conveyed.
Observations are made about volume, rate, spontaneity, sentence structure, and
vocabulary. Any speech abnormality such as dysarthria or aphasia is described. The speech

57
of a manic patient may be loud and pressured. Conversely, the speech of a depressed
patient may be soft and hesitant.

Illustrated report on speech

He speaks spontaneously and very rapidly, becoming pressured at times, but he is

interruptible. Volume is occasionally loud. Rhythm and expressive intonation are normal.
Speech is understandable, but some words are poorly articulated because of the high rate of
speech production.

Emotional Expression: Describes mood and affect. Mood is the prevailing emotional state,
and affect as the expression and expressivity of a patient's emotions. The term affect
describes the feeling tone accompanying ideas or mental representations of external
objects. The subjective component is how individuals describe their inner emotional state: I
feel happy; I feel sad, anxious, hopeless, exhilarated, etc

While Mood is the he summation of affects. Affect would fluctuate with an individual's
changing thoughts whereas Mood is more constant over time. The objective component
describes the way in which emotion is communicated through facial expression, vocal tone,
and body posture. The two may be discordant. A patient whose eyes are filling up with tears
may describe himself as feeling “fine.”
Because the mental status examination describes only what is observed at the time of
interview, an evaluation of temperament is not possible.

Thinking and Perception: Thinking is subdivided into form and content.

Thought Form Thought form refers to the way in which ideas are linked, not the ideas
themselves. Thoughts may be logically associated and goal directed. If they are not, a
disorder of thought form may exist. For example, clang associations and flight of ideas are
most closely associated with manic states, derailment and thought blocking with
schizophrenia.

Illustrated report on thought form

His thoughts are generally logical and goal directed, although he is quite circumstantial,
launching into emotional accounts of relevant ideas but including many irrelevant details.
There is no evidence of flight of ideas, loosening of associations, perseveration, tangentiality,
or thought blocking.

Thought Content Thought content describes a patient's ideas. Abnormalities of content

include delusions, ideas of reference, and obsessions. Delusions are fixed, false beliefs that
are not shared by others as part of a religious or cultural group. They are rigidly held
regardless of evidence to the contrary. For example, delusions of guilt and somatic
delusions are characteristic of major depression. Delusions of persecution may be seen in
schizophrenia and mania.
The patient who believes that everyday occurrences carry specific, unique, and personal
significance is said to have ideas of reference. A person may believe, for example, that a

58
television announcer is attempting to convey a hidden message or that a stranger passing by
on the street is signalling something of significance by brushing his hair or blowing his nose.
Depending on the fixity and details of the belief, some ideas of reference may also be
delusional.
Obsessions are unwanted, intrusive thoughts experienced by patients as symptomatic and
beyond their control. The content of an obsession may be virtually anything but is often a
disturbing thought of doing something embarrassing, hurtful, or dangerous. For example a
young father may have thoughts of his daughter being sexually molested. Because of the
effort to control their thinking and because patients with obsessions are often deeply
bothered by their content, it is necessary to inquire specifically about their presence and not
rely on voluntary reporting.

Illustrated report on thoughts

He is preoccupied with thoughts that his girlfriend may have cheated on him. He also
expresses extreme mistrust of the staff's motives, believing that the staff overanalyzes and
carelessly misinterprets his statements and actions. He threatens to flee from the unit,
claiming to know several ways to escape. He has inflated self-esteem, claiming to be
extremely talented in a lot of areas, accepting that there are people who are better than he
is, but that with a little practice, for example, he can be the best musician ever. He denies
current suicidal thoughts, intent, or plan.

Perception Perceptual abnormalities include hallucinations and illusions. Hallucinations are

sensory perceptions generated wholly within the central nervous system (CNS) in the
absence of any external stimulus. They can occur in a sensory modality: auditory, visual,
tactile, olfactory, or gustatory.

Auditory and visual hallucinations are the most common. The modality of hallucination has
no diagnostic significance, with the exception of formication, a tactile hallucination of
insects crawling over or under the skin, which is associated with withdrawal from alcohol
and other central nervous system (CNS) sedatives. A patient looking at the shadows created
on a wall by a curtain may actually see threatening monsters. Illusions are more common in
delirium than in other psychiatric disorders.

Illustrated report on Perception

He described hearing a woman's voice, softly, but at times understandable, saying his name
or short phrases such as “they're wrong.” There was no evidence of hallucinations in any
other modality.

Definition of psychiatric admission

It is when a patient is accepted to stay in hospital for inpatient services.

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TYPES OF ADMISSIONS

There are several types of admissions: Voluntary, emergency, involuntary or compulsory, medical
board and court adjudication.

Voluntary Admission

This is where a patient is willing to be admitted and knows that he/she has a problem, and the
medical officer in charge of the mental hospital sees that the patient really needs admission. The
Mental Health Services Bill, (2006) states that:

“Patients aged 18 years and above must be encouraged to opt for voluntary admission into a
psychiatric institution, facility or ward.

Patient with mental health problems may seek help from any health institution including primary
health care clinics, as first contact before being transferred to a psychiatric facility.

If any patient is admitted to a psychiatric facility as a voluntary patient, the person in-charge of the
hospital or ward must notify the patient’s parents, guardians or relatives as soon as possible. In the
absence of the relatives, community leaders from the same locality must be notified.

Where a patient is already admitted to a mental health facility as a voluntary patient but wishes to
discharge himself contrary to the considered opinion of the person in-charge, the patient may be
held at the institution or ward as an involuntary admission upon recommendation of the attending
mental health practitioner.

A mental health practitioner should physically and mentally examine any voluntary patient within 24
hours of admission to a mental health facility.”

Emergency admission

A family member, friend, community health worker or any responsible citizen may request orally or
in writing that health institution admits a suspected mentally disordered person as an emergency
admission under the following conditions:

If a person in a community begins to act in a manner inconsistent with the norms of society because
of suspected mental illness;

If a person in the community is believed to be mentally ill and because of mental illness lacks proper
care in terms of food, clothing and shelter or is neglected or cruelly treated.

If any person believed to be suffering from mental disorder is dangerous to himself, others and
property.

Involuntary or Compulsory Admission

This is where the patient is not willing to be admitted and does not accept treatment, or is unable to
give consent for treatment, but he or she has a problem, illness or he is a potential abscondee. A
detention order will permit a compulsory emergency admission under the legislation or law in place.

60
According to human rights you are not supposed to force the patient to be admitted or to force the
patient to take medication, hence you get detention orders, a form that is signed by the magistrate,
which will allow medical personnel to enforce an admission and administer medication. Without
detention orders you can be sued, Detention orders are obtained from the police station or
magistrate’s court.

The Mental Health Services Bill, (2006) stipulates that:

“Involuntary admissions to be are initiated by a family member, a friend or a community health

worker who takes a person suspected of suffering from mental illness to the nearest health centre
where such a person is examined by an approved health worker who then certifies in writing that
the person required to be detained suffers from a mental illness.

An approved health worker, if satisfied that a person is mentally disordered and is dangerous to
himself and others, shall refer such a person to a psychiatric facility or ward within five days of such
certification, where the person so certified to be suffering from a mental illness shall be admitted.

Upon receipt of the patient the person in-charge of the said psychiatric facility shall ensure that the
patient is examined physically and mentally.

The patient must not be admitted to or detained in a psychiatric institution unless the person in-
charge of the psychiatric institution is of the opinion that no other care of a less restrictive kind is
appropriate and reasonably available to the patient.

Where it is not possible for a family member, friend or social worker to convey a person suspected
of suffering from mental disorder to a psychiatric institution a family member, friend or social
worker may seek the assistance of the nearest health centre or police station which wherever
possible shall provide transport with which to convey a suspected mental patient to the psychiatric
institution. The in-charge of the health facility or police station must provide transport within 24
hours.

A person in-charge of the health centre or police station should provide transport for conveyance of
a patient to a specialist psychiatric institution.

The in-charge of the health centre or police station may enter premises of the mentally disordered
person if need be in order to facilitate conveyance of the patient to the health centre.

Where the patient is of the opinion that his admission or continued detention is unjustified he may
appeal to a mental health review board for review of his detention. The review must be carried out
within fourteen (14) days of the receipt of the application.

Any patient involuntarily admitted shall not be detained for more than fourteen (14) days without
review by a mental health practitioner.”

Request for compulsory admission may be made by any family member or relative who are above 18
years. Other people like friends, employers etc who have good knowledge of the person and have
been with the individual for at least 15 days may request for compulsory admission.

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Medical Practitioners may also certify a patient for admission for as long as they have identified
reasonable grounds for compulsory treatment after a medical examination. Police officers, judges,
local or traditional rulers in whose jurisdiction the individual resides are also empowered to request
for compulsory admission. In other words it’s an admission where by the patient is not willing to be
admitted but he’s a danger to himself, society as well as to property.

Admission under medical board

This is when the employers writes a letter to the hospital requesting the medical officers who in turn
consult the psychiatrist where applicable, to examine the patient thoroughly and come up with a
report to say whether that person can continue working or be retired on medical grounds.

Admission by Court Adjudication

The client is admitted into a psychiatric forensic unit by the court’s decision, whilst his/her case is
being reviewed by the courts of law. In the psychiatric hospital courts request for assessments,
treatment and psychiatrists are required to submit periodical reports to the courts.

In these reports the following examinations should be included: Previous psychiatric history, past
medical, surgical, obstetric, early childhood and adolescent developmental history, social histories,
alcohol and drug history, family history of any mental history or any offences in the family, marital
status, educational and employment record, prognosis of disorder and outcome if treated.

The important issues on which opinion may be required in the psychiatric report are:

Mental state at time of interview and of the alleged offence. – it must be established whether the
person was mentally ill at the time of the offence.

Competence to attend court and make a defence.

Criminal responsibility – does the patient understand the difference between pleading guilty and not
guilty. Does the patient understand the nature of the charge.

THE ADMISSION PROCEDURE

The admission procedure consists of history taking, mental state examination, physical examination,
investigations and a diagnosis is arrived at. The clinician or psychiatrist will come up with a
psychiatric diagnosis after which the patient is commenced on appropriate medication to stabilize
him or her and reduce symptoms. You as a nurse have to conduct your own assessment which
should include demographic details, chief complaint, various histories and mental state examination.

As you learned in the last psychiatric nursing skill of physical examination, you conduct a systemic
examination and obtain the vital signs. In addition, you will ensure recommended investigations are
carried out and prescribed treatments given. The information derived from the above assessment is
used to identify needs and problems of the patient thereby coming up with a nursing diagnosis. At
the same time you also identify strengths of the patient. You will work with the patient assisting him
or her to solve problems noted by utilizing the strengths, or resources that you have identified to
solve his or her problems.

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The actual admission procedure involves receiving the patient into an inpatient psychiatric or
medical ward in which there are restrictions that will prevent him or her absconding if he or she has
come on an involuntary or emergency basis. For indications, principles and actual procedure refer to
your Procedure Manual, Learning Guide and Evaluation Manuals for admission of a psychiatric
patient.

THE DISCHARGE OF A PSYCHIATRIC PATIENT

We have discussed how a psychiatric patient is admitted. It therefore goes without saying that when
a patient is admitted, a day will come when upon his recovery, he will get discharged. A process to
prepare the patient for discharge begins as soon as the patient is admitted to hospital. This process
is known as discharge planning.

DISCHARGE OF A PSYCHIATRIC PATIENT FROM HOSPITAL

The leaving of the hospital by a patient is officially termed DISCHARGE, and involves a corresponding
discharge note.

DISCHARGE PLANNING

Discharge Planning begins as soon as the patient enters hospital. It is most effective when the
patient and his or her family are active in the discharge planning process. In addition to the family or
friends, a variety of hospital staff (also known as the multi-disciplinary team - MDT) can be involved
in the discharge planning process. Discharge planning involves working through phases:

Introduction or admission phase

Introduction or admission phase in which the admitting nurse and multi disciplinary team holds a
meeting with the client and relatives on admission in which they together begin to plan for the
patient’s eventual discharge upon recovery.

In this meeting clients and relatives are given Information Education Communication (IEC) on the
condition of the patient, signs and symptoms, treatment, hospital stay, visiting of patient whilst in
hospital, preparation of home environment and family resources for discharge, and prognosis of
illness. In addition, relatives are involved in the goal formation of the patient so that upon discharge
they will continue care, in line with goals.

Working (treatment phase)

After the patient has stabilized the nurse meets with relatives and the rest of the MDT (mental
health nurse, psychologist, psychiatrist, clinical officer, community health nurse / team to review /
evaluate patient’s progress, ascertain his/her suitability for discharge, and to further prepare patient
for discharge. At this time the community mental health team may be called upon to make a home
visit to assess the home environment for any psychosocial stressors before a patient goes there.

Termination phase

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Termination phase (this is when the patient goes into the community): this is a transition ( passing
from mental hospital to the community) in which the patient is discharged and given a review date
for continuity of care. If the patient is in need of other services such as a physician, surgeon,
counseling services, rehabilitation services etc, he/she is discharged via those services.

Advantages of discharge planning

Discharge planning reduces relapses or hospitalization by identifying clients who are at risk for
experiencing problems when discharged, so that they can be referred to appropriate places or
people who can be of good help to prevent relapses and admissions.

To help patients re-socialize or reintegrate in to community:

Those with chronic enduring psychiatric illness,

Those with special education needs, or elderly living alone, Homeless etc.

PREPARATION FOR DISCHARGE

Assess the readiness of patient to leave the treatment setting.

Assess the level of functioning with regard to activities of daily living.

Financial resources – Ask the family about financial resources and that they should identify
anticipated problems associated with discharge as soon as possible after admission from hospital.
Let them suggest possible solutions for their problems.

Conduct home visit for home exploration prior to client’s discharge.

Provide client and family with verbal and written information about available medical, social,
vocational and support resources in the community (services)

ACTUAL DISCHARGE PROCEDURE

For the actual practical discharge procedure you can refer to your procedure and Evaluation
manuals.

Throughout hospitalization, and indeed, upon discharge, Information, Education and Communication
(IEC) are given to the patient, relatives and significant others on the following:

PATIENT’S CONDITION

The client’s symptoms. Train relatives on how to handle and respond to the patient when he/she
becomes violent

Educate family on emotionally supporting client (importance of preventing High Expressed Emotion)

Importance of compliance to medication – it can take as long as 6 months for antipsychotic drugs to
be excreted from the system during which time a patient might think they no longer need the drug.
However, once the drug has all been excreted, the patient will relapse.

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Prevention of relapse (how to recognize early signs of relapse)

MEDICATION

Clear information about medication (dosage, frequency, route – if i/m which place and days it will be
administered from), who will keep medication, who will assist/support/ensure pt takes medication.

Duration of drugs

Side effects of drugs

Review dates that should be open appointments

Nutrition, that some foods cannot interact with certain drugs i.e. alcohol, or patient has to eat
something before taking drugs.

Give the patient medication that will be taken at home and the discharge slip.

When a patient’s behavior and thoughts become normal, they are ready to go home. Various
measures are undertaken to successfully prepare the patient for discharge. The community, that’s
the patient’s neighbourhood, workplace and church must undergo sensitization for successful
integration of the patient upon discharge.

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Unit 3: CLASSIFICATION AND MANAGEMENT OF PSYCHIATRY
DISORDERS
Definition of Mental Health

A person is health mentally if he/she manages to deal with the demands made upon him by
the society in a way that compatible with his /her idea both of the society and of himself. If
he/she fails to meet the demands of the society the person may be considered to be ill.

Definition of Mental Illness

The definition remains elusive because the behaviour that is considered normal in one
society maybe abnormal in another [Link] wearing swimming pants in a swimming pool
in presence of older children in Zambia may not be considered very normal while it is very
normal in western countries.

However, there is a criteria that is used to determine normality of an individual.

Major criteria for the diagnosis of mental illness :( Psychosis)

1. Bizzare (strange, percular) behaviour

2. Abnormal experience

3. Loss of reality-contact

4. Lack of insight

GENERAL CLASSIFICATION MENTAL ILLNESS AND SPECIFIC MENTAL OF ILLNESSES

Broadly there are two types of mental illness.

There are;

[Link]

[Link]

Neurosis: Is a minor mental illness in which the person reality is intact and behaviour does
not violet disorders etc.

Psychosis: Is a major mental illness in which a person’s mental capacity to recognise reality,
communicate and relate to others is impaired, thus interfering with the capacity to deal
with life demands.

E.g. mood disorders, schizophrenia, delusional disorders, schizo-affective disorders,

pervasive developmental disorders etc.

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12 Major Differences between Neuroses and Psychoses ( Saritha Pujari )

Some of the major difference between neuroses and psychoses are as follows:

Neuroses also known as Psychoneuroses refer to minor mental disorders. They are
characterized by inner struggles and certain mental and physical disturbances.
Psychoneuroses include the milder abnormalities of the cognitive, co native and motor
processes precipitated by conflicts, frustrations and other emotional stresses. These
partially incapacitate the individual to meet the demands of life property and effectively.

Clinically, psychoneuroses implies a bodily disturbance without any structural or organic

defect These symptoms in fact are the functions of certain mental disturbances the origin of
which the patient is unable to understand; but nevertheless, he realizes that something is
wrong with him.

Psychoses are major personality disorders marked by gross emotional and mental
disruptions. These diseases make the individual incapable of adequate self management and
adjustment to society.

While neuroses refer to mild mental disorder, Psychoses refer to insanity or madness.

The distinction between psychotics and neurotics in general are symptomatic,

psychopathological and therapeutic.

1. Psychoses involve a change in the whole personality of the person in whom it appears,
while in psychoneuroses only a part of the personality is affected. With the development of
psychoneuroses, there is often no marked outer change of personality of any kind. As Meyer
puts it, a psychoneuroses is a part reaction, while a psychoses is a total one.

2. In a psychoses, contact with reality is totally lost or changed. The reality contact
practically remains intact in a psychoneurotic, though its value may be quantitatively
changed. In fact insight and reality have the same meaning for them as the rest of the
community.

3. The changes in the reality values of the psychotic, psycho- pathologically is partly
expressed through projection, for example, the strong belief that one is being constantly
watched. Projection of this sort often based on a sense of guilt, subjective but unconscious,
does not occur in the psychoneuroses.

4. Language, which is a means of communication, is the symbolizing function for social

adaptation. In the psychoneuroses language as such is never disturbed, whereas in the
psychoses language often undergoes gross distortion.

5. Some psychoses are primarily organic. Even in the functional psychoses organic factors
enter into the etiology. The psychoneuroses on the other hand are predominantly socially
conditioned. Horney has therefore remarked “Psychoneurotic is the individual who deviates
in his behaviour from the norms accepted by his culture because of anxiety and who feels
lonely and inferior because of this deviation.”

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6. In psychoanalytic theory the psychoses may be differentiated from the psychoneuroses in
terms of the amount of ego and libido regression and in terms of the topographical location
of the conflict. In psychoses therefore the libidinal regression goes as deep as the early anal
period i.e., beyond the level of reality testing.

Psychoses may therefore be considered dynamically as a disorder in which the ego looses
much of its contact with reality and is more concerned with the forces of the id. The
psychoneurotic on the contrary, suffers libidinal regression only to the phallic or late anal
period as his conflict may be considered as a struggle between the forces of the id and the
ego, in which the ego maintains its contact with expressed reality. The regression is only to
the level of reality testing and so the neurotic retains insight and does not deny reality.

7. As regards etiology Page says that in psychoneuroses the psychogenic factors and
heredity are of considerable importance, where as neuro physiological and chemical factors
are insignificant. On the other hand, in psychoses, heredity, toxic and neurological factors
are the determining agents. Psychogenic factors as such may or may not be important.

8. So far as general behaviour is concerned, in the neurotic the speech and thought
processes are coherent and logical. There are little or no delusions, hallucinations and
confusion in case of psychoneurotic. On the contrary, in case of the psychotics speech and
thought processes are incoherent, disorganised, bizzare and irrational. There is constant
confusion. Delusion and hallucination are marked symptoms.

9. Neurotics are capable of self management, partial or completely self supporting, are
rarely suicidal. They do not need hospitalisation on the other hand; psychotics are incapable
of self management. They often attempt to commit suicide and need hospitalization or
equivalent home care.

10. The personality of the neurotic undergoes little or no change from normal self. A
neurotic has good insight. In case of a psychotic, on the other hand, there is radical change
in personality, insight is partially or completely lost.

11. The psychotics and psychoneurotic also differ in treatment procedure.

Psychoneurotic respond favourably to psychotherapy, such as suggestion, psychoanalysis

and other forms of psychotherapy while the psychotics do not effectively respond to
psychotherapy and treatment is mainly chemical and physiological.

12. As regards prognosis, the symptoms of psychoneurotics are transitory and outcome of
treatment is usually favourable. The deterioration and mortality rate is quite less.

On the other hand, in psychotics, the symptoms are relatively constant from day to day,
outcome less favourable and cure temporary and death rate is high.

In spite of these differences, the psychotics and neurotics cannot be separated by watertight
compartments and there is no sharp break between behaviour which is to be called
psychotic and the behaviour which is to be called neurotic.

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In fact, there are many cases of mental illness where it is quite difficult to assess definitely
whether it belongs to the psychotic or psychoneuroses group. In such cases the problem of
border line psychotics and border line neurotics arise.

In-spite of everything, between well developed psychoses on the one hand and full-fledged
psychoneuroses on the other hand there is a world of difference from the descriptive as well
as from the therapeutic respect.

Transitions also occur, so that a patient who reacts psycho neurotically at one time may
react psycho neurotically at another.

Wishner (1961) believed that behavioural efficiency will be taken as a predictable correlate
of psychopathology, with lower efficiency in severe pathologies. Being undimensional, the
measure of efficiency places neuroses and psychoses on the same continuum. But Lewis
firmly established the point that they have little in common each being an independent
entity with a different origin and outcome.

Follow up studies indicate that only 4 to 7% of neurotics develop psychoses in later life.
However Henderson cites an example of case history of a patient who began with
psychoneurotic anxiety symptoms and later on developed into paranoid schizophrenic
psychoses. But such transitions are the exceptions and not the rule.

Chief differences between neurosis and psychosis.

The chief differences between neurosis and psychosis are the extent to which a person is
alienated from reality and can make a workable adjustment to normal living. The neurotic
person can still effectively function in the world, while the psychotic person cannot. A
person suffering from neurosis may feel serious anxieties but still be able to handle the
ordinary activities of daily living. For example, a woman may have a phobia about being left
alone with a red-headed man because a male with red hair once assaulted her. Yet, as long
as she avoids that particular situation, she is able to conduct her domestic and business
duties in a normal manner. Through psychiatric counseling she may learn to understand the
cause of her phobia and either get rid of it or control it.

Fears of heights and crowds are other examples of neuroses. They are not central to the
way one organizes his or her life, and they can be alleviated either by counseling or by
avoidance of situations in which the neurotic response is likely to occur. Thus, while
neuroses may limit a person’s range of behaviours, they do not render a person totally
incapable of acting and functioning in everyday society.

A psychotic person, on the other hand, is so divorced from reality that in severe cases, like
paranoid schizophrenia, he or she lives in a private world which has little relation to the real
one. A man who thinks he is Moses, and feels a divinely granted right to punish those who
break any of the Ten Commandments, has reorganized experience around a delusion that
makes life bearable for him. His delusion is necessary to his continued existence. In a sense

69
he has found a therapy that works for him. He will resist psychiatric help because he thinks
he no longer has any problem: it is the sinners who have problems. Unfortunately, these
delusions make it very difficult for a psychotic person to navigate the realities of everyday
life. The delusions rarely integrate properly with the physical and cultural norms of the
surrounding world. Given that the delusion is often a reaction against the surrounding
world, this is hardly surprising. Such a person may be helped to some degree by specialized,
institutional care, but the chances of a complete recovery are slim. His or her alienation
from the rest of the world is much more comprehensive than a neurotic’s, and social
integration is unlikely. On the whole, neurosis and psychosis differ mainly in the degree to
which they create psychic distress and allow individuals to function with other people.
Neurosis, which is characterized by fear of specific situations and behaviours, can be
isolated and often treated. Psychosis, which is defined by its intense and far-reaching
delusions, is highly debilitating. Both are psychological conditions that deviate from normal
psychological and social functioning, but their differences in severity show that mental
illness is defined on a spectrum rather than in absolute
COMPARISON BETWEEN MENTAL HEALTH AND MENTAL ILLNESS

MENTAL HEALTH MENTAL ILLNESS

[Link] self and others [Link] inadequate, poor self concept
Ability to cope with stress Inability to cope with stress
Forms lasting relationships Inability to form lasting relationships
Use of sound judgement to make decisions Displays poor judgement
Accepts responsibility for action Irresponsibility
Optimistic(hopeful) pessimistic(negative, unenthusiastic)
Recognises limitations Does not recognise limitation
(abilities, deficiencies) (abilities, deficiencies)
Functions effectively independently Exhibits dependency needs because of
feeling of inadequacy
Able to perceive imagined circumstances Inability to perceive reality
from reality
Develops potential and talents to fullest Does not recognise potential and talents due
extent to poor self concept
Able to solve problems Avoids problems rather than handling them
or attempting to solve them
Can delay immediate gratification Desires or demands immediate gratification
Reflects a person’s approach to life by Reflects a person’s inability to cope with
communicating emotions, giving and stress, resulting in disruption,
receiving. Working alone as well as with disorganisation, inappropriate reactions,
others, accepting authority, displaying a unacceptable behaviour and the inability to
sense of humour, and coping successfully respond according to his expectations and
with emotional conflicts. the demands of society.

70
 People who are healthy do not necessary possess all the characteristics listed above. Under
stress, they may exhibit some of the traits of mental illness but are able to respond to the
stress with automatic, unconscious behaviour that serves to satisfy their basic needs in a
socially acceptable way

CLASSIFICATION OF MENTAL ILLNESS (Lalitha, 1995)

Neurosis

Anxiety
Emotional
Neurosis
Disturbances

Anxiety Neurotic Hysteria

Neurosis depressio Obsessive Phobic Traumatic
n Compulsive Neurosis Neurosis
Neurosis

Dissociative
Conversional
Hysteria
Hysteria 71
 Psychosis

inorganic
Organic

Affective
Non - Affective

Acute Chronic

Mania Depression
Delirium Dementia

Schizoaffective
Schizophrenia

Paranoid Illness Paranoid

Schizophrenia

Catatonic
Reactive Psychosis Schizophrenia

Hebephrenic
Schizophrenia

Residua 72
Schizophrenia
 Addiction

Alcohol Drugs

Marijuana

Pot

Kaht

Mental sub normality (MentaL retardation)

Personality disorder
Sexual disorders
Obsessive Compulsive Disorders (OCD)
Neurotic depression

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Neurosis

INTRODUCTION

Neurosis is a less form of psychological disorder where patients show excessive or

prolonged emotional reaction to any given stress. These patients are aware of their
problems and they will usually seek help. They have no clear cut organic problems, no
violation of basic social norms, no loss of orientation to reality but the individual still shows
a lifelong pattern of self defeating and inadequate coping strategies aimed at reducing
anxiety

DEFINITION

Neurosis is any fault or inefficient way of coping with anxiety or inner conflict usually
involving use of an unconscious deficiency mechanism that may ultimately lead to a neurotic
disorders e.g. anxiety

THEORIES

Freud Sigmoid Theory

According to Freud Sigmoid theory, neurosis may be rooted in ego defense mechanisms, but
the two concepts are not synonymous. Defense mechanisms, are normal way of developing
and maintaining a consistent sense of self (i.e. an ego) while only those thoughts and
behaviour patterns that produce difficulties in living should be termed “neuroses” for
example frustration in current life prevents direct achievement of a wish or a goal.

Jung’s theory

Car Jung found his approach particularly fitting for people who are successfully adjusted by
normal social standards but who nevertheless have issues with the meaning of their life.
Some people become neurotic when they consent themselves with inadequate or wrong
answers to the question of life

In summary Carl Jung was a prominent psychologist who studied Freud’s findings regarding
neurotic, personality disorder and [proposed a different theory than had been accepted by
Freud. He was convinced that neuroticism was caused by frustrations that a patient
underwent during important sexual phases of their early lives. Jung on the other hand
believed that neurocism was caused by a person’s inability to explore and assert their
individualism. In short Freud focused on the patient’s childhood in order to uncover the
routes of the neurotic behaviors while Jung believed that an intense focus on the things that
went wrong in a patient’s past would actually intensify the neurotic behaviour.

CAUSES

Neuroses are caused by mental conflicts which are:

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1. Environmental stress – disappointment and frustrations, loss of loved one, loss of
employment, divorce.
2. Interpersonal problems – This involve the problems that the individual can
encounter with his family, at work and his friends
3. Conflict within the mind – This conflict may be unconscious and you are not even
aware of it e.g. sexual conflict.
4. Individual susceptibility – Personality make up of an individual, early life experience

CHARACTERISTICS OF NUEROTIC DISORDER

There is no clear line between neurotic and normal individual. These patients have
the following characteristics;
a) Feeling of inadequacy and inferiority which lead them to see their day to day
problems as difficult and threatening
b) They are under constant tension and worry and have vague bodily complaints
c) They are more sensitive, emotional and less reliable than normal individuals.
d) They are more dependant upon other people and they are insecure
e) They may seek to protect themselves emotionally and therefore often appear
selfish.
f) They frequently experience difficulties in their relationship with friends,
colleagues and relatives.
g) They live in a life which they see no exit from life’s problems
h) They are confined in a psychologically prison in which the mind is both jailer
and the prisoner
COMMON NEUROTIC DISORDERS
1. OBSESSIVE COMPULSIVE DISORDER

This is a disorder characterized by persist ant and an controllable thoughts

and irrational beliefs that cause an individual to perform compulsive rituals
that interfere with his/her daily life (Nambi, 2006)

SIGNS AND SYMPTOMS

Recurrent persistent ideas, thoughts or images or repetitive, stereotyped,

seemingly purposeless behaviour

2. PHOBIC DISORDER

A phobia is unreasonable fear of an object or situation. Phobias are divided

into three groups

A. Simple phobia
B. Agora phobia
C. Social phobia

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 SIGNS AND SYMPTOMS

1) Tachycardia
2) Palpitation
3) Dry mouth
4) Diarrhea
5) Frequency of urination
6) Tensional headache
7) Tremors
8) Inability to relax

3. HYSTERICAL DISORDER

It’s a disturbance of behaviour with signs and symptoms of physical ill health
are imitated more or less unconsciously for some personal advantage

SIGNS AND SYMPTOMS

1) Exaggerated diarrhea and vomiting

2) Generalized weakness, dizziness, pain
3) Delusions
4) Seizures

4. ANXIETY DISORDERS
Panic disorder and generalized anxiety disorder
This is a feeling of apprehension, uneasiness, agitation and uncertainty
resulting from anticipation and some threat or danger usually of
intrapsychic and not external origin whose source is usually unrecognized
and unknown

SIGNS AND SYMPTOMS

i. Restlessness
ii. Difficult in concentration
iii. Irritability
iv. Sleep disturbance
v. Loss of appetite

MANAGEMENT OF NEUROSES

Neurosis should be treated by a counselor, therapists, psychologist, psychiatrist or other

mental health care professionals. Treatment for a neurotic disorder depends on the

76
presenting symptoms and the level of discomfort they are causing the patient. Modes of
treatment are similar to that of other mental disorders and can include:

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is the standard psychotherapy for treating neurotic disorders. It
help suffers to identify, understand and change faulty thinking and behavior patterns, thus allowing
them to learn how to control their worries. The cognitive part of the CBT helps by changing the
thinking patterns that creates and support fears, then the behavioral part helps the sufferer react to
anxiety provoking situation.

Physical exercises

Exercise is a natural anxiety reliever according to help guide organization and as little as 30
minutes of exercises 3-5 days a week can help shorten the duration of panic attack and
lessen anxiety symptoms. The website treatment for anxiety argues that exercises helps to
distract the mind from focusing on anxiety filled thoughts. For maximum benefits anxiety
sufferers should aim for at least 60 minutes of aerobic exercise on most days

Relaxation Techniques

Relaxation techniques such as meditation, muscle relaxation deep breathing and

visualization can reduce anxiety. The website points out that many of these techniques
helps to increase the oxygen levels in the body that can help reduce frequently and duration
of panic attacks.

Other techniques used in the treatment of neurotic disorders are:

 Desensitization
 Creative therapy, e.g. Art or Music therapy
 Psychoactive drugs

DRUGS

Medication will not cure neurotic disorders but it can keep the symptoms under control
while the patient receives psychotherapy. Medication used include antidepressants, anti
anxiety and beta blockers

Anxiolytic e.g. Diazepam

Action- It depresses the central nervous symptom and also the polysynaptic reflexes in the
spinal cord resulting in muscle relaxation

Dose – 2 – 10mgs BD

77
Side effect

 Drowsiness
 Dizziness
 Brandycardia
 Nursing care
 Avoid driving or operating machines
 Avoid drinking alcohol

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Introduction to Development, Personality, and Stage Theories
 
When discussing any type of development, most theorists break it down into specific
stages.  These stages are typically progressive.  In other words, you must pass through one
stage before you can get to the next.  Think about how you learned to run; first you had to
learn to crawl, then you could learn to walk, and finally you could develop the skills needed
to run.  Without the first two stages, running would be impossible.
 
In this chapter we will discuss the most prominent stage theories in regard to motor and
cognitive, social development, development, and moral development.  Most of these stage
theories are progressive, although in some, such as Erikson's psychosocial and Freud's
psychosexual, a person can fail to complete the stage while still continuing.  This failure,
however, will result in difficulties later in life according to the theories.  The following offers
an overview of development according to the principles of psychology.
 

Motor Development in Infancy and Childhood

Most infants develop motor abilities in the same order and at approximately the same age.
In this sense, most agree that these abilities are genetically preprogrammed within all
infants. The environment does play a role in the development, with an enriched
environment often reducing the learning time and an impoverished one doing the opposite.

The following chart delineates the development of infants in sequential order. The ages
shown are averages and it is normal for these to vary by a month or two in either direction.

2 months – able to lift head up on his own

3 months – can roll over

4 months – can sit propped up without falling over

6 months – is able to sit up without support

7 months – begins to stand while holding on to things for support

9 months – can begin to walk, still using support

10 months – is able to momentarily stand on her own without support

11 months – can stand alone with more confidence

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12 months – begin walking alone without support

14 months – can walk backward without support

17 months – can walk up steps with little or no support

18 months – able to manipulate objects with feet while walking, such as kicking a ball

 Cognitive Development in Children

Probably the most cited theory in the cognitive development in children is Jean Piaget
(1896-1980). As with all stage theories, Piaget’s Theory of Cognitive Development maintains
that children go through specific stages as their intellect and ability to see relationships
matures. These stages are completed in a fixed order with all children, even those in other
countries. The age range, however, can vary from child to child.

Sensorimotor Stage. This stage occurs between the ages of birth and two years of age, as
infants begin to understand the information entering their sense and their ability to interact
with the world. During this stage, the child learns to manipulate objects although they fail
to understand the permanency of these objects if they are not within their current sensory
perception. In other words, once an object is removed from the child’s view, he or she is
unable to understand that the object still exists.

The major achievement during this stage is that of Object Permanency, or the ability to
understand that these objects do in fact continue to exist. This includes his ability to
understand that when mom leaves the room, she will eventually return, resulting in an
increased sense of safety and security. Object Permanency occurs during the end of this
stage and represents the child’s ability to maintain a mental image of the object (or person)
without the actual perception.

Preoperational Stage. The second stage begins after Object Permanency is achieved and
occurs between the ages of two to seven years of age. During this stage, the development
of language occurs at a rapid pace. Children learn how to interact with their environment in
a more complex manner through the use of words and images. This stage is marked by
Egocentrism, or the child’s belief that everyone sees the world the same way that she does.
The fail to understand the differences in perception and believe that inanimate objects have
the same perceptions they do, such as seeing things, feeling, hearing and their sense of
touch.

A second important factor in this stage is that of Conservation, which is the ability to
understand that quantity does not change if the shape changes. In other words, if a short

80
and wide glass of water is poured into a tall and thin glass. Children in this stage will
perceive the taller glass as having more water due only because of its height. This is due to
the children’s inability to understand reversibility and to focus on only one aspect of a
stimulus (called centration), such as height, as opposed to understanding other aspects,
such as glass width.

Concrete Operations Stage. Occurring between ages 7 and about 12, the third stage of
cognitive development is marked by a gradual decrease in centristic thought and the
increased ability to focus on more than one aspect of a stimulus. They can understand the
concept of grouping, knowing that a small dog and a large dog are still both dogs, or that
pennies, quarters, and dollar bills are part of the bigger concept of money.

They can only apply this new understanding to concrete objects ( those they have actually
experienced). In other words, imagined objects or those they have not seen, heard, or
touched, continue to remain somewhat mystical to these children, and abstract thinking has
yet to develop.

Formal Operations Stage. In the final stage of cognitive development (from age 12 and
beyond), children begin to develop a more abstract view of the world. They are able to
apply reversibility and conservation to both real and imagined situations. They also develop
an increased understanding of the world and the idea of cause and effect. By the teenage
years, they are able to develop their own theories about the world. This stage is achieved by
most children, although failure to do so has been associated with lower intelligence.

Erikson’s Stages of Psychosocial Development

Like Piaget, Erik Erikson (1902-1994) maintained that children develop in a predetermined
order. Instead of focusing on cognitive development, however, he was interested in how
children socialize and how this affects their sense of self. Erikson’s Theory of Psychosocial
Development has eight distinct stage, each with two possible outcomes. According to the
theory, successful completion of each stage results in a healthy personality and successful
interactions with others. Failure to successfully complete a stage can result in a reduced
ability to complete further stages and therefore a more unhealthy personality and sense of
self. These stages, however, can be resolved successfully at a later time.

Trust versus Mistrust. From ages birth to one year, children begin to learn the ability to
trust others based upon the consistency of their caregiver(s). If trust develops successfully,
the child gains confidence and security in the world around him and is able to feel secure
even when threatened. Unsuccessful completion of this stage can result in an inability to
trust, and therefore a sense of fear about the inconsistent world. It may result in anxiety,
heightened insecurities, and an over feeling of mistrust in the world around them.

81
Autonomy vs. Shame and Doubt. Between the ages of one and three, children begin to
assert their independence, by walking away from their mother, picking which toy to play
with, and making choices about what they like to wear, to eat, etc. If children in this stage
are encouraged and supported in their increased independence, they become more
confident and secure in their own ability to survive in the world. If children are criticized,
overly controlled, or not given the opportunity to assert themselves, they begin to feel
inadequate in their ability to survive, and may then become overly dependent upon others,
lack self-esteem, and feel a sense of shame or doubt in their own abilities.

Initiative vs. Guilt. Around age three and continuing to age six, children assert themselves
more frequently. They begin to plan activities, make up games, and initiate activities with
others. If given this opportunity, children develop a sense of initiative, and feel secure in
their ability to lead others and make decisions. Conversely, if this tendency is squelched,
either through criticism or control, children develop a sense of guilt. They may feel like a
nuisance to others and will therefore remain followers, lacking in self-initiative.

Industry vs. Inferiority. From age six years to puberty, children begin to develop a sense of
pride in their accomplishments. They initiate projects, see them through to completion, and
feel good about what they have achieved. During this time, teachers play an increased role
in the child’s development. If children are encouraged and reinforced for their initiative,
they begin to feel industrious and feel confident in their ability to achieve goals. If this
initiative is not encouraged, if it is restricted by parents or teacher, then the child begins to
feel inferior, doubting his own abilities and therefore may not reach his potential.

Identity vs. Role Confusion. During adolescence, the transition from childhood to adulthood
is most important. Children are becoming more independent, and begin to look at the
future in terms of career, relationships, families, housing, etc. During this period, they
explore possibilities and begin to form their own identity based upon the outcome of their
explorations. This sense of who they are can be hindered, which results in a sense of
confusion ("I don’t know what I want to be when I grow up") about themselves and their
role in the world.

Intimacy vs. Isolation. Occurring in Young adulthood, we begin to share ourselves more
intimately with others. We explore relationships leading toward longer term commitments
with someone other than a family member. Successful completion can lead to comfortable
relationships and a sense of commitment, safety, and care within a relationship. Avoiding
intimacy, fearing commitment and relationships can lead to isolation, loneliness, and
sometimes depression.

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Generativity vs. Stagnation. During middle adulthood, we establish our careers, settle
down within a relationship, begin our own families and develop a sense of being a part of
the bigger picture. We give back to society through raising our children, being productive at
work, and becoming involved in community activities and organizations. By failing to achieve
these objectives, we become stagnant and feel unproductive.
 
Ego Integrity vs. Despair. As we grow older and become senior citizens, we tend to slow
down our productivity, and explore life as a retired person. It is during this time that we
contemplate our accomplishments and are able to develop integrity if we see ourselves as
leading a successful life. If we see our lives as unproductive, feel guilt about our pasts, or
feel that we did not accomplish our life goals, we become dissatisfied with life and develop
despair, often leading to depression and hopelessness.
 

Freud’s Stages of Psychosexual Development

Sigmund Freud (1856-1939) is probably the most well known theorist when it comes to the
development of personality. Freud’s Stages of Psychosexual Development are, like other
stage theories, completed in a predetermined sequence and can result in either successful
completion or a healthy personality or can result in failure, leading to an unhealthy
personality. This theory is probably the best known as well as the most controversial; as
Freud believed that we develop through stages based upon a particular erogenous zone.
During each stage, an unsuccessful completion means that a child becomes fixated on that
particular erogenous zone and either over– or under-indulges once he or she becomes an
adult.

Oral Stage (Birth to 18 months). During the oral stage, the child if focused on oral pleasures
(sucking). Too much or too little gratification can result in an Oral Fixation or Oral
Personality which is evidenced by a preoccupation with oral activities. This type of
personality may have a stronger tendency to smoke, drink alcohol, over eat, or bite his or
her nails. Personality wise, these individuals may become overly dependent upon others,
gullible, and perpetual followers. On the other hand, they may also fight these urges and
develop pessimism and aggression toward others.

Anal Stage (18 months to three years). The child’s focus of pleasure in this stage is on
eliminating and retaining feces. Through society’s pressure, mainly via parents, the child has
to learn to control anal stimulation. In terms of personality, after effects of an anal fixation
during this stage can result in an obsession with cleanliness, perfection, and control (anal
retentive). On the opposite end of the spectrum, they may become messy and disorganized
(anal expulsive).

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Phallic Stage (ages three to six). The pleasure zone switches to the genitals. Freud believed
that during this stage boy develop unconscious sexual desires for their mother. Because of
this, he becomes rivals with his father and sees him as competition for the mother’s
affection. During this time, boys also develop a fear that their father will punish them for
these feelings, such as by castrating them. This group of feelings is known as Oedipus
complex (after the Greek Mythology figure who accidentally killed his father and married his
mother).

Later it was added that girls go through a similar situation, developing unconscious sexual
attraction to their father. Although Freud Strongly disagreed with this, it has been termed
the Electra complex by more recent psychoanalysts.

According to Freud, out of fear of castration and due to the strong competition of his father,
boys eventually decide to identify with him rather than fight him. By identifying with his
father, the boy develops masculine characteristics and identifies himself as a male, and
represses his sexual feelings toward his mother. A fixation at this stage could result in sexual
deviancies (both overindulging and avoidance) and weak or confused sexual identity
according to psychoanalysts.
 
Latency Stage (age six to puberty). It’s during this stage that sexual urges remain repressed
and children interact and play mostly with same sex peers.
 
Genital Stage (puberty on). The final stage of psychosexual development begins at the start
of puberty when sexual urges are once again awakened. Through the lessons learned during
the previous stages, adolescents direct their sexual urges onto opposite sex peers; with the
primary focus of pleasure are the genitals.
 
Freud's Structural and Topographical Models of Personality
 
Sigmund Freud's Theory is quite complex and although his writings on psychosexual
development set the groundwork for how our personalities developed, it was only one of
five parts to his overall theory of personality.  He also believed that different driving forces
develop during these stages which play an important role in how we interact with the world.
 
Structural Model (id, ego, superego)
 
According to Freud, we are born with our Id.  The id is an important part of our personality
because as newborns, it allows us to get our basic needs met.  Freud believed that the id is
based on our pleasure principle.  In other words, the id wants whatever feels good at the
time, with no consideration for the reality of the situation.  When a child is hungry, the id

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wants food, and therefore the child cries.  When the child needs to be changed, the id cries. 
When the child is uncomfortable, in pain, too hot, too cold, or just wants attention, the id
speaks up until his or her needs are met.
 
The id doesn't care about reality, about the needs of anyone else, only its own satisfaction. 
If you think about it, babies are not real considerate of their parents' wishes.  They have no
care for time, whether their parents are sleeping, relaxing, eating dinner, or bathing.  When
the id wants something, nothing else is important.
 
Within the next three years, as the child interacts more and more with the world, the
second part of the personality begins to develop.  Freud called this part the Ego.  The ego is
based on the reality principle.  The ego understands that other people have needs and
desires and that sometimes being impulsive or selfish can hurt us in the long run.  It’s the
ego's job to meet the needs of the id, while taking into consideration the reality of the
situation.
 
By the age of five, or the end of the phallic stage of development, the Superego develops. 
The Superego is the moral part of us and develops due to the moral and ethical restraints
placed on us by our caregivers.  Many equate the superego with the conscience as it
dictates our belief of right and wrong.
 
In a healthy person, according to Freud, the ego is the strongest so that it can satisfy the
needs of the id, not upset the superego, and still take into consideration the reality of every
situation.  Not an easy job by any means, but if the id gets too strong, impulses and self
gratification take over the person's life.  If the superego becomes too strong, the person
would be driven by rigid morals, would be judgmental and unbending in his or her
interactions with the world.  You'll learn how the ego maintains control as you continue to
read.
 
 
Topographical Model
 
Freud believed that the majority of what we experience in our lives, the underlying
emotions, beliefs, feelings, and impulses are not available to us at a conscious level.  He
believed that most of what drives us is buried in our unconscious.  If you remember the
Oedipus and Electra complex, they were both pushed down into the unconscious, out of our
awareness due to the extreme anxiety they caused.  While buried there, however, they
continue to impact us dramatically according to Freud.
 

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The role of the unconscious is only one part of the model.  Freud also believed that
everything we are aware of is stored in our conscious.  Our conscious makes up a very small
part of who we are.  In other words, at any given time, we are only aware of a very small
part of what makes up our personality; most of what we are is buried and inaccessible.
 
The final part is the preconscious or subconscious.  This is the part of us that we can access if
prompted, but is not in our active conscious.  It’s right below the surface, but still buried
somewhat unless we search for it.  Information such as our telephone number, some
childhood memories, or the name of your best childhood friend is stored in the
preconscious.
 
Because the unconscious is so large, and because we are only aware of the very small
conscious at any given time, this theory has been likened to an iceberg, where the vast
majority is buried beneath the water's surface.  The water, by the way, would represent
everything that we are not aware of have not experienced, and that has not been integrated
into our personalities, referred to as the nonconscious.

Ego Defense Mechanisms

 
We stated earlier that the ego's job was to satisfy the id's impulses, not offend the moralistic
character of the superego, while still taking into consideration the reality of the situation. 
We also stated that this was not an easy job.  Think of the id as the 'devil on your shoulder'
and the superego as the 'angel of your shoulder.'  We don't want either one to get too
strong so we talk to both of them, hear their perspective and then make a decision.  This
decision is the ego talking, the one looking for that healthy balance.
 

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Before we can talk more about this, we need to understand what drives the id, ego, and
superego.  According to Freud, we only have two drives; sex and aggression.  In other
words, everything we do is motivated by one of these two drives.
 
Sex, also called Eros or the Life force, represents our drive to live, prosper, and produce
offspring.  Aggression, also called Thanatos or our Death force, represents our need to stay
alive and stave off threats to our existence, our power, and our prosperity.
 
Now the ego has a difficult time satisfying both the id and the superego, but it doesn't have
to do so without help.  The ego has some tools it can use in its job as the mediator, tools
that help defend the ego.  These are called Ego Defense Mechanisms or Defenses.  When
the ego has a difficult time making both the id and the superego happy, it will employ one or
more of these defenses:
 
 
DEFENSE DESCRIPTION EXAMPLE
denial arguing against an denying that your physician's
anxiety provoking diagnosis of cancer is correct and
stimuli by stating it seeking a second opinion
doesn't exist
displacement taking out impulses slamming a door instead of hitting
on a less threatening as person, yelling at your spouse
target after an argument with your boss
intellectualization avoiding focusing on the details of a funeral
unacceptable as opposed to the sadness and grief
emotions by focusing
on the intellectual
aspects
projection placing unacceptable when losing an argument, you state
impulses in yourself "You're just Stupid;" homophobia
onto someone else
rationalization supplying a logical or stating that you were fired because
rational reason as you didn't kiss up the boss, when
opposed to the real the real reason was your poor
reason performance
reaction taking the opposite having a bias against a particular
formation belief because the race or culture and then embracing
true belief causes that race or culture to the extreme
anxiety
regression returning to a sitting in a corner and crying after

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 previous stage of hearing bad news; throwing a
development temper tantrum when you don't get
your way
repression pulling into the forgetting sexual abuse from your
unconscious childhood due to the trauma and
anxiety
sublimation acting out sublimating your aggressive
unacceptable impulses toward a career as a
impulses in a socially boxer; becoming a surgeon because
acceptable way of your desire to cut; lifting weights
to release 'pent up' energy
suppression pushing into the trying to forget something that
unconscious causes you anxiety
 
Ego defences are not necessarily unhealthy as you can see by the examples above.  In fact,
the lack of these defences, or the inability to use them effectively can often lead to
problems in life.  However, we sometimes employ the defences at the wrong time or
overuse them, which can be equally destructive.

Kohlberg’s Stages of Moral Development

Although it has been questioned as to whether it applied equally to different genders and
different cultures, Kohlberg’s (1973) stages of moral development is the most widely cited.
It breaks our development of morality into three levels, each of which is divided further into
two stages:

Preconventional Level (up to age nine):

     ~Self Focused Morality~

1. Morality is defined as obeying rules and avoiding negative consequences. Children in this
stage see rules set, typically by parents, as defining moral law.

2. That which satisfies the child’s needs is seen as good and moral.

Conventional Level (age nine to adolescence):

     ~Other Focused Morality~

3. Children begin to understand what is expected of them by their parents, teacher, etc.
Morality is seen as achieving these expectations.

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4. Fulfilling obligations as well as following expectations are seen as moral law for children in
this stage.

Postconventional Level (adulthood):

   ~Higher Focused Morality~ 

5. As adults, we begin to understand that people have different opinions about morality and
that rules and laws vary from group to group and culture to culture. Morality is seen as
upholding the values of your group or culture.
 
6. Understanding your own personal beliefs allow adults to judge themselves and others
based upon higher levels of morality. In this stage what is right and wrong is based upon the
circumstances surrounding an action. Basics of morality are the foundation with
independent thought playing an important role.
 
PERSONALITY DISORDERS
Introduction
Personality disorders are disorders in which ones personality results in personal distress or
significantly impairs social or work functioning. Every person has a personality that is
characteristic way of thinking and relating to others, most people experience at least some
difficulty and problems that result from their personality. Personality disorders involves
behaviour that deviates from the norms or expectations of one’s culture, however people
who deviate from cultural norms are not necessarily dysfunctional nor are people who
conform to cultural norms are necessarily healthy. Many personality disorders represent
extreme variants of behaviour patterns that people usually value and encourage. A
behaviour that seems deviant to one person may seem normal to another depending on
one’s gender, ethnicity, and cultural background. Personality disorders often decrease in
severity as the person ages.

Definitions

Personality
“the sum total of hereditary and inborn tendencies, with influences from environment and
education, which goes to form the mental make-up of a person and influence his attitude to
life”. (weller and wells, 2000)

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Personality disorders

 “these are disorders characterised by patterns of perceiving, reacting, and relating

that are relatively fixed, inflexible and socially maladaptive across a variety of
situations”. (berkow, 1997)
 “personality disorders are a group of mental disorders characterized by lifelong
patterns of maladaptive response to stress, by problems in developing work
behaviours and intimate relationship behaviours and by the capacity to perpetuate
interpersonal problems and among others”. (brunner l.s. And sudarth d.s., 1992)

Theories
The theories pertaining to personality disorders are known as biopsychosocial theories. The
biopsychosocial theories are composed of biological factors and psychosocial theories.
Biopsychosocial theories
Our styles of perceiving, thinking and responding, sharp our ability to adapt and defend our
sense of self. There are biological factors and psychosocial theories that explain some
personality disorders.

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Biologic factors
These point to genetic factors in the development of some personality disorders for
instance;

 Kaplan and sadock (1991) identified significant familiar correlations of schizotypal

(clustster a) personality disorder among people with family members who are
schizophrenic. They also say that cluster b illnesses (histrionic, narcissistic and antisocial)
are often corrected with history of mood disorders, alcoholism and somatization
disorders among family members.

 Loranger and tulis (1985) report that borderline clients have a significant higher family
history of alcoholism compared to health clients.

 Mccormick (1993) points that the development of obsessive-compulsive personality

disorders (cluster c) is associated with based ganglia and fronted cortex dysfunctions.

 Dillon and brokers (1992) discuss possible links between changes in the progesterone
levels in college aged women and obsessive-compulsive disorders.

Other literature by kaplan and sadock (1991) suggest that central nervous system
dysfunctions early in childhood and children with minimal brain development of some of the
type of cluster b personality disorders. This speculation is supported by andrulonis et al
(1980) who report organic involvement including episodes of minimal brain dysfunctions
and episodic dyscontrol syndromes among subjects in an intensive study of borderline
personality disorder.

Psychosociol theories

Psychosocial fixation in the genital stage of development may account for many of the
noted in the dramatic disorders, emotional clusters of personality disorders. (cameron and
rychlak, 1985).

Erick erickson (1964) coined the term identify diffusion to describe the failure to integrate
various childhood identification into a harmonious adult psychosocial identity.

Keenbery (1975) suggested that, as infant’s borderline clients perceive with mothers as both
nurturing and punishing. The child learns to reduce anxiety and resolve resulting conflicts by
the use of primitive defensive strategies such as projective identification, devaluation and
denial.

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Aetiology

 Not much is known about the causes, the cause remains controversial and observe.

 Possible genetic factors e.g. Borderline patients are predisposed to a higher than
normal level of aggression and rage, making her more difficult to care for a child and
relate to as an adult.

 Disturbance in early childhood involving presence of inconsistence, neglectful

parents. (environment-nurture)

Types and characteristics of personality disoders

Cluster a (odd eccentric styles)

 Paranoid personality disorders.
 Schizoid personality disorders
 Schizotype personality disorders.

Cluster b (dramatic- emotional styles)

 Boarderline personality disorder
 Histrionic personality disorder
 Narcistic personality disorder
 Anti-social personality disorder

Cluster c (anixious-fearful styles)

 Avoidant personality disorder
 Dependant personality disorder
 Obsessive-compulsive personality disorder

Cluster a (odd eccentric styles)

Paranoid personality disorders

 Characterized by unjustification suspicious and mistrust of others leading to jealous.
 Accusation of infidelity.
 Guardedliness
 Hypersensitive and usually feels mistrusted and misjudged.
 Restricts feeling leading to lack of human
 Absence of segmental or tender feelings and pride in being called and
unemotional.
 Bears grudge and are quick to content attack.

Schizoid
 Characterized by being emotional cold and aloof.
 Shows in difference to the praise or criticism of others

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  Has little or no desire for sexual involvement
 Does not enjoy or desire close relationships

 Has few friends

Schizotypal
 Manifest various oddities of thoughts, perceptions, speech, affects and behaviours
such as ideas of reference, bizarre fantasies, and pre-occupation.
 Suspicions and hypersensitivity to real or imagined criticism
 Isolate self from society because of actuate discomfort.

Claster b (dramatic emotional styles.)

1. Borderline.

Characterized by:
 Impulsive and unpredictable in areas of life that are self-damaging.
 Has unstable but interpersonal relationships involving manipulation of others.
 Displays temper inappropriately
 Has unstable moods
 Uncertain about identity
 May experience sever dissociative symptoms
 May inflict physical damage on self
 Has chronic feelings of boredom and emptiness
 Fears abandonment

2. Histrionic

Characterized by: -
 Overly dramatic and reactive, and responds intensely
 Engages in attention seeking
 Sexual dramatic provocation
 Irrational outburst of emotions
 Is perceived by other as shallow, self indulgent demanding
 Users appearance and style of speech to draw attention to self
 He suggested overrates the intimacy of relationships

4. Narcissistic

Characterized by:
 Grandiose sense of self-importance.
 He is pre-occupied with fantasies of unlimited success, power, beauty, brilliance etc.
 Needs attention and admiration.
 Shows an arrogant attitude based on feelings of entitlement and envy.
 In relationships with others expects specially favours
 Takes advantages of others

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5. Anti-social

Characterized by:
 Behaviour that causes conflict with society, such as theft, vandalism, fighting,
delinquency, truancy lying.
 Unable to sustain constant work or to function as a responsible parent or spouse.
 Cannot maintain or induary attachment to a sex partner.
 Lacks respect and loyalty, irritable and aggressive.
 Manipulates others for personal gain.
 Does not plan ahead
 Lacks guilty
 Does not learn from past experiences
 Blames others
 Disregards the safety and others

Cluster c (anxious – fearful styles)

1. Avoidant

Characterized by:
 Hypersensitive rejection and interprets innocuous events as ridicules.
 Unwilling to become involved with others, unless given a guarantee of acceptance.
 Withdraws society and interpersonal and work roles, avoids new situations.
 Desire in intimate situations for fear of ridicule.
 Fear inept and infuriated

2. Dependant

Characterized by:
 Passively allows others to assume responsibility for major areas of life.
 Lacks self-confidence and initiative.
 Have difficulties in disagreeing with others.
 Fears being alone, so urgently seek a close relationship.

Obessive compulsive personality disorders

Characterized by:
 Over conscientious, over meticulous, perfectionist.
 Excessive concern with conformity.
 Adheres rigidly to strict standards of morality and values.
 Pre-occupied with trivial details rules, schedules and lists.
 Keeps worthless objects
 Unable to delegate without control
 Misery and stubborn

Management of personal disorders

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Treatment modalities

Treatment is very difficult, because of the anxiety generated with responses of anger and
staff. In addition, patients do not perceive self as sick. The treatment does not attempt to
alter personality but promotes more adaptive responses and the formulation of positive
interpersonal strategies.

Selected treatment modalities

 Psychotherapy
 Group therapy
 Family therapy
 Electro convulsive therapy (ect)
 Activity therapy
 Other modalities

Psychotherapy

1. Psychoanalysis (freud)
 Use of unconscious material; dream analysis free association, interpretation and
transference to assist the patient achieve re-organization of his personality.
 Treatment may exceed over a period of 1-7 years.

[Link] (sullivan)
 Use of relationship with analyst to focus on interpersonal relationship and
communication process.
 Dreams analysis, free association, interpretation and transference are also used to
assist the individual.

3. Psychotherapy (rogers)
 Use of empathetic understanding, concerteness, self-exploration and positive
regard to encourage individuals towards self-actualisation.

4. Cognitive therapy (beck)

 Use of guided discovery to assist patient in focusing on dysfunctional thought or
behaviour and analysing them in the assignment of tasks.
 The strategy for behaviour change is based on interrupting the sequence of
cognition, imagery and affect.
 Method has been studied and proven useful in depression.

5. Rational – emotive psychotherapy, ret (ellis)

 Therapist teaches patient to use an abc method
 A, is for activating experience by actively fantasizing experience to determine
emotional consequence.
 B, is belief system that a person notes as the allows self to feel uncomfortable
 C, is for confronting irrational beliefs by using positive imagery.

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6. Interpersonal therapy ipt (klerman)

 Focus is on interpersonal transactions that have not gone well and on the
development of specific strategies for coping with the internal and external stress.

7. Transactional analysis (berne)

 Use of concepts of parents, child and adult to describe ego states and transactions
and games to view interactions with others.
 Goal is to obtain the adult ego state of “am ok – you are ok“ or a game free
relationship.

8. Reality therapy (glaser)

Focus is an acceptance of reality and responsibility self with the therapy who is involved in
loving and teaching.

Supportive therapy psychotherapy

Use of techniques to achieve other ways for control of impulse, to strengthen defences, or
to maintain adaptation.

Crisis therapy

Focus is on offering emotional support. Communicating hope, setting model for action,
listening selecting for material for assessment, providing factual information, setting limits
on acting our behaviour, writing out contract, and formulating problem in terms of
precipitating factors, back ground prevents available coping mechanism.

Duration of 1 to 6 sessions

Brief psychotherapy

Use of 1 to 20 session using techniques to help patient relate present situation to past
experiences in order to assist him to removal of specific symptoms.

Outcome is related to experience of trust in the therapist relationship.

Group psychotherapy

Selected persons are placed in a group 4-10 guided by a trained therapist to effect
personality change or to assist with problems affecting mental health.

Analytic group

Leader uses psychoanalytic concepts to produce change.

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Sullivanian group

Leader uses interpersonal therapy to explore problems and eliminate maladaptations.

Bion group

Leader uses concepts concerning group life including basic assumptions, to interpret group
phenomena.

Transactional group

Leaders focus on games and not on calls of problems or uncovering unconscious material to
achieve cure.

Gestalt group (perls)

Leaders use rules and games to assist a person in acknowledgement immediate feelings and
to prevent their avoidance in order to restore the person to a sense of wholeness.

Psychodrame (moreno)
 Is a treatment method offering opportunity for problem solving through enactment
of conflict situation.
 Many techniques are used to promote involvement and analysis; some are, self-
presentation. Mirror, note reversal, and double.

Family therapy

Structure model (miuchin)

 The therapist seeks to alter the family structure because changes in the psychic
processes.
 The therapist uses joinery operations as he recreates communication patterns.

Bowen therapy

A therapist assists family members in achieving differentiating and in reducing reactivity.

Electro-convulsive therapy (ect)

Ect is a series of treatment given under anaesthesia and muscle relaxants involving the brain
in order to produce convulsions.

It is indicted in severe cases of depression, psychoses, catatonic or mania.

 Behavioural changes are probably the result of biochemical changes in the brain
function.

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  Treatment preparation involves physical examinations, lab tests, x-rays of spine, if
indicated, full information consent of patient, nothing by mouth after midnight,
voiding prior treatment and removal of dentures.

Other modalities of treatment

Sex therapy (master and johnson)

Use of desensitising techniques to increase sexual pleasure and arousal, and to demystify
sex.

Assertive training

Teaching of skills to assist people in getting what they want in firm, effective and useful
manner as opposed to an aggressive manner in which emotions are expressed in
destructive, aggressive ways.

Token economy

Use of positive reinforcement in form of tokens and extinction of undesirable behaviour by

ignoring or being fined tokens to achieve behaviour change.

Hypnosis

Therapist uses techniques such as repetitive suggestion to induce state of altered

consciousness or intense concentration to provide additional data for diagnosis and
treatment.

Nursing care of personality disorders

Paranoid client

Problem 1

Defensive coping resulting from exclusion restricted and controlled affected, guarded lines
and secretiveness.

Nursing intervention:
 ● respect client, privacy and preferences.
 Give feed back to the client based on observed non-verbal cues of responsiveness
e.g. Eye movements, posture and voice tones.
 Point out consistent behaviour such as affect and verbalization.
 Provide a daily schedule of activities and inform client on changes. This is to diminish
anxiety about social interaction and may ensure participation.
 Use role-playing to help clients to identify feelings, thought and responses brought
on by stressful situations.

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 
Problem 2

Impaired thought process resulting from suspiciousness, rigidity, distortions of reality and
hypersensitivity.
Nursing intervention

 The nurse should say firmly and kindly that she does not share client’s
interpretations of an event but do acknowledge client’s feelings.
 Assign the same staff member to work with client to establish consistency and trust.
 Give positive re-enforcement for success in a matter of fact manner.
 Respond honesty to client at all times.
 Respond conversation to reality – based topics and set limits on duration and
frequency of suspicious concerns during one-to-one sessions and groups.
 Do not argue with illogical assertions; simply point out that you do not share the
same belief.
 Help client identify and verbalize feelings.
 Include client in formulating the treatment plan.

Problem 3

Impaired social interaction resulting argumentativeness, critical comments about others,

aggressiveness and defensiveness

Nursing interventions.
 Use an objective matter of fact, approach with client to help him identify the nurse
as a reliable person who will respect him without arguments.
 Use concrete specific words rather than global obstructions.
 Keep verbal and non-verbal messages clear and consistent.
 Conduct brief one to one sessions daily to decrease fear and anxiety.
 Involve client in communication skills group such as assertiveness training or any
other associations to help client gain awareness of personal behaviours contributing
to isolation.
 Inform client of the emotional cues he/she is doing to other such as suspiciousness
and intimidation. Self-awareness is enhanced with non-threatening feedback.
(mirroring)

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Schizoid and schizotypal clients

Problem 1

Impaired social interaction resulting from absence of warm feelings for other, inadequate
social skills and lack of desire for social encounters.

Nursing intervention
 Encourage client to participate in on-going support systems offered by community
mental health clinic e.g. Carpentry.
 Encourage client to initiate at least one interaction with a staff member as significant
others daily.
 Encourage client to write a list of two people with whom to speak about a concern.

Problem 2
Impaired Verbal Communication as a result of aloofness, excessive social anxiety and
fragmented speech patterns.

Nursing Intervention
 Encourage the client to select one activity for the group (in a support system), three
times weekly.
 Encourage the client to remain out of the room at least 4 hours daily.
 Encourage the patient to speak for 5 – 10 minutes without introducing circumstantial
material

PROBLEM 3

Hygiene: Self care deficit particularly in homeless clients.

Nursing Intervention
 Encourage he client to bath and change clothing.
 Encourage patient to prepare dirty laundry for washing.
 The Nurse should use hygiene / glooming checklist for the client.
 Encourage the client to make a list of daily glooming / hygiene tasks.

Problem 4

Feeding self-care deficit as a result of lack of knowledge, inadequate living arrangements or

lack of interests and motivation

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Nursing interventions
 Encourage the client to link up with fellow clients during meals, so as to promote
adequate nutrition and increased social interaction.
 Encourage client to eat 2 to 3 balanced meals everyday.
 Help client prepare a list identifying foods he/she eats and has access to daily.
 Teach client minimum daily requirements for an adequate diet and how to provide
these requirements from the foods currently used in the diet.
 Teach client how to chew small bite-sized pieces of food slowly.

Problem 5
Impaired home management due to underlining condition.

Nursing intervention
 Teach client home management skills necessary for independent living: how to buy
food, paying bills.

Borderline personality disorder clients

Problem 1

Personal identity disturbance related to physical verbal abuse.

Nursing Intervention
 Encourage client to discuss personal body image.
 Help client deal with loss of body image associated with history of abuse.
 Help client examine belief systems and identify how perceptions and beliefs
influence responses.
 Encourage client to write an autobiographical essay or story and give feed back if
able to read and write.
 Help client accept disappointment by altering thoughts within statements like “It will
be nice if ……………….” Rather than magnifying loses.
 Encourage participation in a variety of group situations.
 Provide step-by-step, concrete self-care instructions when the client is unable to
make decisions.
 Establish schedules for personal acre activities and provide sufficient time for client
to complete tasks.
 Teach female clients the appropriate use of cosmetics and encourage male clients to
shave frequently and care for facial hair.

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Problem 2
Risk of violence, self-directed or directed at other related to inability to verbalize frustration
and anger.

Nursing intervention
 Help client identify situations in which self-destructive ideas occur or are trigger – so as to
avoid the situation.
 When client verbalizes anger during one to one session point out that anger is not caused by
current situations but by perceptions of things in the past.
 Help client to explore ways to express anger and give positive re-enforcement for the same.

Rehabilitation
Rehabilitation starts immediately the condition stabilizes. In addition to what has been said
in nursing care the following will also be added.
Occupational therapy

Use of selected activities like painting, pottery, leather work, crocheting, hammering, shopping,
washing clothes, budgeting etc. To improve general performance to learn essential skills of living and
to assist in symptom reduction.
Recreation therapy

 Use of recreational activities (social, sports, games, hobbies, arts, crafts, service activities,
outdoor sports, etc) in treatment of behaviour.
 Special emphasis is given to re-socialisation, reality orientation and involvement when
working with psychiatric patients.

Bibliotherapy

Use of literature, films and persons own creative writing with group discussion to promote self-
knowledge and integration of thoughts and feelings.
Dance therapy

Use of rhythmic movements and interaction to express emotions, thereby increasing awareness of
body and ego strength.

CLASTER C (Anxious fearful personality disorders)

 Avoidant
 Dependant
 Obsessive-compulsive personality disorders.

Problem 1.
Social isolation as a result of lack of significant purpose, insecurity in public, shyness and inhibition,
verbalized fears of rejection.

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Nursing Intervention
 As a Nurse, establish a positive relationship with a client.
 Encourage the client to describe himself / herself in a positive way.
 Encourage the client to verbalize feelings of anxiety related to independent function so as to
enhance the ability to problem solving.
 Introduce client to Social Skills Training groups such as carpentry, Weaving, Cooking etc so as
to promote Social Interaction.
 Using group therapy to provide support emphasize that client is not along in experiencing
fear of failure of success. This minimizes feelings of isolation.

Problem 2
Chronic Low Self Esteem from Lack of an Awareness of Self and Unawareness of their own Social
Needs.

NURSING INTERVENTIONS
 Teach a client problem solving techniques including goal setting making alternative
responses and evaluating consequences so as to build self-confidence.
 Help client develop a realistic time frame in which to achieve independent living activities to
enhance feelings of self-control.
 Give positive reinforcement for successful achievements, this reinforces client’s ability to
success.
 Gradually introduce different staff members to do one to one with client, this fosters
feelings of independence.
 Introduce client to termination and discharge planning from admission and throughout stay,
termination can be a positive experience if client work through feelings.

PROBLEM 3
Ineffective individual coping as a result of self-doubt and the exclusion of self-pleasure

Nursing Interventions

 Encourage physical activity, this reduces tension and fosters relaxation.

 Discuss with the client on how to recognized behaviour changes, this strengthens self-
awareness.
 Help client identify coping methods to deal with stressful situations.
 Help client identify feelings of anxiety generated in stressful situations and the usual
responses to this anxiety, future behaviour can be altered based on understanding the past.
 Teach clients how to use human in situations of stress, human and laughter, provide a
release of tension and anxiety.
 Encourage the client to maintain routine schedules and appointments, consistency enhances
trust and reduces anxiety.

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Medical management

The psychiatrist will assess the patient’s type of disorder and will also identify key areas of
maladaptive behaviour. The drugs may be prescribed for the different types of personality
disorders as follows:

DISORDER TREATMENT
(cluster a disorders) FOR ACUTE PSYCHOSIS
1. Schizal typal personality. [Link] (Lagactil)
2. Schizoid personality disorder. Dose:
3. Paranoid Personality 150 – 600mg in divided doses
Disorder Maintenance Dose:
100 to 400mg
(Cluster b disorders)
Border line Personality
Disorders Noradrenergic
Dosage: 2 – 4mg dilute with 48mls of 5% Dextrose or
Normal Saline stat
Route: Intravenous (I.V.)
Mode of Action: Stimulates Adrenergic receptors within
the sympathetic nervous system.
Side Effect: Headache, Hypertension, Respiratory
difficulties and restlessness. Peripheral Disorders.
Contra- indications: Hypertension and in pregnancy
Nursing consideration always give it 5% Dextrose or Normal
Saline, Report decreased urine output
Cluster A and B
Chlorpromazine
Dosage
Tablet 150 – 600mg in divided for acute disorders.
Action:
Unknown, probably blocks postsynaptic dopamine receptors
in the brain and inhibits the medullary chemoreceptor trigger
zone.
Side Effects:
Nasal congestion, gastric upset, blurred vision, Tachycardia,
Drowsiness, and Seizers.
Nursing Implications
Use cautiously in patients with peptic ulcer.
Do not withdraw drug abruptly unless required by severe
adverse reactions.
Use cautiously in elderly or debilitated patients and C.V
disease (may cause sudden drop in blood pressure).

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Intersectoral collaboration, care of patient in the community

The following are some of the collaborator agents in the community.

 Churches for skills, spiritual and financial counselling.
 Mental Association of Zambia.
 Special schools in the community.
 Social Welfare Department.
 Rehabilitation Centres within the communities e.g. Sazu in Eastern province. Kawimbe in
Mbala.
 The Family Providers both psychological and physical support.

PREPARATION FOR DISCHARGE

The most obvious goal for inpatient or partial hospital to outpatient status. Therefore, a
critical focus of the inpatient stay should be establishing the involvement of family
members, signify others and follow up providers in discharge planning that increase the
potential for on-going care.
 The Nurse must be knowledgeable about the patient’s environment.
 Potential needs and resources should be identified on admission.
 Once the Nurse has decided what knowledge, skills and behaviours will help the patient
adapt to the discharge environment, creative and purposeful activities can be planned to
provide the needed resources.
 Information regarding supportive resources and medications should be provided to patients
and their families to encourage functional independence and decrease the chores of relapse
once discharged. This can significantly influence patient’s ability to maintain adaptive coping
responses.
 Psychiatric discharge planning for personality disorders can be considered as part of the
psychiatric rehabilitation model that addresses biopsychosocial needs in a manner similar to
the physical rehabilitation process.
 A discharge checklist can be used as an interdisciplinary tool to review the patient’s
discharge needs and include the patient in the planning process.
 Areas pertinent to discharge planning that should be included are:

Medications
 Activities of Daily Living
 Metal Health Aftercare
 Residence
 Physical Health Care
 Special Education and the need for financial assistance also should be reviewed with the
patient and family.
 Strong communication linkages between hospital – based and community – based providers
are essential in order to ensure:
 Continuity of care.
 Minimize the value of hospital – based services and
 Minimize future admissions

105
Theories

The theories pertaining to personality disorders are known as bio psychosocial theories. The
bio psychosocial theories are composed of biological factors and psychosocial theories.

Biopsychosocial theories

Our styles of perceiving, thinking and responding, sharp our ability to adapt and defend our
sense of self. There are biological factors and psychosocial theories that explain some
personality disorders.

A. Psychosociol theories

Psychosocial fixation in the genital stage of development may account for many of the
noted in the dramatic disorders, emotional clusters of personality disorders. (cameron and
rychlak, 1985)

Erick erickson (1964) coined the term identify diffusion to describe the failure to integrate
various childhood identification into a harmonious adult psychosocial identity.

Keenbery (1975) suggested that, as infant’s borderline clients perceive with mothers as both
nurturing and punishing. The child learns to reduce anxiety and resolve resulting conflicts by
the use of primitive defensive strategies such as projective identification, devaluation and
denial.

B. Biologic factors

These point to genetic factors in the development of some personality disorders for
instance;

 Kaplan and Sadock (1991) identified significant familiar correlations of schizotypal

(clustster a) personality disorder among people with family members who are
schizophrenic. They also say that cluster b illnesses (histrionic, narcissistic and
antisocial) are often corrected with history of mood disorders, alcoholism and
somatization disorders among family members.
 Loranger and Tulis (1985) report that borderline clients have a significant higher
family history of alcoholism compared to health clients.

106
  McCormick (1993) points that the development of obsessive-compulsive personality
disorders (Cluster C) is associated with based ganglia and fronted cortex dysfunctions.
 Dillon and Brokers (1992) discuss possible links between changes in the progesterone levels
in college aged women and obsessive-compulsive disorders.

Other literature by Kaplan and Sadock (1991) suggest that central nervous system
dysfunctions early in childhood and children with minimal brain development of some of the
type of Cluster B personality disorders. This speculation is supported by Andrulonis et al
(1980) who report organic involvement including episodes of minimal brain dysfunctions
and episodic dyscontrol syndromes among subjects in an intensive study of borderline
personality disorder.
Aetiology

 Not much is known about the causes, the cause remains controversial and obscure.
 Personality disorders results from a complex interaction of inherited traits and life
experience not from a single cause. For example some cases of antisocial personality
disorder may result from:
o a combination of genetic predisposition to impulsiveness and violence.
o Very inconsistent or erratic parenting, and
o A harsh environment that discourages feelings of empathy and warmth but rewards
exploitation and aggressiveness.
 Borderline personality disorder may result from a genetic predisposition to
impulsiveness and emotional instability combined with parental neglect intense marital
conflicts between parents, and repeated episodes of severe emotional or sexual abuse
(Environment-Nurture).
 Dependent personality disorder may result from genetically based anxiety, an inhibited
temperament, and overly protective, clinging, or neglectful parenting.

Types and characteristics of personality disoders

Cluster a (odd eccentric styles)

 Paranoid personality disorders.

 Schizoid personality disorders
 Schizotype personality disorders.

Cluster b (dramatic- emotional styles)

 Borderline personality disorder

 Histrionic personality disorder
 Narcistic personality disorder

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  Anti-social personality disorder

Cluster c (anixious-fearful styles)

 Avoidant personality disorder

 Dependant personality disorder
 Obsessive-compulsive personality disorder

Cluster a (odd eccentric styles)

1. Paranoid personality disorders

 Characterized by unjustification suspicious and mistrust of others leading to jealous.
 Accusation of infidelity.
 Guardedliness
 Hypersensitive and usually feels mistrusted and misjudged.
 Restricts feeling leading to lack of human
 Absence of segmental or tender feelings and pride in being called and unemotional.
 Bears grudge and are quick to content attack.

Schizoid

 Characterized by being emotional cold and aloof.

 Shows in difference to the praise or criticism of others
 Has little or no desire for sexual involvement
 Does not enjoy or desire close relationships
 Has few friends

Schizotypal

 Manifest various oddities of thoughts, perceptions, speech, affects and behaviours such as
ideas of reference, bizarre fantasies, and pre-occupation.
 Suspicions and hypersensitivity to real or imagined criticism
 Isolate self from society because of actuate discomfort.

Cluster b (dramatic emotional styles.)

1. Borderline.

Characterized by:

 Impulsive and unpredictable in areas of life that are self-damaging.

 Has unstable but interpersonal relationships involving manipulation of others.
 Displays temper inappropriately
 Has unstable moods
 Uncertain about identity
 May experience severe dissociative symptoms

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  May inflict physical damage on self
 Has chronic feelings of boredom and emptiness
 Fears abandonment

2. Histrionic

Characterized by: -

 Overly dramatic and reactive, and responds intensely

 Engages in attention seeking
 Sexual dramatic provocation
 Irrational outburst of emotions
 Is perceived by other as shallow, self indulgent demanding
 Uses appearance and style of speech to draw attention to self

3. Narcissistic

Characterized by:

 Grandiose sense of self-importance.

 He is pre-occupied with fantasies of unlimited success, power, beauty, brilliance etc.
 Needs attention and admiration.
 Shows an arrogant attitude based on feelings of entitlement and envy.
 In relationships with others expects specially favours
 Takes advantage of others

4. Anti-social

Characterized by:

 Behaviour that causes conflict with society, such as theft, vandalism, fighting, delinquency,
truancy, lying.
 Unable to sustain constant work or to function as a responsible parent or spouse.
 Cannot maintain or endure attachment to a sex partner.
 Lacks respect and loyalty, irritable and aggressive.
 Manipulates others for personal gain.
 Does not plan ahead
 Lacks guilty
 Does not learn from past experiences
 Blames others
 Disregards the safety and others

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Cluster c (anxious – fearful styles)

1. Avoidant

Characterized by:

 Hypersensitive rejection and interprets innocuous events as ridicules.

 Unwilling to become involved with others, unless given a guarantee of acceptance.
 Withdraws society and interpersonal and work roles, avoids new situations.
 Desire in intimate situations for fear of ridicule.
 Feel inept and infuriated

2. Dependant

Characterized by:

 Passively allows others to assume responsibility for major areas of life.

 Lacks self-confidence and initiative.
 Have difficulties in disagreeing with others.
 Fears being alone, so urgently seek a close relationship.

3. Obsessive Compulsive Personality disorders

Characterized by:

 Over conscientious, over meticulous, perfectionist.

 Excessive concern with conformity.
 Adheres rigidly to strict standards of morality and values.
 Pre-occupied with trivial details, rules, schedules and lists.
 Keeps worthless objects
 Unable to delegate without control
 Misery and stubborn

Management of a patient with personality disorders

Treatment modalities

Before any kind of treatment can begin the person with a character disorder must be
confronted in one way or another with what might be the matter with him even if he feels
he is perfectly justified in the action and responses that get him into trouble.

To treat these disorders it is often difficult, drug are not usually required. Therefore,
individual or group psychotherapist, therapeutic community and behavioural therapy can be

110
beneficial. Manipulation of social environment can be tried. Usually these conditions
improve with age and maturity

1. SELECTED TREATMENT MODALITIES

Psychotherapy (Sullivan)

Use of relationship with analyst to focus on interpersonal relationship and communication

process.

Free association, interpretation and transference are also used to assist the individual.

Group therapy

Since the patient’s problem is his way of relating it others, the interaction setting of group
therapy would seem to be ideally calculated to force the necessary confrontation and to
provide a sheltered opportunity for working out more adaptive problems of relationships
.The group setting also provide more support for the patient than he can find in individual
therapy. Group therapy is frequently used for patients with schizoid or avoidant personality
disorder because it helps them to break out of their social isolation. It is also recommended
to patients with histrionic and social disorders, these patients tend to act out and pressure
from peers in group treatment can motivate the change. The feeling of being included in
events and participating in group endeavour mean a great deal to these people, particularly
the schizoid personality who difficulties with object relations. The opportunity of relating to
other people also offer great resources for testing action patterns than the one to one
relationship with the therapist.

Selected persons are placed in a group 4-10 guided by a trained therapist to effect
personality change or to assist with problems affecting mental health.

Family therapy (Structure model-miuchin)

The therapist seeks to alter the family structure because of changes in the psychic
processes.

This may be suggest for patients whose personality disorders cause serious problems for the
members of their family especially for borderline from over involved or possessive families

The therapist uses joinery operations as he recreates communication patterns.

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Electro-Convulsive Therapy (ECT)

ECT is a series of treatment given under anaesthesia and muscle relaxants involving the
brain in order to produce convulsions.

It is indicted in severe cases of depression, psychoses, catatonic or mania.

 Behavioural changes are probably the result of biochemical changes in the brain
function.

 Treatment preparation involves physical examinations, lab tests, X-rays of spine, if

indicated, full information consent of patient, nothing by mouth after midnight,
voiding prior treatment and removal of dentures.

Other modalities of treatment

Sex therapy (master and Johnson)

Use of desensitising techniques to increase sexual pleasure and arousal, and to demystify
sex.

Assertive training

Teaching of skills to assist people in getting what they want in firm, effective and useful
manner as opposed to an aggressive manner in which emotions are expressed in
destructive, aggressive ways.

Token economy

Use of positive reinforcement in form of tokens and extinction of undesirable behaviour by

ignoring or being fined tokens to achieve behaviour change.

Hypnosis

Suggestion to induce state of altered consciousness or intense concentration to provide

additional data for diagnosis and treatment.

Medical management

The psychiatrist will assess the patient’s type of disorder and will also identify key areas of
maladaptive behaviour. The drugs may be prescribed for the different types of personality
disorders as follows:

112
Anti-psychotic drugs
Chlorpromazine (largactil)
DOSE – 25 – 100mgs in divided doses
ACTION - Unknown
Probably blocks synaptic dopamine receptors in the brain and inhibits the medullary
chemoreceptor triggers on. Drowsiness, dry mouth, jaundice, allergic reactions

Precaution
 Use cautiously in elderly or debilitate patient and in patient with hepatic or renal
disease.
 Do not withdraw drug abruptly unless required by severe adverse severe reaction
 Wear gloves when preparing solutions and prevent contact with skin and clothing
 Give deep im, and massage afterwards to prevent sterile abscess
Nursing consideration

Always give 5% Dextrose or Normal Saline.

Report decreased urine output.

2. Noradrenergic
Dosage: 2 – 4mg dilute with 48mls of 5% dextrose or normal saline stat
Route: intravenous (i.v.)
Mode of action: stimulates adrenergic receptors within the sympathetic nervous system.

Side effect: headache, hypertension, respiratory difficulties and restlessness. Peripheral

disorders.

Contra- indications: hypertension and in pregnancy

Nursing care
The long term goal of nursing care is helping the person to accept responsibility for and
consequences of his/her actions.
A short term goal aims at minimizing manipulation and acting out.
Problems
 Impaired social interaction resulting in argumentativeness, critical comments about
others
 Impaired verbal communication as a result of aloofness, excessive social anxiety and
fragmented speech patterns.
 Feeding self-care deficit as a result of lack of knowledge, inadequate living arrangements or
lack of interests and motivation
 Personal identity disturbance related to physical verbal abuse

113
  High risk for self mutilation related to absence of support as evidenced by cutting
wrists.

Problem one

High risk for self mutilation related to absence of support as evidenced by cutting wrists
Defensive coping related to low self esteem as evidenced by angry and labile emotions
Nursing interventions

 Monitor and set limits on acting out behaviours.

 Assist patient with identification and verbalisation of feelings
 Discuss fears about accepting responsibility for self and decision making
 Teach health coping behaviour
Problem two

Impaired social interaction resulting in argumentativeness, critical comments about others.

Nursing interventions.
 Use an objective matter of fact, approach client to help him identify the nurse as a reliable
person who will respect him without arguments.
 Keep verbal and non-verbal messages clear and consistent.
 Conduct brief one to one sessions daily to decrease fear and anxiety.
 Involve client in communication skills, group such as assertiveness training or any other
associations to help client gain awareness of personal behaviours
 Self-awareness is enhanced with non-threatening feedback.
 Contributing to isolation.
 Inform client of the emotional cues he is doing to other such as suspiciousness and
intimidation
Problem three

Impaired verbal communication as a result of aloofness, excessive social anxiety and fragmented
speech patterns.

Nursing intervention
 Encourage the client to select one activity for the group (in a support system), three times
weekly.
 Encourage the client to remain out of the room at least 4 hours daily.
 Encourage the patient to speak for 5 – 10 minutes without introducing circumstantial
material
Problem four

Feeding self-care deficit as a result of lack of knowledge, or lack of interests and motivation

114
Nursing Interventions
 Encourage the client to link up with fellow clients during meals, so as to promote
adequate nutrition and increased social interaction.
 Encourage client to eat 2 to 3 balanced meals everyday.
 Help client prepare a list identifying foods he/she eats and has access to daily.
 Teach client minimum daily requirements for an adequate diet and how to provide
these requirements from the foods currently used in the diet.
 Teach client how to chew small bite-sized pieces of food slowly.

PROBLEM FIVE

Personal identity disturbance related to physical verbal abuse

Nursing Intervention

1. Help client deal with loss of body image associated with history of abuse.
2. Help client examine belief systems and identify how perceptions and beliefs
influence responses.
3. Encourage client to write an autobiographical essay or story and give feed back if
able to read and write.
4. Encourage participation in a variety of group situations.
5. Provide step-by-step, concrete self-care instructions when the client is unable to
make decisions.
6. Teach female clients the appropriate use of cosmetics and encourage male clients to
shave frequently and care for facial hair.

Problem six

Ineffective individual coping as a result of self-doubt and the exclusion of self-pleasure

Nursing interventions
1. Encourage physical activity, this reduces tension and fosters relaxation.
2. Discuss with the client on how to recognized behaviour changes, this strengthens
self-awareness.
3. Help client identify coping methods to deal with stressful situations.
4. Help client identify feelings of anxiety generated in stressful situations and the usual
responses to this anxiety, future behaviour can be altered based on understanding
the past.
5. Teach clients how to use human in situations of stress, human and laughter, provide
a release of tension and anxiety.

115
 6. Encourage the client to maintain routine schedules and appointments, consistency
enhances trust and reduces anxiety.
Family involvement and others

The following are some of the collaboratory agents in the community.

1. The family providers both psychological and physical support.

2. Churches for skills, spiritual and financial counselling.
3. Mental association of Zambia.
4. Special schools in the community.
5. Social welfare department.
6. Rehabilitation centres within the communities

Preparation for discharge

The most obvious goal for in-patient or partial-hospital is to be an outpatient status.

Therefore, a critical focus of the inpatient stay should be establishing the involvement of
family members, signify others and follow up providers in discharge planning that increase
the potential for on-going care.

1. The Nurse must be knowledgeable about the patient’s environment.

2. Potential needs and resources should be identified on admission.
3. Once the Nurse has decided what knowledge, skills and behaviours will help the
patient adapt to the discharge environment, creative and purposeful activities can be
planned to provide the needed resources.
4. Information regarding supportive resources and medications should be provided to
patients and their families to encourage functional independence and decrease the
chores of relapse once discharged. This can significantly influence patient’s ability to
maintain adaptive coping responses.
5. Psychiatric discharge planning for personality disorders can be considered as part of
the psychiatric rehabilitation model that addresses biopsychosocial needs in a
manner similar to the physical rehabilitation process.
6. A discharge checklist can be used as an interdisciplinary tool to review the patient’s
discharge needs and include the patient in the planning process.
 Areas pertinent to discharge planning that should be included are:
 Medications
 Activities of Daily Living
 Metal Health Aftercare
 Residence
 Physical Health Care

116
 Special Education and the need for financial assistance also should be
reviewed with the patient and family.
 Strong communication linkages between hospital – based and community –
based providers are essential in order to ensure:
 Continuity of care.
 Minimize the value of hospital – based services and
 Minimize future admissions

117
Anxiety
Introduction

Everyone from time to time experiences fear and anxiety. Fear is an emotional, physical, and
behavioural response to an immediately recognizable external threat. Anxiety is a distressing,
unpleasant emotional state of nervousness and uneasiness; its causes are less clear. Anxiety is
less tied to the exact timing of a threat; it can be anticipatory before a threat, persist after a
threat has passed, or occur without an identifiable threat. Anxiety is often accompanied by
physical changes and behaviours similar to those caused by fear. Some degree of anxiety is
adaptive; it can help people prepare, practice, and rehearse so that their functioning is improved
and can help them be appropriately cautious in potentially dangerous situations. However,
beyond a certain level, anxiety causes dysfunction and undue distress. At this point, it is
maladaptive and considered a disorder.

Anxiety occurs in a range of physical and mental disorders, but it is the major symptom of
several. Anxiety disorders are more common than any other class of psychiatric disorder.
However, they often are not recognized and consequently not treated. Left untreated, chronic,
maladaptive anxiety can contribute to or interfere with treatment of some physical disorders.

Definitions
Anxiety: may be defined as a state of neurological arousal characterized by both physical and
psychological signs. Anxiety may be a normal reaction that acts as a signal to the body that
aspects of its systems are under stress or out of equilibrium.

Anxiety Disorder:
Anxiety disorders constitute being ‘the apprehensive anticipation of future danger or misfortune
accompanied by a feeling of dysphoria or somatic symptoms of tension are the most common
forms of psychiatric disorder (APA, 1994; Kessler et al., 2005).

118
Types of anxiety disorders
 Generalized Anxiety
 Panic disorder
 Phobias
 obsessive-compulsive disorder (OCD)
 posttraumatic stress disorder (PTSD)

Aetiology of Anxiety Disorders

The causes of anxiety disorders are not fully known, but both mental and physical factors are
involved. Many people develop anxiety disorders without any identifiable antecedent triggers.
The following are common etiological causes:

1. environmental stressors, such as the ending of a significant relationship

2. exposure to a life-threatening disaster
3. Hyperthyroidism
4. Pheochromocytoma
5. Hyperadrenocorticism
6. Heart failure
7. Arrhythmias
8. Asthma
9. Chronic Obstructive Pulmonary Disease
10. drugs; effects of corticosteroids, cocaine, amphetamines
11. Withdrawal from alcohol, sedative

Symptoms and Signs of Anxiety Disorders

Anxiety can arise suddenly, as in panic, or gradually over many minutes, hours, or even days.
Anxiety may last from a few seconds to years; longer duration is more characteristic of anxiety
disorders. Anxiety ranges from barely noticeable qualms to complete panic. The ability to
tolerate a given level of anxiety varies from person to person.

Sign and symptoms of Anxiety disorder

Physical signs
 Headache
 Muscle tension
 Back pain
 Abdominal pain
 Tremulousness or ―shakiness
 Fatigue
Psychological signs
 Feeling of dread

119
  Poor concentration
 Impaired sleep
 Impaired sexual desire

Generalized Anxiety Disorder

Definition

A condition characterized by 6 months or more of chronic, exaggerated worry and tension that is
unfounded or much more severe than the normal anxiety most people experience. People with
Generalized Anxiety Disorder usually expect the worst. They worry excessively about money,
health, family, or work, even when there are no signs of trouble. They are unable to relax and
often suffer from insomnia. Sometimes the source of the worry is hard to pinpoint. Simply the
thought of getting through the day provokes anxiety.

Causes

As with many mental health conditions, the exact cause of generalized anxiety disorder isn't
fully understood, but it may include genetics as well as other risk factors.

Predisposing factors

 Personality. A person whose temperament is nervous or negative or who avoids anything

dangerous may be more prone to generalized anxiety disorder than others are.
 Genetics. Generalized anxiety disorder may run in families.
 Being female. Women are diagnosed with generalized anxiety disorder somewhat more
often than men are

Symptoms

 Persistent worrying or obsession about small or large concerns that's out of proportion to
the impact of the event
 Inability to set aside or let go of a worry
 Inability to relax, restlessness, and feeling keyed up or on edge
 Difficulty concentrating, or the feeling that your mind "goes blank"
 Worrying about excessively worrying
 Distress about making decisions for fear of making the wrong decision
 Carrying every option in a situation all the way out to its possible negative conclusion
 Difficulty handling uncertainty or indecisiveness

Physical signs and symptoms may include:

 Fatigue
 Irritability

 Muscle tension or muscle aches

120
  Trembling, feeling twitchy

 Being easily startled

 Trouble sleeping

 Sweating

 Nausea, diarrheoa or irritable bowel syndrome

 Headaches

Symptoms in children and teenagers

 Feel overly anxious to fit in
 Be a perfectionist

 Redo tasks because they aren't perfect the first time

 Spend excessive time doing homework

 Lack confidence

 Strive for approval

 Require a lot of reassurance about performance

Tests and diagnosis

 Do a physical exam to look for signs that your anxiety might be linked to an
underlying medical condition
 Order blood or urine tests or other tests, if a medical condition is suspected

 Ask detailed questions about your symptoms and medical history

 Use psychological questionnaires to help determine a diagnosis

DSM-5 criteria for generalized anxiety disorder include:

 Excessive anxiety and worry about several events or activities most days of the week
for at least six months
 Difficulty controlling your feelings of worry

 At least three of the following symptoms in adults and one of the following in
children: restlessness, fatigue, trouble concentrating, irritability, muscle tension or
sleep problems

 Anxiety or worry that causes you significant distress or interferes with your daily life

 Anxiety that isn't related to another mental health condition, such as panic attacks or
post-traumatic stress disorder (PTSD), substance abuse, or a medical condition

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Treatments and drugs

The two main treatments for generalized anxiety disorder are psychotherapy and
medications.

Psychotherapy

Also known as talk therapy or psychological counseling, psychotherapy involves working

with a therapist to reduce your anxiety symptoms. It can be an effective treatment for
generalized anxiety disorder.

Cognitive behavioral therapy is one of the most effective forms of psychotherapy for
generalized anxiety disorder.

Medications
 Antidepressants. Antidepressants, including medications in the selective serotonin
reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI)
classes, are the first-line medication treatments. Examples of antidepressants used
to treat anxiety disorders include escitalopram (Lexapro), duloxetine (Cymbalta),
venlafaxine (Effexor XR) and paroxetine (Paxil, Pexeva). Your doctor also may
recommend other antidepressants.
 Buspirone. An anti-anxiety medication called buspirone may be used on an ongoing
basis. As with most antidepressants, it typically takes up to several weeks to become
fully effective.

 Benzodiazepines. In limited circumstances, your doctor may prescribe one of these

sedatives for relief of anxiety symptoms. Examples include alprazolam (Niravam,
Xanax), chlordiazepoxide (Librium), diazepam (Valium) and lorazepam (Ativan).
Benzodiazepines are generally used only for relieving acute anxiety on a short-term
basis. Because they can be habit-forming, these medications aren't a good choice if
you've had problems with alcohol or drug abuse.

Lifestyle

 Keep physically active. Develop a routine so that you're physically active most days
of the week. Exercise is a powerful stress reducer. It may improve your mood and
help you stay healthy. Start out slowly and gradually increase the amount and
intensity of your activities.
 Avoid alcohol and other sedatives. These substances can worsen anxiety.

 Quit smoking and cut back or quit drinking coffee. Both nicotine and caffeine can
worsen anxiety.

 Use relaxation techniques. Visualization techniques, meditation and yoga are

examples of relaxation techniques that can ease anxiety.

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 Make sleep a priority. Do what you can to make sure you're getting enough sleep to
feel rested. If you aren't sleeping well, see your doctor.

 Eat healthy. Healthy eating — such as focusing on vegetables, fruits, whole grains
and fish — may be linked to reduced anxiety, but more research is needed .

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Social Phobia/Social Anxiety Disorder

Definition

A phobia is an overwhelming and unreasonable fear of an object or situation that poses little
real danger but provokes anxiety and avoidance. Unlike the brief anxiety most people feel
when they give a speech or take a test, a phobia is long lasting, causes intense physical and
psychological reactions, and can affect ability to function normally at work or in social
settings.

Types of phobias

Phobias are distressing emotions initiated by out-of-proportion-fears, both real and

imaginary. To the sufferer, a phobia can seem unbearable or even life-threatening, while
others might find these strange and bizarre phobias quite fascinating

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Trypophobia – The fear of holes

Biological revulsion and culturally learned fears are the primary causes of Trypophobia,
which is the extreme and irrational fear of holes. While this fear might seem irrational to
‘normal’ people, the mere sight or thought of holes can set off a panic attack in the
Trypophobe. As a result, the individual avoids objects such as coral, sponges, skin, meat,
dried honeycombs and pretty much everything that has holes on it. Holes seem disgusting
and gross to the sufferer and s/he goes to all lengths to avoid it.

Aerophobia – The fear of flying

Aerophobia is the fear of flying which affects nearly 6.5% of the world’s population. The
phobia is usually associated with other fears including Agoraphobia (fear of being unable to
escape) and Claustrophobia (fear of small and restricted spaces). Naturally, the fear affects
the person’s professional and personal life as air travel is nearly impossible for him/her. The
mere thought of an upcoming flight can cause intense distress in the sufferer including
nausea, panic attacks, etc.

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Mysophobia – The fear of germs

Mysophobia is the excessive fear of germs which is often closely related to obsessive
compulsive disorder (OCD). Many people suffer from both OCD as well as Mysophobia, as a
result of which they might indulge in excessive bathing or hand washing. The unhealthy fear
of germs causes the phobics to also fear contamination of food or exposure to bodily fluids
from those around them. Mysophobia might lead to many complications since the person
goes to extreme lengths to avoid all kinds of social situations. Isolation is a common
symptom of this phobia. The condition might also give rise to other phobias such as
Agoraphobia as well as various anxiety disorders.

Claustrophobia – The fear of small spaces

Claustrophobia – the fear of small or restricted spaces. This phobia is mainly related to the
fear of suffocation or the fear of restriction.. Claustrophobia is often confused with
Cleithrophobia which is the extreme fear of being trapped.

Astraphobia – The fear of thunder and lightning

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Storms are a common occurrence in many parts of the world, and to an Astraphobic
individual, they can be downright debilitating. The majority of sufferers of Astraphobia are
children, although the phobia can persist into adulthood as well. Even the most ferocious
and wild animals have an extreme fear of thunder and lightning, and hiding is the natural
psychological defense. 

Cynophobia – The fear of dogs

Cynophobia, the extreme fear of dogs, is one of the most common animal phobias around
the world. The extreme fear of dogs is actually even more debilitating than the fear of
spiders and the fear of snakes due to the fact that dogs are commonly present in most
residential areas. Nearly 75% of Cynophobes are women, though the fear also affects men.
The condition usually begins in childhood, but many patients are also known to have
developed the fear in their adulthood.

Agoraphobia – The fear of open or crowded spaces

This is a debilitating condition which prevents the phobic from visiting malls, markets,
theaters and other crowded areas as well as open grounds. The individual feels intense
panic at the mere thought or sight of such a space (that s/he feels it will be difficult to
escape from). Agoraphobia becomes a vicious circle where the sufferer feels afraid of
experiencing a panic attack and these thoughts again lead to a panic attack. Limiting
activities and avoidance behavior becomes a part of the phobic’s life. Depression is hence a
common symptom of this phobia.

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Acrophobia – The fear of heights

Acrophobia is an irrational fear of heights or the fear of falling (even when the person is not
really that high up). It is a specific phobia that causes the sufferers to be highly agitated or in
a state of panic which could interfere with his/her ability to climb down.

Ophidiophobia – The fear of snakes

The fear of snakes or Ophidiophobia is the second most common

zoophobia affecting nearly 1/3rd of the adult human population. The fear of snakes also has
evolutionary roots. To an extent, the fear of venomous snakes is also essential for survival.

Arachnophobia – The fear of spiders

Arachnophobia (the excessive fear of spiders or other arachnids like scorpions) It is one of

the most common animal phobias around the world. The cause of the phobia is often
evolutionary meaning that some species of spiders are deadly and it is a natural human
response to survive. Arachnophobes however tend to go to extreme lengths to ensure that
their surroundings are free from spiders, often causing themselves a great deal of
embarrassment, which is something most phobics try hard to avoid.

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Not all phobias need treatment. But if a phobia affects your daily life, several therapies are
available that can help you overcome your fears — often permanently.

Predisposing factors

Age: Social phobia typically develops early in life, usually by age 13. Specific phobias first
appear in childhood, usually by age 10. Agoraphobia occurs most frequently in the late
teens and early adulthood, usually before the age of 35.
Genetics: Inherited tendency or children may learn phobias by observing a family member's
phobic reaction to an object or a situation.
Temperament: sensitive, more inhibited or more negative than the norm.
A traumatic event. Experiencing a traumatic event, such as being trapped in an elevator or
attacked by an animal, may trigger the development of a phobia.

Causes

Much is still unknown about the actual cause of phobias. However, there does appear to be
a link between phobias of patient and the phobias of parents. This could be due to genetics
or learned behavior.

Symptoms

Phobias are divided into three main categories:

Specific phobias. A specific phobia involves an irrational, persistent fear of a specific object
or situation that's out of proportion to the actual risk. This includes a fear of situations (such
as airplanes or enclosed spaces); nature (such as thunderstorms or heights); animals or
insects (such as dogs or spiders); blood, injection or injury (such as knives or medical
procedures); or other phobias (such as loud noises or clowns). There are many other types
of specific phobias. It's not unusual to experience phobias about more than one object or
situation.

Social phobia. More than just shyness, social phobia involves a combination of excessive
self-consciousness and a fear of public scrutiny or humiliation in common social situations.
In social situations, the person fears being rejected or negatively evaluated or fears
offending others.

Fear of open spaces (agoraphobia). This is a fear of an actual or anticipated situation, such
as using public transportation, being in open or enclosed spaces, standing in line or being in
a crowd, or being outside the home alone. The anxiety is caused by fearing no easy means
of escape or help if intense anxiety develops. Most people who have agoraphobia develop it
after having one or more panic attacks, causing them to fear another attack and avoid the

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place where it occurred. For some people, agoraphobia may be so severe that they're
unable to leave home.

Regardless of type of phobia it produces the following reactions:

 A feeling of uncontrollable panic, terror or dread when you're exposed to the source
of your fear
 The feeling that you must do everything possible to avoid what you fear

 The inability to function normally because of your anxiety

 Physical as well as psychological reactions, including sweating, rapid heartbeat,

difficulty breathing, a feeling of panic and intense anxiety

 Often, the knowledge that your fears are unreasonable or exaggerated but feeling
powerless to control them

 In some cases, anxiety just thinking about what you fear

 In children, possibly tantrums, clinging or crying

 Social isolation. Avoiding places and things you fear can cause academic,
professional and relationship problems. Children with these disorders are at risk of
academic problems and loneliness, and they may not develop good social skills.

 Depression. Many people with phobias have depression as well as other anxiety
disorders.

 Substance abuse. The stress of living with a severe phobia may lead to substance
abuse.

 Suicide. Some individuals with specific phobias may be at risk of suicide.

Tests and diagnosis

There are no lab tests for phobias. Instead, the diagnosis is based on a thorough clinical
interview and diagnostic guidelines. To be diagnosed with a phobia, you must meet certain
criteria in the Diagnostic and Statistical Manual of Mental Disorders published by the
American Psychiatric Association. This manual is used by mental health providers to
diagnose conditions and by insurance companies to reimburse for treatment.

Specific phobias

Diagnostic criteria for specific phobias include:

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  An intense fear or anxiety triggered by an object or situation, such as snakes, flying
or storms
 An immediate anxiety response when you confront the source of your fear

 Fear or anxiety that is irrational or out of proportion to the risk posed by the object
or situation

 Avoidance of the object or situation you fear, or endurance of it with extreme

distress

 Significant distress or problems with social activities, work or other areas of your life
due to the fear, anxiety and avoidance

 Persistent phobia and avoidance, usually lasting six months or longer

Social phobia (social anxiety disorder)

Diagnostic criteria for social phobia include:

 An intense fear or anxiety in one or more social situations where there is the
possibility of scrutiny by others
 Fear that you'll embarrass or humiliate yourself or be viewed negatively by others
with the possibility of rejection or offending others

 Intense anxiety, which may take the form of a panic attack, that almost always
results from exposure to social situations

 Avoidance of social or performance situations you fear, or endurance of them with

extreme distress

 Fear and anxiety that are out of proportion to any real risk of being viewed
negatively in the situation

 Problems or distress caused by the phobia that severely affect your life, including
your job, social activities and relationships

 Persistent phobia and avoidance, usually lasting six months or longer

Agoraphobia

Diagnostic criteria for agoraphobia include a severe fear or anxiety about two or more of the
following situations:

 Using public transportation, such as a bus, plane or car

 Being in an open space, such as a parking lot, bridge or large mall

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  Being in an enclosed space, such as a movie theater, meeting room or small store

 Waiting in a line or being in a crowd

 Being out of the home alone

In addition, diagnostic criteria for agoraphobia include:

 Fear or anxiety that almost always results from exposure to the situation
 Avoidance of the situations, required assistance of a companion or endurance of
situations with extreme distress

 Fear or anxiety that is out of proportion to the actual danger posed by the situations

 Significant distress or problems with social situations, work or other areas in life
caused by the fear, anxiety or avoidance

 Persistent phobia and avoidance, usually lasting six months or longer

Treatments and drugs

behavior therapy or both to treat phobias. Most adults don't get better on their own and
may require some type of treatment. The goal of phobia treatment is to reduce your anxiety
and fear and to help you better manage your reactions to the object or situation that causes
them.

Medications

Medications can help control the anxiety and panic from thinking about or being exposed to
the object or situation you fear.

 Beta blockers. These medications work by blocking the stimulating effects of

adrenaline on your body, such as increased heart rate, elevated blood pressure,
pounding heart, and shaking voice and limbs that are caused by anxiety. Short-term
use of beta blockers can be effective in decreasing symptoms when taken before an
anticipated event, for example, before a performance for people who have severe
stage fright.
 Antidepressants. Antidepressants called selective serotonin reuptake inhibitors
(SSRIs) are commonly used in the treatment of phobias. These medications act on
the chemical serotonin, a neurotransmitter in your brain that's believed to influence
mood. As an alternative, your doctor may prescribe another type of antidepressant,
depending on your situation.

 Sedatives. Medications called benzodiazepines help you relax by reducing the

amount of anxiety you feel. Sedatives need to be used with caution because they can
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 be addictive and should be avoided if you have a history of alcohol or drug
dependence.

Psychotherapy
 Desensitization or exposure therapy focuses on changing response to the object or
situation that you fear and may be helpful for phobias. Gradual, repeated exposure
to the cause of phobia may help learn to conquer anxiety. For example, if patient
afraid of elevators, go WITH PATIENT near an elevator encourage patient to step
into an elevator. Next, take a one-floor ride, and then ride several floors and then
ride in a crowded elevator.
 Cognitive behavioural therapy involves exposure combined with other techniques to
learn ways to view and cope with the feared object or situation differently. Learn
alternative beliefs about fears and the impact they have on life.

Treatment depends on the type of phobia:

 Specific phobias usually are treated with exposure therapy.

 Social phobias may be treated with exposure therapy or with antidepressants or
beta blockers.

 Agoraphobia, especially when it's accompanied by a panic disorder, is usually

treated with exposure therapy or with SSRIs.

Coping and support

Professional treatment can help overcome phobia or manage it

Try not to avoid feared situations.

 Reach out. Consider joining a self-help or support group where you can connect with
others who understand what you're going through.
 Take medication as directed.

 Selfcare : Get enough rest, eat healthy and try to be physically active every day.

Helping children cope with fears

Childhood fears, such as fear of the dark, of monsters or of being left alone, are common,
and most children outgrow them. But if child has a persistent, excessive fear that's limiting
child`s ability to function in daily life.

To help child cope with fears, do the following:

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  Talk openly about fears. Don't trivialize the problem or belittle the child for being
afraid. Instead, let the child know that you're there to listen and to help.
 Don't reinforce phobias. Instead, take advantage of opportunities to help children
overcome their fears. If the child is afraid of the neighbour’s friendly dog, for
example, don't go out of the way to avoid the animal. Instead, help child cope when
confronted with the dog.

 Model positive behaviour. Because children learn by watching, demonstrate how to

respond when confronted by something the child fears. Demonstrate fear and then
show how to overcome the fear.

NURSING MANAGEMENT

PROBLEMS NURSING GOALS NURSING EVALUATIONS

IDENTIFIED DIAGNOSIS INTERVENTIONS

Insomnia or Insomnia due to To establish -I will encourage my The patient has a

disturbed talking patient’s patients to sleep at normal sleeping
sleeping pattern continuously normal sleeping night and remove pattern and has
day and night pattern within any stimulant that no insomnia
manifested by one week of may precipitate him within one week
not sleeping admission to be talking of admission.
continuously like

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 onlookers.

-I will ensure that

the environment at
night is quiet and
conducive for
sleeping to promote
sleeping

-Prescribed drugs
will be given like
valium to promote
sleeping.

Risk of injury to Risk of injury to To create safe -I will ensure that all My patient has
himself and himself and environment for injurious things like not injured
others others related both the patient knives, sticks or anyone or himself
to and others chairs are removed within 48 hour of
hallucinations within 48 hours from the patient’s admission
manifested by of admission sight because he
threatening to might use those to
beat the young injure others or
ones at home himself

-I will ensure my
patient is put into
inclusions if he is
very violet.

Inadequate Inadequate To ensure my -I will encourage my My patient has

food intake food intake patient has patient to sit down adequate food
related to adequate food and eat food to intake within 24
talking intake within 24 promote adequate hours of
continuously hours of food intake admission.
admission
-I will ensure that
relatives bring his
food preference so
as to promote good
appetite.

Obsessive-Compulsive Disorder

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The essential feature of this disorder is recurrent obsessional thoughts or compulsive acts. (For
brevity, "obsessional" will be used subsequently in place of "obsessive-compulsive" when
referring to symptoms.) Obsessional thoughts are ideas, images or impulses that enter the
individual's mind again and again in a stereotyped form. They are almost invariably distressing
(because they are violent or obscene, or simply because they are perceived as senseless) and the
sufferer often tries, unsuccessfully, to resist them. They are, however, recognized as the
individual's own thoughts, even though they are involuntary and often repugnant. Compulsive
acts or rituals are stereotyped behaviours that are repeated again and again. They are not
inherently enjoyable, nor do they result in the completion of inherently useful tasks. The
individual often views them as preventing some objectively unlikely event, often involving harm
to or caused by him or herself. Usually, though not invariably, this behaviour is recognized by the
individual as pointless or ineffectual and repeated attempts are made to resist it; in very long-
standing cases, resistance may be minimal. Autonomic anxiety symptoms are often present, but
distressing feelings of internal or psychic tension without obvious autonomic arousal are also
common. There is a close relationship between obsessional symptoms, particularly obsessional
thoughts, and depression. Individuals with obsessive-compulsive disorder often have depressive
symptoms, and patients suffering from recurrent depressive disorder may develop obsessional
thoughts during their episodes of depression. In either situation, increases or decreases in the
severity of the depressive symptoms are generally accompanied by parallel changes in the
severity of the obsessional symptoms.

Obsessive-compulsive disorder is equally common in men and women, and there are often
prominent anankastic features in the underlying personality. Onset is usually in childhood or
early adult life. The course is variable and more likely to be chronic in the absence of significant
depressive symptoms.

Diagnosis

For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on
most days for at least 2 successive weeks and be a source of distress or interference with
activities.

The obsessional symptoms should have the following characteristics:

a) They must be recognized as the individual's own thoughts or impulses;

b) There must be at least one thought or act that is still resisted unsuccessfully, even though
others may be present which the sufferer no longer resists;
c) )the thought of carrying out the act must not in itself be pleasurable (simple relief of
tension or anxiety is not regarded as pleasure in this sense);
d) The thoughts, images, or impulses must be unpleasantly repetitive.

OBSESSIVE DISORDERS

Introduction

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It’s normal, on occasion, to go back and double-check that the iron is unplugged or your car
is locked. But in obsessive-compulsive disorder (OCD), obsessive thoughts and compulsive
behaviors become so excessive that they interfere with daily life. And no matter what you
do, you can’t seem to shake them. OCD consists of two components - obsessive thinking and
compulsive actions. It's possible to get the diagnosis without having both components. OCD
used to be thought of as involving intra-psychic conflict, but the modern Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) sees the condition as having complex
biological and psychological origins, and defines it in the following way:

Definition

Obsessive–compulsive disorder (OCD) is an anxiety disorder characterized by intrusive

thoughts that produce uneasiness, apprehension, fear, or worry, by repetitive behaviors
aimed at reducing anxiety, or by a combination of such thoughts/obsessions and
behaviors/compulsions (Mineka et al, 1998).

Types of obsessive compulsive disorders (OCDs)

In adults

Most people with obsessive-compulsive disorder (OCD) have both obsessions and
compulsions, but some people experience just one or the other. Often, the symptoms get
worse in times of stress.

1. Common obsessive thoughts in OCD

 Fear of being contaminated by germs or dirt or contaminating others

 Fear of causing harm to yourself or others
 Intrusive sexually explicit or violent thoughts and images
 Excessive focus on religious or moral ideas
 Fear of losing or not having things you might need
 Order and symmetry: the idea that everything must line up “just right.”
 Superstitions; excessive attention to something considered lucky or unlucky

2. Common compulsive behaviors in OCD:

 Excessive double-checking of things, such as locks, appliances, and switches.
 Repeatedly checking in on loved ones to make sure they’re safe.
 Counting, tapping, repeating certain words, or doing other senseless things to reduce
anxiety.
 Spending a lot of time washing or cleaning.
 Ordering, evening out, or arranging things “just so.”
 Praying excessively or engaging in rituals triggered by religious fear.
 Accumulating “junk” such as old newspapers, magazines, and empty food
containers, or other things you don’t have a use for.

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3. Obsessive-compulsive disorder (OCD) symptoms in children
While the onset of obsessive-compulsive disorder usually occurs during adolescence or
young adulthood, younger children sometimes have symptoms that look like OCD.
However, the symptoms of other disorders, such as autism, and can also look like
obsessive-compulsive disorder, so a thorough medical and psychological exam is essential
before any diagnosis is made. It’s also important to note that OCD is an anxiety disorder,
and in children, the symptoms o f anxiety usually changes over time. So a child with OCD
symptoms will not necessarily have OCD as an adult. What’s most important is to make
environmental and behavioral changes to reduce your child’s anxiety.

Attention –deficit and disruptive behavior disorders (ADD) occurs in children in whom
behavior is comprised of either attention deficit or hyper activity and impulsivity. It is due to
failure of brain mechanism for self control and inhibition of impulses or frontal lobe
executive functions. This may be in form of conduct disorderliness, oppositional defiant,
child antisocial and disruptive behavior.

Theories related to OCDs

1. Genetic theory

Ocd is thought to run in families. A mutation has been found in the human serotonin
transporter gene .moreover; data from identical twins supports the existence of a "heritable
factor for neurotic anxiety". Further, individuals with ocd are more likely to have first-degree
family members exhibiting the same disorders than do matched controls.

2. Biological theory

Ocd are associated with increased brain activity in the frontal lobe.

3. Biochemical theory

Ocd has been linked to abnormalities with the neurotransmitter serotonin. Serotonin is
thought to have a role in regulating anxiety by transmitting chemical messages from one
neuron to another and bind to the receptor sites located on the neighboring nerve cell.
Serotonin dysregulation(excess production of serotonin) is involved in the development of
ocd. This suggestion is consistent with the observation that many ocd patients benefit from
the use of selective serotonin reuptake inhibitors (ssris), a class of antidepressant
medications that allow for more serotonin to be readily available to other nerve cells.

Medical management

Diagnosis

1. Clinical features and history taking

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formal diagnosis may be performed by a psychologist, psychiatrist, clinical social worker, or
other licensed mental health professional. To be diagnosed with ocd, a person must have
obsessions, compulsions, or both, according to the diagnostic and statistical manual of
mental disorders (dsm).

2. Yale –Brown obsessive compulsive scale(Y-BOCS).

A standardized psychiatric rating scale is used, with measurements like these, psychiatric
consultation can be more appropriately determined because it has been standardized .

MEDICATION

Selective Serotonin Reuptake Inhibitors (SSRIs) such as: SSRIs prevent excess serotonin from
being pumped back into the original neuron that released it.

1. Fluvoxamine maleate

Dosage

adults: initial 50mg po hs; increase in 50mg increments at 4-7 day intervals (100-
300mg/day)

Children: initial 25mg po hs with daily increment of 25mg/day every 4-7 days

Geriatric/patients with hepatic impairment: 25mg po hs.

Action: selectively inhibits cns neuronal uptake of serotonin, blocks uptake of serotonin with
weak effect on norepinephrine, little affinity for muscurinic, histaminergic and alpha-
adrenergic receptors.

Side effects: headache, insomnia, anxiety, dizziness, sedation, abnormal gait, seizures,
sweating, rash, acne, alopecia, contact dermatits, nausea, vomiting, diarrhoea, sexual
dysfunction, impotence.

Contraindications: hypersensitivity, lactation,

Precaution: impaired hepatic or renal function, pregnancy and suicidal tendencies.

1. Tricyclic antidepressants

Clomipramine

Dose:

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Adult: initial 25mg po daily, gradually increase as tolerated to approximately 100mg

Children: 3mg/kg po daily with gradual increase

Action: inhibits presynaptic reuptake of neurotransmitters norepinephrine and serotonin,

antichorlinergic at cns and peripheral receptors, sedative.

Side effects: sedation, confusion, aggressive reaction, mania, delusions, disorientation,

hypertension, palpitations, heart block, hyper/hypoglycaemia, constipaion, urinary
retention, bone marrow depression, withdrawal symptoms, skin rash.

Caution: hypersensitivity, pre-existing cardiocascular disorders.

Other drugs:

Sedatives, benzodiazepines.

behavioral therapy (bt) or exposure & response therapy (erp)

This involves gradually learning to tolerate the anxiety associated with not performing the
ritual behavior. At first, for example, someone might touch something only very mildly
"contaminated" (such as a tissue that has been touched by another tissue that has been
touched by the end of a toothpick that has touched a book that came from a
"contaminated" location, such as a school.) The person fairly quickly habituates to the
anxiety-producing situation and discovers that their anxiety level has dropped considerably;
they can then progress to touching something more "contaminated" or not checking the
lock at all—again, without performing the ritual behavior of washing or checking. Exposure
ritual/response prevention (erp) has a strong evidence base. It is generally considered the
most effective treatment for ocd

Electroconvulsive therapy (ect)

electroconvulsive therapy (ect) has been found effective in severe and refractory cases

Nursing care

1. Family therapy

Because ocd often causes problems in family life and social adjustment, family therapy is
often advised. Family therapy promotes understanding of the disorder and can help reduce
family conflicts. It can also motivate family members and teach them how to help their
loved one. The nurse educates family members about the patient’s condition and explains

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that the patient needs social support from them as part of treatment. She further explains
the roles of the family in patient care as follows:

I) viewing patient’s obsessive-compulsive behaviors as symptoms, not character flaws. The

family should remember that their relative is a person with a disorder, but who is healthy
and able in many other ways and they should focus on the whole person.

Ii) not allowing ocd to take over family life. As much as possible, they should keep stress
levels low and family life normal.

Iii) not participating in patient’s rituals. In order for people with ocd to make progress,
family and friends must resist helping with ritual behaviors. Supporting the rituals, including
reassurance rituals, hinders progress.

Iv) communicating positively, directly and clearly. The family should state what they want
to happen, rather than criticizing their relative for past behaviors. Avoiding personal
criticism can help the patient feel accepted while he or she is making difficult changes.

V) mixing humor with caring. Support doesn’t always have to be serious. People with ocd
know how absurd their fears are. They can often see the funny side of their symptoms, as
long as the humor does not feel disrespectful. Humor from family members can often help
their relative become more detached from symptoms.

2. Group therapy

Group therapy is another helpful obsessive-compulsive disorder treatment. Through

interaction with fellow ocd sufferers, group therapy provides support and encouragement
and decreases feelings of isolation. The nurse links the patient and family to any ocd interest
groups nearby to allow them share experiences and challenges.

3. Self-help for ocd

The mental health nurse can teach patients with ocd and help them learn how to provide
self care by learning how to deal with obsessive thoughts and compulsive behaviors in the
following ways:

Educating self: the client should earn everything he/she can about ocd, read books on the
disorder and talk to your therapist and doctor in order to better able you will be to manage
your symptoms.

Practicing the skills learned in therapy. Using the skills you’ve learned in therapy, actively
work toward eliminating your obsessions and compulsive behaviors. This is a challenge that
requires commitment and daily practice.

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Staying connected to family and friends. Obsessions and compulsions can consume
patient’s life to the point of social isolation. In turn, social isolation can aggravate ocd. It’s
important to have a network of family and friends whom the patient can turn to for help
and support. Involving others in his/her treatment can help guard against setbacks and keep
him/her motivated.

Joining an ocd support group. This reminds the patient that he/she is not alone in his/her
struggle with ocd, and participating in a support group is an effective reminder of that. In a
support group, he/she can share experiences and learn from others who are going through
the same thing.

Practicing relaxation techniques. Meditation, deep breathing, and other stress relief
techniques may help reduce the symptoms of anxiety brought on by ocd. Mindfulness
meditation may be particularly helpful to ocd sufferers.

Post-Traumatic Stress Disorder

This arises as a delayed and/or protracted response to a stressful event or situation (either short-
or long-lasting) of an exceptionally threatening or catastrophic nature, which is likely to cause
pervasive distress in almost anyone (e.g. natural or man-made disaster, combat, serious
accident, witnessing the violent death of others, or being the victim of torture, terrorism, rape,
or other crime). Predisposing factors such as personality traits (e.g. compulsive, asthenic) or
previous history of neurotic illness may lower the threshold for the development of the
syndrome or aggravate its course, but they are neither necessary nor sufficient to explain its
occurrence.

Typical symptoms include episodes of repeated reliving of the trauma in intrusive memories
("flashbacks") or dreams, occurring against the persisting background of a sense of "numbness"
and emotional blunting, detachment from other people, unresponsiveness to surroundings,
anhedonia, and avoidance of activities and situations reminiscent of the trauma. Commonly
there is fear and avoidance of cues that remind the sufferer of the original trauma. Rarely, there
may be dramatic, acute bursts of fear, panic or aggression, triggered by stimuli arousing a sudden
recollection and/or re-enactment of the trauma or of
the original reaction to it. There is usually a state of autonomic hyperarousal with hyper
vigilance, an enhanced startle reaction, and insomnia. Anxiety and depression are commonly
associated with the above symptoms and signs, and suicidal ideation is not infrequent. Excessive
use of alcohol or drugs may be a complicating factor. The onset follows the trauma with a latency
period which may range from a few weeks to months (but rarely exceeds 6 months). The course
is fluctuating but recovery can be expected in the majority of cases. In a small proportion of
patients the condition may show a chronic course over many years and a transition to an
enduring personality change.

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Essentials of Diagnosis

This disorder should not generally be diagnosed unless there is evidence that it arose within 6
months of a traumatic event of exceptional severity. A "probable" diagnosis might still be
possible if the delay between the event and the onset was longer than 6 months, provided that
the clinical manifestations are typical and no alternative identification of the disorder (e.g. as an
anxiety or obsessive-compulsive disorder or depressive episode) is plausible. In addition to
evidence of trauma, there must be a repetitive, intrusive recollection or re-enactment of the
event in memories, daytime imagery, or dreams. Conspicuous emotional detachment, numbing
of feeling and avoidance of stimuli that might arouse recollection of the trauma are often present
but are not essential for the diagnosis. The autonomic disturbances, mood disorder, and
behavioural abnormalities all contribute to the diagnosis but are not of prime importance.

Treatment of Anxiety Related Conditions

Counselling Interventions for Anxiety-Related Conditions

Managing any type of anxiety involves first an awareness of factors that may underlie the anxiety
and an ability to recognize signs of anxiety. Specific techniques can then be used to reduce the
anxiety. Techniques will vary depending on the type of anxiety disorder one experiences – that is,
some techniques may be better for certain types of anxiety (e.g. graded exposure is particularly
helpful for phobias). In addition, one does not necessarily have to have a disorder to benefit from
using an intervention (e.g. the breathing and relaxation exercises can be useful for calming nor-
mal anxiety).

Step 1 – Understanding factors that underlie anxiety

Understanding where anxiety may stem from may help some individuals put their reactions to
stress in perspective. Having a perspective about stress is important to control subsequent
anxiety feelings. Factors underlying anxiety may include:

a) The structure and composition of an individual‘s nervous system (e.g. family genetics).
b) Environmental influences (e.g. the expression of emotion encouraged in the family, school, or
social settings).

Step 2 – Identifying specific anxiety symptoms

Patients should be encouraged to identify their anxiety by making a list of the people, places and
situations that make them uncomfortable (i.e. feel increased stress) or avoidant. The patient
should also indicate the specific anxiety feelings that are experienced in these circumstances.

Step 3 – Reducing anxiety using specific techniques

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To reduce anxiety, one may apply techniques including muscle relaxation, breathing exercises,
problem-solving, managing negative thinking, and graded exposure. Details for each of these
techniques have been outlined in the following pages. Different techniques may be effective for
different types of anxiety disorders.

Breathing Exercise

(May be especially useful for panic/agoraphobia; generalized anxiety; phobias; social

phobia/anxiety; post-traumatic and acute stress). Shortness of breath is a common feeling that
many people get when anxious. When one feels out of breath the natural tendency is to breathe
in more or faster. This can lead to hyperventilation which can make anxiety worse. An effective
way to manage abnormal breathing when anxious is to do the following:

Breathe in slowly to the count of three.

Breathe using your abdomen instead of the chest.

When you get to three, slowly breathe out to the count of three seconds.

Pause for three seconds then breathe in again for 3 seconds.

Continue this exercise for five minutes.

Practice twice a day.

Medication Therapy for Anxiety-Related Conditions

General

Treatments vary for the different anxiety disorders, but typically involve a combination of
psychotherapy and drug treatment.

a) The benzodiazepine class of medication is commonly used for anxiety but caution should be
used in prescribing since tolerance, dependence, and serious withdrawal may occur. Use of the
benzodiazepines in short-term is usually recommended.
b) For chronic anxiety conditions (e.g. panic disorder, obsessive-compulsive disorder, generalized
anxiety disorder, post-traumatic stress, and social anxiety disorder) other agents such as the
tricyclic imipramine may be used.

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 Recommended Dosage Ranges for the Treatment of Anxiety Disorders

Effective
Dose Side Effects and
Medication Starting Dose Range Contraindications Comment
For intermittent anxiety disorders,
2-5mg every 8-12hrs on an as
needed basis; safe to increase dose by 2-5mg
every 1-7 days until effect is observed.

For Generalized Anxiety Disorder 2-5mg

daily; Onset in 20-30minutes;
safe to increase dose by 2-5mg every 1-7 Sedation; respiratory
Long-acting;
days 2-20mg depression; Has addiction
Diazepam until effect is ob-served daily delirium potential

For panic disorders, 25-50mg daily;

safe to increase dose by 25-50mg
every 3-7days
to 150mg daily;
If blood test is not available,
monitor for symptoms of
toxicity and adjust accordingly;
may be given in divided doses . 150-300mg
daily;
requires
therapeutic
For Social Anxiety Disorder blood level *If blood test is
25-50mg daily; safe to increase dose monitoring not avail-able,
by 25-50mg every 3-7days to 150mg daily; ; (if blood Sedation; arrhythmia;
monitor for symptoms of
If blood test is not available, test is constipation; toxicity
monitor for symptoms of available, urinary retention; (flu; fever; muscle/joint
toxicity and adjust accordingly; therapeutic May make a seizure moreaches;
may be given in divided doses. blood level possible in patients with
nausea or vomiting
should be an existing abnormal HR;
Imipramine >225ng/ml) seizure disorder delirium
For Compulsive Obsessive Disorder, 25mg qhs-
50mg bid;
safe to increase dose by 25-50mg every 3-7
days to 50mg-200mg daily; Sedation; constipation;
Clomipramin monitor for 2-4 weeks before additional 50-200mg urinary retention; Used for Obsessive-
e increases daily arrhythmia Compulsive Disorder
For all anxiety disorders ,
25-50mg daily; safe to increase dose by 25-
50mg every 3-7days to 50-100mg daily;
monitor for 4 weeks before additional gastrointestinal distress;
Sertraline increases; usually given as a single dose delayed ejaculation

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Panic Attacks and panic Disorders

A panic attack is the sudden onset of a discrete, brief period of intense discomfort, anxiety, or
fear accompanied by somatic or cognitive symptoms. Panic disorder is occurrence of repeated
panic attacks typically accompanied by fears about future attacks or changes in behaviour to
avoid situations that might predispose to attacks. Diagnosis is clinical. Isolated panic attacks may
not require treatment. Panic disorder is treated with drug therapy, psychotherapy (eg, exposure
therapy, cognitive-behavioural therapy), or both.

Panic attacks are common, affecting as many as 10% of the population in a single year. Most
people recover without treatment; a few develop panic disorder. Panic disorder is uncommon,
affecting 2 to 3% of the population in a 12-mo period. Panic disorder usually begins in late
adolescence or early adulthood and affects women 2 to 3 times more often than men.

Symptoms and Signs

A panic attack involves the sudden onset of at least 4 of the 13 symptoms listed in Table [Link].

 Symptom
 Cognitive
 Fear of dying
 Fear of going crazy
 Feeling of unreality strangeness
 Cognitive
 Fear of dying
 Fear of losing control
 Feeling of choking
 Flushes or chills
 Nausea or abdominal distress
 Numbness or tingling sensations
 Palpitations or accelerated heart rate
 Sensations of shortness of breath or smothering
 Sweating

Symptoms usually peak within 10 min and dissipate within minutes thereafter, leaving little for a
physician to observe.
Panic attacks may occur in any anxiety disorder, usually in situations tied to the core features of
the disorder (eg, a person with a phobia of snakes may panic at seeing a snake).

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Treatment

Many drugs can prevent or greatly reduce anticipatory anxiety, phobic avoidance, and the
number and intensity of panic attacks:

 Benzodiazepines: These anxiolytics work more rapidly than antidepressants but are more
likely to cause physical dependence and such adverse effects as somnolence, ataxia, and
memory problems.
 Antidepressants plus benzodiazepines: These drugs are sometimes used in combination
initially; the benzodiazepine slowly tapered after the antidepressant becomes effective.
Panic attacks often recur when drugs are stopped.

Different forms of psychotherapy are effective. Exposure therapy, in which patients confront
their fears, helps diminish the fear and complications caused by fearful avoidance. For example,
patients who fear that they will faint during a panic attack are asked to spin in a chair or to
hyperventilate until they feel faint, thereby learning that they will not faint during an attack.
Cognitive-behavioral therapy involves teaching patients to recognize and control their distorted
thinking and false beliefs and to modify their behavior so that it is more adaptive. For example, if
patients describe acceleration of their heart rate or shortness of breath in certain situations or
places and fear that they are having a heart attack, they could be taught the following:

 Not to avoid those situations.

 To understand that their worries are unfounded.

 To respond instead with slow, controlled breathing or other methods that promote
relaxation.

Treatment of Panic Attacks

Medication

IMIPRAMINE

25-50mg daily; safe to increase dose by 25-50mg every 3-7days to 150mg daily;
If blood test is not available, monitor for symptoms of toxicity and adjust accordingly;may be
given in divided doses
150-300mg daily; requires therapeutic blood level monitoring; (if blood test is available,
therapeutic blood level should be >225ng/ml)

DIAZEPAM

2-5mg daily; safe to increase dose by 2-5mg every 1-7 days until effect is ob-served
2-20mg daily
Sedation; respiratory depression; delirium

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Depression
Depression is a sense of hopelessness, in which the world seems totally unresponsive to one’s
effort to meet one’s needs (Shives:1990) According to Mendls "the central symptoms of
depression are sadness, pessimism, self dislike along with loss of energy, motivation and
concentration".

Reactive Depression:
Reactive depression is commonest type of depression It may be caused by a reaction to external
events such as loss of a loved one or a disaster. It is not usually responsive to physical therapies
i.e. drug and ECT. It is not genetically determined or it does not occur in cycles or reoccur, and it
is usually milder than the endogenous depression.

Clinical features of depression

Regardless of age the classification of depressions are more alike than different. Their clinical
features include changes of mood, thought behavior and appearances. In addition depressives
are often characterized by somatic symptoms as well as anxiety. The following are clinical
features of depression
Mood: Sad, unhappy, blue and crying
Thought: Pessimism, ideas of guilt, self dislike loss of interest and
motivation, decrease in efficiency and concentration.
Behavior and appearance:
- Neglect of personal appearance
- Psychomotor retardation or agitation
Somatic:
- Loss of appetite or voracious appetite
- Loss of weight or over weight
- Constipation
- Poor sleep (insomnia or hypersomnia)
- Aches and pains
- Menstrual change in female patients
- Loss of libido
Anxiety features: such as
- Palpitation
- Sweating
- Tremor
- Suicidal thoughts, threats and attempts or self destruction
behavior etc
- Psychomotor retardation
- AgitationSad face
- Stooped posture
- Crying at intervals
- Slow speech
- Dejected mood
- Diurnal mood variation
- Suicidal wishes
- Indecisiveness

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- Hopelessness
- Inadequacy
- Conscious quiet
- Loss of interesLoss of motivation
- Fatigability
- Disturbed sleep (early morning awaking)
- Loss of appetite
- Constipation

Treatment Amitriptyline (elavil) 75 - 200 mg/d in divided dose

1. Imipramin (tofranil)75 - 300 mg/d in divided dose
2. ECT (Electroconvulsive therapy)

Nursing interventions for depression

Persons who are depressed may be difficult to communicate with or approach. Isolation,
withdrawal, ambivalence, hostility, guilt or impaired thought processes are but a few symptoms
that can interfere with the development of a therapeutic relationship. The manic patient’s
hyperactivity, pressured speech, and manipulation also interfere with attempts at
communication.

The nurse must be aware of personal vulnerability to depressive behavior: working with such
persons may cause one to react to the depressed atmosphere and in turn experience symptoms
of
depression. The following is a list of attitudes that the nurse should display toward
depressed and manic persons:
1. Acceptance
2. Honesty

Empathy
4. Patience
Assessment focuses on mood, affect, behavior, and appearance.
Body language may replace communication skill because the person is unable to convey feelings
of anger, hostility and ambivalence.
Questions the nurse can ask the patient to assess the level of depression, while observing facial
expression, body posture, tone of voice, and overall appearance, include the following:
1. Do you have difficult falling asleep at night?
2. Do you wake in the middle of the night?
3. If so, are you able to return to sleep?
4. Do you wake earlier than usual in the morning?
5. Are you alert or depressed when you get up in the morning?
6. Do you sleep excessively?
7. Have you been experiencing feelings of worthlessness, self reproach, or guilt?
8. Do you have difficult concentrating or making decisions?
9. Can you watch an entire movie or television show?
10. Does your mood change or fluctuate during the day?
11. Has your sex drive lessened?

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12. Are you frequently constipated?
13. Has your energy level decreased?
14. Have you lost interest in life?
15. Has there been a change in your appetite?
16. Do you feel alienated from those around you?
Have you ever considered or attempted suicide? (If so, ask the patient when and whether s/he
has a plan at present.)

Simple activities are most effective for a person with a short attention span or an inability to
concentrate. Completion of such tasks enhances the person’s self-concept because they feel
more worthwhile after the job is done. The nurse must also consider the person’s energy level;
the more energy the task requires, the less energy s/he will have to engage in hostile, aggressive
behavior. Protective care may be necessary for the manic as well as for the depressed person.
Persons who exhibit manic behavior may injure themselves owing to excessive motor activity,
inability to concentrate, distractibility and poor judgment. Their destructive tendencies may
include self-inflicted and accidental injury. They also may provoke self-defensive actions
unintentionally from others who fear injury. Assisting with electro convulsive or electric shock
therapy is another nursing intervention while caring for depressed patients. Such persons are
given a complete physical examination before treatment.
The nurse’s role before treatment is to withhold breakfast and to administer and anti cholinergic
medication to decrease or dry up body secretions to lessen chances of aspiration, to provide
supportive care, and to assist with the treatment and monitor the person’s responses during a
recovery period that usually lasts from a half hour to one
hour. Patient education is another nursing intervention for depressed and manic persons. Such
persons should be informed about the importance of outpatient treatment as well as the
continuation of prescribed drugs. They may relapse if they discontinue the drugs.
They should be taught to recognize the onset of side effects, as well as the recurrence of
symptom, to avoid re-hospitalization. A person diagnosed as having bipolar depression, mixed
type, should be helped to describe the changes in affect and behavior in the initial phases of his
illness.

Another aspect of nursing care is being supportive during psychotherapy sessions. The person
may have difficulty expressing feelings of hostility, ambivalence, and guilt. Feelings of anxiety
may occur or increase as the person begins therapy sessions. Such sessions may be directed at
exploring feelings about self and the patient’s relationship with the environment in an attempt to
improve his or her self-esteem and decrease feelings of helplessness, hopelessness, and
powerlessness. The nurse can be supportive simply by making him or herself available to the
patient and by recognizing symptoms such as anxiety.

Nursing diagnoses and nursing interventions for depressed

NURSING DIAGNOSES NURSING INTERVENTIONS

Suicide precautions. It is advisable to follow
suicide rating scale for protective care of the
Potential for injury: Suicidal ideation suicidal patient.
Social isolation Establish trust. Assign the same staff
members to work with the person whenever

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 possible. Accept the patient as he or she is.
When approaching the person, avoid being
overly cheerful, sympathetic or superficial.
Display empathy. Use therapeutic
communication skills such as silence and
active listening. Encourage ventilation of
feelings.
Observe for signs of fatigue. Provide
opportunities for rest. Set limits regarding
time to arise in morning and the amount of
time spent in bed during the day. Decrease
external stimuli before hour of retiring. Offer
warm milk and backrub at bedtime.
Administer prescribed medication for
Dysrhythmia of sleeprest activity insomnia
Monitor Input and output. Provide a high
protein, high-calorie diet as needed. Attempt
to include the patient’s favorite foods.
Provide frequent, nutritional snacks in the
form of finger foods. Encourage adequate
Alterations in nutrition: Less than body fluid intake. Offer high calorie drinks. Weigh
requirements the patient weekly or as ordered.
Monitor Input and output. Encourage the
intake of fluids. Encourage exercise. Provide
Alternation in bowel elimination: bulk and fiber in diet. Administer laxatives as
Constipation needed.
Involve in activities directed toward raising
self-esteem. Display a sincere interest and
offer praise or recognition for
Alteration in self-concept accomplishments.
Decrease or limit environmental stimuli.
Provide. Adequate room for hyperactivity.
Provide private. Room if necessary, to reduce
external stimuli. Limit social interactions
initially to prevent intrusive behavior. Select
activities that provide an outlet for excessive
Activity intolerance because of energy yet do not trigger loss of control.
hyperactivity Administer drugs as ordered to decrease
and distractibility hyperactivity.
Give simple explanations regarding hospital
routine and nursing care. Contact the patient
frequently but briefly to reassure him or her.
Set limits and be consistent. Avoid arguing
Manipulation with the patient.

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CHILD BIRTH AND MENTAL HEALTH

The birth of a child can be a very joyous and exciting time but following child birth, some women may
experience post partum disorders that can adversely affect a woman’s mental health. Mothers
commonly experience what is called baby’s blues mood swings that are the result of high hormonal
infatuations that occur during and immediately after child birth. They may also experience more
serious mental health disorders such as;
Post partum depression.
Birth related post traumatic stress disorder or a severe but rare condition called post partum
psychosis
In general, clinical depression occurs in approximately 15 to 25 percent (%) of the population and
women are twice as likely as men to experience depression. Because women are likely to experience
depression during the primary reproductive years (25 to 45), they are especially vulnerable to
developing depression during pregnancy and after child birth, women who develop these disorders
do not need to feel ashamed or alone treatment and support are available.
WHAT ARE POST PARTUM BLUES OR BABY BLUES?
Post partum blues are very common, occurring in up to 80% of new mothers characterized by mood
swings. Post partum post partum blues or baby blues are normal reactions that many mothers
experience following child. The onset of post partum blues usually occurs three (3) to five (5) days
after delivery and should subside as hormone levels begin to stabilize.
Symptoms generally do not last for more than few weeks, if a person continues to experience mood
swings or depression for more than two weeks after child birth the problem may be more serious.

WHAT IS POST PARTUM DEPRESSION (PPD)?

PPD is a major form of depression and less common that post partum blues. PPD includes all the
symptoms of depression but occurs only following child birth. It can begin any time after delivery and
can last up to a year. PPD is estimated to occur approximately 10 to 20% of new mothers.
WHAT ARE SYMPTOMS OF PPD?

Symptoms of PPD are the same as those of clinical depression and may include specific fears such as
excessive preoccupation with the child’s health or inclusive thoughts of harming the baby.

Given the stressful circumstances of caring for a new baby, it is understandable that new mothers
may be more tired, irritable and anxious. But when new mother is experiencing drastic changes in
motivation, appetite or mood she should seek the help of a mental professional. For clinical diagnosis
of post partum to be made, symptoms for PPD generally must be present for more than two weeks
following child birth to distinguish them from post partum blues.

CONTRIBUTING FOCTORS TO PPD

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The causes of PPD are not quite clear but research suggests that the following factors may contribute
to the onset of PPD:

- Hormonal changes; the woman experiences the greatest hormonal fluctuations, such as
serotonin levels, occur after delivery and may play a role in the development of PPD.
- Situational risks; child birth itself is a major life change and transition and big changes can
cause at great deal of stress and result in depression. If a major event coincides with child
birth, a mother may be more susceptible than average to PPD.
- Life stresses; on going stressful circumstances can compound the pressures of having a new
baby and may trigger PPD. For example stresses at the office added to the responsibilities of
being a mother can cause emotional strain that could lead to PPD.
- The nature of the mother’s relationship with the baby’s father and any unresolved feeling
about the pregnancy might also affect a mother’s risk of getting PPD.

AVAILABLE TREATMENT

- Taking antidepressant medication may help alleviate the symptoms of PPD and should be
combined with on going counseling with a therapist trained in issues surrounding child birth.
Studies show that some antidepressant medications have no harmful effects on the breast
feeding infants. Psychotherapy alone may also be used to treat PPD. New mothers should be
encouraged to talk about their feelings or fears with others.

- Socializing through support groups and with friends can play a critical role in recovery.
Exercise and good nutrition may improve a new mother’s mood and also aid in recovery.
Caffeine should be avoided because it can trigger anxiety and mood changes.

CAN PPD LEAD TO OTHER PROMBLEMS?

- When a new mother has severe depression the vital mother-child relationship may become
strained. She may be less able to respond to her child’s needs, several studies have now
shown that the more depressed the new mother is, the greater the delay in the infant’s
development. A new mother’s attention to her newborn is particularly important immediately
following birth because the first year of life is critical time in cognitive development.

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 IS PPD PREVENTABLE?

 In most cases PPD is preventable, early identification can lead to early treatment.
 A major part of prevention is being informed about the easy factors and medication
community can play a key role in identifying and treating PPD.
 Because of social support is vital in prevention. Early identification of mothers who are at risk
can enable a woman to seek support from physicians, partners, friends and co-workers.

WHAT IS BIRTH RELATED POST TRAUMATIC STRESS DISORDER (PTSD)?

 After child birth women may also experience post traumatic stress disorder (PTSD). PTSD
includes two key word elements:
 Experiencing or witnessing an event involving actual or threatening dangers to themselves or
others.
 Responding with intense fear, helpless or horror.

Symptoms of birth related PTSD may include:

 Obsessive thought about the birth.

 Feelings of panic when near the site where the birth occurred.

POST PARTUM PSYCHOSIS

 Feeling of numbness and detachment.
 Disturbing memories of the birth experience.
 Night mares.
 Flash backs.
 Sadness, fearfulness, anxiety or irritability
 In rare cases, women may experience post partum psychosis (PPP). A condition that affects
about one-tenth of percent of new mothers. Onset is quick and severe and usually occurs
within the first two to three weeks following child birth. Symptoms are similar to those of
general psychotic reactions such as delusion (false beliefs) and hallucination (false perception)
often include;
 Physical symptoms; refusal to eat/inability to cease activity frantic energy.
 Mental symptoms; extreme confusion, memory loss, incoherence.
 Behavioral symptoms; paranoia irrational statements, preoccupation with typical things.
 A woman who is diagnoses with PPP should be hospitalized until she is in a stable condition.
Doctors may prescribe a mood stabilizer, antipsychotic or antidepressant medications to treat
PPP. Mothers who experience PPP are high likely to suffer from it again in there next
pregnancy.

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COMMUNITY PSYCHIATRIC

Community psychiatric/mental health can be best described as movement in an ideology or

perspective that promotes earl comprehensive mental treatment in a community, assessable to all
including children and adolescents.
Community psychiatric starts from the discharge and how the participate in the mental health of the
patient.
ASSISTED-LIVING OR ADULT DAY CARE SELF HELP GROUPS
SKILLED NURSING OR OTHER
FACILITY RESOURCES

DISCHARGING PLANNING
AFTER CARE OR
DETERMINES LEVELS OF
REHABILITATION AT
COMMUNITY MENTAL
SUB ACUTE CARE COMMUNITY
HEALTH SERVICES
UNIT MENTAL HEALTH

HOME HEALTH CARE RESIDENTIAL

TREATMENT

ASSOCIATION

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When clients are discharged from psychiatric hospital, the community mental health care provides
support and rehabilitation for the client. Many of this require minimal support with weekly or bi
weekly individual or family therapy and medication evaluations.

Pacts (program for assertive community treatment also called “ACT”. This is the service delivery
model that provides comprehensive locally based treatment to clients with seasons and persistant
mental illness. Pact provides high individual services. The key is to treat psychiatric disorders.

REHABILITATION

This is the program that helps the mental patients at least reform them to normal behavior as they
used to and perform to their capacities e.g. behaviorally oriented skills teaching, supported
employment and support for resuming education.

CHURCHES

The church all in all needs to help in the taking care of these patients by showing love to them and
educate the community members in church to love and accept them.

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Definition

It is a severe mental disorder in which thought and emotions are impaired that contact is lost with external
reality

Or

It is a serious mental disorder characterized by thinking and emotion that are so impaired that they

Causes of psychosis

The causes of psychosis have been divided into three [3] main classes. These are;

 psychological [mental] conditions

 General medical conditions e.g. malaria, syphilis and HIV
 substances such as alcohol and drugs

Psychological conditions

The following conditions have been known to trigger psychotic episodes in some people

 schizophrenia; a chronic [long term] mental condition that causes hallucinations and delusions
 Bipolar disorder ; a condition that affects a person’s mood ,which can swing from one extreme to
another[highs and lows].
 severe stress and anxiety
 severe depression; feelings of depression and sadness that last for more than six weeks including post
natal depression which some women experience after delivery
 lack of adequate sleep

GENERAL MEDICAL CONDITIONS

These are known to trigger psychotic episodes in some people.

 HIV/AIDS; a virus that attacks the immune system[the body’s natural defense against illness and
infection]
 Malaria; a tropical disease spread by an infected female anopheles mosquito
 Syphilis; a bacterial infection that’s usually passed on through sexual contact
 Parkinson’s disease ;a long term condition that affects the way the brain co-ordinates body
movements including walking, talking and
 Hypoglycemia; abnormally low sugar levels in blood
 Brain tumors ;a growth of cells in the brain that multiply in an abnormal or uncontrollable way

SUBSTANCES

Alcohol misuse and drugs can trigger a psychotic episode.

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A person can also experience a psychotic episode if they suddenly stop drinking alcohol or taking drugs after
having used them for a long time. This is known as withdrawal.

Drugs known to trigger psychotic episodes include;

 cocaine
 amphetamine
 methamphetamines [crystal meth]
 mephedrone [MCAT]
 cannabis
 ketamine

SIGNS AND SYMPTOMS

 Hallucinations; a person perceives something that doesn’t exists in reality. It occurs in live senses i.e.
sight, sound, touch, smell and taste
 Delusions; an idiosyncratic belief or impression that is not in accordance with a generally accepted
reality.
 confused and disturbed thoughts; people with psychosis often have disturbed or confused and
disrupted patterns of thought
 lack of insight and self awareness; people who have psychiatric episodes are often totally immature.
Their behavior is in any way strange
 Depression

MANAGEMENT

INVESTIGATIONS

 Medical history and physical examination

 To identify pos
 CT scan
 MRI
 ECG
 CBC
 Pregnancy test
 RPR
 Liver function test

TREATMENT

ANTI PSYCHOTIC DRUGS

Haloperidol

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Phenothiazine

Chlorpromazine

Fluphenazine

Ileperidone

MECHANISM OF ACTION

All anti-psychotic drugs are more effective than placebo in treating symptoms of psychosis but some people
do not respond fully to the treatment. They work by affecting the work of dopamine a neurotransmitter in the
brain by blocking its receptor sites helping patient calm down.

SIDE EFFECTS

Drowsiness, stiffness and shaking

PSYCHOLOGICAL THERAPIES

BEHAVIORAL THERAPY

These are techniques based on learning theories that are used in order to distinguish normal behavior to
abnormal behavior

COGNITIVE BAHAVIOR THERAPY

Its development was prompted by observation of psychotic patients, how they conduct themselves and view
themselves negatively, their future and environment, Hence this therapy is based on idea that disorder is not
caused by events but by how patient handles the event e.g. loss of a loved one , disappointment from the
loved one

RATIONAL EMOTIVE THERAPY

It proceeds by guiding the patient to identify challenges and change their irrational thought. These can be
viewed as a series of “I MUST” behavior in relation to on self, others and the environment e.g. The feeling of I
must be better that everyone else all the time failure to which patient feels worthless and not good enough

INTERPERSONAL THERAPY

This focuses on current inter personal relationships and their relationship to development of illness.
Interventions are directed at dysfunction in social relationship’s rather than underlined belief. Treatment is
inventory for all close relationships and focus is on role transitions e.g. new mother, work difficulties and
relationship problems

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AFFECTIVE DISORDERS

INTRODUCTION

Mood disorders, previously termed ‘affective disorders’, are mental disorders in which the
prominent aspect is a disturbance of affect, mood, or feelings. Mood, like the weather, is
always changing. Individuals with mood disorders also can display dysfunctions in
physiological systems such as arousal, food intake, reproduction, circadian rhythms, and
pituitary regulation. Affective disorders are the most important psychiatric syndromes in
medical practice. Depression and Mania being the commonest. They are the most common
public health problems in Zambia. This is against a background of various challenges facing
the people, such as a rise in poverty levels, the spread of HIV/AIDS, unemployment, gender
based physical and sexual violence and a rising number of street and drug abused children.
They commonly occur among general medical patients and are often unrecognised until
serious complications occur. The recognition of these syndromes and accurate differential
diagnosis are crucial because effective treatment can be easily instituted.

DEFINITION OF TERMS

Mood

- is a prolonged emotional state that influences person’s whole personality and life
functioning (Stuart and Laraia 2005)

-it is an emotional feeling tone (Sungani G, 2010)

Affect – refers to behaviours such as hand and body movements, facial expression and pitch
of voice that can be observed when a person is expressing and experiencing feelings and
emotions (Stuart and Laraia 2005)

Depression – is the feeling of intense sadness; it may follow a recent loss or other sad event
but is out of proportional to that event and persists beyond an appropriate length of time
(Berkow et al, 1997).

Mania – is characterized by an elevated, expansive, or irritable mood.

Manic Depressive Disorder - Manic Depressive Illnesses are mood disorders in which the
person’s mood becomes so intense and persistent such that it interferes with his/her social
and psychological function (Diseases, 1992).

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THEORIES RELATED TO CONDITION

(a) Interpersonal Theory

The theory emphasises the role of environmental and familial factors in the development
of depression. According to Meyer, the client’s response to environmental and stress was
a result of experiences within the family system and in social groups. The early
developmental experiences influencing the development of depression include;

 Family disharmony
 Parental neglect
 Abuse
 rejection
 Loss of a parent

Children with one or more depressed parents have an increased chance of developing
depression. Separation, divorce and other marital problems, losses especially of loved
ones and the absence of supportive social relatives are some of the factors that may
contribute to the development of Depression (McFarland, 1990).

(b) Cognitive Theory

This theory originated by Aaron Beck, identifies depression as stemming from a world
view based on false beliefs about one’s self, the future, and the world. A central feature
of this theory is that the depressed individuals’ negative view is usually a distortion of
reality. Therefore, other symptoms typical of depression (motivational deficits, suicidal
impulses, and sadness) are generated by distorted thinking patterns (McFarland, 1990).

Beck identifies cognitive triad, silent assumptions, and logical errors as necessary
elements to the psychopathology of depression. The cognitive triad includes the negative
view by depressed clients of themselves, their future, and their world, along with the
belief that they are doomed for unhappiness. Silent assumptions are irrational beliefs or
rules that significantly affect the depressed person’s emotional, behavioural and thinking
patterns. Depressive assumptions are inferred by examining the situations, emotions and
themes associated with the various negative automatic thoughts.

(c) Psychoanalytic Theory

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 Freud views depression as the inward turning of aggressive instinct, which for some
reason is not directed at an appropriate object and accompanied y feelings of guilt. The
person feels angry and loving at the same time and is unable to express anger because it
is considered inappropriate or irrational. The person may have developed a pattern
throughout life of containing feelings especially those that are viewed negatively. Angry
feelings are then directed inward. In psychoanalytic theory the therapeutic aim in
depression is to redirect the anger outward (McFarland, 1990).

(d) Behavioural Theory

The dominant behavioural theory of depression is the social learning theory which
postulates that psychological functioning can best be understood in terms of continuous
reciprocal interactions among personal factors, such as cognitive processes, behavioural
factors, and environment factors. The central key of behavioural theories of depression is
that being depressed is a consequence of a decrease in person-environment interactions
that have positive outcomes for a person (McFarland, 1990). The environment may fail to
provide reinforcement and thus worsens the person’s condition.

(e) Learned Helplessness Theory

This theory originated from laboratory studies involving animals. Human studies led to the
assumption that learned helplessness was a model of depression. The main concept of
this theory is that when individuals believe they have no control over their situation, are
unable to reduce suffering or to gain praise or re-enforcers in their environment, they
experience feeling of helplessness and powerless. Their experiences caused them to
believe that they were helpless and incapable of influencing their sources of suffering and
they have developed no coping responses against failure.

(f) Biologic Theories

The most common biologic theories concern monoamines and other neurotransmitter
systems, neuro-endocrine factors, limbic system defects, circadian rhythm, and genetic
transmission. Neurotransmitters originate from the brain to provide the means by which
the brain changes and regulates mood, behaviour, and virtually all bodily functions.

162
 Neurotransmitters may be implicated in mood disorders caused by faulty synthesis of
transmitters, dispatching wrong amounts, excesses not broken down, or withdrawn, or by
receptor neurons malfunctioning.

(g) Genetic Theory

 Both heredity and environment play an important role in mood disturbances.
Major depression and bipolar are familial disorders resulting from genetic
influences. Family, twin, and adoptive studies show that a life time risk is 20% for
relatives of people with depression and 24% for relatives with people with mania.
A person with an identical twin with an affective disorder is 2 to 4 times more at
risk for the disorder than her fraternal twins or siblings. Thus good evidence exists
for the role of genetic factors in mood disorders.

CLINICAL MANIFESTATIONS

These will depend on specific affective disorders e.g

Major Depression

At least five of the following (including one of the first two) must be present most of the day, nearly
daily, for at least two weeks.

 Depressed mood
 Loss of interest or pleasure
 Weight loss or gain
 Insomnia or hyper insomnia
 Feelings of guilt, anger, sadness, or regret.
 Limited relationships
 Frequent episodes of crying
 Negative self – talk (Pessimistic feelings).
 Feelings of insecurity, loneliness or rejection.

Mania (Bipolar)

At least three of the following must be present to a significant degree for at least one week

 Elevated mood.
 Increased energy which may manifest as
- Over activity

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 - Pressed speech ( flight of ideas)
- Racing thoughts
- Reduced need for sleep
 Increased self esteem evidenced as
- over optimistic ideation
- grandiosity
- reduced social inhibition
- over familiarity
 Reduced attention / increased distractibility.
 Tendency to engage in behaviour which could have serious consequences
- In appropriate sexual encounter
- Spending recklessly.
 Other behavioural manifestation
- Excitement
- Irritability
- Aggressiveness
- Suspiciousness
 Marked disruption of work, usual social activities and family life.

MANAGEMENT/NURSING CARE PLAN

Investigations

Investigations are based on the history and clinical features. The criteria are that at least 5 of the
symptoms must have been present during the same two weeks period and represent a change from
previous functioning. Diagnosis is also based on the Diagnostic Statistical Manual (DSM) IV. There is
an experience of elevated mood. During the period of mood disturbance at least 3 of the following
must have been present to a significant degree these include:

 Inflated self esteem or grandiosity

 Decreased need for sleep
 More talkative than usual or pressure to keep talking
 Flight of ideas
 Increased goal directed activity or psychomotor agitation
 Excessive involvement in pleasurable activities that have a high potential for painful
consequences

Differential diagnosis

 Schizophrenia
 Delusional disorder
 Alcohol or drug misuse
 Physical illnesses e.g. head injury, HIV/AIDS and other encephalopathy

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  Drug related causes.

MEDICAL TREATMENT

There are three phases in the treatment of affective disorders and these are;

Acute treatment phase- the goal is to eliminate the symptoms and lasts 6-12weeks.

Continuation treatment phase- the goal is to prevent relapse and lasts 4-9months

Maintenance treatment phase – prevention of recurrence or a new episode of illness.

Drug: Chlorpromazine (Largactil) Adults: 30-75mg PO in 2-4 divided doses. Dosage may be increased
20-50mg twice weekly until symptoms are controlled, Children: 0.55mg/kg PO 4-6 hrs or IM 6-8hrs
Action: Same as Haloperidol

Side effects: dry mouth, difficult in micturition, hypotension, tarchycardia, gynaecomaastia,

impotence, nightmares, insomnia, apathy

Precaution – cardiovascular and cerebral vascular disease,parkinsonism,epilepsy,respiratory

disease,pregnancy and renal and hepatic impairement ( avoid if severe)

Drug: Amitriptyline hydrochloride, Adults: 30-75mg PO daily in divided doses or as a single dose at
bed time gradually increase to 150mg as maximum, children:7-10years,10-20mgPO,11-16years,25-
50mg PO at night.

Intravenous or intramuscular 10-20mg qid.

Children under 16years not recommended.

Action: It prevents serotonin re-uptake and reduces Noradrenaline uptake

Side effects: Dry mouth, sedation, vision constipation, arrhythmias, postural hypotension,
tachycardia syncope, interference with sexual function, testicular enlargement.

Precaution: cardiac disease with arrhythmias, history of epilepsy, pregnancy, breastfeeding, thyroid
disease, urinary retention. History of mania and psychosis may aggravate symptoms.

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Drug: Carbamazipine, 400mg daily in divided doses increased until symptoms controlled maximum
1.6g daily.

Action: Same as Haloperidol

Side effects:nauses,vomiting,dizziness,drowsiness,headache,ataxia,confusion,diarrhoes,

constipation, steven Johnson syndrome, acute renal failure, hepatitis, impotence, pulmonary
hypersensitivity (dyspnoea and pneumonitis).

Precaution: Hepatic and renal impairment, cardiac disease, skin reaction, glaucoma, pregnancy,
breast feeding (avoid sudden withdrawal.

Drug: Haloperidol Adults and children > 12years the dose varies. 0.50 – 5mg PO or TID of 2-5 mg IM

Action: Decreases brain Dopamine function by blocking the Dopamine D2 receptors

Side effects: same for chlorpromazine

Precaution: same for chlorpromazine

ROLE OF FAMILY AND COMMUNITY IN MANAGING THIS CONDITION

The family and the community should accept and give them the dignity due to them by:

 Not stigmatising them by calling them names like chainama or any traditional names that
people call them as this names remind them of who they are and they turn to withdraw and
isolate themselves or believe that this is what they are and starting behaving according to
what people label them as a result this people do not improve.
 Ensures that the patient takes the drugs as prescribed everyday and to be conscious of the
review date.
 The family should continue counselling the patient and to encourage the patient to have a
positive thinking about themselves

 The nurse can support community based rehabilitation by liaising with other sectors dealing
with community based programmes. These organisations may include faith based
organisations such as “Catholic Secretariat and other church organisations” (CBoH, 2002).
There are also other interest groups such as Association for Mental Health and other Non
Government Organisations.

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  The family should be educated and informed that there are certain groups in the community
who can assist these people by helping them to know the support groups that are in the
community.

 The community and family should facilitate the entry of the mentally ill into appropriate
community groups, by ensuring that group members understand the situation and are willing
to make efforts to provide support.

Rehabilitation

Rehabilitation is the restoration with the community’s active involvement of the individual’s ability to
function adequately as a member of the community. There are various approaches that are used in
rehabilitating the mentally ill persons and these include the following:

Psychosocial Stimulation:

(i) This encourages the revitalization of the integrity and individuality of each client.

(ii) Social interaction: This can be effective in drawing individuals out of passive withdrawal,
hostile rejection or channel acting out or disruptive behaviour through socially acceptable
and mutually rewarding interpersonal involvement.
(iii) Behaviour modification and habit training: Support is given to the client to maintain
acceptable behaviour and these increase functional levels of the clients.
(iv) Sensory Stimulation: Helps the regressed patient to come back in touch with the
surrounding.
(v) Group Counselling Strategies: -
 Have numerous advantages for dealing with emotional problems of the client.
 More clients can be reached by a single therapist.
 Group members can provide both support and insight for each other.
 Interpersonal skills can be tested in a non-threatening environment.
 Self esteem and self worth can be enhanced.

Nursing Management Using the Nursing Process

In Nursing Management of a client with Manic Depressive Illnesses, the nursing process is employed.
This is discussed under the following headings:-

 Assessment (Data Collection)

 Nursing Diagnosis (Analysis of data)
 Planning (Goal/Objective Setting)
 Implementation (Nursing Interventions)
 Evaluation

(a) Assessment

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Assessment would include some of the following

 Patient has sad mood and loss of interest or pleasure in daily activities
 Patient expresses doubts about his self worthy or ability to cope
 Patient appear unhappy and apathetic
 Relative reports suicidal attempts
 Patient appears euphoric, expansive and irritable
 Patient elaborates plans for numerous social activity
 Patient looks malnourished and has poor personal hygiene
Problem:

 Self esteem disturbance

 Impaired social interaction
 Risk for self directed violence
 Self care deficit
Nursing Diagnosis

After analysis of data, the nursing diagnoses would be as follows: -

 Self esteem disturbance related to disease process evidenced by self defeating thought,
patterns and behaviours
 Impaired social interaction due to disease process evidenced by mood swings of sadness and
anxiety.
 Risk for self directed violence related to suicidal attempts
 Self care deficit related to disease process evidenced by poor hygiene, grooming, and unable
to feed self.
Planning, Implementation and Evaluation stages are outlined in the table on the next pages.

168
Planning, Implementation and Evaluation of the Nursing Care for a Client with Manic
Depressive disorders

Nursing Goals/Objectives Interventions Rationale Evaluation of

Diagnosis Outcome

Self esteem To help client  Encourage the client The re-call of past  The client
disturbance demonstrates self discover own accomplishments demonstrate
related to esteem, thought irrational, beliefs or and positive s self esteem
other cognitive through
disease and good experiences
distortions by allowing behaviour
process behaviour with facilitate self
him to talk about and and talk with
evidenced by two weeks of writing down his validation and two weeks of
self defeating hospitalization feelings where affirmation. hospitalizatio
thought, possible. n
patterns and  Teach the client
behaviours effective interpersonal
communication
 Encourage the client
to talk about past and
present situations that
endangered feelings
of self worthy
Impaired To increase the  Provide daily  Allocating  The client
social ability of interaction time with time demonstrate
interaction interaction and the client enhances s expected
 Encourage the client the clients social
due to disease socialization
to attend group feelings of interaction
process activities. self worthy  The relatives
evidenced by  Arrange brief visits by and reports
mood swings a family member or provides an effective
of sadness and friend. opportunity social
anxiety.  Help client to discover to develop interaction
and verbalise a with the
circumstances or therapeutic client
stressors that result in relationship
social withdraw  Awareness
 Encourage the client helps client
to identify and discuss to
factors that contribute understand
to problems in social his feelings
relationships and
behaviour.

Planning, Implementation and Evaluation of the Nursing Care for a Client with Manic Depressive disorders

169
Nursing Goals/Objectives Interventions Rationale Evaluation of
Diagnosis/Problem Outcome

Risk for self directed Coping skills that  Teach the client Knowledge of The client
violence related to reduce the chance non destructive healthy options to demonstrates
moods changes of relying on self methods of handle intense understanding of
expressing
destructive emotions decreases conflict resolutions
intense
behaviour the frequency of through constructive
emotions.
throughout  Explore the impulsive or acting expression of
hospitalization. feelings of loss out behaviours. feelings. Relatives
and facilitate the report no more
grieving process. intentions of suicide
 Discuss self within four weeks
defeating
hospitalization.
behaviours,
unrealistic
expectations and
possible
distortions of
reality
Self care deficit To help client to  Supervise the The client’s inability Client demonstrates
related to disease regain the ability to client’s bathing, to concentrate may self care ability
process witnessed by perform self care grooming and prevent the within one week.
toileting.
unkempt behaviour, activities and completion of
 Give the client
dirty skin and clothes. grooming within necessary self care
small frequent
one week. amounts of high tasks. Information
Relatives report the
calorie foods will help meet to
patient’s ability to
that can be devise a plan to
maintain self care
eaten or drunk meet the
while being nutritional needs
active
since client does
 Monitor the
not demonstrate
client’s
elimination awareness of them.
 Teach the client
how to perform
or maintain self
care activities

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Preparation for discharge
 The client and the family should have knowledge of the disorder and early signs of relapse.
 Make the Client and family understand the medication regime, timetable and its side effects
to make adherence to treatment possible before discharge.
 Discuss the importance of the review date and reporting back to the hospital in case of any
problem.

MANIC DEPRESSIVE ILLNESSES

INTRODUCTION

Mental disorders are one of the most common public health problems in Zambia. This is against a background
of various challenges facing the people, such as a rise in poverty levels, the spread of HIV/AIDS,
unemployment, gender based physical and sexual violence and a rising number of street and drug abused
children. Some of the mental disorders which are prevalent in Zambia are; manic depressive illnesses, organic
brain syndrome, personality disorders, schizophrenia and substance abuse.

In our discussion we have outlined the types of manic depressive disorders (mood disorders), the theories
explaining these disorders, aetiology and characteristics, the pathophysiology, management (medical and
nursing), rehabilitation and intersectoral collaboration. Finally, we have outlined our conclusion to this
discussion.

DEFINITION

(a) Manic Depressive Illnesses are mood disorders characterised by the development of an abnormal
mood which may last from 2 weeks to 2 years. (Saunders, 1997).

(b) Manic Depressive Illnesses are mood disorders in which the person’s mood becomes so intense and
persistent such that it interferes with his/her social and psychological function. (Diseases, 1992).

(c) Manic Depressive Illnesses are mood disorders characterised by a depressed or elevated mood. They
manifest symptoms indicating dysfunction in affect, emotions, thinking and general activities. (Copel,
1996)

TYPES OF MANIC DEPRESSIVE ILLNESSES

Mood disorders are determined by the patterns of mood episodes. Mood disorders are classified in two
categories. These are:-

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  Depressive Disorders (Unipolar Disorders)
 Bipolar Disorders

(a) Depressive Disorders (Unipolar Disorders)

These include Major Depressive Disorders and Dysthymias

(i) Major Depressive Disorders

This is a mood disturbance characterised by one or more major episodes in which the
symptomatology would be

 Sleep and Appetite disturbance

 Change in Weight
 Loss of Energy
 Psychomotor Retardation
 Feeling of Helplessness

(ii) Dysthymia
Dysthymia is a chronic disturbance in mood characterised by

 Depressed mood for most of the day for at least 2 years

(b) Bipolar Disorders

These are disorders that refer to mood disturbances that are characterised by mood swings from
elated, expansive or irritable mood with erratic hyperactivity (Manic) to severe depression
(Depression)

THEORIES ASSOCIATED WITH MANIC DEPRESSIVE ILLNESSES

(a) Psychoanalytic Theory

Freud believed that depression was anger turned inward and Mania is best understood as a
defence against Depression. This defence involves both a denial and reversal of affect. Depression
is seen as a reaction to nassistic injury and loss. In psychoanalytic theory the therapeutic aim in
depression is to redirect the anger outward.

(b) Interpersonal Theory

The theory emphasises the role of environmental and familial factors in the development of
depression. According to Meyer, the client’s response to environmental and stress was a result of
experiences within the family system and in social groups. The early developmental experiences
influencing the development of depression include;

 Family disharmony

172
  Parental neglect
 Abuse
 rejection
 Loss of a parent

Children with one or more depressed parents have an increased chance of developing depression.
Separation, divorce and other marital problems, losses especially of loved ones and the absence of
supportive social relatives are some of the factors that may contribute to the development of
Depression

(c) Cognitive Theory

This theory originated by Aaron Block, identifies depression as stemming from a world view based
on false beliefs about one’s self, the future, and the world. A central feature of this theory is that
the depressed individuals’ negative view is usually a distortion of reality. Therefore, other
symptoms typical of depression (motivational deficits, suicidal impulses, and sadness) are
generated by distorted thinking.

Black identifies cognitive triad, silent assumptions, and logical errors as necessary elements to the
psychopathology of depression. The cognitive triad includes the negative view by depressed
clients of themselves, their future, and their world, along with the belief that they are doomed for
unhappiness. Silent assumptions are irrational beliefs or rules that significantly affect the
depressed person’s emotional, behavioural and thinking patterns. Depressive assumptions are
inferred by examining the situations, emotions and themes associated with the various negative
automatic thoughts.

(d) Behavioural Theory

The dominant behavioural theory of depression is the social learning theory which postulates that
psychological functioning can best be understood in terms of continuous reciprocal interactions
among personal factors, such as cognitive processes, behavioural factors, and environment
factors. The central key of behavioural theories of depression is that being depressed is a
consequence of a decrease in person-environment interactions that have positive outcomes for a
person.

(e) Learned Helplessness Theory

This theory originated from laboratory studies involving animals. Human studies led to the
assumption that learned helplessness was a model of depression. The main concept of this theory
is that when individuals believe they have no control over their situation, are unable to reduce

173
 suffering or to gain praise or re-enforcers in their environment, they experience feeling of
helplessness and powerless.

(f) Biologic Theories

The most common biologic theories concern monoamines and other neurotransmitter systems,
neurotransmitter systems, neuro-endocrine factors, limbic system defects, circadian rhythm, and
genetic transmission. Neurotransmitters originate from the brain to provide the means by which
the brain changes and regulates mood, behaviour, and virtually all bodily functions.

Neurotransmitters may be implicated in mood disorders caused by faulty synthesis of

transmitters, dispatching wrong amounts, excesses not broken down, or withdrawn, or by
receptor neurons malfunctioning.

(g) Genetic Theory

Family, twin, and adoptive studies had suggested a genetic basis in bipolar disorder. In 1987, the
National Institute of Mental Health announced a major break-through in the field of genetic
research. Bipolar disorder was found to be linked to DNA markers on chromosome 11 in the Old
Order Amish (OOA).

AETIOLOGY

(a) Major Depression (Unipolar)

The cause of depression is idiopathic. However, there are a number of factors that may make a
person more likely to experience depression.

Predisposing Factors

(i) Genetic factors which runs in families

(ii) Biochemical and physiological factors which is a result of alteration in catecholamine or
serotonin biosynthesis.
(iii) Physical factors such as diseases or disorders which may directly or indirectly cause a person
become depressed.
(iv) Psychological factors that may cause a person to have feelings of helplessness and
vulnerability, anger, hopelessness.
(v) Social factors such as family disharmony, parent neglect, loss of a parent, separation, and
loss of loved one.
(b) Mania (Bipolar)
The cause is idiopathic. However, the following may play a part in the cause of mania:

174
 Predisposing Factors

(i) Hereditary incidence of mania is higher in the maternal side.

(ii) Biological intracellular sodium concentration increases during illness and returns to normal
with recovery.
(iii) High levels of norepinephrine and dopamine are associated with mania.
(iv) Psychological causes. Emotional and physical trauma such as bereavement, disruption of an
important relationship or severe accident injury may precede the onset of bipolar.
(v) Physical factors. These may include;
 Side effects of drugs e.g. Mostly Amphetamines and Antidepressants.
 Infections such as AIDS and encephalitis.
 Connecting tissue disorders such as systemic lupus erythmatosus.
 Neurological disorders such as brain tumours and head injury.

CHARACTERISTICS

(a) Major Depression

(i) Feelings o guilty, anger, sadness, or regret.

(ii) Limited or few relationships

(iii) Frequent crying episodes

(iv) Negative self – talk (Pessimistic feelings)
(v) Expression of guilty or shame.
(vi) Immature and inappropriate behaviour
(vii) Little or no communication with others.
(viii) Feelings of insecurity, loneliness or rejection.

(b) Mania

(i) Disorganized manner.

(ii) Denial of physical needs.
(iii) Inability to sit down or eat a meal.
(iv) Inability to carry out proper hygiene.
(v) Perpetual involvement with activities.
(vi) Extreme restlessness.
(vii) Inability to sleep or sleeping for very short periods
(viii) Very late retiring and very early rising.
(ix) Delusional thinking.
(x) Unsuccessful interaction with peers or family.
(xi) Egocentric behaviour.
(xii) Lack of impulse control.

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PATHOPHYSIOLOGY OF MANIC DEPRESSIVE ILLNESS

Depressed status may involve at least 3 neural transmitters (i.e. Norepinephrine, Serotonin and Dopamine) as
well as several hormonal system including pituitary, thyroid and adrenal system. Manic states seem to include
excess amounts of catecholamine. Disruption in circadian rhythm, diet and exposure to light has been
associated with mood deregulations, but the connections are not wholly understood.

MANAGEMENT

1. Medical Management

(a) Major Depression

Investigations

Diagnosis is based on the criteria documented in the DSM IV. The criteria are that at least 5 of the
following symptoms must have been present during the same two week period and represent a
change from previous functioning. One of the symptoms must be either depressed mood or loss of
interest in previously pleasurable activities. Substance abuse disorders and schizophrenia must be
ruled out.

The symptoms are as follows:

 Depressed mood most of the day, nearly every day indicated subjectively or objectively.
 Markedly diminished interest or pleasure in all, most of the day or nearly every day.
 Significant weight loss or weight gain when not dieting.
 Insomnia or hyper insomnia, nearly every day.
 Fatigue or loss of energy nearly every day.
 Feelings of worthlessness nearly every day.
 Diminished ability to think or concentrate nearly every day.

(b) Mania

Investigations

Diagnosis is also based on the DSM IV. There is an experience of elevated mood. During the period of
mood disturbance at least 3 of the following must have been present to a significant degree these
include:

 Inflated self esteem or grandiosity

 Decreased need for sleep
 More talkative than usual or pressure to keep talking
 Flight of ideas
 Increased goal directed activity or psychomotor agitation

176
  Excessive involvement in pleasurable activities that have a high potential for painful
consequences

Treatment of Manic Depressive Illnesses

The treatment goals are:-

(a) Maintenance of safety for the person for the parson experiencing psychosis
(b) Relief of psychotic symptoms being exhibited by the particular patient
(c) Return to the highest possible level of functioning

The pharmacological treatment is as outlined in the table on pages 6 and 7.

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 Pharmacological Treatment

It is as shown in the table below:-

No. Drug Dose Action Side Effects Nursing Implications

1 Chlorpromazine Adults: - 30-75mg PO in 2-4 Exerts antipsychotic effects by  Extra pyramidal  Obtain baseline
(Largactil) divided doses. Dosage may be post synaptic blockade of CNS reactions BP before starting
increased 20-50mg twice dopamine receptors, there by  Drowsiness therapy
 Sedation  Watch for
weekly until symptoms are inhibiting dopamine mediated
 Tachycardia orthostatic
controlled effects
 Naso congestion hypotension
 Constipation
Children:- 0.55mg/kg PO 4-6
 Menstrual
hrs or im 6-8hrs irregularities
 Hypostatic
hypotension
2 Haloperidol Adults and children > 12years Has Strong Postsynaptic  Extra pyramidal  Warn to avoid
the dose varies. blockade of CNS Dopamine reactions activities that
Receptors thereby inhibiting  Drowsiness require alertness
0.50 – 5mg PO or TID of 2-5 mg  Sedation and good
Dopamine effects.
im  Tachycardia psychomotor co-
 Headache ordination e.g.
 Dry Mouth driving.
 Tell to avoid
alcohol as it
worsens
drowsiness.
Advise to relieve dry
mouth by chewing
sugarless gum

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No. Drug Dose Action Side Effects Nursing Implications

3 Trifluoperazine Adults 1-2 mg P.O. BD Has Postsynaptic blockade of  Extra pyramidal  Keep patient in
CNS Dopamine Receptors reactions supine position
thereby inhibiting Dopamine  Orthostatic after
hypotension administration
mediated effects.
 Blurred Vision  Protect patient
 Cholestatic Jaundice from light
 Urine Retention  Monitor Intake
 Drowsiness and Out-Put
 Skin Photo
Sensitivity reactions
4 Fluphenazine Adults 0.5-10 mg P.O. QID or Has Postsynaptic blockade of  Drowsiness  Warn to avoid
TDS CNS Dopamine Receptors  Dry Mouth activities that
thereby inhibiting Dopamine  Menstrual require alertness
Maintenance Dose 1-5 mg P.O. Irregularities and good
mediated effects
Daily  Gynaecomastia psychomotor co-
 Inhibited Ejaculation ordination e.g.
 Jaundice driving.
 Allergic Reactions  Advise to relieve
 Tachycardia dry mouth by
 Seizures chewing sugarless
gum
 Check Liver
Function tests

179
2. Nursing Management Using the Nursing Process

In Nursing Management of a client with Manic Depressive Illnesses, the nursing process is employed. This is
discussed under the following headings:-

 Assessment (Data Collection)

 Nursing Diagnosis (Analysis of data)
 Planning (Goal/Objective Setting)
 Implementation (Nursing Interventions)
 Evaluation

(a) Assessment

Assessment would include some of the following

(i) Patient has sad mood and loss of interest or pleasure in daily activities

(ii) Patient expresses doubts about his self worthy or ability to cope

(iii) Patient appear unhappy and apathetic

(iii) Relative reports suicidal attempts
(iv) Patient appears euphoric, expansive and irritable
(v) Patient elaborates plans for numerous social activity
(vi) Patient looks malnourished and has poor personal hygiene

(b) Nursing Diagnosis

After analysis of data, the nursing diagnoses would be as follows: -

(i) Self esteem disturbance in relation to self defeating thought patterns and behaviours

(ii) Impaired social interaction in relation to thought conflicts within him/her self

(iii) Risk for self directed violence related to suicidal attempts

(iii) Self care deficit in Hygiene, grooming, feeding and toileting in relation to failure to practice
daily health routines

Planning, Implementation and Evaluation stages are outlined in the table on the next pages (9 and 10).

180
 Planning, Implementation and Evaluation of the Nursing Care for a Client with Manic Depressive disorders

Nursing Goals/Objectives Interventions Rationale Evaluation Of

Diagnosis/Problem Goal/Outcome

Self esteem Client will identify self Help the client discover The re-call of past The client
disturbance defeating thought patterns own irrational beliefs accomplishments and demonstrates self
and behaviours and or other cognitive positive experiences esteem through
behaviour and
practice positive thought distortions by allowing facilitate self validation
talk
patterns and coping him to talk about and and affirmation.
strategies for handling writing down his
stress and solving feelings where
problems. possible.

Teach the client

effective interpersonal
communication

Encourage the client to

talk about past and
present situations that
endangered feelings of
self worthy
Impaired social Client will establish Establish daily Allocating time The client
interaction therapeutic relationships interaction time with enhances the clients demonstrates
with the nurse and will use the client feelings of self worthy expected social
interaction
the security of this and provides an
relationship to allow the Encourage the client to opportunity to develop
attend group activities. The relatives
examination of thought, a therapeutic reports effective
feelings and conflicts in Arrange brief visits by a relationship social interaction
other current relationships. family member or with the client
friend.
Help client to discover Awareness helps to
and verbalise which understand feelings
circumstances or and behaviour.
stressors result in
social with draw

Encourage the client to

identify and discuss
factors that contribute
to problems in social
relationships.

181
Planning, Implementation and Evaluation of the Nursing Care for a Client with Manic Depressive disorders

Nursing Goals/Objectives Interventions Rationale Evaluation Of

Diagnosis/Problem Goal/Outcome

Risk for self Client will lean Teach the client non Knowledge of  The client
directed violence coping skills that destructive methods healthy options demonstrates
reduce the chance of expressing intense to handle intense understanding
of conflict
of relying on self emotions. emotions
resolutions
destructive decreases the
 Explore the through
behaviour. frequency of constructive
feelings of
impulsive or expression of
loss and
facilitate the acting out feelings
grieving behaviours.  Relatives
process. reports no
 Discuss self more
defeating intentions of
behaviours, suicide
unrealistic
expectations
and possible
distortions of
reality
Self care deficit Client will regain Supervise the client’s The client’s  Client
the ability to bathing, grooming inability to demonstrates
perform self care and toileting. concentrate may self care ability
activities. prevent the
 Relatives
 Give the client report the
completion of
small patient’s
necessary self ability to
frequent
amounts of care tasks. maintain self
high calorie Information is care
foods that can required to
be eaten or devise a plan to
drunk while meet the
being active
nutritional needs
 Monitor the
client’s since client does
elimination not demonstrate
 Teach the awareness of
client how to them.
perform or
maintain self
care activities

182
PREPARATION FOR DISCHARGE

(a) The client and the family should have knowledge of the disorder and early signs of relapse.

(b) Make the Client and family understand the medication regime, timetable and its side effects
to make adherence to treatment possible before discharge.

PROGNOSIS

 “Depression is a treatable illness. About 65% of patients respond to treatment

(antidepressants). 85% respond when given antidepressants and psychotherapy.” (Saunders,
1997).
 “Mania has 75% to 80% successful treatment rate.” (Saunders, 1997).

INTERSECTORAL COLLABORATION

The nurse can support community based rehabilitation by liaising with other sectors dealing with
community based programmes. These organisations may include faith based organisations such as
“Catholic Secretariat and other church organisations” (CBoH, 2002). There are also other interest
groups such as Association for Mental Health and other Non Government Organisations

REHABILITATION

Rehabilitation is the restoration with the community’s active involvement of the individual’s ability
to function adequately as a member of the community. There are various approaches that are used
in rehabilitating the mentally ill persons and these include the following:

Psychosocial Stimulation: This encourages the revitalization of the integrity and individuality of each
client.
Social interaction: This can be effective in drawing individuals out of passive withdrawal, hostile
rejection or channel acting out or disruptive behaviour through socially acceptable and mutually
rewarding interpersonal involvement.
Behaviour modification and habit training: Support is given to the client to maintain acceptable
behaviour and these increase functional levels of the clients.
Sensory Stimulation: Helps the regressed patient to come back in touch with the surrounding.

Group Counselling Strategies: -

 Have numerous advantages for dealing with emotional problems of the client.
 More clients can be reached by a single therapist.
 Group members can provide both support and insight for each other.
 Interpersonal skills can be tested in a non-threatening environment.
 Self esteem and self worth can be enhanced.
Schizophrenia
Definitions:

1. A severe disturbance of thought or association characterized by impaired reality,

hallucinations, delusions and limited socialization (Saito,2000)
2. I t is a devastating disease of the brain that affects a person’s thinking, language,
emotions, social behaviour and ability to accurately perceive reality (Andreasen an
Munich, 1995).
3. It is mental disorder often characterized by abnormal social behaviour and failure to
recognize what is real (Carpenter and Buchanan 1995)

The term schizophrenia was introduced by a Swiss Psychiatrist, Eugene Bleuler in 1911.
Schizein means “to split” and Phren mean means “Mind”. Therefore, Schizophrenia literally
means “split mind”. It reflects a split form of personality from emotional and cognitive
aspects of personality.

Causes of schizophrenia: The causation is a complicated matter. What is known, however, is

that, the brain chemistry and brain activity are different in a person suffering from
Schizophrenia compared to a person with it (Andreasen 1999).However, the disease most
likely occurs as a result of a combination of the following factors:

 Hereditary
 Viral infection
 Birth injuries
 Nutritional factors

Hereditary findings: It has been observed that schizophrenia and schizophrenic-like

symptoms occur at an increased rate in people who have relatives with schizophrenia (Jones
and cannon 1998) for example the following have been observed:
 If one parent has schizophrenia, about 12% of the children develop the disease
 If both parents have Schizophrenia, 46% of the children with get the disease
 Among identical twins (From one egg), there is a 50%chance that both twins will
develop Schizophrenia.
 Among the fraternal twins (from different eggs) there is15% chance that both twins
will develop the disease.
 Children of parents who do not have schizophrenia when they are placed in an
orphanage or foster homes, in which a foster parent later had schizophrenia, do not
show an increased rate of developing the disease.

Birth complications and pregnancy: Infants born with history of birth complications are at
increased risk for developing schizophrenia as adults. Infection during pregnancy, poor
nutrition during pregnancy or exposure to toxins could damage neurons or affect
neurotransmitter system in fetus.
Stress related factors

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Family stress and poverty, long term unemployment, homelessness, incarceration, violence,
substance abuse and HIV infection may precipitate individual develop schizophrenia.

Epidemiology
 World wide- in 2013 there were an estimated 23.6 million cases globally.
 Onset late teen and early 20s
 Men and women are equally affected with variation in age. More males aged
between 18-25 and women between 25-35 years respectively

Course of the disease

Schizophrenia usually involves recurrent and acute exacerbations of psychosis. With each
relapse of psychosis, there is an increase in dysfunctional and deterioration. The phases in
the course of the disease are:
I. Acute phase: Characterised by florid (extravagant, elaborate or fancy) positive
symptoms (e.g. Hallucination, delusions) as well as negative symptoms (e.g. apathy,
withdrawal, no motivation).
II. Maintenance Phase: This period is marked by decrease in severity of acute
symptoms. The phase can last up to 6 months or more.
III. Stable phase: Period when symptoms are in remission.

Signs and symptoms

According to Eugene Bleuler, 1950, schizophrenia has fundamental signs referred to as the
four As. These four As are:
1) Affect: The outward manifestation of a person`s feelings and emotions. In
Schizophrenia, affect is flat, blunted, inappropriate or bizarre.
2) Associative looseness: This is manifested by haphazard and confused thinking. The
patient`s speech is jumbled and illogical and reasoning. This is also termed looseness
of association.
3) Autism: Thinking that is not bound to reality but reflects the private perceptual
world of the individual. Delusion, hallucinations, and neologisms are examples of
autistic thinking.
4) Ambivalence: Simultaneously holding two opposing emotions, attitudes, ideas, or
wishes toward the same person, situation, or object. Ambivalence occurs normally in
all relationships.
However, symptoms in schizophrenia are many and not all people with schizophrenia have
the same symptoms.

The four main areas of signs and symptoms

1. Positive symptoms
Hallucination: A sense perception (seeing, hearing, tasting, smelling, or touching) for
which no external stimulus exists (e.g. hearing voices when none exists)
Delusions: A false belief held to be true even with evidence to the contrary (e.g. the
false belief that one is being singled out for harm by others)
Delusion of reference: e.g. “At Cock pit bar in Garden compound, whenever they
play that music, the words in the music is sending message to me”

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 Grandiose delusion: “I own the Bank of Zambia and my people are going to put up
K20million for my release from here”.
Neologism: Words a person makes up that have meaning only for that person, it is
part of delusional system. E.g. “it takes screeg because of those nerflexes”
Disorganised speech (LOA) e.g. “Whenever a knife take you”
Word salad: A mixture of phrases which are meaningless to the listener and to the
speaker as well, e.g. “Blue monkey. Makes me scratch. Jones wore a hair shirt. Birds
and fishes, mud and stars and thump-bump going, are we victims?, ”
Tangentiality: An association disturbance in which the speaker goes off the topic.
When it happens frequently and the speaker does not return to the topic,
interpersonal communication is destroyed. e.g. “I love eating from Hungry Lion.
Candy is my parakeet`s name. Where do you work?”
Nihilism: A delusion that the self or part of the self does not exist. e.g. “Iam locked
in concrete and i have stopped breathing.”
Echolalia: Mimicking or imitating the speech of another person.
Disordered movement: restlessness, repetitive movements (mimicking or imitating
the movements of another person-echopraxia) or immobility (Catatonia)

Negative symptoms
Flat affect
Inability to plan or carry out activities
Constricted, concrete thinking
Poverty of speech (alogia), flat speech
Social withdrawal, lack of pleasure in activities (anhedonia)
Deep apathy
Loss of motivation (avolition)

Cognitive symptoms
Impaired ability to pay attention and to understand
Impaired ability to make decisions (ambivalence)
Problems in using just-learned information.
Inattention, easily distracted
Impaired memory
Poor problem-solving skills
Illogical thinking
Impaired judgement

Co-occurring Problems
Anxiety
Depression
Substance abuse
Suicidal tendencies

All these symptoms alter the individual`s ability to work, interpersonal relationships,
self care abilities, social functioning and quality of lif
Summary of delusions

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Delusion Definition example
Misconstruing trivial events and When announcement was made
Idea of reference remarks and giving them on the radio that tomorrow there
personal significance will be heavy rains, Mary believed
the message to be aimed at
harming her
James believed the state
Persecution False belief that one is being intelligence services were planning
singled out for harm. Usually it to kill him. He therefore become
takes the form of a plot. conscious and care careful of what
he ate suspecting that the food
may be poisoned.
Graduer Joyce believed that she was Mary
False belief that one is a very the mother of Jesus and that Jesus
powerful and important person controlled her thoughts and was
telling her how to save the world.
The false belief that the body is James told the doctor that his
Somatic delusions changing in an unusual way e.g. brains were rotting away.
rotting inside.
Mulenga accused his wife of
having extra marital affairs with
The false belief that one`s other men, even though this was
Jealousy spouse is unfaithful. May have not the case. His proof was that
so-called proof. she came home late on two
occasions last week. But the wife
called her boss who also testified
that she everyone at the company
worked late.
My brain is connected to the
Thought The belief that one`s thoughts world mind. I can control all
broadcasting can be heard by others. presidents in African countries
through my thoughts.
Thought insertion The belief that thoughts of They make me think bad thoughts
others are being inserted into
one`s mind.
Thought The belief that thoughts have The witch takes my thoughts away
withdrawal been removed from one`s mind and leaves empty
by an out side agency.

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Summary of Hallucinations

Hallucinations Definition example

Hearing voices or sounds that do JB hears the voice of his dead
Auditory not exist in the environment but mother calling him as a useless
are projections of inner man and a thief
thoughts or feelings
Visual Seeing an object, a person or JB who is experiencing alcohol
animal that does not exist in the withdrawal delirium “sees” hungry
environment rats coming towards him
Olfactory Smelling odours that are not JB “smells” his inside rotting
present in the environment
Gustatory Tasting sensations that have no JB will not eat his food because he
stimulus in reality “tastes” the poison the secrete
police is putting in this food.
Tactile Feeling strange sensations JB feels electrical impulses
where no external objects controlling his mind
stimulate such feelings.

Summary of Negative observable fact

observable fact Explanation

There is severe reduction in the expression and range
Affective blunting and intensity of affect. Facial expression of emotion
does not exist.
Anergia Lack of energy, passivity, impersistence at work or
school.
Inability to experience any pleasure in activities that
Anhedonia usually produce pleasurable feelings; result of
profound emotional barrenness.
Lack of motivation; unable to initiate tasks e.g. social
Avolition contacts grooming and other aspects of activities of
daily living.
Speech that is adequate in amount but conveys little
Poverty of content f speech information because of vagueness, empty repetitions,
or use of stereotypes or obscure phrases.
Poverty of speech Restriction on the amount of speech-answers range
from brief to monosyllabic one-word answers.
Patient may stop talking in the middle of the sentence
Thought blocking and remain silent. When asked why the patient did not
complete his speech, he may say that, he forgot what
he was saying. Something took his thoughts away.

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Summary of negative and positive symptoms of schizophrenia

Negative symptoms Positive symptoms

Affective flattening Hallucinations
Unchanging facial expression Auditory
Decreased spontaneous movements Voice commenting
Paucity of expression Voices conversing
Poor eye contact Somatic tactile
Inappropriate affect Olfactory
Lack of vocal inflection visual
Alogia Delusions
Poverty of speech Persecutory, Jealous, Grandiose
Poverty of content of speech Religious, somatic, delusion of reference, delusion of
Blocking being controlled, delusion of mind reading, thought
broadcasting, thought insertion, thought withdrawal.
Avolition-apathy Bizarre behaviour
Impaired grooming, and hygiene, lack Clothing, appearance, social, sexual behaviuor,
of persistence at work or school, aggressive-agitated, repetitive-stereotyped
physical Anergia.
Anhedonia- asociability Positive formal thought disorder/speech pattern
Few recreational interests / activities. Derailment, Tangentiality, incoherence, illogicality,
Little sexual interest/ activity circumstantiality, pressure of speech, distractible speech
Impaired intimacy/closeness and clanging
Few relationships with friends/peers
Attention
Social inattentiveness

General Nursing care of patient with schizophrenia

Patient with schizophrenia has troubled mind. Therefore, nurse should devise ways of helping the
patient cope with voices and worrying thoughts.

When patient is hearing voices and experiencing strange, worrying thought.

Distracting: Encourage patient to listen to music, reading aloud, watching TV, describing an
object in detail and or counting backwards from 100. These activities will help patient cope
with the situation.

Interacting: Encourage patient to tell the voices to go away, talk to the voices while
pretending to be talking on the mobile phone, and agreeing to listen to the voices at
particular times.

Activity: Allow patient to take a walk, tidying the house, having a relaxing bath, play the
guitar, sing and going to the gym to help cope with hearing of voices and experiencing
worrying thoughts.

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Socialize: Provide opportunities for patients to talk to trusted friends or member of the
family, phoning a helping line, avoiding people who exacerbate the symptoms and visit a
favourite place.
Physical: Encourage patient to undertake such activities as relaxation methods, breathing
exercises to cope with voices and worrying thoughts.

Psychotherapy: Cognitive behavioural therapy, cognitive rehabilitation, and social skills

training are helpful.

Individual therapy: Skills training can enhance social functioning, cognitive rehabilitation
focuses on improving information processing skills such as memory, attention, and
conceptual abilities.

Group therapy: helps clients achieve interpersonal skills, resolution of family problems and
effective use of community support.

Family therapy: Families are the most consistent factor in patient`s life. Patients return to
their families after discharge from hospitals. Family education and family therapy is an
integral part of patient`s recovery. Families endure hardships while coping with these
patients. They become isolated from their communities and relatives. The family is blamed
for having caused or triggered schizophrenic episodes. Actively involve families in an effort
to develop new and effective treatment strategies and make them partners in the treatment
process.

Psychopharmacology:
Schizophrenia is the most common indication of for antipsychotic drugs

Action
Reducing as many of the psychotic symptoms as possible, enables patient to participate
more effectively in other forms of treatment
Choosing the medication also depends on its side-effects – again, idiosyncratic
Some people respond better to one drug than to another – idiosyncrasy (habit)

Commonly used drugs

 Halperidol 50mg Orally/IM

 Stelazine (trifluoperazine) 60mg orally/IM
 Chloropromazine (Largactil) 200-1600mg orlly/IM
 Mellaril ( Thioridazine) 600mg orally
 Serentil ( Mesoridazine) 300mg Orally/IM

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General side effects of Psychotic drugs

Extrapyramidal side-effects (EPS)

Akathisia: (Gk. Not being able to sit). Feeling restless or jittery, needing to fidget, pace
around, be about
Dystonia: sudden muscle spasm characterized by torticollis (twisting of neck), opisthotonos
(spasm of the neck and back forcing the head backwards), oculogyric crisis (a fixed gaze that
cannot return to lateral)
Parkinsonism: tremor, stiffness, rigidity, stooped posture, shuffling gait, akinesia (feeling
slowed down), pill-rolling movement of fingers, oscillations of distal parts of extremities.
Neuroleptic malignant syndrome: muscle rigidity, hyperpyrexia, hypertension, confusion,
delirium.
-Tardive dyskinesia: involuntary movements of face and body (lip smacking, tongue
protrusion, rocking, foot tapping), impaired gait and posture.
The symptoms of frowning, blinking, grimacing, puckering, blowing, smacking, licking,
chewing, tongue protrusion and spastic facial distortions are very troubling.

Abnormal movements of the arms and legs also occur, including rapid, purposeless irregular
movements; tremors and foot tapping. Body symptoms include dramatic movements of the
neck and shoulders, rocking, twisting pelvic gyrations and thrusts.

Because tardive dyskinesia is often irreversible, the goal is prevention.

- If symptoms begin to appear, the medication is reduced or the person is switched to a
newer antipsychotic.
Sexual functioning is fairly common
Weight gain.

Identifying and managing side effects is important

Identifying and managing side effects is important

Some people stop taking their medication and relapse whereas others relapse first, and as a
result, stop taking their medication.

Monitoring white blood cells is essential with some medications as agranulocytosis is

common with some drugs and can be fatal, since the patient can easily succumb to an
overwhelming infection.
Toxicity and overdose

CNS depression, which may extend to the point of coma.

Other symptoms include agitation, restlessness, seizures, fever, EPS, arrhythmias, and
hypotension.
Caring for a client with overdose includes monitoring vital signs, especially of cardiac
function; maintaining a patent airway and gastric lavage.

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Nursing Care Plan
Multiple Setting Nursing Care Plan for a Patient with Schizophrenia

JB is a 19-year-old man exhibiting symptoms of schizophrenia for the first time. His parents brought
him to the hospital after he was brought home for Christmas break. Teaching College. He is the
oldest child of three and is the first in his family to go to college. His father is a foreman at the local
mechanical workshop, and his mother is a receptionist for a local private physician.

JB has always been a quiet, hard worker with a small circle of friends. His first semester was a lonely
one, with disappointing grades. At Christmas time, JB was quieter than usual but participated in
family activities without enthusiasm. When aunts and uncles asked him about school he was
preoccupied and answered simply that it was fine. His parents returned him to school with some
anxiety but thought it was just a difficult adjustment being away from home for the first time.

When his parents picked him up for midterm break he was dishevelled and had not bathed. His side
of the dormitory room was covered with small pieces of taped paper with single words on them. The
words made no sense but JB stated that he put them there “to organize (his) thoughts.” His
roommate informed his parents that this behaviour started about the same time JB began staying in
the room and skipping classes and meals.

JB agreed to leave with his parents only after they agreed to take everything home with them. As
they packed his belongings, JB sat in the corner of his bed listening to his CD disk player. When his
parents asked him what was happening, he merely said, “I have the power.” On the way home JB
responded to their questions by saying his lecturers were trying to take away what he knew. He sat
bundled in the back seat of the car with his jacket over his head. He laughed and mumbled in
response to nothing his parents could hear.

SETTING: INTENSIVE CARE PSYCHIATRIC UNIT/GENERAL HOSPITAL

Baseline assessment: This is the first admission for JB, a 19-year-old single college student who has
not slept for 4 days and is frightened with wide-eyed hyper vigilance, pacing, and periods of
extended immobility. Is vague about past drug use. Parents do not believe he has used drugs. He
appears to be hallucinating, conversing as if someone is in the room. At times he says he is receiving
instructions from “the power.” He is unable to write, speak, or think coherently. He is disoriented to
time and place and is confused. JB is 2m 78cm tall and weighs 75kgs, thin in appearance, but
normally developed. Lab values are within normal limits except Hgb, 10.2 and Hct, 32. He has not
eaten for several days.

Associated Psychiatric Diagnosis

Schizophrenia, catatonic type

Educational problems (failing)
Social problems (withdrawn from social contacts)

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Mental state examination

Inaccurate interpretation of stimuli (people thinking his thoughts, trying to take information from his
brain).
Cognitive dysfunction, including memory deficits, difficulty in problem solving and abstraction.
Suspiciousness, Hallucinations, Confusion/disorientation, [Link] social behavior

Medications

Risperidone (Risperdal) 2 mg bid then titrate to 3 mg bid if needed

Lorazepam (Activan) 2 mg PO or IM PRN IM for agitation

Nursing Diagnosis 1: Disturbed Thought Processes

Interventions

1. Recognize changes in thinking and behaviour.

2. Learn coping strategies to deal effectively with hallucinations and delusions.
3. Express delusional material less frequently.
4. Take Risperdal as prescribed orally.
5. Participate in unit activities according to treatment plan.
6. Use coping strategies to deal with hallucinations and delusions.
7. Communicate clearly with others.
8. Agree to take antipsychotic medication as prescribed.
9. Maintain reality orientation.

Interventions Rationale Ongoing Assessment

Initiate a nurse-patient A therapeutic relationship Determine whether or not

relationship by will provide JB support JB can engage in a
demonstrating an as he develops an relationship.
acceptance of JB as a awareness of
worthwhile human being schizophrenia and the
through the use of implications of the
nonjudgmental disorder.
statements and behavior.
Approach in a calm,
nurturing manner. Be
patient (patient’s brain is
not processing data
normally) and nurturing.

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Assist JB in differentiating
between his own
thoughts and reality.
Validate the presence of
hallucinations. Identify
Initially, JB will be unable to Determine if JB is convinced
them as a part of the
determine whether or that his perceptual
disorder and explain that
not his hallucinations are experiences are
they are present because
reality based. Because hallucinations.
of the metabolic changes
hallucinations tend to be
that are occurring in his
repeated, the patient
brain. Focus on reality-
learns that recurring
oriented aspects of the
perceptual experiences
communication.
that are not confirmed
by others are
hallucinations. The
Teach JB about his disorder.
patient can learn to
Assure him that the
focus on reality and
symptoms can be
ignore the perceptual
improved and that he can
experience.
manage the disorder.
Helping JB understand his
disorder will give him a
sense of control over his
disorder and give him
Administer Risperdal as Assess whether or not JB
the information he
prescribed. Teach about can process the
needs to manage the
the action, side effects, information. Has the
symptoms.
and dosage of confusion been
medication. Emphasize Risperdal is a alleviated?
the importance of taking monoaminergic
medication after antagonist of D2 and 5-
discharge, even if HT2 postsynaptic. It is Observe for relief of

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 symptoms go away indicated for the positive symptoms and
completely. Ask patient management of the assess for side effects,
for a commitment to take manifestations of especially extrapyramidal
the medication. psychotic disorders. symptoms (specifically
acute dystonic reactions,
When patient is
akathisia,
hallucinating, determine
By refocusing JB’s attention pseudoparkinsonism).
the significance to the
from hallucinations to Observe for orthostatic
patient (what are the
reality, he will begin to hypotension.
voices telling him?), then
develop coping skills to
try to reassure JB that he
control the perceptual
is not alone and then
experience. It is Determine whether or not
redirect him to the here-
important for the nurse the hallucination is
and-now.
to understand the frightening to the patient
context of the or giving patient
hallucination to provide command, especially to
the appropriate harm self or others.
supportive intervention. Assess patient’s response
to the hallucination.
When patient is making Delusions, by definition, are
Assess his ability to be
delusional statements, fixed false beliefs. They
redirected to the here-
assess the significance of cannot be changed
and-now.
the delusion to the through logical
patient (it is frightening), argument. Because the
support patient if patient is convinced of
Assess the meaning of the
necessary, and redirect to the truth of the
delusion to the patient.
the here-and-now. Do not delusion, the individual
Determine if the patient
try to convince JB that the should be supported if
can be redirected.
delusion is false. the delusion is upsetting
to him.
Assist patient in
communicating Patients with schizophrenia
effectively. Encourage typically have problems

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 patient to attend because of the
communication groups. disordered thought
process. Improving
communication skills will
help the patient cope
with the disorder.
Determine situations that
The negative symptoms of
Assess ability for self-care cause JB the most
schizophrenia can
activities. Identify areas problem in
interfere with the
of physical care for which communicating.
patient’s ability to
the patient needs
complete daily living
assistance. Note level of
activities.
motivation and interest in
appearance.

Assess sleep and rest JB was unable to sleep

patterns. If problems with before admission. The
sleep continue after prescribed medications Monitor patient’s actual

initiation of medication, are sedating and may ability to complete self-

explore techniques that reverse the insomnia. care activities. Assist

may promote sleep. when necessary.

Structure times for sleep,

rest, and diversional
activities.

Observe patient’s sleep

cycle.

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Evaluation

Outcomes Revised Outcomes Interventions

Within the safety of the Continue to learn about Refer to symptom

nurse-patient schizophrenia. management group at
relationship, JB the mental health center.
acknowledges that his
thinking and behavior
have changed from the
beginning of school
until now. He is
perplexed by the
change.

JB continues to have
hallucinations and
delusional thinking. He
is beginning to develop Encourage JB to practice
Use strategies to reduce
strategies for dealing strategies that reduce
hallucinations and
with the unusual hallucinations and
delusions. Structure
perceptual experiences. delusions. Discuss the
daily activities to avoid
He is also having development of a daily
isolation, withdrawal,
problems with being routine with JB and his
and negative symptoms.
motivated to complete parents.
daily activities.

JB understood that he had

a disorder called
schizophrenia, but was
not sure what it meant.

The medication has

Refer to case manager and
decreased the intensity
Continue to learn about recommend individual
of the hallucinations

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 and the frequency of schizophrenia. supportive therapy at the
delusional thoughts. He mental health clinic.
agrees to take the
Refer to medication group
Risperdal as prescribed.
at the mental health
Through attending the unit Continue to take center.
activities, JB was able to medication as
improve his prescribed.
communication skills
and maintain reality
orientation.

Discuss the possibility of a

day treatment program
for JB that will help him
improve his
Develop communication
communication skills.
skills to interact with
others.

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Nursing Diagnosis 2: Risk for Violence

Defining Characteristics Related Factors

Assaultive toward others, self, and Frightened, secondary to auditory

environment hallucination and delusional thinking

Presence of pathophysiologic risk factors: Excessive activity and explosive agitated

delusional thinking comments (catatonic excitement)

Poor impulse control

Dysfunctional communication patterns

Outcomes

Initial Discharge

1. Avoid hurting self or assaulting other 3. Control behavior with assistance from
patients or staff, with assistance from staff and parents.
staff.

2. Decrease agitation and aggression.

Interventions

Interventions Rationale Ongoing Assessment

Acknowledge patient’s fear, Hallucinations and Determine if patient is able

hallucinations, and delusions change an to hear you. Assess his
delusions. Be genuine and individual’s perception of response to your
empathetic. Assure environmental stimuli. comments and his ability
patient that you will help Patient is truly frightened to concentrate on what is
him control behavior and and is responding out of being said.
keep him safe. Begin to his need to preserve his
establish a trusting own safety.

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 relationship.

Offer patient choices of By giving patient choices, Listen for his response to
maintaining safety: he will begin to develop a choices. Is he able to
staying in the seclusion sense of control over his make choices at this
room, medications to behavior. Seclusion and time? Is he starting to
help him relax. Avoid restraint are options only engage in the nurse-
mechanical restraints and for persons exhibiting patient relationship?
a show of force by having serious, persistent
several persons aggression. The person’s
approaching him at once. safety must be protected
at all times.

The exact mechanisms of

Administer Ativan 2 mg.
action are not understood,
Offer oral medication
but the medication is Observe for relief of
first. If IM necessary, give
believed to potentiate the agitation and side effects:
injections deep into
inhibitory drowsiness, dizziness,
muscle mass; monitor
neurotransmitter γ– constipation, diarrhea,
injection sites.
aminobutyric acid. It dry mouth, nausea.

relieves anxiety and

produces a sedative effect.
Ativan is rapidly absorbed,
thus produces desired
effects quickly.

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Evaluation

Outcomes Revised Outcomes Interventions

JB was placed in seclusion Demonstrate control of Teach JB about the effects

with constant behavior by resisting of hallucinations and
observation. Ativan hallucinations and delusions. Problem-solve
decreased his agitation delusions. with him ways of
and was administered controlling auditory
three times. After 2 days hallucinations if they
he was less agitated and continue.
less aggressive. On his
third day in the hospital,
he was able to come out
of the seclusion room for
brief periods of time. At
these times he would
stand in one spot for as
long as 20 minutes
without moving except to
shake his head once in a
while.

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Nursing Diagnosis 3: Imbalanced Nutrition: Less than Body Requirements

Defining Characteristics Related Factors

Inadequate food intake less than Refusal to eat because of delusional

recommended daily requirement. thinking: He has “the Power.”

Outcomes

Initial Discharge

1. Food intake will match energy 3. Weight will be between 160 and 174 lb.
expenditures (roughly 2,000-3,000
4. JB will be able to describe the food
calories)
pyramid and identify foods he likes and
2. JB will eat at least 3 meals per day, with amounts for each section.
snacks in late afternoon and late
evening.

Interventions

Interventions Rationale Ongoing Assessment

Offer small frequent meals. For someone who has not Intake and output and a
been eating well, small calorie count until fluid
meals are easier to intake is adequate and
tolerate. calorie intake is 2,500 to
3,000 cal.

Intake and output when

Familiar foods are more
family members present.
likely to be eaten.
Suggest parents bring Observe family interaction.
meals that JB likes when
they visit; encourage
family to visit at
mealtimes occasionally.
Observe JB’s interaction
Allow JB to eat alone Being comfortable when with others to know when

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 initially; gradually allow eating is important. A he should be encouraged to
him to eat with increasing patient who is eat with others.
numbers of patients at uncomfortable with
mealtimes. others may not eat in
front of other people.

JB will not be able to retain Assess cognitive functioning

After medications have
information while to determine when
improved JB’s attention
confused and teaching can be
span, teach him about
disoriented. implemented.
nutritious food selection
and the food pyramid.

Evaluation

Outcomes Revised Outcomes Interventions

JB is eating all meals and Maintain adequate Explore the need to

snacks with other nutrition. continue nutritional
patients. He has a healthy education based on plans
appetite and has been for JB and his family after
consuming at least 3,000 discharge.
calories a day. He weighs
158 lb.

JB can identify the foods in

the food pyramid but
states his mother knows
what foods to boy.

SUMMARY OF INPATIENT TREATMENT: JB was discharged 2 weeks after admission. He was

no longer agitated or aggressive. He reluctantly participated in the group activities, but
willingly met with his primary nurse. The discharge plan included JB returning home with his

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parents and beginning outpatient treatment at the community mental health center. JB
adhered to his medication regimen. JB is to participate in the day treatment program.

SETTING: DAY TREATMENT CENTER AT THE COMMUNITY MENTAL HEALTH CENTER

CMHC ASSESSMENT: JB is a 19-year-old with a diagnosis of schizophrenia, catatonic type,

discharged from an inpatient unit. Hears voices (telling him “you have the power”) and has
some delusional thinking (believes people are stealing his thoughts). He is oriented,
coherent, and able to complete basic mathematical calculations. He has been faithfully
taking his medication (Risperdal 4 mg od). No side effects are evident. He is reclusive at
home, staying in his room most of the time. Refuses to contact old friends. He is eating well,
but his parents report that he is not sleeping well at night. They hear him pacing and
mumbling to himself. He then naps during the day. He has agreed to attend the day
treatment program with eventual reintegration into society.

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Nursing Diagnosis 1: Disturbed Sleep Pattern

Defining Characteristics Related Factors

Difficulty falling or remaining asleep Excessive hyperactivity secondary to

catatonic excitement
Dozing during the day
Excessive daytime sleeping

Inadequate daytime activities

Outcomes

Initial Discharge

1. JB will sleep between 5 and 8 hours 3. JB will sleep 7-8 hours each 24-hour
each 24-hour period. period between the hours of 10 PM and
7:30 AM.
2. Describe factors that prevent or inhibit
sleep. 4. Identify techniques to induce sleep.

5. Report an optimal balance of rest and

activity.

Interventions

Interventions Rationale Ongoing Assessment

Assess JB’s sleep cycle. A thorough understanding Determine if JB has trouble

Report time he goes to of sleep cycle is important falling asleep or if he
bed, ability to fall to to develop strategies that wakes up in the middle of
sleep, waking up in the will improve sleep the night. Do his voices
middle of the night. hygiene. and thoughts wake him?
Is there any evidence of
nightmares?

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 Monitor JB’s ability to stay
alert and active at the
Increase activities by Increasing activities during
day treatment center.
attending day treatment the day will help readjust
program daily. Encourage sleep cycle.
JB to resist urge to sleep
during the day. Establish
a daily routine for getting
up and going to bed.

Plan with patient how to

Determine if JB is willing to
increase physical
exercise and can develop
exercise. Regular physical exercise
a realistic exercise plan.
improves sleep hygiene.

Evaluation

Outcomes Revised Outcomes Interventions

After JB began attending None. None.

day treatment program,
he and his family
reported that he slept all
night.

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Nursing Diagnosis 2: Impaired Social Interactions

Defining Characteristics Related Factors

Inability to establish and maintain stable Embarrassment about mental illness

relationship
Communication barriers secondary to
Dissatisfied with social network schizophrenia

Avoidance of others Alienation from others secondary to

hallucinations, delusions, disorganized
Interpersonal difficulties
thinking
Social isolation
Lack of social skills

Outcomes

Initial Discharge

1. Establish a therapeutic relationship with 3. Describe strategies to promote effective

the nurse. socialization.

2. Identify barriers in interpersonal 4. Practice new social interaction skills.

relationships that interfere with
socialization.

Interventions

Interventions Rationale Ongoing Assessment

Initiate a nurse-patient Through a nurse-patient Determine whether or not

relationship with JB. relationship, the patient JB can engage in a
Establish a time each day can learn about his relationship.
to meet with him to strengths and
support him as he learns limitations.
to cope with his disorder.

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Provide supportive group
therapy to focus on the
The negative symptoms of Assess JB’s ability to
here-and-now, establish
schizophrenia can make interact in the group.
group norms that
it difficult to
discourage inappropriate
automatically recall
social behavior, and
appropriate social
encourage testing of new
behavior. Reinforcing
social behavior.
appropriate behavior in
a group can help the
patient add new skills to
a limited repertoire of
behaviors.

Role-play certain accepted Through practicing social

social behaviors. Foster interaction, the patient
development of can become comfortable
relationships among in social situations.
group members through Assess JB’s willingness to
self-disclosure and participate with others.
genuineness. Encourage Assess the availability of
members to validate their people who are his age
perception with others. and have similar

Monitor adherence to interests.

medication regimen.
Encourage JB to attend
Patients may not be aware
medication group. Ask
that symptoms are
patient about specific
erupting. By specifically
side effects and symptom
asking about symptoms
exacerbations. Encourage
and medication side
JB to attend the evening Assess for nonverbal cues
effects, patients can
symptom management that symptoms are
focus on specific

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 group. experiences that present. Monitor for
represent evidence of relapse.
Identify the environment in
symptomatology.
which social interactions
are impaired (living, Different social skills are
learning, working, needed in different
leisure). situations.

Role-play aspects of social

interactions such as
initiating/terminating a
conversation, refusing a By practicing specific skills,
request, asking for patients will be able to
Assess for readiness to
something, interviewing use them in specific
return to learning and
for a job, asking someone situations. It is then
working environment.
to participate in an possible to assign a
activity (going to a patient to practice a
movie). Give positive specific social skill. Too
feedback. Focus on no much feedback adds
confusion and increases Assess for ability to engage
more than three
anxiety. in social interactions.
behavioral connections at
a time.

Assist family and

community members in
understanding and
providing support. With
JB’s permission, develop
an alliance with the Family members are often

family. Encourage them the patient’s main

to attend a support source of support. The

group. family needs help and

support in dealing with

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 the care of a person with
a long-term mental
illness.

Assess family interaction.

Evaluation

Outcomes Revised Outcomes Interventions

JB was able to establish a Continue to develop social Continue on a part-time

therapeutic relationship interaction skills. Discuss basis with the day
with one of the nurses. with the group the treatment center.
Through the relationship everyday problems
and the group, JB encountered outside the
identified barriers in his day treatment
interpersonal environment.
relationships. He was
afraid of telling his friends
about the mental
disorder.

JB was able to practice

various communication
strategies and eventually Continue to practice

was able to contact his communication strategies.

Maintain medication Monitor medication
old friends. He also

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 developed some new adherence. adherence and ability to
ones and started sharing communicate.
leisure activities with
them.

JB would like to return to

school and live at home.

Enroll in community college

for one course.

Teach patient about dealing

with stress and relapse
prevention techniques.

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 PSYCHOSIS AND HIV AND AIDS
Definition

It is a severe mental disorder in which thought and emotions are impaired that contact is lost with
external reality

Or

It is a serious mental disorder characterized by thinking and emotion that are so impaired that they

Causes of psychosis

The causes of psychosis have been divided into three [3] main classes. These are;

 psychological [mental] conditions

 General medical conditions e.g. malaria, syphilis and HIV
 substances such as alcohol and drugs

Psychological conditions

The following conditions have been known to trigger psychotic episodes in some people

 schizophrenia; a chronic [long term] mental condition that causes hallucinations and
delusions
 Bipolar disorder ; a condition that affects a person’s mood ,which can swing from one
extreme to another[highs and lows].
 severe stress and anxiety
 severe depression; feelings of depression and sadness that last for more than six weeks
including post natal depression which some women experience after delivery
 lack of adequate sleep

GENERAL MEDICAL CONDITIONS

These are known to trigger psychotic episodes in some people.

 HIV/AIDS; a virus that attacks the immune system[the body’s natural defense against illness
and infection]
 Malaria; a tropical disease spread by an infected female anopheles mosquito
 Syphilis; a bacterial infection that’s usually passed on through sexual contact
 Parkinson’s disease ;a long term condition that affects the way the brain co-ordinates body
movements including walking, talking and
 Hypoglycemia; abnormally low sugar levels in blood
 Brain tumors ;a growth of cells in the brain that multiply in an abnormal or uncontrollable
way

SUBSTANCES

Alcohol misuse and drugs can trigger a psychotic episode.

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A person can also experience a psychotic episode if they suddenly stop drinking alcohol or taking
drugs after having used them for a long time. This is known as withdrawal.

Drugs known to trigger psychotic episodes include;

 cocaine
 amphetamine
 methamphetamines [crystal meth]
 mephedrone [MCAT]
 cannabis
 ketamine

SIGNS AND SYMPTOMS

 Hallucinations; a person perceives something that doesn’t exists in reality. It occurs in live
senses i.e. sight, sound, touch, smell and taste
 Delusions; an idiosyncratic belief or impression that is not in accordance with a generally
accepted reality.
 confused and disturbed thoughts; people with psychosis often have disturbed or confused
and disrupted patterns of thought
 lack of insight and self awareness; people who have psychiatric episodes are often totally
immature. Their behavior is in any way strange
 Depression

MANAGEMENT

INVESTIGATIONS

 Medical history and physical examination

 To identify pos
 CT scan
 MRI
 ECG
 CBC
 Pregnancy test
 RPR
 Liver function test

TREATMENT

ANTI PSYCHOTIC DRUGS

Haloperidol

Phenothiazine

Chlorpromazine

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Fluphenazine

Ileperidone

MECHANISM OF ACTION

All anti-psychotic drugs are more effective than placebo in treating symptoms of psychosis but some
people do not respond fully to the treatment. They work by affecting the work of dopamine a
neurotransmitter in the brain by blocking its receptor sites helping patient calm down.

SIDE EFFECTS

Drowsiness, stiffness and shaking

PSYCHOLOGICAL THERAPIES

BEHAVIORAL THERAPY

These are techniques based on learning theories that are used in order to distinguish normal
behavior to abnormal behavior

COGNITIVE BAHAVIOR THERAPY

Its development was prompted by observation of psychotic patients, how they conduct themselves
and view themselves negatively, their future and environment, Hence this therapy is based on idea
that disorder is not caused by events but by how patient handles the event e.g. loss of a loved one ,
disappointment from the loved one

RATIONAL EMOTIVE THERAPY

It proceeds by guiding the patient to identify challenges and change their irrational thought. These
can be viewed as a series of “I MUST” behavior in relation to on self, others and the environment
e.g. The feeling of I must be better that everyone else all the time failure to which patient feels
worthless and not good enough

INTERPERSONAL THERAPY

This focuses on current inter personal relationships and their relationship to development of illness.
Interventions are directed at dysfunction in social relationship’s rather than underlined belief.
Treatment is inventory for all close relationships and focus is on role transitions e.g. new mother,
work difficulties and relationship problems

HIV/AIDS
HIV-Human immune deficiency virus, this is the virus that causes AIDS by a lowered functioning of
the immune system.

AIDS- Acquired immune deficiency syndrome, it comes about when the HIV infection is so massive
that it destroys a large number of the immune system processes and leads to the patient having

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multiple opportunistic infections resulting into illness such as chronic diarrhea, persistent fever,
weight loss, anemia, and a typical rash

WAYS OF TRANSIMMISSION

HIV is transmitted primarily via penetrative unprotected sexual intercourse including anal and oral
sex, with an infected person. Blood transfusion with infected blood, sharing sharp instrument with
an infected person, mother to child transmission and contact with infected blood through broken
skin or open wounds.

Organ transplant with an infected person.

SIGNS AND SYMPTOMS

There are three main stages of HIV infection which are Asymptomatic also called Acute infection,
symptomatic (Clinical latency) and the AIDS stage.

ASYMPTOMATIC (Acute Infection)

This stage usually follows the contraction of HIV, many individuals develop an influenza like illness
and generalized lymphadenopathy while others have no significant symptoms.

SYMPTOMATIC STAGE (CLINICAL LATENCY)

The initial symptoms are followed by this stage, the patient will present the following signs and
symptoms; fever, weight loss, gastrointestinal problems, muscle aches, skin infection, puritis, herpes
zoster within last 5yers, recurrent of upper respiratory tract infection.

The secondary stage of HIV infection can vary between years, during this phase of infection, HIV is
active within lymph nodes, which typically become persistently swollen, in response to large amount
of viruses that become trapped in the follicle dendrite cells network.

LAST STAGE (AIDS)

In the last stage symptoms of AIDS start to manifest such as weight loss, chronic diarrhea more than
1month, unexplained prolonged fever etc. the immune system tend to be weak thereby allowing
opportunistic infections.

TREATMENT OF HIV/AIDS

• There is no definitive data currently existing regarding superiority of one’s acceptably potent
initial regimen over another, therefore no recommendation of individual drugs is possible. The initial
choice must be individualized based on the strength of the supporting data on the following criteria;

• Regimen potency

• Tolerability with low adverse effects profile

• Drug interaction

• Convenience and adherence likelihood

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• Potential for alternative treatment option if initial regimen fails

• Cost

• Availability

ARVs (ANTIRETROVIRALS) RECOMMENDED FOR FIRST LINE REGIMENS

Zidovudine + Lamivudine+Abacavir or

Zidovudine + Lamivudine+ Efavirenz or

Stavudine + Didanosine+ Efavirenz/ Niverapine

Monotherapy is not recommended due to the rapid emergency of resistance and poor response.

ZIDOVUDINE

Action: Antiretroviral

Dose: 200mg 8hourly or 300mg twice in a day

Route: Oral

Side effects: headache, fatigue, nausea, diarrhea, skin rash, abdominal pains.

Nursing Implication: check for pallor, check for excessive reactions e.g. headache and report the side
effects

LAMIVUDINE

Action: Antiretroviral

Dose: 150mg twice daily

Route: Oral

Side Effects: headache, fatigue, skin rash, diarrhea, nausea, diarrhea

Nursing Implication: Give with food; observe for dehydration and extent of rash.

DIDANOSINE

Action: Antiretroviral

Dose: 200mg

Route: Oral

Side Effects: diarrhea, nausea, vomiting, abdominal pains, peripheral neuropathy in severe reactions.

Nursing Implication: make sure patient chews the tablets; observe for signs of dehydration and signs
of peripheral neuropathy

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EFAVIRENZ

Acton: Antiretroviral

Dose: 600mg nocte

Route: Oral

Side Effects: skin rash, neurological disturbances, hepatitis

Nursing Implication: give at a right time, observe for rash, jaundice

ABACAVIR

Action: Antiretroviral

Dose: 300mg twice daily

Route: Oral

Side Effects: Nausea, anorexia, fatigue, sleeps disturbances, rash

Nursing Implication: Observe appetite; observe skin rash and report as treatment is discontinued in
hypersensitivity.

NEVIRAPINE

Action: Antiretroviral

Dose: 200mg once daily for 14 days 400mg

Route: Oral

Effects: skin rash, abdominal pain

Nursing implication: observe skin rash, jaundice

HIV AND PSYCHIATRY CLINICAL PRESENTATION

1. Depression- individuals with HIV/AIDS become depressed at diagnosis period. Clearly depression
in this context has multiple causes and the challenge is to identify all the contributing factors.
Depression illness should be differentiated from physical effects of HIV such as weight loss, loss of
energy as well as from HIV related Dementia problems of weight loss and headache.

2. suicide- High risk factors of committing suicide in individuals who are HIV positive are at risk
higher than those who are not as a result of death of friend and individual experiencing
deterioration in physical health

3. Mania-manic symptoms may develop in the context of HIV psychosis or as a result of treatment
with ARV’S. Treatment with lithium is evidence suggesting that sodium valproate may increase viral
replication and reduce white cell count

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4. Anxiety- infection with virus related is associated with risk of generalized anxiety disorder, panic
attacks, post-traumatic stress diseases and obsessive compulsive disorders

5. Delirium- this is due to infections of the brain by virus or secondary infections or tumors. Delirium
may be the initial manifestation of HIV associated dementia.

6. Psychosis- a psychotic illness characterized by fluctuating symptoms that may alter over’s hours to
days may occur in the context of HIV infection

The improved outcome for patients on anti-retroviral therapy brings additional stress related to
living with uncertainly about the future. The responsibility of case takes beyond healing immediate
physical problems immediate .Holistic practices require the health care professional to adopt a true
bio psycho social approach with appreciation of emotional status of the patient as well as the host of
social economic, spiritual and ethical challenges accompanying diagnosis of the disease.

CONTEXT IN WHICH PSYCHIATRIC PROBLEMS MAY ARISE IN HIV POSITIVE PEOPLE

The worries HIV negative People may be concerned with infected due to contact with an HIV positive
source or individual

• Pre testing anxiety

• Post testing stress may precipitate a psychiatric illness such as adjustment disorder, major
depression episodes and they may become suicidal

• Living with HIV/AIDS often results into stressful life events e.g. losing a job, becoming
economically disadvantaged and experiencing social alterations

• HIV directly affects the neurons in the brain causing neuro psychiatric symptoms

• HIV patients are susceptible to secondary opportunistic infections which manifest as neuro
psychiatric symptoms eg AZT may precipitate a major depressive disorder while isoniazid
prophylaxis is known to precipitate a psychotic illness

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Unit 5: condition not attributed to mental Disoder that are a focus of
attention and treatment

MENTAL RETARDATION
Introduction

When onset occurs at the age of 18 or after the condition cannot be called mental
retardation but dementia which can coexist with a diagnosis of mental retardation.

Intelligence levels as determined by individual standards, assessment is below 70, and the
ability to adapt to the demand of normal life is impaired. This is important because it
distinguishes a diagnosis of mental retardation from individuals with low intelligence
quotient iq but are able to adapt to demands of everyday life.

Education, job training, support from family, and individuals characteristics such as;
motivation and personality can all contribute to the ability of individuals with mental
retardation to adapt.
Definition of terms

1. Mental: relating to disorders or illness of the mind.

2. Retardation: Being less advanced in mental physical, or social development than usual for
ones age.
3. Mental retardation: Is a mental or mind disorder diagnosed before the age of 18 usually
in infancy or prior to birth and is characterised by luck of skills necessary for daily living and
below average intellectual function.
[Link]; refers to the ability to reason and understand objectives.

Other behavioral traits associated with retardation but not deemed criteria for mental
retardation diagnosis.

These traits include; aggression,dependency,impulsivity, passivity,self injury, and

sturbonness, low self esteem and low frustration tolerance. Some may also exhibit mood
disorders, such as psychotic and attention disorders through others are pleasant, otherwise
they are physically healthy individuals.

Sometimes physical traits like shortness in stature and malfomation of the facial traits
/elements, while others may have nomal appearance.

Levels of mental ratardation

1. Mild
2. Moderate
3. Severe

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 4. Profound

MILD MENTAL RETARDATION

People with mild mental retardation have few physical impairement,reach the sixth grade in
accademic functioning aquire vocational skills and live in community with or without special
support. They have an IQ scores of behavior 50-55 and 70.

MODERATE MENTAL RETARDATION

These people have obvious physical abnomalities such as of the features of down
[Link] develop into adults with mental ages of about 8-12 years children.
(moron). Academic achievements generally reaches second grade level.

Work activities require close training and supervision and special supervision in families or
group homes in the community. They have IQ between 35-40 and 50-55.

Severe mental retardation

At this severity level, motor development is abnomal,communicative speech is limited and

close supervision is needed for community living mental adult age is from 3-7 years
(imbecile) their IQ score are between 20-25 and 35-40.

Profound mental retardation

Motor skills, communication and self care are severely limited and content supervisions is
required in the community or institution. Their mental adult age is below3 years(idiot) and
their IQ scores are below 20-25 years.

[Link] retardation affect about 1% to 3% of the population.

Causes

Causes of mental retardation are numerous, but specific reasons for mental retardation are
determined in only 25% of cases. Failure to adapt normally and to grow intellectually may
become apparent in early life or, in the case of mild retardation, may not become
recognisable until school age or later. Assessment of age or later. Assessment of age –
appropriate adaptive behaviours can be made by the use of developmental screening test.
The failure to achieve developmental screening tests. The failure to achieve developmental
milestones is suggestive of mental retardation.

A family may suspect mental retardation if motor skills, language skills do not seem to be
developing far more slowly than others peers of the same age group. The degree of
impairment from mental retardation ranges widely, from profound impairment to a mild or
borderline and more on the amount of intervention and are required for daily activities.

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  Trauma. head penetrating injuries
 infections eg syphillis,meningitis
 metabolic disorders, eg mal absorption syndrome
 genetic abnormalities; can be inherited
 environmental factors eg exposure to toxins eg lead
 chromosomal disorders. Eg down syndrome

SIGNS AND SYMPTOMS

Persistent infertile behaviour

Lack of curiosity
Decrease in learning ability
Inability to meet educational demands of school.
Failure to meet intellectual developmental makers.
Treatment/ rehabilitation

In order to develop an appropriate treatment plan, an assessment of; family history such as;
age, appropriate adaptive behaviours should be made using the developmental screening
tests.

The objectives of these tests are to determine which developmental milestone have been
missed. The primary goal of treatment is to develop the persons potential to the fullest.
Special education and training may begin as early as infancy.

Attention is given to social skills to help the person to function as normally as possible.

It is very important for a specialist to evaluate a person for coexisting affective disorders
that may require treatment. Behavioural approaches are important in understanding and
working with mentally retarded individuals in order to bring them to the normal functional
capacity of society.

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ATTENTION DEFICIT HYPERACTIVITY DISORDER (ADHD)

What is attention deficit hyperactivity disorder?

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood
disorders and can continue through adolescence and adulthood. Symptoms include
difficulty staying focused and paying attention hyperactivity (over activity).

ADHD has three subtypes;

1 .Predominantly hyperactive-impulse

- Most symptoms (six or more) are in the hyperactivity-impulsivity categories.

- Fewer than six symptoms of inattention are present, although inattention may still
be present to some degree.

2 . predominantly inattentive

- The majority of symptoms (six or more) are in the inattention category and fewer than six
symptoms of hyperactivity-impulsivity may still be present to some degree.

- Children with this subtype are less likely to act out or have difficulties getting along with
other children. They may sit quietly, but they are not paying attention to what they are
doing. Therefore, the child may be overlooked, and parents and teachers may not notice
that he or she has ADHD.

3 .Combined hyperactive-impulsive and inattentive

- Six or more symptoms of inattention and six or more symptoms of hyperactivity-

impulsivity are present.
- Most children have the combined type of ADHD.

SIGNS AND SYMPTOMS

Inattention, hyperactivity and impulsivity are the key behaviors of ADHD. It is normal for all
children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD,
these behaviors are more severe and occur more often to be diagnosed with the disorder, a
child must have symptoms for 6 or more months and to s degree that is greater than other
children of the same age.

Inattention symptoms

- They easily distracted, miss details, forget things and frequently switch from one
activity to another.
- Have difficulty focusing on one thing

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 - Become bored with a task after only a few minutes, unless they are doing something
enjoyable
- Have difficulty focusing attention on organizing and completing a task or learning
something new.
- Have trouble completing or turning in homework assignments often doing things (e.g
pencils toys assignments) needed to complete tasks or activities.
- Not seem to listen when spoken to.
- Daydream, become easily confused and move slowly.
- Have difficulty processing information as quickly and accurately as others Struggle to
follow instruction.

Hyperactivity symptoms

- Fidget and squirm in their seats

- Talk nonstop
- Dash around, touching or playing with anything and everything in sight
- Have trouble sitting still during dinner, school and story time
- Be constantly in motion
- Have difficulty doing quiet tasks or activity

Impulsivity symptoms

- Be very impatient
- Blurt out inappropriate comments, show their emotions without restraint and act
without regard for consequences
- Have difficulty waiting for things they want or waiting their turns in games
- Often interrupt conversations or others` activities.

ADHD can be mistaken for other problems

Parents and teachers can miss the fact that children with symptoms of inattention have the
disorder because they are often quiet and less likely to act out. They may sit quietly,
seeming to work, but they are often not paying attention to what they are doing. They may
get along well with other children, compared with those with the other subtypes, who tend
to have social problems. But children with the inattentive kind of ADHD are not the only
ones whose disorder can be missed.

Those at risk

- Boys are four times at risk than girls

- The disorder affects 9.0% of American children age 13 to 18 years
- The average age of onset is 7 years old

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Diagnosis

No single test can diagnose a child as having ADHD. Instead, a licensed health professional
needs to gather information about the child and his or her behavior and environment.
Between them, the referring pediatrician and specialist will determine if a child:

- Is experiencing undetected seizures that could be associated with other medical

conditions
- Has a middle ear infection that is causing hearing problem
- Has any medical problems that affect thinking and behavior
- Has any undetected hearing or vision problems
- Has any learning disabilities
- Has anxiety or depression, or other psychiatric problems that might cause ADHD-like
symptoms.

The specialist also will ask;

 Are they behaviors a continuous problem or a response to a temporary situation?

 Do they happen more often in this child compared with the child`s peers?
 Are the behaviors excessive and long-term, and do they affect all aspects of the
child`s life.
 Do the behaviors occur in several settings or only in one place, such as the
playground, classroom, or home?

Some children with ADHD also have other illnesses or conditions. For example, they may
have one or more of the following:

1. A learning disability. A child in preschool with a learning disability may have

difficulty understanding certain sounds or words or have problems expressing
himself or herself in words. A school-aged child may struggle with reading, spelling,
writing and math
2. Oppositional defiant disorder. Kids with this condition, in which a child is overly
stubborn or rebellious, often argue with adults and refuse to obey rules.
3. Conduct disorder. This condition includes behaviors in which the child may lie, steal,
fight, or bully others. He or she may destroy property, break into homes, or carry or
use weapons. These children or teens are also at a higher risk of using illegal
substances. Kids with conduct disorder are at risk of getting into trouble at school or
with the police
4. Anxiety and depression. Treating ADHD may help to decrease anxiety or some forms
of depression.

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 5. Bipolar disorder. Some children with ADHD may also have this condition in which
extreme mood swings go from mania (an extremely high elevated mood) to
depression in short periods of time.

Treatments

Currently available treatments focus on reducing the symptoms of ADHD and improving
functioning. Treatments include medication, various types of psychotherapy, education or
training, or a combination of treatments.

The most common type of medication used for treating ADHD is called a ‘’stimulant’’. Below
is a table of drugs used.

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Trade name Generic name Approved age
Adderall Amphetamine 3 years and older
Adderall XR Amphetamine(extended 6 years and older
release)
Concerta Methylphenidate (long 6 years and older
acting)
Daytrana Methylphenidate patch 6 years and older
Desoxyn Methamphetamine 6years and older
hydrochloride
Dexedrine Dextroamphetamine 3 years and older
Dextrostat Dextroamphetamine 3 years and older

Not all ADHD medications are approved for use in adults.

NOTE; ‘’extended release’’ means the medication is released gradually so that a controlled
amount enters the body over a period of time. Long acting means the medication stays in
the body for a long time.

Side effects of stimulant medications

 Decreased appetite
 Sleep problems
 Anxiety
 Irritability
 Mild stomach-ache and headache

Under medical supervision, stimulant medications are considered safe. Stimulants do not
make children with ADHD feel high, although some kids report feeling slightly different or
‘’funny’’. Although some parents worry that stimulant medications may lead to substance
abuse or dependence.
But note that no medication cure ADHD. Rather, they control the symptoms for as long as
they are taken.

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Unit 5: Management of a client with Psychiatry emergency

Aggressive

Aggressive behavior generally includes abusive language, violent threats of harm,

physical assault to self or others, & damage to property. Behavior may be
understood in terms of negative appraisals & attitudes toward self, others, the world
& the future.

Aggression, hostility-related behavior

 Related variables to hostility are emotions, attitudes & behaviors that occur
regularly & are predictable in aggressive & violence-prone individuals.
 Emotions – such as anger, irritability & resentment à which can lead to BP &
heart disease.

 Attitudes – such as persistent negative views of others & the world, cynicism,
mistrust, suspiciousness & looking at everything in it’s worst light.

 These emotions & attitudes may result in hostile behavior a.k.a. expressive
hostility – such as facial expressions, body language, verbalizations, gestures,
acts against self, others or property.

Anger

 Is an emotion that occurs when an individual’s expectations are not met.

 It can be a positive emotion when it motivates some positive change.

 It loses it constructiveness when it is turned inward, is used ineffectively

towards others with little or no cause, bullies, harms or hurts self or others,
or is expressed out of control.

Impulsivity

 Is a way of interacting à acts performed with little or no regard for the

consequences (In MH nursing impulsivity can be viewed as being related to
an underlying disorder or pervasive personality trait).
 Impulse control disorders are characterized by three things:

o An inability to control an impulse viewed as harmful.

o A sense of increasing tension.

o A sense of excitement, gratification & tension release

during the act.

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  Possible causes of impulsivity are – a life pattern of impulsive behavior,
nervous system abnormalities, anxiety, life crisis, & sexual & aggressive
drives.

 Signs/symptoms of impulsivity may include – unpredictable behavior, threats

towards others, irresponsible acts, low frustration tolerance, poor problem
solving skills, disturbed interpersonal relationships, restlessness & general
disregard for social rules & customs.

Violence

 Is a form of aggression.
 Includes verbal or written threats (including sexual harassment), physical
assault (including sexual assault) and damage to property.

 Intent – is what differentiates accidental harm or injury from purposeful

harm or injury.

Aggressive behaviors & violence occur in all clinical diagnostic categories à however
certain subgroups of psychiatric diagnosis have been linked with violent behavior
such as:

 Antisocial personality disorder

 Paranoid schizophrenia

 Schizoaffective disorder

 Bipolar disorder

 Substance abuse disorder

Profiles related to aggressive behavior

Client arrest profiles – show that those hospitalized in public psychiatric facilities
tend to have higher arrest rates than the general public. Arrests for aggressive
behavior were higher in antisocial personality, paranoid schizophrenia & substance
abuse disorder à and highest in schizoaffectrive disorder.

Inpatient profiles – show that most incidents occur the 1st week of hospitalization &
steadily decline, are highest in males 26-35 y/o and females 36-45 y/o. Physical
incidents occurred more with men & suicide occurred more often with women. The
most common diagnosis was schizophrenia (highest for assault), substance abuse or
major depression.

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  Two types of antecedent events of escalating violence were linked with staff-
client interactions

 A. Where the patient is frustrated or angered do to, for example, not

being able to leave the ward/unit, a dispute over medications or not
having a request granted. (Staff should explain all behavior or verbal
requests).

 B. Ignoring the patient – Here the patient may become aggressive to

gain staff attention.

 Client backgrounds – Rural vs. Urban – studies suggest a higher incidence of

aggressive behavior of patient’s from rural areas. Possibly due to abused
substances prior to admission & barriers to mental health care in rural areas.

Outpatient profiles

 30% of male & female psychiatric patients with a HX of violent behavior will
become violent again within a year of discharge à and may be related to
medication noncompliance à they feel good & stop taking their medications.
This is why patient teaching is so important!

Families with a mentally ill member

 Families with a violence-prone mentally ill member – report other family

members as being the object of an attack 56% - 65% of the time.

General Population vs. Seriously Mental Ill

 Findings support an increased risk of violence among mentally ill persons

with a HX of violent behavior, substance abuse & noncompliance with
medications when compared with the general population.

AGGRESSION – WHAT DETERMINES IT?

 First let’s define aggression – which is any behavior that expresses anger or
its related emotions.
 Now, to answer your question – aggressive is determine by several factors
including psychological, biological, sociocultural & environmental.

 The Psychological view (or theory) refers to the classic frustration-aggression

theory that states as people become more frustrated à the greater the
chance for aggressive behavior. An example might be – you searching &

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 searching for a major care plan paper that’s due that morning, which is lost in
the mess that is your house since you began nursing school, as you continue
to search & continue NOT to find the paper your frustration builds until you
are yelling at your house plants & throwing dirty laundry about in anger… a
mild example… but you get the picture!

 The Temperament view (or theory) – refers to your personality disposition

(which is partly inherited). It is thought to influence three parts of the
personality: negative emotionality, positive emotionality & constraint.

o Negative emotionality – is most commonly discussed as a ‘difficult’

temperament à this is the shy, inhibited person who is withdrawn in
novel or new situations, has irregular biological functions, is slow to
adapt, with an intense & negative mood.

o Positive emotionality – refers to the easy person, who has regular

biological functions, positive & active with people, seeks out new
situations, positive adaptation, agreeableness & a mild & generally
positive mood.

o Constraint – examples include – people high in constraint are

conscientious, cautions, reliable, responsible & hardworking while
those low in constraint are impulsive, careless & concerned with their
own immediate wants.

 The Cognitive view (or theory) – refers to how a person thinks, or interprets
situations & events – and how they interpret or view the event determines
whether or not they become aggressive.

o A person uses their attitudes, beliefs & appraisals to explain or

interpret events that happen. (That appraisal you do in your head is
referred to as self-talk, private speech or automatic thoughts – they
all refer to the same thing).

o If a person appraises an event or situation as aversive (unpleasant) &

anger inducing à then it is likely that they will react with anger.

 The Neurobiological view (or theory) – Research, through brain

neuroimaging, has found that neurobiological deficits or injuries in the limbic
system or frontal or temporal lobes of the brain are related to aggressive
behavior.

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  Aggressive behavior, personality changes & irritability have been seen incases
of limbic tumors & frontal lobe lesions. Rabies, encephalitis & some brain
injuries are associated with loss of impulse control.

Neurotransmitter Dysregulation

 Low Serotonin Syndrome – refers to, of course, conditions of low serotonin or

low 5-hydroxyindoleacetic acid (a.k.a. 5-HIAA) a little ol’ metabolite of
serotonin in the CSF (cerebrospinal fluid) à this is characterized by episodes
of mood changes and/or impulsive behavior.
 Studies have found that patients who attempted suicide had the lowest CSF
levels of 5-HIAA.

 MAO activity may also be linked to behavioral expression of aggression à

MAO metabolizes serotonin & thus contributes to decreased serotonin levels
in the brain… physiology is just too cool…

Substance Abuse

 Alcohol intoxication is often a contributor to violent behavior. Studies suggest

that alcohol abusers have a neurological defect in serotonin turnover à this
deficit increase the chance for violent behavior. This defect id thought to be
inherited.

The Social learning view (or theory)

 Explains aggressive behavior as learned from exposure to aggressive models

(i.e. in the family, gangs, TV, movies, video games) or as the result of random
positive reinforcement or direct experience.

Environmental & situational determinants

 Dehospitalization & deinstitutionalization have resulted in thousands of MH

displacements.
 There is a great need for a supportive social network after discharge.

 Dehospitalization & unsupervised patients in the community may become

involved in antisocial acts & violence.

The Nursing Process

Assessment

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  watching and listening for clues to behaviors allows the nurse to prevent
angry and hostile feelings from turning into something dangerous (i.e. the
person acting with violence)
 The following are causes to aggressive or dangerous behavior:

 Thinking and perception- A person having hallucinations or delusions that

are threatening to hurt them or commanding them to hurt someone else.
(ex: women thinks husband is trying to kill her)

 Motor activity- A person with increased psychomotor agitation can indicate a

person cannot tolerance others being close or a way to release building
tension is not available. (ex: a pacing person)

 Mood and Affect- Has their mood and affect become more intense? Angry
tone of voice that gets louder. Is there a noticeable change in the way they
express themselves?

 Physical state- Are they in a state where they cannot communicate a

warning- such as beginning seizures, delirium or brain lesions.

 Context- Does the person have a history of violent outbursts against

themselves or others (include criminal behavior and suicide).

Some studies say the single best predictor of violence is a history of violence à Ask
that question, "Do you feel like hurting yourself or anyone else?" (This does not
suggest violence to the person but gives them a route of expression by talking about
it rather than acting out)

There should be concern about the following types of patients as well:

 Those who lack perspective regarding their anger

 Those who continually want to hurt specific others

 Those with a history of episodic aggression

 Those who do not verbally communicate their anger to others.

 Assault occurred more frequently with schizophrenia, mania or organic

psychotic conditions.

Some of the tools (scales or tests) used to measure aggressive behavior include
the:

 Overt aggression scale (OAS) – this is used to document behaviors and

interventions during an aggressive episode. It helps to justify the use of

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 medications and is a way to compare other facilities to one another in terms
of using seclusion, restraints and PRN meds.
 The Minnesota Multiphasic Personality Inventory - measures general
psychopathology through a variety of tests.

 The Brief Anger Aggression Questionnaire- is a six-item measure (test) used

for quick assessment of irritability and tendency toward aggressive or violent
behavior.

Nursing Diagnosis

 Risk for violence: self directed or directed at others. Will be the primarily
relevant diagnosis with aggressive and violent persons.

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Patient Outcomes and Goals

 The ultimate goals are to improve the patient’s health outcomes and health
status.

Discharge Planning

 Early discharge of violent or potentially violent persons is a growing and

urgent concern to all.
 Continuity of care involves:

 A seamless care delivery system after discharge. Here all care systems work
from one database to meet patient needs.

 Creating a through-computerized database on the patient. That can be

quickly assessed for inpatient and outpatient use.

 Collect outcome data- what interventions worked? Medication effects? Side

effects?

 Recent research findings show that intensive case management programs are
effective in reducing patient’s dangerousness in the community.

Interventions

 Staff must maintain attitudes of caring, concern and nonauthoritarianism,

while setting appropriate limits to demonstrate social norms within the
milieu. (This is essential to prevent violent behavior, especially on inpatient
units)
 Self-awareness by the nurse: The nurse should be awareness for herself, that
in the fall of aggressive or assaultive behavior a universal response is fear.
Outcomes of the nurse’s fear could lead to countertransference reaction due
to angry feelingè which leads to limit setting, instead of talking through
behavior. Anxiety reactions due to helpless feelingè leading to right from the
situation. Or a therapeutic reactionè where the nurse explores thoughts,
feelings and behaviors.

Three Intervention Strategies

 Include verbal, pharmacological (medications) and physical (seclusion and

restraint). Used separately or in combination.

Safety Guidelines when Interacting with Angry or Potentially Aggressive Patients:

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  Stand just outside the patient’s personal space (slightly out of arms reach)
 Stand on the patients nondominate side (usually the side the wrist watch is
worn)

 Keep the patient in visual range

 Make sure the door is accessible

 Don’t let the patient come between you and the door

 Retreat from the situation and call for help if the patient becomes violent.

 Avoid dealing unaided with a violent patient

Verbal Intervention

 It is most helpful with milder levels of aggression, although it works for all
and can prevent escalation of aggressive behavior.

 Attend to what the patient is saying with empathy and genuine concern

 Talk with the patient one on one.

There are 3 phases to verbal intervention to prevent the escalation of

agressiveness:

1. Make contact- appear calm and in control when approaching the patient.
Speak in a normal tone and nonjudgemental. Watch their verbal and
nonverbal behavior. Tell them what you see them doing behaviorally and
how you think they feel. Then check your understanding. Example: Sue, I see
you pacing and hitting your leg with a magazine. You seem angry. Are you
angry?
2. Discovering the source of distress- use open-ended questions to elicit more
meaningful descriptions. Encourage the patient to describe and clarify the
problematic feelings and what triggers them (increases the patient self-
awareness). Don’t ask why questions (puts them on the defensive). Do not
"parrot" this patient rather paraphrase.

3. Focus on the patients competency and alternative problem solving: If

possible talk with the person how their ideas regarding a plan that would
help them deal with the situation.

Limit Setting

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  Is a process through which someone in authority determines temporary and
artificial ego boundaries for another person.
 The nurse must have a keen sense of detecting a patient’s desire for control
and must be able to set limits without being punitive. It is usually reassuring
to patients to know that they will not be allowed to be destructive to self,
others or property,

 Compliment patients on whatever degree of control they can maintain.

(saying,"Aren’t you proud of yourself?) This focuses the patient on pride in
his own behavior rather than pleasing another person.

 Knowing limits gives the patient a framework within which to function more
freely and adequately, maintain self-esteem, learn new behaviors and gain
new self-awareness.

The following are useful for setting limits:

1. Assess the need for limit setting.

2. Describe the patient’s unacceptable behavior and communicate expected
behavior and give alternatives. Acceptable substitute behaviors for example
are walking with the nurse, talking about feelings and thoughts, or
participating in recreational therapy.

3. State the limit. Inform the patient exactly what the consequence or limit is.

4. Help the patient understand the reason for the limit. Explaining
consequences gives the patient a sense of responsibility for the outcomes or
results of behavior.

5. Enforce the limit. When a patient tests a limit, they experience some anxiety
and having the stuff respond in a predictable manner ensures the safety and
protection of the patient and provides security and comfort.

Remember DISC:

D - describe patient behavior

I - indicate desired behavior

S - specify nurses’ actions

C – confronts with positive or negative consequences

Intervention with medication in managing aggression:

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  May be needed to calm when the patient does not respond to verbal
intervention.

 Medications may not be advisable if the assaultive patient is believed to be

under the influence of an unknown drug.

 Antipsychotics are the most commonly used for aggression in acute psychosis
è the sedative effect decreases the aggression (Haldol, Thorazine, Clozaril and
Risperdal).

 Rapid tranquillization may be used.

 Haloperidol and diazepam (a benzodiazepine) are most commonly used PRN

for sedation and calmness. Works within 30 minutes è and provides a "calm
settle" within 1 hour.

 Lithium is effective in decreasing aggression, irritability, manipulation,

persecutory delusions and hostile behaviors. Also decreases aggression and
self-injurious behavior in children è however it may increase aggression in
patients with temporal lobe epilepsy. (lithium is an antimanic)

 Antidepressants – have also been used to decrease aggression. (Elavil,

Desyrel, Prozac, and Zoloft)

 Sedative and anxiolytics such as benzodiazepines (Ativan), barbiturates, and

chloral hydrate decrease aggression by sedating è use short-term only.
(Ativan and Benadryl)

 A nonbenzodiazepine anxiolytic is buspirone (Buspar) which does not sedate,

relax muscles or have anticonvulsant activity.

 Anticonvulsant, such as carbamazepine (Tegretol and Valproic Acid) is used,

Side effect: BONE MARROW DEPRESSION, aplastic anemia and
hepatotoxicity.

 Beta blockers – such as propanolol (Inderal), pindolol (Visken) and Metoprolal

(Lopressor) are found to decrease aggression in both children and [Link] &
Restraint

 Should be used only when all other interventions fail.

 The purpose is to stop injurious actions, decreases difficult interpersonal

interactions and decrease sensory input to relieve sensory.

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  Some experts believe that seclusion and restraint do not teach patients
coping skills that will help them- may also foster distrust.

 Greater use is being made of less restrictive forms of isolation such as quiet
rooms without using restraints or quiet rooms with the door open to
decrease stimuli (but isolation is minimal).

 The Supreme Court ruled in Youngberg vs. Romeo that a person could be
deprived of his liberty in terms of being restrained if it could be justified to
protect him or her self or others. It could be justified on professional clinical
judgement.

According to Task Force of the American Psychiatric Association indications for use
of seclusion and restraint are:

A. To prevent harm to patient and others- if no others means are effective.

B. Prevent serious disruption of treatment program or damage to environment.

C. As part of an ongoing behavior treatment program.

D. As the patients request (for seclusion, used for violence, patient on the verge
of exploding).

E. Seclusion and restraint should be viewed as important as CPR in mental

health.

When the decision for use of seclusion and restraint is made, the staff:

 approached with 4 members behind the team leader

 approach in a calm, helpful and nonprovacative manner

 inform patient what is occurring and why

 if patient refuses to walk with or without help progress to

*Each team member holds a limb and transports patient to seclusion or to

apply restraints, (include wrist and ankle

cuffs, sheet restraints and camisoles {straight jackets}).

 if this occurs, all other interventions must be DOCUMENTED as having failed

to help the patient maintain control.
 Criteria for release from seclusion or restraints:

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  decreased psychomotor agitation- decreased restlessness, lowered BP and
pulse rate

 stabilization of moods- absence of physical threats, lowered anxiety level,

consistency of verbal and nonverbal behavior and feelings of trust in staff

 cognitive processes – signs of insight and ability to look at the incident in an

objective manner, increased ability to concentrate and improved reality
testing

 Staff discussion occurs after the incident to discuss what happened, what
would have prevented it, the rationale for the seclusion/restraint and the
reactions of the patient and staff.

Behavior Therapy

 A behavior therapy program requires target behaviors be clearly stated.

 Terms such as assaultive or violent should not be used but rather use
pushing, shoving, hitting, pulling hair and throwing chairs.

 Limit setting and behavioral management techniques by use of behavioral

contracts, token economics or seclusionary time out.

 a behavioral contract or no-harm contract is a statement signed by the

patient that he/she will not harm themselves or others

 token economy-is probably the most commonly used behavioral

management strategy- desired behavior results in receipt of tokens while
undesired behavior results in token loss

 reinforcing patient positive social behaviors can proactively decrease hostile

and aggressive response on inpatient units and decrease aggressive episodes

 time-out- removes patients who are exhibiting socially in appropriate

behavior from over stimulating and reinforcing situations- effective with
people who experience loss of as a negative consequence, for example in a
quiet room (some are locked, some are not)

Cognitive Therapy

 Is a brief, directive, collaborative form of psychotherapy that is useful in

assisting patients to confront their dysfunctional and irrational thinking; test
the reality of their thinking and behavior and learn to use more positive and
assertive responses in interactions with others.

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  Guided discovery- is a technique that helps patients recognize the
connection between their thoughts, feelings and behaviors, identify, negative
thinking and replace it with more positive thinking and identify dysfunctional
expectations and appraisals using more reality based interpretations.

 Anger - management training- is where patients are taught anger cues and
dynamics, signals related to anger arousal, signs of impending loss of control
and re-channeling aggressive response in early stages. Patients are also
taught the difference between acceptable responses (anger, frustration and
fear) from inappropriate and destructive behavioral responses.

- Often responses of anger are deeply ingrained.

 Less anger is aroused if a person can define a situation as a problem that calls
for a solution rather that as a threat that calls for an attack.
 Problem-solving skills training- teaches patients to be aware of other’s points
of view and anticipate and understand the consequences of their own
emotional and behavioral responses.

Group and Family Therapy

 Has its advantages, in that patients can receive feedback form other group
members.
 There is peer pressure for socially acceptable behavior.

 Family members can be educated about anger deceleration and problem

solving strategies.
Evaluation

 Was an escalation of violence prevented?

 Was safety maintained?

 Were institution guidelines followed?

 Did aggressive and violent behavior decrease?

 Did the patient or nurse learn new problem solving techniques?

Cultural Issues

 MH care facilities must employ case managers who are culturally similar to
the patients served.
 Subcultures such as hearing impaired or homosexual may require other
cultural considerations as well.

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 Legal Issues

 There are primarily four issues:

o Involuntary commitment to mental hospitals.

o Protection for potential victims of a patient’s aggressive behavior.

o Maintenance of patient rights.

o Preservation of the rights of staff.

 Many states have started a requirement for the "least restrictive treatment
alternative" à and use outpatient treatment settings whenever possible.

 Preventive commitment – refers to allowing outpatient treatment and

inpatient treatment when needed à the statute that governs this is called
"predicted deterioration" standard.

 Conditional release – refers to the requirement of continued supervision of a

person following discharge from a hospital à if the patient violates the
conditions of release, immediate rehospitalization may result, or in some
cases a court hearing. This release tests the person’s ability to function in the
community.

 Principals of Medical Ethics – states a physician shall safeguard patient’s

confidence within the constraints of the law à protective privilege ends
where public peril begins.

 Voluntary patients may refuse any treatment & involuntary patient’s have a
right to refuse antipsychotic drugs unless found incompetent.

 And last but certainly not least – if a violent person makes clear threats to
harm specific people à MH care providers can be held responsible if potential
victims are not warned à and yes, you can face legal liability either way!

SUICIDAL BEHAVIOR

Suicidal behavior is major public health priority. As it has for decades remained one of the
leading causes of death in the western world.

The costs of suicide are not only loss of life the mental, physical and emotional stress
imposed on family members and friends. Other costs are to the public resources as people
who attempt suicide often require help from health care and psychiatric institutions

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Suicide- is a final act of behavior that is probably the end result of interaction of several
different factors. It is a complex entity, involving biological, genetic and environmental risk
factors

Suicide is defined as the act of intentionally terminating ones own life hence a suicide
attempt should possess the following characteristics:

1. Self initiated, potentially injurious behavior.

2. Presence of intent to die.
3. Non fatal outcome.

EPIDEMIOLOGY

The WHO estimates that almost one million people die with suicide each year world wide
representing an annual global suicide mortality rate of 16 per 100,000. In the United States
(US) alone suicide claims over 32,500 lives annually. Besides the increasing number of
deaths by suicide, suicide attempts one even more prevalent. It is estimated that they are
twenty- four more frequent in the general population suicide attempts are associated with
significant morbidity and constitute a major predictor of safer suicide.

In other words thoroughly systematic review on the epidemiology of suicide (Nock etal
2012) reviewed governmental data on suicide and suicidal behavior and conducted a review
on the epidemiology of suicide published 2000 to 2013 and protective factor for suicidal
behavior in the U.S and cross nationally which revealed that completed suicide is more
prevalent among men where as non fatal suicidal behavior are more prevalent among
women and persons who are young, are unmarried or have a psychiatric disorder.

RISK FACTORS

1. Psychopathology: studies have shown that there is correlation between suicide

attempts suffering from depression and high levels of impulsive and aggressive
behaviors and others are those suffering from schizophrenia.
2. Aggression- multiple epidemiologic, clinical, retrospective, prospective and family
studies have identified a strong link between aggressive and suicide. Research
suggests a common neurobiology of suicide and other forms of aggressive behavior.
3. Impulsivity is prominent construct in theories of personality, encompasses a broad
range of behavior that reflects impaired self regulation, such as poor planning,
premature responding before considering consequences sensation seeking, risk
taking, an inability to inhibit responses and preference for immediate over delayed
rewards.
- Loneliness, alienation, communication difficulties
- Mental pain.

RISK BEHAVIORS THAT INDICATE SUICIDE RISK

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 - Past attempts.
- Disrupted sleep patterns.
- Increased anxiety and agitation.
- Risk taking behavior.
- Increased alcohol and drug use.
- Sudden mood changes for the better.
- Any talk or indication of suicidal intent, planning or actual actions taken to procure a
means.
- Living alone, poor social support.
- Unemployment.
- Low socio economic status.

TREATMENT

- Psychoanalytic oriented psychotherapy.

- Cognitive behavior therapy for suicide prevention (CBT-SP)
- Dialectics therapy
- TASA C treatment adolescent suicide attempts study.

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Unit 6: Forensic Psychiatry
FORENSIC PSYCHIATRY

 Forensic psychiatry is the branch of psychiatry that deals with issues arising in the
interference between psychiatry and the law, and the flow of the mentally
disordered offenders along with the continuum of social systems.
 Forensic psychiatry is can also be defined as a specialized branch of psychiatry which
deals with the assessment and treatment of mentally disordered offenders in
prisons, secure hospitals and the community.

It requires sophisticated understanding of the interfere between mental health and the law

SCOPE AND CHALLEGES

The sub specialty of forensic psychiatry is commonly defined as a branch of psychiatry which
deals with issues arising in the interference between psychiatry and the law.

This definition is however in some what reatrictive, in that a good portion of the work is
forensic psychiatry is to help the mentally ill in trouble with the law to navigate three
completely imminical social systems; mental health, justice and correctional. The definition
therefore should be modified to read the branch of psychiatry and the law, and with the
flow of mentally disordered offenders along.

MENTAL HEALTH LEGISLATION AND SYSTEMS

The double resolving door phenomenon, whereby mental patients circulate between a
mental institutions and prisons, has made forensic psychiatrists deeply aware of the
interactions in the mental health system and links between this system and justice and
correctional systems by virtue of their involvement in legal matters, forensic psychiatrists.

ETHICAL CONTROVERSIES

Because of its dual role in medicine and in law, the practice of forensic psychiatry is fraught
with ethical dilemmas worldwide. A forensic psychiatrists is first a clinician with there
oriental and practical knowledge of general psychiatry and forensic psychiatry, and
experiences in making rational decisions from a clearly stated scientific base.

In law forensic must know the legal definitions, the legal policies and procedure, the legal
precedents relating to the questions.

NATURE OF THE WORK IN FORENSIC

 Forensic psychiatrists must balance between the need of the offender with the risk
of the society.

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  They provide the psychiatric treatment in the secure environment or where the
patients are subjected to legal restrictions.
 Assessment and treatment settings vary, from high security hospitals through to
medium units, low secure units, prison settings and community based services.
 Forensic psychiatrists also evaluate the outcome to treatment program and provide
expert advice to health and social care professionals.
 Knowledge of mental health legislation is central to the work and there is regular
involvement with criminal justice agencies and the courts.
 Forensic psychiatrists need an in-depth understanding of criminal, civil and case law
as it relates to patients care in forensic settings.
 An important part of the work is risk assessment.
 A forensic psychiatrist assesses and manages patients at risk in emergency and
routine situations, in collaboration with colleagues and as part of larger
multidisplinary team. They some times have to control patients with violent behavior
using medication, rapid traquillitions, restraint or seclusion.
 Referral can range from those who have committed minor offences to serious and
violent offenders.
 Forensic psychiatrists may also assess non-offenders displaying high risk behavior.
 They also provide specialist advice to courts, the probation service, prison service
and other psychiatric colleagues. They also prepare reports for mental health
reviews tribunals.

COMMON PROCEDURES AND INTERVENTIONS

COURT WORK

 Forensic psychiatrists regularly provide expert witness evidence to courts, for

example to crown courts in criminal cases (including serious violent crimes) such as
homicide or through court diversion schemes in magistrate’s court.
 They provide expert opinions to the courts which includes:
 Defendant’s fitness to plead and fitness to stand trial
 Capacity to form an intent advice to courts on the available psychiatric defences.
 Appropriateness of a mental health disposal at the time of sentencing, nature of a
particular mental disorder and link to future risks.
 Prognosis and availability of appropriate treatment level of security required to treat
a patient and manage risk.

CONSULTATION WORK

When advising colleagues in the care of patients deemed to be at risk to others, forensic
psychiatrists needs to be competent to provide a detailed forensic psychiatry assessment
including advice on:

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  Risk assessment including use of structured risk assessment.
 Risk management.
 Expertise on pharmacological and psychological treatment approaches to violent
behaviors associated with mental disorders.
 Psychodynamic formulation of the case.
 Therapeutic use of security.
- Community forensic work provides opportunities to asses and work with mental
health disordered offenders in residential facilities. In addition there are
opportunities to provide consultation to probation staff regarding clients in bail
hostels and probation accommodation.
- Forensic psychiatrists participate in regular audit which helps to improve the quality
of the service offered to patients.
- They attend clinical governance meetings and investigate complaints and serious
incidents along side colleagues in the multidisplinary team.
- Teaching and training is also an important part of work.
- Psychiatrists in forensic and general adult psychiatry.

SUB-SPECIALITIES

Specialized services and teams in forensic psychiatry includes:

(1) Adolescent forensic psychiatry.

(2) Forensic learning disabilities.
(3) Forensic psychotherapy.

TYPES OF PATIENTS WHO NEED FORENSIC PSYCHIATRY

Regardless of whether psychiatrists adopt categorical or dimensional model, there

assessments are complicated by the high prevalence of personality disorder in forensic
settings (Trest man, 2000, Hart, 2002).

For example 50% to 80% of all incarcerated adult offenders meet the diagnostic criteria for;

(1) Antisocial personality disorder- these usually have no feelings for others. They
always lie, steal and normally conmen. They are persistently in problem with the law.
They are irresponsible and lack remorse.
(2) Sexual offenders due to mental disorder- these patients are characterized by
extreme impulsivity and lack of empathy.
(3) Individuals who manifest with symptoms of personality disorder that do not meet
the criteria for any specific disorder (and normally clinicians diagnose such patients
as suffering from traits of one or more personality disorders e.g. histrionic and
narcissistic traits).

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 Type of patient that needs forensic Psychiatry

TYPES OF PATIENTS THAT NEED FORENSIC PSYCHIATRY

The patient in the forensic setting is guilty of committing a crime believed to be caused by
their mental illness. Alternatively, the forensic psychiatric patient might have committed a
crime independently of their mental illness, but is presently too ill to participate in court
proceedings.

For example, a patient experiencing symptoms of schizophrenia might injure a neighbor

because he or she heard voices stating that the neighbor intended to harm her or him. This
is quite different from a patient who injures someone whilst their illness is stable. A patient
judged to have committed a crime in connection with a mental illness might be found not
guilty by reason of insanity. A ruling is made by the courts in which the patient is confined
until such a time it is deemed by the treatment facility that the patient is no longer a threat
to society.

The following are types of patients that are admitted to forensic facilities:
a. Anti-social personality disorder – is more strongly related to offending and violence.
Aspects related to offending in a person with personality disorder include
impulsivity, lack of empathy, paranoid thinking, poor relationships with others,
problems with anger and assertiveness.
b. Substance dependence (alcohol and drugs such as cocaine, heroine, chamba)
Intoxication reduces inhibitions and is strongly associated with crimes of violence,
including murder. Neuropsychiatric complications of alcoholism may also be linked
with crime.
c. Mental retardation or Intellectual disability – People with learning disability may
commit offences because they do not understand the implications of their behavior,
or because they are susceptible to exploitation by other people. Eg. Property
offences, sexual offences such as indecent exposure by males & arson.
d. Mood disorder – Depressive disorder is sometimes associated with shop lifting and
may also lead to homicide & suicide. Manic patients may spend excessively and fail
to pay. They are also prone to irritability and aggression leading to crimes of
violence.
e. Schizophrenia and other psychotic disorders – are associated with violence especially
if paranoid or coupled with substance abuse.
f. PTSD in cases where battered women have killed a battering partner.
g. Morbid jealousy
h. Organic mental disorders – Dementia and delirium. Eg aggression
i. Epilepsy – Violence is commoner in the post ictal state than ictally.

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CARE OF PATIENTS DURING DETENTION

In Zambia mentally disordered offenders are cared for under the Penal Code 87 and Prisons
Act of the Zambian Constitution as follows:

Presumption of sanity: Every person is presumed to be of sound mind, and to have been of
sound mind at any time which comes in question, until the contrary is proved. When a
person getting psychiatric treatment commits a serious offence while they are not
documented legally that they are suffering from mental disorders, such a person is liable to
prosecution until proven mentally ill by a qualified and registered psychiatrist.

Insanity: A person is not criminally responsible for an act or omission if at the time of doing
the act or making the omission he is, through any disease affecting his mind, incapable of
understanding what he is doing, or of knowing that he ought not to do the act or make the
omission. But a person may be criminally responsible for an act or omission, although his
mind is affected by disease, if such disease does not in fact produce upon his mind one or
other of the effects above mentioned in reference to that act or omission.

Defence of diminished responsibility: Where a person kills or is a party to the killing of

another, he shall not be convicted of murder if he was suffering from such abnormality of
mind (whether arising from a condition of arrested or retarded development of mind or any
inherent causes or is induced by disease or injury) which has substantially impaired his
mental responsibility for his acts or omissions in doing or being party to the killing.” (Laws of
Zambia).

Treatment settings for mentally disordered offenders

In Zambia according to the Mental disorders Act of 1951, mentally disordered offenders are
treated in all hospitals administered by the Government; and all places declared to be
prisons under section three of the Prisons Act; under compulsory detention (Detention
Order) to safe guard the lives and property of the public.

While prisons focus solely on control these forensic facilities focus on both control and
treatment. Buildings are therefore designed for maximum security to prevent patients
escaping. Prison warders guard these facilities.

In Zambia Chainama East is used to confine people who have committed homicide or
grievous bodily harm to others, as a result of being insane. Like a prison, Chainama East is a
secure environment with strict rules and regulations to ensure safety and security to

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prevent patients escaping. Individuals admitted to this place have been charged with
criminal offences and are deemed too dangerous to live in the community.

Chainama East is also used to care for persons that develop mental disorder and therefore
require psychiatric treatment and care whilst in prison.

Those who have committed violence against property as a result of insanity are kept in the
acute wards in Chainama.

Female offenders are detained in the acute female ward of Chainama Hills Hospital and are
guarded by female prison warders.

LEAVE OF ABSENCE

Detained patients cannot go on leave or be discharged from the hospital as long as they are
a danger to others and to property.

ABSCONDING

Immediately it is noticed that a patient has absconded, the police and relatives should be
notified, indicating the date, time, circumstances under which the patient absconded and
clothes they were last seen wearing, and direction which they took. A search by police is
instituted. This should be documented in the nurses’ and ward report.

CORRESPONDENCE
During detention correspondence between the courts of law and the head of the psychiatric
department is entered into concerning the detention and care of patients using the
following methods:

Adjudication order forms: Is to hear and settle a case by judicial procedure. In the case of
forensic patients it means the patient has to be tried before a court of law, and it has to be
determined whether they are guilty of a crime or not. However, before they can be tried,
two psychiatrists have to examine and determine whether they are competent to stand trial
or not.

Control order forms: After an adjudication order has been made, the courts shall make a
control order, for the control, care or detention of the patient, specifying that the patient be
detained in a prescribed place whilst his or her case undergoes judicial review. The patient
may therefore be transferred from prison to the prescribed place, in Zambia, Chainama
East / hospital.

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Detention Order form – This is a form that restrains the client with mental illness to be
admitted in a mental hospital for a minimum of 14 days after which psychiatric personnel
should furnish a report to the magistrate about their findings concerning the patient. (See
involuntary or compulsory admission under unit two)

Court reports: Psychiatrists provide a report of the patient’s progress whilst in detention.
Court reports – are required by the prosecution, court and lawyer. The reports consists of a
psychiatric assessment, that should be objective, and professional, and should not be
influenced by which ‘side’ has made the request. The report should indicate whether the
offender was mentally insane at the time of committing the crime or not. It should also
indicate the competence of the mentally disordered offender to stand trial, and whether he
understands what he has been accused of, and the meaning of pleading guilty or not guilty.

Give evidence in criminal proceedings on the patient’s dangerousness, so that a suitable

sentence may be made.

Transfer Order form – This is a form that is used when transferring a patient with mental
illness from one hospital to another. It has to be duly filled in by a senior magistrate in the
subordinate court.
SEXUALITY
Sexual offences tend to be repeated because patients with psychosexual disorders may not
cooperate with treatment as we saw when we covered that particular unit. (The most
common offences are indecent assault of women, indecent exposure, unlawful intercourse
with girls under 16, rape, paedophilia.)

For this reason psychiatrists may be asked to give an opinion on an offender’s

dangerousness, which if present may lead to long periods in confinement. Treatment of sex
offenders can only be carried out if the offender admits to having committed the crime and
if he or she is willing to undergo therapy with a view to changing his or her sex offending
behavior.

Victims of crime are referred to appropriate services where they are given the necessary
psychological support available within the community and mental health department. For
example women and child shelters, victim support unit in police, support groups, Non
Governmental Organizations such as Young Women’s Association (YWCA), Children In Need,
orphanages, voluntary counselors, Child Counselors at ‘A’ Block in University Teaching
Hospital and so on.

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Referral / discharge

Forensic offenders are reviewed every fourteen days by two different psychiatrists under
the Detention Order. Their confinement in a mental hospital tends to be for long periods of
time until it is determined that they no longer pose a danger to the public and to property;
again by two psychiatrists who get their views from the observations and assessments by
nurses, psychologists and other members of the MDT.
According to His Excellency’s Pleasure (This is Prerogative of Mercy of the President where
he pardons prisoners that have been recommended by both prison and mental health
personnel); the psychiatrists will complete a medical certificate in which a patient’s mental
fitness is confirmed. It is this certificate that the court will use to either discharge or reduce
the sentence, or sentence a mentally disordered offender.

Forensic psychiatric nursing care

The forensic focus for nursing is the therapeutic nursing inventions targeted at patient’s
behaviours (psychiatric symptoms) that cause him/her to commit crimes. Nursing
interventions therefore, are directed towards reducing the frequency and severity of these
behaviors.

Crisis intervention
This treatment helps patients cope with the crisis brought about by their criminal behavior
and subsequent detention in their lives, and to learn effective ways of dealing with future
difficulties. Treatment is aimed at reducing emotional arousal that takes place during a crisis
together with any accompanying behavioural disorganization. This is done by reassuring the
patient and enabling him/her to have an opportunity to express emotions, in a supportive
environment (empathy, non-judgmental).

Anxiolytic medication may be required for a few days. Once emotional arousal has been
contained, a problem solving approach is used, in which the nurse in collaboration with the
patient helps identify and list problems that are causing distress.
Rehabilitation
In order for patients in this setting to be eligible for return to the community, both the
criminal act and the psychiatric illness must be addressed. If anger is behind the criminal act
specific programs targeting anger management should be offered.

Suicide prevention – treatment for depression and close observation by staff in ward and
relatives in community if discharged.

Behaviour management – any abnormal behaviour such as being anti-social or manipulative

is treated using behaviour modification training.

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Substance abuse treatment – Detoxification is done in the psychiatric unit and thereafter
the patient is referred and connected to long term support groups.

Discharge planning – begin to plan for the discharge of the patient together with him/her
and relatives with the input of the Multi Disciplinary Team (MDT). The way forward and how
he/she will go back into the community.

Special challenges a nurse faces with forensic patients

Since forensic patients have two main problems; namely the serious crime they have
committed and the mental disorder that caused them to commit that crime, he or she
becomes very complicated and difficult to manage. In fact, forensic patients are well known
as being very dangerous, both to each other, and to staff caring for them.

Potential for Physical Violence: Since most patients admitted to a forensic setting have a
history of criminal behaviour, they pose a high risk of physical violence to both staff and
fellow patients. This can be prevented or reduced by training forensic nurses in violence
prevention and management techniques. If a nurse has been exposed to physical violence
they must be supported and undergo debriefing.

Verbal abuse: Daily stress of verbal abuse of nurses needs to be addressed so as to maintain
staff morale. It is addressed by support from senior nurses in which the affected nurses are
given the opportunity to reflect on and discuss reactions to patients.

Difficulties in the nurse patient relationship: Physical or verbal abuse disturbs the forming
of a meaningful nurse-patient relationship.

To be able to carry out the above mentioned nursing interventions the forensic nurse
functions as follows:

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Unit 7: Community Psychiatry
Definition of terms

1. Community: a group of people living together in one place, especially one having
similar interests.

2. Psychiatry: this is a branch of medicine that is concerned with the study and treatment of
mental illness, emotional disturbance and abnormal behavior.

3. Community psychiatry: this is a licensed, certified and nationally accredited or adopted

non-profit mental health care service, which provide a comprehensive series of mental
recovery measures to the psychiatric patients in the community.

Or is the branch of psychiatry that advocates for quality psychiatry care in the community
care.

4. Deinstitutionalization: discharge of an individual from an institution such as a psychiatric

hospital or prison.

5. Psychiatrist: a medical practitioner that is specialized in the diagnosis and treatment of

mental illness.

[Link] psychiatric nurse: this is a professional healthcare practitioner who helps,

visits, gives practical advise and support and even medication to mentally ill patients.

[Link] worker: this is a trained individual, who is responsible to help people with the aim
of alleviating suffering from social deprivation. They link people to appropriate organizations
that can help such people with social challenges.

8. Occupational therapist: these help people to get back to doing the practical things of
everyday life such as:

 Helping patients to work out what they can and cannot do

 Giving advice on where you could or should live.
 To find things to do that you want to do.
 To rebuild patients confidence
 To become independent.

CLINICAL PSYCHOLOGIST: they work with clients and learn how to give psychological
treatment (by talking to the on how they are feeling, thinking and behaving using cognitive
behavioural therapy and approach).

This is a medical consultant who gives expert advice to doctors and nurses and talk to
patients and caretakers about medication.

Introduction

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Movement has emphasized the concern on the care of members of the community on the
preventive measures of mental illnesses, and stated that; (the care begins from prevention
and ends with treatment). Furthermore, the evolution of community mental health is
viewed by some emergence concepts in the social policies that are being used to determine
program and directing responsible citizen action towards community based efforts. The
mental health to promote mental health in the community.

This branch of psychiatry advocates for quality psychiatry care in the community setting.
Therefore, in this discussion we will look at some of the activities offered in the community
by answering the following questions; Why should we have mental health services /teams in
the community, how they work?, who works in the community to achieve this? And what do
they do or their role?

Functions of mental services in the community

Since there are so many factors that can cause mental illness such as; past experience,
difficulty relationships, drugs and alcohol problems or stress for example unemployment.
Hence, all these factors need a community system in order to promote good mental health
as well as prevent and treat any occurring mental illness by the respective health care
teams. These healthcare trained teams are also important in order to identify and make a
diagnosis and make appropriate referrals if need to do so is necessary.

Workers in the community psychiatry and their functions

Mental health workers come from a number of professional back-ground with the
aim to promote a respectful and helpful relationship with the clients who seek their
services. These individuals help by:
 Working with the patient in order to keep an eye on any changes in behavior,
feeling and thinking.
 Being someone the patient can talk to.
 Developing the patient’s strength or potential.
 Working to find answers to the patients current problems.
 Helping the patient to become independent
 To review the patients as individuals and involving the family members in the
care.
 To apply the academic knowledge in the making of the appropriate diagnosis.

Some of the professions in the community psychiatry may include;

 Psychiatrist
 Community psychiatric nurse(CPN)
 Social worker
 Occupational therapist(OT)
 Clinical psychologist

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  Pharmacist

How does community psychiatry work?

 Community psychiatry works as a team with different specialized professionals and
work using a care plan of the individual who are having mental deviations or
changes.
 The care plan includes;
 Identifying the problems of the individual client and any risks involved.
 Determining their strengths in-order to overcome their problems and risks
 Identifying what needs to be done to help the patient to recover.
 To review and evaluate the patient’s condition.

CONCEPTS OF COMMUNITY PSYCHIATRY

The evolution of community psychiatry are viewed as an emerging concepts in the social
policy that is currently determining program and directing responsible citizen action
towards community based efforts to promote mental health. The concepts of community
psychiatry are as follows:

COMMUNITY MENTAL HEALTH CENTRES; this concept is structured in such a way that
mental health facilities are put close to the community in-order to promote mental health.
Good examples of such centre are clinics where professionals are deployed in-order to look
into these mental aspects.

COMMUNITY SURPPORT; In-order to address to issues to of deinstitutionalization the

federal recommends that funds are established in-order to provide the mental health care
services and needs to the community in older to achieve the care.

MENTAL CHILD AND ADDOLESCENT SERVICE SYSTEM; This system labors to expand the
health care of a child in order to ensure a continuum of care and classification of mental
state for example detection of psychiatric disorders at birth.

4. MENTAL HEALTH CARE/ PROVISION AND ASSISTANCE TO MENTALLY ILL PATIENTS; This
concepts refers to the appropriate measures taken in order to identify the level of mental
health, care and the appropriate facilities for effective care or treatment.

LEVELS OF INTERVENTION Levels Of

Intervention In Community Refers Various To Different Ways In Which The Community
Participate In The Healthy Of The Mentally Challenged Individuals, And The Following Are
The Ways.

 Prevention
 Promotion
 Treatment

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  Resource Mobilization
 Rehabilitation.
Prevention In community

Definition Of Prevention: It’s A Process In Which Measures Are Put Up To Avoid Something
From Occurring (Longman English Dictionary).

This Intervention Preserves Mental Health By Removing The Precipitating Factors Or Causes
That Could Contribute To Departure Of Good Health. A Good Example Is A Situation In
Which The Government Identifies The Drugs Or Other Harmful Substances That May Disturb
The Mental Health Of An Individual, And Then Set Strict Laws To Prohibit These Drugs From
Being Used For Example: Marijuana, Cocaine, And Cannabis. If A Member Of The Public Is
Found Using These Illegal Drugs By The Drug Enforcement Commission (Dec) This Individual
Will Be Locked Up In Order To Prevent Them From Intake Or Use Of These Illegal Drugs.

Health Education To Communities In Full Participation With Lifestyles That Ensure That They
Have A Good Mental Health Such As ,Massive Sensitization On Mental Health By Use Of
Relevant Structures In The Community Such The Village Headman, School Authorities And
Churches.

Promotion In Community

Definition Of Promotion: Activity Supports Or Encourages(Longman English Dictionary)

This Intervention Enables People To Increase Control Over And Improve Their Health Where
Mental Well Being Is Involved. These Interventions Are Normally Carried Through
Community Based Approaches and Through Improved Interpersonal Communication And
Relationships/Socialization.

Resource Mobilization in community psychiatry

For Community Psychiatry Resources Mobilization Involves The Whole Community To

Gather Resources That Help Such ;

 Human Resource; Community Health Workers Are In Place For Purpose

Promoting,Preventing,Curing And Rehab Of Mental Health Patients
Financial resource; the community should gather funds from support originations such as
the youth empowerment fund ,churches health association of Zambia, banks, and other
non-governmental organizations on the public and private partnership like Toyota Zambia
etc
Material Resource from the Community; the Community Due To the Problem at Hand,
Willing Offer Themselves To Service. Others Contribute Physical Efforts in the Construction
Of Mental Health Facilities, Other Offer Land, Others Its Food For Workers Etc
Treatment In Community Psychiatry

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Various In Individuals Participate In The Treatment Of The Mentally Ill Persons In Our
Communities And The Following Are Some Of Them.

Some of the Professions In The Community Psychiatry May Include;

 Psychiatrist
 Community Psychiatric Nurse
 Social Worker
 Occupational Therapist
 Clinical Psychologist
 Pharmacist
 The Above Team Work By Identifying The Problems Of The Individual Client And Any
Risks Involved.
 Determining Their Strengths In-Order To Overcome Their Problems And Treat Them
As Required ,If Unable To Treat Then Refer(according to the new scope of practice)
Rehabilitation In Community Psychiatry

Definition of Rehabilitation; To Help Someone Live A Healthy Or Useful Life Again After
They Have Been Ill Or In Prison (Longman English Dictionary)

Community Psychiatry Rehabilitation Or Physical Medicine Is A Specialty That Is Aligned

with the community development, it promotes full recovery of a mentally ill person through
community integration and improved quality of life for persons who have been diagnosed
with any mental health condition that seriously impairs their ability to lead meaningful
lives. Psychiatric rehabilitation services are collaborative person directed and individualised.
These services are an essential element of the health care and human services spectrum and
should be evidenced based. They focus on helping individuals develop skills and access
resources needed to increase their capacity to be successful and satisfied in the living,
working, learning and social environments of their choice, core principles of an effective
psychiatric rehabilitation (how services are delivered)must include the following;

 Providing hope when the client lacks it

 Respect for the client whenever they are in the recovery process
 Empowering the client
 Teaching the client wellness, planning and emphasizing the importance for the client
to develop social support networks.

Psychiatric rehabilitation varies by the provider and may consist of eight main areas

1. Psychiatric Symptom Management: Psychotherapies (it’s the talking cure) As

Discussed In The Previous Lecture Discussion And Physiotherapy.
2. Health and Medical: maintaining consistency of care and good health habits and
emphasized family physician/psychiatrist and mental health counsellors.

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 3. Housing Safe Environment Supported Housing);Community Residential Services,
Group Homes, Apartment Living(social workers responsibility)
4. Basic Living Skills; Personal Hygiene Or Personal Care, Preparing And Serving Meals
Home And Travelling Safety, Skills ,Goal, Life Planning , Group Decision Making,
Shopping(Given Money To See If They Know Charge To Bring Home)And
Appointments.
5. Social And Spiritual; Family and friends the church to do counselling and advise on
spiritual matters ,boundaries to communication and community integration are
explained too with the aim to help individuals attain good mental health.
6. Vocational And / Or Educational; Vacational trainning, Assistance To Employment
Preparation Programs e.g. calculations and mathematical logics, Televised Education,
Coping Skills, Etc.
7. Financial (personal budgeting, planning for own apartment start up funds and
security with deposits-savings, bank accounts,etc
8. Legal: This where the keeping of the laws is adhered to both formals (laws of the
state-killing a fellow human being is an offence) and informal laws of the community
and other laws or rules (killing of a fellow human being is an offence), Christian
values/rules from the bible (love your neighbour as you love yourself in short you
shall not kill) and imprecations if found on the other side of the law are explained to
them. To explain the law stakeholders include (Zambia police, prisons, judiciary, and
headmen, spiritual leaders which are done in form of role play or dramatization.

N.B-Rehabilitation Of The Mentally Ill Individuals Depends On The Level The Of The Needs
Identified Therefore, The Above Eight Components May Not Apply To Some Individual.

TREATMENT

Community psychiatric is a process that deals the linking the community and health
institutions in handling or dealing with cases of mental health problems in designated
communities.

GOALS OF TREATMENT
 To give hope to the patient and the community
 To increase the quality of life of patients
 To participate in treatment competency
 To empower patients
 To decrease readmissions to the inpatient units
 To improve social ,vocational and emotional function
 Decrease burden on care givers
 To promote independence and growth
 To promote community involvement

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  To promote patient adaptation to or recovery from mental illness
 To provide continuous treatment
 To provide cost effective treatment

The following are the types of treatment offered in community psychiatric.

I. Evaluation clinic services

These are clinics provided throughout the week at the community psychiatric
program. And it’s open to their catchment areas. The Community psychiatric
program is the entry way to services here and point at which eligibility for continued
treatment is determined for persons that criteria for serious mental illness which
include functional impairment. Those who come for evaluation will be seem by the
medical students.

II. Psychotherapy services

Psychotherapy services offer individual group, family which include; dietetically

behavior .therapy anxiety, co-occurring and illness management

III. Psychopharmacology
Psychopharmacology clinic services patient who have been diagnosed with a serious
mental illness and who need follow-up services including monitoring of response to
medication and general psychosocial assessment.

IV. Community psychiatric supportive treatment

These services provide and an array of services delivered by the community

based mobile individuals or milt displinary teams of professionals and trained
others.

These services are directed towards adults, children, adolescents and families
and will veer with respect to hours, type, intensity, dependency and the changing
needs for each individual. The main purpose for this service is to provide specific
measurable and individualized services to each person served.

It’s mainly focuses on individual‘s ability to succeed in the community ,to identify
and access needed services and how these individual can show in improvement
in school, work and family and integration and contributes within the
community. Some of the component of community psychiatric support
treatment must include;

 Assisting the mental restarted people in are achieving in managing basic needs as
identified by the individual or parent or guardian.

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  Facilitation of further development or daily living skills for these people .(mental
retarded)
 Monitoring symptoms
 Mental health interventions that address symptom behaviors thoughts process etc.
that assist an individual in eliminating barriers to seeking or maintaining education
and employment.
 Help in coming up with achieve that increase the individual capacity to possibly
adapt in his/her own environment.

This service help families meet the challenge associated with young person’s emotions
and behavioral difficult, it is effective in helping youths with chronic, serious problems
including

 Severe depression.
 Destruction of property.
 Aggression towards others.
 Thoughts or acts of self-injury or harming others.

Treatment for patients is provided a their homes, at schools and throughout neighbor and
community setting .Treatment focuses on helping parent build supportive social networks
and empowering them to address their child’s needs more effectively .

V. Psychiatric Emergency Care

The community psychiatry health centers act of 1963 mandated that communities make
the necessary provision for psychiatric emergency services.-it was believe that accessible
that emergency services were needed to provided crisis intervention to prevent
unnecessary hospitalizations and to attempt to decrease chronically of and dependence on
institutional care.

The community mental health administration and health practioners responded either by
establishing an emergency care on a 24hour services. Mobile crisis units and crisis residence
units have also he includes.

VI. Day-Treatment Programs

DAY TREATMENT PROGRAMS are also known as day hospital or partial hospitalization
programs are usually located in a near community health center or an important treatment
facility such as a psychiatric hospital.

These programs are usually supervise by psychiatrist and staffed by psychologist, social
worker psychiatric nurses, family therapist, and mental health consolers.

Research shows that day treatment programs have been successful, as induced by the
increased in the number of programs in communities.

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 VII. Residential Treatment Programs

Some clients with diagnose of chronic schizophrenia severe affective disorder, borderline
personality disorder and mental retardation are viewed as individuals who benefit from
participation in residential treatment programs.

The goal of this program is to improve self-esteem and social skills, promotes independence,
prevent isolation and decrease hospitalization.

Each type of residential treatment program offers different support services; the services
provided include shelter, food, housekeeping, personal care and supervision, health care,
individual or group counseling training and employment as well as leisure and socialization
opportunities.

VIII. Psychiatric Health Care

With an increased emphasis on community mental health in 1969’s, programs were

established to treat the psychiatric clients at home with a visiting nurse providing care.

Home base care programs have been put up to take care of those that have chronic mental
illness.

REHABILITATION

Rehabilitation and rehabilitation units is one of the components involved in community

psychiatric. It is where prolonged rehabilitation is carried out on people whose social and
work skills have either never developed or have been seriously impaired by their psychiatric
illness.

Community psychiatric rehabilitation of a patient with psychiatric illness is also called

TERTIARY PREVETION. Usually patients who have conditions like psychosis w have been
hospitalized for a long time and have recovered from the illness.

GOAL OF PSYCHATIC REHABILITATION

The goal of psychiatric rehabilitation is to limit the after effects of mental illness and
hospitalization and restore patients to effective functioning in the community.

As mentioned earlier, some patients with mental illness or chronic mental illness are taken
care of in many hospitals and clinics. Some of these patients suffer from” hospital
dependency syndrome”. But patients in psychiatric hospitals Psychiatric hospitals suffering
from such conditions are also rehabilitated by the psychiatric nursing where they consisted
of custodial care. Many of these patients are restored to the community after a period of
rehabilitation and re-socialization.

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In order to make it possible the transition of these mentally retarded people who have
recovered to a rehabilitated state, the community itself, through employers of labor and
volunteers are all encouraged to become involved in the aftercare of discharged patients.
They should be able to make up follow ups of these patients in the community to help them
fit in the community.

Rehabilitation of these patients can also be done in two ways depending on inner resources,
motivation of these patients and resources of the community.

INTENSIVE REHABILITATION
 Care of small selected and prepared groups of ex-patients in a center of a particular
area to facilitate community participation in the social rehabilitation of the patient
and to involve patients or community activities. The programme for ex-patients or
ex-psychiatric patients requires three major therapeutic strategies.

 Placement of patients in houses (called half way houses). In these houses the
domestic routine lifestyle of residents is different from psychiatric patients in
hospitals to a marked degree and resemble that of people in the outside world just
like I normal life. In this way patients will be able to fit into the way of life of a
normal life.
 Resocialisation or in some cases, some cases socialization mainly through the
efforts of volunteer workers.

 Vocational Rehabilitation-The aim for being the ex-patient to be placed in a

job and to become independent.

Mass rehabilitation care in smith, Mitchell hospital is aimed at the improvement of

the quality of life of patients who cannot return to the community, also to help those
who have enough inner resources to return to the community.
The severity of some mental illness has affected to some of these patients who have
deteriorated to such an extent that they cannot be rehabilitated sufficiently to
restore them to the community.
On the other hand some patients such as those with hospital –dependent people,
there may be some with rehabilitative potential but have no caring families to
support them in their efforts to socialize and adjusted to the society after discharge
from the hospital. Most of these patients may have just been rejected or abandoned
by the family members; hence they are unable to fit in the society on their own. The
smith, Mitchell hospital and other health institutions plays an important role in
helping such patients because of lack of social facilities for these patients in the
community.
Some of the assistance that may be rended to these people by health institution
include

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  To provide transport to take them back to their designated areas
 To provide shelter to those that have no homes as well as food.
 Help them to fit in the community by helping them to attach to certain
social groups in the society so that they are able to socialize with others.
 Assist them to be accepted in the society after recovery.
 Assist with medical treatment even after discharge.
 Provide them training in their skills so that they can develop them and
use their skills in earning a living.

RESOURCE MOBILISATION

Resource mobilization can be referred to all activities in involved in securing needs and
additional resource in order to the required health services to the community .in order of
the community psychiatric health services to be able to give the community, they need to
resource for resources to be used .some of the intervention taken by the ministry of health
to source for resources in so as to offer effective health services.

Integration of mental health in public health

The ministry of health is collaborating together or health institution in other countries to

mobilize for resources for community psychiatric health services.

The ministry of health is integrating the mental or the psychiatric mental health into public
health. They have embarked on collaborating with Asia, Australia mental health
development project designed to enhance institutions under the district mental health
programmers and increase accessibility of essential community health services.

Functions of a forensic nurse

 Patient advocate in which she speaks out for the rights of clients (see UNIT 8).
 A trusted counsellor in which she is able to offer psychological support to patients.
 A provider of primary, secondary, and tertiary health care interventions to clients
before during and after forensic admission to psychiatric hospital..

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Unit 8: Advocacy in Nursing
Introduction

People are entitled to be in control of their own likes but sometimes, whether disability
financial circumstances or social attitudes, they may find themselves in a position where
their ability to exercise choice of represents their own interests is limited. In these
circumstances independent advocates can help ensure that an individual’s rights are uphold
and that views, wishes and needs are heard, respected and acted upon.

Definitions

Advocacy is taking action to help people say what they want, secure their rights, represent
their interests and obtain services they need. Advocacies and advocacy provides work in
partnership with the people they support and take their side. Advocacy promotes social
inclusion, equality and social justice.

A principle is a general belief that you have about the way you should behave, which
influences your behavior.

Principles of advocacy

The advocacy providers and planned activities are within the objects set out in its governing
document and providers should be able to demonstrate how these meet the principles
contained in this chapter. Advocacy providers should ensure that the people they advocate
on behalf of health and social care services and funding agencies have information on the
scope and limitations of the advocacy provider’s role.

Independence
the advocacy provider will be structurally independent from statutory organizations. The
advocacy provider will be as free from conflict of interests as possible, both in design and
operation of advocacy services, and seek actively to reduce conflicting interests, in particular
where the organization provides, additional services such as housing provision and good
health services.
Person centred approach
advocacy provider will ensure that the wishes and interests of the people it advocates on
behalf directs its work. Advocates should be non judgmental and respectful of people’s

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needs, views, culture and experiences. For example if this mental patient wants to spend
time praying to god, respect his choice because he is humans like us.
Empowerment
the advocacy provider will support self-advocacy and empowerment through its work.
People who access the service should have a say in the level of involvement and style of
advocacy support they want where they are able and wish to where clients lack the ability
or capacity to influence the service. The advocacy provider should have a process in place to
enable those with an interest in the welfare of the person to influence this. Providers will
ensure that people who want can influence and be involved in the wider activities of the
organization. E.g. If the client is interested in gardening, carpentry, painting and other
activities encourage him and give them support because it may help to rehabilitate.
Equal opportunity
the organization will have a written equal opportunity policy that recognizes the need to be
pro-active in tackling all forms of inequality, discrimination and social exclusion. The
advocacy provider will have systems in place for fair and equitable allocation of advocate
time.
Accessibility
advocacy will be provided free of choices to exit eligible people. Where clients need or want
to purchase advocacy or where someone has an appointed deputy baloney in place who
wishes to instruct an advocate on the person’s behalf, suitable processes should be in place
to safeguard the person and ensure that they are not open to financial abuse.
Supporting advocates
the advocacy provider will ensure advocates are suitably prepared, trained and supported in
their role and provided with opportunities to develop their skills, knowledge and experience
e .g if clients are interested in plumbing we need to encourage them to keep doing so, in
order for them not to lose the skill.
Accountabitiy

The advocacy provider will have system in place for the effective monitoring and evaluation
of its work, including identification of outcome for people’s support .all those who access
the service will have a named advocate and a means of contacting them.

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Confidentiality

The advocacy provider will have a written policy on confidentiality that is in line with the
data protection act1998 and the mental capacity act 2005. It should outline how
information about a person accessing the service maybe shared as well as the circumstance
under which confidentiality might be breached. Advocates must also be aware of situation
that would require making a child and adult safe guarding alert. For example as a nurse i
need to keep secrets for the patients, if i know that the person, i should not expose to the
community about his condition secrets.

Complaints

The advocacy provider will have a written policy describing how individuals including
relevant stakeholders can make complaints or give feedback about the service or about
individual advocate where necessary the organization will enable people who use its
services to access external independent support to or pursue a complaint.

Safeguarding

Clear policies and procedures will be in place to ensure upon safeguarding issues are
identified and acted upon, advocates will be supported to understand the different forms of
abuse and neglect issues relating to confidentiality and what to do if they suspect a client is
at risk.

Conculusion

As a nurse it is important that we talk on behalf of these mental patients in order to improve
their well being we need to listen to their problem, fear, complaints and put measures on
how to help them live a productive life as human being.

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REFERENCES

 Keltner, N.L et al (2007), Psychiatric Nursing, 5th Edition,Mosby Elsevier Inc. St. Louis: USA
ISBN 0-323-03906-5
 Karch, A.M, (2005), Nursing drug Guide, Lippincott Williams & Wilkins, Philadelphia: USA
ISBN 1-58255-297-5.
 [Link] (20/12/2010 : 16:00hours).
 Bennett P.N and Brown M.J (2008), Clinical Pharmacological. Elsevier, Edinburgh.
 Mc Farland G.K and Thomas M.D (1991), Psychiatric Mental Health Nursing, Application
of the Nursing Process. J.P. Lippincott Company Philadelphia
 Stuart G.W and Laraia M.T (2005), Principles and Practice of Psychiatric Nursing. 8th
edition, Elsevier, Mosby Philadelphia, United States of America.
 Nambi S.(2006), Psychiatry for Nurses. Jaypee Brothers Medical publishers (P) Ltd, New
Delhi, India.

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