COURSE: MENTAL HEALTH NURSING

TOPIC: EATING DISORDERS

TARGET: 2 YEAR STUDENTS

PRESENTER: EM KUNDA

TEACHING METHOD: DISCUSSION/DEMONSTRATION

AUDIO VISUAL AIDS: DUSTER, CHALK. FLIPCHART, CHALK BOARD

GENERAL OBJECTIVE

At the end of the session students should be able to acquire sufficient knowledge eating
disorders and management

SPECIFIC OBJECTIVES

1. Define eating disorder

2. Mention the predisposing factors of eating disorder

3. List clinical features

EATING DISORDERS
Eating disorders have become the focus of much interest among mental health professionals in
recent years. In India, eating disorders are not as common as in the West. An increasing number
of people, predominantly women, report gross disturbances in their eating behaviour. The two
most important eating disorders are:
1. Anorexia nervosa, and
2. Bulimia
Although these eating disorders are described as primary i.e.as not resulting from some
medical illness, many patients with this disorder also suffer from other psychiatric
disorders.

ANOREXIA NEVOSA

It is a condition of marked weight loss due to reduction in food intake and /or vomiting.
The anoxia nervosa syndrome may be secondary to schizophrenia, depression, organic
illness and endocrine disorders.
Anorexia nervosa is more common in females, more so in adolescent girls .It is common
in the upper social class and in unhappy families. The precipitating events may be
 separation, puberty, sexual experience, threat of sex, marriage, pregnancy,
responsibility, etc.
Clinical picture

The patient is usually an adolescent or youth adult female. There may be a history of
reduction in the intake of high calorie food and of vomiting. The other features are
amenorrhea, constipation and hyperactivity. The examination shows a low B.P. low
pulse rate, subnormal temperature, cyanosis, atrophy of breast, axillary and public
hair. Investigation reveals anaemia, low blood sugar, raises cholesterol and reduced
basal metabolic rate.

Anorexic nervosa is a potentiality lethal disorder. It should be treated as a

psychiatric emergency. If there is severe weight loss, metabolic disturbances, anaemia,
hypoglycemia and depression with suicidal ideals, the patient should be immediately
hospitalised for further management.

Treatment
Treatment includes hospitalization, tube feeding and IV fluids. A high calorie diet should
be prescribed, drugs like minimal does of chlorpromazine, cyprohetadine and insulin
may be beneficial. Behaviour therapy is much beneficial.

Nursing Care of Anorexia Nervosa

When a nurse sees people, especially young girls, who have eating disorder problem
with poor intake, vomiting, self starvation, severe weight loss, it should be immediately
reported.
 Monitor physiologic signs and symptoms like amernorrhoea, constipation,
hypoglycemia, breast atrophy, hypotension etc.
 Weight regularly
 Have one to one supervision during and 30 minutes after meal time to prevent
attempts vomit food.
 Health education should be given regarding maintaining normal weight, normal
sexual growth and complications of starvation.

Mood Disorder (Affective Disorder)

Mood is an internal emotional state of an individual. A mood disorder is characterized by an
excessive swing of mood. The mood state of a normal individual fluctuates between mild
depression to mild elation depending on many factors. For example: if she passes an examination
she may elated or happy; if she fails she may be a little depressed or sad. There is also a period.
It is only when the mood swing is excessive in severity and in duration and when it interferes
with a person’s day-to-day activities that it becomes a mood disorder.
CLASSIFICATION OF MOOD DISORDERS
Old Term New Term
1. Manic depressive psychosis Bipolar disorder
2. Endogenous depression Major depression
3. Neurotic depression Dysthymic disorder
______________________________________________________________________________
Mood Disorder (secondary mood disorder depression and mania)
Depressive disorder Bipolar disorder Sec. to other psychotic Sec. to Systemic medical
Disorder (Like) disease (like)

Single or recurrent manic, depression schizophrenia dementia CNS disorder endocrine

Depressive episode mixed substance abuse disorders Drug-induced
Disorder infections

DEPRESSION
Mood is the common cold of psychiatric illness. Very often we come across people saying that
they are ‘sad’, ‘depressed’, ‘down’, ‘mood out’, feeling that they have lost interest in everything
and that they are isolated. All these refer to depression. Depression is a mood state. Depression
may be a normal mood state if it follows a painful, distressing situation and if it is transient or
short-lived. All of us at times feel depressed for a variety of reasons and after some time we
come out of that gloom to normal state.

Depression as a Disorder
If depressive mood is very severe in intensity; and if it is going to create problems for the
individual ad others, if it is going to interfere with the individual day-to-day activities and if it is
prolonged, then this depression is abnormal and a disease. Depression is a very real disease, just
like typhoid fever of hypertension. It may come about as reaction to an event, such as the death
of a loved one or a change in financial situation, or it may come without any obvious external
cause.

Epidemiology
Depression is a widespread mental health problem affecting many people, young and old, rich
and poor, men and women. In India 1-6 percent of the general population suffer from depression.
5-20 percent of psychiatric out-patient attending general hospitals suffers from depression.
The common age group is 30-50 years. Depression is more common in old people. In the
elderly above 60 years 13-22 percent suffer from depression. Female suffer more than males.
Depression occurs twice as frequently in women as in men. Children and adolescents also suffer
from depression, but not as commonly as adults.

Major Depression
Major psychiatric classification isolates a syndrome termed major depression. This may be
defined as the presence of:
A. Depression mood or
B. Loss of interest and pleasure
C. With 4 or more of the following seven symptoms:
1. Feeling of worthlessness or guilt
2. Impaired concentration
3. Loss of energy and fatigue
4. Thoughts of suicide
5. Loss or increase of appetite and weight
6. Insomnia or excessive sleep and
7. Retardation or a agitation
The above symptoms are required to be present for at least two weeks, in the absence of
other primary disease. Major depression may be present with or without psychotic features like
delusion hallucination or bizarre behaviour.

Dysthymic disorder
A. Depression mood for most of the day for at least two years.
B. Presence of at least two of the following six symptoms:
1. Decreased or increased appetite
2. Decreased or increased sleep
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or indecisiveness
6. Feelings of hopelessness-without any evidence of major depressive disorder for two
years and without any other primary disorder.

Bipolar Disorders
These disorders are characterized by mood swings, from profound depression to extreme
euphoria (mania), with intervening periods of normalcy. Bipolar disorders are of three kinds
1. Bipolar disorder
 Mixed (both manic and depressive episodes intermixed)
2. Bipolar disorder
 Manic (the predominant mood is elevated, expansive or irritable; motor activity
excessive, psychotic features may be evident)
3. Bipolar disorder
  Depressed (symptoms are characteristic of major depression with a history of at least
one manic episode).

Masked Depression
In masked depression the patient complaints of multiple, vague, bodily symptoms without any
other primary disease. Patient may not express a depression may be underneath or marked and
the vague bodily symtoms may be due to an underlying depressive illness.

Seasonal Depression
The mood changes that occur during the winter months.

Aetiology of Depression

Biological factors
Genetic factor numerous studies have been conducted which support the involvement of heredity
in depressive disorders. The incident of disorder appears to be substantially higher among
relatives of individuals with the disorder than among the general population.

Biochemical: Depression is due to the imbalance of biogenic amines in the brain. The amines
involved are norepinephrine, serotonin and dopamine. The levels of these amines are reduced in
individuals with depressive illness.
Electrolyte imbalance appears to play a role in depressive illness. An error in metabolism
result in the transposition of sodium and potassium. The biochemical theories of depression
remain controversial

Psychological Factors
 Low self-esteem
 Guilt
 Lack of support system
 Lack of clear goals
 Feelings of failure
 Inability to fulfill expectations
 As a response to separation or object loss.

Cognitive: narrow negative attitude about self, the environment and the future, bad or
inadequate judgments.

Behavioral Hopelessness
Loss of positive reinforcement.
Socio cultural Factors
 Social situations that bring feelings of powerlessness and low self-esteem
 Status of minority group
 Status of women in a male-dominated occupation
 Role loss (empty nest syndrome)
 Adverse events
 Injustice
 Poverty
 Unemployment

Alcohol and Depression

There is a strong relationship between alcohol, drug abuse and depression. Alcohol drinking
itself may induce depression. People claim that to some extent all alcoholics are depressed. Thus,
there exists a cause and effect relationship between alcohol and depression.

Complications of Depression
Some patients with depression recover spontaneously after some time, even without any
treatment. But once depression is recognized as an illness it should be actively treated, otherwise
there may be the following complications:
1. The individual with depressive illness suffers; his work and day-to-day activities suffer
and his family suffers as well.
2. There may be loss in productivity or in the financial status of individual. Because of his
disinterest and incapacitation he may lose his job.
3. Depression leads on to alcoholism and drug abuse among vulnerable groups
4. Depressives are prone to suicide.

Management of Depression
Hospitalization: if the depression is severe and there are suicidal tendencies, it is better to
hospitalize the patient for further management.

Drug therapy: with the help of anti-depressant, depression can be relieved in a few weeks time.
The details regarding drug therapy are given in the chapter on drug treatment (Anti-depressant
drugs)

Electro-convulsive therapy: it is an effective physical method of treatment in major depression. It

is advisable if the depression is severe and with suicidal tendency. ECT is widely used in
combination with anti-depressant drugs.
Psychotherapy: psychotherapy means understanding the depressed patients and their problems
and guiding them positively. It includes reassurance and supportive measures, and encouraging
patients to freely communicate wit the therapist. The emotional ventilation has dramatic effect in
relieving depression. Family therapy, group therapy and cognitive therapy are also indicated in
selected cases of depression. The selection of treatment depends on the individual patients.

Nursing Care in Depression

1. Promote sleep and food intake-give the prescribed drugs in time and monitor food
intake and, if necessary, administer IV fluids.
2. Assess if there is any suicidal tendency. Take safety measures and keep vigil if patient
has suicidal ideas. The patient’s safety is a nursing priority.
3. Diminish feelings of loneliness. Build trust by a one-to-one relationship. Improve
interaction with the patient.
4. The interaction should focus on the present, not the past or far into the future. Reassure
the patient that the present depressed mood state is temporary and that he will be
protected and helped. Use a kin, firm and warm attitude. The presence of a trusted
individual provides emotional security for the patient.
5. Postpone to your patients decision making and resumption of duties.
6. Provide non-intellectual activities. For example, cleaning and physical exercise provide
safe and effective methods for changing pent-up tension.
7. Encourage expression of emotions, denial, hopelessness, helplessness, guilt, etc.
provide the patient the opportunity to cry out and ventilate his anger.
8. Keep strict records of sleeping patterns. Discourage sleep during the day to promote
more restful sleep at night. At night use measures that may promote more sleep, such
as warm drinks (milk), warm baths, soft music etc. limit intake of drinks like coffee,
tea, and colas. Assist patient in getting to sleep until normal sleep pattern is restored.
9. Health Education
a. Regarding the disease: Education your depressive patients with the following
guidelines
 Depression is far more common than you might think.
 Depression can occur without any obvious external causes, due to
biochemical imbalance.
 Some ties the process of getting better takes time and one must wait.
 You are not alone; there are many people around you who care about your
well-being like your family, your friends and your doctor and his team.
b. Regarding drugs
 Take your medicines carefully and regularly. Never take less or more than
the prescribed dose. Never skip a dose.
 Don’t expect miracles. It could be at least two weeks before you feel better.
  There may be some side effects due to the anti-depressants, like dry mouth,
constipation, giddiness; don’t worry about them.
 Some medicines can make you sleep initially and it is good for you to feel
well. Avoid driving or performing any activity which might need a lot of
concentration after taking these drugs.
 Avoid taking alcohol when you are on medication. They may interact and
produce harm.
 Do not stop treatment without the doctor’s advice.
10. Advice to family Members: educate the family members in the following ways.
 Understand that the patient’s problem are due to depression, a disease like any
other physical disease and needs active treatment.
 Give correct history to doctor
 Give the medication regularly as prescribed by the doctor.
 Give adequate support and encouragement to that patient may feel more secure
and the recovery will be faster.
 Watch for any suicidal ideas or gestures and inform your doctor immediately.
 Accept him as he is, and give him care and hope.

MANIA
Mania is mood disorder. It is the name give to the illness when the patient is excessively happy
and energetic. Usually mania occurs as a part of bipolar, i.e. mania and depression occurring in
cycles (manic depression psychosis). Very rarely patients get only recurrent attacks of mania
alone without history of depressive episodes.
Mania is now considered either primary or secondary in nature. Primary mania is an
effective or mood disorder. Secondary mania occurs secondary to a variety of organic
disorders. E.g. drug intake, infection, neoplasm, epilepsy or metabolic disturbances).

Aetiology

Biological Factors
Genetic: The incidence of bipolar disorder among relations of affect individuals is higher than in
the general population.

Biochemical: Mania is considered to be due to an excess of biogenic amines (norepinephrine or

serotonin) in the brain.

Psychological Factor
Faulty dynamics in the family system and disturbed ego development gives way to a strong Id
(uncontrollable impulsive behavour). In the psychoanalytic model, mania is viewed as the
mirror image of depression-a denial of depression.

The Clinical Features of Mania

1. A persistently elevated, expansive or irritable mood
2. Inflated self-esteem or grandiosity.
3. Hyperactivity or psychomotor agitation
4. Disturbance in sleep-decreased need for sleep.
5. Pressured speech-more talkative than usual or pressure to keep talking.
6. Flight of idea-a subjective experience where thoughts are racing.
7. Distracted-poor attention span, responds to multiple. Unimportant or irrelevant
external stimuli.
8. Excessive involvement in pleasurable activies. For example: excessive spending habit,
uninhibited and excessive sexual activity.
9. Dress is often inappropriate with bright colours that do not match excessive make-up
and jewellery.
10. Marked impairment in occupational functional, in social activities or relationships with
others.

Different Forms of Mania

If the person is euphoric, elated, dressing colourfully cracking jokes, talking excessively and
overactive, this is labeled as hypomania, a less severe form of mania.
If the person with mania becomes very irritable, excited, violent, and is a nuisance to
public, then the condition is labeled as Manic excitement.

Management of Mania
Hospitalization: If patient is too excited, as a public nuisance and unable of taking care of
himself, the hospitalization is essential.

Drug treatment: To control manic symptom s anti-psychotics like haloperidol and

chlorpromazine can be used. Inj. Haloperidol 5-10 mg IM 2 hour by till the patient is sdated or,
maximum of 50 mg (rapid neuroleptization) and change to tablet haloperidol 1.5 to 10 mg three
times a day.
Or
Inj. Chlorplomazine 50-100 mg IM to start with, followed by tablet chlorpromazine 100-200 mg
three times a day and to be reduced gradually. Both haloperidol and chlorpromazine tablets
can be combined. For patients who suffer from frequent relapses Litium is best indicated.
Litium is an anti-manic and a preventive drug. It is a mood stabilizer. Carbamazepine and
sodium valproate can also be given in addition to anti-psychotics. ECT may be considered in
manic excitement.

Nursing Care of Manic Patient

The person suffering from manic disorder is an overactive individual with an excessive amount
of energy. The patient is easily stimulated mentally and physically. The patient may react to this
stimulated by constantly being excited, domineering, irritable or vulgar. His attention is easily
distracted. Feelings of aggression and hostility are directed outward, to the environment. The
overactive might be extremely likeable, talkative and euphoric.

Diet: Special attention must be given to the patient’s diet because he is usually too busy to eat
and hence may lose weight and dehydration may occur. Meals and fluids are to be given under
supervision. Extra nourishment may be required to compensate for extra activity.

Drugs : Drugs are of great help in dealing with problems of restlessness, sleepless and fatigue
associated with overactivity.

Others
 Supervision is necessary for adequate nutrition and rest.
 Bursts of excitement and destructive actively may result in injuries. Therefore they
should be observed and attended.
 Supervision and directions to maintain personal hygiene like bathing, oral hygiene are
essential.
 Care to be taken that the patient is dressed appropriately.

Emotional needs: Frequent mood changes and excitement may be there. Approach the patient
in a calm, unhurried and consistent manner. Always speak quietly, tactfully and patiently. Avoid
arguments, discussions or situations that are stimulating and irritating.
 Suggestions and persuasion are more effective
 One nurse should establish rapport with one overactive patient and improve his
confidence in her.
 Short, simple direct answers should be quietly given when the patient asks questions.
Maintain a low level of stimuli in the patient’s environment. Observe the patient’s
behaviuor frequently. Remove all dangerous objects from patient’s environment so that in his
or her hyperactive , agitated state they cannot be used to harm self or others.
 Maintaining a therapeutic environment: the ward must be quiet and pleasant. Factors that
irritate the patient like excessive noise, bright colours etc. are to be avoided. Separate rooms
may be ideal with simple furnishing. Fluctuation of mood states must be watched. Active
games, ward occupation and creative work will channelize his energy. Drug therapy is essential
for sedation.

Schizophrenia
Schizophrenia is a major mental disorder. It is the common of the psychotic disorder. It has
been estimated that 50 percent of all mental hospital beds are occupied by patients diagnosed
as schizophrenic.
The word schizophrenic is derived from a Greek word schizo (slit) and phrenic (mind).
The term schizophrenia was first coined by a Swiss Psychiatrist Eugen Bleuler.
Schizophrenia indicates a group of disturbances which sometimes occurs in different
combinations and intensities. Hence , it is heterogenous in nature. Schizophrenia has general
been considered to be ancient origin.

Definition
schizophrenia is defined as a functional psychosis characterized by disturbances in thinking ,
emotion, volition and perception. Finally, it leads on to personality deterioration. The illness
occurs in a state of clear consciousness. Unlike many psychological disorders, schizophrenia
often incapacitates a person. People suffering from schizophrenia display sudden changes in
mood, thought, perception and overall behaviour. These changes are often accompanied by
distortions of reality.

Epidemiology
Schizophrenia is a common disease prevalent in all cultures and in all parts of the world. Three
to four per 100 in any community suffer from schizophrenia. About one percent of the general
population stands the risk of this disease in their lifetime. About two-thirds of the cases are in
the lower social classes.

AETIOLOGY
How or why schizophrenia develops remains a puzzle despite extensive research. Current views
indicates that it is most likely to be a breakdown in the balance between three interacting sets
of factors, namely, biological, psychological and social.

Genetic Factors
The case for a genetic basis of schizophrenia disorders has been supported by a variety of
studies, including adoptional studies and twin studies. Such studies lend support to the
hypothesis that genetic factors play an important role in the causation of schizophrenia, which
probably varies from person to person.

Incidence of schizophrenia in specific populations:

Population Incidence (%)
General population 1.o
Sibling of schizophrenic patient 8.0
Child with one schizophrenic parent 12.0
Dizygotic twin of a schizophrenic parents 12.0
Child of two schizophrenic parents 40.0
Monozygotic twin of a schizophrenic patient 47.0

Biochemical Factors
The idea of the physical basis of schizophrenia is not new. A number of biochemical theories
have been put forth as the probable cause for schizophrenia. But nothing has proved to be
confirmative although there are some important theories.

Dopamine Hypothesis
It is based on the idea that the mechanism of action of antipsychotic drugs can shed light on the
psychotic disorders they treat. Antipsychotic drugs block postsynaptic dopamine receptor sites in
the brain. This led to the speculation that schizophrenia might involve excessive levels of
dopamine as a neurotransmitter.

Transmethylation Hypothesis
Schizophrenia may result from abnormal transmethylation of catecholamines.

Findolamine Hypothesis
A defect in the metabolus of indolamine, most probably serotonin, is being investigated as a
possible cause of schizophrenia.
According to the bioplogical view as the cause of schizophrenia, the environment
triggers this behaviour in people who are predisposed to it. Thus, for those who opt for the
combined view of nature and nurture, genetic abnormalities lead to situation in which
environmental stressors trigger the behavioural pattern of schizophrenia.

Genetic ___ Enzyme ____ Biochemical ____Physiological ---- Environmental

Abnormality Abnormality Abnormality and stressors
psychological
predisposition
 Behavioural pattern
characteristic of a
chizophrenic Disorder

Psychological Factors
Persons who are withdrawn and have very social contacts (introverted personalities or schizoid
personalities) are moiré prone to develop schizophrenic illness.
Ego boundary disturbance is also considered tom be a cause of schizophrenia.
behaviourists asserts that negative reinforcement and extinction schedules cause schizophrenia.
Most psychoanalysts and behavioural theories suggest that a person’s relationship to the
environment can bring about schizophrenia. Freud believed that schizophrenic patients regress to
a phase of primary narcissism and ego disintegration.

Social or Environmental Factors

Children and adults develop schizophrenia because their home environment is not conducive to
normal emotional growth. People who have developed schizophrenia tend to come from
families where there I considerable conflict. Generally, communication between parent and
children in such families is inadequate. There is communication deviance.
Some studies have shown that schizophrenia is more prevalent in areas high social
mobility and disorganization, especially, in members of very low social class.

CLINICAL FEATURES OF SCHIZOPHRENIA

Schizophrenia can be grouped as:
1. Schizophrenia with positive symptoms.
2. Schizophrenia with negative symptoms.

Positive symptoms of schizophrenia are:

1. Delusions
2. Hallucinations
3. Bizarre behaviour
4. Aggression
5. Agitation
6. Suspiciousness
7. Hostility
8. Excitement
 9. Grandiosity
10. Conceptual disorganization

Negative symptoms of schizophrenia are:

1. Apathy
2. Avolition
3. Social
4. Diminished emotional responsiveness.
5. Blunted affect
6. Stereotyped thinking
7. Artificial gestures/ detachment
8. Lack of spontaneity.
There are fundamental groups of signs symptoms which may occur singly or together in various
clinical patterns. The groups of symptoms are:
1. Thought disturbance
2. Autistic behaviour
3. Volitional disturbance
4. Emotional disturbance (affective)
5. Perceptual disturbance
6. Behavioural disturbance.

Thought Disturbance
A prominent disturbing symptom of schizophrenia. In thought disorder, the derangement is
basically due to three mechanisms, namely:
a. Condensation: Ideas are mixed, having something in common, though not necessarily
logical.
b. Displacement: An associated idea instead of the correct one is used.
c. Symbolisation: Abstract thoughts are replaced by concrete ones.
Sometimes, there will be over-inclusive thinking in schizophrenia, where irrelevant
thoughts are incorporated into the speech. Some schizophrenics may coin new words which
others cannot understand. This is known as neologism. The end result of this combination is a
meaningless jumble of words and ideas leading to incoherence and mutism. In some cases,
there will be a sudden block in the train of thought for a fraction of a second, followed by a
change in discussion of an unrelated topic (though block), or diversion of thought where
individual does not seem to be thinking much at all.
People we see schizophrenia often have delusions disturbances in the content of
thoughts. A delusion is a false belief, inconsistent with the relationship that is held, inspite of
evidence to the contrary, many schizophrenics have delusions of persecutions believing that
they are victims of plots and conspiracies. Some patients may have delusions of grandeur,
believing that he or she is an important popular or highly placed person. Passively feelings or
inserted into his /her mind or that his/her behaviour is controlled by outside forces.

Autism
Autism is a slow progressive withdrawal from reality. The patient loses interest in his
environment, is remote and preoccupied with fantasy.

Volitional Disturbance
Volitional disorder is deterioration in will power, drive and ambition. A pathy may become so
profound that self-neglect occurs.
Emotional (or Affective) Disturbance
This develops insidiously, or suddenly, as episodes of unexplainable depression, elation, ectasy,
giggling or perplexity. The most change is the flattening or blunting of emotion. In other cases,
the mood is incongruous, that is, inappropriate to thoughts and current situation. Without
reason the person may laugh or cry.

Perceptual Disturbance
Hallucinations are importance perceptual disturbances occurring in schizophrenia. A
hallucination is a perceptual in the absence of an external stimulus. Hallucination may be
auditory, visual, tactile, olfactory of gustatory. Auditory hallucinations are the commonest form
of hallucination in schizophrenia.

Behavioural Change
The withdrawal from reality in fantasy may increase apathy and indifference to the point of
complete inability and stupor or catatonic stupor. The reverse may also occur, that is catatonic
excitement. There is purposeless repetition of words and movements and imitation of words
(echolalia) and actions (echopraxia). Sometimes, the patient exhibits organism that obeying or
doing the reverse of what has to be done.
Some chronic patients may reveal various minor, bizarre mannerisms, like pouting,
blinking, grunting ect.
Usually, in schizophrenia, there will be poor personal hygiene. They do not take care of
themselves. Various degree of sleep disturbances will always be present. Orientation and
memory remains intact, although they may be although they may be difficult to test. The
patients is invariably in clear conscious, although his insight and judgment are defective. Lack of
insite means the person is not aware that he /she is suffering from the illness.

TYPES OF SCHIZOPHRENIA
Paranoid Schizophrenia
The essential features are prominent persecutory or grandiose delusions together with
associated jealousy. Hallucinations are common. Associated with features include unfocussed
anxiety, anger, argumentativeness and violence. In addition, there may be doubts about
gender identity
Hebephrenic Schizophrenia
The essential features are marked incoherence and flat, incongruous or silly effects. Age of on
set is 15 – 25 years. The clinical picture is usually associated with extreme social impairment,
poor premorbid personality, and early and insidious onset and a chronic course without
significant remissions. In other classification this type is termed as disorganized type.

Catatonic schizophrenia

The clinical picture is dominated by psychomotor disturbance. This may take the form of
catatonic stupor or rigidity, catatonic excitement, catatonic posturing or negativism.

Residual Schizophrenia

This category should be used when there has been at least one episode of schizophrenia in the
past but without prominent psychotic symptom at present. Emotional blunting, social
withdrawal, eccentric bahaviour, illogical thinking and loosening of association are common.

Undifferentiated schizophrenia

Prominent psychotic symptoms that cannot be classified in any category previously listed or
have features of more than one.

Simple schizophrenia

A uncommon disorder insidious in onset but with progressive development of odd behaviour.
Wander tendency, self – absorbed, idle and aimless activity are present.

CLASSIFICATION OF THE COURSE OF ILLNES

Subchronic

The time from the beginning of the illness, during which the individual begins to the illness
more or less continuously. It is than two years but least six months.

Chronic

Same as above, but duration is greater than two years.

Course and Prognosis

The onset may be acute or gradual. Onset is usually in adolescence. There may be a precipitating
event, though not necessarily. The classic course of schizophrenia is one of exacerbation and
relative remissions. After the onset of the illness, the patient will never come back to his original
level of functioning.

Schizophrenic prognosis

Schizophrenia prognosis is not always a deteriorating course. A variety of factor are associated
with good or poor prognosis.

Good Poor

Later onset Young onset

Obvious precipitating factors No precipitating factors
Acute onset Insidious onset
Good premorbid social sexual Poor premorbid, social, sexual and work history
and work history
affective symptom Withdrawn, autisticbehaviour
(especially depression)
Paranoid or catatonic features Undifferentiated or disorganized features
Married Single, divorced or widowed.
Family history of mood Family history of schizophrenia
disorders
Good Support Systems Poor Support System
Undulating Course Chronic Course
Positive Symptom Negative Symptoms
Neutorological Signs And Symptoms
History Of Perinatal Trauma
No Remission In 3 Years
Many Relapses.
Around 20 to 30 percent of schizophrenic are able to able to lead somewhat normal lives.
Approximately, 20 to 30 percent of patients continue to experience moderates symptoms, and 40
to 60 percent of patients remain significantly impaired by their illness for their entire life. Most
of them need for chronic course.

MANAGEMENT OF SCHIZOPHENIA
The treatment of schizophrenia can be arduous process for patient, families, and clinics alike.
No cure exists for this tenacious disease. So, therapeutic efforts are aimed at management of
symptoms and at social and psychological rehabilitations. Nevertheless, carefully designed
treatment programmes can help many schizophrenics to regain lost functioning and a greater
sense of psychological well – being. Long – term support is necessary for most schizophrenics to
maximize both, their ability to function and their quality of life.
Treatment Method in Schizophrenia

Somatic (Physical) Therapies

1. Antipsychotic medications
2. ECT

Psychological Treatment

1. Hospitalization
2. Psychotherapy
3. Rehabilitation – social, vocational
4. Aftercare – day treatment, halfway homes
5. Education about the illness for patient and families.

The Principles of Treatment

The patient is initially admitted to a hospital for assessment over a period of time. Out – patient
treatment is unsatisfactory, especially in more acute cases because of the patient’s
uncooperativeness and unpredictability, usually during his medication.

Nursing Care of Schizophrenia

First, the nurse should understand the following general principle of management of
schizophrenic patients.
1. Schizophrenia is a chronic illness, hence, the maintenance of long term is essential.
Total cure may not be possible in most of the cases.
2. What one should aim at is good improvement, with regular, appropriate treatment.
3. Furthermore, in times of stress, the patient may get a relapse of symptoms inspite of
regular treatment.
4. A schizophrenic patient
i. Requests a substantial increase in his own self – esteem.
ii. Needs to be assisted to live with the real world.
iii. Needs to live a place where he gets a change to use his own initiative and
judgment.
iv. Needs to have human contacts.
v. Needs to find a nurse who will be a stable and consistent modal. He needs
assurance as to his own personal identity.
vi. Needs patience, and forebearance.
5. Accept him as he is. that means the nurse should realize the limitations and weaknesses
of the patient.
 6. The nurse can minimize her own frustration by learning not o expect the impossible
from him. The patient’s condition can be made to improve, but slowly. Hence, it is the
duty of the nurse to refrain from rejecting him and accepting him wholeheartedly as he
is.
7. Assign small responsibilities to the patient
8. Engage and support the patient
9. Supervise him in all his needs
10. Appreciate him even if he does a small task
11. Do not – Ignore
Criticize
Exert social behaviour
Refrain from over involvement

Nursing Care Of Acutely Iii Schizophrenics

Schizophrenic patient may become acutely ill, mostly during the initial stage of the illness or
they may get acute exacerbations during their long – term course of the illness. Acute
excitement s is more common in catatonic and paranoid types. The main nursing concern is
controlling his impulsive behaviour when he hears voices and respond to them. He will be also
verbally abusive to the staff. It may be difficult to communicate with someone who is psychotic,
but it is importance to obtain valuable data on how severe the thought disorder is. These data
can be obtained by the nurse who can establish some degree of trust with the patient.
During the acute phase, the important thing is to meet the physical need of the patient.
Proper nutrition care is essential since the patient may refuse food because of
1. Suspicion
2. Indifference (negligence) or too busy or over-active that he forgets to take food.
So it is important to supervise the patient’s nutrition and if necessary, intravenous fluids
given to avoid dehydration. In the acute phase, schizophrenic patients require drugs mainly by
parenteral form. For example, inj. Chlorpromazine 100mg intra muscular, inj. Haloperidol 10 to
20 mg intra – muscular or intra – venous. The injections are to be continued periodically till the
patience is able to take oral drugs. During acute state, it is important to look for any injuries
sustained during excitement and these should always be approached with the assistance of
other nursing staff or at tenders.
Nursing Care of the chronic schizophrenics

Schizophrenia is a disease which is chronic in nature and the chronic patients are usually
withdrawn and have a lot of negative symptoms. So, very important in the nursing care of
chronic schizophrenics to engage the patient in some useful activity. “An idol mind is the devil’s
workshop”, therefore, the patients will lose their original potentials, yet, they will have some
minimum capabilities.
To make him lead a benefitical life with the existing potential, he should be encouraged to do
some positive, physical work. This is otherwise known as rehabilitation. It is the role of the
nurse to encourage and motivate the patient to have some occupation or to work in some
industrial therapeutic unit. The nurse should also constantly supervised the patient’s
performance and appreciate him at the appropriate time.

Following are physical, emotional and therapeutical needs of the chronic patients.

Physical needs
1. Appropriate nutrition – regular diet and supervision of his diet.
2. Taking care of personal hygiene - regular bath and cleanliness.
3. Elimination has to be carefully watched – attend to care of the skin because a chronic
schizophrenic living in a crowded, closed place are prone to develop skin problem like
scabies eczema etc.

Emotional needs
1. The withdrawn patient’s main problem is lack of communication and poor interpersonal
relationship because of less social contact.
2. It is responsibility of the nurse to give importance to the personal identity of the patient.

Therapeutic needs
He should be accepted as a human being and should be given responsible work in the ward set
– up. Patiently and positively hear the suggestions from the patient himself in implementing the
routine ward work. This type of therapeutic environment will minimize the damage and will
improve the quality of the person. This will again prevent institutional neurosis – a condition
which may occur in a long – term mentally ill patients in a mental hospital set –up.
The chronic patient needs stimulation, occupational and recreational therapies.
In nursing care of a chronic schizophrenic, emphasis should be plaed on the five “R”s.
1. Reassurance
2. Readjustment
3. Rehabilitation
4. Reeducation receation
5.
The Abuse of Alcohol and Drugs
From time in memorial human beings have looked for substances to make life more
pleasurable to avoid or decrease pain, discomfort and frustration. Despite definite
improvements in health care in most countries; problems related to drug and alcohol abuse are
increasing almost everywhere.

Drug use is abnormal if it causes disturbances, such as:

 When it interferes with normal activities
 Cause physical damage and
 Leads to social disapproval
Drug abuse has been showing a rising trend all over the world including India, as a result of
newer and greater stresses related to rapid changes in lifestyles. Various terminologies are used
in this area like drug abuse, drug addiction and drug dependence-all denoting a basic problem,
with some differences.

Drug abuse: Drug abuse is defined as persistent or sporadic drug use inconsistent with, or
unrelated to, acceptable medical practice.

Drug addiction: A disease process characterized by the continued use of a specific psychoactive
substance despite physical, psychological or social harm. Addiction usually indicates a more
serious problem than abuse.

Drug dependence: a maladaptive pattern of substance use, leading to significant impairment or

distress as manifested by the following.
1. Tolerance-a need for markedly increased amount of the substance in order to achieve
intoxication or desired effect.
2. Characteristic withdrawal symptoms: if the abused drug is stopped or reduce in quantity
the person develops physical and/ or psychological disturbances.
3. Frequent preoccupation with seeking or taling the substance.
4. Often takes the substance to in larger amounts or over a longer period than was
intended.
5. Often takes the substance to relieve or avoid withdrawal symptoms.
6. There are unsuccessfully efforts to cut down or control substance use.
7. Much time is spend in search of, or to obtain, the drug.
8. Important social, occupational or recreational activities are give up or reduced because
of substance use.
 9. Intoxicated by substance when expected to attend to his duties (e.g. does not go to
work because of hangover; goes to work high; drives when drunk).
10. Continuation of substance use despite a significant occupational, social or legal problem
or a physical disorder.

Types of Abuse Substances

Types of substance Examples Effect
Depressants Alcohol, barbiturates Drowsiness, pleasant
Sedatives, sleeping tables relaxation, disinhibition
Opiates Morphine, methadone, Relief from pain, pleasant
Heroin detached feeling, euphoria
Stimulants Cocaine, Amphetamines Exhilaration, reduced, fatigue
And hunger
Hallucinogens LSD, Mescaline Other worldliness, perceptual
Distortions
Cannabis Marijuana, ganja, bhang relaxation and hallucinogenic
Effecs
Nicotine tobacco Sedation and stimulation
Volatile Gues, paint Drowsiness, relaxation
Inhalants thinners perceptual disturbances

ALCOHOL ABUSE
Even though alcohol is a depressed, it will be considered separately due to the complex effects
and widespread nature os its use. Alcoholism is defined as a chronic disease manifested by
repeated drinking that produces injury to the drink’s health or to his social or economic
functioning.
Low to moderate consumption produces a feeling of well being and reduced inhibitions.
At higher concentrations, motor and intellectual functions are impaired, mood becomes very
labile and behaviour characteristic of depressed, euphoria and aggression are exhibited. The
medical use of alcohol are:

1. As an ingredient in medicines in some pharmacological preparations like cough syrup,

tonics etc.
2. As an antidote for methanol consumption.
Alcoholic beverages are widely used in many societies because of which their abuse
potential is often underestimated. Commonly used alcohol preparations are beer, wine, brandy,
whisky, rum, gin, arrack and toddy.
 Alcoholism is the most common psychiatric disorder. Epidemiological surveys carried out
in India reveal that 20 to 40 percent of subjects aged above 15 are current users of alcohol and
nearly 10 percent of them are regular or excessive users. Nearly 15 to 30 percent of patient
seeking admission in psychiatric facilities are for alcoholrelated problems. Among the acute
medical admissions in a general hospital 10 to 20 percent are due to alcohol-related problems.

The Causes of Alcohol Abuse

Availability: Alcohol is easily available and drinking is accepted as a ‘norm’ in function and social
gathering.
Genetic factors: Some excessive drinkers have a family history of excessive drinking. There is
genetic relation between alcoholism, depression and antisocial disorder.

Biochemical Factors: several biochemical factors have been suggested including abnormalities
in alcohol dehydrogenase or in the neurotransmitter mechanism.

Learned behaviour: it has been suggested that learning processes may contribute in a more
specific way to the development of alcohol dependence through the repeated experience of
withdraw symptoms. Alcohol may acts as a reinforcer for further drinking. Children, especially
boys, tend to follow their parent’s drinking pattern. Some people drink to get away from pain.

Personality factors: Alcoholism is more common in anxiety, prone or cyclothymic personalities.

Drinking alcohol is also more common among antisocial personalities.

Poor coping strategies: the person unable to face stress often resort to alcoholism. The defense
mechanisms involved in alcoholism include denial, rationalization and projection.

Psychiatric disorders: some patients with depressive disorders take to alcohol in the mistaken
hope that it will alleviate low mood. Persons suffering from anxiety disorder and phobic
disorders are prone to take alcohol as an escape.

Social causes: isolation, unemployment, loss, injustice and other social causes may lead to
alcoholism.

High risk groups: persons suffering from chronic physical illness, business executives, travelling
salespersons, industrial workers, urban slum dwellers, students in hostels , military personnel
etc. are more prone to develop alcohol abuse.

The process of Development of Alcoholism

External : to begin with, persons start drinking alcohol due to peer pressure and curiosity.

Recreational: Gradually, whenever they meet in functions like marriages, hostel day or college
day, parties, conferences, they drink occasionally.

Relaxational: further, whenever they want relaxation, on holidays and week ends, they start
enjoying their drink and continu to do so. Hence the frequency gradually increase.

Compulsive: some people who started drinking occasionally, start drinking almost daily and
heavily for a period of time for pleasure or to avoid the discomfort of withdrawal symptoms.
The disease goes through distinct stages:

Early Stage
Increasing tolerance- needing more and more of alcohol to experience the same pleasure as
experienced earlier.
Preoccupation – always thinking about how, when and where to drink.
Middle Stage
Loss of control over amount, time and occasion of drinking. Keeping away from alcohol for
sometime but going back to obsessive drinking after each such abstinent period.

Chronic stage
Getting drunk even on small amount of alcohol.
Willing to lie, beg, borrow or steal to maintain supply of alcohol.
Living to drink-alcohol takes priority over family or job.

Physical Complication of Alcohol Abuse

Gastrointestinal
 Dyspepsia
 Vomiting
 Acute or chronic gastritis
 Peptic ulcer
 Cancer
Liver
 Fatty degeneration of the liver
 Alcoholic hepatitis
 Cirrhosis
Pancreas
 Acute and chronic pancreatitis.
Cardiovascular
 Alcoholic cardiomyopathy
 High risk for myocardial infarction
Blood
 Folic acid deficiency anaemia
 Decrease WBC production.
Muscle
 Peripheral muscle weakness and
 Wasting of muscles
Nutrition
 Protein malnutrition
 Vitamin deficiency disorders like pellagra and beriberi
Joints
 Gout due to increase in uric acid level
Reproductive System
 Sexual dysfunction in males
 Failure of ovulation in females
Pregnancy
 Fetal alcohol syndrome-fetal abnormalities like mental retardation and growth
deficiency.
Nervous System
 Alcoholic peripheral neuropathy
 Wernicke’s-korsakoff syndrome
 Rum fits during withdrawal

Psychiatric Complications of Alcohol Abuse

Pathological intoxication: Maladaptive behaviour effects, such as fighting, impaired judgment,
physiological signs such as slurred speech, incoordination unsteady gait, psychological changes
such as mood changes, irritability and impaired attention.
Withdrawal phenomenon: the general withdrawal symptoms are- tremor, nausea and vomiting,
malaise, tachycardia, elevated B.P., irritability, anorexia, insomnia, fits.
Delirium tremens (DT) is a complicated withdrawal state. An acute organic mental
disorder and this should be treated as a psychiatric emergency. DT is a short-lived, but
occasionally life threatening, toxic, confusional state with accompanying somatic disturbance.
Prodromal symptoms are insomnia, tremulousness and fear, and occasionally convulsions. The
classical features are:
a. Clouding of consciousness and confusion
b. Vivid visual hallucinations and illusions
 c. Marked tremor and fever
d. Delusion, agitation, increased ANS activities.
Alcoholic hallucinosis: Vivid hallucinations developing shortly after cessation or reduction of
alcohol.

Alcoholic psychosis: person drinking alcohol for a long time and In large quantities is prone to
developa psychotic disorder which resembles a paranoid schizophrenia with clinical features
like behavioural problem, thought disturbance delusions, hallucinations and impaired of
primary mental functions.

Morbid jealousy (Othello syndrome) A paranoid disorder with predominal delusion of infedility
of spouse (suspecting wife’s character).

Alcoholism and depression: alcoholics are more prone to develop depression. To get relief from
depression some people drink, which will further aggravate the depression. Attempted suicide
and suicide are more common in alcohol.

Alcoholism and criminality: Alcoholism reduces inhibition and increase hostility behaviour.
Hence alcoholics are more prone to violence and antisocial behaviour.

Alcoholic and sex: alcohol increases sexual desire but takes away the performance. Alcohol
males suffer from sexual dysfunction

Alcohol amnestic disorder: Impairment in short and long-term memory with disorientation and
confabulation

Alcoholic dementia: A chronic organic mental disorder due to long-term alcohol drinking.
Irreversible impairment in memory, orientation, impulsive control, ability to solve problems etc.
may be there.

Social Complications of Alcohol

Work problems: Decrease work performance, hence decrease productivity due to chronic
absences. As a result, the economy of the nation suffers.

Family problems: Alcoholism is a disease which not only effects the individual but his whole
family. Loss of job, loss of income will make the family condition miserable. There will be a role
model reversal, i.e. the bread-winner becomes an alcoholic and the wife takes the role of
earning. Marital disharmony is a common complication.
Drunken driving will lead to accidents.

Management of Alcoholism
 Assessment of the patient
 His drinking pattern
 Work spot
 Family
 Environment
 Physical methods
 Detoxification
 Disulfiram therapy
 Psychological methods
 Counseling
 Individual and group psychotherapy
 Marital/family therapy
 Behaviuoral modification (aversion therapy)
 Rehabilitation
 Alcoholic Anonymous.
Detoxification: Detoxification is the process by which an alcoholic depend person recovers from
the intoxicating effects of alcohol in a supervised way. It includes:
1. Administration of minor tranquilisers (anti-anxiety drugs like chlodiazepoxide or
diazepam) to control anxiety, insomnia, agitation and tremors.
2. Assess fluid and electrolyte balance for dhydration-IV fluids are essential.
3. Re-establish proper nutrition by giving a diet high in protein (when there is no liver
damage), carbohydrate, vitamins C and B Complex (especially vit. B1, B6 AND B12)
preparation parenterally.
4. Provide calm, safe environment
5. Control nausea and vomiting
6. Administer anti-convulsants if there is withdrawal seizure (rumfit)

Disulfiram (Antabuse) therapy: This drug produces intense headaches, severe flushing, extreme
nausea, vomiting, palpitations, hypotension, dyspnoea and blurred vision when alcohol is
consumed by the person.

Aversion therapy: Patient is subjected to pain-inducing stimuli at the time of drinking to

establish alcohol rejection behaviour.
Alcoholics anonymous (AA) A self of ex-addicts who confront, instruct and support fellow-
drinkers in their efforts to stay sober one day at a time, though fellowship and acceptance.

Nursing Care of Alcohol Dependents

The nursing taking care of an alcohol in a deaddiction ward should understand some basic
concepts about the problem:
1. Alcohol is a chronic disorder.
2. It is a relapsing disorder.
3. It is a disease affecting physical, mental, and social well-being.
4. Not only does the individual suffer but his family, work and community also suffer.
5. Accepting drinking as a problem by the patient is an important first step, because most
of the alcoholics deny that they are addicts (denial)
6. They are prone to pathological lying and manipulative behaviour
7. The involvement of other significant persons especially the family members enhance
the recovery process.
The important five goals in the management of alcoholism include:
1. Improving social relationships and supports.
2. Developing confidence and ability to change
3. Identifying reasons to change.
4. Developing alternative activities.
5. Learning to prevent relapse.

Care in the Acute Stage (immediately after admission during detoxification )

 Patient to be kept in a quite environment. Excessive stimuli increase the patient’s
agitation. Well-lighted rooms help reduce fears and illusions.
 Safety precautions-careful observation of the patient’s behaviour observe for any sign of
developing delirium tremens (DT).
 Be sure that the side-rails are up when patients is in bed.
 Physical restraint may be necessary if patient is highly disturbed or hyperactive.
 Keep potentially harmful objects away from the room since the chance of deliberate self
harm is there.
 Keep the bed clean, dry and warm since some patients may be incontinent.
 Monitor vital signs every 15 minutes initially.
 Frequently orient the patient to reality and surroundings.

Medication
 Follow medication as advised by the doctor
  Anti-anxiety drugs like chlodiazepoxide (Librium) and diazepam, if necessary,
parenterally given.
 Plenty of vitamins especially Inj. B1,B6, and B12 and Tab. B Complex and Vitamin C
 Antacids to relieve gastritis.
 Correct fluid and electrolyte imbalance by IV fluids.

Nutrition
 Take care of the nutrition of the patient
 Document intake, output and calorie content
 Weigh daily
 Ensure that the patient receives small frequent feedings rather than large meals.
 Ask family members to bring food that the patient enjoys.

Delirium tremens (DT) is an acute organic mental disturbance during the withdrawal period of
alcoholism. Watch for symptoms like confusion, disorientation, tremor, illusion, hallucination,
agitation and apprehension and increased sweating, heart beat and pulse rate. Some patients
may throw fit (Rum Fit). DT should be treated as emergency since it may sometimes be fatal. IV
fluid and IV diazepam, keep the patient in quite room, supplement with B complex vitamins and
reassurance are essential.

Nursing Care During Later Stage of Hospitalization (After detoxification is over)

 To understand the alcoholic, it is important to look beyond the symptoms and learn
about the person
 These persons are in need of physical as well as social rehabilitation
 Attention to their rest, diet, personal hygiene and appearance is important.
 During the recovery and rehabilitation period the acceptance of the patient by the
nurse is essential. The nurse’s acceptance may encourage the patient to socialize and
participate in planned ward activities
 The alcoholic patients have inferior feelings and low self-esteem. If the nurse accepts
him as an individual and acordialy talks to him, these feelings will be reduced.
 The nurse should be empathetic with the person but should not be over-sympathetic
and be sure that they do not become dependent on her.
 The nurse has an important role in the care and rehabilitation of alcoholic patients and
their families. The wives should always be included in the psychological therapy.
 It is important for the nurse to anticipate improvement instead of complete cure.
 Expression of kindness and being nonjudgmental, accepting him, being consistent and
understanding in approach all induced a favorable relationship which will help the
recovery process.
Nursing Role in the Prevention of Alcohol Abuse
Primary Prevention: Aim to avoid the appearance of new cases of alcohol abuse by reducing
the consumption of alcohol through health promotion, especially health education.

Secondary Prevention: attempt to detect cases early, and to treat them before serious
complications cause disability.

Tertiary Prevention: aim to avoid further disabilities and to reintegrate individuals into society
who have been harmed by severe alcohol related problems.
The nurse will be involved in all these levels.

DRUG ABUSE
Drug abuse was considered a problem in the West but now it is a serious public health and
socio-economic problem in India as well. Drug abuse is increasing among Indian youth. Drug
addiction is spreading to all sections of the society, especially high in major cities. It is estimated
that 10-25 percent of college students take drugs for euphoria and 1-2 percent abuse drugs.
The problem of drug addiction is more common in urban slum dwellers, especially unemployed
youths. In India 19-23 per 1000 abuse drugs in the general population.
Drug addiction is neither delinquency nor deviancy, but is a disease worse than
cancer. It is a disease because it affects physical health, mental health, prestige, finance, social
status and occupation of the individual.

Why people take drugs?

 They search for euphoria (a sense of well-being)
 Relief of psychological pain of diverse origins
 Wanting to feel better than they do
 To avoid withdrawal symptoms

The Factors Involved in Drug Abuse

1. The drug is seen as a reinforcer
2. Tolerance
3. Physical dependence
4. The abuser.
 The personality, degree of stability and attitude of individual
5. The environment
 Isolation
  Stress
 Peer group influence
6. The motivating factors
 Initiation in company
 Curiosity
 Pleasure
 Acceptance by the group

Identification of an addict
It is possible to identify the early signs and symptoms of addiction.
They are:
 Lack of interest in studies and poor academic performance
 Loss of interest in hobbies, games and sports
 Withdrawal from the family
 Social isolation, preferring to be aloof
 Blank expressions and irresponsible and aggressive behaviuor
 Irregular eating and sleeping habits.
 Long hours in the bathroom
 Persistent lying and stealing
 Low productivity
 Impaired judgement

Common Drug Abused in Our Country

1. Alcohol (dealt in detail already)
2. Cannabis (ganja)
3. Opium product
 Brown sugar(heroin)
 Synthetic preparation
4. Hypnotic and minor tranquliser(diazepam, nitrazepam)
Cannabis: it is the generic name given to the drug containing plant products of Indian hemp.
This plant material contains psychoactive chemicals, the most important of which is
tetrahyrocannbinol (THC). The dried leaves or flowing top often referred to as Ganja or
marijuana. The resin of the plant is referred to as hasish. Bhang is a drink made from cannabis
produces psychological dependence.

The Psychiatric Complication of Cannabis Abuse

 1. Intoxication tachycardia, euphoria perceptual intensification, apathy relaxation,
drowsiness, anxiety, suspiciousness, increased appetite, dry mouth, conjunctival
infection. On overdose it produces confusion disorientation, panic and hallucination.
2. Flashback the re ex – experience of perceptual symptoms that occurred during acute
intoxification.
3. Cannabis induced psychosis: psychosis resembling paranoid schizophrenia. Clinical
feature include persecutory ideas or delusions, auditory hallucination anxiety,
apprehension, suspicion, severe depersonalization , derealisation and, at times, acute
depression.
4. Cannabis includes chronic conditions:
1. Personality deterioration
2. Cognitive functional disturbance
3. Sexual dysfunction
4. Social withdrawal
5. Amotivational syndrome (apathy – inactivity – self neglect and nonproductivity
The common physical complaint associated with cannabis abuse is bonchititis.
SLEEP DISORDERS

Sleep and dreams have been subjects of interest for many years. Sleep can be regarded as a
physiological, reversible reduction of conscious awareness. There are two types of sleep:

1. REM sleep (Rapid Eye Movement Sleep)

2. NREM sleep (Non REM Sleep)

REM sleep is active sleep

Characteristics of REM Sleep

 Rapid eye movements

 Dreaming
 Increased brain metabolism
 Oxygen utilization and temperature
 A loss of muscle tone
 Tachythmia, and
 Penile erection

Characteristics of NREM Sleep

NREM Sleep is divided according to its EEG recordings into four stages. NREM sleep is
accompanied by a slowdown of bodily functions. There is reduction in heart rate, respiration,
urine output, blood pressure, temperature and state of relaxation in metabolism and motor
activities.

Sleep requirement

Most people require between 6-9 hours of sleep per day. Those who require less than 6 hours
are called ‘short sleepers’, and those who require more than 9 hours of sleep are called ‘long
sleepers’. REM sleep is longer in long sleepers. Short sleepers are generally more healthy, active
and better adjusted. Sleep requirements increase in children and old people. More hours of
sleep are needed in pregnancy, sickness, mental stress, depressed mood and after strenuous
work.

Sleep deprivation

Sleep deprivation is a pressing health problem. If a person is not sleeping continuously for few
days or nights, it is harmful to his health.

Sleep deprivation may produce

1. Impaired mental alertness and performance.

2. Thinking process is disturbed
3. Results in poor attention, concentration and judgment
4. Mental fatigue may even trigger physical illness like heart attack
5. May lead to traffic accidents and industrial mishaps
6. May lead to poor performance in studies and problems like drug abuse in students

CLASSIFICATION OF SLEEP DISORDERS

Primary Sleep Disorders (Disordered sleep is the only sign and symptom of abnormality)

a. Cataplexy-Sudden decrease or loss of (sleep paralysis) muscle tone, often generalized

and may lead to sleep
b. Hypersomnia-Excessive sleep at night or during the day
c. Insomnia-Inability to fall asleep and maintain sleep. When it occurs in the absence of
physical or psychological disorders it is called primary insomnia
d. Kleine-Levin syndrome-Periodic episodes of hypersomnia
e. Narcolepsy-Uncontrollable, recurrent brief episodes of sleep associated with cataplexy
f. Nightmares-Sleep disturbance with frightening or bad dreams. A good recall of dreams
occurs during REM sleep
 g. Night terrors-Sleep disturbance accompanied by panic, confusion and no recall of the
frightening dream
h. Pick Wickian-Occurs during stage 4 (NREM) sleep with hypersomnia associated with
obesity and respiratory disturbance

Secondary Sleep Disorders (Clinical problem accompanied by specific or non-specific

disturbances)

a. Alcoholism-Variable sleep disturbance

b. Anorexia nervosa-Decreased total sleep time
c. Depression-Less sleep time, more awakenings
d. Hyperthyroidism-Insomnia
e. Hypothyroidism-Increased sleep
f. Schizophrenia-Variable

Parasomias (Waking up during sleep)

a. Bruxisam (teeth grinding): Occurs during stage 2 (NREM) sleep with loud noise and
damage to sleep.
b. Enuresis Bed wetting during sleep.
c. Sleep talking: Mainly occurs during NREM sleep. Very common by itself or as a part of
some other sleep disorder or psychiatric disorders.
d. Sleep walking: Occurs during stage 4 (NREM) sleep, in which walking or other motor acts
are performed.

INSOMNIA

Insomnia is defined as quantitatively or qualitatively insufficient sleep on the basis of the

individual need. Insomnia is the term applied collectively to complaints involving the chronic
inability to obtain adequate sleep. Insomnia is difficulty in falling asleep, difficult in maintaining
sleep. Insomnia is of three types

1. Sleep onset insomnia-difficult in falling asleep.

2. Frequent nocturnal awakening-interrupted sleep characterized by frequent awakening.
3. Early morning awakening-waking up early in the morning and not being able to fall back
asleep.

Causes of Insomnia

1. Primary- Due to specific sleep disorders.

2. Secondary-Due to
 Physical causes
  Behavioural causes
 Psychiatric disturbances
 Social causes
 Drug- related causes.

Physical causes

Uneasiness, discomfort: Dyspnoea, cough, itching, nocturia.

Chronic pains Headache, neuralgia, Cramps, orthopaedic disorders, cancer.

Endocrine disorder Menopause, hyperthyroidism, hypoglycemia.

Behavioural Causes

Naps (during the day)

 Irregular sleep hours

 Lack of physical exercise
 Alcohol or tobacco abuse
 Excessive coffee in the evening
 Disturbing bed partner
 Disturbing environment (heat, cold, noise).

Psychiatric Disorders

 Depression
 Anxiety
 Hypomania
 Schizophrenia
 Chronic alcoholism and drug addiction

Social Causes

 Separation or devorce
 Overwork, career change
 Traumatic experience (accident, assault)
 Immigration
 Serious illness in the family
 Birth in the family
  Death of spouse or close relative
 Financial loss
 Acquiring a physical handicap
 Son or daughter leaving home
 Retirement
 Failure (Exam, Love).

Drug-related Causes

 Stimulants
 Thyroid hormones
 Sympathomimetic
 Corticosteroids
 Beta-blockers

Treatment of Insomnia

 Detailed assessment and evaluation

 Identifying the causative factors and treating them.

Most patients who seek treatment for insomnia suffer from anxiety and depression. Other
causes are less common.

Treatment of insomnia depends on duration. Transient insomnia can be treated initially

with hypotics (like nitrazepam, lorazepam etc.) hypnotics should not be for longer periods.

Non-Drug Treatment for Insomnia

1. Progressive relaxation: Relax the body (muscle), thereby relaxing the mind.
2. Autogenic training: Autosuggestion.
3. Meditation, yoga: Produces relaxation of the mind.
4. Biofeedback self monitoring, keeping record of sleeping and waking.
5. Stimulus control therapy: Do not use the bed for reading or chatting. Go to bed for
sleeping only.

Nursing Care of Persons with Insomnia

The common complaint a nurse receives during her night duty is disturbance in sleep. Hence, a
nurse should understand in detail the concept of sleep, the effects of sleep deprivation and
various causes of insomnia. Apart from giving medication as prescribed by the doctors, the
nurse should be in a position to educate the patient in getting good sleep.
Sleep hygiene: Nurse should advise her patients to avoid heavy meals or exercise before sleep.
Coffee, tea or smoking should also be avoided before sleep. Try to minimize the use of
hypnotics substitute back rubs, warm milk and relaxation exercises.

Sleep environment: Make the environment conducive to sleep. Too much light, noise and heat
or cold are to be avoided. Close doors, dim lights and turn of unnecessary machinery.
Encourage staff to talk in low tones during the night in the wards. The nurse should keep a daily
record of how many hours the patient has slept. If there is any sleep disturbance or sleep
associated problem, inform the doctor.

DElIRIUM
Delirium is again a common psychological disturbance in the elderly. It is an organic brain
syndrome characterized by impaired in consciousness, orientation, attention and behaviour;
onset is acute fluctuating in course. Elderly are particularly vulnerable to the development of
delirium in association with any physical illness. Often it occurs in the general medical ward.

Aetiological organic factors could be identified I 80-95% of reported cases of delirium in

the elderly.

The commonest causes of delirium in elderly are:

1. Drugs
2. Metabolic causes
3. Malnutrition
4. Respiratory diseases
5. Cardiovascular diseases
6. Liver diseases
7. Cerebrovascular disorders
8. Fever
9. Alcohol
10. Trauma

Management of Delirium
In the elderly management of delirium includes assessment of basic causes, treating the cause,
maintaining fluid and electrolyte balance and good nursing care. Minimal doses of anti-
psychotic drugs for a short time can be given.

Nursing Care of Delirium

Keep the patient in a comfortable, quite, well lighted place. Less stimuli is advisable. Reassure
the patient and be supportive. Orient the patient to time, place and people frequently. Have a
consistent, sympathetic and understanding nursing care.

PARANOID DISORDERS.
Apart from dementia, paranoid disorders (delusional disorders) occur occasionally in old age.
Paranoid disorder occurring in old age is at times known as paraphrenia, more common among
elderly women.

Clinic Features Include:

Suspiciousness, persecutory delusion, agitation, restlessness, depression and insomnia.

Treatment with mild dose of major tranquilizers is beneficial.

NURSING CARE OF ELDERLY WITH MENTAL HEALTH PROBLEM

The nurse should understand that most old people are dependents and have a feeling of
insecurity. The nurse should also understand the common symptoms of senility like:

1. Change in attention span

2. Memory loss for recent events and names
3. Altered intellectual capacity
4. Diminished ability to respond to others

The long term nursing goal is to help the patient in reducing hopelessness and
helplessness. Short term goals are to educate the patient to preserve their self image and
preserve their abilities to perform. The nurse should reassure and encourage the patient to
reduce depression and feelings of isolation and educate them to correct sensory deficit (e.g.
cataract operation of eye will improve their vision and reduce their dependency). Teach them
to take care of physical illnesses which are common in elderly. If possible encourage them to do
simple physical exercise like walking which will enhance blood flow.
SIDE EFFECTS OF ECT
Commonly side effects are:

1. Confusion-recovers within a day

2. Muscle aches, headache- recovers after a few days.
3. Memory impairment-recovers in three to six weeks.

MODE OF ACTION
The exact mechanism is not known. However, the probable theories are:

Psychological Theories

1. Fear induced by the treatment is the effective agent.

2. Patient regards the treatment as punishment, conscience is assured, guilt and
depression relieved.
3. During treatment, the patient is allowed to regress to infantile levels and conflicts are
resolved.
All the psychological theories are unsatisfactory.

Biological Theories

1. Increased concentration of neurotransmitters such as nor-adrenaline, dopamine and

serotonin in the brain after the convulsions. Hence, ECT modifies biochemical imbalance
in the brain.
2. Membrane permeability and electrolyte changes induced by the convulsions.
3. Increased receptor sensitivity following the convulsions.
4. ECT may reduce the synthesis and release of GABA.

NURSING CARE AND PREPARATION FOR ECT

The procedure should be explained to the patients and relatives in details and informed
consent should be obtained. The patient’s relatives are to be told that ECT is an effective
treatment without much complication. The nurse should assure the relatives that there will not
be any permanent brain damage to the patient. Minimum investigations like x-ray chest and
ECG are to be done and a physician’s opinion regarding physical fitness to be obtained.

Preparation prior to ECT

The nurse should see that-

 Skin is cleared in the fronto-temporal areas.

  Starvation for minimum six hours.
 All dentures are be removed, as well as hairpins, jewelry, eyeglasses, contact lenses
and other objects those may cause injury
 The patient should wear loose clothing.
 Bladder is to be emptied.
 ECT chart is put up. Vital signs like temperature, pulse, BP and respiration should be
checked before ECT.
 Oxygen supply is kept ready. A tray containing essential drugs like Inj. Decadron,
deriphyline, adrenaline must be kept ready.
 Inj. Atropine 0.1-2 mg as premedication to reduce secretion to be given 15-30 minutes
before the treatment.
 Anaesthetic agent like pentathol sodium and muscle relaxant like scoline may be used.

Psychological preparation : the patient is usually somewhat apprehensive because of the nature
of the treatment, reassurance and support must be given and patient should be assured that he
will not remember the treatment procedure. A calm, confident manner during the preparation
of the patient, allowing him to express his feelings, will help in relieving tension. The nurse
should accompany the patient and remain with him during treatment and until he recovers
consciousness. It is reassuring for the patient to have to be present during the period of
confusion.

Care During the Treatment

The patient is usually placed in a bed, with a hard mattress or on a specially prepared table,
with a sand bag or hard pillows under the neck so that it is hyperextented. In straight ECT,
generally , about four persons are used to hold the shoulders, arms and legs firmly to prevent
fractures and dislocation of the during the jerky movements. A mouth gag is inserted between
the teeth to prevent tongue-bite and the jaw is supported by upward pressure to avoid jaw
dislocation . Airway is to be maintained. At the end of the convulsion, the patient’s head is
turned to one side to prevent the collection of mucus in the back of the throat.

In modified ECT anaesthetic induction and muscle relaxant (Inj. Succinyl choline) is to be
given. Oxygen is to be given for two to three minutes and airway inserted. Treatment should be
given within two minutes of Inj. Succinyl chroline. In modified ECT there will not be muscular
pain, and dislocation and fractures can be prevented.

Nursing Care after ECT

Some patients will go off to sleep and some patients will be confused, agitated and restless. At
times they become violet too. Hence Inj. Diazepam is to be kept ready and if necessary to be
given intravenously and slowly. The side rails ought to be put up while the patient is confused
or he should be made to lie down on a mat or clean sheet on the floor in a sideways position.
Blood pressure and respiration are to be recorded.

The nurse should stay with the patient till he awakens and responds to questions. Orient the
patient to time and place to make him feel more secure and relaxed. If patient develops
nausea/ vomiting, headache or body pain, appropriate medication is to be given. Patients can
be give drink 20-30 minutes after treatment.

For the Treatment of Phobia

1. Systematic desensitization The phobic patient is exposed slowly to a gradual hierarchy of
Phobic objects or situations.
2. Flooding: The phobic patient is forced to remain in the phobic situation until his anxiety is
exhausted.
3. Implosion: The phobic patient is instructed to imagine the phobic situation and remain in it
until his anxiety is exhausted. Imagination is used when any other way is not feasible. For
the Treatment of Compulsive Acts

For the Treatment of Compulsive Acts

4. Modeling: where the therapist carries out the act which the patient is afraid of and
requires the patient to imitate.
5. Response prevention: where the therapist prevents the patient from avoiding unpleasant
acts or situations.
6. Thought stopping: where the therapist prevents the patient from continuing to ruminate
his obsessive thoughts by shouting “stop” or inflicting mild pain on his arm with a rubber
band.
For the Treatment of Schizophrenia or Mental Retardation
7. Operant conditioning: the patient is rewarded for desired behaviour and punished
behaviour.
8. Social skills training: this is to improve social manners like encouraging eye contact,
speaking appropriately, observing simple etiquette, and relating to people.

For the Treatment of Alcohol and Sexual Deviations

9. Aversion therapy: the undesirable behaviour is paired with an unpleasant stimulus, e.g.,
drinking alcohol is followed with a mild electtrick shock.

Relaxation therapy
Relaxation therapy: aim s at producing relaxation to those with anxiety and stress related
problems. Such people are tense and agitate and what they require is a relaxed mind. By
relaxing the body can one achieve relaxation of the mind. This forms the basis for all the
relaxation techniques. These includes:
 Progressive muscle relaxation technique (Jacobson)
 Transcendental meditation
 yoga
The following four elements are the basis to all types of relaxation techniques.
1. Quiet environment
2. Mental devices
3. Passive attitude
4. Comfortable position

Relaxation of produces the following physiological changes:

1. Decreased oxygen consumption
2. Decreased respiratory rate
3. Decreased heart rate
4. Increased alpha brainwaves
5. Decreased blood pressure
6. Decreased blood lactate levels.
Relaxation Exercises
The following is the simple technique whereby relaxation can be achieved. This can be
practiced by normal people who require more concentration, students to improve memory,
persons who face stressful situations often, anxiety prone personalities and also who suffer
from various types of anxiety and stress-related disorders.

Are you the worry kind? It would seem that there are two types of personalities. There are
striving, competitive, ambitious and impatient people, the so-called type A, and there those
who take life easier, and are called type B. the type Aare more prone to a number of problems
including heart disease and ulcers. It may well be that type B people can suffer from type A
problems if they are put under great stress.

What puts people under stress? Stress is a normal part of our lives. In small amounts, it makes
us more alert and helps us enjoy life more.
The worrying type of person puts him or herself under constant stress even when their life
is on an even level. For all of us, there are periods that we are under particular stress from our
jobs or home life. Obviously unhappy events, as the death of spouse, divorce, imprisonment or
redundancy are very stressful. But even pleasant occurrences such as marriage, birth of a child
or a new job carry a considerable degree of stress.
 These periods of stress are unavoidable and we should try to cope with them the best we
can.
What can you do to relax: it is important that one develops a method of relaxing.
One can keep busy during free time. A hobby or sport will give no time to worry. The
following relaxation exercises can be done singly or in sequence. For best results lie down or sit
somewhere quiet.
1. Begin the relaxation by clenching all your muscles, hold for a count of three and then
relax. Do this three times.
2. Breathe in slowly to a count of four, hold for a count of two and then let the breath rush
out. Do this three times and as you exhale feel your body become more relaxed. These
first two exercise can be done whenever you feel tense.
3. Close your eyes and breath easily. Focus you attention first of all on what you can
hear. You will gradually become aware of sounds you have not noticed before. Then
focus your attention on what you can feel, e.g. can you feel your clothes against your
skin or the pressure of the chair against your back? As you breathe your should be
conscious of the air entering your nose, throat and lungs. Do this for minutes.
4. This rhythmic breathing exercise will not only aid relaxation but should also help
concentration. Breathe regularly and evenly, breathe in and as you exhale mentally say
‘one’ and concentrate on the number. If other thoughts intrude, block them and return
to thinking about the number. Do this for five minutes.
5. Picture yourself somewhere pleasant and relaxed, e.g., lying on a beach. Can you hear
the sea and feel the sand? By imagining the sounds you hear and the sensations you
feel, you can almost recreate the pleasant experience, and this will bring relaxation. Do
this for five minutes.
6. Imagine yourself walking along a path, through a gate, across a meadow, through a
wood and to a pool. Imagine the sounds and sights on your journey. As you repeat this
exercise on subsequent occasions, you will probably add more detail to your journey. Do
this for five minutes.
You may find the above exercise difficult at first, but with practice they will become
easier and every enjoyable. If you can do them once or twice a day you will find after a week or
so that you feel much more relaxed..

Meditation and yoga

This is well-recognized relaxation technique. Meditation helps to focus our attention at one
point and thereby improvement our concentration and be relaxed. Meditation is a
psychological exercise based on physiological facts. Meditation is claimed to help transform the
mind and lead onto happiness and serenity, and paves the way to a creative mind, free from
anxieties and stresses
 Recently, there has been a worldwide interest in yoga and other meditation
techniques. They have long existed in the eastern cultures. Yoga has been used since ancient
times as a method to treat the disorders of the mind and body. Yoga is supposed to be a
powerful curative as well as preventive system.
The relaxation response is a physiological reaction brought about by stimulation of the
hypothalamus, resulting in decreased sympathetic nervous system activity. This change occurs
in yoga and transcedental meditation. These techniques involve involves assuming a passive
attitude and repetition of a word or phrase. Meditation and yoga are stress-reducing relaxation
techniques which have been followed in our country for a long time.
These procedures will help to minimise anxiety and tension in the psychologically
disturbed and also disturbed and also in normal persons

Psychiatric Emergencies
A psychiatric emergency is an disturbance in thoughts, feelings or actions for which immediate
therapeutic intervention is necessary. It is any psychiatric condition or circumstance of a patient
which calls for immediate action. Emergency in the psychiatric set up is usually due to one of
the following reasons:
1. The patient may be a source of danger to himself or to others because of his mental
state.
2. The patient may be extremely anxious regarding the patient‘s condition.
3. The patient may create disturbance in the community to an intolerant and
unmanageable degree.
4. The patient may be in extreme and unbearable distress.

APPROCH TO A PSYCHIATRIC EMERGENCY

1. Brief history to be taken
2. Assess the possibility of any probable precipitating factor
3. Assess the distress and extreme behaviuor pattern
4. Assess the degree of seriousness

The following are the common psychiatric emergencies

1. Excitement and violence
2. Stupor
3. Delirium
4. Attempted suicide
5. Panic attacks
6. Epilepsy related
 7. Alcohol and other addictive drugs related psychiatric emergencies
8. Ant-psychotic drugs induced psychiatric emergencies
9. Lithium toxicity
10. Refusal of food
11. Attempted suicide

Any act of self damage inflicted with self destructive intention. However, vague or ambivalent,
is an attempted suicide. If the patient dies as a result of the act it is called suicide. Otherwise it
is called attempted suicide.
A suicidal attempt with self destructive intension is attempted suicide whereas an attempt
without any intention of dying, but only to threaten or manipulate others is called Para-suicide.

Evaluation of Attempted Suicide

It is advised to get answers to the following questions to assess the suicidal patient.
1. Whether the patient belongs to the high risk group?
a. Old age, lonliness, social isolation.
b. Metal illness – severe depression, schizophrenia, hysteria, antisocial personality.
c. Physical illness – incurable, painful, longterm physical illness.
d. Alcohol and drug dependence.
e. Past history and family history of suicidal behaviour
2. The method used – was it harmless or potentially fatal.
3. Is there any real intention to die? If so why?
4. The place and time – was it carried out in the absence of other

Are There Any Serious Risk factors?

5. Is there any significant recent loss, e.g. death of close relative, loss of job or self esteem.
6. Were there any suicide talk, suicide letters, suicide plans?
7. Is there a will or any last wish?

Management of attempt suicide

1. The initial intensive medical care of the acute physical conditions.
2. The psychological approach; Attempted suicide requires crisis intervention. Persons who
attempt suicide need individual conselling and psychotherapy. Also, family and other
significant people should be involved.

Nursing Care of Attempted Suicide

a. Give the patient an opportunity to express his feelings.
b. Improve communication by a sympathetic approach.
 c. Strengthen self – esteem by supportive psychotherapy and reassurance.
d. Facilitate problem solving by:
 Identifying the problems,
 Identifying the alternatives,
 Being clear of the situation and practical solution,
 Choosing one alternative and following it up.

A person who attempt suicide needs medical and psychiatric treatment. The nurse must
assess the severity of the injury. Medical resuscitation is the priority, only then psychiatric
intervention is needed.
The patient’s safety is a nursing priority. The nursing care starts with suicide prevention or
preventing further attempts by making sure that the patient has no access to weapons, sharp
objects, rope, poisons, Psychotropic drugs and situations where self harm can be inflicted. This
requires close supervision by the nurse. Assessment and treatment, if underlying mental illness
is present, is essential after the patient recovers from the critical condition.
Encourage verbalizations of honest feelings. Allow the patient to express angry feelings.
Depression and suicidal behaviour are viewed as anger turned inward on the self. It this anger
can be verbalized the patient may become quiet, calm and comfortable.
The most importance responsibility of the nurse is to spend some time with the person who
attempted suicide. This provides a feeling of safety and security.
Crisis intervention is essential for the person who attempted suicide. This is more beneficial
for persons who have interpersonal and marital problems. Crisis intervention is similar to
supportive psychotherapy and includes ventilation abreaction and solving conflicts. It starts
with identifying the problem and ends with helping the person to understood and non –
suicidal methods to solve them.

Excitement (Violence)
Patients with excitement are prone for violence. They may harm other or harm themselves.
Violence is physical aggression inflicted by one person on another. Violence may be done due
to a wide range of psychiatric disorders. Violence and threats of violence are frequently
encountered in psychiatric emergency settings. The nurse should know how to rapidly initiate
procedures for the prevention of violence.

Common Mental Disorder Associated with Excitement and Violence Behaviour

1. Psychotic disorder
a. Schizophrenia (especially paranoid and catatonic)
 b. mania
c. Paranoid disorders (delusional disorder
d. Postpartum psychosis
2. Organic mental disorders
a. Delirium
b. Drug intoxication and withdrawal (alcohol and heroin)
3. Personality disorder
a. Antisocial personality disorder
b. Paranoid personality disorder
4. Brain disorder
a. Seizure disorders (post-epileptic confusional state)
b. Brain injury, encephalitis
c. Mental retardation with behaviour problem

Following are some important questions a nature should ask a relative or the person
accompanying an excited patient to have quick assessmet:
1. Is a person a known mentally ill? If so what type and what treatment has he been
taking?
2. Has he had a similar excitement earlier?
3. Is there any history of loss consciousness, head injury, epilepsy, alcoholism or drug
addicition?
4. Is involved in any criminal or antisocial activity?

Nursing Care of a Violent and Excitement Patient

1. First protect yourself, do not approach alone, call for assistance to manage any
situation. Do not close the door of the consulting room. Leave physical restraint to the
staff members who are trained for that.
 Do not challenge or confront a violent patient.
 Always keep an eye of a way through which you can escape.
 Never turn your back on the patient
 Be sure that sufficient staff members are there to restrain the patient.
2. After physical restraint, approach the patient cautiously; do not be too brave or
confident.
3. The most effective drugs are:
 Inj. Chlorpromazine 100mg IM
 Inj. Haloperidol 10 – 20 mg IM/IV
 Inj. Diazepam 10mg IV (slowly).
If there is a history of head injury or brain infection avoid these drugs.
 4. Assess the nutritional state and, if there is dehydration, IV fluids are essential.
5. Attend to the external injury, if required.
6. If psychiatric treatment is needed you may call the police for help.

Stupor
Stupor is a condition where the patient is conscious, but there is non – responsiveness to the
surroundings. There will be total absence of selfcare, neglecting physiological needs like food
and fluids intake and almost total motor inactivity. Stupor can occur in two mental disorders.
1. Schizophrenia (especially catatonic)
2. Depression.
They are emergencies because there is risk of neglect of nutritional needs of the body.

Nursing Care
Assess the nutritional states and hydration. Give immediate IV fluids and Ryles tube feeding if
necessary. Plenty of vitamins are also essential as well as physiotherapy to facilitate movements
and to prevent contractures. Minimal dose of drugs (antipsychotics and anti – depressants) are
helpful to relieve basic problems.

Delirium
Delirium is an acute organic mental disorder. It is a sign of acute brain dysfunction and is
therefore an emergency. The important clinical factors of delirium are: confusion, clouding of
consciousness, disorientation, insomnia, nightmares, illusions and hallucinations, restlessness,
perplexity, agitated mood, increased autonomic system activity, fever and fits. The patient is
more disturbed during the night.
Delirium is often reversible, the course usually being brief and fluctuating. Delirium is
common in the medically ill, hence most often seen in a general hospital setting. It is commonly
seen in medical wards, surgical wards, trauma wards, geriatric wards and deaddiction wards.

Important Causes of Delirium

1. Severe infections – typhoid, pneumonia, speticaemia, puerperal sepsis.
2. Intracranial infections – Encephalitis, meningitis, cerebral malaria, cerebral abscess.
3. Acute brain disorders – Head injury, cerebral haemorrhage, hypertensive encephalothy.
 4. Metabolic disturbance – Uraemia, liver failure, cardiac failure, respiratory failure,
electrolyte imbalance.
5. Vitamin deficiency – pellagra (nicotinamide) wernicke’s encephalopathy (thiamine)
6. Drug withdrawal – From opiates (heroin), alcohol (delirium tremens) barbiturates.
7. Drug intoxication – atropine, cocaine, bromides.

Nursing Management of Patient with Delirium

 Keep the patient in a well ventilated room with good lighting.
 Assess the vital signs periodically
 Assess the hydration and level of consciousness
 Watch for an attack of fit or altered behaviour.
 Identify any likely cause from the history of the patient.
 Remember that if untreated, delirium can lead to death
 If the patient is agitated, physical restraint may be necessary
 Correct any metabolic, nutritional, electrolyte or fluid imbalance. Fever and fit to be
treated appropriately.
 Start the treatment when a definite diagnosis is made.

Inj. Haloperidol 2-5 mg is helpful when the patient is agitated and restless. If it is alcohol or
drug withdrawal delirium or associated fit is there, inj. Diazepam 10 mg slow IV may be helpful;
gradually oral treatment with anti-psychotics or benzodiazepines may be continued. Associated
infections should be treated with appropriate antibiotics.

Panic Attack (Panic Disorder)

Panic attack is severe form of acute anxiety. Panic disorder is characterized by spontaneous,
episodic and intense period of anxiety. It usually last for few a minutes to 30 minutes. Panic
disorder usually occurs once or twice a week. The symptoms of panic disorder include:
 Shortness of breath (dyspnoea)
 Dizziness, feeling unsteady or faint
 Palpitations (tachycardia)
 Trembling or shaking
 Increased sweating
 Chocking sensations
 Abdominal distress
 Flushes or chils
 Chest pain or discomfort (without any ECG abnormality)
 Fear of dying
 Fear of going crazy
  Not all the above symptoms should occur to call it a panic attack; just four or more
symptoms may be sufficient. In the typical case, the patient has been repeatedly
presented to the emergency rooms or a doctor’s consulting room, with physical
symptoms, feelings of uneasiness, chest pain, fear of dying etc.
 All the above symptoms occur despite the absence of cardiac or medical disease.
Panic attacks can be provoked by inhalation of carbon dioxide (CO 2). Psychosocial
stressor may also precipitate an attack of panic. Most of these patients suffer from
anticipatory anxiety.

Management and Nursing Care

It is very essential to map out all possible causes for panic symptoms. All the necessary
investigations, especially ECG, should be taken. It is necessary to get a detailed history about
the patient’s medication and drugs.
Management of panic disorder includes drug treatment, behaviour therapy and
relaxation therapy.
The drugs commonly used in the management of panic attacks are:
1. Alprazolam (Alzalam, Anxit, Restyl etc) 0.25.05 mg every 4 hours
2. Lorazepam (Atival, Larpose etc) 1-2 mg every 4 hours
3. Clonazepam (rivotril, Lonazep etc) 0.5 mg-2mg.

Sometime even higher does may be required to control panic attacks. Tricylic anti-
depressants like Imipramine are also effective. If the attack is very severe Inj. Diazepam one
amp IV slowly may be useful in rare case.
The nursing care of panic disorders include the following measures:
1. It is essential to explain the nature of the disease to the patient that is, it is only an acute
form of anxiety, and emotional problem. There is no risk to her life, and things will settle
down totally after proper treatment. This sort of health education to the patient and to
the relatives will provide insight regarding this dreadful disease. This sort of reassurance
itself will dramatically improve the situation.
2. Sometimes panic disorders patients are unco-operative to the nurse. They are tense,
trembling, sweating and feel faint. The nurse should act in a calm and quite manner to
handle such patients.
3. Medication like oral alprazolam, clonazepam or lorazepam or occasionally Inj. Diazepam
as instructed should be administered.
4. It is important to teach the patient to reduce their coffee and alcohol intake and
smoking. Caffine, alcohol and nicotine are potentially anxiety producing chemicals.

Epilepsy related psychiatric emergencies

These are two condition related to epilepsy which are to be considered as emergencies
1. Status epilepticus
2. Postictal (epileptic) confusional state

In status epilepticus, seizures follow one another with no intervening periods of

consciousness. The seizure mat be fatal. They may produce cerebral anoxia (poor oxygen
supply to the brain) and hence causes brain damage. The patient should be immediately
hospitalized. IV fluids, oxygen, IV diazepam (very slowly) or parenteral are the emergency
measures to be adopted.
In the postical confusional state the patient may become excited, violent and may harm
or others. Immediate physicalrestrain, Inj. Diazepam IV and if necessary, Inj. Haloperiod IV are
the first steps. The patients is usually confused and will be amnesic of the confusional period.

RECOGNITION OF MENTAL RETARDATION IN CHILDREN

Mental retardation can be recognized in the following ways:

1. By talking to the parents, especially mother, in detail about the growth of the child.
2. By observing the child‘s physical appearance and behaviour.

Mental retardation can be recognized from a history of delayed developmental milestones of

development.

3 months Holding neck erect

6 months Sitting with support

9 months- 1 year Walking

1-1/2 years Speaking few words or phrases

Mental retardation can be identified at different stages of growth through the following
ways.

1. Below five year – through history of delayed milestones.

2. Above five years – through history of school failures, behaviour problems and behaviour
against society’s expectations.

Physical Appearance

Mentally retarded children have certain physical features which make them easily identifiable.
These features are common in the severely retarded. Some mild and moderate retarded
children do not have any physical abnormalities and look normal. The common abnormalities
seen in mental retardation are:

 Small (or) large head

 Slanting eyes
 Thick protruding tongue
 Microcephaly, hydrocephalus
 Rough skin
 Stunted growth

CAUSE OF MENTAL RETARDATION

Genetic

Chromosome abnormalities

 Down’s syndrome
 Klinefelter’s syndrome
 Turner’s syndrome

Metabolic disorder affecting:

 Amino acids (phenylketonuria, homocystinuria, hartnup disease)

 The urea cycle (e.g. citrullinuria, aminosuccinic aciduria)
 Lipids (tay-sach’s Gaucher’s and Niemann-pick diseases)
 Carbohydrate (Lesch-Nyhan syndrome)
 Mucopolysaccaharidoses (Hurler’s, Hunter’s, Sanfilipo’s, and Morquio’s syndrome)

Gross disease of the brain

 Tuberous sclerosis
 Neurofibromatosis

Cranial Malformations

 Hydrocephalus
 Microcephalus

Antenatal Damage
  Infections (rubella, cytomegalo virus, syphilis, toxoplasmosis, AIDS)
 Intoxications (lead, certain drugs, alcohol)
 Physical damage (injury, radiation, hypoxia)
 Placental dysfunction (toxaemia, nutritional growth retardation)
 Endocrine disorders (hypothyroidism, hypoparathyroidism)

Perinatal

 Birth asphyxia
 Complications of prematurity
 Kernicterus
 Intraventricular hemorrhage

Post-Natal Damage

 Injury (accidental,childabuse)
 Lead intoxication
 Infection (encephalitis,meningitis)
 Malnutrition

Common causes of mental Retardation in our country

1. Infection during infancy-Encephalitis Meningitis

2. During pregnancy-rubella,syphilis,AIDS,etc.
3. Nutrition deficiency during pregnancy and childhood.
4. Primary and genetically related causes.
5. Chromosomal abnormality-e.g. Downs syndrome
6. Endrocrine-cretinism due to hypothyroidism
7. Phenyiketonuria-diochemical abanormality

Downs syndrome

A condition of mental retardation caused by a chromosomal abnormality. Downs syndrome

children usually have trisomy in21st chromosome (instead of usual pair, there are 3
chromosomes).The features of Downs syndrome include stunted growth, oblique palpebral
fissure, small flattened head, high cheek bones, big mouth and small fingers. They are moderate
to severely mentally retarded. They are cheerful and lovable children.

Cretinism

A mentally retarded condition due to hypothyroidism. Symptoms begin to appear around the
age of six months.
 Clinical features include stunted physical growth, grayish yellowish colour of the skin,
puffy face, reduced pulse rate, subnormal temperature, slow (usually) and retarded activity,
apathy and lethargy. They are of moderate to severly mentally retarded.

Treatment : oral thyroid preparation (thyroxine). If treatment is started very early the prognosis
is good.

Phenylketonuria

A condition of mental retardation due to an inborn error of metabolism. This is an autosomal

recessive disorder. The metabolism of the essential aminoacid phenylalanine to tyrosine. This is
due to the absence or inactiveness of an enzyme known as phenylalanine hydroxylase.

Treatment: phenylalanine free diet from very early infancy.

REHABILITATION AND NURSING CARE OF THE MENTALY RETARDED

Rehabilitation depends upon their ability. It can be assessed through IQ and clinical evaluation.
It must be remembered that there are three aspects to the problem of the mentally retarded.

1. The impairment itself e.g. brain injury as a result of prenatal or infection.

2. The disability which results e.g. inability to read or to perform arithmetic.
3. The social handicap in which the disability results e.g. resultant problem with regard to
occupation, or personal relationships.

Assessment of the need: As soon as mental retardation is suspected, it is essential to assess

whether the condition is treatable and reversible. Then it is important to assess whether the
person can be educated and trained (if the mental retardation is mild and moderate) or if
custodial care only is possible (if the mental retardation is severe and profound)

Education of Mentally Retarded Children.

Mild and moderate mentally retarded children can have a planned education program in a
special school meant for these children. Here, these children will be helped by specially trained
teachers to read, write and develop to the best of their ability. Mentally retarded children
require early stimulation. Parents of mentally retarded children have an important role in this
regard, but require guidance from trained personnel.

Training the Mentally Retarded

Mild and moderate mentally retarded persons require special training, if possible, in sheltered
workshops, under supervision, to acquire skill In simple jobs like gardening, book binding, paper
cover making etc. They require training by specially trained teachers or occupational therapists.
To learn simple tasks they may require much longer time than normal children, hence much
patience is required to train them. The purpose of this occupation is to give the mentally
retarded a meaningful and useful life so that he should not depend on others of their daily
needs.

Custodial Care of the Mentally Retarded

Some severe or profound mentally retarded require custodial care either at home or in the
institutions like special centers or mental hospital

The indications for institutional care include:

1. Severely mentally retarded without any social support.

2. Severe mentally retarded with behavioural problems.
3. Severe mental retarded with complications like intractable epilepsy.
4. Institutionalization for short time for the convenience of the family members, e.g.
during the time of some function at home.

Some severely mentally retarded children are so physically disabled that they have to
be nursing in bed. In such cases specialized nursing is the most important part of treatment.
For every physical need, they require assistance. The nursing care includes training to walk,
toilet training and training to eat properly.

As the years go, these mentally retarded children will gradually learn things, but very
slowly.

PREVENTION OF MENTAL RETARDATION

Mental retardation can be prevented in the following ways.

Before conceiving (for mothers)

 Rubella immunization
 Genetic counseling
 Health education for pregnant mothers including advice about nutritious diet, avoiding
smoking and drinking alcohol.
 Use of contraception and family planning methods to avoid unwanted pregnancies
 As much as possible to avoid consanguineous marriages.
Prenatal

 Identification of risk groups and genetic counseling

 Rubella screen
 Syphilis and AIDS screening
 Diagnostic ultrasound of growth retardation
 Microcephalus
 Hydrocephalus
 Multiple births
 Improved antenatal care with special reference to factors leading to low birth weight.

Natal

Improved obstetric and neonatal care (with the aim of reducing hypoxia and birth trauma).

Postnatal

 Neonatal screening of treatment of hyporthyroidism phenylketonuria.

 Prompt surgical treatment of hydrocephalus.
 Improved care on immunization to reduce incidence of encephalitis and meningitis.
 Prevention of further damage of impaired children, control of epilepsy.
 Preventive measures to reduce child abuse, road traffic accidents and home activities

Health Education Regarding Mental Retardation

As far as possible the mentally retarded children should be taken care of at home so that they
get emotional support.

 Mental retardation cannot be cured but can be improved through proper care.
 Mentally retarded children improve with training, but slowly.
 Mentally retarded children require:
 Good food
 Love and affection
 Special education and training
 Good social support.
 Mental retardation is due to poor development of the brain. Two to three out of a
hundred children are, to some extent retarded. It is a medical problems and not due to
fate, one’s misdeeds or bad luck.
 Medicines cannot cure mental retardation, but complications such as behavioural
problems and epilepsy can be effectively controlled by them
  The goal of rehabilitation of the mentally retarded is to make them as independent as
possible.
 Marriage is not a cure for mental retardation. Moderate to severely retarded persons
cannot take the responsibilities of marital life.

Parent’s Counselling

The parents of mentally retarded children require lifelong adjustment hence; the parents need
guidance and counseling which is an important aspect of the management of the mentally
retarded. This will help the parents to understand and to accept the child’s mentally retarded
person.

Counseling should focus on:

a. Giving information regarding the condition of the mentally retarded child.

b. Developing the right attitude towards the handicapped child.
c. Educating the parents regarding their role in the training of the retarded child.

The parents should:

1. Understand the actual condition of the mentally retarded child.

2. Not harbor false hopes regarding cure or improvement.
3. Have available information regarding professional help for treating associated
conditions or complications like seizures (epilepsy), hyperactivity and psychosis.
4. Avoid attitude like rejection or overprotection.
5. Not feel guilty, depressed or responsible for the condition.

Their co-operation and support is essential in the rehabilitation of the mentally retarded

20

Other Disorders

Sexual Disorder

It is difficult to define what is normal or abnormal in sexual behaviour. Patterns of

morality, social norms and customs vary in different countries and cultures as well as
change over short periods of time. The term abnormal, consequently tends to mean
unusual rather than pathological
 Normal sexual behaviour usually means any activity which an a heterosexual
relationship leads to intercourse and orgasm. The important aspects of normal sexual
behaviuor are:

1. Sex drive: This motivates the person to seek sexual stimulation. It is a strong force in
determining human behaviour.
2. Sexual arousal: Sexual arousal is a response to sexual stimulation. Different people
are aroused by different stimuli which include sights, sounds, smell, touch and
fantasy.
3. Genital response: This is a response to sexual arousal. In the male the genital
response is rapid. The essential component is penile erection. In the female, the
genital response is slow. The essential components are vasocongestion of the vulva
and labia minora and vaginal secretion. The genital response is accompanied by
increase in blood pressure and heart rate.
4. Orgasm: in the male it is a pleasurable experience accompanied by ejaculation or
forceful expulsion of semen from the urethra. In the female, it is a pleasurable
experience accompanied by a spasm of the muscles of the outer third of the vagina.

Psycho sexual disorders can be grouped under the following headings.

1. Sexual dysfunction not caused by organic disorder (sexual inadequacies).

2. Gender identity disorder or transsexualism
3. Disorder of sexual preference
 Fetishism
 Transvestism
 Exhibitionism
 Voyeurism
 Paedophilia
 Sadism
 Masochism
4. Sexual orientation disorder-homosexual

Sexual Inadequancies

Common sexual inadequacies are:

In the male:

1. Erectile impotence-inability to sustain an erection adequate for penetration

2. Premature ejaculation-ejaculation before, during or immediately after penetration
In the female:

1. Frigidity-orgasm rarely or never achieved

2. Vaginismus-Involuntary contraction of vaginal introitus at penetration

In Zambia females rarely complain about sexual inadequacies. The most common complaint
is male erectile impotence.

Erectile impotence (impotence)

It is the inability to reach an erection or sustain it long enough for satisfactory penetration. Only
when it affects 75 percent of the sexual attempts it is considered a disorder. It may be
accompanied by premature ejaculation.

Causes of impotence

1. Medical Illness
 Diabetes mellitus, thyroid disorder
 Testicular atrophy
 Hypertention
 Genital abnormalities
 Spinal cord lesions
 Brain damage
2. Psychiatric disorders
 Anxiety, drug dependences
 Schizophrenia
 Alcoholism, depression
3. Drug that may produce impotence
 Antihypresensive drug like propranolol,methy ldopa,clonidine
 Hormonal preparation-steroids,oetrogen
 Anticholinergic drugs
 Psychotrophic drugs,antipsychotic drugs
 Some antidepressants
 Anti-inflammatory drugs like indomethecin
4. Psycho social factors
 Performance anxiety-during early period of marriage
 Situations-lack of privacy, fear of STD or AIDS, fatigue
 Unco-operative partner
  Poor marital relationship
 Reduced sex drive-old age-ill health
 Homosexuality

Management –Rule out medical psychiatric disorder that may produce impotence.

 Analyse the problems and decide sexual therapy

 Counseling and educating the persons on sexual anatomy, sexual response and sexual
practices
 Teach the patient to relieve anxiety through relaxation techniques
 Use some principles of Masters and Johnsons sensate focus technique, in which the
couple is to start slowly with no genital stimulation for a few weeks, followed by manual
genital stimulation before proceeding to attempt sexual intercourse. This reduces
anxiety, increases feeling of security and improves communication and understanding.

Gender IdentityDisorder-Transsexualism

Transsexualism is a gender identity disorder characterized by a sense of discomfort and a wish

to physically become a member of the opposite sex. The patient is psychologically a member of
the opposite sex, e.g a male transsexual believes that he is a woman and he wants to convert
himself into a woman by a sex change operation.

Disorders of Sexual Preference

1. Fetishism-A psychosexual disorder in which sexual arousal and gratification are brought
about by objects such as shoes, underwear or toilet articles.
2. Transvestism-A psychosexual disorder characterized by recurrent and persistent
crossdressing for the purpose of achieving sexual excitement.
3. Exhibitionism-A psychosexual disorder in which the preferred method of sexual
stimulation and gratification consists of repetitive acts of exposing the genitals to
strangers.
4. Voyeurism- A psychosexual disorder in which the preferred method of sexual
gratification consists of repetitive observation of people in different states of undress or
sexual activity.
5. Paedophilia- A psychosexual disorder in which the preferred method of sexual
stimulation and gratification consists of repetitive sexual activity with children.
6. Sexual sadism-A psychosexual disorder in which an individual inflicts physical or
psychological pain, on another person to achieve sexual excitement.
 7. Sexual masochism-A psychosexual disorder in which an individual seeks physical or
psychiological pain, including humiliation or being bound or beaten, to achieve sexual
excitement.

Sexual Orientation Disorder-Homosexuality

Homosexuality is sexual attraction to, and sexual activity with, members of the same sex. It
usually refers to the male. For females, it is called lesbianism. In India homosexual activity is an
offence. According to an important study, four percent of males and four percent of single
females are homosexual. Their practices vary and they may engage in perverted practices.

Treatment-Most homosexuals do not seek treatment. If they come for psychiatric help they
may benefit by behavioural modification therapy.

SLEEP DISORDERS

Sleep and dreams have been subjects of interest for many years. Sleep can be regarded as a
physiological, reversible reduction of conscious awareness. There are two types of sleep:

3. REM sleep (Rapid Eye Movement Sleep)

4. NREM sleep (Non REM Sleep)

REM sleep is active sleep

Characteristics of REM Sleep

 Rapid eye movements

 Dreaming
 Increased brain metabolism
 Oxygen utilization and temperature
 A loss of muscle tone
 Tachythmia, and
 Penile erection

Characteristics of NREM Sleep

NREM Sleep is divided according to its EEG recordings into four stages. NREM sleep is
accompanied by a slowdown of bodily functions. There is reduction in heart rate, respiration,
urine output, blood pressure, temperature and state of relaxation in metabolism and motor
activities.

Sleep requirement

Most people require between 6-9 hours of sleep per day. Those who require less than 6 hours
are called ‘short sleepers’, and those who require more than 9 hours of sleep are called ‘long
sleepers’. REM sleep is longer in long sleepers. Short sleepers are generally more healthy, active
and better adjusted. Sleep requirements increase in children and old people. More hours of
sleep are needed in pregnancy, sickness, mental stress, depressed mood and after strenuous
work.

Sleep deprivation

Sleep deprivation is a pressing health problem. If a person is not sleeping continuously for few
days or nights, it is harmful to his health.

Sleep deprivation may produce

7. Impaired mental alertness and performance.

8. Thinking process is disturbed
9. Results in poor attention, concentration and judgment
10. Mental fatigue may even trigger physical illness like heart attack
11. May lead to traffic accidents and industrial mishaps
12. May lead to poor performance in studies and problems like drug abuse in students

CLASSIFICATION OF SLEEP DISORDERS

Primary Sleep Disorders (Disordered sleep is the only sign and symptom of abnormality)

i. Cataplexy-Sudden decrease or loss of (sleep paralysis) muscle tone, often generalized

and may lead to sleep
j. Hypersomnia-Excessive sleep at night or during the day
k. Insomnia-Inability to fall asleep and maintain sleep. When it occurs in the absence of
physical or psychological disorders it is called primary insomnia
l. Kleine-Levin syndrome-Periodic episodes of hypersomnia
m. Narcolepsy-Uncontrollable, recurrent brief episodes of sleep associated with cataplexy
n. Nightmares-Sleep disturbance with frightening or bad dreams. A good recall of dreams
occurs during REM sleep
o. Night terrors-Sleep disturbance accompanied by panic, confusion and no recall of the
frightening dream
 p. Pick Wickian-Occurs during stage 4 (NREM) sleep with hypersomnia associated with
obesity and respiratory disturbance

Secondary Sleep Disorders (Clinical problem accompanied by specific or non-specific

disturbances)

g. Alcoholism-Variable sleep disturbance

h. Anorexia nervosa-Decreased total sleep time
i. Depression-Less sleep time, more awakenings
j. Hyperthyroidism-Insomnia
k. Hypothyroidism-Increased sleep
l. Schizophrenia-Variable

Parasomias (Waking up during sleep)

e. Bruxisam (teeth grinding): Occurs during stage 2 (NREM) sleep with loud noise and
damage to sleep.
f. Enuresis Bed wetting during sleep.
g. Sleep talking: Mainly occurs during NREM sleep. Very common by itself or as a part of
some other sleep disorder or psychiatric disorders.
h. Sleep walking: Occurs during stage 4 (NREM) sleep, in which walking or other motor acts
are performed.

INSOMNIA

Insomnia is defined as quantitatively or qualitatively insufficient sleep on the basis of the

individual need. Insomnia is the term applied collectively to complaints involving the chronic
inability to obtain adequate sleep. Insomnia is difficulty in falling asleep, difficult in maintaining
sleep. Insomnia is of three types

4. Sleep onset insomnia-difficult in falling asleep.

5. Frequent nocturnal awakening-interrupted sleep characterized by frequent awakening.
6. Early morning awakening-waking up early in the morning and not being able to fall back
asleep.

Causes of Insomnia

3. Primary- Due to specific sleep disorders.

4. Secondary-Due to
 Physical causes
 Behavioural causes
 Psychiatric disturbances
  Social causes
 Drug- related causes.

Physical causes

Uneasiness, discomfort: Dyspnoea, cough, itching, nocturia.

Chronic pains Headache, neuralgia, Cramps, orthopaedic disorders, cancer.

Endocrine disorder Menopause, hyperthyroidism, hypoglycemia.

Behavioural Causes

Naps (during the day)

 Irregular sleep hours

 Lack of physical exercise
 Alcohol or tobacco abuse
 Excessive coffee in the evening
 Disturbing bed partner
 Disturbing environment (heat, cold, noise).

Psychiatric Disorders

 Depression
 Anxiety
 Hypomania
 Schizophrenia
 Chronic alcoholism and drug addiction

Social Causes

 Separation or devorce
 Overwork, career change
 Traumatic experience (accident, assault)
 Immigration
 Serious illness in the family
 Birth in the family
 Death of spouse or close relative
 Financial loss
  Acquiring a physical handicap
 Son or daughter leaving home
 Retirement
 Failure (Exam, Love).

Drug-related Causes

 Stimulants
 Thyroid hormones
 Sympathomimetic
 Corticosteroids
 Beta-blockers

Treatment of Insomnia

 Detailed assessment and evaluation

 Identifying the causative factors and treating them.

Most patients who seek treatment for insomnia suffer from anxiety and depression. Other
causes are less common.

Treatment of insomnia depends on duration. Transient insomnia can be treated initially

with hypotics (like nitrazepam, lorazepam etc.) hypnotics should not be for longer periods.

Non-Drug Treatment for Insomnia

6. Progressive relaxation: Relax the body (muscle), thereby relaxing the mind.
7. Autogenic training: Autosuggestion.
8. Meditation, yoga: Produces relaxation of the mind.
9. Biofeedback self monitoring, keeping record of sleeping and waking.
10. Stimulus control therapy: Do not use the bed for reading or chatting. Go to bed for
sleeping only.

Nursing Care of Persons with Insomnia

The common complaint a nurse receives during her night duty is disturbance in sleep. Hence, a
nurse should understand in detail the concept of sleep, the effects of sleep deprivation and
various causes of insomnia. Apart from giving medication as prescribed by the doctors, the
nurse should be in a position to educate the patient in getting good sleep.
Sleep hygiene: Nurse should advise her patients to avoid heavy meals or exercise before sleep.
Coffee, tea or smoking should also be avoided before sleep. Try to minimize the use of
hypnotics substitute back rubs, warm milk and relaxation exercises.

Sleep environment: Make the environment conducive to sleep. Too much light, noise and heat
or cold are to be avoided. Close doors, dim lights and turn of unnecessary machinery.
Encourage staff to talk in low tones during the night in the wards. The nurse should keep a daily
record of how many hours the patient has slept. If there is any sleep disturbance or sleep
associated problem, inform the doctor.

MEMORY DISORDERS

Memory is a function by which information stored in the brain is later recalled to

consciousness.

There are three processes occurring in memory

1. Registration
2. Retention
3. Recall

Memory function is generally divide into three categories

1. Immediate
2. Recent
3. Remote

Immediate memory: Immediate memory is treated by recalling given digits. The patient is given
a series of random numbers (e.g. 2-6-9 or -4-7-5-8) and asked to recall them immediately.
Normal persons can repeat an average of six to seven digits forward and four or five digits
backward.

Recent memory: Ask the patient how they spent the last 24 hours and what they ate for
breakfast.

Remote memory: Ask the patient important names and dates from his or her earlier life (e.g.
birth, marriage, school, job).

Disturbances of memory can be classified as follows

 1. Amnesia
2. Paramnesia
 False recognition
 Retrospective falsification
 Confabulation (filling up memory gaps)
 Dejavu (feeling of familiarity to unknown things or situations)
3. Hypermnesia-Jamaivu (known persons or places look unfamiliar).

AMNESIA

Amnesia is loss of memory and partial or total inability to recall past experiences. Amnesia may
be anterograde or retrograde.

Anterograde: Amnesia is the inability to recall events occurring after the amnesia causing
incident (e.g. head injury or administration of a drug).

Retrograde amnesia: is loss of memory for events that occurred prior to the amnesia causing
incident.

Classification of Amnesia

1. Psychogenic
a. Fugue
b. Dual and multiple personalities
c. Ganser state
d. Slip of the tongue and amnesia for word finding
2. Organic:
a. Cerebral disease
b. Transient global amnesia
c. Amnestic syndrome
d. Traumatic amnesia
e. Temporal lobe amnesia
f. Amnesia associated with ECT

Psychogenic Amnesia

Emotional factors produce amnesia and usually affect only affect only the ability to recall
experiences. Registration and retention are unaffected. Psychogenic amnesia is either dense
and global or restricted to certain specific themes. The psychoanalytic theory of psychogenic
amnesia ‘is forgetting of disagreeable’
Fugue state: A state of amnesia in which the person wanders away from his normal
surroundings and is associated with loss of personal identity. Fugue state can occur in hysteria,
depression, alcoholism, epilepsy head injury.

Organic Amnesia

Amnesia in cerebral disease may be transient or persistent.

Transient amnesia state can occur in toxic or metabolic disturbance, due to certain drugs,
cerebral anoxia and Carbone monoxide, intracranial infection, epilepsy and acute alcoholic
intoxication.
Persistent abnormalities of memory can occur in chronic alcoholism, vascular
disorders, cebral tumors, brain operations, dementia etc.
Confabulation is a memory disturbance commonly seen in alcoholics. Confabution is a condition
of inventing stories about situation or events that are not remembered it is a condition of filing
up of memory.

Transient global amnesia is a organic memory disturbance of acute onset occurring usually in
middle age and lasts for four to twelve hours and remits spontaneously. The characteristics are
total loss of memory, confusion, repeated purposeless behaviuor and some degree of clouding
of consciousness. The cause lies within the temporal lobe.

Amnesic syndrome is an impaired memory state occurring in a state of clear awareness. It may
be due head trauma, hypoxia, thiamine deficiency or encephalitis ECT included amnesia occurs
after electro convulsive therapy. There is always a transient memory loss. The amnesia is both
retrograde and anterograde in nature. The ECT induced amnesia may persist for few weeks and
remit spontaneously. Unipolar ECT (keeping the ECT electrodes only on the non-dominant side)
and brief pulse ECT may reduce this memory disturbance.

Nursing Care of Amnesia

The nurse should first understand the disturbance of, memory is a common symptom in the
psychiatric set up. It may due to psychological or organic factors. Because of amnesia, patient
may often not be in a position to give correct history. Hence, it should be cross-checked with
relatives later. In short-term memory disturbances other practical problems may come up. The
patient who has already had his medication may ask for the drugs again. This specially occurs in
the elderly. Medication given should carefully recorded otherwise a double dose may be given
which can have adverse effects. Patients with confabulation give immediate answers. Even
though they seem correct, they may be totally false. This should be kept in mind.

EATING DISORDERS
Eating disorders have become the focus of much interest among mental health professionals in
recent years. In India, eating disorders are not as common as in the West. An increasing number
of people, predominantly women, report gross disturbances in their eating behaviour. The two
most important eating disorders are:
3. Anorexia nervosa, and
4. Bulimia
Although these eating disorders are described as primary i.e.as not resulting from some
medical illness, many patients with this disorder also suffer from other psychiatric
disorders.

ANOREXIA NETVOSA

It is a condition of marked weight loss due to reduction in food intake and /or vomiting. The
anoxia nervosa syndrome may be secondary to schizophrenia, depression, organic illness and
endocrine disorders.
Anorexia nervosa is more common in females, more so in adolescent girls .It is common in the
upper social class and in unhappy families. The precipitating events may be separation, puberty,
sexual experience, threat of sex, marriage, pregnancy, responsibility, etc.
Clinical picture

The patient is usually an adolescent or youth adult female. There may be a history of reduction
in the intake of high calorie food and of vomiting. The other features are amenorrhea,
constipation and hyperactivity. The examination shows a low B.P. low pulse rate, subnormal
temperature, cyanosis, atrophy of breast, axillary and public hair. Investigation reveals
anaemia, low blood sugar, raises cholesterol and reduced basal metabolic rate.

Anorexic nervosa is a potentiality lethal disorder. It should be treated as a psychiatric

emergency. If there is severe weight loss, metabolic disturbances, anaemia, hypoglycemia and
depression with suicidal ideals, the patient should be immediately hospitalised for further
management.

Treatment
Treatment includes hospitalization, tube feeding and IV fluids. A high calorie diet should be
prescribed, drugs like minimal does of chlorpromazine, cyprohetadine and insulin may be
beneficial. Behaviour therapy is much beneficial.

Nursing Care of Anorexia Nervosa

When a nurse sees people, especially young girls, who have eating disorder problem with poor
intake, vomiting, self starvation, severe weight loss, it should be immediately reported.
 Monitor physiologic signs and symptoms like amernorrhoea, constipation,
hypoglycemia, breast atrophy, hypotension etc.
 Weight regularly
 Have one to one supervision during and 30 minutes after meal time to prevent
attempts vomit food.
 Health education should be given regarding maintaining normal weight, normal
sexual growth and complications of starvation.
BULIMIA
Bulimia is an eating disorder manifested by excessive hunger, resulting in compulsive or
overeating. Bulimics lose con troll over eating behaviour and consume large quantities of
calorie rich food. Associated with bulimia are other conditions like abuse of alcohol and drugs,
laxative abuse, diuretic abuse
Bulimia nervosa is an eating disorder of unknown aetiology occurring in women. Bulimia is
often associated with depressed mood and suicidal ideas. Antidepressants, especially tricyclic
anti-depressants may be beneficial.

21
MENTAL HEALTH PROBLEMS

IN CHILDREN
Children’s health has been recognized as an important component of any nation’s health. The
concept of good mental health in children has also gained importance in the recent past.
Children constitute about 40 percent of our population.
The mental health problems in children are different from adults, because of the
following reasons.
1. The child is a growing organism. Children are in a constant state of rapid physical,
emotional and intellectual development. Their personality is not yet fully formed.
2. They are unable to verbalise or express themselves and their problems.
3. They are dependents of their family mem bers, especially parents
4. They mimic what they observe

Child psychiatric problems are widely prevalent in Zambia figures from various studies
in….suggest that 2.5-17.2% of children suffer from some kind of mental health problem.
The commonest psychiatric disorders among children in India are mental retardation,
neurotic , psychosomatic disorders, and attention deficit disorders. Problems like enuresis and
speech disorders and less commonly, conduct disorders.

The causes of child psychiatric disorders are:

1. The cause of child psychiatric disorders are
 Hereditary
 Physical defects
 Illness
 Low intelligence
2. Psychologyical factors
 Parent-child relationship
 Quarrels between parents
 Broken homes
 Discipline
 Too much discipline
 Alcoholic father
 3. Social factors
 Poverty
 Unhealthy environment

FAMILY AND CULD MENTAL HEALTH PROBLEMS

The child‘s behaviour and emotional problems are usually the reflection of the family. “the child
is the biopsy of the family”. A health child will come only from a happy family. Families are
miniature societies in which learn adaptation and social behaviour.
The family should facilitate development, from infantile dependence to adult independence.
Children who are deprived of a happy family life suffer from serious mental health problems at
a later date. Parental deprivation, especially maternal deprivation, may be the cause for
psychological problems, especially depression in later years. In children much of the
behavioural disorders and personality deviance can be linked to the faulty parental attitudes.
Rejection, hostility and neglect by parents may damage their psychological equilibrium. In the
same way over-protection also will harm the child’s mental health.

COMMON MENTAL HEALTH PROBLEMS IN CHILDREN

Mental Retardation and Associated Problems (discussed in a different chapter)

Autistic Disorder
Autistic disorders are characterized by a withdrawal of the child into the self and into a fantasy
world of his own creation. This disorder is rare. Course is chronic. It is also known as infantile
austism if the age of onset is before 3 years.

The common symptoms are:

1. Failure to form interpersonal relationships
2. Impairment in communication
3. Bizarre responses to the environment.
4. Extreme fascination for objects that move (e.g. fans, trains)
5. Fluctuation mood-sudden crying or laughing

Attention Deficit Disorders (Hyperactive Disorders)

A disorder occurring in children characterized by poor attention span, overactivity and
impulsiveness. The child responds to multiple stimuli at the same time.

The common symptoms are:

1. Early distracted; not able to sit or do things some time. Disorganized behaviour
2. Sustaining attention is difficult. Hence is disruptive and overactive in the class room.
3. The child often has excessive gross motor activity (e.g.: excessive running-climbing,
difficulty in sitting for long, restlessness.

Conduct Disorder
Disorders where the child’s behaviour is against social norms and values. The behaviours are
repetitive and persistent. They violate riles. Their conduct is worse than ordinary mischief.
The common problems are:
1. Truancy (not attending school, spending time somewhere else.
2. Lying, stealing, substance abuse, breaking things, things fire often running away from
,gambling, poor peer group relations fights with others thefts outside home.
3. Does not accept responsibility and learning from past experiences and go on repeating
the same mischief again and again. They often get cought by the police.
Sometimes this condition is known as juvenile delinquency. The cause of this disorder is
mainly social, especially in the family. Parental rejection, harsh punishment, alcoholic or
drug addict parents, illegitimate child, absent father are some of the causes.

School Refusal (School Phobia)

The reluctance or fear to go to school is seen among many children. This is known as
school phobia or school refusal. School refusal may be associated with other neurotic
symptoms such as: shyness, fears and separation anxiety (separation from mother). The mother
may be over-protective and anxious.

The reason for school may be due to:

1. Problems at school
2. Problems at home.
3. Problems in the child.

Enuresis (bed-wetting)
The involuntary passage of urine over five years of age is termed as enuresis. Till five years of
age it may be regarded as physiological. Enuresis as a psychological problem is more common
among boys. The causes may be fear and anxiety in child hood, childhood depression, lack of
toilet training and being shy and inhabited.
Treatment includes proper blander training. Anti-depressant like imipramine 25 mg at
night for two to three months is beneficial. Behavioural modification also may be helpful.

Child Abuse
Child abuse is defined as physical or psychological demand to a child under the age of 18,
that is sustained as a result of neglect or maltreatment.
The abuse may be physical, sexual and / or emotional. Physical abuse is also called
battered child syndrome. Usually the abuse is caused by a parent, parent surrogate (e.g. step
mother), a relative or an employer.

THE ROLE OF A NURSE IN CHILD MENTAL HEALTH PROBLEMS.

It is a basic responsibility of a nurse to recognize a child with a mental health problem. It
is done based on three features
1. The child’s behaviuor is not appropriate for this age.
2. The child’s behaviour leads to disability.
3. The child’s behaviour is against social expectations.
 A nurse who happens to see a child with behavioural problems should understand that
it is probably a reflection of the family’s problem. Hence, understanding the family pathology is
very essential
A nurse, apart from carrying out the instructions from the doctor, can help the children
with mental health problems in the following ways:
 Finding out the details of the underlying problem.
 Trying to explain this to the concerned people and thereby reducing the problem.
 Reassuring the parents.
 Telling the parents not to give the child much attention when she/he is complaining.
 Talking to the child in a sympathetic way and explain reasons to him/her.
 Play

MENTAL HEALTH PROBLEMS IN ADOLESCENTS

About 10-20% of adolescents in developed countries have educational, emotional, behavioural
or social difficulties. The incidence is more in older adolescents living in deprived areas.
Adolescent’s mental health problems can be classified in three groups
1. Serious Psychiatric Disorder: Found in a few young people. These disorders include,
anxiety, depression, conduct disorders, alcoholism and drug abuse, psychosis like
schizophrenia and eating disorders.
2. Disorders of mood and behaviour: they are problematic but are not serious psychiatric.
They are quite common and influenced by social and family problems.
3. Transient reaction to adverse circumstances: Associated with more anxiety or sadness.
Miss-behaviour, shyness, bed-wetting, anxiety about friendship, school, sexual
development and / or sexual preference and mix feelings about impendence and
dependence. It may be aetiological or symptomatic.
The incidence of depressive illness and attempted suicide rises dramatically during
teenager years. In the later teens attempted suicide is a commonest problem especially among
girls.

SOCIAL FACTORS THAT AFFECT ADOLESCENT

1. Poverty and over-crowding
2. Parental attitude ( e.g. inconsistency, extremes of discipline and neglect).
3. Parental illness or social problems, particularly maternal depression.
4. Marital disharmony in parents and family break-down.
5. Poor schooling.
6. Repeated institutionalization (keeping him/her in hotel, boardings.)

MANAGEMENT OF ADOLESCENT MENTAL HEALTH PROBLEMS.

1. Individual treatment
 Psychotherapy
 Behaviuor therapy
 Medication e.g. anti-depressant; if necessary.
2. Working with the family
  Counseling and advice to the family members
 Family therapy
 Marital therapy to the parents
3. Social and educational
 A change of class or school.
 Career guidance
 Job training schemes
 Organized leisure activities
 Encouragement to involve themselves in sports and games
 Moral education

In developing country like India, the life style of the population as a whole is undergoing
a dramatic change. There is a tendency to mimic traditions of the West, at times blindly, with
resulting frustration. A widening gap between the conventional life style and changing social
values causes ongoing conflicts and the victim of this is adolescent.

MENTAL HEALTH PROBLEMS IN WOMEN

Women are two to three times more at risk of developing mental disorders than men. One
community survey reported the prevalence rate of mental illness among women to be 33.3 per
1 000, while the corresponding figure for men was 15.7 per 1,000.
Women are more prone to more certain types of illness such as affective (mood)
disorders, anxiety disorders etc. thus leading support to the view that the difference are
qualitative rather than quantitative.

Why are women more prone to develop mental disorders?

The famine role: This may be due to social role of women. In a male dominated world female
are not getting full opportunity to ventilate their feeling. Hence they adopt a sick role which is
more suitable for them to express themselves

Genetics: Several disorders with a proven degree of heritability are commoner in females, e.g.
affects disorder

Endocrine factors: Women are prone to considerable degree of fluctuation in endocrine

functions, and these have been important factors in the onset of mental illness.

Stressors: The stages of life cycle in women namely puberty, menstruation, pregnancy, child
birth and menopause all are associated with endocrine changes and psychosocial stresses.
Hence, during these stages they are move vulnerable to psychiatric disturbances. The
multiplicity of roles like daughter, wife and mother are believed to predispose women to
greater stress in our culture.
Age factor: Women at the late stage of their life (after 50 years) are more prone to developing
mental disorders due to multiple psychobiosocial factors. In adulthood, however, men and
women suffer equality.

PSYCHIATRIC DISORDERS IN FEMALES

Affective (Mood) Disorders

They are commoner in women, especially so with depression. Roughly twice as many as men
are pathologically depressed.

Neurotic Disorders
These are reported to be higher among woman. Anxiety and phobic disorders are twice as
common in women as in men. Hysteria is believed to be almost exclusively confined to women.

Dementia
Women are at increased risk for the development of dementia, more believed to be almost
exclusively confined to women.
Attempted suicide
It is more common in females, especially in the age group of 15 to 30 years, whereas completed
suicides are more prone to suicidal ideas and gestures during the phase menstruation.

Anorexia Nervosa
This disorder is more common in adolescent girls.

Schizophrenia
It’s prevalence is almost equal in the both sexes, though some studies quote more males suffer
than females. Alcoholism, drugs abuse, personality disorder and criminality are much less
common in females.

Specific Female Psychiatric Disorders

Premenstrual Syndrome
Behaviour changes occurring in association with the menstrual cycle is well documented. The
premenstrual syndrome, a cyclic recurrence of physical and psychological symptoms, may
produce behavioural changes which are severe enough to disrupt interpersonal relationships
and interfere with normal activities.
The psychological symptoms include anxiety, irritability and depression. The physical
symptoms include breast tenderness, abdominal discomfort and a feeling of distension.
The aetiology is uncertain. The biological basis of this disorder is claimed to be due to the
fluctuation of hormonal and water levels.
 This syndrome is widely treated with progesterone and also with oral contraceptives,
bromocriptine, diuretics and psychotropic drugs like anti-depressants and anxiolytics.

Psychiatric Disorders that can Occur after Children

(postpartum or puerperal psychiatric disorders)
The increase of psychiatric disorders during the postpartum period is well known.

The possible causes are:

1. A large drop in sex hormones in puerperium.
2. A rise in cortisol.
3. Changes in endorphin levels.
4. Changes infections and complications during delivery.
5. Psycho social conflict about playing the mother role or wifw role.
6. Getting a child during an unwanted time or period, female child birth.

There is one in four chances of having a recurrence in the subsequent delivery.

The more common psychiatric problems in the postpartum period are:

1. Maternity blues (mild depression).
2. Puerperal depression of mild to moderate severity.
3. Puerperal (or) postpartum psychosis.
Maternity blues: In normal deliveries, between half and two-thirds experience brief episodes of
irritability, lability of mood and episodes of crying. Symptoms reach the peak on 3 rd or 4th day
after delivery. More shortly in primi. It is a short lived condition.
Specific treatment is required and good, sympathetic nursing care will help women.
Supportive psychotherapy may be beneficial.

Puerperal depression: less severer depressive disorders are much more common. Depression
usually begins after the first two weeks of the Puerperium. The total picture includes
depression, tiredness, irritability and anxiety. Most patients recover after a few months. Anti-
depressants are effective in relieving the symptoms, psychological and social support will speed
up recovery.

Puerperal psychosis: One in five hundred women after delivery may develop this disorder.

Three types of clinical pictures are observed:

1. Acute organic psychosis
2. Affective psychosis
3. Schizophrenia- like psychosis

Affective syndrome or a mixture of affective and schizophrenia like psychosis are common.
Treatment is symptomatic, with anti-depressant and / or anti-psychotics. If necessary ECT may
be considered.
 Nurses should see that the baby should remains with the mother to help maintain
emotional attachment.

Menopause
In addition to the physical symptoms of flushing, sweat and vaginal dryness, menopausal
women often complain of headaches, dizziness and multiple somatic complaints along with
depression.
Depressive and anxiety-related symptoms at the time of menopause is sometimes known
as involutional melancholia. Paranoid symptoms also occur in this condition.

The causes are:

1. Hormonal changes.
 Deficiency of oestrogen
2. Psychosocial
 Changes in the woman’s role during menopause.
 Children leaving home (empty nest syndrome)
 Relationship with her husband alters.
 Own parents become ill die.

The treatment includes oestrogen preparation and anti-depressants and anti-anxiety drugs.
Supportive and insight oriented psychotherapy will be beneficial.

MENTAL HEALTH PROBLEM IN OLD AGE

Human ageing, a progressive loss of adaptability in an individual, is due to complex interplay
between intrinsic (mainly genetic) and extrinsic (mainly environmental) factors. Longevity is not
in all cases a blessing. Old age has always been fraught with problems that are intensified by
the pressure of modern society and changing attitudes.
The definition of ageing depends upon how it is viewed from different perspectives. In
India, it is has been conventional to take 6oth year as the point of turning old .The proportion of
the people aged 60 or above the constitute 7% of the total population of India and number
about 50 million today. This number is expected to research 60 million in 2 000 A.D.

THE MENTAL HEALTH PROBLEM IN THE ELDERLY

Epidemiological study have estimated the prevalence of mental morbidity among the aged at
89 per/1 000 yielding figure of nearly 4 million in country to be severely mentally ill.
Affective disorders (mostly depression and to a lesser extent mania (paranoid states and
organic mental disorders constitute the bulk of mental illness in the elderly. Depression is most
frequent with the prevalence late of 60 per / 1 000. Dementias formed 20% of the total mental
morbidity among the hospital age patients.
Psychopathology increases with age. The organic mental disorders as well as functional
psychoses increase in frequency with age. Suicide rates also rise sharply. Neurotic reaction are
also a problem as an old person’s adaptability wanes to the extent that minor tresses
precipitate depression and anxiety states. Depression paranoid reaction and anxiety states
should be as vigorously treated in the old as in the young. Psychiatric illness in old age is not to
be viewed in isolation. The mental health problems of the aged have to be examined along with
the prevailing social system. In view of the multiple system involvement, including g psychiatric
illness and also in view of the social, economic and the nutritional problems, the care of the
elderly, to be meaningful, needs to be comprehensive.

The major mental health problems in old age are

1. Depression
2. Dementia
3. Delirium
4. Paranoid disorder
The three important factors associated with depression in old age are:
1. Emotional factors
 Feeling lonely
 Dissatisfaction with life
 Self pity
2. Physical factors
 Deterioration in health
 Difficult in self care
 Difficulty in mobility
 Sensory deficits
3. Socioeconomic factors
 Widowed state
 Loss of social status
 Loss of income
 Retirement
 Bereavement

DEPRESSION
Depression in old people may be present in ways which are rather different than those seen in
younger people. The patient may be extremely agitated, with bizarre delusions concerning guilt,
worthlessness or bodily disorder. Sometimes the depression may be hidden behind an array of
vague symptoms of anxiety or other neurotic complaints. When the symptoms are vague with
no specific underlying cause the diagnosis could be depression. Hence the use of the term
masked depression is often used.
Sometimes the perplexity, the apparent lack of awareness and the total disregard of
surroundings gives the picture of a dementing illness. This is called as pseudo dementia

Management of depression in Elderly

Drugs play an important role in addition to psychological and social support in managing
depression. Anti depressants with less anti-cholinergic and less cardio-toxic side-effects are
preferred. Electroconvulsive therapy is safe, if given with proper care, in selected cases.

Step to Minimise Depression in Elderly

 1. Regular and periodic check-up of physical health
2. Proper planning of retirement
3. Low-cost health insurance schemes for old people
4. Encouragement of traditional values and joints family system
5. Advise to engage old people in religious activities and reading habits.

DEMENTIA

Dementia is defined as a major public health problem in old age. Dementia is an organic mental
impairment with involvement of the brain. Dementia is defined as an acquired global
impairment of intellect, memory and personality without impairment of consciousness.
Dementia is a dying mind in a living body. Dementia is not normal ageing or accelerated ageing,
but a qualitative and quantitative change in intellectual function.

Causes of Dementia in Old Age (Primary cerebral cortical degrenerations)

 Alzheimer’s disease
 Pick’s disease

Cerebro-vascular

 Multi-infarct dementia

Primary Sub-cortical Degenerations

 Parkinsons’s disease
 Multiple system atrophy
 Huntington’s disease
 Progressive supra-nuclear palsy
 Punch-drink syndrome.

Cerebral Infection and Inflammation

 Neurosyphilis (G.P.I)
 Post-encephalitis
 Creufzfeldt-Jakob disease
 Multiple sclerosis.

Alcohol, Toxic and Metabolic

 Hypothyroidism
 Hypocalcaemia
 Chronic hepatic encephalopathy
 Chronic uraemia and dialysis
  Vitamin B12 deficiency
 Pellagra
 Malabsorption syndrome

Tumors and Hydrocephalus

 Meninggiomas
 Benign gliomas
 Parapituitary tumours
 Intra ventricular tumours
 Pineal and midbrain tumours
 Secondary deposits
 Subdural haematomas
 Giant aneurysms
 Aqueduct stenosis
 Communicating hydrocephalus.

After excluding secondary dementia the most common among the primary dementias are:

1. Alzheimers disease and

2. Multi-infarct dementia

The Diagnostic of Dementia

1. Demonstrable evidence of impairment in short and long-term memory.

2. Impairment in abstract thinking, judgement, higher cortical functions and personality
change.
3. Disturbance that significantly interfere with work and social activities.
4. Not a part of delirium that is, there is no change in consciousness
5. Evidence of organic chage.

Management of Dementia in Elderly

Drugs have a limited role to play in the management of dementia. Drugs are helpful in
managing associated psychosis, behavioural problem and to improve the cerebral blood
circulation

Psychosocial Management of Demented Elderly

Dementia is often accompanied by a behaviour supervened by psychotic symptoms.
Management in addition to psychopharmacology should include a totally psychosocial
approach.

Psychosocial intervention in dementia includes:

1. Behavioural methods
2. Milieu therapy
3. Activity engagements
4. Physical exercise
5. Problem-orientation approach
6. Reality orientation
7. Organization of psychiatric services.

Behavioural methods: Much rehabilitation is based on the analysis of problems and the setting
of goals. Behavioural methods share these principles, but add specific procedures to modify
particular aspects of behaviour. Lately, these methods have been directed to improve deficits of
memory, e.g. use of lists and reminders and by practice.

Methods have been identified for training patients with problem in eating, continence or
social skills. Reality orientation therapy which is intended to reduce confusion and improve
behaviour.

As the illness progresses the patient may be incapable of managing activities of daily
living. Activities which entail potential danger must be avoided, such as driving, using power
tools, smoking and using a stove. Leaving the house unaccompanied may also be a potential
risk. The patient’s daily routine should be continuously monitored, simplified and regularized to
maintain wee-learned behaviour’s and to minimize stressful changes. The family and other
care-givers should be fully involved in these changes. Dementia affects the entire family.
Education of the patients and the family is essential.

Supportive psychotherapy to demented patients, with clearly defined aims may be

required. Organization of supportive services for demented patients whenever available would
go a long way in sharing the burden.

DERIRIUM

Delirium is again a common psychological disturbance in the elderly. It is an organic brain

syndrome characterized by impaired in consciousness, orientation, attention and behaviour;
onset is acute fluctuating in course. Elderly are particularly vulnerable to the development of
delirium in association with any physical illness. Often it occurs in the general medical ward.

Aetiological organic factors could be identified I 80-95% of reported cases of delirium in

the elderly.

The commonest causes of delirium in elderly are:

11. Drugs
12. Metabolic causes
13. Malnutrition
14. Respiratory diseases
15. Cardiovascular diseases
16. Liver diseases
17. Cerebrovascular disorders
18. Fever
19. Alcohol
20. Trauma

Management of Delirium

In the elderly management of delirium includes assessment of basic causes, treating the cause,
maintaining fluid and electrolyte balance and good nursing care. Minimal doses of anti-
psychotic drugs for a short time can be given.

Nursing Care of Delirium

Keep the patient in a comfortable, quite, well lighted place. Less stimuli is advisable. Reassure
the patient and be supportive. Orient the patient to time, place and people frequently. Have a
consistent, sympathetic and understanding nursing care.

PARANOID DISORDERS.

Apart from dementia, paranoid disorders (delusional disorders) occur occasionally in old age.
Paranoid disorder occurring in old age is at times known as paraphrenia, more common among
elderly women.

Clinic Features Include:

Suspiciousness, persecutory delusion, agitation, restlessness, depression and insomnia.
Treatment with mild dose of major tranquilizers is beneficial.

NURSING CARE OF ELDERLY WITH MENTAL HEALTH PROBLEM

The nurse should understand that most old people are dependents and have a feeling of
insecurity. The nurse should also understand the common symptoms of senility like:

5. Change in attention span

6. Memory loss for recent events and names
7. Altered intellectual capacity
8. Diminished ability to respond to others

The long term nursing goal is to help the patient in reducing hopelessness and
helplessness. Short term goals are to educate the patient to preserve their self image and
preserve their abilities to perform. The nurse should reassure and encourage the patient to
reduce depression and feelings of isolation and educate them to correct sensory deficit (e.g.
cataract operation of eye will improve their vision and reduce their dependency). Teach them
to take care of physical illnesses which are common in elderly. If possible encourage them to do
simple physical exercise like walking which will enhance blood flow.

22

COMMON PSYCHOPHYSIOLOGICAL DISORDERS (PSYCHOSOMATIC DISORDERS)

Psychophysiological disorders are a group of disorders in which emotional factors have a

demonstrable role in the aetiology. Chronic, severe stress may play an aetiological role in the
development of certain physical diseases. They are also known as stress related disorders.

The word psychosomatic means mind and body. Just as the emotion of anxiety can
produce sweating, palpitation and tremor, severe emotions of long duration can produce
permanent damage in the body system. Most of these disorders are treated in a general
hospital set up rather than in psychiatric hospital.
Possible Progression of psychosomatic disorders

Prolonged Anxiety
Leads to

Persistant psychophysiological Reactions

With causes

Structural alteration, circular diseases and functional impairment

Which may lead to

Psychosomatic disorders

PSYCHOSOCIAL THEORIES

1. Individuals exhibit specific psychological responses to certain emotions e.g. in response

to the emotion of anger, one person may experience peripheral vasoconstriction,
resulting in an increase in blood pressure. The same emotion in another individual may
evoke the response of cerebral vasodilatation, manifesting a migraine headache.
2. Personality theory individuals with specific personality traits are predisposed to certain
disease processes. Personality traits may form a possible relationship but cannot be the
total cause for the disease.

Personality characteristics psychosomatic disorders

1. Dependence Asthma
2. Repressed anger Peptic ulcer/ Hypertension
3. Aggressive, ambitious coronary heart disease
Type of personality
4. Compulsive perfectionist Migraine
5. Self sacrificing and inhibited rheumatoid arthritis and
Ulcerative colitis
3. Learning Theory conditioned responses reinforced by secondary gains
4. Family dynamic theory pathogenic family patterns in childhood predispose
psychosomatic disorders and stressful, conflicting interpersonal relationship among
family members also may be a cause
5. Biological theory psychosomatic disorders occur when the body is exposed to prolonged
stress, producing a number of physiological effects under direct control pituitary adrenal
axis. Genetic predisposition also influences which organ system will be affected and
determine the psychosomatic disorders

COMMON PSYCHOSOMATIC DISORDERS

Cardiovascular system Coronary heart disease
Essential hypertension
Gastrointestinal system Bronchial asthma
Hyperventilation syndrome
Gastrointestinal system Peptic ulcer
Ulcer colitis
Irritable bowel syndrome
Musculoskeletal Rheumatoid arthritis
Headaches vascular-migraine headache
Muscle contraction-tension headache
Skin Eczema
Endocrine disorders Hyperthyroidism
Diabetes mellitus
Premenstrual syndrome
Menopausal disorders
Eating disorders Anorexia nervosa
Bulimia
Obesity
Psychogenic pain

Some important psychosomatic disorders

Asthma
The possibility that a psychosomatic component may have a role to play in asthma has
been observed for a long time. It is observed that asthma manifest more negative
emotional than normal people. Hostility, anxiety, depression, a sense of helplessness,
personality disorders and a decreased competence were common features in
asthmatics. Increased attacks of asthma were reported in the morning during crying,
shouting or laughing.
 In the management of asthma, along with medication, supportive psychotherapy,
relaxation exercise and yoga could play a vital role in the long-term control of the
disease.

Coronary Heart Disease.

A link has been claimed between coronary heart disease and Type A behaviour pattern.
The behaviour pattern of type A personality includes excessive ambition, high
performance standards, persistent urgency, competitiveness, aggressiveness and
hostility. Hence, type A personality person have a high risk of developing coronary heart
disease. The treatment includes, apart from medication, insight-oriented psychotherapy
and teaching a better way of relaxation in between their work.
It is also reported in various studies that persons suffering from myocardial
infarction are exposed to stressful events prior to the onset of their attacks.

Peptic ulcer (Acid Peptic Disease)

Clinical observation and experimental evidence have indicated that stress produces
increased adrenocortical secretion which results in the initiation, formation and severity
of gastric ulcers.

Irritable Bpwel Syndrome (IBS)

The symptoms of IBS include abdominal pain, a sensation of distension, altered bowel
habits, passage of mucus and a sense of incomplete evacuation after defecation.
Persons suffering from IBS are reported to be having more psychological symptoms an d
illness. The psychological symptoms associated with IBS are anxiety, depression,
obsessional characteristics, multiple somatic symptoms and “illness behaviour”. The
psychiatric illnesses associated with IBS are depressive disorder, generalized anxiety
disorder, panic disorder and phobic disorder.

MANAGEMENT
Management includes symptomatic treatment of the disease, supportive psychotherapy
and teaching measures to cope with stress and stress reducing measures like relaxation
therapy.

Nursing Care in Psychosomatic Disorders

The nurse should establish a good therapeutic to cope with the patient. She should first
understand the exact problem, the basic personality type, the family background, the
stress inducing situations, the positive and negative qualities of the individuals etc.
  The nurse should help the patient to learn to cope with his stresses more
effectively. Encourage patient to discuss his problems. The patient may need
assistance with problem solving, verbalization of feelings in a non-threatening
environment. This may help the patient to come to terms with unresolved issues.
Patient may be unaware of the relationship between physical symptoms and
emotional problems. This should be clarified.
 Therapy is facilitated by considering areas of strength and utilizing them to the
patient benefit.
 Positive reinforcement enhances self-esteem and encourages repetition of
desirable behaviour.
 The feeling of acceptance by others increases self esteem, hence the nurse
should accept the patient as he is.
 Encourage family participation in the therapy. Family may require assistance in
this process.
 Teach the patient assertiveness technique. The nurse should teach the patient
adaptive methods of stress management such as relaxation techniques, physical
exercises, medication, breathing exercise and yoga. Use of these adaptive
techniques may decrease the appearance of physical symptoms in response to
stress.
23
Community Psychiatry
Community psychiatry is the branch of psychiatry that develops and maintains
organization programs for the for the promotion of mental rehabilitation of the
psychiatric patient.

Concept of community care

Community care involves a community health service which provides comprehensive care and

Treatment for a defined population the two essential aspects are:

1. There should be continuity of care:

2. The available services are to be integrated.

The basic requirement of community care involves.

1. Treatment close to the patient’s home.

2. Comprehensive services t.
3. Multi-disciplinary team approach.
4. Continuity of care.
5. Consumer participation.
 6. Programme evaluation and research.

The two main components of community psychiatry are:

1. Promotion of positive mental health.

2. Prevention of mental illness.

Mental health

Health is not absence of disease. It is a condition of psychiatry, mental and social wellbeing.

One should strive to attain the highest possible level of health that will permit one to lead a
socially and economically productive life. Mental health does not mean mere absence of mental
illness . there should be some positive qualities in every human being to contribute to his or her
society. The individual must have a sense of wellbeing. Mental health and physical health are
interrelated and interdependent. A sound mind resides health in a sound body.

Definition of mental health

WHO defines mental health as “the capacity of an individual to form harmonious relationship,
with other and to actively participate in the change in the social environment”.

Maninger defines mental health as, “the adjustment of a human being to the world and to each
other, with a maximum of effectiveness and happiness.”

Mental health is an ability to maintain:

1. An even temper.
2. An alert intelligence.
3. A socially considerate behaviuor.
4. A happy disposition.

Good adjustment is the basis for positive mental health. Mental health is an individual matter.
It involves an individual human mind. A social environment or culture may be conducive either
to sickness or health, but the quality produced is characteristic only of a person. Mental health
is a state in which one’s potentials capacities are fully realized. Maturity, as adjustment, can
also be regarded as mental health. The term mature, well adjusted, and psychologically health
are often used as synonyms. There should be a positive approach towards attaining mental
health.

Characteristic of a mentally healthy person

1. A mentally healthy person is free from internal conflicts. He is not at war with
herself.
 2. He is well adjusted; i.e. he is able to get along well with others. He is able to form
effective relationship. He accepts criticism and is not easily upset.
3. He searches for an entity.
4. He has a strong sense of self-esteem.
5. He knows himself, his need, problems and goals. This is known as self-
actuallisation .
6. He has good control over his behaviour.
7. He is productive.
8. He faces problems and tries to solve them intelligence. He is able to cope with
stress and anxiety. Mental health is the full and harmonious function of the
whole personality. The requirements of mental health are:
a. Full expression of potential, personality etc.
b. Harmonization .
c. The direction to a common end of native and acquired potentials.

Living in stress free environment will pave the way for mentally healthier and happier life.
In general, mental health can be achieved through many ways including individual treatment,
treatment of families, educational programmes etc. sound behavioural. sound behavioural.
Patterns can be encouraged and reinforced in a well established social netwok. Widespread
mental health is the need of the hour. Mental health is a positive science in that it aims at a
condition of health mindedness.

PREVENTION OF MENTAL ILLNESS

The prevention of mental illness is based on public health principals and has been divided into:

1. Primary prevention
2. Secondary prevention
3. Tertiary prevention.

The aim of prevention is to decrease the onset (incidence) duration (prevalence) and residual
disability of mental disorder.

Primary Prevention

Primary prevention involves the promotion of general mental health and protection against the
occurrence of specific diseases. Primary prevention aims to prevent the onset of a disease or
disorder, thereby reducing the in cadence (number of new cases occurring in a specific period
of time).

Measures for primary prevention include:

 1. Elimination of aetiological agents.
2. Reducing host resistance or interfering with disease transmission.
3. Reducing stress factors.
4. Enhancing host resistance or interfering with disease transmission
5. Counseling
 Student’s counseling
 Marriage counseling
 Sex counseling
 Genetic counseling
6. Special centre
 Child guidance centre
 Crisis intervention centre
 Geriatric counseling
7. Mental health education

Mental health promotion programmes should not be considered scientifically based.

Medical matters, but rather with the notion of recreation, entertainment and moral
upliftment.

Mental Health Education

Among health problems, mental illness is poorly understood by the general public. The message
of prevention, early recognition and effective treatment should reach them. Repeated efforts to
give correct information will lead to a positive change and the misconceptions about mental
illness removed.

Secondary prevention

Early identification and effective treatment of an illness or disorder, with the goal of reducing
the prevalence (total number of existing cases in a year) is the aim of secondary prevention.
The three essential components of secondary prevention are:

1. Population screening
2. Crisis intervention services
3. Mental health education

The paramedical professionals have to be trained to understand mental illnesses,

identify them early, treat many of them and refer the rest to a specialist. Mental health
education aims at educating the public to recognize mental illness at an early stage and seek
help.
 Secondary prevention of mental illness is generally accepted as an important aspect of
mental health services.

Tertiary or Rehabilitation

This aims to reduce the prevalence of residual defect or disability due to illness or disorder.
Tertiary prevention involves rehabilitation after and disability have been fixed. Human
behaviour can be changed, by gradual shaping, into completely new responses. This can be
achieved by behaviuor therapy methods like token economy. Modern tertiary prevention of
mental illness or rehabilitation of the seriously disable mentally ill persons is one of the great
success stories of psychiatry.

24

Treatment of Mental Disorders

Patients suffering from physical illnesses are given specific treatment because the causes are
specific and the signs and syndromes are specific. The doctor generally knows how then
treatment works, and the patient co-operates with the doctors, and nurses, in order to get
better. In psychiatric hospital the treatment may not be so specific and most patients are given
more than one treatment. These treatment methods vary from patient to patient. Some
psychiatric patients do not want treatment and may not co-operate with the doctors and
nurses. Some do not realize that they are ill and may actively resist all forms of treatment.

The nurse has an extremely important role to pay in the treatment of the mentally ill. She
has always much closer contact with the patient than any other members of the hospital team.
She also has a greater opportunity to get to know him and report on his improvement. Her
action s, attitude and skills to help him to deal with his problem are themselves an essential
part of his treatment.

The treatment for psychiatric disorders can be divided into two types-physical methods
of treatment and psychological methods of treatment. Most patients will be treated with one
or more methods of treatment.

PHYSICAL METHODS

1. Physical methods of treatment include:

1. Drug treatment (pharmacotherapy).
2. Electroconvulsive therapy (ECT)
3. Psychosurgery
 2. Psychological methods of treatment includes
a. Bio feedback
b. Psychotherapy
 Individual psychotherapy
 Group therapy
 Family therapy
 Psychoanalytic psychotherapy
c. Hypnotherapy
d. Cognitive therapy
e. Behaviour therapy
f. Relaxation therapy

DRUG TREATMENT IN PSYCHIATRY

Drug therapy is an important aspect of the total treatment plan for the patient. Drugs may be
given to meet both physical and psychological needs. Some important points to remember in
giving medications are as follows.

1. No drug should be administered unless there is a written order by the doctor. No

medication should be given after the order has been cancelled. Do not hesitate to
consult the doctor when in double about any medication.
2. All medication given must be charted on the patient’s case record sheet.
3. In giving medication:
 Do not leave the patient until the drug is swallowed.
 Do not permit the patient to go to the bathroom to take the medication.
 Do not allow one patient to carry medicine to another
 Always address the patient by the name and make certain of identification
 Give fresh water after all medications.
4. It is necessary to leave the patient to get water or assistance, do not leave the tray
within reach of the patient or unsupervised. Do not take the tray within reach of
disturbed or delirious patients.
5. Do not force oral medication because of the danger of aspiration. Unconscious patients
should not be given medication except on the specific order of the doctor

Care of the Drug Cupboard

1. Make sure no patient has access to the drug cupboard

2. Check drugs daily for any change in colour, odour and number.
3. Bottles should be tightly closed and labeled. Labels should be written brightly.
4. Make sure that can adequate supply of drugs is on hand, but do not over stock.
 5. Drug cupboards are always to be kept locked when not in use. Never allow a patient or
worker to clean the drug cupboard. The drug cupboard keys should not be given to
patients.
6. Poison drugs are to be legibly labeled and to be kept in separate cupboard.

Drug used in the treatment of mental disorders are:

1. Anti-psychotics
2. Anti-depressants
3. Anti-anxiety drugs
4. Others:
 Lithium
 Anti-Convulsants
 Disulfiram

Anti-psychotics

These are drugs used in the management of psychotic disorders. They are otherwise known as
major tranquilisers or neuoleptics. There are a large number of anti-psychotic drugs. There are
usually classified according to their chemical structures.

Mechanism of Action

All conventional anti-psychotic drugs act by blocking dopamine receptors in the brain especially
in the limbic system. This dopamine blocking activities are evidence by:

1. Their extrapyramidal side effects

2. The raise in prolactin levels

Anti-psychotics also possess anti-cholinergic, anti-adrenergic and anti-histamine activities.

Indications of Administering Anti-psychotic drugs

1. Schizophrenia
2. Paranoid (delusional) disorders
3. Mania
4. Organic psychosis
5. Any other psychotic disorder, either acute or chronic
6. Anorexia nervosa
7. Agitate depression (in low dose along with anti-depression)
8. Attention deficit disorder in children
9. Mental retardation with behaviuoral problem
 Commonly Used Anti-psychotic Drugs
Class Genetic name Trade name Daily dose
(in divided doses)

1. Phennothiazines:
Chlorpromazine Largactil 100-900mg
Thiorideazine Melleril
Thioril
Ridazine 100-600 mg
Trifluoperazine Espazine
Trazine 5-15mg
Fluphenazine deconate Inj. Anatensol 25-50 mg
(long acting) Monthly once
2. Butyrophenones
Haloperidol serenace
Halidol 3-15 mg
Long acting Haloperidole Inj. Senorm LA 50 mg
3. Thioxanthines
Flupenthixol Fluanxol
4. Diphenyl butyl piperidines
Pimozide Orap
Neurap 4-8 mg
5. Other new Anti- pschoyics
Clozapine Lozapine 75-300 m
Sizopine
Sulpiride at present not available in India
Risperidone Respidon
Sizodon 3-10 mg
Loxapine Loxapac
Olanzepam at present not available in India

Chlorpromazine: Chlorpromazine is a low potency anti- psychotic drug. It reduces drowsiness,

reduces hyperactivity and psychotic symptoms like delusion and hallucination and diminishes
responses to external stimuli. Chlorpromazine (CPZ) is available in syrup form (for paediatric
use), tablet form and injection form (each ampoule consists of 2 ml of CZ; each ml has 25 mg of
CPZ). Standard maintenance dose for the schizophrenia and paranoid disorder is oral
Chlorpromazine 50-10 mg two to three times per day.
Trifluoperazine: Trifluoperazine is a high potency anti-psychotic drug. Trifluoperazine is a high
potency anti-pschotic drug. Trifluoperazine reduces psychotic symptoms like delusions and
hallucination. Standard maintenance dose for schizophrenia and paranoid disorder is 50-100
mg two to three times per day.

Haloperidol: Haloperidol is a high potency anti-psychotic drug. Haloperidol reduces

hyperactivity and psychotic symptoms like delusion and hallucination without producing much
drowsiness. It is available in drops, tablet and injection forms (each ampoule contains 1 mg
haloperidol). The standard maintenance dose for schizophrenia and paranoid disorder is 1.5 to
10 mg two to three times per day. It can be given in large doses (rapid neuroleptisation) to
control disturbed psychotic behaviour.

The haloperidol drops are colourless and odouurless, hence it is useful in the non co-
operative and suspicious patients.

Clozapine: it is an anti-psychotic. It is newly available alternative drug for the treatment of

psychotic disorders, particularly schizophrenia. It is a dibenzodiazepine. The big advantage is
that clozapine is not much associated with extra-pyramidal adverse effects or with tardive
dyskinesia. Clozapine is much useful for the treatment of resistant schizophrenic patients. The
drugs also appears to have a greater effect on negative symptom than conventional anti-
psychotics. Major disadvantage is a 1-2% incidence of agranulocytosis.

Risperidone: it is a new anti-psychotic drugs now available in India. It is a benzisoxazole

derivative. It has high bin ding to dopamine and serotonin receptors. It is very useful in the
management of schizophrenia as it reduces both positive and negative symptoms. It has
extrapyramidal side-effects. Average daily dose is 3-10mg per day.

Pimozide: Pimozide is a highly potent and pure dopamine antagonist. 4-8 mg is effective in
treating schizophrenia and also used in the treatment of Tourette’s disorder.

Long acting anti-psychotics: Long acting anti-psychotics are useful in non co-operative (non-
compliant) patients for maintenance therapy.

1. Inj. Fluphenazine deconate (Inj. Anatensol) needs to be given only once a month.
2. Penfluridol (Semap, Flumap) one tablet once a week is sufficient to maintain the therapy
in schizophrenia.
3. Inj. Haloperidol deconate (Depidol L.A.) one injection of 50 mg may be sufficient for one
month to control the symptoms as maintenance therapy.
Anti-psychotic Drugs - Side Effects and Nursing Management

1. Anticholinergic effects
a. Dry mouth-frequent sips of water, sugarless candy, and ice may help. Strict oral hygiene
is important.
b. Blurred vision – offer reassurance that symptom will sub side after a few weeks.
c. Constipation – advise food high in fiber; increase physical exercise, increase fluid intake
d. Urinary retention – instruct patient to report; monitor intake and output.
2. Sedation: Request the doctor to give drugs preferably at bed time and to decrease or to
change to a less sedating drug, if possible. Instruct the patient not to drive or work in
places involving dangerous equipment and machinery.
3. Orthostatic hypotension: instruct the patient to rise slowly from a lying or sleeping
position; monitor B.P. at each shift (lying and standing), report and record the changes.
4. Photosensitivity (skin rashes and photosensitive dermatitis) protective sunscreen,
clothing and sunglasses.
5. Endocrine effects.
a. Amenorrhoea and lactation (women) – offer reassurance of reversibility.
b. Weight gain – weight patients often; order calorie – controlled diet; provide
opportunity for physical exercise.
c. Decreased libido, gynaecomastia (men) – provides explanation of the effects and
reassurance or reversibility; may request doctor for alternate drugs.
6. Reduction of seizure threshold (occurrence of epilepsy) close observation of patient
with history of seizures
7. Agranulocytosis: Rare in conventional anti-psychotics; occurs’ during clozapine
treatment. Very serious side-effect. Observe for symptoms of sore throat, fever,
malaise. Ensure that complete blood count is monitored regularly.
8. Extrapyramdal side effects (EPS) observe for symptoms and report. Administer anti-
parkinsonian drugs, as ordered.
a. Parkinsonian (tremor, shuffling, gait, rigidity, drooling, mask-like face). Symptoms
may appear in 1 to 5 days following anti-psychotic medication.
b. Akinesia (muscular weakness).
c. Acute dystonia (sudden muscular contraction and stiffness often In neck, tongue and
pharynx). It is very common in young patients taking high potency drugs like
trifluoperazine, haloperidol for the first time. Often associated with occulogyric crisis
(uncontrolled rolling up of the eyes) acute dystonia may be mistaken for seizure
activity and should be treated as an emergency. It can be quickly relieved by treated
as an emergency.it can be quickly relieved by injecting 50mg of intramuscular
promethazine (phenergan).stay with the patient, offer reassurance and support to
patients and relatives.
 d. Akathisia (onset1-2 weeks) (motor restlessness).the patient may need to walk and
keep moving his limbs. Treatment with ant-parkinsonian drugs will relieve the
symptoms. Propranolol (inderal) may be useful.
e. Tardive dyskinesia (onset1-2 years) (bizarre facial and tongue movements ,stiff neck
and difficult in swallowing ).it is an involuntary bucco-linguo masticatory movement.
All patients on long –term ant-psychotic therapy are at risk. Symptoms are gereally
irreversible . treatment consists of withdrawal of the ant-psychotic drug and
changing it to a low potency drug like clozapine ,risperidone or sulpiride.

Other adverse effects:

Neuroleptic malignant syndrome: It is occasionally associated with high potency anti –

psychotics. Young men and patients with organic brain disease are reported at high risk. The
important clinical features include muscular rigidity, fever autonomic dysfunction and
disturbance in mental status. It can cause death, hence early recognition is essential. Treatment
includes immediate stopping of the anti-psychotic and supportive measures. Monitoring vital
signs and renal output are essential. Dantrolene, a muscle relaxant and bromocryptine may be
useful in the management.

Anti-Anxiety Drugs

They are also known as anxiolytics or minor tranquillizers. Most of the anti-anxiety drug belongs
to the benzodiazepine group of drugs. Anti-anxiety drugs are effective for symptomatic relief of
neurotic conditions; where symptoms of anxiety are present, like sweating, tremor palpitation.
They also facilitate sleep. Their curative effect is restricted.

Mechanism of Action

Depression of the central nervous system

Classification of Anti-anxiety Drugs

I. Benzodiazepines
 Chlordiazepoxide
 Diazepam
 Oxazepam
 Alprazolam
 Nitrazepam
 Clonazepam
II. Buspirone
III. Beta-blockers
Benzodiazepines: inhibit GABA. They act mainly on the recticular and Limbic system.
Therapeutic actions of benzodiazepines include:

1. Anti-anxiety All benzodiazepines

2. Hypnotic flurazepa
Nitrazepam
3. Anti-convulsant Diazepam and Clonazepam (status epilepticus)
4. Nuscular relaxant Diazepam (tetanus, muscle tension)
5. Anti-depressant Alprazolam (minor depression).
Indication and dosage
For acute anxiety attack (panic attack)
Tab. Or Inj. Diazepam 10 mg
Tab. Alprazolam 1 mg
For anxiety disorder
Tab. D 5 mg BD for 12 weeks, then gradually reduce
Tab. Chlordiazepoxide 10-20 mg tds.
Alprazolam: it has potent anti-anxiety properties. It is the drug of choice in panic disorder. It
also has the advantage of moderate anti-depressant activity. Alprazolam acts by altering the
functions of proteins. The common adverse effects are sedation and development of
dependence on long-term use.

Buspirone: buspirone is a non-benzodiazepine anxiolytic agent. It is the drug of first choice in

generalized disorder. But the onset of effects may be delayed. It lacks many of the
disadvantages of benzodiazepines.

Beta –blockers : beta blockers have been used for a long time in the treatment of anxiety
disorder. Their action is mostly peripheral. They are useful in controlling somatic symptoms of
anxiety especially palpitation and tremor.

Common Anti-anxiety Drugs Available in India

Group Generic Name Table Name Dosage
1. Benzodiazepines Diazepam Valium 2-5 mg in
Calmpose divided
Placidox does
Chlordiazepoxide Librium 10-50
Lorazepam Ativan
Larpose 1-4
Nitrazepam Nitravet
Dormin 5-20 mg
 Alprazolam Zolax
Alzolam
Alprax
Anxit
2. Buspirone Buspain
3. Beta blocker Inderal

Side effects of Anti-anxiety Drugs and Nursing Management

1. Drowsiness, confusion, lethargy instruct patient not to drive or operate dangerous

machinery while on medication.
2. Addiction : Physiologically addiction forming drugs, so instruct patients not to increase
the dose on their own or not to quite the drug abruptly
3. Potentiates the effects of our CNS depressant instruct the patient not to drink alcohol or
take other tranquillisers without prescription.
4. Aggravate symptoms in depressed persons: Assess for suicidal idea and take necessary
precautions for potential suicide.
5. Orthostatic hypotension: Monitor vital signs and instruct the patient to get up slowly
from a lying or sitting posture.
6. Paradoxical excitement: Withhold drug and inform the doctor.
7. Nausea: Take drug with food or milk

Constraindications : hypersensitivity, glaucoma, pregnancy and lactation.

Anti-Depressants

These drugs are used to treat depression. The drugs currently used in the treatment of
depression include:

1. Tricyclin anti-depressants – most commonly used (e.g., imipramine, amitriptyline,

dothiepin, trimipramine)
2. Tetracycline anti-depressants – rarely used (Mianserin)
3. Newer anti-depressants – less toxic and minimal side-effects (trazodone, fluoxine,
clomaipramine, amineptin, sertarline)
4. Monoamine oxidas inhibitors – not available in India
5. Lithium.

Mechanism of Action
These drugs increase the concentration of norepinephrine and serotonin in the brain. This is
accomplished in the brain by blocking the reuptake of these chemicals by the neurons
(tricyclics). Some drugs act as selective serotonin reuptake inhibitors (SSIRI, e.g. fluoxetine).

Indications of Anti-depressant

These drugs are effective in treating

1. Major depression
2. Bipolar depression
3. Prophylaxis against recurrence of depression
4. Panic disorder
5. Obsessive compulsive disorder.
6. Atypical depression
7. Reactive depression
8. Adjustment disorder with depressive mood
9. Dysrhythmia
10. Enuresis
11. Bulimia
12. Neuropathic pain
13. Attention deficit disorder in children
14. Some phobic disorders (school phobia)
The commonly used anti-depressants and their characteristics

Generic name Trade name Daily dosage Remarks

range (mg)

Imipramine Imipramine 50-30 Oldest and most widely studies

Antidep
Depsol
Depranil
Depsonil
Amitriptyline Tryptomer 50-300 sedating
Amitryn
Amiline
Amitone
Eliwell
Nortriptyline Primox 50-150
Sensival
Doxepin Doxin 50-300 Less sedating
Doxetor Cardiotoxic
spectra
Doxthepin Prothiaden 50-300
Trimipramine Surmontil 50-200
Amoxapine Demolox 150-600 sedating
Less cardiotoxic
Trazadone Trazolon 150-300 Sedating
Trazonil Less cardiotoxic
Flu0xetine Fludac 20-80 Least cardiotoxic,
Flunil Least sedating
Dawnex
Prodep
Oxydep
Nuza
Clomipramine Anafranil 50-150 Anti-depressant
Clonil with specific anti-
Obsessive property
Sertraline serenata 50-150 Less sedating
Zosert least cardiotoxic
Serlift
Mianserin Tetradep 20-120
Aminepine Survector 100-400
Lithium 900-1200

Common Side –Effects and Nursing Care

1. Anti-cholinergic effects
a. Dry mouth – frequent sip of water may help
b. Blurred vision – reassure the patient that this problem will subside after few weeks
c. Constipation – food high fibre preferred ; increase physical exercise; increase fluid
intake
d. Urinary retention – instruct to report; monitor intake and output
2. Sedation: if sedation is too much only night dose may be preferable. Request your
doctor to reduce dose or change to less sedation drug if possible. Instruct patient not to
drive or work with machinery.
3. Orthostatic hypotension: instruct the patient to rise slowly from a lying or sitting
position; monitor blood pressure frequently.
4. Tachycardia, arrhythmias: (Tricyclics and Tetracyclics). Monitor blood pressuer
frequently.
5. Glaucomama, paralytic ileus, convulsions.

Overdose or poisoning os anti-depressants.

Tricyclic anti-depressants are a major problem in the overdose. They are prescribe to
depressive, who may have suicidal tendencies and intentions. Most of these drugs are
dangerous in overdose. Any dose above 600mg likely to produce serious effects in adults. The
problem of accidental overdose among children is also worrying and even 250 mg proves fatal
on occasions.
The effects of overdose on the cardiovascular system are the most life threatening a d
range from sinus tachycardia to major arrhythmias. Central effects comprises excitement, or
coma with shock. Metabolic acidosis and convulsions may occur.
The recent drugs like trazadone, fluoxetine, sertraline are considered as less toxic.
Management of overdose: stomach wash within 12hours. Activated charcoal to be given to
reduce absorption. Respiration must be rendered adequate. Electrolyte and blood gas
disturbances to be rectified. The correction of metabolic acidosis by intravenous infusion of
bicarbonate will reduce cardiac abnormalities. IV arrhythmic effect as well. Body temperature
and vital functions are monitored and maintained.

Lithium Carbonate
Lithium carbonate is effective in treating cases of mania. It is a potential anti-manic agent. It is
widely used in preventing recurrent manic depressive psychoses.
Mechanism of Action
Exact mechanism is not known. Lithium is thought to enhance the reuptake of the biogenic
amines in the brain, thus lowering their levels in the body. Another theory suggests that it alters
sodium metabolism within nerve and muscle cells.

Indications
1. Prevention and treatment of mania, hypomania and bipolar disorders.
2. In the treatment of recurrent depression
Before starting lithium treatment the patient must be investigated for cardiac, renal and
thyroid functions. The patient must be free from cardiac, renal and thyroid disorders. Lithium
takes about 1-2 weeks to control manic symptoms and should always be given another anti-
psychotic drug like haloperidol or chlorpromazine. It has a low therapeutic index and hence has
to be monitored by serum levels.
The dosage of lithium is 900-1200 mg per day in three divided doses. The therapeutically
effect serum lithium level is 0.8 to 1.2 millimol / litter.

Side-effects of Lithium
Dry mouth, GI upset nausea, fine hand tremors, pulse irregularities and frequent urination.

Toxic effects of Lithium: Serum level beyond 2.0 millimol / litter, toxic effects manifest in the
form of abdominal discomfort, nausea, vomiting, diarrhea, tremor of hand, drowsiness. If they
occur, the drug must be immediately stopped. Lithium may produce problems if the person is
depleted of his normal sodium. It is therefore extremely important that the patient consumes a
diet adequate in sodium, as well as 2500-3000 ml of fluid per day. Accurate records of intake-
output and patient weight should be kept on a daily basis.

Contraindication for lithium therapy: cardiovascular disorder, rental disease, thyroid disorder,
dehydration, concurrent with diuretics, pregnancy and children below 12 years of age.

Anti-convulsants
Apart from their main role as anti-epileptic agents, anti-conculsants are widely used in the
management of psychiatric disorders.

Carbamazepine
1. In the treatment of mania, it is as effective as Lithium. Abamazepine, can be used alone
or with an anti-psychotic drug for the treatment of mania.
2. Carbamazepine, alone or in combination with lithium, is an effective e prophylactic
treatment for dipolar disorder.
 3. Carbamazepine is also indicated in the treatment of the following disorders:
 Schizoaffective disorder
 Depression
 Impulse control disorder
 Alcohol withdrawal syndrome
 To minimize aggressive behaviour in schizophrenia.

Valproic Acid (Sodium Valproate)

Valproate is an annti-convulsant. Also it is a potentially effective drug for the treatment of
bipolar disorder. It is effective in controlling both mania and depressive symptoms. Valproic
acid may be effective in controlling psychotic symptoms of schizophrenia patients and organic
mental disorder patients.

Clonazepam
A benzodiazepine derivative, it has an effective anti-convulsant activities especially in myoclonic
seizures. Clonazepam is also effective in the management of acute mania. It is also useful in the
treatment of panic disorder, drug induced extra-pyramidal disorders and bipolar mood
disorders.

Anti-parkinsonism Drugs
This group of drugs are effective against all forms of parkinsonism and anti-psychotics-induced
extra-pyramidal side-effects. They need not be routinely used.

Mechanism of Action
Block action of acetylcholine, thereby reducing excitation of basal ganglia.

Commonly used drugs

Pharmacologic name Trade name Daily doze
Anti-cholinergic Trihexyphenidyl Pacitane 2-6 mg
Parkin
Procycline Kemadrin 5-15 mg
Anti-histamine Diphenhydramine Benardryl 50-200 mg
Miscellaneous Amantadine Amantrel 100-300 mg

Disulfiram
Disulfiram (Antabuse) is used in the treatment of alcoholism. Its main effects is to produce an
unpleasant reaction in a person who drinks even a small amount of alcohol while is on
disulfiram treatment.
 Disulfiram interferes with the metabolism of alcohol by producing a marked increased in
blood acetaldehyde levels. The accumulation of acetaldehyde produces unpleasant reactions
called the disulfiram-alcohol (DA) reaction, characterized by the following signs and symptoms:
nausea, throbbing headache, vomiting, hypotension, flushing, sweating, thirst, dyspnoea,
tachycardia, chest pain, vertigo and blurred vision. The reaction occurs almost immediately
after the ingestion of one drink and may last up to 30 minutes.
Disulfiram is supplied in tablets of 250 mg. the usual initial dose is 500 per day for one or
two weeks followed by maintenance as tab. Esperal and tab. Antadict.

Nursing Guidelines
Disulfiram should not be administered until the patient has abstained from alcohol for at least
12 hours. Patient should be warned that the DA reaction may occur even after 1 week after the
last dose of disulfiram. Nurse should instruct the patient to carry identification cards describing
the DA reaction and the name and telephone number of the psychiatrist to be called. Before
initiating disulfiram therapy consent letter should be obtained from the patient.

ELECTRO CONVULSIVE THERAPY (ECT)

Electro convulsive therapy (ECT) is one of the most effective treatment available in psychiatry.
ECT was introduced by Cerletti and Bini in 1939. The treatment consists of passing an electric
current of about 110 volts across the temporal regions of the head for about 0.5-1 second. This
produces a grand mal epileptic convulsion which is the essential component of the treatment.
The technique of ECT may vary from centre to centre. Straight ECT was the technique in
many centers earlier and even now some psychiatrists prefer this method. The new techniques
are modified ECT and brief pulse ECT.

Straight ECT – Given with Inj. Atropine to minimize secretion. Oxygen may be given during
recovery.

Modified ECT – Given under Inj. Atropine, muscle relaxant and general anaesthesia.

Brief pulse ECT – In constant current brief pulse ECT a low electrical dose is used. Current flows
in burst known as pulses, with no current in between.

PLACEMENT OF ELECTRODES

1. Bilateral ECT – Electrodes are placed at both temples and current is passed across both
hemispheres.
 2. Unilateral ECT – Both electrodes are placed on the same side of the head on the non-
dominant hemisphere – less memory loss, but more treatments are required.

INDICATIONS FOR ECT

 Major depression – Very effective and acts faster than drugs.
 Catatonice stupor – Wakes patient from stupor.
 Schizophrenia – With severe symptoms and not responding to drugs.
 Acute psychosis – Can be beneficial if drugs are not
 Puerperal psychosis – Effective
 Acute mania – Aborts mania

Contraindications
Absolute: Recent myocardial infarction (within three months) Brain tumors or eneurysms,
raised intracranial pressure.

Relative – Acute illness – chest infections

Fracture and osteoporosis
Cardiac or respiratory failure
Permanent pace maker

THE NUMBER AND PREQUENCY OF TREATMENT

There is no hard and fast rule regarding this. It depends upon the severity of the psychiatric
illness and response needed. In number, three to six may be sufficient in most cases. It can
either be given daily or on alternate days.

COMPLICATIONS

 Fractures-Spine, long bones.

 Dislocation-jaw, shoulder
 Cardiac arrhythmia, myocardial infarction
 Cerebral haemorrhage, status epilepticus
 Aspiration pneumonia
 Death due to cardiorespiratory arrest (extremely rare)
 Complications due to anaesthetic agent.

SIDE EFFECTS OF ECT

 Commonly side effects are:

4. Confusion-recovers within a day

5. Muscle aches, headache- recovers after a few days.
6. Memory impairment-recovers in three to six weeks.

MODE OF ACTION

The exact mechanism is not known. However, the probable theories are:

Psychological Theories

4. Fear induced by the treatment is the effective agent.

5. Patient regards the treatment as punishment, conscience is assured, guilt and
depression relieved.
6. During treatment, the patient is allowed to regress to infantile levels and conflicts are
resolved.
All the psychological theories are unsatisfactory.

Biological Theories

5. Increased concentration of neurotransmitters such as nor-adrenaline, dopamine and

serotonin in the brain after the convulsions. Hence, ECT modifies biochemical imbalance
in the brain.
6. Membrane permeability and electrolyte changes induced by the convulsions.
7. Increased receptor sensitivity following the convulsions.
8. ECT may reduce the synthesis and release of GABA.

NURSING CARE AND PREPARATION FOR ECT

The procedure should be explained to the patients and relatives in details and informed
consent should be obtained. The patient’s relatives are to be told that ECT is an effective
treatment without much complication. The nurse should assure the relatives that there will not
be any permanent brain damage to the patient. Minimum investigations like x-ray chest and
ECG are to be done and a physician’s opinion regarding physical fitness to be obtained.

Preparation prior to ECT

The nurse should see that-

 Skin is cleared in the fronto-temporal areas.

 Starvation for minimum six hours.
  All dentures are be removed, as well as hairpins, jewelry, eyeglasses, contact lenses
and other objects those may cause injury
 The patient should wear loose clothing.
 Bladder is to be emptied.
 ECT chart is put up. Vital signs like temperature, pulse, BP and respiration should be
checked before ECT.
 Oxygen supply is kept ready. A tray containing essential drugs like Inj. Decadron,
deriphyline, adrenaline must be kept ready.
 Inj. Atropine 0.1-2 mg as premedication to reduce secretion to be given 15-30 minutes
before the treatment.
 Anaesthetic agent like pentathol sodium and muscle relaxant like scoline may be used.

Psychological preparation : the patient is usually somewhat apprehensive because of the nature
of the treatment, reassurance and support must be given and patient should be assured that he
will not remember the treatment procedure. A calm, confident manner during the preparation
of the patient, allowing him to express his feelings, will help in relieving tension. The nurse
should accompany the patient and remain with him during treatment and until he recovers
consciousness. It is reassuring for the patient to have to be present during the period of
confusion.

Care During the Treatment

The patient is usually placed in a bed, with a hard mattress or on a specially prepared table,
with a sand bag or hard pillows under the neck so that it is hyperextented. In straight ECT,
generally , about four persons are used to hold the shoulders, arms and legs firmly to prevent
fractures and dislocation of the during the jerky movements. A mouth gag is inserted between
the teeth to prevent tongue-bite and the jaw is supported by upward pressure to avoid jaw
dislocation . Airway is to be maintained. At the end of the convulsion, the patient’s head is
turned to one side to prevent the collection of mucus in the back of the throat.

In modified ECT anaesthetic induction and muscle relaxant (Inj. Succinyl choline) is to be
given. Oxygen is to be given for two to three minutes and airway inserted. Treatment should be
given within two minutes of Inj. Succinyl chroline. In modified ECT there will not be muscular
pain, and dislocation and fractures can be prevented.

Nursing Care after ECT

Some patients will go off to sleep and some patients will be confused, agitated and restless. At
times they become violet too. Hence Inj. Diazepam is to be kept ready and if necessary to be
given intravenously and slowly. The side rails ought to be put up while the patient is confused
or he should be made to lie down on a mat or clean sheet on the floor in a sideways position.
Blood pressure and respiration are to be recorded.

The nurse should stay with the patient till he awakens and responds to questions. Orient the
patient to time and place to make him feel more secure and relaxed. If patient develops
nausea/ vomiting, headache or body pain, appropriate medication is to be given. Patients can
be give drink 20-30 minutes after treatment.

PSYCHOSURGERY

Psychosurgery: Refers to the use of neurosurgical procedures to modify the symptoms of

psychiatric illness.

The most common operation is one or another variety of leucotomy. The first operation was
performed in 1936 by Egous Moniz. It was known as standard prefrontal leucotomy. Lots of side
effects were noted. In 1960, newer operations development with lesser complications. They
were of two types.

1. Modified leucotomy
2. Biomedical orbital undercutting.
In the 1970’s stereotactic leucotomy became popular.

Other rarer operations performed are:

1. Cingulomotomy (for severe OCD)

2. Amydolotomy and thalamotomy (in aggressive, violent individuals).
3. Temporal lobectomy ( in aggressive and intractable temporal lobe epilepsy).

Indications for psychosurgery

Because the effects of psychosurgery are permanent, its continued use is limited to special
cases such as,

1. Severe incapacitating OCD, depression and phobia

2. Intractable severe pain
3. A very small number of schizophrenics, uncontrolled with other methods of treatment
4. Intractable seizures (rarely).

The side – effect of psychosurgery

 1. Apathy, inertia and lack of drive
2. Emotional flatness or slight euphoria
3. Loss of judgement and uninhibited behaviour
4. Epilepsy
5. Some patient become incontinent and vegetable – like

Psychosurgeries should be tried as a last resort. Nowadays, psychosurgeries are

performed very very rarely.

PSYCHOLOGICAL METHOD

PSYCHOLOGICAL

When nurse talks to a patient with an illness, without her knowledge she is practicing the art of
psychotherapy. She listens to what her patient says and talks to understanding and reassuring
way. Psychiatric disorders, is specialized than this, but basically it is a treatment by listening to
what the patient says and talks with him.

Psychotherapy is defined as the treatment of emotional disorder by psychological means. Its

goal is to help people to cope better with life and achieve more emotionally satisfying life
styles. Psychotherapy can help individuals to adopt to new and challenging situations.

Psychotherapy involves communication between two individuals, the patient and therapist.
The patient is encouraged to express freely his most intimate fears, emotions and experiences.

The therapist may be a psychiatrist, psychologist, psychiatric social worker or a trained

psychiatric nurse. An important aspect of psychotherapy is the development of the therapeutic
relationship. Through this relationship, the therapist is able to influence the patient’s attitude
towards his symptoms and his illness.

The nurse giving psychotherapy should have the following qualities, she:

1. Should understand the patient’s family and cultural background.

2. Should be a good listener
3. Should be patient, sympathetic, understanding and tactful
4. Should have interest and concern for the patient’s problems.
5. Should not be upset with the patient’s selfish and irresponsible behaviour.
6. Should not be too emotionally involved with the patient and his problems.

Counseling is different from psychotherapy. Counseling refers to professional assistance given

to a variety of problem by discussion and advice. Counseling can be given to healthy individuals
also and will not go into the depth of the problem or about the unconscious mental processes.
 Psychotherapy involves many techniques which include ventilation, abreaction, reassurance
explanation, suggestion, persuation and relaxation.

Psychotherapy is of many kinds like:

1. Individual psychotherapy
2. Group therapy
3. Family therapy
4. Psychoanalytic psychotherapy
5. Hypnotherapy
6. Cognitive therapy
7. Crisis intervention
8. Behaviour therapy
9. Relaxation therapy

Individual psychotherapy

This method helps the patient by encouraging him to discover for himself the reason for his
behaviour. The therapist listens to be patient and offers explanation and advice when
necessary. By this he helps the patient come to a greater understanding of himself and to find a
way of dealing with his problems.

Individual psychotherapy sessions usually take place at regular interval and many patients are
treated over a period of some weeks or months.

Individual psychotherapy is much used in treatment of persons suffer from neurotic disorders,
stress – related disorders, alcohol and drug dependence, sexual disorders and marital
disharmony.

Group therapy

Group therapy is a method in which several people meet as a group with a therapist for the
treatment of emotional and behavioural problems. Group psychotherapy is just as effective as
individual psychotherapy and it allows the therapist to see several patients at one time. The
patients, usually between eight and twelve in number, learn from other as well as therapist.
The individual feels more comfortable and confident in a group and will begin to talk about his
problems and find that other patients are willing to listen and give him advice. The advantage of
group therapy is that it helps patients develop relationships with each other. This is important
because, at some degree, all mentally ill people experience difficulties in their relationships with
others. The therapist usually says few words and allow the patients to do most of the talking.
The group psychotherapy normally conducted like this is known as traditional group therapy.
Group therapy is particularly useful for persons with similar problems, and it is preferable to
have one group, patients with similar problems e.g. alcoholics, drug dependents ect.

Role of the Nurse in Group Therapy

The nurse needs to play different roles upon the nature of the group which include:

1. Catalyst
2. Transference object
3. Clarifier
4. Interpreter
5. Role model and resource person
6. Supporter.

The nurses should have a non – judgemental acceptance. She encourage silent members
to interact. Should see that nobody in the group dominates over another. She has to facilitate
sharing and communication among members.

There is another group known as encounter groups. In this age of isolation and alienation,
people have become increasingly concerned with learning how to openly and honestly to one
another. Encounter groups are also known as T – groups (training group) or sensitivity groups.
The emphasis here is upon expressing attitudes and feeling not usually displayed outside.

There is another type of non – traditional group therapy, psychodrama, where group
members act out or dramatize various situations, feelings and roles. In this techniques
members are encouraged to act out conflicts, not merely discuss them.

Family Therapy

It consists of treating the family as a unit. Family therapy recently has received a great deal of
attention. The aim in family therapy is to change the way a family interacts.

Family Therapy Aims

1. Helping the family members clarify and express their feelings toward one other.
2. Developing greater mutual understanding
3. Working out effective ways of relating to one another and solving their common
problems.

Two methods can be used:

1. Resolving family conflicts

2. Modifying maladaptive behaviour.
Indications for family therapy

1. Marital problems
2. Child mental health problems like school phobia, mental retardation
3. Adjustment disorder
4. Alcoholism and drug dependence
5. Attempted suicide
6. Any psychiatric problem where the pathology is with other family members

Role of the Nurse in Family Therapy

The nurse should understand that the patient’s problem actually reflect a general
maladjustment of the family. The patient may suffer with the illness but the pathology may be
in the family. A healthy person hails from a happy family. Hence, she should understand the
other family members in maintain treatment regularly. She should instruct the family members
that undesirable emotions expressed by relatives may aggravate or produce a relapse of the
illness. A fundamental rule in family therapy is that nurse should not side with any member of
the family.

Psychoanalysis Psychotherapy (Psychoanalysis)

In psychoanalysis is a form of psychotherapy developed by Sigmund Freud. It aims at

uncovering conflicting, unconscious impulses through special techniques that include free
association, dream analysis and transference.

In psychoanalysis, the therapist helps the patient to discover and cope with thoughts and
feelings that direct his behaviour but of which he is unaware.

Psychoanalysis: psychotherapy is time-consuming and expensive. It may be suitable for

everyone. Psychoanalysis is more commonly preferred in hysteria, other neurotic disorders and
mild personality disorders. It is not suitable for psychosis.

Hypnotherapy (Hypnosis)

Hypnosis is a psychophysiological, altered state of consciousness induced by conditioning and

skilled use of suggestions.

It results in:

1. Lessening of the subject’s inhibitions and reasoning.

2. Height of his ability to relax and his susceptiality to suggestion
Hypnosis is super-concentration of the mind.

Steps of Hypnosis

1. Relaxation
2. Realition of cause of the problem
3. Removal of the cause of the problem
4. Rehabilitation
5. Reinforcement (follow up)

Application of Hypnosis

1. In understanding the problem and conflicts which are deeply placed inside the mind.
2. In treating neurotic disorders especially hysteria, phobia and obsessive compulsive
disorders.
3. Without anaesthesia, in the induction of labour and dental surgeries.
4. To alter unwanted behaviour
5. To teach self-hypnosis and to attain relaxation
6. In the treatment of few psychosomatic disorders.

Cognitive Therapy

Cognitive therapy is based on the theory that behaviour is secondary to thinking. It is a short-
term psychotherapy. Our moods and feelings are in fluenced by our thoughts. Self-defeating
and self deprecating patterns of thinking produce depressed mood. By correcting this distorted
way of thinking, mood disturbances and behaviour changes c can be corrected. Underlying this
approach is the assumption that abnormal behaviour patterns and emotional distress start with
problems in what we think (cognitive content) and how we think (cognitive progress).

The cognitive model of depression includes the cognitive triad, that is:

1. A negative view about self

2. A negative view about the environment, and
3. A negative view about the future.

This negative attitude should b e modified in the thinking level and thereby improve the
depressive mood. Cognitive therapy is very useful in the treatment of depression and anxiety. it
is also effective as an adjuvant tereatment with drug abusers.

Crisis intervention
Crisis intervention is a type of psychological method of treatment for the person who is in an
emotional crisis.A crisis is a sudden event in one’s life that disturbs the mental equilibrium
during which the usual coping me chanisms fail.

Criterial of selection

1. A history of specific traumatic situation of recent origin that produces anxiety.

2. A precipitant event that intensified the anxiety.
3. Clear – cut evidence that patient is in a state of psychological crisis.
4. High motivation to overcome the crisis.
One or two sessions may be sufficient. If necessary brief hospitalization is needed.
Crisis intervention is most suitable for:
1. Attempted suicide
2. Post traumatic stress disorder.

Behaviour Therapy

Behaviour therapy, sometimes called behaviour modification, is based on the application of

learn principles to human behaviour. It is aimed at changing over behaviour.

This method of treatment is based on the learning theory which regards symptoms and
abnormal behaviour as learned patterns of behaviour that are maladaptive. The treatment aims
at helping the patient to unlearn symptoms, i.e. his maladaptive behaviour like phobia or
schizophrenic mannerism.
The goals is to remove the symptoms or improve the behaviour only, and is not
concerned with the underlying cause. It is used for the treatment of phobia, obsessional
thoughts, compulsive behaviour, schizophrenia mannerisms, eating disorders and other
undesirable habits like smoke drinking and sexual perversion.
It is a specialized form of treatment and only some principles are described. The
techniques used include.

For the Treatment of Phobia

10. Systematic desensitization The phobic patient is exposed slowly to a gradual hierarchy of
Phobic objects or situations.
11. Flooding: The phobic patient is forced to remain in the phobic situation until his anxiety is
exhausted.
12. Implosion: The phobic patient is instructed to imagine the phobic situation and remain in it
until his anxiety is exhausted. Imagination is used when any other way is not feasible. For
the Treatment of Compulsive Acts
 For the Treatment of Compulsive Acts
13. Modeling: where the therapist carries out the act which the patient is afraid of and
requires the patient to imitate.
14. Response prevention: where the therapist prevents the patient from avoiding unpleasant
acts or situations.
15. Thought stopping: where the therapist prevents the patient from continuing to ruminate
his obsessive thoughts by shouting “stop” or inflicting mild pain on his arm with a rubber
band.
For the Treatment of Schizophrenia or Mental Retardation
16. Operant conditioning: the patient is rewarded for desired behaviour and punished
behaviour.
17. Social skills training: this is to improve social manners like encouraging eye contact,
speaking appropriately, observing simple etiquette, and relating to people.

For the Treatment of Alcohol and Sexual Deviations

18. Aversion therapy: the undesirable behaviour is paired with an unpleasant stimulus, e.g.,
drinking alcohol is followed with a mild electtrick shock.

Relaxation therapy
Relaxation therapy: aim s at producing relaxation to those with anxiety and stress related
problems. Such people are tense and agitate and what they require is a relaxed mind. By
relaxing the body can one achieve relaxation of the mind. This forms the basis for all the
relaxation techniques. These includes:
 Progressive muscle relaxation technique (Jacobson)
 Transcendental meditation
 yoga
The following four elements are the basis to all types of relaxation techniques.
5. Quiet environment
6. Mental devices
7. Passive attitude
8. Comfortable position

Relaxation of produces the following physiological changes:

7. Decreased oxygen consumption
8. Decreased respiratory rate
9. Decreased heart rate
10. Increased alpha brainwaves
 11. Decreased blood pressure
12. Decreased blood lactate levels.
Relaxation Exercises
The following is the simple technique whereby relaxation can be achieved. This can be
practiced by normal people who require more concentration, students to improve memory,
persons who face stressful situations often, anxiety prone personalities and also who suffer
from various types of anxiety and stress-related disorders.

Are you the worry kind? It would seem that there are two types of personalities. There are
striving, competitive, ambitious and impatient people, the so-called type A, and there those
who take life easier, and are called type B. the type Aare more prone to a number of problems
including heart disease and ulcers. It may well be that type B people can suffer from type A
problems if they are put under great stress.

What puts people under stress? Stress is a normal part of our lives. In small amounts, it makes
us more alert and helps us enjoy life more.
The worrying type of person puts him or herself under constant stress even when their life
is on an even level. For all of us, there are periods that we are under particular stress from our
jobs or home life. Obviously unhappy events, as the death of spouse, divorce, imprisonment or
redundancy are very stressful. But even pleasant occurrences such as marriage, birth of a child
or a new job carry a considerable degree of stress.
These periods of stress are unavoidable and we should try to cope with them the best we
can.
What can you do to relax: it is important that one develops a method of relaxing.
One can keep busy during free time. A hobby or sport will give no time to worry. The
following relaxation exercises can be done singly or in sequence. For best results lie down or sit
somewhere quiet.
7. Begin the relaxation by clenching all your muscles, hold for a count of three and then
relax. Do this three times.
8. Breathe in slowly to a count of four, hold for a count of two and then let the breath rush
out. Do this three times and as you exhale feel your body become more relaxed. These
first two exercise can be done whenever you feel tense.
9. Close your eyes and breath easily. Focus you attention first of all on what you can
hear. You will gradually become aware of sounds you have not noticed before. Then
focus your attention on what you can feel, e.g. can you feel your clothes against your
skin or the pressure of the chair against your back? As you breathe your should be
conscious of the air entering your nose, throat and lungs. Do this for minutes.
 10. This rhythmic breathing exercise will not only aid relaxation but should also help
concentration. Breathe regularly and evenly, breathe in and as you exhale mentally say
‘one’ and concentrate on the number. If other thoughts intrude, block them and return
to thinking about the number. Do this for five minutes.
11. Picture yourself somewhere pleasant and relaxed, e.g., lying on a beach. Can you hear
the sea and feel the sand? By imagining the sounds you hear and the sensations you
feel, you can almost recreate the pleasant experience, and this will bring relaxation. Do
this for five minutes.
12. Imagine yourself walking along a path, through a gate, across a meadow, through a
wood and to a pool. Imagine the sounds and sights on your journey. As you repeat this
exercise on subsequent occasions, you will probably add more detail to your journey. Do
this for five minutes.
You may find the above exercise difficult at first, but with practice they will become
easier and every enjoyable. If you can do them once or twice a day you will find after a week or
so that you feel much more relaxed..

Meditation and yoga

This is well-recognized relaxation technique. Meditation helps to focus our attention at one
point and thereby improvement our concentration and be relaxed. Meditation is a
psychological exercise based on physiological facts. Meditation is claimed to help transform the
mind and lead onto happiness and serenity, and paves the way to a creative mind, free from
anxieties and stresses
Recently, there has been a worldwide interest in yoga and other meditation
techniques. They have long existed in the eastern cultures. Yoga has been used since ancient
times as a method to treat the disorders of the mind and body. Yoga is supposed to be a
powerful curative as well as preventive system.
The relaxation response is a physiological reaction brought about by stimulation of the
hypothalamus, resulting in decreased sympathetic nervous system activity. This change occurs
in yoga and transcedental meditation. These techniques involve involves assuming a passive
attitude and repetition of a word or phrase. Meditation and yoga are stress-reducing relaxation
techniques which have been followed in our country for a long time.
These procedures will help to minimise anxiety and tension in the psychologically
disturbed and also disturbed and also in normal persons.
BIO-FEED BACK TREATMENT
This is the psychological method of treatment. In this method, a person is taught to influence
his or her physiological processes.
It was earlier thought that voluntary control over physiological processes such as heart
rate, blood pressure and galvanic skin response, was not possible. But later it was proved that
these can be modified by learning procedures-operant conditioning and classical conditioning.
With these techniques, it is now possible modified irregular heart beat as seen in anxiety
disorders, reduce lo back pain and chronic headaches.

The steps of bio-feedback are:

1. Monitoring the psychological response that is to be modified. (like BP and skin
temperature),
2. Converting the information to a visual or auditory signal, and
3. Providing a means of prompt feedback-indicating to a subject as rapidly as possible
when the desired change is taking place.
Bio-feedback is aimed to reduce the reactivity of some organ system innervated by the
autonomic nervous system specifically. It is a physiological component of the anxiety response.

25
Rehabilitation in psychiatry
“Strength of mind is exercise and, not rest”
- Alexander Pope, 18th Century Poet.
Rehabilitation in psychiatric is that process which attempts to benefit a mentally ill person back,
as near as possible, to his original state. It is the process designed to help the handicapped
individuals to make maximum use of their residual capacities and to enable them to lead a
beneficial and meaningful life in the community.
Rehabilitation of the mentally ill is an essential component of any therapeutic programme
that proposes to tackle effectively the maladies of mental illness. The proverb that an idle mind
is a devils workshop’ emphasizes the importance of activity in our day to day life. Activity may
be physical, mental, social, recreational job oriented. In the case of mentally ill person due to
various reasons, these activities are disturbed to a varying extent. Rehabilitation aims at the
helping the patient to re-establish or regain his interest to do useful activity
The importance of psychological factors such as motivation, attitude and personality in
the rehabilitation process is well accepted. Rehabilitation is much beneficial in long-term
mentally ill people. The following disorders are indicated commonly for rehabilitation.
1. Chronic Schizophrenia
2. Chronic organic mental disorders
3. Mental retardation
4. Alcohol and drug dependence
The goal of any treatment plan should be rehabilitation and reintegration of the patients to
active community life. For successful rehabilitation co-operation of health care personnel,
patients, their family members, opinion leaders and various voluntary agencies are
indispensable.
 Rehabilitation directs towards preparing the individual and his family to cope with a
problem which is likely to persist for the rest of his life time. Considering the magnitude of the
problem of mental morbidity in the country, the mental health professionals have a definite
role to pay in rehabilitation services for this group of people.
Rehabilitation involves training and educating the patient to deal more successfully with
his problems.

Occupation Therapy
Occupation therapy is a rehabilitation process. Any active mental or physical which contributes
to the recovery and rehabilitation of the mentally ill Is known as occupation therapy in
psychiatric setup.
Occupation therapy is an important part of therapeutic programme. Persons who are
trained to teach occupation therapy is known as occupation therapist. She or he will co-
ordinate with doctors, nurses and social workers.

Aim
The aim is to provide a skilled programme of daily activities for patients based on the
knowledge of his personality, background habits, psychological problems and the diagnosis

Advantages
Occupation therapy is helpful as a medium of treatment and as a medium of expression and
communication. It helps the patients to engage in group activities. And they learn better along
with other people. Occupation therapy improve the old skills, acquire new ones and reduce
social isolation.
Occupation therapy provides many interesting and rewarding jobs for patients to do,
some of them are:
1. Gardening
2. Painting
3. Carpentry
4. Needle and Tailoring work
5. Mat weaving, Basket making
6. Cooking
7. Secretarial work etc

Nurse Role
Nurses must spend some time during their training, in occupation therapy department. The
experience they gain can be of great value in helping them to care for their patients. Nurses an
assess their patients potentials, motivate them to attend OT and regularly supervise them
whether they attend sincerely. They can encourage the patients who attend OT regularly by
some incentives.

Industrial therapy
It is the part of rehabilitation process for the mentally ill. This puts work in its place as a part of
rehabilitation. The patients aptitudes are related to simple commercial tasks and the work
provided may be subcontracted out from industrial firms. The patient is paid according to his
productivity. In this centre, patients are specially prepared for work in the community in full
employment, or in a sheltered workshop.

The industrial therapy unit’s aims are:

1. Patients are encouraged to work and earn and to prepare them to live in the community
in a useful way.
2. Recognizing the talents and interests of the mentally ill.
3. Imparting disciplines vocational training under sheltered condition.
4. Diverting the preoccupied mind to the performance of useful work.
5. Developing a certain degree of self confidence and satisfaction through their economic
independence.
6. Establishing link between the mentally ill person and the society.

Following are some of the units run by certain centers

1. Bakery unit
2. Paper cover making unit
3. Screen printing unit
4. Toys and bags making unit
5. Tailoring unit
6. Soap unit
7. Canteen

Recreational Therapy
Recreation is important for everyone, and not least for the patient in a psychiatric hospital. It
provides interest and enjoyment and a welcome change form daily routine. Many patients have
found it hard to enjoy social activities in the community often because of difficult in relating to
other people. Social activities in hospital can help them to overcome their shyness and provide
opportunities to develop personal relationship.
Recreational therapy must carefully choose to suit the needs of the individual patients,
and should be given as much freedom of choice as possible. Elderly patients will often enjoy
reading newspaper, listening to old time music, playing card, games etc., younger patients will
enjoy sports, games, music etc., outings to places of interest, films, concerts and library facilities
should be available to everyone.

Therapeutic Community (Therapeutic Milieu)

The English psychiatrist Maxwell Jones attempted to organize the psychiatric hospital as a
therapeutic community. His primary goal is the elimination of the divisions between various
mental health professions, which he believed to be artificial and harmful to the patient.
The milieu is everything that has impact upon the psychiatric inpatient. It is the
manipulation of the patient’s environment in order to effect change in the behaviour and
personality of the individual.

The object of the therapy are:

1. Limit settings for the patient who is in need of it.
2. Learning the basic social skill of:
a. Assertion
b. Vocation
c. Recreation
The nurse should focus on patient’s problem solving methods and to motivate him for better
rehabilitation. The important concept is that every mental health professional in a psychiatric
hospital should understand and give due credit to the patient’s right, privilege and
responsibility to make decision about daily living activities in the treatment setting.

Characteristic of Milieu Therapy

1. A friendly, warm trusting, secure, supportive comforting atmosphere in the psychiatric
ward.
2. An optimistic attitude about prognosis of the illness
3. Better comforts, food and daily living needs for patients
4. Better recognition to the patient and measures to improve his self esteem. the nurse
should call the patient by name and positively reinforce if he has done some good jobs
5. Opportunity for patients to take responsibility in the day to day management of the wards
including:
a. Patient government
b. Patient planned and patient directed social activities.
6. Opportunity to discuss interpersonal relationships in the unit among patients and staff
(decreased social distance between staff and patients).

Half-way home
Advances in psychiatric treatment have made it possible to effective control severe mental
illness. With the discovery of effective therapies about 90 percent of today’s mentally disturbed
persons do not stay at hospitals for more than four to six weeks. Then it is possible to
successfully reintegrate the majority of mentally disturbed persons back into society.
However even after treatment in hospitals, a small percentage who are severely mentally
disturbed and emotionally sensitive, do not feel ready to cope with the outside world. Many of
these people who do not require further hospitalized can be admitted as residents at the half-
way home. The half-way home is a transition place that encourages constructive living and
builds on resources and skills. It is therapeutic community and a home away from home away
from home and not a hospital. It is one of the big family with house parents, residents and staff
interacting with each other with a family like closeness and a sense of belonging.
The half-way home is a place where each member is gradually trained to take up
responsibilities under the guidance of caring professionals.
The residents are encouraged to modify them in appropriate behaviour. They are
involved in relearning, reconditioning and readjustment. This transformation takes place in the
atmosphere of love and care provided at the half-way home. The prime objective of a half-way
home is to guide all residents towards self reliance.
The activities of a half-way home are directly supervised and conducted by a
professional team consisting of-counselors/social workers, occupational therapist, psychologist,
house parents and consulting psychiatrists. Half-way homes are commonly run by voluntary
agencies and missionaries.

26
Psychiatric Emergencies
A psychiatric emergency is an disturbance in thoughts, feelings or actions for which immediate
therapeutic intervention is necessary. It is any psychiatric condition or circumstance of a patient
which calls for immediate action. Emergency in the psychiatric set up is usually due to one of
the following reasons:
5. The patient may be a source of danger to himself or to others because of his mental
state.
6. The patient may be extremely anxious regarding the patient‘s condition.
7. The patient may create disturbance in the community to an intolerant and
unmanageable degree.
 8. The patient may be in extreme and unbearable distress.

APPROCH TO A PSYCHIATRIC EMERGENCY

5. Brief history to be taken
6. Assess the possibility of any probable precipitating factor
7. Assess the distress and extreme behaviuor pattern
8. Assess the degree of seriousness

The following are the common psychiatric emergencies

12. Excitement and violence
13. Stupor
14. Delirium
15. Attempted suicide
16. Panic attacks
17. Epilepsy related
18. Alcohol and other addictive drugs related psychiatric emergencies
19. Ant-psychotic drugs induced psychiatric emergencies
20. Lithium toxicity
21. Refusal of food

Attempted suicide
Any act of self damage inflicted with self destructive intention. However, vague or ambivalent,
is an attempted suicide. If the patient dies as a result of the act it is called suicide. Otherwise it
is called attempted suicide.
A suicidal attempt with self destructive intension is attempted suicide whereas an attempt
without any intention of dying, but only to threaten or manipulate others is called Para-suicide.

Evaluation of Attempted Suicide

It is advised to get answers to the following questions to assess the suicidal patient.
8. Whether the patient belongs to the high risk group?
f. Old age, lonliness, social isolation.
g. Metal illness – severe depression, schizophrenia, hysteria, antisocial personality.
h. Physical illness – incurable, painful, longterm physical illness.
i. Alcohol and drug dependence.
j. Past history and family history of suicidal behaviour
9. The method used – was it harmless or potentially fatal.
10. Is there any real intention to die? If so why?
11. The place and time – was it carried out in the absence of other
Are There Any Serious Risk factors?
12. Is there any significant recent loss, e.g. death of close relative, loss of job or self esteem.
13. Were there any suicide talk, suicide letters, suicide plans?
14. Is there a will or any last wish?

Management of attempt suicide

3. The initial intensive medical care of the acute physical conditions.
4. The psychological approach; Attempted suicide requires crisis intervention. Persons who
attempt suicide need individual conselling and psychotherapy. Also, family and other
significant people should be involved.

Nursing Care of Attempted Suicide

e. Give the patient an opportunity to express his feelings.
f. Improve communication by a sympathetic approach.
g. Strengthen self – esteem by supportive psychotherapy and reassurance.
h. Facilitate problem solving by:
 Identifying the problems,
 Identifying the alternatives,
 Being clear of the situation and practical solution,
 Choosing one alternative and following it up.

A person who attempt suicide needs medical and psychiatric treatment. The nurse must
assess the severity of the injury. Medical resuscitation is the priority, only then psychiatric
intervention is needed.
The patient’s safety is a nursing priority. The nursing care starts with suicide prevention or
preventing further attempts by making sure that the patient has no access to weapons, sharp
objects, rope, poisons, Psychotropic drugs and situations where self harm can be inflicted. This
requires close supervision by the nurse. Assessment and treatment, if underlying mental illness
is present, is essential after the patient recovers from the critical condition.
Encourage verbalizations of honest feelings. Allow the patient to express angry feelings.
Depression and suicidal behaviour are viewed as anger turned inward on the self. It this anger
can be verbalized the patient may become quiet, calm and comfortable.
The most importance responsibility of the nurse is to spend some time with the person who
attempted suicide. This provides a feeling of safety and security.
 Crisis intervention is essential for the person who attempted suicide. This is more beneficial
for persons who have interpersonal and marital problems. Crisis intervention is similar to
supportive psychotherapy and includes ventilation abreaction and solving conflicts. It starts
with identifying the problem and ends with helping the person to understood and non –
suicidal methods to solve them.

Excitement (Violence)
Patients with excitement are prone for violence. They may harm other or harm themselves.
Violence is physical aggression inflicted by one person on another. Violence may be done due
to a wide range of psychiatric disorders. Violence and threats of violence are frequently
encountered in psychiatric emergency settings. The nurse should know how to rapidly initiate
procedures for the prevention of violence.

Common Mental Disorder Associated with Excitement and Violence Behaviour

5. Psychotic disorder
e. Schizophrenia (especially paranoid and catatonic)
f. mania
g. Paranoid disorders (delusional disorder
h. Postpartum psychosis
6. Organic mental disorders
c. Delirium
d. Drug intoxication and withdrawal (alcohol and heroin)
7. Personality disorder
c. Antisocial personality disorder
d. Paranoid personality disorder
8. Brain disorder
d. Seizure disorders (post-epileptic confusional state)
e. Brain injury, encephalitis
f. Mental retardation with behaviour problem

Following are some important questions a nature should ask a relative or the person
accompanying an excited patient to have quick assessmet:
5. Is a person a known mentally ill? If so what type and what treatment has he been
taking?
6. Has he had a similar excitement earlier?
7. Is there any history of loss consciousness, head injury, epilepsy, alcoholism or drug
addicition?
8. Is involved in any criminal or antisocial activity?
Nursing Care of a Violent and Excitement Patient
7. First protect yourself, do not approach alone, call for assistance to manage any
situation. Do not close the door of the consulting room. Leave physical restraint to the
staff members who are trained for that.
 Do not challenge or confront a violent patient.
 Always keep an eye of a way through which you can escape.
 Never turn your back on the patient
 Be sure that sufficient staff members are there to restrain the patient.
8. After physical restraint, approach the patient cautiously; do not be too brave or
confident.
9. The most effective drugs are:
 Inj. Chlorpromazine 100mg IM
 Inj. Haloperidol 10 – 20 mg IM/IV
 Inj. Diazepam 10mg IV (slowly).
If there is a history of head injury or brain infection avoid these drugs.
10. Assess the nutritional state and, if there is dehydration, IV fluids are essential.
11. Attend to the external injury, if required.
12. If psychiatric treatment is needed you may call the police for help.

Stupor
Stupor is a condition where the patient is conscious, but there is non – responsiveness to the
surroundings. There will be total absence of selfcare, neglecting physiological needs like food
and fluids intake and almost total motor inactivity. Stupor can occur in two mental disorders.
3. Schizophrenia (especially catatonic)
4. Depression.
They are emergencies because there is risk of neglect of nutritional needs of the body.

Nursing Care
Assess the nutritional states and hydration. Give immediate IV fluids and Ryles tube feeding if
necessary. Plenty of vitamins are also essential as well as physiotherapy to facilitate movements
and to prevent contractures. Minimal dose of drugs (antipsychotics and anti – depressants) are
helpful to relieve basic problems.
Delirium
Delirium is an acute organic mental disorder. It is a sign of acute brain dysfunction and is
therefore an emergency. The important clinical factors of delirium are: confusion, clouding of
consciousness, disorientation, insomnia, nightmares, illusions and hallucinations, restlessness,
perplexity, agitated mood, increased autonomic system activity, fever and fits. The patient is
more disturbed during the night.
Delirium is often reversible, the course usually being brief and fluctuating. Delirium is
common in the medically ill, hence most often seen in a general hospital setting. It is commonly
seen in medical wards, surgical wards, trauma wards, geriatric wards and deaddiction wards.

Important Causes of Delirium

8. Severe infections – typhoid, pneumonia, speticaemia, puerperal sepsis.
9. Intracranial infections – Encephalitis, meningitis, cerebral malaria, cerebral abscess.
10. Acute brain disorders – Head injury, cerebral haemorrhage, hypertensive encephalothy.
11. Metabolic disturbance – Uraemia, liver failure, cardiac failure, respiratory failure,
electrolyte imbalance.
12. Vitamin deficiency – pellagra (nicotinamide) wernicke’s encephalopathy (thiamine)
13. Drug withdrawal – From opiates (heroin), alcohol (delirium tremens) barbiturates.
14. Drug intoxication – atropine, cocaine, bromides.

Nursing Management of Patient with Delirium

 Keep the patient in a well ventilated room with good lighting.
 Assess the vital signs periodically
 Assess the hydration and level of consciousness
 Watch for an attack of fit or altered behaviour.
 Identify any likely cause from the history of the patient.
 Remember that if untreated, delirium can lead to death
 If the patient is agitated, physical restraint may be necessary
 Correct any metabolic, nutritional, electrolyte or fluid imbalance. Fever and fit to be
treated appropriately.
 Start the treatment when a definite diagnosis is made.

Inj. Haloperidol 2-5 mg is helpful when the patient is agitated and restless. If it is alcohol or
drug withdrawal delirium or associated fit is there, inj. Diazepam 10 mg slow IV may be helpful;
gradually oral treatment with anti-psychotics or benzodiazepines may be continued. Associated
infections should be treated with appropriate antibiotics.

Panic Attack (Panic Disorder)

Panic attack is severe form of acute anxiety. Panic disorder is characterized by spontaneous,
episodic and intense period of anxiety. It usually last for few a minutes to 30 minutes. Panic
disorder usually occurs once or twice a week. The symptoms of panic disorder include:
 Shortness of breath (dyspnoea)
 Dizziness, feeling unsteady or faint
 Palpitations (tachycardia)
 Trembling or shaking
 Increased sweating
 Chocking sensations
 Abdominal distress
 Flushes or chils
 Chest pain or discomfort (without any ECG abnormality)
 Fear of dying
 Fear of going crazy
 Not all the above symptoms should occur to call it a panic attack; just four or more
symptoms may be sufficient. In the typical case, the patient has been repeatedly
presented to the emergency rooms or a doctor’s consulting room, with physical
symptoms, feelings of uneasiness, chest pain, fear of dying etc.
 All the above symptoms occur despite the absence of cardiac or medical disease.
Panic attacks can be provoked by inhalation of carbon dioxide (CO 2). Psychosocial
stressor may also precipitate an attack of panic. Most of these patients suffer from
anticipatory anxiety.

Management and Nursing Care

It is very essential to map out all possible causes for panic symptoms. All the necessary
investigations, especially ECG, should be taken. It is necessary to get a detailed history about
the patient’s medication and drugs.
Management of panic disorder includes drug treatment, behaviour therapy and
relaxation therapy.
The drugs commonly used in the management of panic attacks are:
4. Alprazolam (Alzalam, Anxit, Restyl etc) 0.25.05 mg every 4 hours
5. Lorazepam (Atival, Larpose etc) 1-2 mg every 4 hours
6. Clonazepam (rivotril, Lonazep etc) 0.5 mg-2mg.

Sometime even higher does may be required to control panic attacks. Tricylic anti-
depressants like Imipramine are also effective. If the attack is very severe Inj. Diazepam one
amp IV slowly may be useful in rare case.
The nursing care of panic disorders include the following measures:
 5. It is essential to explain the nature of the disease to the patient that is, it is only an acute
form of anxiety, and emotional problem. There is no risk to her life, and things will settle
down totally after proper treatment. This sort of health education to the patient and to
the relatives will provide insight regarding this dreadful disease. This sort of reassurance
itself will dramatically improve the situation.
6. Sometimes panic disorders patients are unco-operative to the nurse. They are tense,
trembling, sweating and feel faint. The nurse should act in a calm and quite manner to
handle such patients.
7. Medication like oral alprazolam, clonazepam or lorazepam or occasionally Inj. Diazepam
as instructed should be administered.
8. It is important to teach the patient to reduce their coffee and alcohol intake and
smoking. Caffine, alcohol and nicotine are potentially anxiety producing chemicals.

Epilepsy related psychiatric emergencies

These are two condition related to epilepsy which are to be considered as emergencies
3. Status epilepticus
4. Postictal (epileptic) confusional state

In status epilepticus, seizures follow one another with no intervening periods of

consciousness. The seizure mat be fatal. They may produce cerebral anoxia (poor oxygen
supply to the brain) and hence causes brain damage. The patient should be immediately
hospitalized. IV fluids, oxygen, IV diazepam (very slowly) or parenteral are the emergency
measures to be adopted.
In the postical confusional state the patient may become excited, violent and may harm
or others. Immediate physicalrestrain, Inj. Diazepam IV and if necessary, Inj. Haloperiod IV are
the first steps. The patients is usually confused and will be amnesic of the confusional period.

Alcohol and Other Addiction Forming Drugs and Psychiatric Emergencies

The common emergencies under this are:
1. Alcohol intoxication (pathological intoxication)
2. Acute alcoholic withdrawal state (delirium tremens)
3. Alcohol overdose (poisoning)
4. Disulfiram-alcohol reaction
5. Opioid intoxiction and withdrawal

Alcohol intoxication
Also called pathological intoxication. It is maladaptive behaviour, usually aggressive (e.g. fight)
that occurs after consuming alcohol. The condition is associated with slurred speech,
uncordinate, unsteady gait, nystagmus and flushed face
The management aims to help the patient through intoxication without injury to self or
others. When the patient becomes sober educate him to undergo dead-diction treatment. If
the patient is violent or agitated Inj. Haloperidol 5-10 mg or Inj. Lorazepam 2 mg by mouth can
be given.

Alcohol Withdrawal Delirium (DT or Delirium Tremens)

This is a severe complication of alcohol withdrawal that occurs in about five percent of patients
withdrawing from alcohol. This condition is potentially life-threatening if untreated. Delirium
tremens cases are commonly seen in dead-diction wards, trauma care units (accidents due to
drunken driving), postoperative wards and in gastroenterology clinics where patients with
alcohol dependence get treatment for alcohol related disorders.
The management of DT requires treatment in the intensive medical care unit.
Dehydration and electrolyte imbalance should be corrected by IV fluids. Associated medical
problems like head trauma, rib fracture, infection, gastrointenstinal bleeding and liver disease
should be attended to. Keep a watch for any nurological decicit. Sometimes withdrawal fit (rum
fit) may occur which should be symptomatically treated with IV diazepam.
Nursing care includes careful monitoring of vital signs, watching foe any physical or
psychological complications. Avoid physical restraint. Keep the patient complications. Avoid
physical should be good lighting in the room. Administer vitamins especially B 1 (Thiamine) 100
mg IM. Carry out the instructions of the doctor control withdrawal symptoms and fits, liver
preparations, IV fluids, vitamins etc.

Alcohol Overdose (poisoning)

It is the ingestion of the quantity of alcohol sufficient to cause severe toxicity, coma or death
A blood level of 0.01 to 0.15 percent alcohol indicates intoxication, a level of 0.3 to 0.4
percent usually induces coma and higher level may cause death. Death may be due to
respiratory depression or the aspiration of vomitus.

Alcohol overdose can occur in two conditions:

1. As a suicide attempt
2. As an accident
Prompt medical attention is essential. Gastric lavage, intubation and care in an intensive
medical care unit is essential. Administer 25 or 10 percent dextrose and oxygen immediately,
and then depending upon the complication, follow the doctor’s advice.
Disulfiram Alcohol Reaction
This may occur in patients who are undergoing alcohol deaddiction treatment with disulfiram
(Antabuse, Esperal). When the patient is on this drug, if he consumes alcohol it may produce a
severe reation which sometimes becomes fatal due to a sudden fall in BP. When a patient is on
disulfiram treatment, if he is found unconscious, it may be due to this reaction. The patient
should be immediately hospitalized. IV. Fluids, Inj. Dexamathasone, dopamine drip (if needed)
Inj. Avil and oxygen should be given immediately.

Opioid Intoxication and withdrawal

Opioid intoxication follows the recent ingestion, inhalation or injection of an opioid
preparation. It is characterized by drowsness. Euphoria, analgesia, slured speech, impaired
attention. Loss of appetite etc. opioid intoxication can lead to opioid overdose, which can be a
life threatening emergency. The opium drugs (includind synthetic) are opium, morphine, heroin
(brown sugar), methadone, codeine , pentazocine (Fortwin) Buprenorphine (tidigesic) and
propoxyphene (proxyvon), pethidine cte.
Management of opioid intoxication requires assessment of vital signs, a detailed history
about drug behaviour and assessing other medical respiratory disorders.
If CNS depression or respiratory depression is there, it indicates overdose. Treatment with
naloxone 0.8 mg IV, if no improvements after 15 minutes give another 1.6 mg IV. It can be
repeated later depending upon the need. Ask the patient to undergo a deaddiction treatment
programme.
Opioid withdrawal (like heroin withdrawal) occurs after the cessation or decrease in the
dose of opioids take by a long-term user. The withdrawal symptoms are called by the user as
‘Turky’ . the features