Mental Health Nursing - Sessions 1 (1) (Repaired)

THE UNITED REPUBLIC OF TANZANIA
MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

CHILDREN
DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT
FACILITATOR’S GUIDE FOR ORDINARY DIPLOMA

IN NURSING AND MIDWIFERY
NTA LEVEL 6
NMT 06211: Mental Health Nursing

DECEMBER, 2018
© Ministry of Health, Community Development, Gender, Elderly and Children, Department of Human Resources
Development Nursing Training Section 2018, Dodoma, Tanzania
NMT 06211: Mental Health Nursing ii

Table of Contents
Acronyms....................................................................................................................................................iv
Preamble.....................................................................................................................................................v
Acknowledgement......................................................................................................................................vi
1.0. Background...................................................................................................................................vii
2.0. Rationale.......................................................................................................................................vii
3.0. Goals and Objectives of the Training Manual..............................................................................viii
3.1. Overall Goal for Training Manual.............................................................................................viii
3.2. Objectives for Training Manual................................................................................................viii
4.0. Introduction...................................................................................................................................viii
4.1. Module Overview......................................................................................................................viii
4.2. Who is the Module For?.............................................................................................................ix
4.3. How is the Module Organized?..................................................................................................ix
4.4. How Should the Module be Used?............................................................................................ix
Sessions one:..............................................................................................................................................1
NMT 06211: Mental Health Nursing iii

Acronyms
AGYW Adolescents Girl and Young Women
AIDS Acquired Immune Deficiency Syndrome
AIHA American International Health Alliance
ARV Antiretroviral
VMMC Voluntary Medical Male Circumcision
WHO World Health Organization
NMT 06211: Mental Health Nursing iv

Preamble
The Ministry of Health Community Development Gender Elderly and Children among other roles
ensures that Tanzanians receive quality health care and service. This can be achieved through
production of competent nurses and midwives amongst other health cadres. The training of competent
nurses and midwives can be achieved through various teaching and learning materials; one of them being
facilitator’s guides and student’s manual .
Dr. Loishook Saitori

Director for Human Resource Development
Ministry of Health, Community Development, Gender, Elderly and Children
NMT 06211: Mental Health Nursing v

Acknowledgement
Ministry of Health, Community Development, Gender, Elderly and Children through the Directorate of
Human Resource Development, Nursing training section has reviewed Facilitator’s guide for Nursing
and Midwifery training program. The review was informed by revised curriculum of the same. The
successfully completion of this facilitator’s guide has been made possible by the commitment of the
technical team through a series of writers’ workshops. Understanding the crucial role of the team, the
Ministry would like to express sincere appreciation to all those who involved in the completion of this task.
Special gratitude goes to coordinators of Nursing and Midwifery training, technical expert from NACTE
and other facilitators who tirelessly supported the development of this guide whose names are listed
with appreciation:-
SN FULL NAME INSTITUON/ ORGANIZATION
1. Nassania Shango CDNT -MOHCDGEC-Dodoma
2. Professor Eliezer Tumbwene Lecturer -Aga Khan University
3. Ramadhani Samainda NACTE-Dodoma
4. Dr. Patrick Mwidunda Program Manager-Amref Health Africa
5. Lupyana Kahemela Program Officer-Amref Health Africa
6. Joseph Pilot Program Officer- Amref Hhealth Africa
7. Mary Kipaya Principal- Kahama School of Nursing
8. Paul Magessa Ag. Principal –Newala School of Nursing
9. Dominic Daudi Tutor –Newala School of Nursing
10. Dr. Beatrice Mwilike Lecturer-MUHAS
11. Lilian Wilfred Tutor KCMC School of Nursing
12. Upendo Mamchony Tutor KCMC School of Nursing
13. Tito William Nurse Officer Muhimbili National Hospital
14. Sixtus Ruyumbu Nurse Officer- Mbeya Refferal
15. Dr Lenatus Kalolo Medical Specialist-Mbeya Refferal
16. Emmanuel Mwakapasa Principal Mbeya -OTM
17. Salma Karim Tutor- Mirembe School of Nursing
18. Athanas Paul Principal- Mirembe School of Nursing
19. Dr. Mwandu Kini Jiyenze Tutor –CEDHA
20. Joseph Mayunga Tutor- Kisare
21. Elizabeth Kijugu Principal-Kairuki School of Nursing
22. Charles Magwaza Principal Njombe School of Nursing
23. Meshack Makojijo Tutor Bugando School of Nursing
24. Stellah Kiwale Tutor- PHN Morogoro
25. Evance Anderson Tutor Geita School of Nursing
26. Juliana Malingumu Tutor Mchukwi School of Nursing
27. Rehema Mtonga Tutor -
28. Masunga Isesero Assistant Lecturer -MUHAS
29. Mbaruku Luga Driver-Mirembe School of Nursing
Lastly would like to thank the collaboration and financial support from Amref Health Africa who made
this task successfully completed.
Ndementria Arthur Vermand
NMT 06211: Mental Health Nursing vi
vi
Assistant Director Nursing Training Section, Ministry of Health, Community Development, Gender,
Elderly and Children
1.0. Background
In 2015 the Ministry of Health, Community Development, Gender, Elderly and Children through the
Directorate of Human Resource Development, Nursing training section started the process of reviewing
the nursing curricula NTA level 4-6. The process completed in the year 2017 and its implementation
started in the same year. The rationale for review was to comply with the National Council for Technical
award (NACTE) Qualification framework which offers a climbing ladder for higher skills opportunity.
Amongst other rationale was to meet the demand of the current health care service delivery. The
demand is also aligned with human resource for health strategic plan and human resource for health
production plan which aims at increasing number of qualified human resource for health.
The process of producing qualified human resource for health especially nurses and midwives requires
the plentiful investment of resources in teaching at the classroom and practical setting and the
achievement of clinical competence is acquired in step wise starting from classroom teaching to skills
laboratory teaching. In addition, WHO advocates for skilled and motivated health workers in producing
good health services and increase performance of health systems (WHO World Health Report, 2006).
Moreover, Primary Health Care Development Program (PHCDP) (2007-15) needs the nation to
strengthen and expand health services at all levels. This can only be achieved when the Nation has
adequate, appropriately trained and competent work force who can be deployed in the health facilities
to facilitate the provisions of quality health care services.
In line with the revised curricula, the MOHCDGEC in collaboration with developing partners and team of
technical staff developed quality standardized training materials to support the implementation of
curricula. These training materials address the foreseen discrepancies in the implementation of the
curricula by training institutions.
This facilitator’s guide has been developed through a series of writers’ workshop (WW) approach. The
goals of Writer’s Workshop were to develop high-quality, standardized teaching materials and to build
the capacity of tutors to develop these materials. The new training package for NTA Level 4-6 includes
a Facilitator Guide and Student Manual. There are 33 modules with approximately
520 content sessions
2.0. Rationale
The vision and mission of the National Health Policy in Tanzania focuses on establishing a health
system that is responsive to the needs of the people, and leads to improved health status for all.
Skilled and motivated health workers are crucially important for producing good health through
increasing the performance of health systems (WHO, 2006). With limited resources (human and non-
human resources), the MOHSW supported tutors by developing standardized training materials to
accompany the implementation of the developed CBET curricula. These training manuals address the
foreseen discrepancies in the implementation of the new curricula.
Therefore, this training manual for Certificate and Diploma program in Nursing (NTA Levels 4-6) aims at
providing a room for Nurses to continue achieving skills which will enable them to perform competently.
These manuals will establish conducive and sustainable training environment that will allow students
and graduates to perform efficiently at their relevant levels. Moreover, this will enable them to aspire for
attainment of higher knowledge, skills and attitudes in promoting excellence in nursing practice.
NMT 06211: Mental Health Nursing vii
vii
3.0. Goals and Objectives of the Training Manual
3.1. Overall Goal for Training Manual
The overall goal of these training manuals is to provide high quality, standardized and Competence-
based training materials for Diploma in nursing (NTA level 4 to 6) program
3.2. Objectives for Training Manual

• To provide high quality, standardized and competence-based training materials.
• To provide a guide for tutors to deliver high quality training materials.
• To enable students to learn more effectively.
4.0. Introduction
4.1. Module Overview
This module content has been prepared as a guide for tutors of NTA Level 6 for training students. The
session contents are based on the sub-enabling outcomes of the curriculum of NTA Level 6 Ordinary
diploma in Nursing and Midwifery.The module sub-enabling outcome are as follows:
6.1.1 Describe concepts of personality development in relation to mental health

6.1.2 Describe psychobiological concepts in relation to the practice of mental health nursing
6.1.3 Describe legal issues related to mental health nursing in the provision of nursing care to mentally
ill patient
6.1.4 Describe cultural and spiritual issues in caring a patient with mental illness
6.2.1 Provide psychological therapies to a patient with mental illness according to guidelines
6.2.2 Provide psychosocial therapies to patient with mental disorders according to guidelines and
protocols
6.2.3 Provide physical therapies to patients with mental disorders according to standards
6.2.4 Provide pharmacotherapy to patients with mental disorders according to standards
6.3.1 Provide care to patients with personality disorders according to standards
6.3.2 Provide nursing care to patients with dissociative and somatoform disorders according to
standards
6.3.3 Provide nursing care to patients with mood disorders according to standards
6.3.4 Provide nursing care to patients with psychotic disorders according to standards
6.3.5 Provide care to patients with cognitive disorders according to standards
6.3.6 Provide care to special group with mental illness according to guidelines and standards
6.3.7 Provide rehabilitative and domiciliary care to a patient with mental illness
6.3.8 Provide care to patients with psychiatric emergencies according to standards and guidelines
NMT 06211: Mental Health Nursing viii
viii
4.2. Who is the Module For?
This module is intended for use primarily by tutors of NTA Level 4 certificate and diploma in nursing
schools.
The module’ sessions give guidance on the time and activities of the session and provide information
on how to teach the session to students. The sessions include different activities which focus on
increasing students’ knowledge, skills and attitudes.
4.3. How is the Module Organized?

The module is divided into 18 sessions; each session is divided into sections. The following are the
sections of each session:
 Session Title: The name of the session.
 Learning Tasks – Statements which indicate what the student is expected to learn at the end of the
session.
 Session Content – All the session contents are divided into steps. Each step has a heading and an
estimated time to teach that step. Also, this section includes instructions for the tutor and activities
with their instructions to be done during teaching of the contents.
 Key Points – Each session has a step which concludes the session contents near the end of a
session. This step summarizes the main points and ideas from the session.
 Evaluation – The last section of the session consists of short questions based on the learning
objectives to check the understanding of students.
 Handouts are additional information which can be used in the classroom while teaching or later for
students’ further learning. Handouts are used to provide extra information related to the session
topic that cannot fit into the session time. Handouts can be used by the participants to study
material on their own and to reference after the session. Sometimes, a handout will have questions
or an exercise for the participants. The answers to the questions are in the Facilitator Guide
Handout, and not in the Student Manual Handout.
4.4. How Should the Module be Used?

Students are expected to use the module in the classroom and clinical settings and during self-study.
The contents of the modules are the basis for learning Mental Health Nursing. Students are therefore
advised to learn each session and the relevant handouts and worksheets during class hours, clinical
hours and self-study time. Tutors are there to provide guidance and to respond to all difficulty
encountered by students.
NMT 06211: Mental Health Nursing ix
ix
SESSIONS 01: CONCEPTS OF PERSONALITY DEVELOPMENT IN RELATION TO
MENTAL HEALTH
Total Session Time: 120 minutes
Pre requisite: None
Learning Tasks
At the end of this session a learner expected to be able to:
Define personality development
Explain structure of personality
Describe stages of psychosexual development (Freud’s theory)
Describe stages of psychosocial development (Erickson theory)
Describe stages of cognitive development (Piaget theory)
Resources Needed:
 Flip charts, marker pens, and masking tape
 Black/white board and chalk/whiteboard markers
 LCD Projector and computer
 Note Book and Pen
Session Overview
Step Time (min) Activity/ Method Content
1 05 Presentation Presentation of Session Title and Learning tasks

2 05 Brainstorming
Presentation Definition of Personality Development
3 10 Lecture discussion Structure of personality
4 30 Lecture discussion Stages of Psychosexual Development (Freud’s theory)
5 30 Lecture discussion Stages of Psychosocial Development (Erickson theory)
6 30 Lecture discussion Stages of Cognitive Development (Piaget theory)
7 05 Presentation Key Points

8 05 Presentation Session Evaluation
SESSION CONTENTS
NMT 06211: Mental Health Nursing 1
1
STEP 1: Presentation of Session Title and Learning tasks (5 minutes)
 READ or ASK participants to read the learning objectives
 ASK participants if they have any questions before continuing
STEP 2: Definition of Personality Development ( 5 minutes)
Activity: brainstorming
 ASK students to brainstorm on the definition of personality development
 ALLOW time for them to respond
 WRITE their answers on the flipchart/board
 SUMMARISE with information given below
STEP 3: Structure of personality (10 Minutes)

 Personality Structure Freud (1960) delineated three major and distinct but interactive systems of the
personality: the id, the ego, and the superego.
Id.
 At birth we are all id. The id is the source of all drives, instincts, reflexes, needs, genetic inheritance, and
capacity to respond, as well as all the wishes that motivate us.
 The id cannot tolerate frustration and seeks to discharge tension and return to a more comfortable level of
energy.
 The id lacks the ability to problem solve; it is not logical and operates according to the pleasure principle.
The only needs that count are its own. A hungry, screaming infant is the perfect example of id.
Ego
 Within the first few years of life as the child begins to interact with others, the ego develops. The ego is the
problem solver and reality tester.
 It is able to differentiate subjective experiences, memory images, and objective reality and attempts to
negotiate with the outside world.
 The ego follows the reality principle, which says to the id, “You have to delay gratification for right now,” and
then sets a course of action.
o For example, a hungry man feels tension arising from the id that wants to be fed. His ego allows him not
only to think about his hunger but to plan where he can eat and to seek that destination.
o This process is known as reality testing because the individual is factoring in reality to implement a plan
to decrease tension.
Superego
 The superego, the last portion of the personality to develop, represents the moral component of personality.
 The superego consists of the conscience (all the “should nots” internalized from parents) and the ego ideal
(all the “shoulds” internalized from parents).
2
 The superego represents the ideal rather than the real; it seeks perfection, as opposed to seeking pleasure
or engaging reason.
 In a mature and well-adjusted individual, the three systems of the personality—the id, the ego, and the
superego work together as a team under the administrative leadership of the ego.
 If the id is too powerful, the person will lack control over impulses; if the superego is too powerful, the person
may be self-critical and suffer from feelings of inferiority.
STEP 4: Stages of Psychosexual Development - Freud’s theory (40minutes)

 Freud believed that personality develops through a series of childhood stages in which the pleasure-seeking
energies of the id become focused on certain erogenous areas.
 An erogenous zone is characterized as an area of the body that is particularly sensitive to stimulation.
 The five psychosexual development stages, are
o Oral Stage
o Anal Stage
o Phallic Stage
o Latent Stage
o Genital Stage
The Oral Stage –

This stage ranges from birth to 1 Year
Erogenous Zone: Mouth
 During the oral stage, the infant's primary source of interaction occurs through the mouth, so the rooting and
sucking reflex is especially important. The mouth is vital for eating, and the infant derives pleasure from oral
stimulation through gratifying activities such as tasting and sucking.
 Because the infant is entirely dependent upon caretakers (who are responsible for feeding the child), the
child also develops a sense of trust and comfort through this oral stimulation.
 The primary conflict at this stage is the weaning process--the child must become less dependent upon
caretakers.
 If fixation occurs at this stage, Freud believed the individual would have issues with dependency or
aggression. Oral fixation can result in problems with drinking, eating, smoking, or nail biting.
3
The Anal Stage
Age Range: 1 to 3 years
Erogenous Zone: Bowel and Bladder Control
 During the anal stage, Freud believed that the primary focus of the libido was on controlling bladder and
bowel movements. The major conflict at this stage is toilet training--the child has to learn to control his or her
bodily needs. Developing this control leads to a sense of accomplishment and independence.
 According to Freud, success at this stage is dependent upon the way in which parents approach toilet
training. Parents who utilize praise and rewards for using the toilet at the appropriate time encourage
positive outcomes and help children feel capable and productive. Freud believed that positive experiences
during this stage served as the basis for people to become competent, productive, and creative adults.
 However, not all parents provide the support and encouragement that children need during this stage. Some
parents instead punish, ridicule or shame a child for accidents.
 According to Freud, inappropriate parental responses can result in negative outcomes. If parents take an
approach that is too lenient, Freud suggested that an anal-expulsive personality could develop in which the
individual has a messy, wasteful, or destructive personality. If parents are too strict or begin toilet training too
early, Freud believed that an anal-retentive personality develops in which the individual is stringent, orderly,
rigid, and obsessive.
The Phallic Stage

Age Range: 3 to 6 Years
Erogenous Zone: Genitals
 Freud suggested that during the phallic stage, the primary focus of the libido is on the genitals. At this age,
children also begin to discover the differences between males and females.
 Freud also believed that boys begin to view their fathers as a rival for the mother’s affections. The Oedipus
complex describes these feelings of wanting to possess the mother and the desire to replace the father.
However, the child also fears that he will be punished by the father for these feelings, a fear Freud termed
castration anxiety.
 The term Electra complex has been used to describe a similar set of feelings experienced by young girls.
Freud, however, believed that girls instead experience penis envy.
 Eventually, the child begins to identify with the same-sex parent as a means of vicariously possessing the
other parent. For girls, however, Freud believed that penis envy was never fully resolved and that all women
remain somewhat fixated on this stage. Psychologists such as Karen Horney disputed this theory, calling it
both inaccurate and demeaning to women. Instead, Horney proposed that men experience feelings of
inferiority because they cannot give birth to children, a concept she referred to as womb envy.
The Latent Period

Age Range: 6 to Puberty
Erogenous Zone: Sexual Feelings Are Inactive
 During this stage, the superego continues to develop while the id's energies are suppressed. Children
develop social skills, values and relationships with peers and adults outside of the family.
 The development of the ego and superego contribute to this period of calm. The stage begins around the
time that children enter into school and become more concerned with peer relationships, hobbies, and other
interests.
 The latent period is a time of exploration in which the sexual energy repressed or dormant. This energy is
still present, but it is sublimated into other areas such as intellectual pursuits and social interactions. This
stage is important in the development of social and communication skills and self-confidence.
4
 As with the other psychosexual stages, Freud believed that it was possible for children to become fixated or
"stuck" in this phase. Fixation at this stage can result in immaturity and an inability to form fulfilling
relationships as an adult.
The Genital Stage

Age Range: Puberty to Death
Erogenous Zone: Maturing Sexual Interests
 The onset of puberty causes the libido to become active once again. During the final stage of psychosexual
development, the individual develops a strong sexual interest in the opposite sex. This stage begins during
puberty but last throughout the rest of a person's life.
 Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows
during this stage.
 If the other stages have been completed successfully, the individual should now be well-balanced, warm,
and caring. The goal of this stage is to establish a balance between the various life areas.
 Unlike the many of the earlier stages of development, Freud believed that the ego and superego were fully
formed and functioning at this point.
 Younger children are ruled by the id, which demands immediate satisfaction of the most basic needs and
wants.
 Teens in the genital stage of development are able to balance their most basic urges against the need to
conform to the demands of reality and social norms.
Implications for Psychiatric Mental Health Nursing

 Freud’s theory has relevance to psychiatric mental health nursing practice at many junctures. First, the
theory offers a comprehensive explanation of complex human processes and suggests that the formation of
a patient’s personality is strongly influenced by childhood experiences.
 Freud’s theory of the unconscious mind is particularly valuable as a baseline for considering the complexity
of human behavior.
 By considering conscious and unconscious influences, a nurse can identify and begin to think about the root
causes of patient suffering.
 Freud emphasized the importance of individual talk sessions characterized by attentive listening, with a
focus on underlying themes as an important tool of healing in psychiatric care.
STEP 5: Stages of Psychosocial Development (Erickson theory) (30 Minutes)

 Erik Erikson (1902-1994), an American psychoanalyst, was also a follower of Freud; however, Erikson
(1963) believed that Freudian theory was restrictive and negative in its approach.
 He also stressed that an individual’s development is influenced by more than the limited mother-child-father
triangle and that culture and society exert significant influence on personality.
 According to Erikson, personality was not set in stone at age 5, as Freud suggested, but continued to
develop throughout the life span.
 Erikson described development as occurring in eight predetermined and consecutive life stages
(psychosocial crises), each of which consists of two possible outcomes (e.g., industry vs. inferiority). Ref
 The successful or unsuccessful completion of each stage will affect the individual’s progression to the next.
o For example, Erikson’s crisis of industry versus inferiority occurs from the ages of 7 to 12. During
this stage, the child’s task is to gain a sense of personal abilities and competence and to expand
relationships successfully at a later time.
Table 1.1
5
Stage Psychosocial Crisis Basic Virtue Age
1. Trust vs. Mistrust Hope 0 - 1½
2. Autonomy vs. Shame Will 1½ - 3
3. Initiative vs. Guilt Purpose 3-5
4. Industry vs. Inferiority Competency 5 - 12
5. Identity vs. Role Confusion Fidelity 12 - 18
6. Intimacy vs. Isolation Love 18 - 40
7. Generativity vs. Stagnation Care 40 - 65
8. Ego Integrity vs. Despair Wisdom 65+
1. Trust vs. Mistrust

 During this stage, the infant is uncertain about the world in which they live. To resolve these feelings of
uncertainty, the infant looks towards their primary caregiver for stability and consistency of care.
 If the care the infant receives is consistent, predictable and reliable, they will develop a sense of trust which
will carry with them to other relationships, and they will be able to feel secure even when threatened.
 Success in this stage will lead to the virtue of hope. By developing a sense of trust, the infant can have hope
that as new crises arise, there is a real possibility that other people will be there as a source of support.
Failing to acquire the virtue of hope will lead to the development of fear.
 For example, if the care has been harsh or inconsistent, unpredictable and unreliable, then the infant will
develop a sense of mistrust and will not have confidence in the world around them or in their abilities to
influence events.
 This infant will carry the basic sense of mistrust with them to other relationships. It may result in anxiety,
heightened insecurities, and an over feeling of mistrust in the world around them.
2. Autonomy vs. Shame and Doubt

 Autonomy versus shame and doubt is the second stage of Erik Erikson's stages of psychosocial
development.
 This stage occurs between the ages of 18 months to approximately 3 years.
 The child is developing physically and becoming more mobile, and discovering that he or she has
many skills and abilities, such as putting on clothes and shoes, playing with toys, etc. Such skills
illustrate the child's growing sense of independence and autonomy.
o For example, during this stage children begin to assert their independence, by walking away
from their mother, picking which toy to play with, and making choices about what they like to
wear, to eat, etc.
 Erikson states it is critical that parents allow their children to explore the limits of their abilities within
an encouraging environment which is tolerant of failure.
o For example, rather than put on a child's clothes a supportive parent should have the patience
to allow the child to try until they succeed or ask for assistance. So, the parents need to
6
encourage the child to become more independent while at the same time protecting the child
so that constant failure is avoided.
3. Initiative vs. Guilt Age

 Initiative versus guilt is the third stage of Erik Erikson's theory of psychosocial development. During
the initiative versus guilt stage, children assert themselves more frequently.
 These are particularly lively, rapid-developing years in a child’s life. According to Bee (1992), it is a
“time of vigor of action and of behaviors that the parents may see as aggressive."
 During this period the primary feature involves the child regularly interacting with other children at
school. Central to this stage is play, as it provides children with the opportunity to explore their
interpersonal skills through initiating activities.
 Children begin to plan activities, make up games, and initiate activities with others. If given this opportunity,
children develop a sense of initiative and feel secure in their ability to lead others and make decisions.
 Conversely, if this tendency is squelched, either through criticism or control, children develop a
sense of guilt. They may feel like a nuisance to others and will, therefore, remain followers, lacking
in self-initiative.
 The child takes initiatives which the parents will often try to stop in order to protect the child. The
child will often overstep the mark in his forcefulness, and the danger is that the parents will tend to
punish the child and restrict his initiatives too much.
 It is at this stage that the child will begin to ask many questions as his thirst for knowledge grows. If
the parents treat the child’s questions as trivial, a nuisance or embarrassing or other aspects of
their behavior as threatening then the child may have feelings of guilt for “being a nuisance”.
 Too much guilt can make the child slow to interact with others and may inhibit their creativity. Some
guilt is, of course, necessary; otherwise the child would not know how to exercise self-control or
have a conscience.
4. Industry vs. Inferiority
 Erikson's fourth psychosocial crisis, involving industry vs. inferiority occurs during childhood
between the ages of five and twelve.
 Children are at the stage where they will be learning to read and write, to do sums, to do things on
their own. Teachers begin to take an important role in the child’s life as they teach the child specific
skills.
 It is at this stage that the child’s peer group will gain greater significance and will become a major
source of the child’s self-esteem. The child now feels the need to win approval by demonstrating
specific competencies that are valued by society and begin to develop a sense of pride in their
accomplishments.
 If children are encouraged and reinforced for their initiative, they begin to feel industrious (competent) and
feel confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by parents or
teacher, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his or
her potential.
 If the child cannot develop the specific skill they feel society is demanding (e.g., being athletic) then they
may develop a sense of inferiority.
5. Identity vs. Role Confusion
7
 The fifth stage is identity vs. role confusion, and it occurs during adolescence, from about 12-18 years.
During this stage, adolescents search for a sense of self and personal identity, through an intense
exploration of personal values, beliefs, and goals.
 During adolescence, the transition from childhood to adulthood is most important. Children are becoming
more independent, and begin to look at the future in terms of career, relationships, families, housing, etc.
The individual wants to belong to a society and fit in.
 This is a major stage of development where the child has to learn the roles he will occupy as an
adult. It is during this stage that the adolescent will re-examine his identity and try to find out exactly
who he or she is. Erikson suggests that two identities are involved: the sexual and the
occupational.
 According to Bee (1992), what should happen at the end of this stage is “a reintegrated sense of
self, of what one wants to do or be, and of one’s appropriate sex role”. During this stage the body
image of the adolescent changes.
 Erikson claims that the adolescent may feel uncomfortable about their body for a while until they
can adapt and “grow into” the changes. Success in this stage will lead to the virtue of fidelity.
 Fidelity involves being able to commit one's self to others on the basis of accepting others, even
when there may be ideological differences.
 During this period, they explore possibilities and begin to form their own identity based upon the
outcome of their explorations. Failure to establish a sense of identity within society ("I don’t know
what I want to be when I grow up") can lead to role confusion. Role confusion involves the
individual not being sure about themselves or their place in society.
6. Intimacy vs. Isolation

 Intimacy versus isolation is the sixth stage of Erik Erikson's theory of psychosocial development. This stage
takes place during young adulthood between the ages of approximately 18 to 40 yrs.
 During this period, the major conflict centers on forming intimate, loving relationships with other people.
 During this period, we begin to share ourselves more intimately with others. We explore relationships leading
toward longer-term commitments with someone other than a family member.
 Successful completion of this stage can result in happy relationships and a sense of commitment, safety,
and care within a relationship.
 Avoiding intimacy, fearing commitment and relationships can lead to isolation, loneliness, and sometimes
depression. Success in this stage will lead to the virtue of love.
7. Generativity vs. Stagnation

 Generativity versus stagnation is the seventh of eight stages of Erik Erikson's theory of psychosocial
development. This stage takes place during during middle adulthood (ages 40 to 65 yrs).
 Generativity refers to "making your mark" on the world through creating or nurturing things that will outlast an
individual.
 People experience a need to create or nurture things that will outlast them, often having mentees or creating
positive changes that will benefit other people.
 We give back to society through raising our children, being productive at work, and becoming involved in
community activities and organizations. Through generativity we develop a sense of being a part of the
bigger picture.
 Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in
the world.
8
 By failing to find a way to contribute, we become stagnant and feel unproductive. These individuals may feel
disconnected or uninvolved with their community and with society as a whole. Success in this stage will lead
to the virtue of care.
8. Ego Integrity vs. Despair

 Ego integrity versus despair is the eighth and final stage of Erik Erikson’s stage theory of psychosocial
development. This stage begins at approximately age 65 and ends at death.
 As we grow older (65+ yrs) and become senior citizens, we tend to slow down our productivity and explore
life as a retired person.
 It is during this time that we contemplate our accomplishments and can develop integrity if we see ourselves
as leading a successful life.
 Erikson described ego integrity as “the acceptance of one’s one and only life cycle as something that had to
be” and later as “a sense of coherence and wholeness”
 Erik Erikson believed if we see our lives as unproductive, feel guilt about our past, or feel that we did not
accomplish our life goals, we become dissatisfied with life and develop despair, often leading to depression
and hopelessness.
 Success in this stage will lead to the virtue of wisdom. Wisdom enables a person to look back on their life
with a sense of closure and completeness, and also accept death without fear.
 Wise people are not characterized by a continuous state of ego integrity, but they experience both ego
integrity and despair.
Implications for Psychiatric Mental Health Nursing

 Analysis of behavior patterns using Erikson’s framework can identify age-appropriate or arrested
development of normal interpersonal skills.
 A developmental framework helps the nurse know what types of interventions are most likely to be effective.
 For example, children in Erikson’s initiative versus-guilt stage of development respond best if they actively
participate and ask questions.
 Older adults respond to a life- review strategy that focuses on the integrity of their life as a tapestry of
experience.
 In the therapeutic encounter, individual responsibility and the capacity for improving one’s functioning are
addressed. Treatment approaches and interventions can be tailored to the patient’s developmental level.
STEP 6: Stages of Cognitive Development -Piaget theory (20 Minutes)

 Jean Piaget's theory of cognitive development suggests that children move through four different
stages of mental development.
 His theory focuses not only on understanding how children acquire knowledge, but also on
understanding the nature of intelligence. Piaget's stages are:
o Sensorimotor stage: birth to 2 years
o Preoperational stage: ages 2 to 7
o Concrete operational stage: ages 7 to 11
o Formal operational stage: ages 12 and up
 Piaget believed that children take an active role in the learning process, acting much like little
scientists as they perform experiments, make observations, and learn about the world.
The Sensorimotor Stage -Ages: Birth to 2 Years

 Major Characteristics and Developmental Changes:
9
o The infant knows the world through their movements and sensations.
o Children learn about the world through basic actions such as sucking, grasping, looking, and listening.
o Infants learn that things continue to exist even though they cannot be seen (object permanence).
o They are separate beings from the people and objects around them.
o They realize that their actions can cause things to happen in the world around them.
 During this earliest stage of cognitive development, infants and toddlers acquire knowledge through
sensory experiences and manipulating objects.
 A child's entire experience at the earliest period of this stage occurs through basic reflexes, senses,
and motor responses.
 It is during the sensorimotor stage that children go through a period of dramatic growth and
learning. As kids interact with their environment, they are continually making new discoveries about
how the world works.
The Sensorimotor Stage of Cognitive Development -The Preoperational Stage Ages: 2 to 7 Years
o Children begin to think symbolically and learn to use words and pictures to represent objects.
o Children at this stage tend to be egocentric and struggle to see things from the perspective of others.
o While they are getting better with language and thinking, they still tend to think about things in very
concrete terms.
 The foundations of language development may have been laid during the previous stage, but it is
the emergence of language that is one of the major hallmarks of the preoperational stage of
development.
 Children become much more skilled at pretend play during this stage of development, yet still think
very concretely about the world around them.
 At this stage, kids learn through pretend play but still struggle with logic and taking the point of view
of other people.
 They also often struggle with understanding the idea of constancy.
 Preoperational Stage of Cognitive Development in Young Children
The Concrete Operational Stage-Ages: 7 to 11 Years

 Major Characteristics and Developmental Changes
o During this stage, children begin to thinking logically about concrete events.
o They begin to understand the concept of conservation; that the amount of liquid in a short, wide cup is
equal to that in a tall, skinny glass, for example.
o Their thinking becomes more logical and organized, but still very concrete.
o Children begin using inductive logic, or reasoning from specific information to a general principle.
 While children are still very concrete and literal in their thinking at this point in development, they
become much more adept at using logic.
 The egocentrism of the previous stage begins to disappear as children become better at thinking
about how other people might view a situation.
The Concrete Operational Stage in Cognitive Development - The Formal Operational Stage - Ages: 12 and Up
10
o At this stage, the adolescent or young adult begins to think abstractly and reason about hypothetical
problems.
o Abstract thought emerges.
o Teens begin to think more about moral, philosophical, ethical, social, and political issues that require
theoretical and abstract reasoning.
o Begin to use deductive logic, or reasoning from a general principle to specific information.
 This final stage of Piaget's theory involves an increase in logic, the ability to use deductive
reasoning, and an understanding of abstract ideas.
 At this point, people become capable of seeing multiple potential solutions to problems and think
more scientifically about the world around them.
 The ability to thinking about abstract ideas and situations is the key hallmark of the formal
operational stage of cognitive development.
 The ability to systematically plan for the future and reason about hypothetical situations are also
critical abilities that emerge during this stage.
STEP 7: Key Points (5 minutes)

 Freud’s theory has relevance to psychiatric mental health nursing practice at many junctures. The theory
offers a comprehensive explanation of complex human processes and suggests that the formation of a
patient’s personality is strongly influenced by childhood experiences.
 Erikson’s developmental model is an essential component of patient assessment. Analysis of behavior
patterns using Erikson’s framework can identify age-appropriate or arrested development of normal
interpersonal skills.
 Piaget believed that children take an active role in the learning process, acting much like little
scientists as they perform experiments, make observations, and learn about the world.
STEP 8: Session Evaluation (5 minutes)

 What are stages of psychosexual development (Freud’s theory)?
 What are stages of psychosocial development (Erickson theory)?
 What are stages of cognitive development (Piaget theory)?
11
Reference
Keltner N.K, & Steele D, (2015) Psychiatric Nursing 7th ed. St Louis, Missouri: Mosby
Blashki. G, Judd. F, Piterman. L, (2007) General Practice Psychiatry, Australia: McGraw-Hill companies
Halter MJ. (2014). Varcarolis’ Foundation of Psychiatric Mental Health Nursing 7th ed. St. Louis:
Elsevier Sounders
Townsend M C. (2011), Essentials of Psychiatric Mental Health and Nursing: Concepts of Care in
Evidence –Based Practice.5th ed. Philadelphia. F.A Davis
Puri, B. K., Laking, P. J., &Treasaden, I. H.( 2011). Textbook of psychiatry (3rd ed.). London UK,
Churchill Livingstone
Stuart GW.,(2013) Principles and practice of psychiatric nursing .(10th ed). St Louis Missouri. Mosby
12
Handouts 1.1: Stages of Psychosocial Development (Erickson theory)
 Erik Erikson’s Ego Theory Erik Erikson (1902-1994), an American psychoanalyst, was also a follower of
Freud; however, Erikson (1963) believed that Freudian theory was restrictive and negative in its approach.
 He also stressed that an individual’s development is influenced by more than the limited mother-child-father
triangle and that culture and society exert significant influence on personality.
 According to Erikson, personality was not set in stone at age 5, as Freud suggested, but continued to
develop throughout the life span.
 Erikson described development as occurring in eight predetermined and consecutive life stages
(psychosocial crises), each of which consists of two possible outcomes (e.g., industry vs. inferiority). The
successful or unsuccessful completion of each stage will affect the individual’s progression to the next.
 For example, Erikson’s crisis of industry versus inferiority occurs from the ages of 7 to 12. During this stage,
the child’s task is to gain a sense of personal abilities and competence and to expand relationships
Table: Erickson Eight Stages of Development
Successful Unsuccessful
Approximate age Psychosocial crisis
Developmental task resolution of crisis resolution of crisis
Infancy(0-11⁄2yr) Formingattachment Trustvs.mistrust Sound basis for General difficulties
to mother,whichlays relating to other relatingtopeople
foundationsforlater people;trustin effectively;suspicion;
trustinothers people;faithandhope trust-fearconflict;fear
aboutenvironment offuture “Ican’ttrust
and future “Ifhe’slate anyone;no onehas
inpickingme up,there everbeenthere whenI
mustbea good neededthem.”
reason.”
Earlychildhood Gainingsomebasic Autonomyvs. shame Sense of self-control Independence/fear
(11⁄2-3yr controlofself and and doubt andadequacy; will conflict;severe
environment (e.g., power “I’m surethat feelings of self-doubt
toilettraining, with the proper diet “I couldnever lose
exploration) andexercise the weight they want
program,Ican me to, so why even
achieve mytarget try?”
weight.”
Preschool (3-6yr) Becoming Initiative vs. guilt Ability to initiate Aggression/fear
purposeful and one’s own activities; conflict; sense of
directive sense of purpose “I inadequacyor guilt “I
like tohelp mommy wanted the candy ,so
set the table for I took it.”
dinner.”
Schoolage(6-12yr Developingsocial, Industry vs. inferiority Competence;ability Sense of inferiority;
13
physical,andschool to work “I’mgetting difficulty learningand
skills reallygoodat working “I can’tread
swimmingsinceI’ve as well as the others
beentakinglessons.” in my class; I’m just
dumb.”
Adolescence(12-20 Makingtransition Identityvs.role Senseofpersonal Confusionaboutwho
yr) fromchildhoodto confusion identity;fidelity “I’m one is;weaksense of
adulthood; goingtogotocollege self “Ibelongtothe
developing senseof tobeanengineer;I gang becausewithout
identity hope togetmarried them, I’mnothing.”
before Iam30.”
Earlyadulthood (20- Establishingintimate Intimacyvs. isolation Ability to lovedeeply Emotionalisolation;
35yr) bondsofloveand and commit oneself egocentricity
friendship “Myhusband has “There’snooneout
beenmy best friend there for me.”
for25 years.”
Middleadulthood Fulfilling life goals Generativityvs. self- Ability to give andto Self-absorption;
(35-65yr) that involvefamily, absorption care for others “I’m inability to grow asa
career, and society; joining the political person “After Iwork
developing concerns action committee to all day,I just want to
that embrace future help people get the watchtelevision and
generations health carethey don’t want to be
need.” around people.”
Lateryears (65yrto Lookingbackover Integrityvs. despair Senseofintegrityand Dissatisfactionwith
death) one’s lifeand fulfillment; life; denialofor
acceptingits willingness to face despair over
meaning death; wisdom “I’ve prospect of death
led a happy, “What a waste mylife
productive life, and I has been;I’m goingto
still have plenty to die alone.”
give.”
14
Handout 1.2: Stages of Psychosexual Development (Freud’s theory)
 Psychosexual Stages of Development Freud believed that human development proceeds through five
stages from infancy to adulthood.
 His main focus, however, was on events that occur during the first 5 years of life.
 From Freud’s perspective, experiences during the early stages determined an individual’s lifetime
adjustment patterns and personality traits.
 In fact, Freud thought that personality was formed by the time the child entered school and that
subsequent growth consisted of elaborating on this basic structure.
Stage /age Source of Primary Tasks Desired Other possible
satisfaction conflict outcome personality traits
Oral(0-1yr) Mouth (sucking, Weaning Masteryof Developmentof Fixationattheoral

biting,chewing) gratification oforal trust in the stageis associated
needs;beginning environment, withpassivity,
of ego with the gullibility,and
development (4-5 realization that dependence; the
mo) needscan be useofsarcasm;may
met developorally
focusedhabits (e.g.,
smoking,nail-biting).
Anal(1-3yr) Analregion Toilet Beginningof Controlover Fixationattheanal

(expulsion and training development ofa impulses stageis associated
retentionof feces) senseofcontrol withanal
overinstinctual retentiveness
drives; abilityto (stinginess,rigid
delayimmediate thoughtpatterns,
gratificationtogain obsessivecompulsiv
a futuregoal edisorder)or anal-
expulsivecharacter
(messiness,
destructiveness,
cruelty).
Phallic (oedipal) Genitals Oedipusand Sexualidentitywith Identification Fixationmayresultin

(3-6yr) (masturbation) Electra parentofsamesex; with parent of reckless, self-
beginningof the samesex assured,and
superego narcissistic, person.
development Lackofresolution
may resultininability
toloveand
difficultieswith
sexualidentity
15
Stage /age Source of Primary Tasks Desired Other possible
satisfaction conflict outcome personality traits
Latency (6-12yr) Growth of ego The Fixations can result

functions (social, development of in difficulty
intellectual, skills needed to identifying with
mechanical) and cope with the others and in
- - the ability to care environment developing social
about and relate skills, leading to a
to others outside sense of
the home (peers inadequacy and
ofthe same sex) inferiority.
Genital (12yrand Genitals(sexual Developmentof Theabilitytobe Inabilitytonegotiate
beyond) intercourse) satisfying sexual creativeandfind thisstage mayderail
andemotional pleasureinlove emotionaland
relationship; andwork financial
emancipation from independence,may
- parents—planning impairpersonal
oflifegoalsand identityand future
developmentofa goals,anddisrupt
senseof personal abilitytoform
identity satisfying intimate
relationships.
16
SESSIONS 02: PSYCHOBIOLOGICAL CONCEPTS IN RELATION TO
MENTAL HEALTH NURSING
Prerequisite:
Learning Objectives
At the end of this session participants are expected to be able to:
Define neurotransmitters and limbic system
Describe the structure of limbic system
Explain the roles of neurotransmitters
Describe association of neural transmitters with development of mental illness
Describe physiological mechanism by which various psychotropic medication exert their effect
Resources Needed:
Session Overview

2 05 Brain storming
Lecture Discussion Definition of neurotransmitters and limbic system
3 20 Lecture discussion Structure of Limbic System
4 40 Lecture discussion Roles of Neurotransmitters
5 20 Lecture discussion Association of Neural Transmitters with
Development of Mental Illness
6 20 Lecture discussion Physiological Mechanism by which Various
Psychotropic Medication Exert their Effect
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Tasks (5 minutes)
17
STEP 2: Definition of Neurotransmitters and Limbic System (10 minutes)

Activity: brainstorming (5minutes)
 ASK students to brainstorm on the definition of
o Neurotransmitter
o Limbic system
 Neurotransmitters are chemical messenger/ substances stored in axon terminal and are released
when electrical impulse reaches the end of a neuron.
o Neurotransmitters are released from the axon terminal at the presynaptic neuron on excitation
i.e. This neurotransmitter then diffuses across a space, or synapse, to an adjacent postsynaptic
neuron, where it attaches to receptors on the neuron’s surface.
o It is this interaction from one neuron to another, by way of a neurotransmitter and receptor that
allows the activity of one neuron to influence the activity of other neurons.
o Depending on the chemical structure of the neurotransmitter and the specific type of receptor to
which it attaches, the postsynaptic cell will be rendered either more or less likely to initiate an
electrical impulse. It is the interaction between neurotransmitter and receptor that is a major
target of the drugs used to treat psychiatric disease.
o Examples of neurotransmitter
 Dopamine
 Norepinephrine / (noradrenaline)
 Serotonin
 Histamine
 g-aminobutyric acid
 Glutamate
 Substance P
 Acetylcholine
 Somatostatin
 Neurotensin
 Limbic system is a part of the brain that plays a crucial role in emotional status and psychological
function.
o It is associated with feeling of fear and anxiety, anger and aggression, love joy and hope,
and with sexuality and social behaviour.
o They use norepinephrine, serotonin, and dopamine as their neurotransmitters. The
neurotransmitters released by these neurons are major targets of the drugs used to treat
psychiatric disease.
18
o Limbic system is responsible for controlling various functions in the body. Some of these
functions include interpreting emotional responses, storing memories, and regulating
hormones. The limbic system is also involved in sensory perception, motor function, and
olfaction
STEP 3: The Structure of Limbic System (20 Minutes)

 The limbic system is a set of brain structures located on top of the brainstem and buried under the
cortex.
 It consists of the medially placed cortical and subcortical structures and the fiber tracts connecting
them with one another and with the hypothalamus.
 These structures include the hyppocampus, mammillary body, amygdala, olfactory tract,
hypothalamus, cingulated gyrus, Septum pellucidum , Thalamus, and fornix
o Amygdala: the almond-shaped mass of nuclei involved in emotional responses, hormonal
secretions, and memory. The amygdala is responsible for fear conditioning or the associative
learning process by which we learn to fear something.
o Cingulate Gyrus: a fold in the brain involved with sensory input concerning emotions and the
regulation of aggressive behavior.
o Fornix: an arching, band of white matter axons (nerve fibers) that connect the hippocampus to
the hypothalamus.
o Hippocampus: a tiny nub that acts as a memory indexer – sending memories out to the
appropriate part of the cerebral hemisphere for long-term storage and retrieving them when
necessary.
o Hypothalamus: about the size of a pearl, this structure directs a multitude of important
functions. It wakes you up in the morning and gets the adrenaline flowing. The hypothalamus is
also an important emotional center, controlling the molecules that make you feel exhilarated,
angry, or unhappy.
o Olfactory Cortex: receives sensory information from the olfactory bulb and is involved in the
identification of odors.
o Thalamus: a large, dual lobed mass of gray matter cells that relay sensory signals to and from
the spinal cord and the cerebrum.
MCHORO
.
19
STEP 4: Roles of Neurotransmitters (40 Minutes)
 Many neurotransmitters exist within the central and peripheral nervous systems, but only a limited
number have implications for psychiatry. Major categories include the cholinergics, monoamines,
amino acids, and neuropeptides
Cholinergics-Acetylcholine
 Acetylcholine was the first chemical to be identified and proven as a neurotransmitter.
 Location: Acetylcholine is a major effector chemical within the autonomic nervous system (ANS),
producing activity at all sympathetic and parasympathetic presynaptic nerve terminals and all
parasympathetic postsynaptic nerve terminals.
 It is highly significant in the neurotransmission that occurs at the junctions of nerve and muscles. In
the CNS, acetylcholine neurons innervate the cerebral cortex, hippocampus, and limbic structures.
 The pathways are especially dense through the area of the basal ganglia in the brain.
 Functions: Acetylcholine is implicated in sleep, arousal, pain perception, the modulation and
coordination of movement, and memory acquisition and retention.
Monoamines - Norepinephrine
 Norepinephrine is the neurotransmitter associated with the fight-or-flight syndrome of symptoms
that occurs in response to stress.
 Location: Norepinephrine is found in the ANS at the sympathetic postsynaptic nerve terminals. In
the CNS, norepinephrine pathways originate in the pons and medulla and innervate the thalamus,
dorsal hypothalamus, limbic system, hippocampus, cerebellum, and cerebral cortex.
 Functions: Norepinephrine may have a role in the regulation of mood, in cognition and perception,
in cardiovascular functioning, and in sleep and arousal.
Dopamine
 Dopamine is derived from the amino acid tyrosine and may play a role in physical activation of the
body.
 Location: Dopamine pathways arise from the midbrain and hypothalamus and terminate in the
frontal cortex, limbic system, basal ganglia, and thalamus.
 Dopamine neurons in the hypothalamus innervate the posterior pituitary, and those from the
posterior hypothalamus project to the spinal cord.
 Functions: Dopamine is involved in the regulation of movements and coordination, emotions,
voluntary decision-making ability, and because of its influence on the pituitary gland, it inhibits the
release of prolactin (Sadock & Sadock, 2007).
Serotonin
 Serotonin is derived from the dietary amino acid tryptophan.
 The antidepressants called selective serotonin reuptake inhibitors (SSRIs) block the reuptake of
this neurotransmitter to increase levels in the brain.
 Location: Serotonin pathways originate from cell bodies located in the pons and medulla and
project to areas including the hypothalamus, thalamus, limbic system, cerebral cortex, cerebellum,
and spinal cord. Serotonin that is not returned to be stored in the axon terminal vesicles is
catabolized by the enzyme monoamine oxidase.
20
 Functions: Serotonin may play a role in sleep and arousal, libido, appetite, mood, aggression, and
pain perception.
Histamine
 The role of histamine in mediating allergic and inflammatory reactions has been well documented.
Its role in the CNS as a neurotransmitter has only recently been confirmed, and only limited
information is available.
 Location: The highest concentrations of histamine are found within various regions of the
hypothalamus.
 Function: The exact processes mediated by histamine within the CNS are unclear.
Amino Acids Gamma-Aminobutyric Acid (GABA)

 GABA is associated with short inhibitory interneurons, although some long-axon pathways within
the brain have now been identified.
 Location: There is widespread distribution of GABA in the CNS, with high concentrations in the
hypothalamus, hippocampus, cortex, cerebellum, and basal ganglia of the brain; in the gray matter
of the dorsal horn of the spinal cord; and in the retina.
 Functions: GABA interrupts the progression of the electrical impulse at the synaptic junction,
producing a significant slowdown of body activity.
Glycine
 Glycine is also considered to be an inhibitory amino acid.
 Location: Highest concentrations of glycine in the CNS are found in the spinal cord and brainstem.
 Functions: Glycine appears to be involved in recurrent inhibition of motor neurons within the spinal
cord and is possibly involved in the regulation of spinal and brainstem reflexes.
Glutamate
 This neurotransmitter appears to be primarily excitatory in nature.
 Location: Glutamate is found in the pyramidal cells of the cortex, cerebellum, and the primary
sensory afferent systems.
 It is also found in the hippocampus, thalamus, hypothalamus, and spinal cord.
 Functions: Glutamate functions in the relay of sensory information and in the regulation of various
motor and spinal reflexes.
Neuropeptides - Endorphins and Enkephalins

 These neurotransmitters are sometimes called Opioid peptides.
 Location: They have been found in various concentrations in the hypothalamus, thalamus, limbic
structures, midbrain, and brainstem. Enkephalins are also found in the gastrointestinal (GI) tract.
 Function: With their natural morphine-like properties, endorphins and enkephalins are thought to
have a role in pain modulation.
Substance P
 Substance P was the first neuropeptide to be discovered.
21
 Location: Substance P is present in high concentrations in the hypothalamus, limbic structures,
midbrain, and brainstem, and is also found in the thalamus, basal ganglia, and spinal cord.
 Functions: Substance P is thought to play a role in sensory transmission, particularly in the
regulation of pain.
Somatostatin
 Somatostatin is also called the growth hormone-inhibiting hormone.
 Location: Somatostatin is found in the cerebral cortex, hippocampus, thalamus, basal ganglia,
brainstem, and spinal cord.
 Functions: In its function as a neurotransmitter, somatostatin exerts both stimulatory and inhibitory
effects.
 Depending on the part of the brain being affected, it has been shown to stimulate dopamine,
serotonin, norepinephrine, and acetylcholine and inhibit norepinephrine, histamine, and glutamate.
It also acts as a neuromodulator for serotonin in the hypothalamus, thereby regulating its release
(i.e., determining whether it is stimulated or inhibited).
 It is possible that somatostatin may serve this function for other neurotransmitters as well.
STEP 5: Association of Neural Transmitters with Development of Mental Illness (20

Minutes)
Cholinergic - Acetylcholine
 Possible implications for mental illness: Cholinergic mechanisms may have some role in certain
disorders of motor behavior and memory, such as Parkinson’s, Huntington’s, and Alzheimer’s
diseases.
 Increased levels of acetylcholine have been associated with depression.
Norepinephrine
 Possible implications for mental illness: The mechanism of norepinephrine transmission has been
implicated in certain mood disorders such as depression and mania, in anxiety states, and in
schizophrenia.
 Levels of the neurotransmitter are thought to be decreased in depression and increased in mania,
anxiety states, and schizophrenia.
22
Dopamine
 Possible implications for mental illness: Decreased levels of dopamine have been implicated in the
etiology of Parkinson’s disease and depression
 Increased levels of dopamine are associated with mania and schizophrenia
Serotonin
 Possible implications for mental illness: Increased levels of serotonin have been implicated in
schizophrenia and anxiety states.
 Decreased levels of the neurotransmitter have been associated with depression.
Histamine
 Possible implications for mental illness: Some data suggest that histamine may play a role in
depressive illness.
Amino Acids Gamma-Aminobutyric Acid (GABA)

 Possible implications for mental illness: Decreased levels of GABA have been implicated in the
etiology of anxiety disorders; movement disorders, such as Huntington’s disease; and various
forms of epilepsy.
Glycine
 Possible implications for mental illness: Decreased levels of glycine have been implicated in the
pathogenesis of certain types of spastic disorders.
 Toxic accumulation of the neurotransmitter in the brain and cerebrospinal fluid can result in glycine
encephalopathy
Glutamate
 Possible implications for mental illness: Increased receptor activity has been implicated in the
etiology of certain neurodegenerative disorders, such as Parkinson’s disease.
 Decreased receptor activity can induce psychotic behavior.
Neuropeptides Endorphins and Enkephalins

 Possible implications for mental illness: Modulation of dopamine activity by opioid peptides may
indicate some link to the symptoms of schizophrenia.
Substance P
 Possible implications for mental illness: Decreased concentrations have been found in the
substantia nigra of the basal ganglia of clients with Huntington’s disease
Somatostatin
 Possible implications for mental illness: High concentrations of somatostatin have been reported in
brain specimens of clients with Huntington’s disease; low concentrations have been reported in
clients with Alzheimer’s disease
23
STEP 6: Physiological Mechanism by which Various Psychotropic Medication Exert their
Effect (20 Minutes)
SUMMARIZE
 Pharmacodynamics refers to the biochemical and physiological effects of drugs on the body, which
include the mechanisms of drug action and its effect.
 The term pharmacokinetics refers to the actions of the person on the drug. How is the drug
absorbed into the blood? How is it transformed in the liver? How is it distributed in the body? How is
it excreted by the kidney?
 Pharmacokinetics determines the blood level of a drug and is used to guide the dosage schedule.
 It is also used to determine the type and amount of drug used in cases of liver and kidney disease.
 The processes of pharmacokinetics and pharmacodynamics play an extensive role in how genetic
factors give rise to inter individual and cross-ethnic variations in drug response.
 Many drugs are transformed by the liver into active metabolites chemicals that also have
pharmacological actions.
 This knowledge is used by researchers in designing new drugs that make use of the body’s own
mechanisms to activate a chemical for pharmacological use.
 An ideal psychiatric drug would relieve the mental disturbance of the patient without inducing
additional cerebral (mental) or somatic (physical) effects. Unfortunately, in psychopharmacology as
in most areas of pharmacology there are no drugs that are both fully effective and free of undesired
side effects.
 Researchers work toward developing medications that target the symptoms while producing no or
few side effects. Because all activities of the brain involve actions of neurons, neurotransmitters,
and receptors, these are the targets of pharmacological intervention.
 Most psychotropic drugs act by either increasing or decreasing the activity of certain
neurotransmitter-receptor systems. It is generally agreed that different neurotransmitter-receptor
systems are dysfunctional in persons with different psychiatric conditions.
 These differences offer more specific targets for drug action. In fact, much of what is known about
the relationship between specific neurotransmitters and specific disturbances has been derived
from knowledge of the pharmacology of the drugs used to treat these conditions.
 For example, most agents that were effective in reducing the delusions and hallucinations of
schizophrenia blocked the D2 receptors for dopamine. It was concluded that delusions and
hallucinations result from over-activity of dopamine at these receptors.

 Neurotransmitters are chemical messenger/ substances stored in axon terminal and are released
when electrical impulse reaches the end of a neuron.
 Limbic system is a part of the brain that plays a crucial role in emotional status and psychological
function. It is associated with feeling of fear and anxiety, anger and aggression, love joy and hope,
and with sexuality and social behaviour
 Neurotransmitters are responsible for essential functions in the role of human emotion and behavior
24
 Most psychotropic drugs act by either increasing or decreasing the activity of certain
neurotransmitter-receptor systems. It is generally agreed that different neurotransmitter-receptor
systems are dysfunctional in persons with different psychiatric conditions.

 What is neurotransmitter?
 What is limbic system?
 What are the roles of neurotransmitters?
25
References
Elsevier Sounders
26
SESSION 03: LEGAL ISSUES RELATED TO MENTAL HEALTH NURSING
Learning Objectives

Define law and legal
Explain legal issues in relation to mental health
Describe parts of mental health act in Tanzania legal system
Describe the national health Policy and guidelines on mental health service
Resources Needed:

2 5 Brainstorming
Definition of Law and Legal
Presentation
3 50 Presentation Legal Issues in Relation to Mental Health
4 20 Presentation Parts of Mental Health Act in Tanzania Legal
System
5 30 Presentation The National Health Policy and Guidelines on
Mental Health Service
27
SESSION CONTENTS
STEP 2: Definition of Law and Legal (5 Minutes)

o Law
o Legal
 Law is the system of rules which a particular country or community recognizes as regulating the
actions of its members and which it may enforce by the imposition of penalties. Or Law is a set of
rules that plays an important part in the creation and maintenance of social order.
 Legal is term used to describe things that relate to the law.
STEP 3: Legal Issues in Relation to Mental Health (50 Minutes)

 The relationship between psychiatry and the law reflects the tension between individual rights and
social needs.
 Both psychiatry and the law deal with human behavior and the relationships and responsibilities
that exist among people.
 Both also play a role in controlling socially undesirable behavior, and together they analyze whether
the care psychiatric patients receive is therapeutic, custodial, repressive, or punitive.
 Differences also exist between psychiatry and the law. For example, psychiatry is concerned with
the meaning of behavior and the life satisfaction of the individual. In contrast, the law addresses the
outcome of behavior and the enforcement of a system of rules to encourage orderly functioning
among groups of people.
 The legal and ethical context of care is important for all psychiatric nurses because it focuses
concern on the rights of patients and the quality of care they receive. This knowledge enhances the
freedom of both the nurse and the patient, informs ethical decision making, and ultimately results in
better care.
 The evolution of human treatment of mentally ill persons roughly parallels that of advances made in
the jurisprudence system.
 Historically movement has been a slow, cautious process from viewing mentally ill people from
demonic of weak willed to view them as individual with legitimate health care problems.
Governmental system and regulatory bodies thoughtfully attempt to achieve balance between the
rights of individuals and the rights of society at large. SUMMARIZE
Source of law
 There are three basic sources of law:
28
o Common law which is derived from judicial decisions
o Statutory law which is created by legislature
o Administrative law developed by administrative agencies
Common law
 Common law is applied to the body of legal principles that has evolved and continues to evolve and
expand from actual court cases. Many of these legal principles have their origins in the English
common law.
 The judicial system is necessary because having a law that covers every potential event that might
occur is very impossible.
 The judicial system saves as a mechanism for reviewing legal disputes that arise in the written law.
 Many of these ruling have influenced the current legal view of mental illness.
 Rules that have shaped the mental health treatment system and have saved to improve patient
care and protect the public are
 M’Naghten rule- individuals who do not understand the nature and implications of murderous
actions because of insanity cannot be held legally accountable for the murder or person is not
criminally responsible at the time of the act if , because of the “mental disease or defect” a person
did not know the nature and quality o the act, or if the person did not know it, he or she did not
know the act was wrong.
Statutory law
 Statutory law is written law developed from legislative body. Statutory law follows chain of
command, with the constitution of the country being the highest in the hierarchy of the enacted
written law
Administrative law
 Administrative law is public law issued by administrative agencies authorized by statute to
administer the enacted law of the country. This branch of law controls the administrative operations
of government. One example of these agencies is state board of nursing which has been created to
issues guidelines for nursing practice licensure and compliance monitoring in the interest of public
safety.
Torts (Civil Law)

Negligence
 Negligence is described as the failure to do or not to do what a reasonably careful person would do
under the circumstances
 It is a form of conduct that is considered careless and is a departure from the standards of conduct
generally imposed from the reasonable person.
Malpractice
 Malpractice Is a form of profession negligence
 The malpractice claims against nurses are often the result of the nurses failure to take measures to
prevent harm to patients or a failure to maintain standard of care of nurses in the community
 Failure to pay attention to specific legal issues related to nursing practice can results in liability and
suits against the nurse and nurse employer.
29
Assault, Battery and False imprisonment
Assault
 Battery Is apprehension of physical contact or the person mental security battery is the actual
physical contact
Battery
 Battery Is an intentional touching of another person in a socially impermissible manner without the
person consent
False imprisonment
 False imprisonment Is the unlawful restraint of an individuals personal liberty or the unlawful
restraint or confinement of an individual
Rights of the patients

 Some of the most important factors in ensuring patients’ rights are the attitude, knowledge, and
commitment of the nurse.
 If nurses are sensitive to patients’ needs in their relationships with them, they will secure these
human and legal rights.
o Right to communicate with people outside the hospital through correspondence,
telephone, and personal visits
o Right to keep clothing and personal effects with them in the hospital
o Right to religious freedom
o Right to be employed if possible
o Right to manage and dispose of property
o Right to execute wills
o Right to enter into contractual relationships
o Right to make purchases
o Right to education
o Right to independent psychiatric examination
o Right to communicate with people outside the hospital through correspondence,
telephone, and personal visits
o Right to keep clothing and personal effects with them in the hospital
o Right to religious freedom
o Right to be employed if possible
o Right to civil service status
o Right to retain licenses, privileges, or permits established by law, such as a driver’s
or professional license
o Right to sue or be sued
o Right to marry and divorce
o Right not to be subject to unnecessary mechanical restraints
o Right to periodic review of status
o Right to legal representation
o Right to privacy
30
o Right to informed consent
o Right to treatment
o Right to refuse treatment
o Right to treatment in the least restrictive setting
Hospitalizing the patient

 Hospitalization can be either traumatic or supportive for the patient, depending on the institution,
attitude of family and friends, response of the staff, and type of admission (Newton-Howes and
Mullen, 2011; Sheehan and Burns, 2011).
 The two major types of admission are voluntary and involuntary
Voluntary Admission
 Under voluntary admission any citizen of lawful age may apply in writing (usually on a standard
admission form) for admission to a public or private psychiatric hospital.
 The person agrees to receive treatment and abide by hospital rules.
 People may seek help based on their personal decision or the advice of family or a health
professional.
 If someone is too ill to apply but voluntarily seeks help, a parent or legal guardian may request
admission.
 Voluntary admission is preferred because it is similar to a medical hospitalization. It indicates that
the patient acknowledges problems in living, seeks help in coping with them, and will participate in
finding solutions.
 When voluntarily admitted, the patient retains all civil rights, including the right to vote, have a
driver’s license, buy and sell property, manage personal affairs, hold office, practice a profession,
and engage in a business.
 It is a common misconception that all admissions to a mental hospital involve the loss of civil rights.
Although voluntary admission is the most desirable, it is not always possible.
 Sometimes a patient may be acutely disturbed, suicidal, or dangerous to self or others yet rejects
any therapeutic intervention. In these cases involuntary commitments are necessary.
Involuntary Admission (Commitment)

 Involuntary admission or commitment means that the patient did not request hospitalization and
may have opposed it or was indecisive and did not resist it.
 Most laws permit commitment of the mentally ill on one or more of the following three grounds:
 Dangerous to self or others
 Mentally ill and in need of treatment
 Unable to provide for own basic needs
The Commitment Process

 The process begins with a sworn petition by a relative, friend, public official, physician, or any
interested citizen stating that the person is mentally ill and needs treatment.
 The decision of whether to hospitalize the patient is made after assessment. The person who
makes this decision determines the nature of the commitment:
 Medical certification means that physicians make the decision.
 Court or judicial commitment is made by a judge or jury in a formal hearing.
31
 Administrative commitment is determined by a special tribunal of hearing officers. If treatment is
necessary, the person is hospitalized. The length of hospital stay varies depending on the patient’s
needs.
Emergency Hospitalization
 Commitment of patients who are acutely ill with the goal of controlling an immediate threat to self or
others
Short-Term or Observational Hospitalization

 Observational commitment is used for diagnosis and short-term therapy and does not require an
emergency situation.
Discharge
 The patient who is voluntarily admitted to the hospital can leave at any time.
 The voluntarily admitted patient can be discharged by the staff when maximum benefit has been
received from the treatment.
 Voluntary patients also may request discharge.
 A written notice of patients’ desire to leave and also require that patients sign a form that states
they are leaving against medical advice (AMA).
 This form then becomes part of the patient’s permanent record.
Forensic Nursing
 Forensics is an abbreviation derived from forensic science and refers to the application of a broad
spectrum of sciences to answer questions of interest to the legal system.
 In recent years, nurses formalized a specialty of nursing called forensic nursing, which brings
together traditional nursing practice and forensic knowledge to better serve victims and perpetrators
of violence
 The International Association of Forensic Nurses (IAFN) (2006b) defines forensic nursing as: The
application of nursing science to public or legal proceedings.
 The application of the forensic aspects of health care combined with the bio-psycho-social
education of the registered
 The nurse acts as an advocate, educating the court about the science of nursing. The witness
applies nursing knowledge to the facts in the lawsuit and may provide opinions using appropriate
nursing standards.
 Examples of psychiatric mental health forensic nursing may include testimony related to patient
competency, fitness to stand trial, involuntary admission, or responsibility for a crime. Forensic
nurses may also focus on victims and perpetrators of crime and violence, the collection of
evidence, and the provision of health care in prison settings. Violence is often the focus in
forensics.
Forensic Psychiatric Nursing

 A forensic psychiatric nurse is one who is prepared as a generalist or at the advanced practice
level. In the generalist role, nurses are prepared at the entry level as a college/university degree,
associate degree, or diploma graduate, which prepares them to function as direct care providers
and patient advocates.
32
 At this level a nurse who enters a forensic psychiatric setting is expected to advance her education
through continuing education or certificate programs that provide education in caring for the
forensic patient, usually in a corrections setting.
 Evidence collection is central to the role of the forensic psychiatric nurse.
 For example, evidence is collected by a careful evaluation of intent or diminished capacity inthe
perpetrator’s thinking at the time of the crime. This evaluation aids in determining the degree of
crime and may later influence the sentence.
 Forensic psychiatric nurses who work as competency evaluators collect evidence by spending
many hours with a defendant and carefully documenting the dialogue.
 In this capacity, the role of the forensic psychiatric nurse is not to determine guilt or
innocence but to provide assessment data that can help make a final diagnosis within the
multidisciplinary forensic team (Sekula & Burgess, 2006).
 Forensic psychiatric nursing appeals to a particular type of nurse one who thrives in a stimulating
intellectual environment, seeks out opportunities to apply clinical skills to complex legal problems,
and enjoys pushing the limits of traditional boundaries.
 These responses must be met with professionalism in practice, research, and education of future
forensic psychiatric nurses, keeping in mind the tenets of evidence-based practice.
Roles and Functions of the Forensic Psychiatric Nurse

 The forensic psychiatric nurse may function as a psychotherapist, forensic nurse examiner,
competency evaluator, fact or expert witness, consultant to law enforcement agencies or the
criminal justice system, hostage negotiator, or criminal profiler.
 These roles may involve providing therapy, witness testimony, services to a prosecutor or defense
attorney, and criminal profile reports.
 Roles of the forensic psychiatric nurse may be examined in relationship to the outcomes for which
the nurse is contracted to accomplish.
 These nurses may be contracted by the legal system to interface with the perpetrator for a variety
of services. They may also be contracted by the correctional system or a private entity to offer
direct services to the perpetrator. Or they may provide services to the victim in a variety of settings.
STEP 4: Parts of Mental Health Act in Tanzania Legal System (20 Minutes)
 People with mental illness are vulnerable to abuse, stigma, discrimination, and neglect.
Subsequently, Tanzania Government has enacted the Mental health act to provide for the care,
protection and management of persons with mental disorders and to provide for their
voluntaryorinvolnntary admission in mental health care facility and other related matters.
 The act consists of the following parts:
PART I-Preliminary Provisions
 1. Short title and commencement.
 2. Application.'
 3. Interpretation.
PARTII - Admission of Voluntary and Temporary Patients into Mental Health Care Facilities
 4. Voluntary admission to a mental health care facility.
33
 5. Voluntary patients who become incapable of expression.
 6. Provision for temporary treatment etc.
PART III- Management of Persons with Mental Disorder

 7. Jurisdiction of the Court.
 8. Application for reception order.
 9. Mentally disordered person to be taken to a mental health care facility or reported to social
welfare authorities.
 10. Procedure upon inquiry by court into mental disorder.
 11. Involuntary admission of persons with mental disorder.
 12. Powers of bodies other than the court in relation to mentally disordered persons.
 13. Reception order.
 14. Medical certificates.
 15. Appeals.
PART IV- Mental Health Board

 16. Establishment of the Board.
 17. Functions of the Board.
 18. Operations of the Board.
PART V - Management and Administration of Estates of Persons with Mental Disorder

 19. Application for order of management and administration of estate.
 20. Service of notice of application.
 21. Attendance by person whom application is made.
 22. Discretion of court to make orders relating to estate.
 23. Proof of mental capacity and conditions.
 24. Disposal of movable property.
 25. Powers and duties of manager.
 26. Petition for court to make necessary order on estates.
PART VI - General Provisions

 27. Establishment of mental health care facilities.
 28. Special care for admitted patients.
 29. Patient Welfare Board.
 30. Establishment of a National Council for Mental Health.
 31. Functions of the National Council for Mental health;
 32. Operations of the Council.
 33. Execution of bond for care and custody of persons with mental disorder.
 34. Re-admission after absconding from the ward.
 35. Proceedings may be held in camera.
 36. Reception of persons certified by institutions outside Tanzania.
 37. Penalty and offences. 38. Minister may make regulations.
 39. Application of the Criminal Procedure Act.
 40. Protection of persons acting in good faith.
34
 41. Repeal.
Summary
STEP 5: The National Health Policy and Guidelines on Mental Health Service (30
Minutes)
 Tanzania National health Policy
Tanzania mental health guideline

 The mental health policy guidelines are the course of action, laid down strategy, and values
established for mental health services.
 The mental health policy guidelines are derived from the main components of the national health
policy.
 Aims of the mental health policy guidelines are:
o To reduce the number of people who develop mental health problems,
o Assist those with mental disorders improve their overall quality of life,
o Eliminate the stigma associated with having mental or emotional problems,
o Provide effective interventions to all in need,
o Promote and support mental health research
 Objectives of the guidelines includes:

o To coordinate through a common vision and plan all sectors and services (public and private)
that impact on mental health care,
o Strengthen national mental health planning and leadership at the Ministry of Health,
o Improve the quality of mental health service delivery, and
o Iprove community participation in mental health promotion and care
 Desired guiding values are:

o Mental health is seen as an essential component of public health.
o Government policies and actions protect and promote the mental health of its people.
o Services are appropriate, accountable, accessible, and equitable.
o People are treated in the least restrictive and intrusive manner
 Mental health is among the elements in primary health care.

 The purpose of the mental health guideline is to improve the quality of mental health services
through collaborating with non-government organizations and other health care providers including:
 The government will improve the preventive services against psychoactive drug use and treatment
and other mental illness.
 The community, families and individuals will be involved in promotion of mental health services.
 The government will make sure that mental health services are available to all in need.
 The policy guideline on the prevention of mental illness and substance abuse has aimed at
integrating mental services into general health care services, particularly at the district level and
below.
 There are special programs which offer specialized health care services; the objectives of which
are:
35
o To prevent occurrence of mental illness
o To provide appropriate treatment
o To educate health workers on how to manage mental illnesses
o To educate public on ways to protect themselves from mental illness
36
 People with mental illness are vulnerable to abuse, stigma, discrimination, and neglect.
Subsequently, Tanzania Government has established the Mental health act to protect the rights of
individuals with mental illness.
 The main goal of the mental healthcare policy guideline is to provide equitable, affordable,
acceptable mental health services with community participation in planning and implementation
 The policy guidelines are the course of action, laid down strategy, and values established for
mental health services.
 Some of the most important factors in ensuring patients’ rights are the attitude, knowledge, and
commitment of the nurse.

 What is law?
 What is legal?
 What are the parts of mental health act in Tanzania legal system?
37
References
Elsevier Sounders
Stuart GW.,(2013) Principles and practice of psychiatric nursing.(10th ed). St Louis Missouri. Mosby
38
SESSION 04: CULTURAL AND SPIRITUAL ISSUES IN CARING A
PATIENT WITH MENTAL ILLNESS
Prerequisite: None
Learning Objectives
At the end of this session participants are expected to be able:
Define culture and spiritual
Explain culture and spiritual issues
Explain cultural and spiritual factors influencing mental health and illness
Identify client’s spiritual and religious needs
Resources Needed:
Session Overview
Step Time (min) Activity/Method Content
1 5 Brainstorming
Presentation Definition of Culture and Spiritual
2 50 Presentation Culture and spiritual issues in Mental Health Care
3 30 Presentation Cultural and Spiritual Factors Influencing Mental

Health and Illness
4 20 Presentation Client’s Spiritual and Religious Needs
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Objectives (5 minutes)
39
STEP 2: Definition of Culture and Spiritual (5 Minutes)

o Culture
o Spirituality
Culture
 Culture describes a particular society’s entire way of living, encompassing shared patterns of belief,
feeling, and knowledge that guide people’s conduct and are passed down from generation to
generation.
 Ethnicity is a somewhat narrower term and relates to people who identify with each other because
of a shared heritage (Griffith, Gonzalez, & Blue, 2003).
Spirituality
 Spirituality is the human quality that gives meaning and sense of purpose to an individual’s
existence. Spirituality exists within each individual regardless of belief system and serves as a force
for interconnectedness between the self and others, the environment, and a higher power.
STEP 3: Culture and spiritual issues in mental health care (50 Minutes)
 Holistic psychiatric nursing care must take into consideration a wide range of patient characteristics
in the assessment, diagnosis, treatment, and recovery process.
 People live within social, cultural, and spiritual contexts that shape and give meaning to their lives.
These characteristics are expressed as beliefs, norms, and values and they can have both direct
and indirect influences on patients’ perceptions of health and illness, their help-seeking behavior,
and their treatment outcomes.
 They are strong determinants of actual and potential coping resources and coping responses, and
they influence all phases of an illness, including treatment effectiveness.
 These social, cultural, and spiritual characteristics can impact the person’s access to mental health
care, the risk for or protection against developing a certain psychiatric disorder, the way in which
symptoms will be experienced and expressed, the ease or difficulty of participating in psychiatric
treatment, and the ability to achieve recovery.
 Thus quality psychiatric nursing care must incorporate the unique
Culture
 Knowledge related to culture and ethnicity is important because these influences affect human
behavior, its interpretation, and the response to it.
 Many variations and subcultures occur within a culture. These differences may be related to status,
ethnic background, residence, religion, education, or other factors.
40
 Every individual must be appreciated for his or her uniqueness.
Cultural Competency
 Cultural competency is a necessary step in the elimination of disparities in the diagnosis and
treatment of mental illness, and is essential in patient-centered psychiatric nursing care.
 A specific competency for nurses, as defined by the American Association of Colleges of Nursing
(2008), states that patient assessment, treatment, and evaluation are improved by applying
knowledge of cultural factors, using relevant data, promoting quality health outcomes, advocating
for social justice, and engaging in competency skill development.
 Culturally competent nursing practice requires far more than recording the patient’s age, gender,
ethnicity, and religion. It must first be based in desire, awareness, and understanding.
 Cultural competency is the ability to view each patient as a unique individual, fully considering the
patient’s cultural experiences within the context of common developmental challenges faced by all
people and the broader social environment.
 The nurse applies this information in nursing interventions that are consistent with the life
experiences and values of each patient. Five areas of cultural competency for nurses have been
identified
 Cultural desire—the motivation of the nurse to want to engage in the process of becoming culturally
competent
 Cultural awareness—the conscious self-examination and in-depth exploration of one’s own
personal biases, stereotypes, prejudices, and assumptions about people who are different from
oneself
 Cultural knowledge—the process of seeking and obtaining a sound educational base about
different cultures including their health-related beliefs about practices and cultural values, disease
incidence and prevalence, and treatment efficacy
 Cultural skill—the ability to collect relevant cultural data regarding the patient’s presenting problem
and accurately perform a culturally based assessment
 Cultural encounters—the deliberate seeking of face to-face interactions with culturally diverse
patients
How Do Cultures Differ?

 Giger (2013) suggests six cultural phenomena that vary with application and use yet are evidenced
among all cultural groups:
o Communication,
o Space,
o Social organization,
o Time,
o Environmental control, and
o Biological variations.
Communication
 All verbal and nonverbal behavior in connection with another individual is communication.
 Therapeutic communication has always been considered an essential part of the nursing process
and represents a critical element in the curricula of most schools of nursing.
41
 Communication has its roots in culture. Cultural mores, norms, ideas, and customs provide the
basis for our way of thinking.
 Cultural values are learned and differ from society to society.
 Communication is expressed through language (the spoken and written word), paralanguage (the
voice quality, intonation, rhythm, and speed of the spoken word), and gestures (touch, facial
expression, eye movements, body posture, and physical appearance).
 The nurse who is planning care must have an understanding of the client’s needs and expectations
as they are being communicated.
 As a third party, an interpreter often complicates matters, but one may be necessary when the
client does not speak the same language as the nurse.
Territoriality refers to the innate tendency to own space.

 The need for territoriality is met only if the individual has control of a space, can establish rules for
that space, and is able to defend the space against invasion or misuse by others.
 Density, which refers to the number of people within a given environmental space, can influence
interpersonal interaction.
 Distance is the means by which various cultures use space to communicate.
 Hall (1966) identified three primary dimensions of space in interpersonal interactions in the Western
culture: the intimate zone (0 to 18 inches), the personal zone (18 inches to 3 feet), and the social
zone (3 to 6 feet).
Social Organization
 Cultural behavior is socially acquired through a process called enculturation, which involves
acquiring knowledge and internalizing values (Giger, 2013). Children are acculturated by observing
adults within their social organizations.
 Social organizations include families, religious groups, and ethnic groups.
Time
 An awareness of the concept of time is a gradual learning process. Some cultures place great
importance on values that are measured by clock time. Punctuality and efficiency are highly valued
in the United States, whereas some cultures are actually scornful of clock time.
 For example, some rural people in Algeria label the clock as the “devil’s mill” and therefore have no
notion of scheduled appointment times or meal times (Giger, 2013).
 They are totally indifferent to the passage of clock time, and they despise haste in all human
endeavors.
 Other cultural implications regarding time have to do with perception of time orientation. Whether
individuals are present oriented or future oriented in their perception of time influences many
aspects of their lives.
Environmental Control
 The variable of environmental control has to do with the degree to which individuals perceive that
they have control over their environment.
 Cultural beliefs and practices influence how an individual responds to his or her environment during
periods of wellness and illness.
42
 To provide culturally appropriate care, the nurse should not only respect the client’s unique beliefs
but should also have an understanding of how these beliefs can be used to promote optimal health
in the client’s environment.
Biological Variations
 Biological differences exist among people in various racial groups.
 These differences include body structure (both size and shape), skin color, physiological responses
to medication, electrocardiographic patterns, susceptibility to disease, and nutritional preferences
and deficiencies.
 Giger (2013) suggests that nurses who possess factual knowledge about biological variations
among diverse groups are better able to provide culturally appropriate health care.
Spirituality
 Spirituality is difficult to describe. Historically, it has had distinctly religious connections, with a
spiritual person being described as “someone with whom the Spirit of God dwelt.”
 In the treatment of mental illness, some of the earliest practices focused on including spiritual
treatment because insanity was considered a disruption of mind and spirit (Reeves & Reynolds,
2009).
 Thus religion and spiritually have been avoided rather than embraced as a valuable aspect of
treatment. More recently, the focus is changing once again.
 Reeves and Reynolds note that the large volume of contemporary research (more than 60 studies)
demonstrating the value of spirituality for both medical and psychiatric patients is influencing this
change.
 Nursing has embraced this new focus by the inclusion of nursing responsibility for spiritual care in
the International Council of Nurses’ Code of Ethics and in the American Holistic Nurses
Association’s Standards for Holistic Nursing Practice.
 The inclusion of spiritual care is also evidenced by the development of the nursing diagnosis
category “Spiritual Distress” by NANDA International (Wright, 2005).
 Spirituality is the recognition or experience of a dimension of life that is invisible, and both within us
and yet beyond our material world, providing a sense of connectedness and interrelatedness with
the universe.
Spiritual Needs
 Smucker identified the following factors as types of spiritual needs associated with human beings:
o Meaning and purpose in life
o Faith or trust in someone or something beyond ourselves
o Hope
o Love
o Forgiveness
 Humans by nature appreciate order and structure in their lives.
 Having a purpose in life gives one a sense of control and the feeling that life is worth living.
43
 Each nurse’s exploration of their own spirituality and efforts to grow spiritually are foundational to
being responsive to those needs in others.
 Walsh (1999) describes “seven perennial practices” that he believes promote enlightenment, aid in
transformation, and encourage spiritual growth. He identified the seven perennial practices as
follows:
o Transform your motivation: Reduce craving and find your soul’s desire.
o Cultivate emotional wisdom: Heal your heart and learn to love.
o Live ethically: Feel good by doing good.
o Concentrate and calm your mind: Accept the challenge of mastering attention and mindfulness.
o Awaken your spiritual vision: See clearly and recognize the sacred in all things.
o Cultivate spiritual intelligence: Develop wisdom and understand life.
o Express spirit in action: Embrace generosity and the joy of service.
Forgiveness
 “Essential to a spiritual nature is forgiveness—the ability to release from the mind all the past hurts
and failures, all sense of guilt and loss”.
 Feelings of bitterness and resentment take a physical toll on an individual by generating stress
hormones, which, maintained for long periods, can have a detrimental effect on a person’s health.
 Forgiveness enables a person to cast off resentment and begin the pathway to healing.
Forgiveness is not easy.
 Individuals often have great difficulty when called upon to forgive others and even greater difficulty
in attempting to forgive themselves.
 Many people carry throughout their lives a sense of guilt for having committed a mistake for which
they do not believe they have been forgiven or for which they have not forgiven themselves.
 To forgive is not necessarily to condone or excuse one’s or someone else’s inappropriate behavior.
 Holding on to grievances causes pain, suffering, and conflict.
 Forgiveness (of self and others) is a gift to oneself. It offers freedom and peace of mind.
 It is important for nurses to be able to assess the spiritual needs of their clients.
 Nurses need not fulfill the role of professional counselor or spiritual guide, but because of the
closeness of their relationship with clients, nurses may be the part of the healthcare team to whom
clients may reveal the most intimate details of their lives.
44
STEP 4: Cultural and Spiritual Factors Influencing Mental Health and Illness (30
Minutes)
 Patient-centered care requires knowledge of how social, cultural, and spiritual life experiences and
personal characteristics may influence mental health, psychiatric nursing care, and treatment
outcomes without bias, assumptions, or overly simplistic views of complex life experiences.
 Nurses who routinely ask patients questions about these aspects of their lives convey concern
about their well-being and avoid stereotyping.
 The concept of risk factors and protective factors is important to understanding how people acquire,
experience, and recover from illness (Carpenter-Song et al, 2007).
 They develop over time and may change with personal circumstances. These factors are the same
as the predisposing factors that nurses assess
 Six patient characteristics, influenced by social norms, cultural values, and spiritual beliefs, have
been shown to be predisposing factors related to mental health and mental illness.
 These factors are age, ethnicity, gender, education, income, and spirituality. They influence the
patient’s exposure to stressors, appraisal of stressors, coping resources, and coping responses,
 For example, poverty is a risk factor for many psychiatric disorders, such as depression and
anxiety, and numerous psychosocial problems, such as divorce and abuse.
Age
 Age influences an individual’s experience of life stressors, variations in support resources, and
coping skills.
 From school age, to young adult, to retirement and fragile old age, individuals are faced with
challenges and changes in their life.
 Age-related increases and decreases in the use of mental health services can reflect emerging
trends in the physical, social, cultural, and spiritual domains of life.
 Young adolescents can face many social stressors, such as bullying, at a time when they have not
yet developed effective coping skills.
 Such social stressors can be distressing at any age. However, when they are experienced during
transition age periods, such as early adolescence, new parenthood, or recent retirement, they can
seem more overwhelming if at the same time the individual must develop new skills and resources
to cope effectively.
 Many expect to be able to remain active, healthy, and independent. Their expectations can mean
greater demands on all health care services, including mental health care.
 Although age alone can be a determining personal characteristic, age interacts with all other
characteristics and therefore can be somewhat less predictable. For example, different interactions
of age and income, age and gender, and age and ethnicity can yield different effects. Culturally
competent practice requires asking the patient about specific age-related experiences and
concerns.
Ethnicity
 Ethnicity is a cultural characteristic based on racial, national, tribal, genetic, linguistic, and family
origins. Individual members of culturally intact groups can have more shared beliefs and values and
less variation between communities.
45
 However, because ethnicity is largely a cultural characteristic, persons who have similar physical
features can have important cultural differences and distinctions.
Gender
 As a predisposing factor, gender is similar to ethnicity in that at first glance there appears to be
distinctive male and female patterns of risk and protection. However, when all psychiatric disorders
are included, the prevalence of mental illness among males and females is approximately equal.
 The difference between the two groups is in the type of disorder that is most commonly diagnosed.
Substance abuse and antisocial personality disorder are the most prevalent psychiatric disorders
among males, whereas affective disorders and anxiety disorders are most prevalent among
females.
 In contrast, the prevalence of schizophrenia and manic episodes for males and females is about
equal. These findings suggest that male and female role socialization plays a part in the perception
of health and illness, and that the risk of psychiatric disorders may be gender typed by sociocultural
factors, including the way they perceive and cope with life stressors. For example, women are more
likely to ruminate about distressing life experiences, whereas men are more likely to seek
distractions.
Education
 Education is a coping resource that can decrease the risk of developing stress-related psychiatric
disorders or increase the probability of a recovery. For example, it has been shown that more years
of schooling is associated with decreased risk for developing psychiatric disorders, better treatment
outcomes, and more complete recovery.
 Education is more important than income in determining the use of mental health services, with
those with the highest educational level using mental health services most often. However,
education is more than the number of completed years of schooling.
 it is important to remember that patients with less education could have the ability but lack
opportunity, family and community support, or self-confidence. Patients with less education also
may also have limited income. The close interaction of education and income requires that they be
assessed as related characteristics. Perhaps the most consistent impact of education has to do
with problem-solving capacity.
Income
 The profound negative impact of poverty as a risk factor for psychiatric illness is evident regardless
of age, ethnicity, gender, or education.
 The relationship of poverty and severe financial stressors to poor health has been well
documented.
 Poverty seems to multiply the impact of other risk factors. Alternatively, poverty might undermine
the impact of protective factors.
Beliefs
 Personal beliefs touch all aspects of life. A person’s belief system, world view, religion, or
spirituality can have a positive or negative effect on mental health.
 Adaptive belief systems can enhance health and wellbeing, improve quality of life, and support
recovery from psychiatric disorders.
46
 Maladaptive belief systems can contribute to poor health status, refusal of necessary treatment,
nonadherence with treatment recommendations, or even self-injury.
 Beliefs help people make sense of their lives and the world in which they live.
 Beliefs can provide answers to questions without answers, solutions to problems that cannot be
solved, and hope when hope is all that remains. Personal beliefs can have many different sources.
STEP 5: Client’s Spiritual and Religious Needs (20 Minutes)

 Religion - a set of beliefs, values, rites, and rituals adopted by a group of people. The practices are
usually grounded in the teachings of a spiritual leader.
 Religion is one way in which an individual’s spirituality may be expressed. There are more than
6,500 religions in the world (Bronson, 2005).
 Some individuals seek out various religions in an attempt to find answers to fundamental questions
that they have about life and indeed, about their very existence. Others, although they may regard
themselves as spiritual, choose not to affiliate with an organized religious group. Brodd (2009)
suggested that all religious traditions manifest seven dimensions: experiential, mythic, doctrinal,
ethical, ritual, social, and material. He explains that these seven dimensions are intertwined and
complementary and, depending on the particular religion, certain dimensions are emphasized more
than others. For example, Zen Buddhism has a strong experiential dimension, but says little about
doctrines. Roman Catholicism is strong in both ritual and doctrine.
 The social dimension is a significant aspect of religion, as it provides a sense of community, of
belonging to a group such as a parish or a congregation, which is empowering for some individuals.
 Affiliation with a religious group has been shown to be a health-enhancing endeavor (Karren et al,
2010).
 A number of studies have been conducted that indicate a correlation between religious faith/church
attendance and increased chance of survival following serious illness, less depression and other
mental illness, longer life, and overall better physical and mental health.
 In an extensive review of the literature, Maryland psychologist John Gartner (1998) found that
individuals with a religious commitment had lower suicide rates, lower drug use and abuse, less
juvenile delinquency, lower divorce rates, and improved mental illness outcomes.
 It is not known how religious participation protects health and promotes well-being. Some churches
actively promote healthy lifestyles and discourage behavior that would be harmful to health or
interfere with treatment of disease.
 But some researchers believe that the strong social support network found in churches may be the
most important force in boosting the health and well-being of their members. More so than merely
an affiliation, however, it is regular church attendance and participation that appear to be the key
factors.

 Culture encompasses shared patterns of belief, feeling, and knowledge that guide people’s conduct
and are passed down from generation to generation.
 Cultural groups differ in terms of communication, space, social organization, time, environmental
control, and biological variations.
47
 Culture-bound syndromes are clusters of physical and behavioral symptoms that are considered as
illnesses or “afflictions” by specific cultures, but do not readily fit into the Western conventional
diagnostic categories.
 Spirituality is the human quality that gives meaning and sense of purpose to an individual’s
existence.
 Individuals possess a number of spiritual needs that include meaning and purpose in life, faith or
trust in someone or something beyond themselves, hope, love, and forgiveness.
 Religion is a set of beliefs, values, rites, and rituals adopted by a group of people.
 Religion is one way in which an individual’s spirituality may be expressed.
 Affiliation with a religious group has been shown to be a health-enhancing endeavor.
 Nurses must consider cultural, spiritual, and religious needs when planning care for their clients.

 What is culture
 What is spirituality
 What are culture and spirituality issues?
 What are cultural and spiritual factors influencing mental health and illness?
 What are client’s spiritual and religious needs?
48
Reference
Elsevier Sounders
49
SESSION 05: PSYCHOLOGICAL THERAPIES TO A PATIENT WITH
MENTAL ILLNESS
Learning Tasks
At the end of this session a learner is expected to be able:
Define psychological therapy
Describe psychological therapies
Give psychological therapies
Resources Needed:
SESSIONS OVERVIEW
1 5 Brainstorming Definition of Psychological Therapy

Presentation
2 30 Presentation Types of Psychological Therapies
3 10 Presentation Provision of Psychological Therapies to patients

with mental illness
50
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning tasks (5 minutes)
STEP 2: Definition of Psychological Therapy (5 Minutes)

 ASK students to brainstorm on the definition of psychological therapy
 A therapy is a deliberate intervention which aims to treat mental disorder and make it more
manageable. A therapy may be an attempt to ‘cure’ or it may be an attempt to teach the individual
how to cope with the problem.
 Psychological treatment/ therapy is sometimes called ‘psychotherapy’ or ‘talking therapy’ involves
talking about thoughts with a professional aiming at helping client to:
o Better understand own thinking and behaviour
o Understand and resolve problems
o Recognize symptoms of mental illness
o Reduce symptoms
o Change behaviour
o Improve quality of life.
STEP 3: Types of Psychological Therapies ( 30 Minutes)

 There are different types of psychological treatments designed to help people with different mental
health problems.
 Psychological approaches or psychotherapy is a form of giving help which differs from informal
help, such as guidance and advice from friends, in that
 The help is given by a person (the therapist)
 The therapy is administered within a theoretical framework
 The following are the types of psychotherapy:
o Behavioural therapy is a brief, goal - directed psychological treatment, based on behavioural
learning theory, dealing with the current features of the disorder Define
 Behavioural therapies are available for the treatment of phobic disorders (systematic
desensitization with relaxation training, flooding), obsessive-compulsive disorder (exposure
and response prevention, thought stopping, paradoxical injunction), social phobia
(assertiveness training) poor social skills (social skills training), abnormal behaviour in long-
stay patients with chronic schizophrenia or learning disability (token economy) and
functional nocturnal enuresis (star chart, pad and bell method) weka bullet
51
o Cognitive therapy is based on information –processing model of disorders and attempts to alter
the processing of information by patients suffering from psychiatric disorders such as
depression, phobic disorders, anxiety disorders and bulimia nervosa
o Cognitive-behavioural therapy aims to help patients achieve their explicitly stated goals through
time-limited sessions that include problem solving and new adaptive learning, and that focus on
bringing about desired changes outside the therapy sessions
 Cognitive-behavioural therapy has been found to be of benefit in anxiety states, phobic
disorders, obsessive-compulsive disorder, depression, somatic problems, eating disorders,
chronic psychiatric handicaps, marital problems, sexual dysfunction and problem solving
o Individual psychodynamic psychotherapy, based on a school of psychotherapy such as that of
Freud or Jung, uses free association, dream analysis, analysis of transference and
countertransference, working with resistance and defence mechanisms, clarification, linking,
reflection, interpretation and confrontation
o Group psychotherapy has similar aims to individual psychotherapy but is carried out by one
therapist with a group of patients
o Family therapy: this is a special form of group psychotherapy in which the group consists of
members of one family, together with either one therapist or two cotherapists
 It is useful in treating family psychopathology. The difficulties in the family often become
known because one member of the family, a child say, is referred initially
 A key component, however, is the willingness to consider all components of the family
system (even if not all family members are present) and their interactions
 An extension of this that encompasses the wider system impinging on the individual and
family is referred to as systemic therapy
o Marital therapy is offered to couples who require and seek help with difficulties in their
relationship
 It is sometimes sought as a last resort by married couple who wish to avoid getting
divorced. Behavioural models and contracts may be used by the therapist
o Sex therapy aims to enable individuals to feel at ease with their sexuality and to improve the
sexual relationship of the couple being treated
o Art and music therapy Art and music therapies allow patients to express themselves in a way
other than verbally tutoe tafsiri ya moja kwa moja
STEP 4: Provision of Psychological Therapies to patients with mental illness (10

Minutes)
 Evidence shows that psychological treatments work well for emotional, mental and behavioural
issues.
 Psychological treatments are useful for people of all ages, including children.
 They can help people from different cultural, social and language backgrounds.
 Psychological treatments are proven to help with mental illnesses such as:
o Depression
o Anxiety
o Addiction
o Eating disorders
52
o Post-traumatic stress disorder
o Obsessive-compulsive disorder
o Personality disorders.
 They are also used successfully to help people deal with:

o Stress
o Emotional problems
o Grief and trauma
o Relationship problems.
NOTE:
 It may take a number of weeks for you to see results from most psychological treatments. Some
types of treatment can take a year or more for you to get the full benefit.
 They are not a quick fix, but the positive effects are often long-lasting.
Describe the steps of giving c psychotherapies, (we can use the nursing process)

 Psychological treatment/ therapy is sometimes called ‘psychotherapy’ or ‘talking therapy’ involves
talking about your thoughts with a professional to:
o better understand your own thinking and behaviour
o understand and resolve your problems
o recognize symptoms of mental illness in yourself
o reduce your symptoms
o change your behaviour
o Improve your quality of life.
 There are different types of psychological treatments designed to help people with different mental
health problems.
 Evidence shows that psychological treatments work well for emotional, mental and behavioral
issues.
 Psychological treatments are useful for people of all ages, including children.
 It may take a number of weeks for you to see results from most psychological treatments. Some
types of treatment can take a year or more for you to get the full benefit

 SUMERIZE THE CONTENT BASING ON KEY MESSAGES FOR EACH STEP

 What is psychological therapy?
 What are the types of psychological therapies?
53
Reference
Elsevier Sounders
54
SESSION 06: PSYCHOSOCIAL THERAPIES TO PATIENT WITH MENTAL
DISORDERS
Prerequisite:
Learning Task
Define psychosocial therapies
Describe the psychosocial therapies
Assess patients for psychosocial therapy
Give psychosocial therapy
Resources Needed:
Sessions Overview

2 10 Brainstorming Definition of psychosocial therapies
Presentation
3 55 Presentation Different Psychosocial Therapies
4 30 Presentation Assessment of Patients for Psychosocial Therapy
Giving psychosocial therapies
6 5
Presentation Session Evaluation
55
SESSION CONTENTS
READ or ASK participants to read the learning objectives
ASK participants if they have any questions before continuing
STEP 2: Definition of psychosocial therapies (10 Minutes)

Activity: brainstorming (5Minutes)
 ASK students to brainstorm on the definition of psychosocial therapy
 Psychosocial is a term that depicts the close and dynamic connection between the emotional and
the social aspects of people’s lives. Psychosocial support involves providing emotional and
psychological care to an individual
 Psychosocial therapies are a group of non-pharmacological therapeutic interventions which

address the psychological, social, personal, relational and vocational problems associated with
mental health disorders.
STEP 3: Types of Psychosocial Therapies (55 Minutes)

 Psychosocial treatments/ therapy includes different types of psychotherapy and social and
vocational training, and aim to provide support, education and guidance to people with mental
illness and their families.
 They address both the primary symptoms of the mental health problem and the secondary
experiences which arise as a consequence of the mental health problem; as such Psychosocial
Interventions are a person-based intervention rather than a solely symptom-based treatment.
 They are an effective way to improve the quality of life for individuals with mental illness and their
families. They can lead to fewer hospitalizations and less difficulties at home, at school and at
work.
 The following are the types of Psychosocial therapies:
o Cognitive behavioural therapy
o Psychoeducation
o ….
o …..
o ……
o ……
o …… Pia ni vema kuwa na definition kwa kila moja kama hapo chini pychoeducation
Cognitive behavioural therapy
56
 Cognitive behavioural therapy is a psychological therapy developed by Aaron Beck in the 1960s.
 This model explores the sense we make of events (our thoughts), how unhelpful thoughts and
thinking styles are associated with troublesome emotional and physiological states, and drive
behaviours which maintain our problems rather than resolve them. CBT has a robust evidence
base across many mental health disorders.
 To deliver the therapy, specialist training is required.
Psychoeducation
 Psychoeducation refers to the process of providing education and information to those seeking or
receiving mental health services such people diagnosed with mental health condition (or life
threatening/ terminal illness) and their family.
 The purpose of this therapy is to help patients and /or their relatives/ care givers better understand
(and become accustomed to living with) mental health condition.
 Psychoeducation also includes education for family and friends where they learn things like coping
strategies, problem-solving skills and how to recognize the signs of relapse.
 Family psychoeducation can often help ease tensions at home, which can help the person
experiencing the mental illness to recover.
NOTE: it is generally known that those who have a thorough understanding of the challenges they are
facing as well as knowledge of personal ability, internal and external resources, and their own areas of
strength often better able to address difficulties, feel more in control of the condition(s) and have a
greater internal capacity to work towards mental and emotion wellbeing.
Self-help and Support Groups

 Self-help and support groups can help address feelings of isolation and help people gain insight
into their mental health condition.
 Members of support groups may share frustrations, successes, referrals for specialists, where to
find the best community resources and tips on what works best when trying to recover.
 They also form friendships with other members of the group and help each other on the road to
recovery.
 As with psychoeducation, families and friends may also benefit from support groups of their own.
Psychosocial Rehabilitation
 Psychosocial rehabilitation helps people develop the social, emotional and intellectual skills they
need in order to live happily with the smallest amount of professional assistance they can manage.
 Psychosocial rehabilitation uses two strategies for intervention: learning coping skills so that they
are more successful handling a stressful environment and developing resources that reduce future
stressors.
 Treatments and resources vary from case to case but can include medication management,
psychological support, family counseling, vocational and independent living training, housing, job
coaching, educational aide and social support.
Assertive Community Treatment (ACT)

 Assertive community treatment (ACT) is a team-based treatment model that provides
multidisciplinary, flexible treatment and support to people with mental illness 24/7.
57
 ACT is based around the idea that people receive better care when their mental health care
providers work together. ACT team members help the person address every aspect of their life,
whether it be medication, therapy, social support, employment or housing.
 ACT is mostly used for people who have transferred out of an inpatient setting but would benefit
from a similar level of care and having the comfort of living a more independent life than would be
possible with inpatient care.
 Studies have shown that ACT is more effective than traditional treatment for people experiencing
mental illnesses such as schizophrenia and schizoaffective disorder and can reduce
hospitalizations by 20%.
Supported Employment
 Work can be an essential step on the path to wellbeing and recovery, but challenges that come
with mental illness can make it more difficult.
 There are programs, however, designed specifically to help with work readiness, searching for jobs
and providing support in the workplace.
Vocational Rehabilitation
 Rehabilitation programmes are used in the treatment of chronically ill patients, such as those with
chronic schizophrenia who find it difficult to live outside hospital.
 Vocational Rehabilitation provides career counseling and job search assistance for people with
disabilities, including mental illness.
Individual Placement and Support (IPS) Supported Employment

 IPS programs are evidence-based programs that help people with mental illness locate jobs that
match their individual strengths and interests.
 Once an individual locates a job, IPS programs provide continuous support to help the person
succeed in the workplace.
 IPS Supported Employment teams include employment specialists, health care providers and the
individual with mental illness.
 If the individual agrees, family members or a significant other may be part of the team.
Clubhouses
 Clubhouses are community-based centers open to individuals with mental illness.
 Clubhouse members have the opportunity to gain skills, locate a job, find housing, and pursue
continuing education.
 Members work side-by-side with staff to make sure the program operates smoothly. Members also
have the opportunity to take part in social events, classes and weekend activities.
Case Management
 Living well with a complicated health condition (physical or mental) can require working with a
number of medical providers and support resources.
 Case management can help individuals coordinate these services.
 A case manager has knowledge of local medical facilities, housing opportunities, employment
programs and social support networks.
 He or she is also familiar with many payment options, including local, state and federal assistance
programs.
58
 This person can serve an important role in helping you or your family member get the best
treatment possible.
 A case manager will assess your needs and explain what resources are available in your area. He
or she will explain the process of applying for services and help you collect the necessary
documents to prove eligibility.
 A case manager will then keep in touch with you to ensure that you continue to have your treatment
needs met.
 How to fill out official forms, how to get transportation to appointments—these are all questions a
case manager can help with.
 Case managers are professionals with certification in case management or degrees in social work.
 They are typically employed by large health insurance companies or by local county and state
governments.
 If you are staying in a hospital or your doctor has recommended a case manager, you may
automatically receive a call from one.
 If you do not have a case manager and would like to, ask about the process of getting one. Your
best bet is to call your state or county department of health, social services or aging.
 Remember that your case manager is there to work with you for your benefit. Ask questions and if
you don't understand the answers, ask again.
 A good case manager can't guarantee you'll get every resource you apply for, but he or she should
definitely keep you informed and listen to your concerns.
Occupational Therapy
 In occupational therapy the patient is taught skills such as shopping, cooking and how to organize
their life better.
 This therapy is in use for chronic schizophrenia and long stays patients who may lose or never
develop skill required for daily living activities
Social Skills Training

 The main goals of social skills training are to enable patient to:
 Achieve better interpersonal behaviour
 Achieve improved self care o Adapt to life in the community
 Note: Approach used includes behavioural techniques (positive reinforcement, modeling, and role
play), videotapes and psychoeducational material.
Sheltered Workshops
 These are specially set up places of employment which allow chronically ill patients to gain work
experience and an increased sense of self worth.
Accommodation
 Some chronically ill patients need special hostels or place run by psychiatrically qualified staff to
monitor and supervise their conditions in their community
Community Mental Health Services

 Community mental health services enables patient to be seen and treated rapidly in the community
or as a day patients, thereby helping to pre- empty their need for admission as in patient.
59
 These services are offered by multidisciplinary teams, including psychiatrists and community
psychiatric nurses and provide a cost –effective form of treatment rather than hospital – based
treatment.
STEP 4: Assessment of Patients for Psychosocial Therapy (30 Minutes)

 At the beginning of psychotherapy treatment, an accurate assessment or evaluation of the patient
is necessary.
 This includes personal history, both clinical and psychosocial, and family background. Provide
steps in each of these
 The assessment interview has to establish what the patient's problem is, not only as presented by
him, but also the hidden causes and connections.
 As the assessor gathers information about the patient, she has to observe also his responses and
his ways of interacting with her in the here and now.
 It is essential that the assessor foresees and takes care of the consequences of the interview.
 In order to prevent any disappointment or hurt, at the start of the assessment interview it has to be
made clear to the applicant whether, in case of acceptance, the assessor will or will not be the
person who will conduct the subsequent therapy.
 The assessor must be aware of the hopes and expectations created, any psychic disturbance
stirred up by and the depth of rapport established with her during the interview.
 She has to make sure that the patient expresses any negative feelings and thoughts he might have
concerning the meeting before they part.
 If the candidate for psychotherapy is not ruled out on the basis of any of the exclusion criteria, he
might be evaluated also in respect of the following selection criteria. The person should have the
capacity and the readiness to:
 Engage in a good first contact with the assessor which then can be sustained in an interaction. In
other words, there must be some ability to relate and interact.
 Put into words his personal experiences and to be interested in understanding the therapist's
communications and, in case of group-analytic psychotherapy, other people's communications
about themselves.
 Change his present condition and have a certain degree of will and determination to do so. This
means readiness to talk about feelings and inner experiences, not normally discussed in
conversation, such as secret fears and unacceptable impulses. The courage to explore the nature
of emotional difficulties involving himself and others.
 Recognize that he is suffering from anxiety or depression, disappointment or be aware that
something is wrong with himself and to understand that non-physical treatment might help.
 Have a reasonable record of stability or a genuine desire to achieve it, such as holding on to a
suitable job or relationship as far as external circumstances beyond his control allow him to do so.
 Have sufficient ego-strength.
STEP 6: Giving psychosocial therapies

 Psychosocial interventions should be used in mental health care to support a comprehensive and
person-based effective approach that promotes and sustains recovery.
 At the beginning of psychotherapy treatment, an accurate assessment or evaluation of the patient
is necessary. This includes personal history, both clinical and psychosocial, and family background.
60
 The assessment interview has to establish what the patient's problem is, not only as presented by
him, but also the hidden causes and connections.

 What is psychosocial therapy?
 What are the types psychosocial therapies?
61
Reference
Elsevier Sounders
62
Session Seven:
INAFANYIWA KAZI
63
SESSION 08: MANAGEMENT OF PATIENT USING
ELECTROCONVULSIVE THERAPY
Prerequisite: None
Learning Tasks
At the end of this session a learner is expected to be able:
Describe Electroconvulsive Therapy (ECT)
Prepare patient for Electroconvulsive Therapy (ECT)
Explain mode of action of Electroconvulsive Therapy (ECT)
Provide care to patient during ECT
Provide care to patient after ECT
Monitor for complications of ECT
Resources Needed:
Sessions overview
Step Time Activity/Method Content
(min)
1 5 Presentation Session Title and Learning Tasks
2 15 Small group discussion, Description of Electroconvulsive Therapy (ECT)
Presentation
3 5 Lecture discussion Mode of action of Electroconvulsive Therapy (ECT)
4 5 Brainstorming, Presentation Indications of Electroconvulsive Therapy (ECT)
5 15 Brainstorming, Preparing patient for Electroconvulsive Therapy

Lecture discussion (ECT)
6 30 Lecture discussion Role play Provision of care to patient during ECT
7 25 Lecture discussion Role play Provision of care to patient after ECT
8 10 Brainstorming Monitoring complications of ECT
Presentation
64
SESSION CONTENTS

STEP 2: Electroconvulsive Therapy (ECT) (15 Minutes)

Activity: Small Group Discussion (10 minutes)
 DIVIDE students into small manageable groups of 5 to 8 students

 ASK students to discuss on electroconvulsive therapy for 5 minutes
 ALLOW 2 to 3 groups to present and let other groups to provide additional points
 WRITTE their response on the chalk/white board or flip chart
 CLARIFY and summarize their responses using the content below
 Electroconvulsive therapy involves the induction of fits by briefly electrically stimulating the brain.
 It is a type of somatic treatment in which electric current is applied to the brain through electrodes
placed on the templates. A grand mal (generalized) seizure produces the desired effect.
 ECT is effective for the following clients who are currently suicidal and in the treatment of severe
depression, particularly in those clients who are also experiencing psychomotor retardation and
neurovegetative changes such as disturbances in sleep, appetite and energy.
 The ECT is usually given twice per week and a course of around six fits is usually sufficient to cause
remission of a severely depressed illness
 It is often considered for treatment only after a trial of therapy with antidepressant medication has
proved ineffective or when the patient is resistant to medication or when the patient is refractory to
antidepressant medications
STEP 3: Mode of action Electroconvulsive Therapy (ECT) (5 minutes)

 Exact mechanism of action of ECT is still unknown.
 There theories which are trying to explain the mode of action of ECT.
 The most popular theories include:
o Neurotransmitter theory suggests that ECT acts like tricyclic antidepressants by enhancing deficient
neurotransmission in monoaminergic systems. Specifically it is through to improve dopaminergic,
serotonergic, and adrenergic neurotransmission.
 Ongeza theories
STEP 4: Indications of Electroconvulsive Therapy (ECT) (5 minutes)
Activity: Brainstorming (3 minutes)

 ASK the student to brainstorm on indications of Electroconvulsive Therapy for 2 minutes
 ALLOW 2 to 3 students to respond and let other provide additional responses
 WRITTE their responses on the flip chart/ board
 CLARIFY and summarize by using the content below
65
 The main indications for ECT are:
o Major Depressive disorder
o Suicidal thoughts or homicidal
o Puerperal depressive illness
o Mania
o Marked agitation, marked vegetative symptoms or Catatonic schizophrenia
o Schizoaffective disorder
 Contraindications of ECT include;

o Raised intracranial pressure,
o High blood pressure,
o Any physical disorder- like cardiac and chest infections
STEP 5: Preparation of Patient for Electroconvulsive Therapy (ECT) (15 Minutes)
 ASK the student to brainstorm on how to pprepare patient receiving Electroconvulsive

Therapy
 WRITTEN their responses on the flip chart/ board
 Preparation needed for a patient undergoing ECT include the following:

o Educate regarding ECT, including the procedure and expected effects
o Teach family about the treatment
o Encourage expression of feelings by patient and family
o Obtain informed consent either from the patient or next of kin
o Help family members understand behavior related to amnesia and confusion
o Inform the patient not to eat anything from the midnight and morning of the ECT
o Give atropine and muscle relaxant to reduce secretions and movement of the patient during the
therapy
o Check emergency equipment before procedure
o Check vital signs
o Remain available to offer support before and during treatment
STEP 6: Care of Patient with Mental Disorder During ECT (30 Minutes)
 The ECT is administered either by placing one electrode on each side of the skull (bilateral) or by
placing both electrodes (Unilateral ) on the side of head containing non dominant hemisphere (the
right side)
 Patient need to be supported firmly by about 4- 6 people during the procedure to avoid excessive
jerking movements which may cause fractures.
 The nurse whom the patient feels at ease should remain with the patient throughout the treatment
to provide support
66
 The following are care of patient during ECT:
o Introduced all members of the treatment team and their specific roles in the ECT procedure to
the patient
o Remove potentially harmful objects such as jewelry and dentures
o Place a bite in the patient’s mouth to prevent damage from biting during the convulsion
o Observe closely and record the effects of the ECT procedure and the patient’s reaction
o Monitor brain waves using electroencephalogram (EEG)
o Monitor cardiac responses using electrocardiogram (ECG)
o Monitor blood pressure throughout the treatment
o Maintain patent airways
o Offer analgesia or antiemetic as needed
o Maintain patient’s privacy during and after treatment
STEP 7: Care of Patient with Mental Disorder After ECT (25 Minutes)
 Patients normally wake up about 15 minutes after ECT procedure.
 After awaking from ECT, the patient is often confused and disoriented for several hours
 Prepare equipment in the recovery area which must be adjacent to the treatment area. Equipment
include oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment.
 The following are the care needed to a patient after receiving ECT:
o Observe the patient until awaking
o Monitor vital signs frequently until they return to normal
o The nurse and family may need to reorient the patient frequently during the course of treatment
o Provide patient with sufficient time for rest
o Close observation is important to prevent falls
o After assessment for gag reflex return, an analgesic may be administered. If headache is a
recurrent problem a standing order for analgesic to be given as soon as possible after each
treatment may be obtained.
o Change in activity schedule and environment to provide a darkened room or quite area may be
necessary
o Cryotherapy, a frozen gel band, may be an alternative approach because of the different
mechanisms by which it relieves pain in patients with post –ECT headache
STEP 8: Monitoring of Complications of ECT (10 Minutes)

 ASK the student to brainstorm on Complications of ECT
 The side effects of ECT

o Head ache,
o Temporary confusion,
67
o Loss of short-term memory,
o Fractures.
 The most common side effects of ECT are temporary memory loss and confusion.
 Provide general statement on monitoring and management of most side effect

 No evidence has been found to indicate that ECT causes brain damage
 Nursing care in ECT involves:
o Providing emotional and educational support to the patient and family
o Assessing the pre-treatment protocol and patient’s behavior, memory, and functional ability
before ECT
o Preparing and monitoring the patient during the actual ECT procedure
o Observing and interpreting patient responses to ECT with recommendations for changes in the
treatment plan as appropriate

 What are the indications for ECT?
 What are contraindications for ECT?
 What are the preparations needed for a patient undergoing ECT?
68
References
Elsevier Sounders
69
SESSION 09: PHARMACOTHERAPY TO PATIENTS WITH MENTAL
DISORDERS
Pre requisite:
Learning Tasks
Define pharmacotherapy
Describe pharmacotherapy
Administer pharmacotherapies
Monitor for side effects of pharmacotherapies
Resources Needed:
Sessions overview
1 5 Presentation Session Title and Learning Tasks
2 5 Brainstorming
Definitionof pharmacotherapy
Presentation
3 60 Lecture discussion Description of pharmacotherapy
4 15 Buzzing Administration of pharmacotherapies

Lecture discussion
5 25 Group discussion Monitoring side effects of pharmacotherapies
Lecture discussion
6 5
Presentation Key Points
7 5
70
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning Task (5 minutes)

STEP 2: Definition of pharmacotherapy (5 Minutes)

 ASK the student to brainstorm on the definition of pharmacotherapy in mental health for 3 minutes
 CLARIFY and SUMMARIZE by using the content below:
 Pharmacotherapy, involves the use of psychotropic medication (e.g. antidepressants or

antipsychotics) to treatment symptoms and disorders of mental illnesses.
 Pharmacotherapy, also known as drug therapy – or more specifically psychopharmacoptherapy.

 NOTE:Many individuals with mental health issues need medication to help their brains function
normally. Medication is most effective when used in combination with psychotherapy rather than by
itself in the treatment of most psychiatric disorders.
STEP 3: Pharmacotherapy (60 Minutes)

 There are literally hundreds of different psychotropic medications on the market today, the vast majority fit
into five categories:
o Antidepressants
o Antipsychotics
o Anti-anxiety medications (anxiolytics)
o Mood stabilizers
o Stimulants
Antipsychotic drugs (neuroleptics)

 Antipsychotic medications are also known as “major tranquilizers” (due to their sedating effects) and
“neuroleptics” (due to how they work inside the brain).
 These drugs work by targeting the neurotransmitters in the brain.
 They work primarily on dopamine, which is believed to play an important role in psychosis.
 They also affect noradrenaline, serotonin, and acetylcholine levels.
 The main use of antipsychotic drugs is in the treatment of schizophrenia, mania, organic disorders,
and psychoactive substance use.
Classification of antipsychotic drugs

 Classification isbased on when the antipsychotic drugs were developed.
 They are typically divided in two (and sometimes three) categories.
71
 The oldest antipsychotic medications are known as “first generation antipsychotics”followed by
“second generation antipsychotics”, and sometimes “third generation antipsychotics”.
 First generation antipsychotics also referred to as “conventional” or “typical” antipsychotics include:

o Compazine (prochlorperazine)
o Haldol (haloperidol)
o Loxitane (loxapine)
o Mellaril (thioridazine)
o Moban (molindone)
o Navane (thiothixene)
o Orap (pimozide)
o Prolixin (fluphenazine decanoate)
o Stelazine (trifluoperazine)
o Serentil (mesoridazine)
o Thorazine (chlorpromazine)
o Trilafon (perphenazine)
 Although many of these drugs are still used today, they tend to have the most serious potential – and, in
some cases, permanent – side effects
 Typical (conventional)antipsychotics act by causing post synaptic blockage in the central nervous system
and cause extra side effects of extra pyramidal symptoms such as;
o Parkinsonism, dystonia (tongue protrusion, grimacing, opisthotonos, oculogyric crisis- eyes move up
superiorly and laterally and spasmodic torticollis – involving the neck), akathisia and tardive dyskinesia
which is the most common and troubling side effect
o Other side effect symptoms include, dry mouth, blurred vision, urinary retention, nasal congestion and
constipation.
 Second-generation antipsychotics, also commonly referred to as “atypical antipsychotics,” include:
o Clozaril (clozapine)
o Fanapt (iloperidone)
o Geodon (ziprasidone)
o Invega (paliperidone)
o Latuda (lurasidone)
o Risperdal (risperidone)
o Saphris (asenapine)
o Seroquel (quetiapine)
o Symbyax (olanzapine and fluoxetine)
o Zyprexa (olanzapine)
72
 When this second generation of antipsychotics quickly grew in popularity as the first choice of treatment for
schizophrenia and other psychotic disorders.
 This is primarily due to the fact that, overall, they seemed to have fewer and less potent side effects than
their earlier counterpart but they also may cause tardive dyskinesia
 Third-generation antipsychotics, the most recent antipsychotic medications to become available,

are also considered “atypical”, include; Abilify (aripiprazole).
 It’s sometimes listed with the second generation antipsychotics.
 Abilify is not only approved for the treatment of schizophrenia and bipolar mania; it’s also approved
as an adjunct treatment for major depression and irritability associated with autistic spectrum
disorder
 Like the typical antipsychotics, the atypical antipsychotics improve the positive symptoms of
schizophrenia, but unlike the typical drugs, they also improve the negative symptoms.Hence,
Atypical drugs are indicated for psychoses in which both positive and negative symptoms are
prominent.
 Atypical drugs are reported to treat mood symptoms, hostility, violence, suicidal behavior, difficulty
with socialization, and the cognitive impairment seen in schizophrenia
 The atypical drugs have two important disadvantages:
o They can result in metabolic syndrome with problems related to weight gain, diabetes, and
dyslipidemia, often resulting in cardiovascular disease.
o They cost considerably more than the typical antipsychotics.
Side Effects
 Antipsychotics are potent medications that, unfortunately, come with a lot of side effects.
 Many of the side effects increase in severity as the dose increases.
 The risk of some, such as Tardive Dyskinesia, increase the longer the drug is used.
 Some of the most common antipsychotic side effects include:
o Movement effects, such as tics and tremors
o Sedation
o Tardive dyskinesia
o Neuroleptic malignant syndrome (which is very serious and potentially fatal)Increased appetite
o Diabetes
o Significant weight gain
o Elevated cholesterol levels
o Tiredness
o Dry mouth
o Sexual dysfunction
o Constipation
o Blurred vision
o Dizziness
o Peripheral oedema,
73
o Galactorrhoea,
o Amenorrhoea,
o Gynaecomastia,
o Breast pain etc
Indication for antipsychotics

 They are prescribed for the treatment of schizophrenia and other psychotic disorders
 Second to psychotic disorders, they are most often used in the treatment of bipolar mania and mixed mood,
bipolar maintenance, bipolar depression, and major depression (as an adjunct to antidepressant
medication).
 They are also sometimes used in the treatment of borderline personality disorder.
 Additional indications include:
o Tourette’s syndrome
o Autism-related irritability in children
o Agitation
o Severe nausea and vomiting
Antimuscarinic drugs (antiparkinsonism)

 These are anticholinergic drugs which are used to treat parkinsonian symptoms caused by antipsychotic
drugs.
 Drugs used in the treatment of parkinsonism are;
o Procyclidine, trihexyphenidyl (benzhexol), benzatropine, ophenadrine, and biperiden.
Anti-Anxiety Medications
 MostAntianxietyand sedative-hypnotic drugs are effective in themanagement of acute agitation.
 Antianxiety medications are not recommended for long term use because they can result in confusion and
dependency and may worsen depressive symptoms
 The two primary types of medications used to treat anxiety are:
o Benzodiazepines (minor tranquilizers)
o Antidepressants (most commonly the SSRIs, Anafranil, and Buspar)
 Other medications are sometimes used as well, although much less frequently, including:
o Beta blockers (e.g. Inderal (propranolol))
o Antihistamines
o Anticonvulsants
o Antipsychotics
Benzodiazepines
Benzodiazepines are highly effective medications when it comes to alleviating symptoms of anxiety.
 They are fast acting.
 Most people experience at least some benefits within just an hour or two after taking one of these drugs.
 The primary problem with benzodiazepines is that they have a high potential for dependence and addiction.
 They’re classified as a controlled substance and must be used with caution.
 They are usually intended for short-term treatment only.
 As a general rule, these drugs shouldn’t be taken for more than 4 weeks in a row.
 Commonly prescribed benzodiazepines include Valium (diazepam) and Ativan (lorazepam),
74
 Benzodiazepines, such as lorazepam, are often used during psychiatric emergencies to sedate combative
patients.
 Lorazepam in particular is frequently used because of its quick onset and because it can be administered
either orally or intramuscularly.
 Other benzodiazepines include: Klonopin (clonazepam), and Librium (chlordiazepoxide).Xanax (alprazolam).
Side Effects
 The most common ones include drowsiness, impaired thinking, headache, disorientation, dizziness,
impaired coordination, nausea, and short-term memory loss.
 NOTE: benzodiazepines can be particularly dangerous when combined with alcohol, other
medications, or recreational drugs
Mood stabilizing drugs

 Mood stabilizers are primarily used to treat the extreme mood swings in bipolar disorder.
 Mood stabilizers work to stabilize the current mood and also reduce the risk of future mood episodes
Types of Mood Stabilizers

 Lithium (Lithobid, Eskalith)
 Valproic acid (Depakene)
 Divalproex sodium (Depakote)
 Lamotrigine (Lamictal)
 Carbamazepine (Tegretol, Equetro)
 Oxcarbazepine (Trileptal)
 Topiramate (Topamax)
 Valproate is effective in the treatment of aggression resulting from mania.

 The commonly used drugs in the prophylaxis of bipolar mood disorder are the lithium salts (lithium
carbonate and lithium citrate), and the anticonvulsive carbamazepine.
 Lithium salts are used in the:
o Prophylaxis of bipolar mood disorder
o Treatment of resistant depression
o Treatment of resistant mania/hypomania
o Prophylaxis of recurrent depression
o Treatment of aggression
o Treatment of self – mutilation
Side effects
 The following are the common side effects of lithium:
o Fatigue, drowsiness, dry mouth with metallic taste, polydipsia, nausea and vomiting, weight
gain, diarrhea, fine tremor, polyuria, muscle weakness and oedema.
Note: Carbamazepine is used instead of, or in combination with, lithium in cases of:
o Bipolar mood disorder resistant to lithium
o Resistant mania
 Side effects of carbamazepine include;
75
o Depress the white blood count.
Mood-stabilizing antipsychotics
 These are the antipsychotics that may be combined to boost the effects of current medications if bipolar
symptoms persist.
 Mood-stabilizing antipsychotics include:
o Aripiprazole (Abilify)
o Asenapine (Saphris)
o Lurasidone (Latuda)
o Olanzapine (Zyprexa)
o Quetiapine (Seroquel)
o Risperidone (Risperdal)
o Ziprasidone (Geodon)
Other Indications for Mood Stabilizers

 Mood stabilizers are sometimes used in the treatment of borderline personality disorder.
 They can help reduce a variety of symptoms commonly seen in individuals with BPD including
dysphoric mood, anger, self-harm behavior, and impulsive acting-out behavior.
Antidepressant drugs
Tricyclic antidepressants
 Antidepressants are used in the treatment of depression,
 Certain types of antidepressants (primarily SSRIs) are also widely used to treat obsessive-
compulsive disorder, generalized anxiety disorder, panic disorder, phobic states, and nocturnal
enuresis.
 They help alleviate symptoms, such as low energy, poor concentration, and frequent feelings of
sadness, so that you can start feeling normal again.
 Types of antidepressants include:
o SSRIs (selective serotonin reuptake inhibitors)
o SNRIs (serotonin and norepinephrine reuptake inhibitors)
o Tricyclics
o MAO inhibitors (monoamine oxidase inhibitors)
o Atypical antidepressants
The selective serotonin reuptake inhibitors (SSRIs)

 The selective serotonin reuptake inhibitors (SSRIs) appear to reduce the risk of violence associated
with posttraumatic stress.
 Have fewer side effects than some other types.
 They include Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), Luvox
(fluvoxamine), Lexapro (escitalopram), and Viibryd (vilazodone).
 SSRIs work by targeting serotonin, a neurotransmitter that’s believed to play a significant role in
mood regulation. They inhibit selectively the reuptake of serotonin ( 5-HT)
76
 Are used in the treatment of depression, obsessive – compulsive disorder, bulimia nervosa, panic
disorder, and phobic disorders.
 Their side effects includes nausea, vomiting, diarrhea, occasionally they cause sexual dysfunction,
particularly delayed ejaculation
Serotonin and norepinephrine reuptake inhibitors (SNRIs)

 SNRIs – This category of antidepressants are often prescribed when SSRIs have been tried
unsuccessfully.
 They include Effexor and Effexor XR (venlafaxine), Pristiq (desvenlafaxine), Cymbalta (duloxetine),
Fetzima (levomilnacipran), and Khedezla (desvenlafaxine).
 They target both serotonin and norepinephrine in the brain.
Tricyclics
 Once the gold standard for treating major depression, these first generation antidepressants are still
prescribed today
 Drugs in this category include nortriptyline (Aventyl, Pamelor), doxepin (Sinequan), imipramine (Tofranil),
amitriptyline (Elavil), desipramine (Norpramin) and clomipramine (Anafranil). Anafranil is also frequently
prescribed in the treatment of obsessive-compulsive disorder. Amitriptyline is more sedating therefore
useful in those who are agitated and anxious
 The function of tricyclic antidepressants in the central nervous system involves inhibition of the
reuptake of monoamines noradrenaline and 5-HT. This group is also known as MARIs ( monoamine
reuptake inhibitors)
 The side effects of antidepressant drugs include; Dry mouth, blurred vision, constipation, urinary
retention, sedation, nausea, erectile dysfunction/ impaired ejaculation, haematological problems,
postural hypotension, weight gain and sweating.
NOTE: They have troubling side effects, such as weight gain and dry mouth. They are also potentially fatal if
taken in high doses, so extreme caution must be used when prescribed for a depressed patient with a history of
suicide or current suicidal thoughts.
Monoamine Oxidase Inhibitors (MAO Inithibitors)

 MAO inhibitors – balances serotonin, dopamine, and norepinephrine in the brain by inhibiting the enzyme
monoamine oxidase which metabolizes serotonin and norepinephrine
 The main use of MAOIs is in the treatment of depression refractory to other antidepressants,
depression with severe anxiety, hypochondriacal or hysterical features, phobic disorders, agoraphobia
and obsessive – compulsive disorder, hence they are typically prescribed as a last resort only
o The side effects can be very troubling. Also, one of the biggest concerns with MAOIs is the risk of potentially
deadly interactions with certain foods, beverages, and medications.
o Restrictions include cured meats, aged cheeses, beer, ale, wine, soy sauce, and sauerkraut, to name a few.
o Medications in this category include Marplan (isocarboxazid), Nardil (phenelzine), Parnate (tranylcypromine),
and Emsam (selegiline).
o Side effects include hepatotoxicity, appetite stimulation, hypertensive crisis and weight gain.
 Atypical antidepressants – They aren’t typically prescribed as a primary medication for depression, but may
be prescribed for specific symptoms (e.g. difficulties sleeping).
o These antidepressants include Wellbutrin (bupropion), Desyrel (trazodone), Remeron (mirtazapine), Buspar
(buspirone), and Serzone (nefazodone).
o Buproprion is widely prescribed, under the brand name Zyban, to help people stop smoking.
Side Effects
77
 The potential side effects associated with antidepressants vary, depending on the particular
medication.
 Some of the potential side effects include sexual dysfunction, insomnia, dry mouth, nausea, weight
gain, dizziness, constipation, blurred vision, sedation, nervousness, and difficulties with urination.
 Many side effects gradually subside as your body adjusts to the medication.
Hypnotics and anxiolytic drugs

Benzodiazepines
 Benzodiazepines are used as anticonvulsants, muscle relaxants, as a premedication in anaesthesia, in
the immediate treatment of aggressive behaviour, and in the treatment of alcohol dependence.
 Examples of benzodiazepines include:
o Long acting- alprazolan, bromazepam, chlordiazepoxide, clobazam, clorazepate, diazepam,
flunitrazepam,flurazepam, nitrazepam.
o Short acting – loprazolam, lorazepam, lometazepam, and temazepam.
 The side effects of anxiolytic drugs include, physical and psychological dependence, tolerance to their
side effects, may cause withdrawal syndrome when trying to stop taking, drowsy and psychomotor
impairment.
Anticonvulsants drugs
 Barbiturates such as Phenobarbital and methyl Phenobarbital are drugs commonly used in
treatment / prophylaxis of epilepsy.
 Neurological and physical side effects include, slurred speech, incoordination, unsteady gat,
impaired attention or memory, increase in aggressive, hostile or sexual impulses caused by
inhibition, mood lability, impaired judgment and impaired social or occupational functioning.
78
STEP 4: Administration of Pharmacotherapies (15 Minutes)
Activity: Buzzing (5 minutes)
 ASK the student to pair up and buzz on the administration of pharmacotherapies in mental health
 CLARIFY and SUMMARIZE by using the content below
 Nurse have a significant impact on the patient’s experiencewith psychopharmacological agents.

 In many inpatient, daytreatment, home health, and other outpatient settings thenurse works out a
dosing schedule based on drug requirementsand the patient’s needs and preferences,
administerthe medication, and are continually alert for and treat drugeffects.
 A drug should be given within the recommended dose range and for the appropriate amount of time
before determining whether it has had an adequate therapeutic trial for a particular patient
 This role defines the nurse as a key professionalin maximizing therapeutic effects of drug treatment
andminimizing side effects in such a way that the patient is a truecollaborator in managing the
medication regimen.
 The nurse is in a central position to educate the patient and the family about medications. This
includes teaching complex information to the patient so that it can be understood, discussed, and
accepted.
 Patients should be well informed about each drug prescribed for them, including the expected
benefits and potential risks, other available treatments for their condition, and what to do and who
to contact if a question or problem arises.
 The nurse can assume the important role of continuing a therapeutic alliance with a patient on drug
maintenance.
Refer students to Handout 1.1: Medication assessment
STEP 5: Monitoring Side Effects of Pharmacotherapies (25 Minutes)

Activity: Group discussion (20 minutes)
 DEVIDE students into small manageable groups of 5 to 8 students

 ASK them to discuss on monitoring of side effects of pharmacotherapies in mental health
 WRITE their responses on the flip chart/ board
 The nurse has the important role of consistently monitoring the effects of psychopharmacological drugs.
 This includes making standardized measurements of drug effects on baseline target symptoms, evaluating
and minimizing side effects, treating adverse reactions, and noting the often subtle effects of the medication
on the patient’s self-concept, trust, and confidence in the treatment.
79
 Therapeutic drug monitoringis important because some drugs have a narrow therapeuticrange
(e.g., lithium), some can cause sudden serious adversereactions (e.g., neuroleptic malignant
syndrome), and somedrugs are often co-administered, thereby altering the drugmetabolism and
clearance rates.
Refer students to Handout 1.1: Medication assessment

 Antipsychotics are often used for the treatment of aggression. The most common medication strategy for
managing violent patients in a psychiatric emergency is the high-potency typical antipsychotic haloperidol in
combination with the benzodiazepine lorazepam. Both medications are considered effective for decreasing
agitation, and both can be given by injection with a quick onset of action.
 Medication education is an important key to effective and safe use of psychotropic drugs, patient
collaboration in the treatment plan, and patient adherence with drug treatment regimens.
 Antidepressant drugs regulate neurotransmitter systems and their balance with each other. They enhance
communication in brain structures responsible for mood and emotion, as well as many of the anxiety
disorders, because the biochemical underpinnings of mood and anxiety are similar.
 Carbamazepine can be lethal in overdose. It is not recommended during pregnancy, and should not be used
in patients with other medical illnesses, such as diabetes and bone marrow suppression

 What are the target symptoms for antianxiety and sedative-hypnoticbenzodiazepines?
 Mention foods that are norepinephrine agonists that should be avoided by patients taking MAOIs.
 What are the nursing considerations for antipsychotic drug side effects?
80
References
Elsevier Sounders
81
HANDOUT 1.1: Indication for Antidepressant Drugs
Table: Indication for Antidepressant Drugs

Primary Indications
Acute depression, maintenance treatment of depression and prevention of

Major depression relapse, bipolar
depression (when used with a mood stabilizer), atypical depression, and
dysthymic disorder
Anxiety disorders Panic disorder, obsessive-compulsive disorder (OCD), social anxiety
disorder, generalized anxiety disorder (GAD), posttraumatic stress disorder
(PTSD)
Evidence for Other Antidepressant Categories
Selective serotonin reuptake Additional indications: bulimia nervosa, premenstrualdysphoric disorder
inhibitors (SSRIs) (full- and half-cycle administration)
Moderate evidence: obesity, substance abuse, impulsivity, and anger
associated with personalitydisorders, pain syndromes
Preliminary evidence: body dysmorphic disorder, hypochondriasis, anger
attacks associatedwith depression, attention deficit hyperactivity disorder
(ADHD)
Other newer antidepressant Additional indications: bupropion: smoking cessation, seasonal affective
agents disorder; duloxetine:diabetic neuropathy, fibromyalgia, chronic
musculoskeletal pain
Moderate evidence: trazodone: insomnia, dementia with agitation, minor
sedative-hypnoticwithdrawal; bupropion: ADHD, sexual side effects of
antidepressants
Tricyclic antidepressants Strong evidence: panic disorder (most), OCD (clomipramine), bulimia
(imipramine, desipramine),enuresis (imipramine), insomnia (doxepin)
Moderate evidence: separation anxiety, ADHD, phobias, GAD, anorexia,
headaches, diabeticneuropathy and other pain syndromes (amitriptyline,
doxepin), sleep apnea (protriptyline),cocaine abuse (desipramine)
Monoamine oxidase inhibitors Strong evidence: panic disorder, bulimia
(MAOIs) Moderate evidence: other anxiety disorders, anorexia, body dysmorphic
disorder
HANDOUT 1.1: Target Symptoms for Antidepressant Drugs
82
TARGET SYMPTOMS FOR ANTIDEPRESSANT DRUGS
 Middle and terminal insomnia

 Appetite disturbances
 Anxiety and anxiety disorders
 Fatigue
 Poor motivation
 Somatic complaints
 Agitation
 Motor retardation
 Dysphoric mood
 Subjective depressive feelings (anhedonia, poor selfesteem, pessimism, hopelessness, self-reproach, guilt,
helplessness, sadness)
 Suicidal thoughts
83
HANDOUT 1.1: Dosage of Antidepressant Drugs
84
Handout 1.1: Nursing Consideretion for Antidepressant Drug side effects
85
HANDOUT 1.1: Dosage for Antidepressant Drugs
HANDOUT 1.1: Indication for Antidepressant Drugs
86
HANDOUT 1.1: Interventions to Improve Medication Adherence
87
88
SESSION 10: CARE OF PATIENTS WITH PERSONALITY DISORDERS
Prerequisite: None
Learning Tasks
Define personality and personality disorder
Describe types of personality disorders
Assess for personality disorders
Give care to patient with personality disorder
Refer a patient for further management
Resources Needed:
Session overview
1 5 Presentation Session Title and Learning Objectives

2 5 Presentation Definition of personality and personality disorder
3 15 Buzzing Types of personality disorders
Lecture discussion
4 40 Group Discussion Assessment of personality disorders
Lecture discussion
5 30 Buzzing Care of patient with personality disorder
Lecture discussion
6 15 Brainstorming Referring a patient with personality disorder for
Lecture discussion further management
SESSION CONTENTS
89
STEP 2: Definition of Personality and Personality Disorder(5 Minutes)

ASK the student to brainstorm on the definition of Personality and Personality Disorder
ALLOW 3 to 4 students to respond and let other provide additional responses
WRITE their responses on the flip chart/ board
CLARIFY and SUMMARIZE by using the content below
Definition of Personality Disorders

 Personality is a set of deeply ingrained, enduring patterns of thinking, feeling, and behaving.
 A personality disorder is a set of patterns or traits that hinder a person’s ability to maintain
meaningful relationships, feel fulfilled, and enjoy life
 It begins in adolescence or early adulthood, is stable over time, and leads to distress or impairment
 Personality disorders are attitudes toward self, others, and the world expressed in everything a
person thinks, feels, and does. They often decrease in severity as a person ages, mainly because
of corrective life experiences.
Features of personality disorders

The following are three key features of personality disorders:
 The individual has an inflexible and maladaptive approach to relationships and the environment.
 The individual’s needs, perceptions, and behavior tend to foster cycles that promote unhelpful
patterns and provoke negative reactions from others.
 The individual’s coping skills are unstable and fragile, and there is a lack of resilience when faced
with stressful situations
STEP 3: Types of personality disorders (15 Minutes)

 ASK the student to brainstorm on the definition of pharmacotherapy in mental health for 3 minutes
 There are ten types of Personality disorders

 The DSM-V-TR (American Psychiatric Association, 2013) has grouped personality disorders into
the following three clusters based on descriptive features:
o Cluster A includes personality disorders of an odd or eccentric nature

 Paranoid personality disorder
 Schizoid personality disorder
 Schizotypal personality disorder
NOTE: The common features of the personality disorders in this cluster are social
awkwardness and social withdrawal. These disorders are dominated by distorted thinking.
90
o Cluster B disorders are of an erratic, dramatic, or emotional
 Antisocial personality disorder
 Borderline personality disorder
 Histrionic personality disorder
 Narcissistic personality disorder
NOTE: Disorders in this cluster share problems with impulse control and emotional regulation.
o Cluster C includes disorders of an anxious or fearful nature

 Avoidant personality disorder
 Dependent personality disorder
 Obsessive-compulsive personality disorder
STEP 4: Assessment of Personality Disorders (40 Minutes)

 ASK the student to form small groups of 5 -8 students and discuss on assessment of personality
disorders
Refer students to Handout 10.1: Assessment of Personality Disorders
General criteria for a Personality Disorder as per DSM -5: TR (APA – 2013)
 The essential features of a personality disorder are impairments in personality (self and
interpersonal) functioning and the presence of pathological personality traits.
 An enduring pattern of inner experience and behavior that deviates from expectations of the
individual’s culture.
 To diagnose a personality disorder, the following criteria must be met:
 Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy)
functioning.
 One or more pathological personality trait domains or trait facets.
 The impairments in personality functioning and the individual’s personality trait expression are
relatively stable across time and consistent across situations. This is an essential element of the
diagnosis that the symptoms of personality disorders are fixed and long lasting
 The impairments in personality functioning and the individual’s personality trait expression are not
better understood as normative for the individual’s developmental stage or socio-cultural
environment.
 The impairments in personality functioning and the individual’s personality trait expression are not
solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a
general medical condition (e.g., severe head trauma).
STEP 5: Care of Patient with Personality Disorder (30 Minutes)
91
 ASK the student to pair up and BUZZ on Care of Patient with Personality Disorder.
 Nursing interventions for individuals with personality disorder help the patient recognize specific
behaviors distressing to self, others, or both; manage feelings; and develop coping behaviors that
are less dysfunctional.
 Conduct physical assessment on admission and monitoring the patient’s physical status throughout
the hospitalization
 Prepare the nursing treatment or care plan to provide a guide for intervention and promote
consistency among the treatment staff members who provide care to the patient
 The nurse must be physically present with the patient on a regular basis to foster an opportunity for
interaction as nursing care is based on accessibility
 Provide full spectrum of treatment including psychotherapy, engaging patients as collaborators in a
strong treatment alliance, the need for a primary clinician to care for the patient, psychoeducation,
family involvement, and limited use of medications
 Borderline personality disorder is the only major psychiatric disorder for which psychosocial
interventions are the primary treatment.
 Strong evidence supports the efficacy of the atypical antipsychotic medication olanzapine in
reducing anger, impulsivity- aggression, possibly depression, and interpersonal sensitivity in
borderline personality disorder
 Maintain the patient’s safety, facilitate the patient’s participation in care, select the least restrictive
intervention, support behavior change, and help the patient assume responsibility for his own
actions, safety is a nursing priority.
 Involvement the family members as is important in promoting and maintaining positive change for
the patient and family
 Provide education of patients and significant others
 Provide milieu therapy, Milieu work with patients with personality disorders is most effective if it
focuses on realistic expectations and decision making and social behaviors in the here and now.
The best therapeutic milieu is one in which mature, responsible behavior is expected
 Nursing interventions should focus on mobilizing strengths to enhance patient’s self-esteem and
using adaptive defenses and positive coping skills
 Observe the patient constantly to prevent physical harm.
 For patients with cluster B personality disorders:
o Implement a clear structure with rules that are fair, firm, and consistently enforced.
o Provide support while the patient learns to experience painful feelings and try out new
behavioural responses.
NOTE: Even with treatment, it is not possible to completely change someone’s personality. It is
possible to help people with personality disorders improve the quality of their lives. Treatment can lead
to significant improvement in the symptoms, distress, and general functioning of patients with
personality disorders.
92
 Nursing functions when working with patients with personalitydisorders in milieu therapy are
intended to do thefollowing:
o Provide a structured environment.
o Serve as an emotional sounding board.
o Clarify and diagnose conflicts and consequences ofactions.
o Facilitate adaptive change in behaviour.
STEP 6: Referring a Patient with Personality Disorder for Further Management (15 Minutes)


ASK the form groups of 5 to 8 students and discuss about referring a Patient with Personality
Disorder for Further Management

ALLOW 2 to 3 groups to respond and let other provide additional responses

WRITE their responses on the flip chart/ board

CLARIFY and SUMMARIZE by using the content below
The following are the indications for Inpatient Hospitalization which may need referral if the facility
cannot provide the necessarily interventions
 Prevention of harm to self or others
 Stabilization to allow treatment at a less restrictive level of care
 Initiation of a treatment process for patients with safety risks who must be monitored by specially
trained personnel
 Management of severe symptoms such as significant confusion, disorganization, and inability to
care for self
 Need for a rapid, multidisciplinary diagnostic evaluation that requires frequent observation and
monitoring by specially trained personnel
 Summarize the care provided to patient including medications, activities of daily living,
ongoingcomprehensive health care, available support and reason for referral
 Inform the receiving institution about the referral if possible
93
 All individuals have personality traits and characteristics that make them unique and interesting
human beings. Traits are exhibited in the way individuals think about themselves and others and in
the way they behave.
 Individuals with personality disorders have a significant and persistent impairment in their
interpersonal relationships and other aspects of functioning. They are chronic disorders marked by
deviations in cognition, affect, impulse control and interpersonal functioning
 Despite the relatively fixed patterns of maladaptive behaviour, some patients with personality
disorders are able to change their behaviour over time as a result of treatment.
 All personality disorders share characteristics of inflexibility and difficulties in interpersonal
relationships that impair social or occupational functioning
 Psychotherapy is the most important component in the treatment of borderline personality disorder,
leading to large reductions in symptoms that persist over time

 What are the 10 types of personality disorders?.
 What is the role of the nurse when treating a patient with personality disorders?
 What are the key features of personality disorders?
94
References
Elsevier Sounders
95
HANDOUT 10.1: Assessment of Personality Disorders
Antisocial Personality Disorder (DSM-5 Criteria - Revised April 2012)

The essential features of a personality disorder are impairments in personality (self and interpersonal)
functioning and the presence of pathological personality traits. To diagnose antisocial personality
disorder, the following criteria must be met:
A. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning (a or b):
a. Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.
b. Self-direction: Goal-setting based on personal gratification; absence of prosocial
internal standards associated with failure to conform to lawful or culturally normative
ethical behaviour.
AND
2. Impairments in interpersonal functioning (a or b):
a. Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse
after hurting or mistreating another.
b. Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary
means of relating to others, including by deceit and coercion; use of dominance or
intimidation to control others.
B. Pathological personality traits in the following domains:

1. Antagonism, characterized by:
a. Manipulativeness: Frequent use of subterfuge to influence or control others; use of
seduction, charm, glibness, or ingratiation to achieve one’s ends.
b. Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment
or fabrication when relating events.
c. Callousness: Lack of concern for feelings or problems of others; lack of guilt or
remorse about the negative or harmful effects of one’s actions on others;
aggression; sadism.
d. Hostility: Persistent or frequent angry feelings; anger or irritability in response to
minor slights and insults; mean, nasty, or vengeful behaviour.
2. Disinhibition, characterized by:
a. Irresponsibility: Disregard for – and failure to honor – financial and other obligations
or commitments; lack of respect for – and lack of follow through on – agreements
and promises.
b. Impulsivity: Acting on the spur of the moment in response to immediate stimuli;
acting on a momentary basis without a plan or consideration of outcomes; difficulty
establishing and following plans.
c. Risk taking: Engagement in dangerous, risky, and potentially self-damaging
activities, unnecessarily and without regard for consequences; boredom proneness
and thoughtless initiation of activities to counter boredom; lack of concern for one’s
limitations and denial of the reality of personal danger
96
C. The impairments in personality functioning and the individual’s personality trait expression are
relatively stable across time and consistent across situations .
D. The impairments in personality functioning and the individual’s personality trait expression are not
better understood as normative for the individual’s developmental stage or socio-cultural
environment.
E. The impairments in personality functioning and the individual’s personality trait expression are not
solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a
general medical condition (e.g., severe head trauma).
F. The individual is at least age 18 years.
Criteria for Paranoid Personality Disorder (DSM-5 Criteria - Revised June 2011)
functioning and the presence of pathological personality traits. To diagnose Paranoid personality
A. A pervasive distrust and suspiciousness of others such that their motives are interpreted as
malevolent, beginning by early adulthood and present in a various contexts as indicated by four
(or more) of the following:
1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him
or her.
2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or
associates
3. Is reluctant to confide in others because of unwarranted fear that the information will be
used maliciously against him or her
4. Reads hidden demeaning or threatening meanings into benign(kind) remarks or events
5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights)
6. Perceives attacks on his or her character or reputation that are not apparent to other
and is quick to react angrily or to counterattack
7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual
partner
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, or another psychotic disorder and is not attributable to the
physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid”, i.e., “paranoid
personality disorder “premorbid)”
Criteria for Schizoid Personality Disorder (DSM-5 Criteria - Revised June 2011)
97
functioning and the presence of pathological personality traits. To diagnose Schizoid personality
A. A pervasive pattern of detachment from social relationships and a restricted range of
expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety
of contexts, as indicated by four (or more) of the following:
1. Neither desires nor enjoys close relationships, including being part of the family
2. Almost always chooses solitary (lonely) activities
3. Has little, if any, interest in having sexual experience with another person.
4. Takes pleasure in few, if any, activities
5. Lacks close friends or confidants other than first – degree relatives
6. Appears indifferent to praise or criticism of others
7. Shows emotional coldness, detachment, or flattened affectivity
B. Does not occur exclusively during the course of schizophrenia, a bipolar disorder or depressive
disorder with psychotic features, another psychotic disorder or autism spectrum disorder and is not
attributable to the physiological effects of another medical condition.
Note: If criteria are met prior to the onset of schizophrenia, add “premorbid”, i.e., “ schizoid personality
disorder “premorbid)”
Criteria for Paranoid Personality Disorder (DSM-5 Criteria - Revised June 2011)
A pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and
present in a variety of contexts, as indicated by five or more of the following:
1. Is uncomfortable in situations in which he or she is not the centre of attention.
2. Interaction with others is often characterized by inappropriate sexually seductive or provocative
behaviour
3. Displays rapid shifting and shallow expression of emotion
4. Consistently uses physical appearance to draw attention to self
5. Has a style of speech that is excessively impressionistic and lacking in detail
6. Shows self – dramatization, theatricality, and exaggerated expression of emotion.
7. Is suggestible (i.e., easily influenced by others or circumstances)
8. Considers relationships to be more intimate than they actually are
98
Avoidant Personality Disorder (DSM-5 Criteria - Revised June 2011)
functioning and the presence of pathological personality traits. To diagnose avoidant personality
a. Identity: Low self-esteem associated with self-appraisal socially inept, personally
unappealing, or inferior; excessive feelings of shame or inadequacy
b. Self-direction: Unrealistic standards for behaviour associated with reluctance to
pursue goals, take personal risks, or engage in new activities involving
interpersonal contact.
AND
a. Empathy: Preoccupation with, and sensitivity to, criticism or rejection, associated
with distorted inference of others‟ perspectives as negative.
b. Intimacy: Reluctance to get involved with people unless being certain of being liked;
diminished mutuality within intimate relationships because of fear of being shamed
or ridiculed.
1. Detachment, characterized by:
a. Withdrawal: Reticence in social situations; avoidance of social contacts and activity;
lack of initiation of social contact.
b. Intimacy avoidance: Avoidance of close or romantic relationships, interpersonal
attachments, and intimate sexual relationships.
c. Anhedonia: Lack of enjoyment from, engagement in, or energy for life’s experiences;
deficits in the capacity to feel pleasure or take interest in things.
2. Negative Affectivity, characterized by:
a. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction
to social situations; worry about the negative effects of past unpleasant experiences
and future negative possibilities; feeling fearful, apprehensive, or threatened by
uncertainty; fears of embarrassment.
relatively stable across time and consistent across situations.
D. The impairments in personality functioning and the individual’s personality trait expression are
not better understood as normative for the individual’s developmental stage or socio-cultural
environment.
E. The impairments in personality functioning and the individual’s personality trait expression are
not solely due to the direct physiological effects of a substance (e.g., a drug of abuse,
medication) or a general medical condition (e.g., severe head trauma).
Borderline Personality Disorder (DSM-5 Criteria - Revised June 2011)

functioning and the presence of pathological personality traits. To diagnose borderline personality
99
a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often
associated with excessive self-criticism; chronic feelings of emptiness; dissociative
states under stress.
b. Self-direction: Instability in goals, aspirations, values, or career plans.
AND
a. Empathy: Compromised ability to recognize the feelings and needs of others
associated with interpersonal hypersensitivity (i.e., prone to feel slighted or
insulted); perceptions of others selectively biased toward negative attributes or
vulnerabilities.
b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust,
neediness, and anxious preoccupation with real or imagined abandonment; close
relationships often viewed in extremes of idealization and devaluation and
alternating between over involvement and withdrawal.
a. Emotional liability: Unstable emotional experiences and frequent mood changes;
emotions that are easily aroused, intense, and/or out of proportion to events and
circumstances.
b. Anxiousness: Intense feelings of nervousness, tenseness, or panic, often in reaction
to interpersonal stresses; worry about the negative effects of past unpleasant
experiences and future negative possibilities; feeling fearful, apprehensive, or
threatened by uncertainty; fears of falling apart or losing control.
c. Separation insecurity: Fears of rejection by – and/or separation from – significant
others, associated with fears of excessive dependency and complete loss of
autonomy.
d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty
recovering from such moods; pessimism about the future; pervasive shame; feeling
of inferior self-worth; thoughts of suicide and suicidal behaviour.
2. Disinhibition, characterized by:
a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli;
acting on a momentary basis without a plan or consideration of outcomes; difficulty
establishing or following plans; a sense of urgency and self-harming behavior under
emotional distress.
b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging
activities, unnecessarily and without regard to consequences; lack of concern for one ‟s
limitations and denial of the reality of personal danger.
a. Hostility: Persistent or frequent angry feelings; anger or irritability in response to
minor slights and insults.
C. The impairments in personality functioning and the individual‟s personality trait expression are
environment.
100
Narcissistic Personality Disorder (DSM-5 Criteria - Revised June 2011)

functioning and the presence of pathological personality traits. To diagnose narcissistic personality
a. Identity: Excessive reference to others for self-definition and self-esteem regulation;
exaggerated self-appraisal may be inflated or deflated, or vacillate between
extremes; emotional regulation mirrors fluctuations in self-esteem.
b. Self-direction: Goal-setting is based on gaining approval from others; personal
standards are unreasonably high in order to see oneself as exceptional, or too low
based on a sense of entitlement; often unaware of own motivations.
AND
a. Empathy: Impaired ability to recognize or identify with the feelings and needs of
others; excessively attuned to reactions of others, but only if perceived as relevant
to self; over- or underestimate of own effect on others.
b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation;
mutuality constrained by little genuine interest in others‟ experiences and
predominance of a need for personal gain
B. Pathological personality traits in the following domain:
a. Grandiosity: Feelings of entitlement, either overt or covert;self-centeredness; firmly
holding to the belief that one is better than others; condescending toward others.
b. Attention seeking: Excessive attempts to attract and be the focus of the attention of
others; admiration seeking.
environment.
Obsessive-Compulsive Personality Disorder (DSM-5 Criteria - Revised June 2011)

functioning and the presence of pathological personality traits. To diagnose obsessive-compulsive
personality disorder, the following criteria must be met:
101
a. Identity: Sense of self derived predominantly from work or productivity; constricted
experience and expression of strong emotions.
b. Self-direction: Difficulty completing tasks and realizing goals associated with rigid
and unreasonably high and inflexible internal standards of behavior; overly
conscientious and moralistic attitudes.
AND
2. Impairments in Interpersonal functioning (a or b):
a. Empathy: Difficulty understanding and appreciating the ideas, feelings, or behaviors
of others.
b. Intimacy: Relationships seen as secondary to work and productivity; rigidity and
stubbornness negatively affect relationships with others.
1. Compulsivity, characterized by:
a. Rigid perfectionism: Rigid insistence on everything being flawless, perfect, without
errors or faults, including one's own and others' performance; sacrificing of
timeliness to ensure correctness in every detail; believing that there is only one right
way to do things; difficulty changing ideas and/or viewpoint; preoccupation with
details, organization, and order.
a. Perseveration: Persistence at tasks long after the behavior has ceased to be
functional or effective; continuance of the same behavior despite repeated failures.
C. The impairments in personality functioning and the individual‟s personality trait expression are
D. The impairments in personality functioning and the individual‟s personality trait expression are
not better understood as normative for the individual‟s developmental stage or socio-cultural
environment.
E. The impairments in personality functioning and the individual‟s personality trait expression are
Schizotypal Personality Disorder (DSM-5 Criteria - Revised June 2011)

functioning and the presence of pathological personality traits. To diagnose schizotypal personality
C. Significant impairments in personality functioning manifest by:
1. Impairments in self functioning:
a. Identity: Confused boundaries between self and others; distorted self-concept;
emotional expression often not congruent with context or internal experience.
b. Self-direction: Unrealistic or incoherent goals; no clear set of internal standards.
2. Impairments in interpersonal functioning:
a. Empathy: Pronounced difficulty understanding impact of own behaviours on others;
frequent misinterpretations of others‟ motivations and behaviours.
b. Intimacy: Marked impairments in developing close relationships, associated with
mistrust and anxiety.
D. Pathological personality traits in the following domains:
1. Psychoticism, characterized by:
102
a. Eccentricity: Odd, unusual, or bizarre behaviour or appearance; saying unusual or
inappropriate things.
b. Cognitive and perceptual dysregulation: Odd or unusual thought processes; vague,
circumstantial, metaphorical, over-elaborate, or stereotyped thought or speech; odd
sensations in various sensory modalities.
c. Unusual beliefs and experiences: Thought content and views of reality that are
viewed by others as bizarre or idiosyncratic; unusual experiences of reality.
2. Detachment, characterized by:
a. Restricted affectivity: Little reaction to emotionally arousing situations; constricted
emotional experience and expression; indifference or coldness.
b. Withdrawal: Preference for being alone to being with others; reticence in social
situations; avoidance of social contacts and activity; lack of initiation of social
contact.
a. Suspiciousness: Expectations of – and heightened sensitivity to – signs of
interpersonal ill-intent or harm; doubts about loyalty and fidelity of others; feelings of
persecution.
F. The impairments in personality functioning and the individual’s personality trait expression are
environment.
G. The impairments in personality functioning and the individual’s personality trait expression are
Personality Disorder Trait Specified (DSM-5 Criteria - Revised June 2011)

functioning and the presence of pathological personality traits. To diagnose a personality disorder, the
following criteria must be met:
A. Significant impairments (i.e., mild impairment or greater) in self (identity or self-direction) and
interpersonal (empathy or intimacy) functioning.
B. One or more pathological personality trait domains OR specific trait facets within domains,
considering ALL of the following domains.
1. Negative Affectivity
2. Detachment
3. Antagonism
4. Disinhibition vs. Compulsivity
5. Psychoticism
NOTE: Trait domain or one or more trait facets MUST be rated as “mildly descriptive or greater. If trait
domain is rated as “mildly descriptive” then one or more of the associated trait facets MUST be rated as
“moderately descriptive” or greater.
103
environment.
104
SESSION 11: NURSING CARE OF PATIENTS WITH MOOD DISORDERS
Prerequisite: None
Learning Task
At the end of this session learner is expected to be able:
Define mood and mood disorders
Describe types of mood disorders
Assess for mood disorder
Give care to clients/patients with mood disorders
Resources Needed:
Session Overview
Step Time (min) Activity/ Content
Method
1 05 Presentation Learning task
2 10 Brainstorming Definition of mood and mood disorder
3 25 Lecture Types of mood disorder
discussion
4 40 Lecture Assessment of mood disorder
discussion
5 30 Lecture Care to client/patient with mood disorder
discussion
6 05
Presentation Key points
7 05
SESSION CONTENTS
105
 READ or ASK participants to read the learning tasks
STEP 2: Definition of mood and mood disorder (10 Minutes)

Activity: Brainstorming (5 minutes )
 ASK Students to brainstorm on the definition of Mood and Mood disorder

 ALLOW few Students to respond
 WRITE their responses on flip chart /board
 CLARIFY and SUMMARISE by using the content below
 Mood is any sustained emotion, with major influence of person perception
 This is the emotional state of the patient, and determines the general attitude of an individual
 Mood is the patient’s subjective experience of sustained emotions or feelings.
 A person’s mood can only be accurately assessed by asking the person how he or she feels
 Mood disorder refers to disturbance of emotional state of the person that includes mania,
depression and bipolar disorder.Or Disturbance on how people feel
STEP 3: Types of mood disorder (25 Minutes)
 Depression
 Mania
 Hypomania
 Manic-Depressive Psychosis
Mania
 Mania is a mental disorder characterized by mood disorder especially hyper activeness,
Unrestrainedbehavior and violent.
 Mania is a functional mental disorder with a distinct period of psycho-physiologicalactivation
 Manic patient are happiest, most excited and optimistic people you could meet
Aetiological Factors of Mania

 The following are the etiology of mania disorder:
o Genetic vulnerability.
o Physiological stressors-stimuli such as viral infection and child birth including biochemical changes.
o Psychosocial stress-stressful life events that overwhelm coping mechanism.
o Development events – early object loss that may sensitize the individual to future stress.
o Personality organization – low self-esteem, obsessive, seclusive and hypochondriacally
106
Clinical Features of Mania
 The following are clinical features of mania:
o Mood is elevated or irritable or euphoric or may be irritable especially when plans are
interfered.
o Hyperactive (taking of too many activities.)
o Lack of judgment in anticipating consequences.
o Pressured speech and rapid.
o Flight of ideas - thoughts is more quickly than they can be expressed.
o Distractibility.
o Inflated self-esteem.
o Hyper sexuality
o Grandiose delusion
o Loss of weight related to the insomnia and over activity.
o Speech is often loud, rapid and confusing language, irrelevancies that can increase to
loosened associations and flight of ideas.
o Liabilities of mood with rapid shift to depression e.g. laugh and cry.
o Hallucinations of any type
o Ideas of reference
o Delusion of guilt and thoughts of suicide.
Hypomania
 Hypo mania is a mild form of mania, characterized by talkativeness, restlessness and Sleepless
Aetiology Hypomania (stem)

 The constitutional and psychological factor plays a great role in the cause of hypo mania.
 Biochemical disturbances -The serotonin and nor adrenaline raise in the mid brain cause mood
elevation resulting into clinical features of hypo manic,
 Manifested by talkativeness, over activeness, insomnia and shouting
Clinical features of hypomania

 Euphoric mood and often increase in functioning
 Excessive activity and energy lasting for four days
STEP 4: Assessment of mood disorder (30 Minutes)

In assessment of mania and hypomania the following changes can be identified
Mood
 The euphoric mood associated with mania is unstable characterized by euphoria, the patient may
state that he or she is experiencing an intense feeling cheerful, is becoming one with God.
 People experiencing a manic state may laugh, joke, and talk in a continuous stream.
Behavior
In hypomania, they have greedy appetites for social engagement, spending, and activity,
 Constant activity and a reduced need for sleep prevent proper rest.
 Short periods of sleep are possible
107
In mania, a person constantly goes from one activity, place, or project to another many of which are not
completed.
 Hyperactivity may range from mild, constant motion to frenetic, wild activity.
 Individuals become involved in pleasurable activitiesthat can have painful consequences. Such as
spending large sums of money on playful items, giving money awayor making foolish business
investments canleave an individual or family penniless.
 Sexual indiscretion candissolve relationships and marriages and lead to sexually
transmitteddiseases.
 Religious preoccupation is a common symptomof mania.
 Modes of dress often reflect the person’s grandiose unusual, bizarre, colorful, and noticeably
inappropriate.
 People with mania are highly distractible, poor concentration and judgments.
Thought Processes and Speech Patterns

 Flight of ideas is a nearly continuous flow of accelerated speech with abrupt changes from topic to
topic that are usually based on understandable associations or plays on words.
 The content is often sexual explicitly ranges from grossly inappropriate to vulgar common in mania
 And the tone is loud, bellowing, or even screaming.
 Clang associations are the stringing together of words because of their rhyming sounds, without
regard to their meaning common in mania
 Grandiosity is apparent in both the ideas expressed and the person’s behavior.
 People with mania may exaggerate their achievements or importance, state that they know famous
people, or believe they have great powers.
 Grandiose persecutory delusions are common. Eg. People may think thatGod is speaking to them
or that the FBI is out to stop them from saving the world.
 Alteration in sensory perception leading to hallucination commonly in mania
Cognitive functioning
 The onset of bipolar disorder is often preceded by comparatively high cognitive function; however,
there arecognitive problems and difficulties in psychosocial areas.
 The potential cognitive dysfunction among many people withbipolar disorder has specific clinical
implications
o Cognitive function affects overall function.
o Cognitive deficits correlate with a greater number of manicepisodes, history of psychosis,
chronicity of illness, and poorfunctional outcome.
 Medication selection should consider not only the efficacy ofthe drug in reducing mood symptoms
but also the cognitiveimpact of the drug on the patient
Refer HandoutBipolar Disorder Assessment Guidelines
108
STEP 5: Care to client/patient with mood disorder (40 Minutes)
 Ensure good therapeutic environment in order not to harm him and others.
 Create good interpersonal relationship.
 Give simple explanation and concise and trustful answers as they are very talkative.
 Constructive limit setting to safe guard patient and others.
 Encourage patient to carry out agreed limits - use pressure applied by peers rather thanstaff.
 Supervision closely during meal times as may be too busy to eat - setting limits and firmactions are
necessary.
 Elated patients need little encouragement to become involved with others, they needsimple and
that can be completed quickly because of their short attention span andrestlessness. They need
room to move about and furnishing that does not over stimulatethem.
 Occupational and recreational tasks can be most valuable.
 Movement and physical exercise,walking, etc. may help the patient physical conditionand release
emotions and tensions
 Administer drugs such as lithium carbonate to suppress symptoms of the patient.
 Provision for general body care
 Electroconvulsive therapyis used to subdue severe manic behavior, especially in patients with
treatment-resistant mania and patients with rapid cycling
 Team work and safety Staff work together to create a climate of teamwork and safety for patients
who are at risk for self-harm during the acute phase. The whole treatment team is trained to
recognize changesthat may lead to unsafe behavior. Control of hyperactivity during the acute
phase almost always includes immediate treatment with an antipsychotic drug.
 Psychotherapy Psychotherapeutic treatments can also help patients improve their functioning
between episodes and attempt to decrease the frequency of future episodes.Cognitive-behavioral
therapy (CBT) is typically used as It involves identifying maladaptive thoughts and that may be
barriers to a person’s recovery and ongoing mood stability.
 Refer the patient for further management:
o Referral to a specialized facility for diagnosis, management or for ongoing treatment.
o The four main considerations when referring the patient are diagnostic difficulty, clinical severity
as judged by symptoms severity and disability, response to treatment already initiated and the
nature of the service referred for i.e. treatment or therapy

 Mood is the emotional state of the patient, and determines the general attitude of an individual
 Mood disorder refers to disturbance of emotional state of the person that includes mania,
depression and bipolar disorder
 Assessment is key procedure that will determine the proper pharmacological and non-
pharmacological treatment of mood disorder
 A main cause of bipolar disorder is heredity, personality, psychological factors and physiological
stress.
 Mood stabilizing medication is the drugs of choice
109
STEP 7: Session Evaluation (5minutes)
 What is the definition of mood and mood disorder?
 What are the clinical features of mania?
110
References
Elsevier Sounders
111
Handouts11:1Bipolar Disorder Assessment Guidelines
Bipolar Disorder Assessment Guidelines
 Assess whether the patient is a danger to self and others: Patients experiencing mania can
exhaust themselves to the point of death.
 Patients may not eat or sleep, often for days at a time.
 Poor impulse control may result in harm to others or self.
 Uncontrolled spending may occur.
 Assess the need for protection from uninhibited behaviors. External control may be needed to
protect the patient from such consequences as bankruptcy, because patients experiencing
mania may give away all of their money or possessions.
 Assess the need for hospitalization to safeguard and stabilize the patient.
 Assess medical status. A thorough medical examination helps to determine whether mania is
primary (a mood disorder—bipolar disorder or cyclothymic disorder) or secondary to another
condition.
 Mania may be secondary to a general medical condition.
 Mania may be substance-induced (caused by use or abuse of a drug or substance or by toxin
exposure).
 Assess for any coexisting medical condition or other situation that warrants special intervention
(e.g., substance abuse, anxiety disorder, legal or financial crises).
 Assess the patient’s and family understands of bipolar disorder, knowledge of medications, and
knowledge of support groups and organizations that provide information on bipolar disorder.
112
SESSION 12: NURSING CARE TO PATIENT WITH DEPRESSION AND
MANIC-DEPRESSIVE DISORDER
Prerequisite: None
Learning Tasks
At the end of this session a learner is expected to be able to:
Define Depression and Manic-Depressive Disorder
Outline the aetiological factor of Depression and Manic-Depressive Disorder
Mention the clinical features of Depression and Manic-Depressive Disorder
Assessment of patient with Depression and Manic-Depressive Disorder
Nursing care of patient with Depression and Manic-Depressive Disorder
Resources Needed:
Session Overview
1 05 Presentation Presentation of session title andLearning task

2 10 Brainstorming Definition of depression and manic depressive
Lecture discussion disorder
3 15 Buzzling Aetiological factors of Depression and Manic
Lecture discussion Depressive Disorder
4 20 Lecture discussion Clinical features of Depression and Manic
Depressive Disorder
5 35 Lecture discussion Assessment of patient with Depression and Manic
Depressive Disorder
6 25 Lecture discussion Nursing care of patient with Depression and Manic
Depressive Disorder
CONTENTS
113
 READ or ASK participants to read the learning task
STEP 2: Definition of Depression and Manic Depressive Disorder (10 minutes)

 ASK Students to brainstorm on the definition of Depression and Manic depressive disorder
 ALLOW few Students to respond
 WRITE their responses on flip chart /board
 CLARIFY and SUMMARISE by using the content below:
Depression
 Is an abnormal extension or overelaboration of sadness and grief
 Can refer to a sign, symptom, syndrome, emotional state, reaction, disease or clinical entity.
 Is clinical condition that is severe, mal adaptive and incapacitating
 Common subtypes of depression include: psychotic depression, melancholic depression, atypical
depression, seasonal depression, and post-partum psychosis
Manic-Depressive Psychosis/Bipolar Disorder

 Bipolar disorder is a cyclic mental disorder characterized by mood disturbance with episode of
mania, depression or mixed episodes.
 Is a psychotic disorder characterized by the mood swing of depression and elation
 The most common picture of bipolar disorder is repeated episodes of mania or depression, usually
separated by periods of complete remission
STEP 3:Aetiological factors of Depression and Manic Depressive Disorder (25

minutes)

 ASK students to pair up and buzz on etiological factors of Depression and Manic Depressive
Disorder6 minutes
 ALLOW 2 to 3 students to provide responses and let others provide additional responses
 WRITE their responses on the board/flipchart
 CLARIFY and summarize by using the content below:
Aetiological Factors of Depression

 Heredity, family history of depression especially in 1 st degree relatives
 Personality style (anxiety, over-sensitivity
 Dysfunctional relationships
 Social stress ie unmarried, absence of social support ,negative life events
114
 Physiological stresses e.g., hormonal and biochemical changes, fatigue, physical complications,
electrolyte disturbance especially sodium and potassium.
 Alcohol and substance abuse
 Early childhood trauma
 Ineffective coping skills
 Medical illness& chronic illness
Aetiology Manic-Depressive Psychosis/Bipolar Disorder

 Hereditary factors
 Personality vulnerability -Depressive mood and elated mood (Cyclothymic)
 Psychosocial stress - development stresses, and environmental stresses.
 Physiological stressors -viral infections, hormonal changes and biochemical disturbances
STEP 4: Clinical features of Depression and Manic Depressive Disorder (20 minutes)
Clinical Features of patient with Depression
 Marked depressed mood.
 Loss of interest or enjoyment
 Reduced self-esteem and self confidence
 Feeling of guilt and worthlessness
 Bleak and pessimistic views of the future
 Ideas or acts of self-harm or suicide
 Disturbed sleep and appetite
 Decreased libido
 Reduced energy leading to fatigue and diminished activity
 Reduced concentration and attention
Clinical Features of patient with Manic Depressive Disorder

Symptom of mania includes:
 Elevated mood
 Grandiose delusions
 Increased energy and activity.
 Flight of ideas
 Rapid , pressured speech
 Increased libido leading to inappropriate sexual activity example promiscuity, removing clothes in
public
 Impaired judgment and impulsive behavior leading to gross over spending and poor decision
making.
 Decreased need for sleep
 Increased sociability.
 Impaired concentration and attention.
 Hallucinations
 Distraction by environment events
115
 Purposeless movement
Symptoms of depression include:

 Depressed mood
 Loss of interest and enjoyment.
 Reduced self-esteem and self confidence
 Feeling of guilt and worthlessness
 Ideas of suicide
 Disturbed sleep
 Disturbed appetite
 Reduced energy leading to fatigue and diminished activity.
 Reduced concentration.
STEP 5: Assessment of patient with Depression and Manic Depressive Disorder (25
Minutes)
Assessment of patient with depression

 Depressed moods, anhedonia, anergia and anxiety are the symptoms in depression.
 In a depressive episode, thinking is slow, and their memory and concentration are usually
negatively affected.
 A person with major depression may experience delusions of being punished for committing bad
deeds or being a terrible person. Feelings of worthlessness, hopelessness, guilt, anger, and
helplessness are common.
 They also experience psychomotor agitation, psychomotor retardation, Somatic complaints such as
headaches, malaise, backaches, chronic pain ,change in bowel movements and eating habits,
sleep disturbances, and disinterest in sex
Areas to asses include:

Affect
 Affect is the outward representation of a person’s internal state of being and is an objective finding
based on the nurse’s assessment.
 They may shows poor posture, may look older than the stated age.
 Facial expressions convey sadness and dejection, and the patient may have frequent bouts of
weeping, feelings of hopelessness and despair
 For example, failure to maintain eye contact, may speak in a monotone, may show little or no facial
expression (flat affect), and may make only yes or no responses and frequent sighing.
Thought Processes
 During a depressive episode, the person’s ability to solve problems and think clearly is negatively
affected.
 They may shows poor judgment and indecisiveness, memory and concentration
 Patients might complain of intrusive negative thoughts.
 Evidence of delusional thinking may also be seen in a person with major depression.
116
Mood
 Feelings experienced by those with depression include anxiety, worthlessness, guilt, helplessness,
hopelessness, and anger.
 Feelings of worthlessness range from feeling inadequate to having an unrealistically negative
evaluation of self-worth.
 These feelings reflect the low self-esteem that is a painful partner to depression.
 Statements such as “I am no good” or “I’ll never amount to anything” are common.
Physical Behavior
 Psychomotor retardation following lethargy and fatigue result in slow movements decreased facial
expressions and gaze is fixed. The continuum of psychomotorretardation may range from slowed
and difficult movements to complete inactivity and incontinence.
 Psychomotor agitation, in which patients constantly pace, bite their nails, smoke, tap their fingers,
or engage in some other tension-relieving activity,
 Grooming, dress, and personal hygienePeople who usually take pride in their appearance and
dress may be poorly groomed and allow themselves to look shabby and unkempt and completely
neglected. They may neglect to bathe, change clothes, or engage in other basic self-care activities.
 Change in sleep patternsis a cardinal sign of depression; people experience insomnia, wake
frequently, and have a total reduction in sleep, especially deep-stage For some, sleep is increased
(hypersomnia) and provides an escape from painful feelings. In any event, sleep is rarely restful or
refreshing.
 Changes in bowel habits Constipation is seen most frequently in patients with psychomotor
retardation. Diarrhea occurs less frequently, often in conjunction with psychomotor agitation or
anxiety.
 Interest in sexloss of libido occur during depression, some men experience impotence, and a
declining interest in sex often occurs among both men and women, which can further complicate
marital and social relationships.
 Vegetative signs of depressionrefer to alterations in those activities necessary to support physical
life and growth eating, sleeping, elimination, sex., Changes in eating patterns anorexia; however,
overeating and weight gain may occur.
Communication
 A person with depression may speak and comprehend very slowly and lack of an immediate
response by the patient.
 Does not necessarily mean the patient has not heard or chooses not to reply; the patient may need
more time to comprehend what was said and then compose a reply.
 In extreme depression, however, a person may become mute.
Religious Beliefs and Spirituality

 The spiritual beliefs and practices were associated with lower rates of depression and recurrence of
depressive symptoms.
117
 Sreevani and Reddemma (2012) found that depression prevented individuals from engaging in the
spiritual rituals, such as prayer and attendance at church that helped in dealing with negative
thoughts and other symptoms of depression.
 The authors concluded that efforts to support spiritualityare beneficial in patients with depression.
Age Considerations
Assessment in Children and Adolescents
 The core symptoms of depression in children and adolescents are the same as for adults; namely,
sadness and loss of pleasure but they differ in the way symptoms displayed e.g. a very young child
may cry, a school-age child might withdraw, and ateenager may become irritable in response to
feeling sad or hopeless.
 In general, depressed children and adolescents may display increased irritability, negativity,
isolation, anxiety, anger and withdrawal along with a loss of energy
 Younger children may suddenly refuse to go to school while adolescents may engage in substance
abuse or sexual promiscuity and be preoccupied with death or suicide.
Assessment of Older Adults

 It can be easy to overlook depression in older adults because they are more likely to complain of
physical illness than emotional concerns. Older patients likely have comorbid physical issues, and it
is difficult to ascertain whether fatigue, pain, and weakness are the result of an illness or
depression
Assessment of patient with manic depressive disorder

 Manic depressive psychosis is characterized by at least one week of long manic episode that result
in excessive activity and energy alternate with depression .
 Manic depressive may have time of symptoms free.
STEP 6: Nursing care of patient with Depression and Manic Depressive Disorder (25
Minutes)
Care and Treatment to client/patient with Depression

 The highest in priority in case of the patient with severe mood disorder-hospitalization is definitely
indicated when there is suicidal risk.
 Provide Physiological care: Includes physical care, psychopharmacological, and somatic therapies.
 Administer antidepressants to elevate the mood of the patient such as:
o Tricyclics -Amitriptyline, Imiprimine, Clomiprimine (anafranil).
o Non tricyclics – Ludomil
o MomoamineOxidise Inhibitors-Marplan ( isocarboxazid)
o Somatic Therapies (physical) i.e. Electro convulsive therapy, Sleep deprivation therapy -
Research indicates that depraving some patient of a night’s sleep will improve their clinical
condition.
118
o Phototherapy or light therapy. Patients are exposed to bright, artificial light for a specified
amount of time each day.
o Expressing feelings: Encouraging the patient to express unpleasant or painful emotions can
reduce their intensity and make the patient feel more alive and masterful
o Relaxation techniques may help to deal with their anxiety and tension.
 Modify the patient’s thinking (negative thought to positive thoughts) so as to increase the
patients’ sense of control and self-esteem.
 Planned activities, strategies, or home works assignments determined by the nurse and patient
can help to reveal alternative coping responses.
o Patient should not be forced to the activities initially.
o Avoid too many people contact during activities and the nurse should encourage activities gradually
and suggest more involvement on the basis of patient energy.
o The particular task should not be neither too difficult nor too time consuming.
o Social skills: Provide an experience incompatible with depressive withdraw and also provides
increased self-esteem through the social reinforces of approval, acceptance, recognition and
support.
o Avoiding discrimination
o Encouraging social support, confidence, problem-solving and tension reduction
 Family involvement
o Family and group work can benefit patients with depression to reinforce adaptive, non-depressive
behavior and ignore maladaptive depressive responses.
 Group treatment
o Realistic sympathy and support by the group members , enable depressed patient to lessen guilt,
through group can learn more about individuals behavior and relationships with others, increase
social support, gain sense of identity’s, self-understanding, and control over their own lives.
 Mental health education
o Provision of mental health education regarding the nature, extent and treatments available for
mood disorders.
Care and Treatment to client/patient with Manic Depressive Disorder
 Provide prescribed drugs e.g. Tranquillizers to calm the patient, sedatives to induce sleep,
 Psychotherapy -supportive type when the patient has improved and Occupation therapy to occupy
the patient
 Induce sleep and rest by keeping the patient in non-stimulating environment.
 Occupy the patient by indoors games - playing cards, and later with without games such as foot
ball
 Maintain nutritional status by feeding the patient on a balanced diet.
 Ensure general body cleanliness.
 Provide psychological support
 Provide behavioral therapy by showing the patient right way of doing things and accept his
pathological conducts.
 Be aware of the patients’ reactions and annoyances-show tolerance.
 Involve the patients’ relatives to plan future for the patient prior discharge.
 Referral to a specialized facility for diagnosis, management or for ongoing treatment.
119
 The four main considerations when referring the patient are diagnostic difficulty, clinical severity as
judged by symptoms severity and disability, response to treatment already initiated and the nature
of the service referred for i.e. treatment or therapy

 Depression is an abnormal extension or over elaboration of sadness and grief
 Bipolar disorder is a cyclic mental disorder characterized by mood disturbance with episode of
mania, depression or mixed episodes
 Nursing care of patient with depression are to provide Physiological care, family involvement, group
treatmentand mmental health education
 Nursing care of patient with manic depressive psychosis are provide prescribed drugs,
psychotherapy –support, induce sleep and rest maintain nutritional status

 What is depression
 What is Manic Depressive disorder?
 What are the clinical features of Mania ?
 What are the nursing cares of patient with depression?
120
References
Elsevier Sounders
121
SESSION11: NURSING CARE TO PATIENTS WITH DISSOCIATIVE AND
SOMATOFORM DISORDERS
Prerequisite:
Learning Tasks
Define somatoform and dissociative disorders
Describe types of somatoform and dissociative disorders
Identify etiology of somatoform and dissociative disorder
Assess for somatoform and dissociative disorders
Give care to clients/patients with somatoform and dissociative disorders
Refer patients/ clients for further management
Resources Needed:
Session Overview
1 05 Presentation Presentation of Session Title na Learning tasks

2 10 Brainstorming
Presentation Define somatoform and dissociative disorders
3 30 Lecture discussion Describe types of somatoform and dissociative
disorders
4 20 Buzzing Identify etiology of somatoform and dissociative
Lecture discussion disorder
5 20 Presentation Assess for somatoform and dissociative disorders

122
SESSION CONTENTS
STEP 1: Presentation of Session Title and Learning task (5 minutes)

READ or ASK participants to read the learningtask
STEP 2: Define Somatoform and Dissociative Disorders(10 Minutes)
Activity: Activity: Brainstorming (5 minutes )

ASK Students to brainstorm on the definition of Somatoform and Dissociative Disorders
ALLOW few Students to respond
WRITE their responses on flip chart /board
CLARIFY and SUMMARISE by using the content below
Somatoform disorders are characterized by physical symptoms suggestion medical disease, but
without demonstrated organic pathology or known pathophysiological mechanism to account for them.
Psychological factor are the major cause of symptoms and there is no any medical treatment that is
required
Dissociative disorders refer to disruption in the usually integrated function of consciousness, memory,
identity or perception
Occur when anxiety become overwhelming and personality becomes disorganized
STEP 3: Types of Somatoform and Dissociative Disorders (30 Minutes)
Types of somatoform disorder are
 Somatizatization disorder: is a syndrome of multiple somatic symptoms that cannot be

explained medically and are associated with psychological distress and long term seeking
assistance from health care professionals.
Symptoms are
o Pain in four different sites

o Gastrointestinal symptoms i.e nausea, vomiting, diarrhoea
o Sexual symptoms i.e irregular menses,erectile or ejaculatory symptoms
o Anxiety and depression characterized by suicidal threats and attempts
Complication of somatization disorder is drug abuse and dependence
123
 Pain disorder severe and prolong pain that cause clinically significant distress or impairment in
social, occupational or other important areas of functioning
o Onset, severity or exacerbation based on psychological factors
o Occur in correlation with psychological stressor
Characteristics behavioursare
o Frequent visit of the physician

o Excessive usage of analgesic
o Symptoms of depression
o Dependency on addictive disorder
 Hypochondriasis unrealistic or inaccurate interpretation of physical symptoms, sensational,
leading to preoccupation and fear of having a serious disease
 Medical disease may be present, but the individual with Hypochondriasis the symptoms are
excessive in relation to the degree of pathology
 Pre-occupation may be with specific organ or disease cardiac disease with bodily function
peristalsis, small sore as skin cancer
Characteristics behaviour are
o Long history
o Anxiety and depression
o Obsessive compulsive traits
o Impaired social and occupational functioning
 Conversion disorder is a loss of or change in body functioning in body function result from a
psychological conflict, the physical symptoms cannot be explained by any known medical
disorder or pathophysiological mechanism
Characteristics behaviours are
o Affect voluntary motor or sensory functioning suggestive of neurological disease such
as paralysis,aphonia,seizures,coordinationdisturbances, difficult swallowing ,urinary
retention,akinesia,blindness,deafness,doublevision, anosmia ,loss of pain sensation
and hallucination
Body dismophic disorderis characterized by belief that the body is deformed or defective in some
specific way
o Complaining involving imagined or slightly flaws of the face ,or head,thininghair, acne .wrinkles,
scars ,vascular markings and facial swelling
o Symptoms of depression
o Characteristics of obsessive compulsive personality
o Social and occupational impairment
Types of dissociative disorder
Dissociative amnesia is an inability to recall important personal information, usually of traumatic or

stressful nature
124
o Localized amnesia the inability to recall the traumatic event for a specific period of time
following the event
o Selective amnesia the inability to recall only certain events for specific period of time
o Continuous amnesia the inability to recall events occurring after a specific time up and
including the present
o Generalized amnesia not being able to recall anything that has happened during the individual
entire lifetime including personal identity
o Systematized amnesia cannot remember event that relate to specific category of information
 Dissociative fugue a sudden, unexpected travel away from home or customary activity place of
daily activity with inability to recall some or all of ones pasts including personal identity
Last in hours to day
o Minimal contact with other people

o Assume new identity
 Dissociative identity disorder existence of two or more personality in a singleindividual, one
personality is evident at any given moment and one of them is dominant most of the time over
the course of disorder
 Each personality is unique and change from one personality to another is sudden and most of
the time triggered by stress
Characteristics behaviouris
Amnesia when one personality is dominant
 Depersonalization disorder temporally change in the quality of self-awareness, which often

takes from the feeling of unreality, changes in body image feeling of detachment from
environment
o Object in the environment are perceived as altered in size and shape

o Accompanied by fear, anxiety, depression, fear of going insane
o Somatic complaints and disturbances
STEP 4: Etiology of Somatoform and Dissociative Disorder(20 Minutes)

ASK students to pair up and buzz on Etiology of Somatoform and Dissociative
Disorder
125
ALLOW 2 to 3 students to provide responses and let others provide additional
responses
WRITE their responses on the board/flipchart
CLARIFY and summarize by using the content below
Etiology of SomatoformDisorder
o Genetics increased incidence in first degree relatives
o Biochemical decrease level of serotonin and endorphin
o Psychodynamic low self-esteem, feeling of worthless
o Family dynamics related to difficult expressing emotion s and resolving conflict openly
o Past experience with serious or life threaten physical illness
Etiology of Dissociative Disorder
o Genetics increased incidence in first degree relatives and seen in more than one generation
o Neurobiological neurological alteration
o Psychodynamic theory –repressed distressing mental content from conscious awareness
o Psychological trauma traumatic experience that overwhelm the individual capacity to cope by
any other means ,events like physical and sexual abuse
STEP 5: Assessment ofSomatoform and Dissociative Disorders (20 Minutes)
Assessment of Somatoform disorder and dissociative disorder information gathered during assessment
are very crucial in nursing diagnosis and care and the key features that will help nurse during
assessment and come with the conclusion as this is somatoform disorder and dissociative disorder are
as follows:
 Verbalization of numerous physical complaints in the absence of pathological evidence
 Verbal complaining of pain with evidence of psychological contributing factor and excessive
use of analgesic
 Seeking to be alone refusal to participates in therapeutic activity
 Preoccupation with and unrealistic interpretation of bodily sign and sensation
 Transformation of internalized anger into physical complain and hostility toward other
 Loss of or alteration in physical functioning without evidence of organic pathology
 Loss of memory
 Verbalization of frustration over lack of control and dependency on other
 Fear of unknown circumstances and surroundings unresolved grief ,depression, self-blame
,associated with child abuse
 Presence of more than one personality within the individual
 Alteration in the perception or experience of the self-environment
STEP 6: Care of Clients/Patients with Somatoform and Dissociative Disorders
(25 Minutes)
 Fulfil the client most urgent dependent need but gradually withdraw attention to physical
symptoms
 Encourage client to verbalize fear and anxiety
126
 Discuss possible alternatives coping strategies the client may use in response to stress
 Monitor on-going assessments, laboratory report and other data to maintain assurances that
possibly of organic pathology is clear ruled out
 Identify activities that serve to distract client from focus on self and pain
 Observe and record the duration and intensity of pain .note the factors that precipitate the
onset of pain
 Provide nursing comfort measure i.e backrub, warm bath
 Provide pain medication as prescribe
 Provide positive reinforcement for time when client is not focusing on pain or physical
symptoms
 Do not focus on disability and encourage patient to be independent as possible
 Identify primary or secondary gain that the physical symptoms is providing to the clients
 Involve client in activity that reinforce a positive sense of self not based on appearance
 Provide support and encouragement during the time of depersonalization
 Reassure client safe and security through your presence
 Identify stressor that precipitated severity anxiety
 Help client define more adaptive coping strategies and help with new strategies which can help
 Develop a trust relationship with the original personality and with each of the sub personality
 Referring Patients/client with new physical illness to physician, referral to supportive group of
individual with similar histories, survival of suicide, adult abuse

 Somatoform disorders are characterized by physical symptoms suggestion medical disease,
but without demonstrated organic pathology or known pathophysiological mechanism to
account for them
 Dissociative disorders refer to disruption in the usually integrated function of consciousness,
memory, identity or perception
 Etiologies of Somatoform Disorder are genetics increased incidence in first degree relatives,
biochemical decrease level of serotonin and endorphin, psychodynamic low self-esteem,
feeling of worthless, family dynamics related to difficult expressing emotion s and resolving
conflict openly, past experience with serious or life threaten physical illness
 Etiologies of Dissociative Disorder are genetics increased incidence in first degree relatives
and seen in more than one generation, neurobiological neurological alteration, psychodynamic
theory –repressed distressing mental content from conscious awareness, psychological trauma
traumatic experience that overwhelm the individual capacity to cope by any other means
,events like physical and sexual abuse
 What is meaning of the term somatoform and dissociative disorder?
 What are the etiologies of somatoform and dissociative disorder?
REFERENCES
127
Elsevier Sounders
128
Session Fourteen: Session 13:CARE TO PATIENTS WITH PSYCHOTIC
DISORDERS
Learning task

Define psychotic disorder
Describe types of psychotic disorders
Assess for psychotic disorders
Give care to patients/clients with psychotic disorders
Resources Needed:

Method
1
05 Presentation Learning task
2 05 Brainstorming Definition of psychotic disorder
3 45 Brainstorming Types psychotic disorder

Lecture discussion
4 35 Lecture discussion/ Assessment for psychotic disorder
5 35 Buzzling Care to client/patient with psychotic disorder

Lecture discussion
6 05
7 05
SESSION CONTENTS
129
READ or ASK participants to read the learning tasks
STEP 2: Definition of psychotic disorder (10Minutes)
ASK Students to brainstorm on thepsychotic disorder?

 Psychotic disorder psychotic disorders are severe mental disorders that cause abnormal
thinking and perceptions.
 Person’s personality is severely confused and that person loses touch with reality.
 Hallucinations, delusions, and disordered forms of thinking are the main clinical features.
STEP 3: Types of psychotic disorder (45 Minutes )
ASK Students to brainstorm on thetypes of psychotic disorder
Types of psychotic disorder

o Schizophrenia
o Schizoaffective disorder
o Brief psychotic disorder
o Schizophreniform disorder
o Delusional disorder
o Shared psychotic disorder
o Psychotic disorder due to general medical condition
o Substance induced psychotic disorder
Schizophrenia
130
 Schizophrenia comes from two Greek words, schizo – meaning to split, and
phrenicmeaningmind.
 Schizophrenia includes a large group of psychiatric disorders characterized bydisturbances of
thinking, mood / affect and behavioral disturbances.
 Thinking disturbances are shown by changes in concept formation that lead tomisinterpretation
of reality and, on occasion delusion and hallucinations which appear tobe psychologically self-
protective.
 Mood changes may include ambivalent, loss of empathy with others, inappropriateemotional
responsiveness and constricted emotional responsiveness
 Behaviors may be withdrawn, regression and bizarre
Major Subtypes of Schizophrenia
o Disorganized Schizophrenia
o Catatonic Schizophrenia
o Paranoid Schizophrenia
o Undifferentiated Schizophrenia
o Residual Schizophrenia
Common Characteristics of Schizophrenia

Characteristics symptoms include two or more of the following, each of which is presentfor a period of
months or less if successfully treated:
o Alteration in thought characterized with, Delusions, false beliefs that are firmly held
despite objective and contradictory evidence and that does not shared , impaired ability
to think abstractly
o Alteration in speech characterized with loosening of association, clangassociation,
word salad, neoglism, and echolalia.
o Other disorder of thought or speech religiosity, magical thinking, circumstantiality,
tangenintiality, cognitive retardation flight of ideas, thought blocking, inserting, deletion.
o Disorder of perception that include Hallucinations,Derealization and depersonalization
o Disorder of thinking, which result in disorganized speech or irrelevant speech
o Negative symptoms – apathy, blunted or inappropriate affect and inability to speak
o Thought disturbances in which the person believes that thought are being inserted
intoor withdrawn from the mind.
o Alteration in behavior include agitate and bizarre behavior such as
echopraxia,negativism,catatonia,waxy flexibility
Causes of Schizophrenia
 Biological factors: Genetic predisposition, Dopaminergic dysfunction, Cognitive defect and
Neuroanatomic changes prenatal stressor
 Psychological factors: Difficulties in relating, Difficulties with decision making, Self-concept
changes, Decreased stress response and coping, Loss of family relationship and
 Decreased emotional expression
 Social factors: Decreased financial status, Family care giver stress, and Homelessness,
 Stigma and community isolation
131
Schizoaffective disorder characterized by schizophrenic behaviors, with a strong element of
symptomatology associated with the mood disorders (depression or mania).
 Diagnosis of schizoaffective disorder is the presence of hallucinations and/or delusions that
occur for at least 2 weeks in the absence of a major mood episode.
 Prominent mood disorder symptoms must be evident for a majority of the time.
Clinical features of schizoaffective disorder are
o Depressed, with psychomotor retardation
o Suicidal ideation,
o Euphoria, grandiosity,
o Hyperactivity.
o Bizarre delusion
o Prominent hallucination
o Incoherent speech
o Blunted affects
Brief psychotic disorder identified by the sudden onset of psychotic symptoms that may or may not be
preceded by a severe psychosocial stressor
 Symptoms last at least 1 day but less than 1 month and eventual full return to the premorbid
level of functioning.
 Individuals with preexisting personality disorders most commonly, histrionic, narcissistic,
paranoid, schizotypal, and borderline personality disorders are at higher risk to get this disorder
Clinical features of Brief psychotic disorder are
o Experiences emotional turmoil or overwhelming perplexity or confusion
o Incoherent speech,
o Delusions
o Hallucinations
o Bizarre behavior
o Disorientation
Schizophreniform disorder the essential features of this disorder are identical to those of schizophrenia,
with the exception that the duration, including prodromal, active, and residual phases, is at least 1
month but less than 6 months.
Delusional disordercharacterized by the presence of delusions that have been experienced by the
individual for at least 1 month
Clinical features is based on the delusional theme and they are as follows
 Erotomanic Type
o The individual believes that someone, usually of a higher status, is in love with him or her.
o Sometimes the delusion is kept secret, but some individuals may follow, contact, or
otherwise try to pursue the object of their delusion.
 Grandiose Type
o Individuals with grandiose delusions have irrational ideas regarding their own worth, talent,
knowledge, or power.
132
 Jealous Type
o The content of jealous delusions centers on the idea that the person’s sexual partner is
unfaithful
o Idea is irrational and without cause, but the individual with the delusion searches for
evidence to justify the belief
 Persecutory Type
o Individuals believe they are being persecuted or malevolently treated in some way.
o Frequent themes include being plotted against, cheated or defrauded, followed and spied
on, poisoned, or drugged.
 Somatic Type
o Individuals with somatic delusions believe they have some type diseases, conditions or
physical defect
o Common types of somatic delusion are
Emits a foul odor from the skin, mouth, rectum or vagina
Has infestation of insects in or on the skin
Has misshapen and ugly body parts
Have dysfunctional body parts
Shared psychotic disorder delusional system that develop in a second person as a result of close
relationship with another person who already have the psychotic disorder with prominent delusion
Occur in long term relationship.
Psychotic disorder due to general medical condition Psychotic Disorder Due to another medical
Condition
o The essential features of this disorder are prominent hallucinations and delusions that can
be directly attributed to another medical condition.
o Numbers of medical conditions that can cause psychotic symptoms are Hepatic
disease,cerebrovascular disease,Central nervous system (CNS) infections
Substance induced/Medication psychotic disorder
The prominent hallucinations and delusions associated with this disorder are found to be
directlyattributable to substance intoxication or withdrawal or after exposure to a medication or toxin.
o The medical history, physical examination, or laboratory findings provide evidence that the
appearance of the symptoms occurred in association with a substance intoxication or
withdrawal or exposure to a medication or toxin
STEP 4: Assessment for psychotic disorder (30 Minutes)

 Clients in an acute episode of their illness are seldom able to make a significant contribution to
their history.
 Data may be obtained from family members, if possible; from old records, if available; or from
other individuals who have been in a position to report on the progression of the client’s
behavior
 Nurse must familiar with the behaviors common to the disorder for a comprehensive
assessment and the behavior are
133
 Thought content, patient will show
o Delusions of various types like delusion of persecution, grandeur, somatic, nihilistic,
reference, and control or influence.
o Religiosity- obsession with religious ides and behaviors
o Paranoia-excessive suspiciousness of others
o Magical thinking-believe that his/her thought control over specific situation or people
 Thought form, patient will show
o Loosening of association-characterized by speech in which ideas shift from one
unrelated to another
o Clang association-choice of word is governed by sound
o Word salad-group of word put together without any logical connection
o Circumstantiality-individual delay to reach the point of a communication because of
unnecessary and tedious detail
o Tangentiality-patient never really get to the point of communication
o Mutism –individual inability or refusal to speak
o Preservation-persistently repeat the same word or idea in response to different
question
 Perception, patient will show
o Hallucination –false sensory perception can either be auditory, tactile, gustatory,
olfactory and visual.
o Illusion –misinterpretation of the real stimulus
 Sense of self, patient will show
o Echolalia-repeat words that he or she hears
o Echopraxia-purposelessly imitate movements made by others.
o Depersonalization-feelings of unreality
 Affectbehavior associated with an individual’s feeling state can either be
o Inappropriate Affect-the individual’s emotional tone is incongruent with the
circumstances
o Bland or Flat Affect-emotional tone is very weak
o Apathy-indifference to or disinterest in the environment.
 Volitioninability to initiate goal-directed activity can be
o Emotional Ambivalence-coexistence of opposite emotions toward the same object
o Deteriorated Appearance-personal grooming and self-care activities may be neglected
 Interpersonal Functioning and Relationship to the External World
o Impairment in social functioning may be reflected in social isolation, emotional
detachment, and lack of regard for social convention.
o Impaired Social Interaction-cling to others and intrude on the personal space of others,
exhibiting behaviors that are not socially and culturally acceptable
o Social Isolation-focus on themselves to the exclusion of the external environment
 Psychomotor Behavior changes that occur are
o Anergia-deficiency of energy
o Waxy Flexibility-body parts to be placed in bizarre or uncomfortable positions. Once
placed in position, the arm, leg, or head remains in that position for long periods,
regardless of how uncomfortable it is for the client
134
o Pacing and Rocking-Pacing back and forth and body rocking
 Other associated Features are
o Anhedonia-inability to experience pleasure
o Regression-retreat to an earlier level of development
STEP 5: Care to client/patient with psychotic disorder (35 Minutes)
ASK students to pair up and buzz on Care to client/patient with psychotic disorder
ALLOW 2 to 3 students to provide responses and let others provide additional responses
 Acute episodes of psychosis need hospitalization to ensure maximum safety

 A constant nurse should be assigned to the care of each client to avoid disturbing thepatient by
changing care givers frequently.
 Approach the patient in accepting manner / attitude, with friendliness manner as a sourceof
therapeutic help.
 Assess the patient to obtain information from the patient, relatives and friends to validatethe
client’s statement.
 Record clearly all data/ information and use them in planning care.
 Observe the patient closely for the risk of self-harm and harming others.
 Seclude until medication reduces the level of risk of harming themselves and others.
 Ensure general body hygiene of the patient through bathing, dressing and toileting.
 Consider client’s physical needs to avoid malnutrition, dehydration, infections and otherphysical
disorders.
 Ensure low stimulation, low stress and high levels support environment to reducepsychotic
symptoms.
 Maintain none threatening, calm communication style – therapeutic relationship.
 Develop a good nurse – patient relationship to reinforce the sense of trust or to give andreceive
love.
 Use simple short phrases and specific word when communicating to avoid confusion
andinattention.
 Call patient by name to improve self esteem
 Deal with psychotic beliefs by not agree with or in any way enter into the client’s
misperceptions.
 Agree to differ, repeat the client’s statement to show that he or she isbeing head.
 Provide antipsychotic medication to speed recovery and decreasing psychotic symptoms,such
as chlorpromazine, fluphenazinedecanoate, trifluoperazine, thioridazine andhaloperidol.
135
 Clarify reality by telling the client you does not hear the same voice
 Avoid argument over client’s delusions
 Involve family in the care
 Tell the patient to do the opposite of what is expecting when dealing with negativism.
 Provide group activities to improve insight and interpersonal relationship with others and to
reduce hostility
 Provide social and recreational therapy to stimulate patient’s interest on relation to others and
create a sense of acceptance.
 Encourage exercises for those who stand and seat in one position for hours
 Electro convulsive therapy may be given to stimulate the patient
 Occupational therapy is essential for occupying the patient’s mind
o The four main considerations when referring the patient are diagnostic difficulty, clinical
severity as judged by symptoms severity and disability, response to treatment already
initiated and the nature of the service referred for i.e. treatment or therapy

o Psychotic disorder psychotic disorders are severe mental disorders that cause abnormal
thinking and perceptions.
o Nursing assessment of patient with psychiatry disorder based on thought content, thought
form,perception, sense of self, affect,volition,iinterpersonal functioning and relationship to the
external world and ppsychomotor Behavior changes that occur are

 What is the meaning of psychotic disorder?
 What are the types of psychotic disorder?
 What are the nursing cares of patient with psychotic disorder ?
References
Elsevier Sounders
136
Session Fifteen: SESSION 13:NURSING CARE OF PATIENT WITH COGNITIVE

DISORDERS ACCORDING TO STANDARDS

Learning tasks
At the end of this session learner is expected to be ableto:

Define cognitive disorders
Describe types of cognitive disorders
Assess for cognitive disorders
Give care to patients with cognitive disorders
137
Resources Needed:

Method
1
2 40 Brainstorming Definition of Cognitive disorders
3 10 Lecture Types of Cognitive disorders
discussion
4 10 Lecture Assessment for Cognitive disorders
discussion/role
play
5 15 Lecture Care to client/patient with Cognitive
discussion disorders
6 30 Buzzling Refer client/ patient for further
management
7 5
8 5
SESSION CONTENTS

READ or ASK participants to read the learning tasks
138
STEP 2: Definition of Cognitive disorders (10 Minutes)
ASK Students to brainstorm on theCognitive disorders
Cognitive functioning is the ability to focus on environmental cues without distraction and register
information, plan and problem solving, learn and retain information ,use language visually perceive the
environment and read social situations in relation to how others might be feeling and determine what is
appropriate for the environmental context
Cognitive disordersinclude those in which a clinically significant deficit in cognition or memory exist and
representing a significant change from previous level of functioning. Cognitive disorder are divided into
reversible and unrevesible types.
Changes accompany cognitive disorder are
 Disorientation
 Decreased concentration
 Loss of abstract thinking
 Language disturbances
 Hallucination, delusion and misidentification may frighten the patient
STEP 3: Types of Cognitive disorders(25 Minutes)

Types of cognitive disorder are
 Delirium
 Dementia
 Alzheimer’s disease
Delirium
 Delirium refers to dramatic behavior change that the person may experience .the hallmark sign
of delirium its acute onset.
 Delirium is an acute cognitive disturbance and often-reversible condition that is common in
hospitalized patients, especially older patients. It is characterized as a syndrome
 Delirium is associated with may medical illness such as pneumonia, myocardial infarction,
urinary tract infection, drug adverse effects i.e. anticholinergic, tricyclic antidepressant
139
 Delirium is the medical emergency and life threatening treatment should be immediately to
minimize the severity
Predisposing factors
 Age
 Lower EducationLevel
 Sensory Impairment
 Decreased Functional Status
 Comorbid Medical Conditions
 Malnutrition
 Depression
 Postoperative conditions
 Systemic Disorders,
 Withdrawal Of Drugs And Substances Such As Alcohol And Sedatives
 Toxicity Secondary To Drugs Or Other Substances
 Impaired Respiratory Functioning
Clinical features of delirium are
 Fluctuation in level of consciousness
 Slurred speech
 Nonsensical thought
 Day –night sleep reversal
 Visual hallucination
 Patient may be able to follow conversation for a period of time following by an acute confusion
Dementia
 Dementia is the type of illness with progressive detorariating course that ultimately affect
cognition, perception, language, behavior and motor abilities.
 Dementia can be reversible that caused by normal-pressure hydrocephalus and Vitamin B12
deficiency, Wernicke’s encephalopathy and Korsakoff’s syndrome caused by vitamin B12
deficiency in chronic alcoholic patient can also be reversed.
 Alcoholic dementia cannot be reversed
Aetiology Dementia
 Degenerative disease of the central nervous system – Alzheimer’s disease, Pick’s disease,
Huntington’s disease or chorea multiple sclerosis, Parkinson’s disease etc.
 Intracranial causes- space occupying lesions (tumors, chronic subdural haematomas,
abscesses, aneurysms) , Infections such as encephalitis, meningitis neurosyphillis, AIDS and
trauma - head injury
 Metabolic and endocrine disorders
 Vascular causes
 Intoxication
Clinical features of dementia
 Impairment of memory
140
 Impaired judgment
 Impaired thinking – lack of insight, ideas of reference, paranoid thoughts, may develop
delusions
 Impaired concentration
 Lack of motivation (rigid, loss of interest in new activities, agitated, angry)
 Impairment of social behavior - restlessness, inappropriate behavior
 Disorder in control- anxiety, liability of mood, depression
Alzheimer’s disease
Is accompanied by memory loss, starting with short term memory followed by long term memory
Types of Alzheimer’s disease
Agnosia
 Impaired ability to recognize and identify familiar object and people in absence of visual or
hearing impairment
Aphasia
 Language disturbance are exhibited in both expression and understanding spoken words.
Apraxia
 Inability to carry out motor activity despite intact motor function
Risk Factors Alzheimer’s disease
 Age
 Family history of disease
 Heart related condition ie hypertension, high cholesterol, stroke, heart disease
 Head injury
Causes of Alzheimer’s disease
 Neuronal loss the loss of the cholinergic neuron that produces neurotransmitter
acetylcholine.Choligenic system form the basis of memory acquisition, processing new
information and making decisions
 Neurofibrillary tangles collapsing of the microtubules within the neuron that are responsible for
cellular nutrient transport
 B-amyloid plaque combination of the B-amyloid peptide forms the oligomers which interfere
with neuronal and receptors and synapses leading to cell death
 Brain atrophy neuronal loss from plaque and tangles and oxidative stress may contribute to the
reduction of the actual size of the brain
 Genetics familial Alzheimer’s disease has autosomal dominant inheritance pattern.
 Hormones decrease of sex hormones specifically oestrogen during menopause has been
associated with development of Alzheimer’s disease to women.
Clinical feature of Alzheimer’s disease
141
 Repeat statements and questions over and over, not realizing that they've asked the question
before
 Forget conversations, appointments or events, and not remember them later
 Routinely misplace possessions, often putting them in illogical locations
 Get lost in familiar places
 Eventually forget the names of family members and everyday objects
 Have trouble finding the right words to identify objects, express thoughts or take part in
conversations
 Difficulty concentrating and thinking, especially about abstract concepts like numbers.
STEP 4: Assessment for Cognitive disorders (40 Minutes)

Assessment of patient with delirium
 Acute onset and fluctuating course
 Reduced ability to direct, focus, shifts, and sustains attention
 Disorganized thinking
 Disturbance of consciousness suspect the presence of delirium when a patient abruptly
develops a disturbance in consciousness that manifests as reduced clarity of awareness of the
environment
 Cognitive and Perceptual Disturbance it may be difficult to engage patients experiencing
delirium inconversation because they are easily distracted, display markedattention deficits,
and exhibit memory impairment. Illusion and hallucination mostly visual hallucination
 Physical Needs: Self-care deficits, injury, or hyperactivity or hypo activitymay lead to skin
breakdown and possible infection. Often thisis compounded by poor nutrition, forced bed rest,
and possibleincontinence.
 Moods and Physical Behaviors changes may occur such as moods may swing backand forth
among fear, anger, anxiety, euphoria, depression, andapathy.
 Sleep deprivation related to impaired cerebral oxygenation ordisruption in consciousness
 Impaired verbal communication related to cerebral hypoxiaor decreased cerebral blood flow
 Self-care deficits and Impairedsocial interaction
Assessment of patient with dementia

Confabulationis the creation of stories or answers in place of actual memories to maintain self-
esteem.Confabulation is an unconscious attempt to maintain self-esteem.
Perseveration (the repetition of phrases or behavior)is eventually seen and is often intensified under
stress. Theavoidance of answering questions is another mechanism bywhich the person is able to
maintain self-esteem unconsciouslyin the face of severe memory deficits.
Assessment for Alzheimer’s disease
 Memory loss, starting with short term memory followed by long term memory
142
 Word finding difficult patient describing the item rather than naming it, which complicates
communication with the patient
 Difficult concentration trouble understanding conversationor following TV programmes
 Misinterpretation of the environment patient may experience visual hallucination mostly of the
dead relatives, voice or sound typically go along with Visual hallucination.
 Delusions common delusions are
 Thinking the deceased relatives is alive
 Pathologic jealousy that spouse is having extramarital affair
 Stealing something odds i.e. mortgage paper and leaving money
 Illusions misinterpretation of something that does not exist such thinking an image on the mirror
as intruder
 Somatic preoccupation often result in diagnostic testing without clear cut results
 Misidentification calling a family member or friend by another person’s name
 Sundowing period of restless and agitated behavior
 Loss of the ability to take care for oneself
STEP 5: Nursing Care to client/patient with Cognitive disorders(40 Minutes)

 Establish proper therapeutic environment for the patient
o Greet the patient by name introduce yourself by name and show respect
o Nurse the patient with other old patient to avoid violence from energetic patients.
o Allow the patient to be visited by relatives and friends to avoid loneliness.
o Talk to the patient loud enough to avoid misinterpretations.
o Encourage patient to talk about their adventures of their old days which boost up their
esteems.
o Nurse the patient in a good lightened room because of the patient poor sight and
minimizing anxiety.
o Limit furniture to avoid crashing on them
o Keep the floor dry
o Provide heavy furniture to provide support to the patient
o Avoid frequent new changes to the patient because of rigidity.
 Physical needs
o Ensure good rest and sleep
o Provide the prescribed therapies to control signs and symptoms of the patient
o Nurse the patient in a less complicated environment as the patient has memory defect.
 Nutrition
o Provide a well-balanced diet that is easily digested.
o Save the food neatly and small amounts
o Assist in feeding whenever necessary
o Observe and keep a record of the way of eating and amount of food taken
o Provide oral fluids to control dehydration and constipation
 Elimination
o Ask the patient whether he/she feels going to the toilet
o Take him to the toilet because they usually forget attending the call of nature.
143
o Instruct him to clean his private parts and hands after attending toilet
o Redress properly and assist back to the ward to his bed.
 Exercises
o Apply both passive and active exercises to the patient
o Recreational therapy, for example listening to music, playing cards etc.
o Allow the patient to sing traditional songs and dancing.
o Give them chance to tell each other story because they please them, and activate
theirability to recall
 Personal hygiene
o Assist in bathing, cleaning and dressing up clothes
o Assist in care of nails, feet, hair, and rest of the body
 Assessment and treatment of underlying physical problem or illness should be addressed
o Incase of delirium and other cognitive behavior which occurs due to underlying
condition they should all be treated
o The four main considerations when referring the patient are diagnostic difficulty, clinical
severity as judged by symptoms severity and disability, response to treatment already
initiated and the nature of the service referred for i.e. treatment or therapy

 Cognitive disordersinclude those in which a clinically significant deficit in cognition or memory
exist and representing a significant change from previous level of functioning. Cognitive
disorder is sub dived as dementia, delirium and Alzheimer’s disease.
 Nursing care to patient with cognitive disorder includes Establish proper therapeutic
environment for the patient, Provide physicalneeds, nutrition needs, elimination, exercises,
personal hygiene and assessment and treatment of underlying physical problem or illness
should be addressed
 What is cognitive disorder?
 Outline the clinical features of dementia.
 What are the nursing cares to patient with cognitive disorder?
144
REFFERENCE
Elsevier Sounders
145
Session 15: CONCEPTS OF COMMUNITY MENTAL HEALTH CARE
Learning tasks

Define community psychiatry, rehabilitation and domiciliary care
Explain concepts of community mental health
Explain roles of a nurse in community mental health
Explain roles of the family members in caring for a mentally ill patient
Resources Needed:

Method
1 05
Presentation Learning task
2 15 Brainstorming Definition of community psychiatry, rehabilitation
and domiciliary care
3 40 Lecture discussion Concepts of community mental health
4 25 Small group Roles of a nurse in community mental health

discussion
Lecture discussion
5 25 Buzzling Roles of the family members in caring for a
mentally ill patient
6 05
7 05
146
SESSION CONTENTS

STEP 2: Definition of Community Psychiatry, Rehabilitation and Domiciliary Care
(15 Minutes)
ASK Students to brainstorm on Community psychiatry, Rehabilitation and Domiciliary care?
Community is defined as a group, population, or cluster of people with at least one common
characteristic, such as geographic location, occupation, ethnicity, or health concern.
Community Mental Health (Psychiatric) is ….
Community Psychiatry care is care that is provided at the community level. It involves shifting mental
health care from health facilities to the community
o Community mental health services enables patient to be seen and treated rapidly in the
community or as a day patient, thereby helping to pre- empty their need for admission as in
patient.
o These services are offered by multidisciplinary teams, including psychiatrists and community
psychiatric nurses and provide a cost –effective form of treatment rather than hospital – based
treatment
The target within the community is:
o Primary prevention (reducing the incidence of mental disorders within the population)
o Secondary prevention (reducing the prevalence of mental illness by shortening the course
of the illness)
o Tertiary prevention (reducing the defects that are associated with severe or chronic mental
illness.)
Rehabilitation is the type of therapy that focuses on return injured workers to an appropriate level of
work activity.
147
Aims to enhance and restore functional ability to those with physical impairments or disabilities
Domiciliary careis care provided to people who still live in their own homes but who require additional
support with household tasks, personal care or any other activity that allows them to maintain their
independence and quality of life
STEP 3: Concepts of community mental health (40 minutes)

Prevention of mental illness
 Prevention of mental illness can be done in three levels namely:
o Primary prevention,
o Secondary prevention and
o Tertiary prevention
Primary Prevention
Primary prevention in the community includes:
 Identifying stressful life events that precipitate crises and targeting the relevant populations at
risk
 Intervening with these high – risk populations to prevent or minimize harmful consequences.
 Identifying stressful life events that precipitate crises and targeting the relevant populations at
risk
 This can be through maturational crisis and situational crisis
 In which in maturational crisis are crucial experience that are associated with various stage of
growth and development. This includes adolescence, marriage, parenthood, midlife period and
retirement.
 In situational crisis are acute responses that occur as a result of an external circumstantial
stressor, this include poverty, high rate of life change events, environmental condition, trauma.
 Intervention includes:
o Menta Health educational programs that inform about nutritional needs specific for this age
group, sexuality, pregnancy, contraception, and sexually transmitted diseases, use of
alcohol and other drugs support groups for teenagers who are in need of assistance to
cope with stressful situations
o In marital relationship encouraging honest communication, determining what each person
expects from the relationship and ascertaining whether or not each individual can accept
compromise
o In parenthood educate on parent-infant bonding, changing husband-wife relationships,
clothing equipment and feeding.
o Nutrition classes to inform individuals about the essentials of diet and exercise, quit
smoking, cease or reduce alcohol consumption, reduce fat intake
o Support and information related to care of aging parents should be given (rephrsing)
Secondary Prevention
148
 Secondary prevention in the community relates to using early detection and prompts
intervention with individuals experiencing mental illness symptoms.
 Interventions include
o Early identification of the problem and possible solutions; support and guidance as
changes are undertaken
o Referral to sex therapist, financial advisor, couples’ support group
o Recognize the physical and behavioral signs that indicate possible abuse of a child and
care of child may be cared in the emergency department or as an inpatient
o Teaching effective methods of disciplining children, aside from physical punishment and
positive reinforcement for acceptable behavior
Tertiary Prevention
 Tertiary prevention is concerned with preventing or reducing the duration of the long term
disability that is often a residual effect of the major psychiatric disorders such as schizophrenia,
organic brain syndrome.
 Treatment in tertiary prevention depends upon the particular psychiatric disorder.
 Treatment may include:
o Use of somatic therapy
o Group therapy
o Individual therapy
o Psychotherapy
o Rehabilitative therapies
Continuity of care
Group and family therapy

Group therapy
This involve the individual with common purpose come together and benefit by mutually giving and
receiving feedback within the dynamic and unique group context
Groups therapy is advantageous because
o Engaging multiple patients in treatment at the same time, thereby saving resources.
o Participants benefiting not only from the feedback of the nurse leader but also from that of
peers who may possess a unique understanding of the issues.
o Providing a relatively safe setting to try out new ways of relating to other people and practicing
new communication skills.
o Promoting a feeling of belonging.
Family therapy
Focuses on changing the interactions among the people who make up the family the aim of improve the
skills of the individual members and tostrengthen the functioning of the family, concentrate on
evaluating relationships and communicationpatterns, structure, and rules that govern the nature of
family interactions.
149
Community support and control
Community support – including information, accommodation, help with finding suitable work, training
and education, psychosocial rehabilitation and mutual support groups. Understanding and acceptance
by the community is very important
STEP 4: Roles of a nurse in community mental health (25 Minutes)

DIVIDE Students into small manageable groups
ASK Students to discuss on the following question:
What are the Roles of a nurse in community mental health?
ALLOW students to discuss for 10 minutes
ALLOW few groups to present and the rest to add points not mentioned
CLARIFY and SUMMARIZE by using the contents below:
Roles of a nurse in community mental health include:

 Eliminate factors that contribute to mental illness
 Provide care that is familiar to the patient or residents
 Utilize supportive services of the community and family.
 Shorten time of rehabilitation through early detection and treatment of those at risk.
 Coordinate mental health services and other services
 Reduce the illnesses and suffering
 Reduce or eliminate residual disability following the illness
 Influence community on accountability and mastering of their heath.
 Undertake physical check up on regular basis
 Prevent long hospitalization
 Encourage people to live normal life- work, rest, play and good interaction etc.
 Link clients to the needed support and care
STEP 5: Roles of the Family Members in Caring for a Mentally Ill Patient (25 )
150
ASK students to pair up and buzz on Roles of the family members in caring for a mentally ill patient
Roles of the family members in caring for a mentally ill patient
o Understanding of the client vulnerability for future episodes this will help in early detection
of the illness and management
o Family support in helping client accept the necessary ongoing medication administration
and other therapy
o Family dynamics and attitudes plays crucial roles in the outcome of the client recovery
o Family involvement in treatment of mental ill patient is effective in reducing relapses and
increasing medication adherences
o Monitoring their relative’s progress, and watching out for signs of relapse.
o Play a vital role in monitoring the use of medication by learning about side effects and how
to deal with them.
o Helping to foster a lifestyle conducive to recovery and maintenance of good mental health
by providing social support and encouraging engagement in exercise, social activities,
work, school
o Engaging person in a treatment plan learning how to communicate with a person in ways
that will encourage them to seek help
o Learning about mental illness and services available behaviours/symptoms that create
refuse to seek help self-management skills ,medications are used and their side-effects
services needed (WEKA ROLE ANZA NA VERB)

 Community Psychiatry care is shifting from that of in-patient hospitalization to a focus of
outpatient care within the community.
 Rehabilitation is the type of therapy that focuses on return injured workers to an appropriate
level of work activity.
 Domiciliary careis care provided to people who still live in their own homes but who require
additional support with household tasks, personal care
 Prevention of mental illness early detection and treatment

 What is community psychiatry?
151
 What are the roles of family in care of mental ill patient?
 What are the roles of nurse in community mental health?
152
REFERENCES
Elsevier Sounders
Stuart GW., (2013) Principles and practice of psychiatric nursing .(10th ed). St Louis Missouri. Mosby
Session Sixteen: Session 16: CARE OF MENTAL ILL PATIENT IN THE

COMMUNITY
Total Session Time: 120minutes
Prerequisite: None
Learning Task
Identify mentally ill patients in the community
Provide domiciliary care to a patient with mental illness

Rehabilitate a mentally ill patient
Conduct outreach mental health services 153

Resources Needed:

Method
1
2 05 Lecture discussion Identification of mentally ill patients in the
community
3 40 Small group Domiciliary care to a patient with mental illness
discussion
4 35 Buzzling Rehabilitation of a mental ill patient
Lecture discussion
5 30 Brainstorming Outreach mental health services
Lecture discussion
6 05
7 05
SESSION CONTENTS

READ or ASK participants to read the learning Task
STEP 2: Identification of mentally ill patients in the community (5 Minutes)

 Identification of mentally ill patients in the community involves identification of:
154
o Population at risk,
o Individuals at risk
o Mentally ill patients
o Causes and risk factors that lead to mental illness
o Resources available,
The following are methods of identifying mentally ill patients in the community:
Review of documents in various records eg medical records, social welfare records
Observation
Interview with community leaders, religious leaders, health care providers community members,
influential leaders
Community mental health survey YAELEZWE
How are they being identified
Community setting require strong problem solving and clinical skills, cultural competence, flexibility,
solid knowledge of community resource, and comfort in functioning.
o Patient in problem related to individual psychiatry symptoms such as depression, mood
disorder, schizophrenia etc.
o Family and support systems
o Basic living things and financial supports REVIEW
STEP 3:Domiciliary cares to a patient with mental illness (40 Minutes)

DIVIDE Students into small manageable groups
ASK Students to discuss onDomiciliary cares to a patient with mental illness?
ALLOW students to discuss for 10 minutes
ALLOW few groups to present and the rest to add points not mentioned
CLARIFY and SUMMARIZE by using the contents below:

Define D.C
Domiciliary cares to a patient with mental illness based on counseling, education, medicine
administration and compliance, follow-up and the services should be comprise of the following content
Counseling
 Has many types; successful counseling is to know which type you are comfortable with and is
the better treatment of the mental ill.
 Counseling helps in understand your condition, face challenges, change current behaviour,
give room for healing, and alleviate your stress
 Counseling sessions can treat various mental health illnesses such as depression, eating
disorders, anger problems, grief and loss, addictions, compulsive disorders, abuse and
neglects,
155
o Cognitive therapy this form of therapy enables psychiatrists to help you
change the way you are thinking in order to feel or behave better.
o Behaviortherapy – This kind of therapy focuses on the modification of
unwanted as well as unhealthy behaviors. Healthy habits and behavior are
enforced through the use of rewards.
o Grouptherapy experienced personnel leads a group therapy session. It is
a confidential environment where people with the same mental health
issues get to share their feelings. The members support one another when
they need it.
o Psychoanalysis this type of counseling lets you think about your past,
community mental health nurse will help you understand the reasons
behind the way you act, behave and think today.
 Education
o Education provided to the community is based on the mental illness available in the
communities which are mood disorder, substance abuse disorder, depression and
others
o Causes of mental illnesses which are biological which can be genetics, environmental
which can be exposure to toxins such pesticide, psychological stressor such us
unhappy married, unemployment,
o Treatment therapy available for mental illness and disorder which include
pharmacological therapy, psychological therapy
o The role of community and family in takes care of mental ill patient, preventive
measure to mental illness that coping mechanism to life stressor, avoiding substance
abuse, insist the patients on adherence to drugs to avoid relapses. What to do when
the side effects occurs
 Medicine administration, domiciliary cares
o Community mental health nurse Administer drugs to outpatient with known mental illness
they also educate them and family member of the advantage of the drug ,drug duration,
and side effect and
 Compliance
o Compliance therapy improves treatment adherence and clinical outcomes in patients
with mental illness, when providing domiciliary care mental health nurses make
emphasize on the adherence of drug and therapy
 Follow-up
Helps in maintain the progress made during hospitalization, reduce the risk of suicide
and social exclusion and improve care
STEP 4: Rehabilitation of a mental ill patient (35 Minutes)

ASK students to pair up and buzz on Rehabilitation services of mental ill patient
156
 Is the process of restoration of community functioning and well-being of an individual

diagnosed in mental health or mental or emotional disorder and who may be considered to
have a psychiatric disability.
 Rehabilitation can be done by psychiatrists, social workers, nurse psychologists, occupational
therapists and community support or allied health workers
 Rehabilitation services comprise of
o Independent living and social skills training
o Psychological support to clients and their families
o Occupational and Vocational rehabilitation
o Social support and network enhancement and access to leisure activities
STEP 5:Outreach Mental Health Services(30 Minutes)

ASK Students to brainstorm on the Outreach mental health services
Outreach services support service users who experience symptoms of psychosis and who find it
difficult to engage with services
The aims of this service are:
o To work creatively to improve engagement.
o To reduce relapse by working collaboratively with service users to provide service user focused
packages of care.
o To reduce likelihood and duration of admission to hospital.
o To improve social functioning.
o To promote stability in the lives of service users and their families.
o To work in an integrated manner with other statutory and non-statutory local services
Outreach mental health services are

o Outpatient treatment
o Rehabilitation
o Psychosocial therapies such a psychoeducation, rehabilitation and group therapy
o Integrating mental health care within the primary health care system;
o Rehabilitating long-stay mental hospital patients in the community;
o Implementing anti-stigma programmes for communities;
o Initiating population-based effective preventive interventions; and
o Ensuring full participation and integration of people with mental disorders within the
community
157
o Psychiatry home care

o Domiciliary cares to a patient with mental illness based on counseling, education, medicine
administration and compliance, follow-up and the services should be comprise of the following
content, counseling , education, medicine administration, compliance and follow-up
o Outreach mental health services are outpatient treatment, rehabilitation psychosocial therapies
such a psychoeducation, rehabilitation and group therapy, integrating mental health care within
the primary health care system; rehabilitating long-stay mental hospital patients in the
community, implementing anti-stigma programmes for communities, initiating population-based
effective preventive interventions; and ensuring full participation and integration of people with
mental disorders within the community and psychiatry home care SUMMERIZE

 What are the mentally illness in the community?
 What are the outreach mental health services?
 What are the rehabilitative services in the community?
158
Reference
Elsevier Sounders
159
Session Seventeen: CARE TO PATIENTS WITH PSYCHIATRIC EMERGENCIES
Learning Task
Define psychiatry emergency
Describe common psychiatry emergencies
Give care to aggressive patient to prevent harm to patient and others
Give care to suicidal patient prevent harm to patient and others
Give care to patient with acute psychotic to prevent harm to patient and others
Give care to patient with status epilepticus to prevent harm to patient and others
Perform risk assessment
Resources Needed:

Method
1
2 10 Brainstorming Definition of Psychiatry Emergency
3 05 Lecture discussion Common Psychiatry Emergencies
4 20 Lecture discussion Care to aggressive patient to prevent harm to patient

and others
5 30 Brainstorming Care to suicidal patient prevent harm to patient and
others
Lecture discussion
6 30 Buzzling Care to patient with acute psychotic to prevent harm to

patient and others
Lecture discussion
20 Lecture discussion Care to patient with status epilepticus to prevent harm to
patient and others
160
20 Lecture discussion Perform risk assessment
7 05
8 05
SESSION CONTENTS

READ or ASK participants to read the learning Tasks
STEP 2: Definition of Psychiatry Emergency (5 minutes)
ASK Students to brainstorm on Psychiatry Emergency
Psychiatry Emergency
Is an acute disturbance of behaviour, thought or mood of a patient which if untreated may lead to harm,
either to the individual or to others in the environment.
It leads to acute changes in behaviour that negatively impact a patient's ability to function in his or her
environment
or
Refer to psychiatric disorders or conditions which call for immediate action so as to protect the patient
and others from harm
This condition needs immediate intervention to safeguard the life of the patient, bring down the anxiety
of the family members and enhance emotional/physical security to others in the environment.
STEP 3: Common Psychiatry Emergencies(5 minutes)
 The following are the common psychiatric emergencies:
o Aggression
o Suicidal ideation
o Acute psychotic states
o Status epilepticus
161
Aggression
 Aggression is an act or gesture, verbal or physical, which suggests that an act of violence
might occur.
 Aetiology of Aggression are:
o Organic psychiatric disorders like delirium, dementia, Wernicke- Korsakoff’s psychosis.
o Other psychiatric disorders like schizophrenia, mania, agitated depression, withdrawal from
alcohol and drugs, epilepsy, acute stress reaction, panic disorder and personality
disorders. FANYA HIVYO NA SUICIDAL ACUTE NA STUTE
STEP 4: Risk assessment in Psychiatric Emergencies
STEP 5: Care of Mentall ill patient in Psychiatric Emergencies (25 minutes)

Aggressive Patient
Immediate care to aggressive patient to prevent harm to patient and others
o A rapid visual assessment of the situation
o Appear calm and unafraid as possible
o Do not try to deal with the situation alone. Call for assistance
o Attempt to restrain the patient, using a little force, while talking to him that you are in a process
of helping him.
o Remove the patient to a calm environment
o Give tranquilizer to calm down the patient
o Close observe the patient
o Try to find the cause of aggression
Nursing care to aggressive patient
o Talk to the patient and see if he responds. Firm and kind approach by the nurse is essential.
o Usually sedation is given. Common d rugs used are: diazepam 10- 20mg, IV; haloperidol 10-
20mg; chlorpromazine 50-100mg IM.
o Once the patient is sedated, take careful history from relatives; rule out the possibility of
organic pathology. In particular check for history of convulsions, fever, recent intake of alcohol,
flunctuations of consciousness.
o Carry out complete physical examinations.
o Send blood specimens for hemoglobin, total cell count etc.
o Look for evidence of dehydration and malnutrition. If there is severe dehydration, glucose
saline drip may be started.
o Have less furniture in the room and remove sharp instruments, ropes, glass items, ties, strings,
match boxes, etc from patient’s vicinity.
o Keep environmental stimuli, such as lighting and noise levels to a minimum; assign single
room; limit interactions with others.
o Remove hazardous objects and substances; caution the patient when there is possibility of an
accident.
o Stay with the patient as hyperactivity increases to reduce anxiety level and foster a feeling of
security.
162
o Redirect violent behavior with physical outlets such as exercise, outdoor activities.
o Encourage the patient to ‘talk out’ his aggressive feelings, rather than acting them out.
o If the patient is not calmed by talking down and refuses medications, restraints may become
necessary.
o Following application of restraints, observe patient every 15 minutes to ensure that nutritional
and elimination needs are met.
o Also observe for any numbness, tingling or cyanosis in the extremities. It is important to choose
the least restrictive alternative as far as possible for these patients
o Refer the patient for further management:
Referral to a specialized facility for diagnosis, management or for ongoing treatment.
The four main considerations when referring the patient are diagnostic difficulty, clinical severity
Prevention of Aggressive Behavior
o Observation and appropriate action
o Discovering incidents or activities that lead to outburst of aggressive behavior in a particular
patient
o Anticipate – for example help the patient to overcome impulses before an actual outburst of
anger
STEP 5: Care of patient with Suicidal attempts (30 minutes)
o Suicide is taking of one’s life
o The suicidal patient is a patient who has given some indication that he is
consideringsuicide in the immediate or near future. It is common in depressive
illness, and commonin females than in men.
ASK Students to brainstorm on the Aetiology of suicidal attempts
Aetiology of Suicidal attempts

o Social isolation
o Social class – incidence is higher among the upper social classes
o Mental illness (depression, alcoholism, psychopath, schizophrenia, hysteria, and
chronicphysical illnessMajor depression, Schizophrenia,drug or alcohol abuse, dementia,
delirium, personality disorder, patients with incurable or painful physical disorders like cancer
and AIDS)
163
o Social degeneration – loss of job, divorce and black mail,failure in examination, dowry
difficulties, maritaldifficulties, loss of loved ones/object, isolation and alienation from social
groups, financial and occupational difficulties
o Other factors – higher in urban areas
Methods that are used in committing suicide

o Drug overdose
o Hanging
o Drowning
o Jumping under vehicles or from high places
o Shooting
o Coal gas poisoning
Immediate care to suicidal patient to prevent harm to patient

o Admission is inevitable for skilled observation and treatment
o Be aware of certain signs which may indicate that the individual may commit suicide, such as:
o Ensure therapeutic environment; close supervision, safe surroundings
o A good nurse- patient relationship is important to speed up recovery; show sympathy,
understand and appreciate his problems, interest his well-being and recovery, trust worth to
gain confidence.
o Enhance self-esteem of the patient by focusing on his strengths rather than weaknesses
o Encourage verbal communication of suicidal ideas as well as his/her fear and depressive
thoughts
o Give sedatives to induce sleep in case of difficulty to sleep.
o Ensure good appetizing diet
o Provide specific treatment for depression
o ECT can be useful if the patient is severely depressed
o Reassurance should be given to the patient and relatives
o Routine precautions ( close observation recording and reporting ( caution card) , teamwork,
hide any dangerous articles and showing genuine interest in the recovery of thepatient)
o Critical observation as the patient improves is of vital to prevent suicide
STEP 6: Care of Patient with Acute Psychotic States (30 minutes)

Acute psychosis occurs when the person may be frightened and excited suddenly and severely
Acute psychosis may be due to:

o Physical illness, such as malaria, typhoid etc.
o Head injury
o Toxins - alcohol, drugs
o Psychiatric disorders, such schizophrenia, mania organic condition etc
164
ASK students to pair up and buzz on Immediate care to patient with acute psychosis
Immediate care to patient with acute psychosis to prevent harm to patient and others
o Calm the patient put the patient in quite place
o Be kind, talk with the patient gently while try to help him
o Assess the situation and plan quickly what to be done
o Make sure you don’t handle the situation alone
o Remove all dangerous objects that could be used as weapon
o Ask patient why he is angry and threatening
o Listen and reassure the patient
o Give antipsychotic medication to cal down the patient
o Restraint is necessary when you have failed to calm a patient who is danger to himself and
others.
o Observe the patient closely to avoid harming himself and others
o Refer the patient for further management:
The four main considerations when referring the patient are diagnostic difficulty, clinical severity
STEP 7: Care of Patient with Status epilepticus (15 minutes)

Status epilepticus
o This fatal condition of repetition of seizures without gaining conscious needs immediate action
if life is to be saved and permanent brain damage averted
Immediate care to patient with Status epilepticus
o Rest: nurse in a quiet, preferably dark room
o Maintenance of good airway
o Head turned sideways to prevent mucus from running into trachea
o Oxygen- ensure that the patient is getting enough
o Anticonvulsant drugs: i.v. diazepam, i.v.phenorbabitone
o Nourishment – tube feed may be necessary
o Good nursing care is vital.
Complications of Status Epilepticus
165
o Pulmonary complications -example pneumonia
o Mental retardation
o Heart failure, which will lead to death
STEP 8: Risk Assessment(15 minutes)

Risk Assessment
Is an estimation of the likelihood of particular adverse events occurring under particular circumstances
within a specified period of time
Principles that guide Risk Assessment are
o Assessment should include a patient’s narrative about their own risk.
o Consent to risk assessment should be sought and an explanation of the risks and benefits
given
o Preparation is crucial and nurse should try to gather information from as many reliable sources
as possible.
o Involving the patient and caregiver (where appropriate) in drawing up the plan can enhance
safety
o The interaction between nurse andpatient is crucial; good relationships make assessment
easier and more accurate, and might reduce risk
o All nurses should carry out careful, curious and comprehensive history taking.
o It might be hard for one nurse alone to complete an adequate risk assessment.
o It is invariably helpful to discuss assessments and management plans with a peer or supervisor
When performing risk assessment the component below will help in the identification of
the risk and the source of psychiatry emergencies also will provide possible way forward
to manage the patient. The components are as follows
 History the assessment will aim in identify
o Previous violence, whether investigated, convicted or unknown to the criminal justice
system.
o Relationship of violence to mental state.
o Lack of supportive relationships.
o Poor concordance with treatment, discontinuation or disengagement.
o Alcohol or substance use, and the effects of these.
o Early exposure to violence or being part of a violent subculture.
o Triggers or changes in behavior or mental state that have occurred prior to previous
violence or relapse.
o Evidence of recent stressors, losses or threat of loss.
o Factors that have stopped the person acting violently in the past.
o Are the family/caregiver at risk
o History of domestic violence
o Lack of empathy.
o Relationship of violence to personality factors and Impulsivity .
 Environment
o Risk factors may vary by setting and patient group.
166
o Risk on release from restricted settings.
o Consider protective factors or loss of protective factors.
o The safety of the patient in the ward
o Risks of reduced bed capacity and alternatives to admission.
o Access to potential victims, particularly individuals identified in mental state
abnormalities.
o Access to weapons, violent means or opportunities.
o Involvement in political or social issues
 Mental state
o Evidence of symptoms related to threat or control, delusions of persecution by others,
or of mind or body being controlled or interfered with by external forces, or passivity
experiences.
o Voicing emotions related to violence or exhibiting emotional arousal (e.g. irritability,
anger, hostility, suspiciousness, excitement, enjoyment, notable lack of emotion,
cruelty or incongruity).
o Specific threats or ideas of retaliation.
o Grievance thinking.
o Thoughts linking violence and suicide (homicide–suicide).
o Thoughts of sexual violence.
o Evolving symptoms and unpredictability.
o Signs of psychopathy.
o Restricted insight and capacity.
o Patient’s own narrative and view of their risks to others.
o What does the person think they are capable of? Do they think they could kill?
o Beware ‘invisible’ risk factors.
STEP …Administering Treatment to Mentally Ill Patient in Emergency Psychiatry
STEP…Referring Patient with Emergency Psychiatric Condition(s)

o
STEP 9:Key Points (5 minutes)
 Psychiatry Emergency Is an acute disturbance of behaviour, thought or mood of a patient
which if untreated may lead to harm, either to the individual or to others in the environment.
 It lead to acute changes in behaviour that negatively impact a patient's ability to function in his
or her environment
 Common psychiatry emergencies, aggression, suicidal ideation, acute psychotic states and
status epilepticus
 Immediate care to prevent harm to person or other in psychiatry emergencies
STEP10 :Session Evaluation (5 minutes)

o What is psychiatry emergency?
o What are the common psychiatric emergencies?
167
REFERENCES
Elsevier Sounders
168
Session Eighteen Session 14:CARE OF SPECIAL GROUP WITH MENTAL
ILLNESS HAMISHA PELEKA KABLA YA COMMUNITY PSYCHIATRY
Pre-requisite: None
Learning tasks

Define special group
Identify special group with mental illness
Describe common mental conditions affecting children, adolescent and old people
Give care to children, adolescents and older people with mental disorders
Give psychosocial care to victim of abuse or neglect
Resources Needed:

Method
1 5
Presentation Learning task
2 40 Brainstorming Definition of Special Group
3 10 Buzzling Special Group With Mental Illness
4 10 Lecture discussion Common mental conditions affecting children,

adolescent and old people
5 15 Lecture discussion Care to children, adolescents and older people
with mental disorders
6 30 Brainstorming Psychosocial care to victim of abuse or neglect
169
7 5
8 5
SESSION CONTENTS

STEP 2: Definition of Special Group (10 Minutes)
ASK Students to brainstorm on Special Group?
Special Group is a group of people who have particular demands and who try to influence political
decisions involving them. TAfuta ingine
STEP 3: Special Group with Mental Illness (5 Minutes)
ASK students to pair up and buzz on Special Group with Mental Illness
Special Groups with Mental Illness are:

 Children
 Adolescence
 Old people
STEP 4: Common mental conditions affecting children, adolescent and old people (40
minutes )
Common mental conditions affecting children and adolescence include:
 Hyperkinetic
 Oppositional
170
 Conduct disorder
 Mental retardation
 Autistic disorder
Hyperkinetic (attention deficit disorder)
Hyperkinetic disorder refers to displaying significant and developmentally inappropriate inattention,
impulsivity, and over activity from an early age (before seven years).
Aetiological factors for Hyperkinetic
o Biological influence i.e genetics
o Biochemical theory, suggest that dopamine, norepinephrine and serotonin possibly
associated with Hyperkinetic
o Anatomical influences –alteration in specific area of brain
o Prenatal, perinatal and postnatal factors –intrauterine exposure to toxic like alcohol,
infections
o Environmental influences
o Diet factors such as artificial flavorings and preservatives
o Psychosocial influences i.e. chaotic environment and disruption of family equilibrium
Common features of children with Hyperkinetic
o Can’t finish anything he starts doing
o Doesn’t seem to listen
o Is completely disorganized
o He forgets to take even his books to school
o Anything distracts him
o Can’t sit still. Gets up the table ten times during dinner.
o Fidgets all the time
o Is very restless.
o Is on the go all the time, seems to have engine inside.
o Runs and climb everywhere
o Talks too much
o Is very loud and noisy
o Can’t wait for his turn
o Seeks attention all the time
o Does things without thinking
o Answers when he is not asked and butts into conversations
o Get injured alot
Oppositionaldisorder refers to a persistent pattern of negativistic and hostile conduct towards people in
authority, typically parents or teachers.
Aetiological factors for Oppositional disorder
o Biological influence such as temperament or biochemical alteration
o Family influence during developmental stages related to parental problems, parental
unavailability
Common features of children with Oppositional disorder
o Loose of temper and swear with little provocation, especially when demands are denied
o Stubborn and cannot give in resulting in frequent arguments
171
o They are touchy, blame others for their mistakes
o Seem to enjoy provoking and annoying others
o Justify their behavior by saying that what they were asked to do is unreasonable or unfair.
Conduct disorderrefers to a pattern of behavior characterized by breaking rules, and lack of respect for
the rights of others.
These adolescents are customary in conflict with parents, teachers, and society
Subtypes of conduct disorder are
o Childhood onset type
o Adolescent onset type
Aetiological factors for Conduct disorder
 Biological influence that includes genetics, temperaments, biochemical factors
 Psychosocial influence like peer relationship
 Family influencesuch as
o Parental rejection
o Inconsistent management with harsh discipline
o Early institutional living
o Frequent shifting of parental figures
o Large family size
o Absent father
o Parents with antisocial personality disorder and/or alcohol dependence
o Marital conflict and divorce
o Inadequate communication patterns
o Parental permissiveness
Common features of children with Conduct disorder
 Bullying, victimization and intimidation of others
 Cruel to people or animals
 Starting physical fights
 Using weapons in fights
 Stealing, shop- lifting or breaking and stealing
 Setting fires to cause damage
 Vandalism or destroying property of others
 Lying or cheating ( to con others )
 Running away from home overnight
 Staying out at night without parent’s permission
 Repeated truancy
 Forcing others to perform sexual acts against their wills
Mental retardation is the deficit in general and intellectual functioning and adaptive function.
o Measured by the individual performance on intelligence quotient test
o Adaptive functioning refers to the patient ability to adapt to the requirement of daily living
and expectation of his/her age and cultural group
Aetiological factors for Mental retardation
o Hereditary factors such as inborn errors of metabolism i.ehyperglycemia, down syndrome.
172
o Early alteration in embryonic development related to toxicity, maternal illness and infections
and pregnancy complication such as toxemia, uncontrolled diabetes
o Pregnancy and perinatal factors such as fetal malnutrition, viral and other infections and
prematurity, placenta previa,premature separation of placenta
o General medical condition acquired in infancy or childhood includes infections, meningitis,
encephalitis, poisoning, head injury, asphyxiation, and hyperpyrexia.
o Environmental influences and other mental disorder includes deprivation of nurtances,
autistic disorder
Common features of children with Mental retardation
o Deficit or impairment in communication
o Self-care deficit
o Inadequate home/living/social and interpersonal skills
o Inadequate utilization of community resource and self-direction
o Poor academic performance and skills
o Inadequate self-protection
o Poor functional and working ability
Autistic disorder characterized by a withdrawal of the child into the self and into a fantasy world of his or
her own creation.
Aetiological factors for Autistic disorder
o Neurological Implications-alterations in major brain structures to patient with Autistic
disorder
o Physiological Implications-medical conditions such as tuberoussclerosis, fragile X
syndrome, maternal rubella, congenital hypothyroidism, phenylketonuria, Down
syndrome, neurofibromatosis.
o Genetics-parents who have one child with Autistic disorder are at increased risk for
having more than one child with the disorder
o Perinatal Influences-women who suffered from asthma and/or allergies around the time
of pregnancy were at increased risk of having a child affected
Common features of children with Autistic disorder
o Impaired development in social interaction
o Deficit or impairment in communication
o Markedly restricted selection of activity and interests
Aged/Demented Patient
Definition
Old age is a gradual and slow process with the following features:
Physical indication of aging
o Slow motor activities
o Loss of muscle tone
o Increased fatigability
o Greater sensitivity to temperature changes
o Decrease in sight and hearing
o Decreased resistance to infection
Psychological indications
o Decrease in problem solving ability
173
o Inflexibility and rigidity in new situation
Clinical Features Aged/Demented Patient
o Patient may be forgetful, unaware of time and place
o Poor judgment
o Tend to be self- centered and resistant to new ideas and changes
o May be careless about appearance
o Slowing down of mental and physical activities
o May be irritable, confused and restless; may laugh or cry suddenly
o May feel useless or unwanted
STEP 5: Care to children, adolescents and older people with mental disorders (30Minutes)
Care and treatment to children and adolescents with mental disorders
 Drug therapy to reduce symptoms-stimulants such as dexamphetamine, methylphenidate,
pemolive
 Tricyclic antidepressants –imipramine indicated only if stimulants produce side effects or can’t
use monitoring of blood pressure, pulse and EEG is advisable.
 Psychological therapy-recommended for all instances
 Behavior therapy
 Family therapy
 Classroom management.
 Diet -Dietary substances, such as artificial flavors and colours, can produce ADD symptoms in
some children
 Family counseling- educates parents’ techniques for handling the behavior and encourages
desired behavior.
 Individual counseling
 Educate on problem solving skills
 Teach parenting skills
 Provide family therapy
 Close and ongoing working relationship between the family and the therapist
 Placement in residential setting
Care to older people with mental disorders
 Reduce discomforts and prevent physical problems through good medical care; good skin care,
oral hygiene, diet, and regular toileting.
 Security, respect, and acceptance to promote self esteem
 Kindness and reassurance
 Call by proper name and title
 Avoid infantilization
 Help to strive toward potential
 Avoid confusing and embarrassing patient. (START WITH ACTION VERBS)
 Give responsibilities within reason and praise for accomplishments
 Offer opportunities for socialization
 Consider likes and dislikes
 Routines should be unchanging; clocks and calendars help in orienting patient
174
 Protect from injury caused by poor eye sight and muscle coordination; careful supervision in
bathrooms
STEP 6: Psychosocial care to victim of abuse or neglect (20 Minutes)
ASK Students to brainstorm onPsychosocial cares to victim of abuse or neglect?
Psychosocial care to victim of abuse or neglect

 Allow patient to discuss feelings regarding assault
 Communicate knowledge and understanding of emotional responses to sexual assault to help in
identification of feelings
 Provide anticipatory guidance regarding common physical, psychological and social responses
 Explore and encourage relationship with significant others
 Encourage the patient to discuss the situation with trusted and supportive people
 Help in identify medical care provider and offer to accompany to the medical examination
 Support decision making and active problem solving
 Provide written information about community service, and encourage the use of them
 Plan for follow up

 Special Group a group of people who have particular demands and who try to influence political
decisions involving them.
 Common mental conditions affecting children and adolescent Hyperkinetic, Oppositional, Conduct
disorder, Mental retardation and Autistic disorder
 Psychosocial care to victim of abuse or neglect are Allow patient to discuss feelings regarding
assault, Communicate knowledge and understanding of emotional responses to sexual assault to
help in identification of feelings, Provide anticipatory guidance regarding common physical,
psychological and social responses

 What is special group?
 What are the special group in mental illness?
 What are the nursing care to children and adolescence with mental illness ?
175
References
Elsevier Sounders
176
177
178
179
180
181
182

Mental Health Nursing - Sessions 1 (1) (Repaired)

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Mental Health Nursing - Sessions 1 (1) (Repaired)

Uploaded by

Copyright:

Available Formats

THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT, GENDER, ELDERLY AND

DIRECTORATE OF HUMAN RESOURCE DEVELOPMENT

FACILITATOR’S GUIDE FOR ORDINARY DIPLOMA

NMT 06211: Mental Health Nursing

NMT 06211: Mental Health Nursing ii

NMT 06211: Mental Health Nursing iii

NMT 06211: Mental Health Nursing iv

Dr. Loishook Saitori

NMT 06211: Mental Health Nursing v

Ndementria Arthur Vermand

NMT 06211: Mental Health Nursing vi

NMT 06211: Mental Health Nursing vii

3.2. Objectives for Training Manual

6.1.1 Describe concepts of personality development in relation to mental health

NMT 06211: Mental Health Nursing viii

4.3. How is the Module Organized?

4.4. How Should the Module be Used?

NMT 06211: Mental Health Nursing ix

Total Session Time: 120 minutes

Pre requisite: None

1 05 Presentation Presentation of Session Title and Learning tasks

5 30 Lecture discussion Stages of Psychosocial Development (Erickson theory)

6 30 Lecture discussion Stages of Cognitive Development (Piaget theory)

7 05 Presentation Key Points

NMT 06211: Mental Health Nursing 1

STEP 2: Definition of Personality Development ( 5 minutes)

 ASK students to brainstorm on the definition of personality development

 ALLOW time for them to respond

 WRITE their answers on the flipchart/board

 SUMMARISE with information given below

STEP 3: Structure of personality (10 Minutes)

NMT 06211: Mental Health Nursing 2

STEP 4: Stages of Psychosexual Development - Freud’s theory (40minutes)

The Oral Stage –

NMT 06211: Mental Health Nursing 3

The Phallic Stage

The Latent Period

NMT 06211: Mental Health Nursing 4

The Genital Stage

Implications for Psychiatric Mental Health Nursing

STEP 5: Stages of Psychosocial Development (Erickson theory) (30 Minutes)

NMT 06211: Mental Health Nursing 5

1. Trust vs. Mistrust Hope 0 - 1½

2. Autonomy vs. Shame Will 1½ - 3

3. Initiative vs. Guilt Purpose 3-5

4. Industry vs. Inferiority Competency 5 - 12

5. Identity vs. Role Confusion Fidelity 12 - 18

6. Intimacy vs. Isolation Love 18 - 40

7. Generativity vs. Stagnation Care 40 - 65

8. Ego Integrity vs. Despair Wisdom 65+

1. Trust vs. Mistrust

2. Autonomy vs. Shame and Doubt

NMT 06211: Mental Health Nursing 6

3. Initiative vs. Guilt Age

4. Industry vs. Inferiority

5. Identity vs. Role Confusion

NMT 06211: Mental Health Nursing 7

6. Intimacy vs. Isolation

7. Generativity vs. Stagnation

NMT 06211: Mental Health Nursing 8

8. Ego Integrity vs. Despair

Implications for Psychiatric Mental Health Nursing