MENTAL HEALTH NURSING

VIJAYAM'S
Inflammation of mucous membrane of the nose. on
Rhinitis derived from inflicting physical or psychological pain
Sadism Pleasure
others.
A large group of disorders usually
of psychotic proportin tion
Schizophrenia mood and behaviour,
characterized by disturbance in thought,
for your self and your abilities.
Self esteem :A feeling of having respect
characterized by multiple physical complainte
Somatic Disorder :A neurotic disorder
without a known organic cause.
restelessness in patients.
Sun downing :Late day confusion and episodes of depression.
Unipolar Depression Characterized by recurrent
on intensely. Swelino
of round read weals on the skin which it
Urticaria Arash
caused by allergic reaction of food.
surrounding the entrance to vagina.
Vaginismus Involuntary spasms of the muscles
A sexual dysfunction in females.
Sexually motivated and often
compulsive interest in watching or
Voyeruism activity.
looking at others genitals or sexual

In
5.1. PATHOPHYSIOLOGY OF HUMAN
BEHAVIOUR h.
la
conception to death.
Behaviour is everything that an organism does from
al

This involves 3 things.

W
es

(Human Behaviour)
ot

Knowing Feeling Doing

N

(Cognition) (affection) (Conation)

Primary Mental function Emotional component Psychomotor Activities

e.g, e.g., e.g.,
Thinking Happiness ADL (Activity of Daily Living)
Recalling Sorrow
Recognition Fear
Judgement Anger

Fig. 5.1

*It helps to one to be aware of and understand the self and the environment.
Psychiatry nursing is a branch ofnursing that deals with the careofpsychiatry patients wbo
considered as abnormal in their behaviour.

5.4
 VIJAYAM'S5
Unit-5:: Mental Disorders and Nursing Interventions

Aristotle

"All hunan actiorns Iave ore or

more of these seven causes
chance, nnture, conmpulsions, hiabit,
Teason. passion, desire"

In
5.2 Human Behaviour
Fig.
h.
la
al

Anticipation Mild Moderatee Severe Extreme

W
es

Behaviour
ot
N

Normal (Adaptive response) Abnormal

(Latin word) (Maladaptive responses)

"Norma" Means

Carpenter square Deviation or

or different from the
rule "norm" or standard

Fig. 5.3

5.5
 MENTAL HEALTH NURSINC
VIJAYAM'S
Abnormalperson Constitutional Factors: Constitutin.
iona
Tohe Traits of Normal and factors include physique, physical handicas
blindness
Traits of a Normal Traits ofan and to stress. Physical handicap like
Person abnormal person affect the self of an individual, as these are
Attitude towards self-| Deviation from stress situations for the adjustment. A person
self identity, accepts statisticalnoms may socialize very less and may
develan

self. genius considered as fecling of inferiority, selt pity and sometimg

retarded pcrson. hostility also.
Perception of reality. Deviation from social
norms-arime, sexual 3Plysical Deprivation: Severe malnutrition
abuse affects the physical and mental growth of
Maladjustment the infant. They are more prone to any type
Integration unity of
-

personality, freedom ineffective of infection, MR and mental depression,

from negative inner adjus tments for Sleep deprivation and fatigue over a long
conflicts good stress physical and social period of time may cause mental disorder.
environment.

In
tolerance.
Autonomy Personal distress, Biochemical Factors: Biochemical
abnormalieitesin the brain are considered to
responsibility self
direction
depression of guilt.
h.
be the cause of some psychological disorder.|
The disturbance in neurotransmitters in the
la
Growth sdf Pcrsonal immaturity
actualization matured, behaving brain is found to play an important role in the
al

self fulfillmant. inappropriate to onee's çauses of certain psychiatric disorder.

age level.
W

Brain Damage; Any damage to the

structure and functioning of the brain can give
riseto mental illness like infection, vascular
es

problem (poor blood supply or bleedingk

injury, tumours, intoxication, degeneration,
ot

52211OLOGICAL THEORIES anoxia.

(GENETICS, BIOCHEMICAL,
N

Phusiological Eactors: Pregnancy, chil

PSYCHOLOGICAL ETC.)
birth, menopause, puberty, fever etc. may be
perceived as stress by an individual which
Causes of Abnormal behaviour or causes
in turn precipitates mental illness.
of mental disorder or Factors influencing
mental illness: Psychological Factors
Biological Fators:
Maternal deprivation:
Genetic Fuctory
Child is deprived of maternal stimulatiou
Chromosomal increase or decrease may
of mothering.
affect the development of foctus. the
e.g. Mongolism, Down's syndrome. *The warmth of a mother passes on
* In some mental illnesses, there may be a child by touching, kissing or hugging
family member suffering from similar
illness.

5.6
 init-5 :: Mental Disorders and hursing tnterverntions UAYAMS
Few examples: Separation of the
child Predisposing Factors
from mother affects the growth of the
child. Mother figure can be grand
mother, Thesc occur before the onset of the
clder sister or anyone else like the mother discase or before psychopathology have
who can give affection to the child. appeared.
Inadequate mothering or stimulation For example, rejection by parent is in the
affectsthe growth and behaviour of the carly age of the child but the disease may
child. come at the age of 16 to 18 or 30 to 40.
Faculty Parent: Child rclationship: 1t affects These factors include genetic make up,
thebehaviour of a child. physical damage to the central nervous system
y
Rejection Parents: It may cause feclings
of and adverse psychosocial influence.
anxiety, insecurity low sclf-cstcem.
Precipitating Factors: These are events that
Over-Protection by Parents: It may lead
to occur shortly before the onset of disorder and
submissiveness, low self-evaluation during
his appear to have induced it. For example, death
intellectual abilities.
of the father ofan adolescent boy may lead him

In
Lack of Discipline: It results in aggressiveness, into depression.
antisocial behaviour.
Strict Discipline: It may produce fear, lack
of
h.
These factors include physical, physiological,
Psychological and social stress.
la
friendly feeling towards others.
Abnormal behaviour in Adolescent; Primary Factors:
al

During
adolescence, parents share the child's feelings It is the condition without which the disorder
W

about studies or any other personal problem. would not have occurred. For example, in a head
If
itis like that they will feel comfortable. If parent-nury the primary cause trauma leads to an acute
es

child relationship is not there, they may be prone confusional state, which is a transient organic
to develop abnormal behaviour. psychotic condition.
ot

Stress: Failure in studies, job, adjusting to marital

life, loss of money or status, death ofa significant
N

person etc...
Social CulturalFactors
Poverty 5.3. CLASSIFICATION OF MENTAL
DISORDERS
Unemployment
Insecurity Classification is a process by which
Severe competitions complex phenomena are organized into
Migration categories, classes or ranks so as to bring
Urbanízation together those things that most resemble
each other and to separate those that
Alcoholism differ.
Prostitution
Broken home

n5.7
VIJAYAN'S MENTAL HEALTH NURSING

*Like any growing branclh of medicinc FI1 Mental and behavioural disorders
psychiatry has seen rapid changes in duc to useof opioids
classification to keep up with a F12 Mental and behavioural disorders
conglomeration of growing rescarch data due to use of cannabinoids
dealing with epidemiology, symptomalogy,
F13 Mental and bchavioural disorderg
prognostic factors, treatment mcthods
due to use ofsedatives or hypnotic
and new thcories for causation of
psychiatric disorders. F14 Mcntal and behavioural disorders
*At prescnt thcre arc two major duc to use of cocaine
classifications in psychiatry, namcly, ICD- Mental and behavioural disorders
FI6
10 (1992) and DSM IV (1994).
due to use of hallucinogens
F20-F29:Schizophrenia, schizotypal and
L.
ICD10 INTERNATIONAL CLASSIFI delusional disorders:
CATION OF DISEASE AND RELAJED
HEALTH PROBLEMS)-1992 F20 Schizophrenia

In
This is WHO's classification for all F20.0: Paranoid schizophrenia
diseases and related health problems. The
chapter F" classifies psychiatric disorders
as mental and behavioural disorders codes
h.
F20.1: Hebephrenicschizophrenia
F20.2 Catatonic schizophrenia
la
them on an alphanumeric system from F00
F20.3 Undifferentiatedschizophrenia
to F99.
al

The main categories in 1CD10 are: F20.4 Post-schizophrenicdepression

W

FOO-FO9:Organic,including F20.5: Residualschizophrenia

symptomatic, mental disorders:
F20.6: Simple schizophrenia
es

F00: Dementia in Alzheimer's disease

FO1: Vascular dementia F21Schizotypaldisorder
ot

FO4 Organic amnestic syndrome F22 :Persistent delusional disorders

N

FO5 Delirium F23: Acute and transient psychotic

F06: Other mental disorders due to brain disorders
damage and dysfunction and to F24 Induced delusional disorders
physical disease.
F07
F25 Schizo affective disorders
Personality and behavioural
disorders due to brain disease, F30-F39: Mood (affective) disorders:
damage and dysfunction F30 :Manic episode
F10-F19: Mental and behaviour
disorders dueto psychoaciive subsiance F31 Bipolaraffective disorder
Use: F32 Depressive episode
F10 Mental and behavioural disorders
due to use of alcohol
F33 Recurrentdepressive disorder
F34 Persistent mood disorder

5.8
 VIJAYAM'S
Mental Disorders and Nursing
Interventions
Unt-5 2:

65: Disorders of sexual preference

F40-F49: Neurotic stress-rolutod und
somato-forin disorders: F70-F79: Mental retardation:
F40 Phobic anxiety tdisorders F70: Mild mental retardation
F41 :Otheranxiety disorders F71 Moderatemental retardation
F42: Obsessive-conmpulsivedisorder F72 Severe mental retardation
F43 Rcaction to severe stross, and retardati
adjustment disorders F73: Profound mental
F80-F89: Disorders of
psychological
F44 Dissociative(conversion) disorders
Somatoform disorders development:
F4S -
Specilic ders of
F50-F59: Behaviouralsyndromos F80 :

associated with physiological speech

disturbancesand physicalfactors: F81Specific de .ii disurders of

In
FSO Eatingdisorders scholastic
FS1: Non-organic sleep disorders F82 :Specificd nenia rders of
F52 Scxual dysfunction, not caused
byy h. motor fur
la
organic disorder or discasc F83 Mixed specific developmental
F60-F69: Disorders of adult personality disorders
al

and behaviour:
F&4: Pervasive developmental disorders
W

F60:Specificpersonalitydisorders F90-F99: Behavioural and emotional

F60.0 Paranoid personality disorder
disorders with onset usually occurring
es

F60.1 Schizoid personality disorder in childhood and adolescence

Dissociative personality disorder
F60.2 F90 :Hperkinetic disorders
ot

F60.3 Emotionally unstable personality F91:Conductdisorders

N

disorder
F604 Histrionic personality disorder
F93 :Emotional disorders with onset
specific to childhood
F60.5: Anankastic personality disorder
F94 Disorders of social functioning with
F60.6: Anxious personality disorder
onset specific to childhood and
F60.7 Dependent personality disorder adolescence
F6l :Mixed and other personality F95: Tic disorders
disorders
F98 Other behavioural and emotional
F62 Enduring personality changes, not
attributable to brain damage and disorders with onset usually
discase Occurring in childhood and
F63 adolescence
:
Habit and impulse disorders
F64: Genderidentity disorders F99 Unspecifiedmental disorder
 MENTAL HEALTH NURSING
VIJAYAM'S
DSM-Iv.TR (DIAGNOSTIC STATISTICAL Neurosis:
I. MANUAL-1v-TEXT REVISED-1994)
*Anxicty neurosis
is the classification of mental Depressive neurosis
This Psychiatric
disorders by the American *Hysterical neurosis
Association (APA).
pattern adopted by DSM-1V is of
Obsessive compulsiveneurosis
The
multiaxial systems. Phobic ncurosis
A multiaxial system that cvaluates Special Disorders:
patients along several versatiles contains five Childhood disorders
axes. Axis I and 11 make up the entirc
classification which contains more than 300 Conduct disorders
specific disorders. Emotional disorders
The five aves of DSM-1V are: Personality disorders

In
AXISI: Clinical psychiatric diagnosis Sociopathy
AXIS II: Personality disorder and mental
retardation h. - Psychopathy

*Substance abuse
la
AXIS II1: General medical conditions
Alcohol abuse
al

AXISIV: Psychosocial and environmental

problems Drug abuse
W

AXIS V: Global assessment of functioning Psycho physiological disorders

in current and past one year
es

Asthma
Indian Classification: In India Neki (1963),
Psoriasis
Wig and Singer (1967), Vahia (1961) and
ot

Varma (1971) have attempted some Mental retardation

N

modifications of 1CD8 to suit Indian Mild

conditions. They are broadly grouped as
follows: Moderate
Paychosis: Severe
Functional psychosis Profound
(e.g. Schizophrenia). In everyday practice classification 5
Affective psychosis made after the history and examination o
mental state have been completed.
(eg. Mania and depression).
Organic psychosis
(eg. Delinium and dementia).

5.10
 VIJAYAM'S
Unit-5 Mental Disorders and Nursing Interventions
him. These are seen in organic psychosis,
schizophrenia and in severe affective
Psychosis) glisorders.
N
Delusians of Reference: Are concerned
D
with the idea that objects, events or people
A have a pcrsonal significance for the
spoken from
N patient. For instance, words
directed to
the radio are believed to be
C
the patient. This is commonly seen in
L
A paranoid schizophrenia.
Neurosis Grandiose Delusions: Are beliefs of
S éxaggeratcd self - importance. The
multimillionaire,
F patient may think he is a
a King or the Prime
Minister of India.
schizophrenia.
This is seen in mania and

In
Delusions of Guilt and Worthlessness:
A
T
depression. Typical
O h.
Are seen often in
themes are that a minor infringement of
discovered and
la
N
Special disorders the law in the past will be
family.
bring divine retribution on his
al

Nihilistic Delusious: Are seen in

Fig. 5.4
W

extreme depression. The patient feels that

body parts are missing or there is failure
es

of bodily function.
Hypochondriacal Delusions: Contrary
ot

5.4.
to medical evidences the patient may
SORDERS OF THOUGHT believe wrongly that he is ill. This may be
N

seen in the elderly and in somatisation

Disorders of Thinkipg: These are recognized disorders, part of psycho physiological
from an individual's speech and writing. disorders.

Abngrmal Ihoughts (Delusions, Delusions of Jealousy: usually in

Ohsessions): A delusion is a false
unshakable belief that cannot be changed by
others. Delusions are grouped as follows:
Persecutory Delusions: Which are
paranoid. The patient feels that other
individuals or organizations are planning
to harm the patient, damage his
reputation, make him insane, or poison
Seen
males. The individual is obsessed with
doubts about the spouse's fidelity. It is
seen commonly in Paranoid states.
Delusion of Control: The patient believes
that his actions, impulses or thoughts are
controlled by an outside agency. This is
common in schizophrenia.

5.11Ra
VIJAYAM'S
ossession of Thoughts: Patients with
delusions concerning the possession of
thoughts may feel that his thoughts are not
his own or that his thoughts arc known to
others.
YThought Insertion: Therc is a beliefthat
their thoughts are not their own and have
been implanted by an outside agcncy. This
is diffcrentiated from obsession in that the
obsessional patients may be distressed by
unpleasant thoughts but know that these
thoughts oniginate within their own minds.
Y Theught Hithdrawal: There is a belief
that thoughts have been removed from
their mind. Thought "blocking" may
accompany this where the patient
Cxperiences a break in the flow of
thoughts and believes that the "missing"
thoughts have been taken away by
outsiders, supposedly his persecutors.
al
Thourht Broadcasting: They believe
W
that their unspoken thoughts are known
to others, through radio, TV, telepathy etc.
es
ii. Disorders of Stream of Thaughi:
Flight of ldeas: Here, the patient's
ot
fhoughts and conversation move rapidly
N
from one topic to another. It is expression
characteristic of mania.
activity) occur frequently in all mental disorders.
Neologism; Is a speech abnormality,
when the patient gives new words or involving a group
phrases, thought byhimself. «g. Foot hat continuously.
for shoes.
Circumstantiulity:
Here, the thinking
process 1s very slow interspersed
with
many trivial unrelated details, but finally
they come back to the starting point of
their speech. It is seen in mania,
schizophrenia and organic mental
disorders.
aN Na5.12
MENTAL HEALTH NURSING
Loosening of Avsociations: Denotes
a
loss of the normal structure of thinking
It occurs often in schizophrenia.
Obsessional Symptoms: These are of
less scrious significance when compared
to delusions. Obsessional and compulsive
symptoms often occur together.
Obsessions are recurrent, persistent
thoughts, impulses or images that enter
the mind despite the person's efforts to
avoid them. He knows that these originate
from his mind. Compulsions are repetitive
and seemingly purposeful behaviour,
performed in a stereotyped manner.
Compulsions are usually associated with
In
obsessions as they reduce the distress
caused by the obsessions. For instance
h.the compulsion of repeatedly checking
la
whether the door is locked often follows
obsessional thoughts that the door has
been left unlocked.
5.4B. MOTOR ACTIVITY
Disorders of Motor Activity:
Abnormalities of social behaviour, facial
and posture (components of motor
Tics are irregular repeated movements
of muscles e.g. winking
Mannerisms are repeated
movements that appear to have some functional
significance e.g. shrugging.
Stereotypes are
repeated movements that are regular (unlike
and without significance (unlike mannerisms)tic
e.g. Rocking to and fro.
Posturing is the maintainingunusual bodily
positions continuously for a long time,
example standing on one leg.
 Unit-5: Mental Disor ders and Nursing interventions
Negativism is doing the oppositc of what
one is asked to do and actively resisting
efforts to comply.
Echopraxia is imitating the other person's
movement automatically even when
asked not to do so.
Echolalia is repeating the last words,
which the other person utters.
Waxy flexibility is reduced muscle tone
in the limbs and ability to bend the limbs
in abnormal positions.
Except for tics all the other symptoms are
observed among schizophrenic patients.
5.4C. PERCEPTION
Disorders of Perception: These are
i Illusions: Mis-perceptions of external
al
stimuli. Aperson walking on a moonlight night
can misperceive a stick on the ground to be
W
a snake.
Hallucinations: Is a perception experienced
es
in the absence of external stimulus to the
sense organs. The type of hallucination
ot
depends on the sensory system affected.
Auditory, visual, olfactory, gustatory
N
tactile.
Auditory Hallucinations: May be
experienced as noises, music or voices.
These voices may talk directly to the
pauent, discuss with each other about the
patient referring to the patient as "he"or
"she". The voices may be clear or vague;
words, phrases or sentences may be
uttered. This is common in schizophrenia.
isual Hallucinations: May be
experienced as seeing persons, objects or
animals. The size of these may appear to
be norrnal or abnormal. These may occur
5.13
LAYAS
in affective disorders, schizopirenia or
organic disorders.
olfoctory Hallucimatioms: Are
experienced as unplezsant stmeils
Gustatory Hallucinutions: Are
experienced as unpleasant tastes.
and Gustatory Hallucina-
olfactory
tions: Are very rare and may occur in
schizophrenia or severe depression2 ihey
also suggest temporal lobe epilepsy or
irritation ofthe olfactory bulb or pathways
by a tumour.
Tactile Hallucinations: are experienced
sensations of being touched. pricked
In
or strangled. They can also be felt as
movements below the skin which may be
h.
expressed as insects or worms burowing
through tissues. Deeper sensations may
la
be experienced such as feelings of the
viscera being pulled upon or distended
sexual stimulation or electric shocks.
These may occur in persons who abuse
alcohol, cocaine and rarely among8
schizophrenics.
Disorder of Perception
ilusions Hallucinations
Auditory hallucinations
Visual hatlucinaticns
Offactory hallucinatons
Gustatory hatlucinations
Tactile halucinations
Fig. 5.5
VIJAYAM'S MENTAL HEALTH NURSING

54p MOOpD 5.4F MEMORY

Disorders of Mood: Scveral kinds of memory failure are seen
among psychiatric patients. Some patients with
The tem "affect" is used for short - term
states, while "mood'" is for sustaincd ones.
| extreme difficulty in remembering may report
as memories, ev that have not taken place
Usually emotions such as anxiety, depression,
elation or anger exist in mental illncess. Changes and/or in which he had no involvement. This is
in these emotions can occur with or without any known as confabulation. (Filling up of memory
gaps with his own ideas).
reason. (Emotional disorders are usually
accompanied by autonomic over-activity,
increased muscle tension and feclings of
depression accompanied with psychomotor
slowness. 5.4G.CONCENTRATION

In
There is mood fluctuation from apathy
(without feeling) on the continuum to blunt Attention is the focusing of one or more

h.
(flattened or retarded emotions), Labile (Rapid,Sensory organs towards a particular stimulus or
abrupt changes in emotions) and emotional stmul.Concentration is the ability to maintain
la
incontinence (Marked mood changes where that focus. These abilities may be imparied ina
there is no control). variety of psychiatric disorders such as
al

depression, mania, anxiety, schizophrenia and:

There can also be incongnuity of affect. The
organic disorders.
W

person's display of affect is not congruent with

the circumstances. For instance, he may laugh
es

while talking about his father's death.

Emotional disorders are a part of all mental
5.4H.JUDGEMENT AND INSIGHT
ot

illnesses. They form the central feature

of
affective disorders (mania and depression)
and
N

anxiety disorders. They are also common Judgement is impaired in many organic
in conditions and in psychosis.
other neuroses, organic disorders and
schizophrenia. *Usually intact in neurosis.
Insight is patient's awarness
disability and need for
of his
help.
5.4E. SPEECH *Insight is rated on 6 poinnt scale.

1. Echolalia: Repetition of
sentences uttered words (or)
by another person.
2. Palilalia: Is a variant of
echolaliawhere only
the last word (or) syllable
is repeated.

NR5,14 R
 Insight

2 (3) 5
Intellectua
6
Trve emotions
Complete Slight Awareness of Awareness of tnsight
awareness being Sick being sick tnsight
denia
of ness of being sick attributed to attrbuted to
external or something
physical factor unknown
in himself

Fig. 5.6

The prognostic factors

can be
5.5. PREVALENCE, ETIOLOGY, demographic (age, sex) disease specific

In
the
SIGNS AND SYMPTOMS, (presentation and symptomatology or
presence of other conditions
PROGNOsis, MEDICAL AND
NURSING MANAGEMENT
h.
(comorbidity).
la
In
Course and Prognosis of Schizophrenia:
as
Prognosis of Mental lllness: general schizophrenia, has been described
al

psychiatric
refers the most appling and devastating ofall
i The prognosis of mental illness usually
W

illnesses.
to the likely outcome of Mental illness.
the 5-
i Several studies have found that over
es

The prognosis of Mental illness may include

i the duration of mental illness, chances of
10 years period after the first psychiatric
hospitalization for schizophrenia.
complications ofMental illness, survival rates,
ot

death rates and other outcome possibilities ii Only about 10-20% of patients can be
N

in the overall outcome possibilities in the described as having a good outcome. More
overall prognosis of mental illness. than 50% of patients have a poor outcomne
with repeted hospitalization.
Factors Influencing prugnosis of illness:
Good Prognotic Factors:
Type ofproblem.
*Abrupt or acute onset.
Duration ofthe problem.
Their personal strengths and weaknesses. *Lateronset.
Presence of Precipitating factor
Availability of support system.
Good Premorbid personality.
Prognosis mental of illness influenced by
medication, Psychotherapy and Strong family Paranoid andcatatonie sub types.
Support: Short duration (<6 months).

5.15
VIJAYAM S s MENTAL. HEALTH NURSING
Prodominance of positive symptons. Personality disorders or alcoha:
Family history of nmood disorders. dependence.
Giood social support. Chronic ongoing stress.
Female sex *Poordrugcomplaincc.
Married. Marked hypochondrial features or mood
Out P'atient treatment. incongruent psychotic fcatures.
Poar Preynotie Factors: Signs and 5ymptoms:
Insidious onset. I. Mania
Younger onset. Mood.
Absence of Precipitating factor. Elevated. - Irritable.
Poor premnorbid personality. Specch.
Simple. undifferentiated sub typecs. Loud. - Rapid.
Long duration (>2 years). Grandiose.

In
Predominance of negative symptoms. Delusions.
Hyperactive.
Family history ofschizophrenia.
Poor social support.
h.
2. Depression
la
Male sex Mood
al

Single, diverced or widowed. Dysphoric depressive.

Institutionalization. Speech
W

Signs and Symptoms: Decreased interest in pleasure.

Tought and specchdisorders. Decreased libido.
es

Disorders of perception. *Insomnia.

Suicidal ldeas.
ot

Disorders of Affect
Disorders ofmotor behaviour. Prognosis of Depression:
N

Course and Prognosis of Mood Disorders: *Major depression disorder is recurrent

An average manic episode lasts for 3-4 months, illness. While cach episodc usually
while a depressive episode lasts for 4-9 months. responds to treatment, it tends to be a
ood Prognøstic Factors: chronic disorder and patients do tendto
Abrupt or acute onset. relapse (the condition deteriorates agatn
before an episode is completely resolved,
Severe depression.
Typical clinicalfeatures. Recurrences of major depressiv
cpisodes are also common for a patien
Well-adjusted premobid personality.
who has required hospitalisation for the
Good responseto treatment. intial episode (i.c., severe depression
Poor Prognostic Fuctors: there is 30-50% chance of recurran
Double depression. within the first two years and 50-700
Co-morbid physical diseasc. chance of recurrence within 5 years.

PEPEIDNELONAKOHte 5,16
 t5Mental Disorders and Hursing toterventfors
Course ond Protynosis of obsessive
compulsive disorder
Course is Usually long and fluctuating.
About 2/3rd of patients improve by the
end of a ycar.
A A good prognosis is indicated by good
social and occupational adjustnment, the
prescnce of a precipitating event and an
cpisodic nature of symptom.
Prognosis appears to be worse when the
onset is in childhood, the personality is
obsessional, synptoms are severc,
compulsions, arc bizarre, or there is a
coexisting of major depressive disorders.
Signs and Symptoms:
Obessional
Thoughts
Images
Ruminations
Impulses
Rituals
W
Slowness
es
Prognosis of Anxiety Disorder:
Generalized anxiety disorder can be quite
chronic, in that the average length of time
ot
the illness lasts is 20 years if untreated.
N
It can significantly interfere with the lives
of individuals who have it and usually
rcquires treatment for it to resolve.
Therfore, people with generalized anxiety
disorder are usually thought to need Early
treatment for at least a year to preventmental illness
its recurrence.
Signs and
Symptoms:
Fearful anticipation irritability,
restlessness.
Poor concentration.
Sleep disturbance.
VEJAYAN'S
Progniosis of Phobias:
Cognitive therapy and exposure therapy
alonc, together or combined with relaxation
training have been found to be effective in
treating phobias. Whilc some interventions, like
sedating people who are phobic about getting
dental work, may be useful in the short term,
they may undermine truely overcoming the
phobia.
Prevention of Phobia: Educatory people,
their loved ones, and other involved
individuals like children's teachesrs have
been found to be effective in preventing
phobias from occuring in the first place.
Coping with Phobia: Ways that phobia
In
Sufferers can work toward overcoming
their fears include talking about their
h.
fears, refraining from avoiding situation
la
they find stressful, imaging them-selves
facing their fears (visualization) and..
al
making positive selfstatements like"I will
be ok". In fact, when self approach as
are combined with brief psychotherapy,
people with phobia may achieve
significant improvement in symptoms.
Signs and Symptoms:
Irrational and persistant fear.
Anxiety
Loss of control
Worry
Impaired social or work functioning.
Treatment and Interventions for
can improve lives and lower
related health care costs:
Mental health services research course
areas such as:
Depression: The Partners in care
programme increases treatment for
depression and improves outcomes.
VIJAYAM
s It
MENTAL HEALTH NURSING

is originally used to describe the

Schizophrenia: Two tool kits were
developed to improve trcatment for theatrical mask worn by some dramatic
schizophrenia. actors at the time.
Adolescents at Risk: New tools can be *Hippocrates concluded stemmed from
used to screen adolescents at risk for cxcess of in the four humors: yellow bile,
suicide to evaluate school mental health black bile, blood and phlegm.
programmes. Yellow-iritable and holistic choleric.
*Quality Assurance: Tools have been Black- Pessimistic melancholic.
developed that promote quality optimistic and
Blood Overly
improvement programmes at managed extroverted sanguine.
behavioral health care organizations.
Phlegm-Apathetic Phlegmatic.
*Professional Education: Rescarchers
Definition:
have identified solutions that can improveDetiniion
education and training for mental health Personality refers to enduring qualities of
care professionals. an individual that are shown in the ways

In
of behaving in a wide varying of

5.6 ERSONALITY AND TYPES OF h.

circumstances.
*Personality disorder result when
la
PERSONALITY RELATED TO personality traits become abnormal i.e.
PSYCHIATRIC DISORDER become inflexible and maladaptive and
al

cause significant social or occupational

INTRODUCTION
W

impairment or significant subjective

The word personality is derived from the distress.
Greek term 'persona'.
es
ot
N

the friendly one the trouble maker

Loves to drink the musician the funny one

best friends the young one the old one the crazy one

oFig. 5.7 Different types of Personality

RRN 5.18ES
Unit-5: Mental Disorders and Nursing
Interventions
VIJAYAM's
Types of Personality:
Z.SchizoidPersonality Disorder: Schizoid
1. Paranoid Personality Disorder: DSM IV personality disorueristaracterized primarily
TR defines paranoid personality disorder by profound defect in the ability to form
as
a "Pervasive distrust and suspiciousness personal relationships or to respond to others
of
others such that their motives are interprcted in any meaningful, emotional way.
as malevolent, beginning by early
adulthood *Social withdrawal, discomfort with human
and present in a variety of contexts.
interaction.
Constantly on guard.
*Diagnosed more frequently in men.
Hypervigilant. Clinical Picture:
Ready for any real or imaginated
threat. *Cold, aloof and indifferent to others.
Tense and irritable. *They prefer to work in isolation and are
They avoid interaction with otherpeople. unsociable.
* Littleneed.
They always feel that others are there to

In
take advantage of them. *The person's appearance seems to be shy,
anxious, uneasy.
They trust no one.
h.
Diagnostic Criteria:
la
7They are constantly "testing" the honesty * Detachment from social relationship.
of others.
al
* Restricted range of expression of emotion
Diagnostic Criteria: in interpersonal settings.
W

Suspiciousness of others. Neither desires nor enjoys close

relationship.
es

Suspects without sufficient basis that

others are exploiting, harming. * Always chooses solitary activities.
ot

Pre-occupied with unjustified doubts Has little interest in having sexual

about the loyality or trustworthiness of experiences.
N

friends. Lack of close friends.

*Unwarranted fear of information will be
used maticiously against him or her.
Perceives attack on her / him.
Predisposing Factors:
Hereditary.
Relatives ofclients with schizophrenia.
Parental antagonism and harassment.
Rejection from others.
Appears indifferent to the praise or
criticism of others.
*Shows.emotional coldness detachment or
flattened affectivity.
Predisposing-Factors:
*The childhood of these, individuals have
often been characterized as cold and
lacking empathy.
* Child having temperamental disposition
that is shy, anxious and introverted.

5.19
 MENTAL HEALTH NURSING
VIJAYAM'S
4. Anfisocial (Dissocial) Personality
3. Schizotypal Disorder: Disorder (Sociopath, Psychopathl
eccentric but Antisocial personality disorder is
*Theirbehaviour is odd and level of characterized by chronic anti social
behavin
docs not decompensate to the
schizophonia. thatviolates other rights or social norms.

a pervasive Clinical Features:

*Odd thinkingand behaviour, deficits
pattem social and intcrpersonal
of *Failure to sustain
relationships.
and acute discomfort with others.
Disregard for the fcelings of others.
Clinical Features: *Impulsiveactions.
*Inappropriate affect * Low tolerance to
frustation.

Oddbeliefs or magical thinking. *Tendency to cause violence.

*Socialwithdrawal. Lack ofguilt.
or peculiar behaviour.
*Odd, eccentric *Failure to learn from experience.

In
ahead.
*-Lackofcloserelationships. Impulsivity and failureto plan
Social Isolation. h.
*Manipulative behaviour for self-
la
gratification.
Not fitting easily with others.
*Inability to maintain close personal or
al

Diagnostic Criteria:
sexual relationship.
ofreference (excluding delusional
W

Ideas Predisposing Factors:

reference).
maintain
The person is unable to
es

Magical thinking.
consistent, responsible functioning at
Unusual Perceptual experiences ofbodily work, school or as a parent.
ot

illusions.
Poverty.
N

Suspiciousness.
*Low socio-economic status.
*Constricted affect. *Alcohol.
Excessive social Anxiety. 5. Borderline Personality Disorder: ls
Predisposing Factors: marked by a pattern of instability in
interpersonal relationships, mood, behaviour
First degree bialogical relatives of people
and self-image.
with shizophrenia.
Clinical Features:
Hereditary factors.
Unstable relationships.
*Anatomical defects or neuro chemical
dysfunctions Unstable self-image.
*Impaired cognitive functions. Unstable emotions.
Impulsivity.
5,20
tlnit-5:: Mental Disorders and Nursing Interventions
Others: -
6Histronic Personality Disorder: Patients
Lack of control on anger.
Recurrent suicidal threats orbehaviour.
Uncertainty about personal identity.
Chronic feelings of emptiness.
VIJAYAM's
with this disorder characteristically have a
pervasive pattern of excessive emotion and
attension sceking behaviour and are drawn
to momentary excitements and fleeling
adventures.

*Transient stress-related paranoid or *Centre of attention at all times.

dissociative symptoms. Clinical Features:
Acting out of feelings instead of *Dramatic emotionality (Emotional
expressing them appropriately or verbally. blackmail, angry scene, demonstrative
Diganostic Criteria: suicide attempts).

Identify disturbances: Unstable self- Craving for novelty and excitement.

image or sense of self. Shallow and lable affectivity.

In
*Impulsivity in at least two arreas that are Attention seeking behaviour.
potentially self-damaging.
Recurrent suicidal behaviour.
h.
*Overconcerns with physical
attractiveness. e.g. Vague speech.
la
Chronic feeling of emptiness. Self-dramatization.
al

Inappropriate, intense anger or difficulty *Suggestibility.

W

in controlling anger. * Egocentricity, self-indulgence and lack of

Predisposing Factors: consideration for others.
es

Biological influences. Predisposing Factors:

Reactivity and senstivity to environmental
ot

Biochemical: Serotonergic defects

stimuli.
Medial and orbitofrontal abnormality may
N

promote the impulsive aggression. * Lightened noradrenergic activity.

Genetic: Relatives with mood disorders.
* Psychosocial influences:
Childhood trauma - Sexual or physical
abuse.
Substance abuse.
Antisocial personality.
Developmental Factors: Six phases
from birth to 36 months.
Heredity.
*Learning experiences.
7. Narcissistic Personality Disorder:Patient
with narcissistic personality disorder is self
centered, self absorbed and lacking in
empathy for others. He typically takes
advantage of people to achieve his own ends,
and uses them without regard to their feelings.

5.21
 MENTAL HEALTH NURSING
VIJAYAMI'S
Delirium is a syndrome, not a discase,
and

Clinical Features: it has many causes. Delirium

self-importancC.
*Inflated sense of underrecognized by the health care
car
Attention seekingdramatic behaviour, workers.
*Unable to face criticism. DSM-IV-TB
Lack of empathy. Delirium: Delirium 1s marked by short.
Exploitative behaviour. cognition
term confusion and changes in
*Arrogance. success, A temporary state of mentalconfusion
of
*Pre occupation with fantacicsideal love. and fluctuating consCiousness resultne
power, beauty, brilliance or
from high fever,
intoxication, shock, r
Predisposing Factors: Children fears,
other causes. It is characterized by
anxiety,
with
failures, dependency needs respondent disorientation, hallucinations, delusions,
criticism, neglect.
and incoherent speech.
Nursing Diagnosis: Deliriuan:
Names of
*Impaired social Interaction evidenced by | Other

In
inconsistent behaviour, fragile relationship, Intensive care unit psychosis.
anger out-bursts. Acute confusional state.
*Anxiety related to low self-esteem,
maladaptive coping and self-mutilating
h.
Encephalitis.
la
Encephalopathy.
episodes.
*Disturbed Thoughtprocess, evidenced by Toxic metabolic state.
al

non-reality based thinking delnsions, Central nervous system toxicity.

W

alteration in perceptions, impaired Sundowning

judgement and suicidal Ideation.
Cerebral insufficiency.
es

Organic brain syndrome.

Epidemiology
ot

5.7ORGANIC MENTAL
-
DISORDERS General surgical ward 10-15%
N

General Medical ward 15-25%

Anmental disorder(OMD), also known
asbrain syndrome or chronicsyndrome, is a form
Patients more than 65 years 30-40% -

ofdecreaseddue to a medical or physical disease, Surgical intensive care units and cardiac
rather than aillness. intensive care - 30-50%
Hip fracture- 40-50%
Etiology:
DELIRIUM
5 The major causes of delirium are central
nervous system disease (for example, epilepsy)
INTRODUCTION
systemic disease (for example, cardiac failure),
*Delirium is defined by the acute onset of and either intoxication or withdrawal from
fluctuaing cognitive impairment and a
pharmacological or toxic agents.
disturbance of consciousness.

5.22 S
 lnit-5:: Mental Disorders and Nursing Interventions VIJAYAM'Ss

Causes of Delirium: Adrenal

. Intracranial causes: Parathyroid
Epilepsy Thyroid
Brain traum
5. Disease of nonendocrine organs:
Infection
Y Liver
Neoplasm Hepatic encephalopathy
Vascular disorders Kidney and urinary tract
2. Extra cranial causes -Uremicencephalopathy
Drugs (ingestion or withdrawal) and Lung
poisons.
Carbon dioxide narcosis
Anticholinergic agents.
Hypoxia
Antihypertensive agents

In
Cardiovascular system
Antiparkinsonian agents
Cardiac failure
Antipsychotic drugs. h.
Arrhythmias
la
3. Poisons Hypotension
al

*Carbonmonoxide Y Deficiency diseases like thiamine, nicotine

*Heavy metals and other industrial poisons acid, B, or folic acid deficiencies.
W

4. Endocrine dysfunction hypo or luyper Systemic infections with fever and sepsis.
es

Junction): Electrolyte imbalance.

Pituitary Postoperative states
ot

Pancreas i Trauma (head or general body).

N

Causes of delirium

Intracranial Extra cranial Poisons Endocrine Disease of

causes causes dysfunction non-endocrine
(hypo or organs
hyper function)

Fig. 5.8

ea E5.23
 MENTAL HEALTH NURS
VIJAYAM'S
Treatment:
Clinical Features:
The two major symptoms of deliriums
key picture of delirium is an treatm at
The may require pharmacological
impairment ofconsciousness insomnia.
are psychosis and
Reduced clarity of awareness of the
Insomnia is best treated with either
environment. benzodiazepines with short half-lives or
or
With reduced ability to focus, sustain, hydroxyzine, 25 to 100 mg.
shift attention
Nursing Management:
Orientationra 1. Assessment: Subjective and objective data
Orientation to time is commonly lost, even in are gathered by various members of the
place and
mild cases of delirium. Orientation to health care team.
be
ability to recognize other persons may also
a. The Client History:
impaired in severe cases.
Behavioural changes, and catastrophic
Language and Cognition:

In
emotional reactions.
*Patients with delirium often have
abnormalities in language. h. *Cognitivechanges.
*Language difficulties.
la
*Cognitivefunctions impaired.
*Orientation to person, place, time, and
*Impaired Memory and generalized
al

cognitive functions. situation.

W

Recall memories. * Appropriate social behaviour.

Perception: Hallucinations are also relatively

b. Physical Examination:
es

common in delirious patients (visual and *Signs of damage to the nervous

auditory). system.
ot

Mood: *Evidence of diseases of other organs

N

*Have abnormalities in the regulation of that could affect mental function.

mood.
*
Anger, rage, and unwarranted fear.
Associated Symptoms:
Sleep-wake disturbance: Disturbed
sleep napping in their beds.
*Neurological symptoms: Dysphasia,
tremor, incoordination, and urinary
incontinence.
Diagnosis:
* Mini mental status examination.
*Physical examination.
2. Diagnosis:
*Risk for trauma related to impairments in
cognitive and psychomotor functioning
Risk for self-directed violence related to
depressed mood, secondary to awareness
in decline of mental and/or physical
capability.
*Disturbed thought processes related to0
cerebral degeneration evidence by
disorientation, confusion, memorydeficits,
and inaccurate interpretation of
environment.

5.24 S2E
t5 :: Mental Disorders and Nursing Interventions VIJAYAM'S

Low self-csteem related to loss of

independent functioning evidenced by
expression of shame and self-degradation
dation
progressive social isolation. Impairment
and
of memory
Self-care deficit related to disorientation,
confusion, memory deficits evidenced by Impairment
Deterioration
inability to fulfill activities of daily living. of
of
intellectual
personality function
7BEMENTIA oSS iakiny
NTRODUCTION

It isa chronic organic mental disorder. It

mainly affects the intellectual abilities and normal
functioning. The term dementia is derived from

In
Latin dementia, meaning "without mind".

Dementia is marked by severe impairment

in memory, Judgement, orientation, and h.
la
cognition.

About 10-20% of all persons above age

al

Fig. 5.9
65 has mild to moderate dementia.
W

Alzheimer's disease is the most common

dementia disorder. Etiology
es

Dementia is most common in elderly Mnemonic "VINDICTIVE MAD"

people. The important causes of organic mental
ot

Dementia affects about 60-64 years syndromes using mnemonic "VINDICTIVE

N

1%, 85 years 30-50%. MAD"

Definition:
Dementia is defíned as a loss of intellectual
abilities of sufficient severity to interfere with
social or occupational functions.
It is characterized by the following main
V Vascular-Hypertensive encephalopathy,
cerebral arteriosclerosis, shock.
L Infections -Encephalitis, meningitis.
N Neoplasms Space occuring lesions,
gliomas, abscess.

.
features:

Impairment of intellectual function.

D- Degenerative Senile and pre senile
-

dementia, Alzheimer's.
2. Impairment ofmemory (predominantly of
L-Intoxication Chronic intoxication,
recent memory, especially in early stages).
bromides, opiates, tranquilizers,
3. Deterioration of personality with lack of anticholinergic.
personal care.

5.25
 MENTAL HEALTH NURSING
VIJAYAM'S

C-Congenital Epilepsy and post ictal
status, aneurysm.
T Traumatic - Subdural and epidural
hematoma, confusion, heat stroke.
- Intraventricular Normal pressure
I -
*As the course of dementia progresses.
memory impairment becomessevereand
only the earliest learned information is
retained.
hOrientation

In as much as memory 1s important for

hydrocephalus.
orientation to person, place and time,
V - Vitamin - Deficiencies of thiamine
Orientation can be progressively affected
(Wernicke - Korsakoff 's), niacin and during the course of a dementia illness.
B12.
*For example, patients with dementia may
E - Endocrine and Metabolic Diabetic
forget how to get back to their rooms
-

coma and shock, uremia, myxedema, acid

after going to the bathroom.
- base disturbances and auto immune

disorders. C. Language:

In
M-Metals lead poisons
- Aphasia.
A - Anaemia: Hypoxia and Anoxia
secondary to pulmonary/cardiac failure,
h. Language difficulty.
la
Stereotyped.
anaemia etc.
Patients may also have difficulty in
al

D - Depression and Others:.Depressive naming objects.

pseudo dementia, hysteria, catatoxia,
W

post operative status, sleep deprivation, d Thinking_and Judgement:

heat, electricity and radiation.
es

Thinking becomes slower with reduced

Signs and Symptoms: flow ofideas and impaired concentration;
ot

Fatigue. Judgement is impaired.

Difficulty in sustaining Paranoid thoughts and ideas ofreference
N

mental
performance. are common.
The inabilityto perform tasks. *Delusions.
1. Intellectual deterioration with failure e. Comprehension ofLearning Capaci
of: The brain's ability to process incoming
information is impaired.
a. Memory:
S. Calculation: This cognitive skill is usually
Memory impairment.
impaired from early on dementia.
Early in the course of dementia, memory
impairmment is mild and is usually most 8. Insight: Poor insight.
marked for recent events; people forget Changes:Reduced control over
telephone numbers, conversations and
2. Emotional
laughter or tears.
events of the day.

5.26ren
 t5: Mental Disorders and Nursing
Interventions VIJAYAM'SS
3, Deterioration of Personality:
Increasing tendency to selfishness.
b. Increased en vironmental Cues:
Orientation to time, place and person.
Lack of consideration for other people's Maintenance of Physical Safety:
feclings.
a. Control of Environment:
Personal habits, table manners, toilet, *
Approach patient in a pleasant, calm
habits and hygiene deteriorate.
way.
Sexual offences maybecommitted. Introduce yourself to the patient and
Medications Treatment: greet him/her.
Cholinesterase inhibitors Tacrine b Enhance the quality of life: Offer
(cognex), donepezil (Aricept). multiple opportunities forfulfillment like
Antidepressants/anxiolytics - Fluoxetine light music walks, exercises, old hobbies,
(Prozac), sertraline, citalopram (Celexa). watching TV etc.
Other
Therapy: Occupational therapy may help Encourage positive feeling of self:

In
persons with dementia with activities
of daily *Openly discuss his feelings of anxiety.
living.

Physical Therapy: May improve mobility by h.

teaching patients to use walkers.
Music and art activities: May be Soothing
*Praise appropriately for expected
behaviour.
la
3. Attainment of an optimal exchange of
ideas between the patient and others:
al

and rewarding for some people with aAmplement strategies to promote the
W

dementia. patient's interpretation of messages:

Respite Care: Having a person with * Be calm,
pleasant, and unhurried.
es

dementia go temporarily to a nursing home,

*Keep verbal message short and
is another important source of help for family
simple.
ot

caregivers.
*Use non-verbal messages along with
Psychotherapy:
N

words.
aBehaviouroriented. *
Write down simple instructions and
Emotional oriented. lists.
ECognition oriented. Develop strategies to improve the
d. Stimulation oriented. patient's ability to express mnessages:
Nursing Management of Patients with *Supply forgotten words when
Dementia possible.This will allow to express his
needs and feelings.
Maintenance of optimal cognifive.
functions: *Allow adequate time for conversation.
dReduce environmental confUsion: *Encourage short, simple sentences.
Keep the environment simple and
pleasing, remove all unwanted utensils
from the room.

aR5.27

VIJAYAM'S
A Maintenance of maximum indepen-
dence in activities of daily living:
a. Develop plan to facilitate daily
performance of activities: Maintain a
regular daily schedule at a time convening
with the patient.
b. Provide specific safeguards of safetyc.
in bathing:
Monitor bath water temperature.
*Encourage use ofsafety measures in
the bathroom like hand rails, rubber
mats to prevent bath room falls.
c. Provide specific measures to
remember places: Provide accessibility
to bath room. Indicate bathroom with
coloured pictures, visual stimuli reinforces
recognition.
5. Maintenance of optimal level of
al
nutrition:
W
a. Monitor food intake and observe food
habits:
es
*Note weight loss or gain.
ot
Provide regular mealtime schedule.
Encourage adequate fluid intake.
N
&Provide balanced diet.
b. Promote regular mouth care:
*Encourage care of gums and teeth
after meals.
*Assist and encourage the patient
maintain clean mouth.
6Maintain optimum personal hygiene:
a. Promote healthy skin:
*Keep the skin clean and dry.
MENTAL HEALTH NURSINC
Massage the extremities and back
t
will help to improve muscle tone
and
and
circulation.
h. Promote healthy hair and scalp: Wadk
hair weckly twice. Comb the hair daily
apply oil if needed and massage the scaln
p.
Encourage nail care: Maintain cle
an
and short nails of both extremities.
7Maintenance of a balance of sleep and
activity: Reduce nighttime distractions such
as noise, nursing procedures of for mid -night
medications etc.
8Enhancement of socialization and
fulfillmentof.intimacy.needs:
In
*Encouragevisits from family andfriends
h.*Use touching to maintain contact with
la
patient. Tactile stimulation is easiest to
interpret.
9Provide Rehabilitation:
Support and retrain the existing skills.
Provide physiotherapy.
Provide hearing aids.
Specch therapy.
*Impaired vision, provide big lettered
books/schedule.
5.8. PSYCHOTIC DISORDERS
to5.34SCHIZOPHRENIC DISORDERS
INTRODUCTION
Schizophrenia is a type of functional
psychosis characterized by disturbances
psychomotor activity, affect, perception and
behaviour. It is mainly a disorder of thinking
5.28
 Iinit-5:: Mental Disorders and Nursing Interventions VIJAYAM'S

Definition double bind and contradictory messages,

Schizophrenia refers to a group of mental rejection and critical attitude etc. are some
illnesses characterized by specific psychological
characteristics of the family commonly
ymptoms leadng to a disorganization of the
observed in schizophrenic patients.
ersonality of the individual The symptoms vjt.Abnormlities: In the brain tissue,
chicfly interfere with the patient's thinking, psychological (or) sociocultural stresses may
emotions and behaviour in a characteristic way. predispose to schizophrenia.
Incidence Psychopathology:
According to the World (Mental)) Health *Not clearly understood.
Report, 2001, about 24 million people worldwide
Several theories suggest.
suffer from schizophrenia. The incidence of
schizophrenia is believed to be about 0.5 per * Depending on Phenomenon of regression.
1000 population.
Reversal of infantile and childhood

Cause-Not clearly known. Probably several
factors contribute to the development of illness.
hHeredity: The incidence ofschizophrenia is
la
very high (86%) in uniovular twins. Relatives *The
of schizophrenic patients commonly suffer
al
In
patterns of psychological living, a state
of organization where reality does not
h.
exist.
patient attempts to resolve his
psychological conflicts by denying the

from the disease. harsh and painful reality world and living
in a fantasy world full of pleasures.
W

i. Age: Peak incidence is between the age of

15 to 30 years. Types:
es

iji. Sex: Equal incidence in both sexes. Broadly two groups are recognized. These
are
iy Personality: Most of the clients of
ot

schizophrenia (64%) are of schizoid 1. Typical

.
N

personality. 2. Atypical
Intelligence: People with low intelligence Undifferentiated:
are more predisposed to schizophrenia.
Childhood development and parent-child The symptoms of schizophrenia cannot be
relationship: Broken homes, overprotection grouped into any one of the above types.
(or) rejection by the parents are alleged to 1/Typical: Typical types ofschizophrenia
be more common in the life histories of
schizophrenics. Eldest child is more
vulnerable.
pi. Family: Disorganisation, weak and
submissive father, dominant and aggressive
mother, improper communication leading to

s5.29E
 MENTAL HEALTH NURSING
VIJAYAM'S

Xable: Tyypical Types of Schizophrenia

Character- Hebephrenic Catatonic Paranoid

Simple
istics
Cata-disturbed Insidious Occurs
Onset Early and Insidious
tonic-tone later in life
insidious
acute or gradual

15-20 years 20-25 years 20-25 years 25-30 years

Age
Male=Female Male> Female
Sex Male> Female Male =Female
Good Good
Prognosis Not good Not good
Disturbance of | Disturbances of Disturbances of
Features Disturbances
thinking motor behaviour, thought, speech
of affect,

In
thinking and thinking, affect, andperception
behaviour (catatonic features)
h.
la
Atypical:Atypical types of schizophrenia are:
ii. Childhood
al

Late
iv. Schizoaffective
ii. Adulthood
W

v. Pseudoneurotic etc.
age of 40 years.
Late Schizophrenia: Seen for the first time around the
es

ii Childhood: Not common, seen in children between the ages of 5 years to 10 years. Prognosis
isnot good.
ot

it Juvenile: Not common onset is acute (or) gradual. Seen in children between the ages of
N

12-14 years.
v. Schizoaffective: When schizophrenia symptoms are associated with symptoms ofdepression
(or) mania. Prognosis is better than pure schizophrenia.
Pseudoneurotic: Schizophrenic clients are presented with neurotic illness.
Clinical Features:
Schizophrenia is characterized by disturbances in
thought, speech, perception, attention, emotions,
, motor behaviour and relationship with the external world.
i. Disturbances of.Thought:
'Autistic thinking thinking is governed by private and illogical rules. For example, Lord
-

Hanuman was celibate, I am celibate too, so, I am Lord Hanuman.

*Thought blocking: Sudden interruption ofstreamofspeech before the thought is completed.
*Poverty of ideas
*Thoughtwithdrawal

5.30
 ait-5 :: Mental Disorders and Nursing Interventions VIJAYAM'SS

Flight ofideas
Circumstantality- inability to focus on the main pointofargument or statement.
Dclusions falseunshakable belicfs like delusions ofpersccution, reference, grandiosity, control
and somatic delusions.
ADisturbanceof Speech:
Loosening of association -Spontaneous specch in which the things said injux
lack of mcaningful relationship. If severc, then it is known as incoherence.
Mutism-No speech production.
Poverty of speech Decreased speech production.
-

Echolalia-Repetition (or) echoing by the patient ofthe word.

Perseveration Persistent repetition of words beyond their relevance.
-

*Verbigeration Senseless repetition of same words or phrases over and over again.
ii. Disturbances of Perception:

In
Hallucinations -perceptions without stimuli are common. Auditory variety is the commonest.
Visual also can occur. The tactile, gestatory and olfactory types are less common.
h.
la
Table: Hallucinations
al

Hallucinations
W

Olfactory Auditoryy Visual Tactile

Tilness Temporal lobe Usually Schizophrenia Delirium Cocaine abuse
es

seizures any other or Bipolar (formation) delirium

tremens
ot
N

ir. Disturbances of Attention:

Autism.
Excessive day dreaming.
Fantasy li'ving
Muttering

Spells oflaughter and crying without reason.

Childish behaviour (passes urine and stools in clothes, plays with own excreta etc.).
Absent mindedness.
Inattentivness resulting into forgetfulness, deterioration in studies and work.

5.31
VIJAYAM'S
A.2Disturbances of Emotions:
*Emotional blunting.
*
Apathy (loss of empathy).
*Anhedonia -incapability ofexperiencing
pleasure.
*Inappropriae and incongruous affect-the
patient laughs when he is expected to Cry,
and cries when he is expected to laugh.
*Ambivalence - simultaneous experience
of two opposite types of feelings.
*Hypersensitiveness (or) insensitiveness of
feelings.
piDisturbance ofwill(or) Volition:.
Anergia-blunting of will power.
Aloofness- avoiding mixing in family
members.
al
*Reduction of drive (or) desire to carry
out routines.
W
*Inability to take decisions.
es
Feeling ofpassivity.
vii Disturbance of Motor Behaviour:
ot
Either decreased (or) increased
N
psychomotor activity.
*Decreased psychomotor activity like
decreased spontainety, inertia, stupor.
Increased psychomotor activity
aggressiveness, restlessness and
agitation.
*Mannerisms
*Grimacing
Stereotypes (repetitive strange behaviour)
*Decreased self-care
*Poorgrooming
5.32
MENTAL HEALTH NURSING
* Catatonic features-common in catatonio
sub type ofschizophrenia
ni
Echolalia
Echoprexia
Verbigeration
Waxy flexibility (wax-like body
posture which permits the body parts
to be put into odd
shapes).
Negative Symptoms like:
*Asociality (social withdrawal)
Alogia (lack of speech output)
In
Anhedonia (inability to experience
h.
*
pleasure)
Avolitional apathy-lack ofinitiativeness
la
and sexual overactivity,
Criminal
perversion, consumption of alcohol and
other substances. Suicide can occur in
any schizophrenia due to several reasons.
Prognosis:
The prognosis is determined by several
factors like shorter duration carries better
prognosis, non-schizoid and stable personality
had better prognosis, acute onset had better
prognosis than gradual onse etc.
Complications:
Violent behaviour, suicidal rate, death
increased, social isolation, impairment in routine
daily functioning leads to physical illhealth, sexual
problems and homicidal behaviour.
Diagnosis:
A detailed history from the reliable infomants
and mental status examination is the backbone
of diagnosis.
 Jnit : Mental Disorders and Nursing Interventions VIJAYAM'SS

Management:
communication skills. It is usually
Medical Management: conducted in a form of social skill training
Sedatives Phenobarbitone sodium, package.
loralhydrate, paraldchyde, diazepam
dFamily Therapy: Family members are
etc. provided social skills training to enhance
Hypnotics -

Barbiturates and non- communication and decrease intrafamilial

barbiturates. tensions.
Neuroleptics Phenothiazines, e. Milieu Therapy (or) Therapeutic
butyrophenones, indole derivates etc. Community: Includes treatment in a
Indications-Early schizophrenia living, learning (or) working environment
ranging from inpatient psychiatric unit to
Along with ECT.
day care hospitals and half-way homes.
Chronicand refractory schizophrenia.
Behaviour Modification Therapy:
Maintenance therapy. Occupation therapy work therapy, art

In
iElectro Convulsive Therapy: The therapy, music therapy, recreational
indications for ECT in schizophreniainclude: therapy etc., are therapeutic adjuvants by
.Catatonic schizophrenia h.
themselves, not very useful but play a
complementary role to other treatments.
la
2. Uncontrolled catatonic excitement
3. Acute exacerbation not controlled with
g: Social Therapy: Social therapy also has
al

complementary role to other treatments.

drugs
Mainly along with psychiatrist, the
W

4Severe side effects with drugs. psychiatric social worker (PSW) involves
Usually 8-12 ECTs are needed given in this therapy.
es

three times a week. Psycho Education: It helps in

Psychosocial Treatment:It is an extremely establishing a good therapeutic
ot

mportant component of the comprehensive relationship with the patient and family.
management of schizophrenia. Educate the patient and family regarding
N

the nature of illness, its course and

a. Psychotherapy: treatment.
Supportive (or) superficial psychotnerupyPrognosis:
is indicated in early schizophrenics and
The prognosis is determined by several
maintenance and rehabilitation en of
recovery patients. Analytical or deep factors like shorter duration carries better
prognosis, non-schizoid and stable personality
psychotherapy is not indicated in
had better prognosis, acute onset had better
schizophrenic clients.
prognosis than gradual onset etc.
Individual Psychotherupy: Is usually
Supportive in nature like cognitiveComplications:
behaviour therapy in the treatment of Violent behaviour, suicidal rate, death
schizophrenia. increased, social isolation, impairment in routine
C.GroupPsychotherapy: Is particularly daily functioning leads to physical illhealth, sexual
aimed at teaching. Problem-solving and problems and homicidal behaviour

SZKE5.33
 MENTAL HEALTH
NURSING
VIJAYAMS
Emil Kracpelin concluded that all thes
mood disorders are identical in certai
tain
5.8B,MOOD (AFFECTIVE) ways. He called the underlyingil ness
DISORDERS manic depressive psychosis".

INTRODUCTION
Definition:
This group of disorders is characterized by.
The emotions can be described as two main
disturbance of mood, accompanicd by a full or
types:
partial manic (or) depressive syndrome that is
1. Affect: Which is a short-lived emotional not due to any other physical or mental disorder
response to an idea or an event, and
Incidence:
2. Mood: Which is a sustained and pervasive
The World Health Report, 2001 estimates that
emotional response which colours the whole
psychic life. there are 121 million people worldwide suffering
from depression.
So, according to these definitions,
Classification: According to ICD-10 (CDDG),

In
depression and mania are 'mood disorders
and not 'affective disorders' as they have the mood disorders are classified as follows:
been called so frequently in the past. h.
la
History:
term
al

*Hippocrates coinedthe
melancholia'.
W

* Jules Falret said that patients become

depressed and elated in a cyclic fashion
es

known as la folie circularize.

*Kurl Ludung Kahlbaum said that these

ot

episodes are different stages ofthe same

N

disease process, which he called

cyclothymia'. Fig. 5.10 Bipolar Affective Disorder

Classification of Mood disorders

Manic Recurrent. Bipolar mood Persistent mood Depressive Other mood

episode depressive disorder disorder episode disorders
disorder

Fig. 5.11

5.34
 Unit-5: Mental Disorders and Nursing Interventions
VIJAYAM'S
Etiology:
Mania is characterized by a triad of
The etiology of mood disorders is currently symptoms viz., elevation of mood, flight of ideas
unknown. Several theories have been and increased psychomotor activity. There are
propounded which include:
some patients who suffer from attacks of mania
Clinical Features/Management: Mania and (or) depressionalternatingwith each otherand
depression.
the syndrome is called manic depressive
psychosis (or) cyclic psychosis.

Causes:
5,CANIA DEPRESSION
Not clearly established; no single factor is
Mania: held responsible The causes of mania and
This is a type of functional psychosis,the depression are similar. Personality of the patients
symptoms of which are diametrically opposite
suffering from mania is hypomanic, extroverted
to those of depression/
individuals who are "happy go lucky type".
Psychopathology:

In
Not clearly understood.
*Mania h. is a denial stage against the
underlying depression.
la
Classification:
al

Hypomania.
W

Mania without psychotic symptoms.

es

Mania with psychotic symptoms.

Fig. 5.12 Manic Client
Manic episodeunspecified.
ot

Definition: Degree of Mania:

A manic episode is defined by a distinct
N

period at least a week or less if hospitalized A distinction is usually made between mild
and severe cases, the former being classified
during which there is an abnormally and
as hypomania and the latter as acute mania, or
persistently elevated, expansive or irritable
hvpermania
mood.
Hypomanid: The.clients have mild
Flight of ldeas
euphoria, the raprd'shiftfrom one ideato
another, the circumstantial speech, and
the tendency tobe witty.

Mania Hypermanig: The clients have greater

Elevation of Mood pressure, the more disconnected speech
SIncreased Psychomotor
activity and increased distractibility, clang
association.
Fig. 5.13 Mania 7Triad of Symptoms

5.35
 MENTAL HEALTH NURSING
VIJAYAYS
Clinical Features; Diagnosis
LMood-Elevation: A reliable detailed history, mental status
examination, and clinical response usually with
Euphoria (mild clevation (or)stage),
diagnosing an atfective
fullremission helptests
Elation(moderate (or)stage 1).
disorder laboratory like)
Exaltation (severe (or) stage II).
Dexamethasone Suppression' lest (DST)
Eestasy (very severe (or) stage IV).
Thyrotrophic, Releasing Hormone
Imitable (or) infectious, labile/
Stimulation Test(TRH).
AAlteration in sleep.
ecstacy Complications:
Substance abuse.
Elationiritable, losses.
Types
Exaltation Financial

In
of
Mood Illegal activities.

h. Sexual promiscuity,
la
Assaults and suicide.
Fig. 5.14 Homicides and drug abuse.
al

Management:
W

2. Psychomotor activity is often increased

sociability, reckless driving, foolish business Hospitalization:
es

investments and promiscuous sexual Abnormalbehavioure.g, financiallosses,loss

behaviour.
of career, family disintegration and delirious
ot

3. Speech is typically loud, rapid and dificult to mania need hospitalization

interpret (i.e. pressure of speech). Sounds
rather than meaningful conceptualedications:
N

relationships may govern word choice Neuroleptics Phehnothiazines and

-

(clanging).
4Thinking: There is flight ofideas (i.e., nearly
continuous flow of accelerated speech with
abrupt changes from topic to topic usually
based on understandably associations,
distracting stimuli or plays on words).
5. Attention: Distractibility is usually present.
Sleep-decreased need forsleep.
.6. Self-worth there is inflated self-esteem.
8. Lability of mood
butyrophenones
Lithium-Its success is. reported tobe
80% in most studies
*Dosage range from 900 mg to 1800 mg
day depending upon serum levels
(0.6-1.2 meq/L is normal serum lithium
value) and the side effects (GIT upset
tremors, muscular twitches etc.)
Prophylaxis for both bipolar and unipolar
disorders.

9. Libido - It is often increased

sE5.36
 oit-5: Mental Disorders and Nursing Interventions
VIJAYAM'S5
Carbamazepine -useful in acute mania
and prophylaxis of unipolar and
disorders. bipolar586. BIPOLAR AFFECTIVE
Clonazepam=1.8 mg/day. DISORDERS (BPAD)

Other drugs like sodium valproate, Bipolar Disorder:

calcium channel blockers, amoxapine,
phenytoin etc.
ECT:
Indicated in acute mania six to eight
convulsions spread out over aperiod of three
Tour weeks are sufficient.
to
Bipolar disorder used to be called 'manic
depression'. As the older name suggests,
someone with bipolar disorder will have severe
mood swings. These usually last several weeks
or months and are far beyond what a normal
person experiences. They are:

Psychotherapy: Low or 'depressive': Feelings ofintense

depression and despair.
Useful tocorrect the underlying

In
DSYchopathology after theactive symptoms High or 'manic': Feelings of extreme
have
been controlled.Interpersonal therapy,cognitive happiness and elation.
behaviour therapy, behaviouralLtherapy,are. h.
Mixed: For example, depressed mood
la
showing successfulresults. with the restlessness and overactivity of
Nursing a manic episode.
al

Care:
Plan activities that remove patient from Causes:
W

group and reduce exposure to stimuli. Bipolar disorder affects men and women
equally. It usually starts between ages 15 25.
es

Be consistent and honest at all times.

The exact cause is unknown, but it occurs more
Plan briefperiods of acts that do not need often in relatives of people with bipolar disorder.
ot

continuous concentration.
In most people with bipolar disorder, there is
N

Physical exercise to use excess energy. no clear cause for the manic or depressive
episodes.
Be kind and firm with patient.

Select nutritious food. Thefollowing may trigger a manic

episode in people with bipolardisorder
Y Care for teeth, bath and towel.
Life changes such as childbirth.
Proper dress-up to the client.
*Medications such as antidepressants or
7 Listen and report abnormalbehaviourto steroids.
Superiorsand treating psychiatrist.
Observe Periods of sleeplessness.
changes with treatment.
Avoid active opposition. Recreational druguse.
Reassure but be careful.

5.37
 MENTAL HEALTH NURSING
VIJAYAM'S

Typesof Bipolar Disorder: Little need for sleep.

Bipolar Poorjudgement.
1:
There has been at least one high or manic Poor temper control.
episode, which has lasted for longer than
Reckless behaviour and lack of self.
one week.
control.
Some people with Bipolar I will have only
Binge eating, drinking, and/or drug use
manic episodes, although most will also
have periods of depression. Poorjudgement.
Untreated, manic episodes generally last Sex with many partners (promiscuity)
three to six months. Spending sprees.
Depressive episodes last rather longer -

Very elevated mood.

6 to 12 months without treatment.
Excess activity (hyperactivity).
Bipolar 11: There has been more than one

In
episode of severe depression, but only mild Increased energy.
manic episodes these are calleed
-
Racing thoughts.
"hypomania'. h.
Talking a lot.
la
Rapid Cycling: More than four mood swings
happen in a 12 month period. This affects around Very high self-esteem (false beliefs about
al

1 in 10 people with bipolar disorder, and can self or abilities).

happen with both types I and II. Very much involved in activities.
W

Cyclothymia: The mood swings are not as Very upset (agitated or irritated).
severe as those in full bipolar disorder, but can
es

These symptoms of mania occur with bipolar

be longer. This can develop into full bipolar
disorder. disorder I. In people with bipolar disorder I, the
ot

symptoms of mania are similar but less intense.

Bipolar The depressed phase of both types of
N

Bipolar lI
bipolar disorder includes the following
Symptoms:
Bipolar Disorder
Rapid Cycling Daily low mood or sadness.
Difficulty in concentrating, remembering,
Cyclothymia
or making decisions.
Fig. 5.15 Eating problems.
Loss of appetite and weight loss.
Clinical Presentation:
TOvereating and weight gain.
The manic phase may last from days to
months. It can include the following symptoms: Fatigue or lack of energy.

Easily distracted.
*
Feeling worthless, hopeless, or guilty.

A DSI5.38
 Unit-5 : Mental Disorders and Nursing Interventions VIJAYAM'S

Loss of pleasure in activities once *Drug abuse may beasymptom of bipolar

enjoyed. disorder.
of self-esteem.
Loss Treatment:
Thoughts of death and suicide. Periods of depression or mania return in most
patients, even with treatment. The main goals
Trouble getting to sleep or sleeping too
of treatment are to:
much.
*Avoid moving from one phase to another.
Pulling away from friends or activities
Avoid the need for a hospital stay.
that were once enjoyed.
There is a high risk of suicide with bipolar *Help the patient function as well as
disorder. Patients may abuse alcohol or other possible between episodes.
substances, which can make the symptoms and * Prevent self-injury and suicide.
suicide risk worse.
*Make the episodes less frequent and
Sometimes the two phases overlap. Manic severe.

and depressive symptoms may occur together
or quickly one after the other in what is called a
mixed state.
Diagnosis:
Many factors are involved in diagnosing
al
In
The health care provider will first try to find
h.
out what may have triggered the mood episode.
The provider may also look for any medical or
la
emotional problems that might affect treatment.
The following drugs, called mood stabilizers,

bipolar disorder. The health care provider may are usually used first:
W

do some or all of the following:

* Carbamazepine.
Family medical history, such as whether
es

*Lamotrigine.
anyone has or had bipolar disorder.
* Lithium.
Recent mood swings and for how long
ot

you've had them. * Valproate (valproic acid).

N

Perform a thorough examination to look
for illnesses that may be causing the
symptoms.
Run laboratory tests to check for thyroid
problems or drug levels.
Take a medical history, including any
medical problems you have and any
medications you take
Watch the behaviour and mood.
Note:
Drug use may cause some symptoms.
However, it does not rule out bipolar
affective disorder.
Other antiseizure drugs may also be tried.
Other drugs used to treat bipolar disorder
include:
*Antipsychotic drugs and anti-anxiety
drugs (benzodiazepines) for mood
problems.
* Antidepressant medications can be added
to treat depression. People with bipolar
disorder are more likely to have manic or
hypomanic episodes if they are put on
antidepressants. Because of this,
antidepressants are only used in people
who also take a mood stabilizer.

2 5.39
 MENTAL HEALTH NURSING
VIJAYAM'S

Getting enough sleep is very important in

ECT bipolar disorder. A lack of sleep can
trigger
Electroconvulsive therapy (ECT) may be
a
manic episode. Therapy may be helpful during
used to treat the manic or depressive phase of the depressive phase. Joining a support grou
bipolar disorder if it does not respond to may
loved
loved
may help bipolar disorder patients and their
medication. ECT uses an clectrical current to ones.
cause a brief seizure while the patient is under
A patient with bipolar disorder cannat
anesthesia. ECT is the most effective treatment
*

always tell the doctor about the state of

for depression that is not relieved with
the illness. Patients often have trouble
medications.
recognizing their own manic symptoms
Transcranial Magnetic Stimulation (TMS):
Changes in mood with bipolar disorder are
Uses high-frequency magnetic pulses to
not predictable. It it is sometimes hard to
target affected areas of the brain. It is most tell whether a patient is responding to
often used after ECT.
treatment or naturally coming out of a
Support Programmes and Therapies:

In
bipolar phase.
Family treatments that combine support and *Treatments for children and the elderly
education bout bipolar disorder
(psychoeducation) may help families cope and
h.
are not well-studied.
la
Broadly two groups are recognized.
reduce the odds of symptoms returning.Types:
Programmes that offer outreach and community These are
al

support services can help people who do not 1. Typical.

W

have family and social support. Atypical.

2.
Important Skills Include: Undifferentiated:
es

Coping with symptoms that are present

The symptoms of schizophrenia cannot be
even while taking medications. grouped into any one of the above types.
ot

Learning a healthy lifestyle, including Atypical: Typical types of schizophrenia are:

i
getting enough sleep and staying away
N

1. Late schizophrenia.
from recreational drugs.
2. Childhood.
Leaming to take medications correctly and
3. Adulthood
how to manage side effects.
to watch forthe return of 4. Schizoaffective.
Learning
symptoms, and knowing what to do when 5. Pseudoneurotic etc.
they return. Late
Schizophrenia: Seen for the first time
Family members and care-givers are very around the age of 40 years.
important in the treatment of bipolar Childhood
disorder. They can help patients find the
Not common, seen in children between the
right support services, and make sure the
ages of 5 years to 10 years. Prognosis 1s no
patient takes medication correctly.
good.

n5.40
 it-5 Mental Disorders and Nursing Interventions
Adulthood (Juvenile):
Not common, onset 1s acute (or) gradual.
Seen in children between the ages of 12-14
years.
Schizoaffective:
When schizophrenia symptoms are
associated with symptoms of depression
(or)
mania. Prognosis is better than pure
schizophrenia.
Pseudoneurotic: Schizophrenic clients are
presented withneurotic illness.
5,9E IROTIC DISORDERS:
5.9PHOBIA
INTRODUCTION
Phobos" was a Greek word which means
god frightened ones enemies'. Phobia first
W
appeared in medical terminology in Rome 2000
years ago. Westphal described agoraphobia.
es
ot
Tablehedifference between normal fear and a phobia.
N
Normal fear
Feeling anxious when flying through
turbulence or taking off during a storm.
Experiencing butterflies when peering down
from the top of a skyscraper or climbing a
tall-ladder.
Getting nervous when you see a pit bull or a
Rottweiler.
Feeling a little queasy when getting a shot
when your blood is being drawn.
or-| Avoiding necessary medical treatments or
s5.41
VIJAYAM'S
Definition:
Phobia is defined as an intense, persistent,
irrational and recurrent fear of a specific object,
place or situation that results in a compelling
desire to avoid the dreaded place, activity or
situation.
"A Phobia is an Irrational and excessive fear
of an object or situation. In most cases, a Phobia
involves a sense of endangerment or a fear of
harm. For example, those suffering from
Agoraphobia fear being trapped in an
inescapable place or situation'".
-American Psychiatric Association.
"Exaggerated pathological fear of a specific
In
type ofstimuli or situation).
Bimla Kapoor, 2002
h.
Marks has defined phobia on the following
criteria:
la
The fear is out of proportion to the demands
al
of the situation.
i At cannot be explained or reasoned away.
i Tis beyond voluntary control.
iv. Thefear
leads to an avoidance of the feared
situation.
Phobia
Not going to your best friend's island
wedding because you'd have to fly there.
Tuming down a great job because it's on the
10th floor
of the office building.
Steering clear of the park because you
might see a dog.
doctor's checkups because you're terrified
of needles.
 MENTAL HEALTH NURSING
VIJAYAM'S G

oFig. 5.16 Phobia

In
h.
la
External
Internal Locus of Control
al

Locus of Control STRESSFUL LIFE EVENT

(e.g., death of a significant
W

other; Interpersonal conflict)

es

Anxiety Anxiety
ot
N

Anxiety is Anxiety is
attributed to attributed to an
the stressor external source

PROBLEM
PHOBIA
SOLVING

Fig. 5.17 Process of Phobia

5.42
 Nursing Interventions VIJAYAM'SS
lnit-5 ::/Mental Disorders and
Types: Phobias
are divided into three groups: The clinical picture consists of:
PhobiaTypes A. Fear of being alone.
2. Fear of leaving home.
3Fear of being away from home.
Agora Phobia
Typical fears are of using public
Simple Phobia Social Phobia
transportation (buses, trains, subways,
Fig. 5.18 planes) being in crowds, theaters, elevators,
restaurants, markets and departmental
stores, waiting in line, travelling a distance
aSimple Phohia:Simple phobia is also called from home.
specific phobia. It is most common type of
phobic disorder in the general population. In addition to panic attacks multiple
phobias, chronic anxiety, depersonalization,
It is characterizedby irational, persistent
secondary depression, multiple somatic
fear of an object or situation, animal.
complaints and alcohol, barbiturates or anti
The most common simple phobias involve anxiety medications abuse may occur. It is

In
animals. These are common in children
precipitated by stress, particularly
and may persist into adult life.
Theseare h.
interpersonal stress.
ZSocial Phobia: Social phobia is irrationalI
la
Claustrophobia - Fear of closed spaces. fear of activities of social interaction,
Hematophobia Fear of the sight of characterized by an irrational fear of
al

blood. performing activities in the presence of other

W

Acrophobia -Fear of height. people (or) interacting with others.

*Gamophobia - Fear of marriage. The client present with disturbance in
es

Insectophobia- Fear of insects. . routine daily activities.

Aiurophobia- Fear of cats. Erythrophobia fear of blushing, eating
-
ot

Cynophobia- Fear of dogs. in company of others, public speaking, public

Mysophobia- Fear of dirt. performance (e-g. on stage), participating in
N

Nyctophobia- Fear of darkness. groups, writing in public (e.g. signing a

Thanatophobia Fear of death.
-
check), speaking to strangers (e.g. For asking
directions), speaking to authority figures and
AIDS phobia- Fear of AIDS. urinating in a public lavatory (shy bladder)
Venerophobia Fear of venereal etc.
diseases.
Symptoms of Phobia:
Nosophobia Fear of IlIness.
-

Phobic symptoms can occur through

Agora phobia: It is most severe form and exposure to the fear object or situation, or
it is most common among those seeking sometimes simply thinking about the feared
treatment. It is more common in women than
object can lead to a response.
in men. Agora phobia is a disorder
characterized by fear of being alone in an
open space.

5.43
 ENTAL HEALTH NURSINc
VIJAYAM'S

Behaviora-Therapy: It is usual
Common symptoms associated with phobias| ii, sually
include: successful. These include some technigaques
Dizziness Breathlessness like
a. Flooding
Nausea *A sense ofunreality.
b. Systematic desensitization.
Fear of dying.
c. Exposure and response prevention
Physical signs and symptoms of a phobia: techniques.
d. Relaxation
Difficultyin breathing
a. Flooding: Flooding or implosion - it
Feling dizy or lightheaded. involves supervised maximum exposure
Racing or pounding heart. to feared stimulus until anxiety reduction/
A churning stomach. exhaustion.
Chest pain or tightness b. Systemic Desensitization: It involves
*Hot orcold flashes, tingling sensations. gradual exposure to phobic stimulus along
Trembling or shaking. hierarchy of increasing intensity until
Sweating. patient habituates and avoidance

Emotional signs and symptoms of a phobia:
Feeling of overwhelming anxiety or panic.
Fearoflosing control or going crazy. h.
la
Feeling an intense need to escape. C.
Feeling like you're going to die or pass
al
In
response is extinguished relaxation
training is used before situational
exposure.
Exposure_and-response prevention:
Response prevention prevents the client

out. from engaging in rituals such as hand

washing before beginning the exposure
W

Feeling "unreal" or detached from|

yourself. treatment, the client has to understand the
rationale for the treatment. It should be
es

*Knowing that you're overreacting, but

feeling powerless to control your fear. clearly explained that the OCD is
Management: maintained through both passive and
ot

i. PharmacotherapPy: active avoidance. The exposure part is

directed at the client's passive avoidance,
N

Tricyclic antidepressants like imipramide,

the MAO inhibitor phenelzine, and high
potency benzodiazepine like alprozolam are
effective in spontaneous panic attacks. Beta
blocker like proprarolol is effective in social
phobias.
ii. Psychotherapy: Psychodynamic therapy is
not usually helpful in treatment of phobias. It
is mainly aimed at exploring conflicts.
Supportive psychotherapy is helpful and
consists of learning coping strategies and
readjustment of life style.
whereas the response prevention deals
with the active avoidance.
d. Relaxation Techniques: Relaxation
exercise is a process of systematicaly
contrasting tension and relaxation, in
which the client learns to differentiate
between tension and relaxation and
controls the onset of these states.
Ultimately, the client learns to substitute
more relaxing sensations for unwanted
tension. Progressive muscle relaxation or
deep muscle relaxation is a specific tye
of relaxion exercise.

5.44 2S
 lnit-5 :: Mental Disorders and Nursing
Interventions VIJAYAM'SS

ANXIETY DISORDERS
Anxiety 1s an alternating signal. It
warns of impending danger, and enables a person to take
measures to deal with a threat.Fear is
a similar alerting signal but should be differentiated from
anxiety.Stress is a response of grief when
the stress is present result in anxiety and some behavioural
changes. Some of the stress-related disorders will be
discussed in this chapter later. Somatoform
or somatization disorder is an illness of multiple
somatic complaints/

CONTINUUM OF ANXIETY RESPONSES

ADAPTIVE RESPONSES
MALADAPTIVE RESPONSES

In
Anticipation Mild Moderate Severe Panic

Fig. 5.19 h.
la
al

Classification According to ICD 10:

Signs and Symptomsof Anxiety Disorders:
W

Neurotic, Stress - Related and Somatoform Persistent state of apprehension or fea.

Disorders.
es

Feelings of dread without valid cause.

II Phobic Anxiety Disorders.
Concentration problems.
ot

Anxiety Disorders:
Catastrophic thinking.
Agoraphobia.
N

Irritability or edginess.
Agoraphobia without panic disorder.
Restlessness and sleeping problems.
Agoraphobia with panic disorder.
Pounding heart/rapid heartbeat.
Social Phobias.
Excessive sweating.
Specific (isolated) phobias.
*Choking sensations.
Other Phobicanxiety Disorders.
Stomach cramps.
Phobia anxiety disorders, unspecified.
I. Other Anxiety Disorders:
Dizziness and vertigo.
Panic Frequent urinationor diarrhoea.
Disorders
Shortness of breath.

5.45
 MENTAL HEALTH NURSING

VIJAYAM'S

Tabletevels of Anxiety
Emotional/Behavioural
Cognitive/Perceptual
Anxiety Physiological
Level Feelings of relative comfort
Perceptual field is broad.
Mild Vital signs normal. and safety. Relaxed, calm
Awareness of multiple appearance and voice.
Minimal muscle
environmental and
tension. Pupils normal, Performance is automatic,
internal stimuli. Thoughts occur
constricted habitual behaviours
may be random, but
controlled. here.
Feelings of readiness and
Alert, perception challenge, energized.
Mode- Vital signsnormal or
narro wed, focused.
rate slightly elevated. Engage in competitive
Optimum state for
Tension experienced, activity and leam new
problem solving and
may be uncomfortable skills. Voice, facial
learning. Attentive.
or pleasurable (labeled expression interested or
as 'tense' or 'excited') concerned.

In
field greatly Feels threatened, stares
Severe Fight or flight response. Perceptual with new stimuli, feels on
Autonomic nervous
system excessively
narrowed. Problem
solving difficult.
h. over load'. Activity may
increase or decrease (may
la
stimulated (vital sings Selective attention (focus
pace, runaway, wring
increased, diaphoresis on one detail). Selective
al

inattention (block out hands, moan, shake, stutter,

increased, urinary
threatening stimuli) become very disorganized
urgency and frequency
W

Distortion oftime (things or withdrawn, freeze in

diarrhea, dry mouth,
seem faster or slower
position/unable to move).
appetite decreased,
es

Dissociative May seem and feel

pupils dilated) Muscles than actual).
tendencies, (automatic depressed. Demonstrates
rigid, tense. Senses
denial, may complain of
ot

affected, hearing behaviour)

decreased, pain aches or pains, may be
agitated or irritable. Need
N

sensation decreased
for space increased. Eyes
may dart around room or
gaze may be fixed. May
close eyes to shut out
environment.
Panic Above symptoms Perception totally Feels helpless with total
escalate until scattered or closed. loss of control. May be
sympathetic nervous Unable to take in stimuli. angry, terTified, may
system release occurs. Problem solving and become combative or
Person may become logical thinking highly totally withdrawn, cry, un.
pale, blood pressure improbable. Perception of| Completely disorganized.
decreased, hypotension. | unreality about self, Behaviour is usually
Muscle coordination environment, or event. extremely active or
poor. Pain, hearing Dissociation may occur. inactive.
sensations minimal

A 5.46
 Unit-s Mental Disorders and Nursing Interventions
Neurotic Disorders:
Neurosis is a less severe form of
nsychological disorder where patients show
chological
either excessive or prolonged emotional reaction
stress. They have symptoms like
to any given
anxiety, fear, sadness, vague aches and pains
and other bodily symptoms. They are aware of
their problems and seek help. The basic and
predominant features of neurosis are tension,
fear and wory. All the people get tension and
wory from time to time especially when faced
with dificult problems. Later, they may able to
cope up with the situations and overcome these|
tensions. f the same tension is continued for
prolonged period, that interferes with the
person's sense of well-being and disturbs his
nomal functioning resulting in primary symptoms
of Neurosis as anxiety.
Common Neurotic Disorders:
al
Anxiety Disorder.
W
Generalised anxiety disorder.
Panicdisorder.
es
Phobic disorder.
ot
Obsessive Compulsive disorder
(Obsessive Compulsive Neurosis).
N
(Hysterical Disorder) Dissociative
(conversion disorder).
Psycho
Generalised Anxiety Disorder:
Definition:
Anxiety disorder is characterized by
recurrent unwanted thoughts (Obsessions) or
ntuals(Compulsions) which feel uncontrollable
to the sufferer.
Anxiety is defined as a response to an
undefined or unknown threat which may be due
tounconscious conflict or insecurity.
Bimla Kapoor.
5.47
VIJAYAMYSE
Generalised anxiety disorder is defined as
excessive anxiety and worry about several
events or activities for most days during at least
a 6-month period. The worry is difficult to
control and is associated with Somatic symptoms
such as muscle tension, irritability, difficulty in
slecping and restlessness.
Epidemiology:
* It is a Common Condition.
*The prevalence is 2.5 -8%.
Women and Men ratio is 2:1.
Comorbidity:
General anxiety disorder most often consists
with another mental disorder, usually Social
In
Phobia, Specific Phobia, Panic disorder or
h.
depressive disorder, 50 to 90% of patients with
General anxiety disorder have another mental
la
illness.
Etiology:
The cause of Generalised anxiety disorder
is not known but some theories support. Let us
discuss.
Biological Factors: Genetic Component -
higher frequency of illness is observed in First
degree of relatives of effected persons. It is
more common monozygotic than dizygotic.
Social Factors:
Any Maladaptive responses.
Strained interpersonal relationships.
Stress, any unresolved conflicts.
*Disturbingmemory.
Conflict between Id and ego.
B. Biochemical Factors:
*Abnormal seratonergic disorder.
*Alterations in GABA levels.
VIJAYAM'S
Increased levels of norepinephrine and
serotonin.
*Alpha- Adrenergic antagonists and c2
adrenergic antagonists can produce
frequent and severe panic attacks.
Behavioral Factors: Unconditional inherent
Tesponse of the organism to painful stimuli.
S. Cognitive Factors: Negative automatic
thoughts.
(6. Medications and Substances which can
induce anxiety are: Caffeine, other
stimulants, drugs. e.g. Heroin, Cocaine,
Amphetamines, decongestants, steroids e.g.
Cortisone, Weight loss products, Hormonal
puffs, withdrawal from benzodiazepines.
Diagnosis:
Generalised anxiety disorder, according to
DSM IV-TR is characterized by a pattern of
al
frequent, persistent worry and anxiety.
Excessive anxiety and worry
W
(apprehensive expectation), occuring
more days than not for at least six months,
es
about a number of events or activities
(such as work or school performance).
ot
person finds it difficult to control the
*The
worry.
N
The anxiety and worry are associated
with three (or more) of the following six
symptoms (with at least some symptoms
present for more days than not for the
past six months).
Note:Only one item is requiredin children.Symptomsof Generalised anxiety disorder
1. Restlessness or feeling keyed up vary from the individual to individual. GAD
or on
edge manifests with both physical and psychological
2. Being easily fatigued.
3. Difficulty in concentrating or mind going
blank.
4. Iritability.
ss 5,48
MENTAL HEALTH
NURSING
5. Muscle tension.
6. Sleep disturbance (difficulty in fallinoe
ingor
staying asleep, or restless unsatisfyino
sleep).
. The focus ofthe anxiety and worry is not
confined to features of an Axis I disorder
e.g., the anxiety or worry is not about
having a panic attack (as in panic
disorder), being embarrassed in public (as
in social phobia), beingcontaminated(as
in obsessive compulsive disorder), being
away from home or close relatives (as in
separation anxiety disorder), gaining
weight (as in anorexia nervosa), having
In
multiple physical complaints (asin
somatization disorder), or having a serious
h.
illness (as in hypochondriasis), and the
anxiety and worry do not occur
la
exculsively during post-traumatic stress
disorder.
*The anxiety, worry, or physicalsymptoms
cause clinically significant distress or
impairment in social, occupationalor other
important areas of functioning.
The disturbance is not due to the direct
physiological effects of a substance (e.g,
a dug of abuse, a medication) or a general
medical condition (e.g., hyperthyroidism)
and does not occur exclusively during a
mood disorder, a psychotic disorder, or a
pervasive developmental disorder.
Clinical Features:
signs and symptoms.
Physical Symptoms include:
1. Cardiovascular System: Tachycardia,
Chest pain, Palpitations, Dropped beats,
flushing, fainting
 Unit-5 Mental isorders and Nursing
Interventions
VIJAYAMS
spiratory System: Sighing, Chocking.
cognitive distortions directly and behavioural
Dyspnea.
approaches address somatic symptoms
Alimentary Systen. Dry mouth, Dysphagia directly. The major techniques used in
3.
Dyspepsia, Nausca, Abdominal Pain behavioural approaches are relaxation and
and
Diarrhoea. bio-feedback.
Genito urinary System: Frequency, Supportive therapy offers patient's
Hesitation, sexual dysfunction.
reassurance and comfort.
s. Nervous System: Tension headaches,
Bluring of Vision, Tinnitus, Sweating, *Insight oriented psychotherapy focuses on
Tremor, uncovering unconscious conflicts and
Dilated pupi.
identifying ego strengths.
6. Musculoskeletal System: Aches, and pain,
Teeth Clenching, Chronic jerks etc. *Mostpatient's anxiety is reduced when
opportunity is given to discuss their
Psychological Symptoms of Anxiety: difficulties with concerned and
1. Anxious mood sympathetic physician.

In
2. Worry or fear Pharmacotherapy- which includes:
Iritability.
Inability to relax.
h.
Benzodiapines: e.g. Alprazolam, clonazepam
Betablockers to Control Severe palpitations that
la
have not responded to anxiolytics
Feeling of being unable to cope.
al

e.gpropranolol.
Feeling of restless.
Selective Serotornin Reuptake inhibitors-may
W

Depersonalisation, Derealisation. be effective patient with co morbid depression.

Initial insomnia.
es

Nightmares.
Panic Disorder:
ot

Course.and Prognosis:
Definition:
*The age of onset is difficult to specify.
N

Patients usually come to the clinician's

1. Panic disorder is defined as an acute intense
attention by age of 20. attack of anxiety accompanied by feelings

*Only 1/3 of Patients who have generalized

of impending doom is known as panic
disorder. Kaplan & Sadock.
-

anxiety disorder seek psychiatric

treatment. Many go to general
practitioners.
*GA.Dis a Chronic Condition.
Treatment-
Psychotherapy:
Cognitive-behavioural, Supportive and
ns1ght oriented - these will be effective.
Cognitive approaches address patients
2. "Panic attacks or panic disorders are
characterized by unexpected or intermittent
or sudden severe episodes of intense fear or
terror or anxiety or serious consequences
unrelated to particular stimuli in which the
physical symptoms are more predominant
and severe".

5.49
NVJAYAM'S MENTAL HEALTH NURSING

Prevalence: Clinical Features:

*In the life time 1.5 to 2% of total
population are subjected to panic attacks.
Females are more prone to panic attacks
than men, onset is sudden without any
warning signs. Age - mostly it begins at
the age of 24 44 years.
Etiology:
a. Genetic Factors:
*15% of 1st degree relatives will be
suffering from panic disorders.
*Monozygotic twins are prone for panic
disorder.
*Extreme fear, and sense of impending
death and doom.
*Patients cannot name the source of their
fear.
*The physical signs often include
Tachycardia, Abdominal discomfort,
distress, pale, cold and clamy skin.
*The attack generally lasts 20-30 minutes.
*Psychological Symptoms include the
patient may experience depression,
depersonalization, risk of suicidal attempts,
paraesthesia.

In
*Individual with genetic abnormalities if Diagnostic Criteriafor Panic Disorder:
subjected to stress and tension may prone
for panic disorder.
Brain Dysfunction: Organs which are
h.
A panic attack is a discrete period of intense
fear or discomfort in which at least four of the
la
following symptoms develop abruptly andreach
responsible for anxiety are Amygdala and
a peak within 10 minutes.
al
limbic system. Specifically hippocampus
dysfunction or imbalance in the functioning *Palpitations, 'pounding heart, or
W

pattern leads to panic disorder. accelerated H.R.

b. Biochemical Fctors: Sweating.
es

*Increased levels of Nor epinephrine. *Tremblingor shaking.

*Undefinedabnormality in seratonin. *Feelings of shortness of breath,
ot

Abnormalities of cortisol. smothering

N

Alteration in GABA Levels. Feeling ofchocking.

C. Physical Factors: Chronic hyperventilation *Chest pain or discomfort.
causes oversensitive Co2 resulting into panic Nausea or abdominal discomfort.
attack.
*Feeling of dizziness, unsteady, light
d. Psychological Factors: Painful or traumatic headed or faint.
events e.g. Separation, divorced, early life
abuse, pessimistic personality traits, Any life
*Derealisation (Feeling of unreality)
Depersonalization (being detached from
stressors, financial difficulties, Marital
disharmony, Bereavement, family conflicts
one self.).
interrupted interpersonal relationship. *Fear of losing control or going crazy.
e. Environmental Fuctors: Occupational Fear of dying.
difficulties, harsh lighting at work, alcoholism *Parasthesias.
and drug abuse e.g. Cocaine, Alcohol etc.
*Chills or hotflashes

ZS 5.50SR
 Unit-5 Mental sorders and Nursing Interventions
VIJAYAM'S
Treatment:
Pharmacotherapy:
Benzodiazepines e.g. Alprozolam,
clonazepam.

Antidepressantsfor panic disorder.

Beta blockers to control severe palpitation
that have not responded to anxiolyticse.g.
propranolol.

#Cognitive Therapy: Helps the individuals

identify their emotions and behaviours.

Psyehotherapy: It will allow them to explore

sOcial or personal difficulties.

it. Supportive Psychotherapy: Reassurances

In
are important nursing measures for the care Fig. 5.20 Repeated Hand Washing
of clients who suffer with panic disorders.
h.
Compulsions are irresistible urges to carry
la
out meaningless and irrational activities. If the
patient does not carry out his impulses, he
al

5.9 ESSIVE cOMPULSIVE experiences discomfort and tension.

DISORDERS Etiology:
W

INTRODUCTION Genetic factor:

es

*Higherin Monozygotic twins.

The disorder may begin in childhood,but
*35% of first degree relatives.
more often begins in adolescence or early
ot

adulthood. *Biochemical: Neuro transmitter

serotonin (5-HT) may be abnormal in
It is equally common among men and
N

individuals.
women.
*BehaviouralFactors.
Itis usually chronic. Clinical Features:
Many OCD sufferers also have major iObsessional Thoughts:
depressive.disorder, panic disorder, social
Ideas and beliefs that enter forcibly intoo
phobia, specific phobia, eating disorder, patients mind.
substanceabuse or personality disorders.
the
A They are usually unplesant and shocking
Definition: to the patient.
Obsessions are persistent recurrence of Contamination.
unwelcome ideas. The patient does not enjoy Repeated doubts.
With those ideas,
he feels miserable and guilt. Orderliness.
he ideas are usually centered around sex,
religion, dirt Impulses.(
and germs.
Sexual imagery.

5.51
 MENTAL HEALTH NURSING
VIJAYAM'S
Command stop: Relaxation muscles and
iicObsessionalRuminations: Intenal debates
even the diverstion of thoughts.
in which arguments for and against
simplest every day actions are reviewed Repeat the procecdure to bring the
the
unwanted thought control.
endlessly.
iüiObsessional Images: Wildly imagined
Scenes, often of a violent or disgusting kind
including abnormal sexualpractices.
iObessionalDoubts:
*May concern actions that may not have
been completed adequately.
*Forgetting to turn off the stove or not
locking a door.
Obsessional Impulses:. Urges to perform

In
acts usually of a violent or embrasing kind,
such as injuring a child, shooting in church
etc.
vi/0bsessive slowness: Obsessive ideas or
h.
Fig. 5.21Say Stop when Unwanted
la
thought comes in your Mind
extensive compulsive rituals characterize
al

obsessional slowness. Mark slowness in daily

activities. Relaxution technique: Deep breathing
W

Treatment: exercise, progressive muscle relaxation,

Pharmaco therapy: Fluvoxamine, sertraline meditation, imagery and music.
es

Anxiolytics e.g. Benzodiazepines. Other therapies:

ot

Behavior therapy: *Supportive psychotherapy.

Exposure and response prevention. *ECT For patient's refractery to other
N

*Thought stoppage. forms of treatment.

*Relaxationtechnique.
*Desensitization.
*Aversive conditioning.
Exposure and response prevention: e.g.
Compulsive hand washers are encouraged
to use towels than Refrain from washing in
order to break the Negative reinforcement.
Thoughtstoppage: Help individual to leam
tostop thinkingunwanted thoughts.
Siting comfortable chair bring to mind the
unwanted"thought"" concentrating on only
one thought per procedure.
Nursing Management:
*Collection ofphysical,psychological and
social data.
Aware impact of obsessions and
compulsions on physical functioning,
mood, self-esteem and normal ability.
| Nursing Diagnosis:
Ineffective individual coping related to
under developed ego, punitive super ego
avoidence learning, possible biochemical
changes, evidenced by ritualistic behaviour
or obsessive thought.

5.52
 Mental Disorders and Nursing Interventions VIJAYAM'S
Altered rule performance related to the
| Freud (1841-1925) developed a classification of
need to perfom rituals, evidenced by
neuroses and his concepts of neuroses have
inability to fulfill usual patterns
responsibility.
of formed the foundation of psychoanalytical
thought.
Meaning:
Neurosis is derived from two greek words,
5.9D DEPRESSIVE NEUROsis Neuron' means 'nerve' with the suffix 'osis'
INTRODUCTION means 'diseased' or 'abnormal condition'.
Neurosis term is not currently widely Neurosis is a normal human experience part of
used. These term descriptions are far human condition. Majority of people are
from perfect and there are clearly rlaffected by neurosis in some mild form or other.
exceptions to the rules. But even Indian Definition:
Classification of Diseases 10 still use In psychoanalytic theory, Sigmund Freud has
this term in its classification. But
DSM-| defined neurosis as

In
IV does not use this term in its
"A symbolic behaviour in defense against
classification. In ICD-10 classification the
excessive psychologicalpainin self-perpetuating
code is F40-49 titled as "Neurotic Stress
related and somatoform disorders".
h.
because symbolic satisfactions cannot fulfill real
la
-
needs. Thought and behaviour patterns th
Neurosis (or) neurotic disorder is less produce difficulties in living is neurosis".
al

severe formofpsychiatric disorder where

Neurosis may be defined as mild to
patients show either. excessive omoderately
W

severe illness, in the personality in

prolonged emotional reaction to anygiven
which the ego function of reality testing is greatly
stress.
es

impaired and in which the maladjustment to life

*Neurosis (singular) neuroses (plural) in is relatively limited. Bimla Kupoor (2001)
traditional usage, neurosis is a
ot

psychological disturbance in which there

are one or more symptoms like obsession,
N

anxiety, phobia etc. that are ineffective

attempts to deal with anxiety. Neurosis is
also known as psychoneurosis;
psychoneurotic symptoms are extremely
varied. Two essential features of|
psychoneurosis are that they are
precipitated by emotional stresses,
conflicts and frustrations and that they are
most effectively treated by psychological
techniques.
History:

Theterm neurosis was first introduced in

1769 byWilliam
Cullen (1710-1790). Sigmund Fig. 5.22 Depressive Neurosis

5.53
 MENTAL HEALTH NURSING
VIJAYAM'S

Characteristics of Neurosis: 1. Physical Factors: Because of the close

Neurosis are among the most common of all
psychiatric illnesses. They have the following
characteristics:
They are distressing to the person and
regarded as unacceptable and alien (ego-
dystonic).
lose touch with
*The patient does notbehaviour
external reality and does not
actively violate important social norms.
to be relatively
*The symptoms tend
enduring of recurrent unless effective
treatment is obtained.
interdependence of mind and body, it
is
incorrect to state that physical tactors play
no role in the development of
psychoneuroses. Sometimes, rarely physicat
exhaustion may so weaken the mental
resources of the individual as to facilitate the
appearance of neurotic symptoms. But they
are not the result of physical diseases or
nerve injuries. In physical health
psychoneurotics do not differ significantlv
from normal individuals.
2. Trauma & Conflict: Disappointing love
affairs, financial reverses, death in the family
terrifying accidents, intratamilial problems

In
The symptoms are limited to temporary
and occupational maladjustment are some
reactions to external stress.
common examples. Since the symptoms
These is no demonstrable organic
aetiology involved.
h.
follow the emotional trauma, there is
temptation to regard the trauma as the cause
a
la
Incidence: of the psychoneurosis.
al

Approximately 5-10% of the population The cause for the psychoneurosis is to

exhibit psychoneurotic symptoms at any given be found in the individual rather than his life
W

time. As many as 20% of the people have shown experiences. Emotional trauma and mental
or will show psychoneurotic reactions at critical conflicts naturally produce temporary
es

moments in their lives. instability in many normal individuals.

3. Conditioning: The emotions, impulses and
Classification:
ot

sensations experienced under certain

According to ICD-10 classification, the
conditions may become so strongly
N

neurotic disorders are classified under the title

associated that the chance occurrence in the
of "neurotic stress related and somatoform future of some element of the original
disorders". Among it, the important conditions situation will reinstate the original reaction.
are For example, a person who sutfered from
1. Anxiety neurosis. nausea, vomiting, headache and dizziness
2. Phobicneurosis. following a railroad accident may experience
3. Obsessive compulsive neurosis. the same symptoms for montlhs afterward
whenever he rides on a train.
4. Depressive neurosis.
4. Heredity: Studies indicate that parents and
5. Conversion disorders. offspring share a common home
6. Dissociative reaction. environment, intrafamilial resemblances with
respect to psychoneurotic traits are due
Causes: The causes of psychoneuroses can be
discussed under. partly to hereditary factors and partly to
imitation and learming.

5.54
 Unit-5:: Mental Disorders and Nursing Interventions
VIJAYAM'S
5. Unfavourable Early Environment and
sensitive to criticism, and are inclined to
Training: Individuals who in later (older) life
blame others for their mistakes. They are
become psychoneurotic are often tense, emotionally immature, dependent and
enuretic, fearful and anxious as children. The
sclfish and finally they crave for affection
more important factors are maternal
and develop sexual maladjustment, guilt
overprotection, rejection, excessive
fondling, feclings and mental conflicts.
pathological parental attachements,
inconsistent home discipline,
strict upbringing
of children, sibling rivalry, over anxious,
broken homes etc. 5.9E. CONVERSION DISORDERs
Characteristics of the Psychoneurotics:
INTRODUCTION
*Age: All ages from childhood to senility
are affected, with the highest frequency Conversion disorder is a loss of or change in
occurring in the period from the early body function resulting from a psychological
is conflict, the physical symptoms of which cannot
twenties to the late fifties. There

In
CC
be explained in terms of any known medical
generally a decrease in frequency and
disorder or pathophysiological mechanism.
severity of attacks with the approach of
old age. h.
Clients are unaware of the psychological basis
and are therefore unable to control their
la
*Sex: Approximately 60% of psycho- symptoms.
neurotics seeking treatment are women
al

Definition:
and about 75% of them are having
W

hysteria but in other forms, both male and A mental disorder whose central feature is
female number is equal. the apperance of symptoms affecting the
es

patient's
*Intelligence: Most patients possess suggest a sense/
voluntary movement theat
neurological (or) General medical
average intelligence, and there is some disease
ot

evidence that psychoneuroses are more

prevalent among bright than lull Prevalence:
N

individuals.
*5-14%- General hospital patients.
*Cultural Status: Cultural status has an 1-3% - OP refferals.
important bearing on type of symptóms
5-25%- Psy. OP patient.
expressed. Educational status and
economic status of psychoneurotic
- Less enable.
patients is comparable with that of the - Socio-economic status.
general population. In ICD 10 convension disorders are
Personality: The psychoneurotic subdivided into
individuals exhibit several characteristics 1. Dissociative motor disorder
and varieties of personality types. Usually,
2. Dissociative anesthesia and sensory loss
they are dissatisfied, unhappy, lack in self-
confidence, unable to plan and make 3. Dissociative convulsions
decisions. For the same reason, they are

E 5.55 ESTARIRESISNE
 MENTAL HEALTH NURSING
VIJAYAM'S
1. Dissociative Motor Disorder: Is Diagnosis:
characterized by motor disturbance like Age: 6-35yrs
paralysis, or abnormal movements. Paralysis
Sex: F to M 2:1 to 10:1
may be monoplegia, paraplegia or
quadriplegia. The abnormal movement may *Residense: Rural areas
be tremors, choreiform movements or gait Treatment:
disturbance with increase when attention is
directed toward them. Examination reveals
*AntiAnxiety agents
Antidepression
normal tone and reflexes.
2. Dissociative Sensory Loss and Anesthesia: Psycho therapy.
Is characterized by sensory distrubancelike Psycho dynamic psychotherapyinsight.
hemianesthesia, blindness, deafness and Family therapy
stocking anesthesia.
Group therapy.
3. Dissociative Convulsions: Or hysterical fits
or pseudo seizures characterized by presenceComplications:

In
of convulsive movements and partial loss of In some cases particularly, if not treated soon
consciousness. Differential
both seizures is important.
diagnosis with
h.
enough conversion disorder symptoms can result
in substantial disability, similar to that caused by
la
Symptoms: medical conditions.
al

Conversion disorder symptoms may appear

suddenly after a stressful event or trauma,
W

whether physical or psychological. Signs and

symptoms that affect movement function may
es

include: 5.9F. DISsoCIATIVE REACTION

*Weakness or paralysis.
ot

Abnormal movement, such as tremors or Dissociative Disorder:

difficulty in walking. Dissociation is the disconnection from full
N

*Loss of balance. awareness of self, time, and / or external

*Difficult in swallowing or"a lump in the
throat".
Seizures or convulsions.
*Episode of unresponsiveness.
Signs and symptoms that affect the senses
may include:
*Numbness or loss ofthe touch sensation.|
Speech problems, such as inability to
speak or slurred speech.
*Vision problems, such as double vision or
blindness
*Hearing problems or deafness.
circumstances. (Turkus 1992).
It is a complicated neuropsychological
process that exists along a continuum from
normal every day experiences to disorder that
interfere with everyday functioning.
Etiology:
Psychodynamic Theories:
Psychodynamics hypothesizes that the
hysterical symptoms occur from failure of mental
forces to integrate mental functions, because o
which certain functions escape from active
central control.

5.56EE
 Unit Mental Disorders and Nursing Interventions
The anxiety of unconscious intra psychic
conflict is converted into somatic symptoms and
anism is called conversion.
themecha
Neurophysiological Mechanisms:
These patients perhaps suffer from
excessivecortical arousal, which causes reactive
inhibitions of signals at synapses in sensory
motor pathways by way of Negative feedback
relationship between the cerebral cortex and the
brainstem reticular formation.
Interpersonal Theories:
The conversion symptoms serve the purpose
ofnonverbal interpersonal communication of the
stress of suffering and also function as nonverbal
means of controlling or manipulating others. An
emotionally charged feelings or idea, blocked
from expression by personal or cultural restraints
is expressed in form of the conversion symptom.
Patients with more frequently recurring
conversion symptoms have been reported to
have significantly higher number of problems in
W
their private lives.
Psychological Factors:
es
According to this theory conversion disorder
1S caused by
the repression of unconscious
ot
intrapsychic conflict and the conversion of
anxiety into a physical symptom.
N
Biological Factors:
Brain imaging studies show hypo metabolism
of the dominant hemisphere and
hypermetabolism of the non dominant
hemisphere and have implicated impaired
nemispheric communication is the cause of
conversion disorder.
Classification:
Dissociative disorders are classified into four
Ypes according to D S M-IV-TR. They are:
. Depersonalization Disorder.te
2. Dissociative Amnesia.
AE5.57
VIJAYAM'S
3. Dissociative fugue.
4. Dissociative identity disorder.
1. Depersonalisation Disorder: During an
episode of depersonalization, one fecls
detached or unconnected to the self. The
individual may feel like a robot working on
automatic.
Depersonalisation is a normal response
to severe anxiety. During the periods of
extreme stress or anxiety depersonalization
serves as a defense Mechanism but it does
nothing to relieve the cause or the distress.
So, it becomes a maladaptive behaviour.
Features: Affective (emotional)
In
*Feels identity is lost.
*Lacks sense ofinner togetherness.
h.
Unable to feel pleasure or pride.
la
*Feeling of detachment from self.
al
Shame and unreality.
Behavioural (Social): Affect blunted
Unresponsive and passive, not lively or
spontaneous, communications odd or
difficult to follow.
Loss ofdrive, decision-making abilities,
impulse control.
*Social isolation and withdrawal.
Cognitive (Intellectual): Confusion,
distorted thinking and memory, impaired
judgement and disoriènted to time.
Perceptual (Physical):
Dream-like experiences of world.
Disturbed body image and Security.
Auditory and visual Hallucinations.
Comorbidity: Depersonalization commonly
associated with acute stress disorder, panic
disorder and Schizophrenia.
 MENTAL HEALTH NURSINC
VIJAYAM's
Amnesia is a loss more friendly and outgoing but their
2. Dissociative Amnesia: reh
behaviours remain appropriate. After retun
Amnesia is
of memory. Dissociative remember to the pre-fugue state,
viduals may
individuals
characterized by an inability to
explained experience aggressive impulses conflic
personal information that cannot be depression, guilt, and suicidal wishes.
attempt to
by ordinary forgetfulness. It is an
the There may be loss of memory for the
avoid extreme stress by blocking
memories from consciousnesSS. events that occurred during the time of the
but some
fugue. Recovery is usually rapid
Individuals with dissociative amnesia
recall Amnesia may remain. Psychosocial nursino
usually have gaps in their ability to important in
care and emotional support are
certain events during their childhood. Most
related to the recovery of these people.
of these lapses in memory are Disorder:
extremely stressful events. 4. Dissociative Identity
Definition: A dissociative identity disorder
eg is defined as the presence of two
or more
*A rape victim often has no memory of identities/personalities that repeatedly take

In
the attack but still experiences the
control the individual's behaviour.
of
emotional numbness, depression, and
distress associated with the trauma.
Actual memories are so painful that they
h. Usually one personality is not aware of
the existence ofthe other personalities.
Each
la
personality has a full range of higher mental
stay hurried, submerged but not forgotten,
functions and performs complex behaviour
al

but still capable of inflicting pain.

patterns, transition from one personality to
The nurses must remember that these
W

another is sudden and the behaviour usually

clients require high levels of emotional contrasts strikingly with the patient's normal
support. Client's safety becomes a
es

state.
primary nursing goal because suicide
attempts are common. Other Dissociative Disorders include:
ot

3. Dissociative Fugue: The word "fugue'| Dissociative Motor Disorders:

N

means to escape from reality. The main Itis characterized by motor disturbances like
characteristic of dissociative fugue is sudden, paralysis or abnormal movements. Paralysis
unexpected travel with an inability to recall may be a monoplegia, paraplegia or
,
the past. A fugue occurs in response toquadriplegia.The abnormal movement may be
stressful or traumatic event. The travel may tremors, choreiform movements or gait disturbs
range froma few miles away from home to which increase when attention is directed
another continent. Individuals behave quite towards them. Examinations reveal normal
normally during periods of travel but are reflexes.
confused about their personal identities,
Dissociative Convulsions:
which brings them to the attention of
authorities. Itis characterized byconvulsivemovemenis
partial loss of consciousness. Differential
During actual fugue few personalityand
diagnosis with true seizures is important. Som
changes are noticable. Individuals may be
differences are explained in the following table

5.58
 tait-5: Mental Disorders and Nursing Interventions VIUAYAM'S

Table: Differences Befhveen Epileptic Seizures and Dissociative

Convulsions
Clinical Points Epileptic Seizures Dissociative Convulsions
Aura (warning) Usual Unusual
Attack pattem Stereotyped known Purposive body movements absence
clinical pattern of any established clinical pattern
Tongue bite Present Absent
Incontinence of urine and Can occur Very rare
feces

Injury Can occur Very rare

Duration Usually about 30-70 20-800 sec (prolonged)
seconds

In
Amnesia Complete Partial
Time of day Any time can occur
during sleep also h.
Never occur during sleep
la
Place of occurrence Any where Usually indoor or in safe places
al

Postictal confusion Present Absent

W

Neurological signs Present AbsentS2

es

Dissociative Sensory loss and Anaesthesia:

ot

Itis characterized by sensory disturbances like hemi anaesthesia, blindness, deafness (absence
of sensations at wrists and ankles).
N

The disturbance is usually based on patient's knowledge of that particular

illness whose symptoms
are produced. A detailed examination does not reveal any abnormality.

Treatment:

*Freeassociation Hypnosis
Abreaction therapy *Supportive psycho therapy
*Behaviourtherapy.
Drug Therapy: If the patient has anxiety, antianxiety drugs; if the patient has depression,
antidepressants should be given. All these medications are given for
short period to encourage
inner coping skills.

5.59 m
 MENTALHEALTH NURSINc
VIJAYAM'S
has now oeen
The term 'psychosomatic been
Nursing Interventions: replaced with 'psychophysiologic'. Followino

*Monitor physician's ongoing assessments, three factors must be

laboratory reports and other data to rule
out organic pathology.
not focus on the disability, encourage
*Do activities
the patient to performself-care
as independently as possible.
Intervene
only when patient requires assistance.
present simultaneously for
a person to develop
a psychosomatic disorder
Biological predisposition.
.
Personality vulnerability.
3Significant psychosocial stress in his/her
susceptible personality area.

* Do not allow the patient to use the Common Examples of Psychophysiological

disability as a manipulative tool to avoid Disorders
participations in the therapeutic activities. psychosomatic
Ffanz Alexander, the father
of

*Withdraw attention ifthe patient continues medicine, described seven classical

to force on physicallimitations. psychosomatic illnesses.

In
*Encourage patient to verbalize fears and Cardiovascular-Disorders
anxieties. Essential hypertension.
Positive reinforcement for identification h. Coronary artery disease.
la
of demonstration of alternative adaptive
coping strategies. * Post cardiac surgery delirium.
al

*Identity specific conflicts that remain Migraine.

W

unresolved and assist patient to identify Mitral valve prolapse syndrome.

possible solutions.
es

Endocrine Disorders:
* Assist the patient to set realistic goals for
the future. Diabetes mellitus.
ot

Help the patient to identify areas of life Hyperthyroidism.

situation that are not within his ability to
N

Cushing's syndrome.
control. Encourage verbalization of
feelings related to his inability. Pre-menopausal syndrome.
* Amenorrhea.
Menorrhagia.
6.PSYCHOSOMATIC DISORDERS Gastrointestinal Disorders:
Esophageal reflux.
The word 'psychosomatic' means mind and
body-Psychosomatic disorders are those Peptic ulcer.
disorders in which the psychic elements are *Ulcerativecolitis.
significant for initiating chemical, physiological
or structural alterations, which in turn create the Crohn's disease.
physical symptoms in the person.

5.60
lnit-5: Mental Disorders and Nursing Interventions VIJAYAM'S

Immune Disorders: Urticaria.

Autoimmune disorders, for example, AAcnevulgaris.

systemic lupus erythematosus.
Warts.
Allergic c disorders, like bronchial asthma
Treatment
and hay fever.
Relaxation techniques: This is one of the
Viral infections.
most important methods aimed at reducing
Musculoskeletal Disorders: anxiety or restlessness. They include:
Rheumatoid arthritis. Jacobson's progressive relaxation
technique.
Respiratory Disorders:
Yoga.
Bronchial asthma.
Auto hypnosis..
Hay fever.
Meditation.

In
Rhinitis.
Biofeedback.
Skin Disorders:

Psoriasis.
h.
2 Behaviour modification techniques.
la
Pruritus.
3 Individual therapy.
al

4. Group therapy.
W
es
ot

(Areatment of Psychosomatic disorder

N

Relaxation Behavior Individual oup

techniques modification therapy therapy
techniques

Jacobson's progressive
relaxation technique
Yoga
Auto hypnosis
-
Biofeedback

Fig. 5.23

n 5.61
 MENTAL HEALTH NURSINC
VIJAYAM'S
symptoms. A separate record of situation
Nursing Management:
that the patient finds especially stressfn
Assessment: should be kept.
Perform thorough physical assessment. Help patient identify needs that are being
met through the sick role. Together,
*Monitor laboratory values, vital signs,
intake and output and other assessments
formulate more adaptive means for
fulfilling these needs, practice byrole
necessary to maintain an accurate
playing.
ongoing appraisal.

*Assess patient's level of anxiety.

*Provide instruction in assertive
techniques, especially the ability to
*Assess patient's level of knowledge recognize the difterences among passive,
regarding cffects of psychological assertive, and aggressive behaviours and
problems on the body. the importance of respecting the rights
Nursing Diagnosis: of others while protecting one's own

In
basic rights.
*Ineffectiveindividual coping related to
Discuss adaptive methods of stress
repressed anxiety and inadequate coping
methods, evidenced by initiation or
h.
management, such as relaxation
la
exacerbation of physical illness. techniques, physical exercises, meditation
and breathing exercises.
al

Knowledge deficit related to

psychological factors affecting physical
W

condition, evidenced by various physical

problems. 5.9H.POST TRAUMATIC STRESS
es

NursingInterventions: DISORDER
ot

Encourage patient to discuss current life INTRODUCTION

situations that he perceives as stressful,
*PTSD can occur in a person who has
N

and the feelings associated with each.

*
Provide positive reinforcement for
adaptive coping mechanisms identified or
used. Suggest alternative coping
strategies but allow patient to determine
which can most appropriately
be
incorporated into his life-style.
*Help patient to identifya resource person
within the community (friend or significant
Definition:
others) to use as a support system for
the expression of feelings.
*Havepatient keep a diary ofappearance,
duration, and intensity of physical
witnessed an extraordinary terifying
event, the person reexperiences all (or)
some of it through dreams (or) walking,
recollect it through flash backs.
New behaviour develops related to the
trauma such as sleep difficulties, hyper
vigilance, thinking difficulties and
agitation.
PTSD is a severe anxiety disorder that
can develop after exposure to any event
that results in psychological trauma.

5.62 ERS
 Mental isorders and Nursing Interventions VIJAYAM'S
Unit-
nit-5 :
yperarousal: A state of nervousness
characterized by fight or flight.
*Depersonalization and derealization.
*Restlessness.
Management:
The treatment consists of the following
measures:
I. Prevention: Anticipation of disasters in the
high risk areas, with the training of personnel
in diaster management.
Fig. 5.24 Disaster 2. Disaster Management: Here, the speed1of
providing practical help is of paramount
importance. This is also a preventive
Events may involve: measure.

In
Threat of death to one self for others. 3. Supportive psychotherapy.
Not able to cope physicaly, sexualy or4.
psychologically.
5.
h.
Cognitive Behaviour Therapy (CBT).
Drug Treatment: Antidepressants and
la
PTSD is characterized by hyperarousal, benzo-diazepines (in low doses for short
reexperiencing of images of stressful periods) are useful in treatment, if anxiety
al

events and avoidance of reminders. and/or depression are important components

W

Causes: of the clinical picture.

Actual or threatened death. Nursing Interventions:
es

* Serious physical injury. * Establish trusting relationship.

Childhood physical, emotional (or) sExual *Encourage thepatient to express her grief,
ot

abuse (or) extreme neglect. complete the mourning process.

*Life-threatening experiences.
N

*Use crisis intervention techniques as

Biochemical changes: Imbalance of needed.
neuro transmitters. *Assist in regaining control over angry
Clinical Manifestations: outbursts by identifying how anger
*Intense feeling of fear. escalates.

*Mental returns of event (flash backs). Encourage move from physical to verbal
Emotional numbness. expressions of anger.

Avoidance of people, places or things.
Insomnia.
Depression.
*Iritability or aggressiveness.
Impaired social (or) work functioning.
Teach the patient about medications and
adverse effects and advise her not to
discontinue medication without physician
consultation.

5.63
 MENTAL HEALTH NURSING
VIJAYAM'S
*Children, especially boys, tend to follow
Nursing Diagnosis: their parents drinking pattern.
Ineffective individual coping related to
or fear of Somepeople drink to get away trom pain.
lack of social relationship
*Alcoholism is more common in anxiety
specific stimuli.
to disorders or phobic disorders as an
*Post trauma syndrome related escape.
distressing event.
*Isolation, unemployment, loss, injustice
*Impaired communication related to and other social causes may lead to
anxiety. alcoholism.
Persons suffering from chronic physical
illness, business, executive travelling sales
5.10 SUBSTANCE USE AND persons industrial workers.
DE-ADDICTION Urban slum dwellers, students in hostels,
military personnel etc. are prone to
5.10A. ALCOHOL develop alcohol abuse.

In
Alcohol Abuse: Physical Complications of Alcohol Abuse:
Alcoholism is defined as a chronic disease
manifested by repeated drinking that causes
h.
Dyspepsia, vomiting, gastritis, pepticlcer,
cancer, cirrhosis of liver, alcoholic hepatitis,
la
injury to the health or social or economic alcoholic cardiomyopathy, myocardial intarction,
folic acid deficiency, anemia, protein malnutrition,
al
functioning
vitamin deficiencies like pellagra and beri beri.
W

Psychiatric Complicationis:
Fighting, impaired judgément, slurred speech,
es

unsteady gait, irritability, impairedattention

Withdrawal Phenomenon: Tremor,
ot

nausea and vomiting, tachycardia,

eKT elevated BP anorexia, insomnia, fits etc.
N

Your
Tones
Causes:
Alcohol is easily available and drinking is
accepted in functions and social gathering
*Some excessive drinkers have a family
history of excessive drinking.
Delirium Tremers (DT): It should be
treated as a psychiatric emergency. The
syraptoms are insomnia, tremulousness,
fear, convulsion, clouding of
consciousness and confusion, marked
tremor and fever.
*Alcoholism and Criminality: Alcoholism
increases hostile behaviour, so alcoholics
are prone to develop violence and
antisocial behaviour.
* Alcoholism
and Sex: Alcohol increases
the sexual desire but takes away the
performance.

5.64
 VIJAYAM'S
iloit-5:: Mental Disorders and Nursing Interventions
Alcohol Amnestic Disorder: Nursing Care of Alcohol Dependent:
Disorinetation of memory.
Patient to be kept in a quiet environment.
Alcoholic Dementia: A chronic organic Observe for delirium tremers
mental disorder due to long-term alcohol
drinking The side rails of bed are raised, when
patient is in bed.
Social Complications of Alcoholism:
Physical restraint may be necessary if
1. Decreased work performance, loss of job, patient is highly disturbed.
loss of income will make the family condition the
Keep harmful objects away from
miserable, marital disharmony is a common
complication. room.
Monitor vital signs every 15 minutes.
2. Drunken driving will lead to accidents.

Management: The alcoholic patients have inferior

feelings and low-esteem. If the nurse

In
Detoxification: accepts him as an individual and cordially
It is a process by which an alcohol dependent talks to him, these feelings will be reduced.
person recovers from the intoxicating effects
of alcohol in a supervised way. It includes:
The h.nurse should be empathetic.
la
The nurse has an important role in the
1. Administration of tranquilizers like
care and rehabilitation ofalcoholic patients
al

chlordiazepoxide or diazepam to control

and then families. The wives should be
anxiety and insomnia.
W

included in psychological therapy.

2. Assess fluid and electrolyte balance for
Nurse's Rolein the Prevention of Alcohol
es

dehydration ifit is IV fluids are necessary.

Abuse:
3. High protein diet (when there is no liver
HPrimary Prevention: Aim to avoid the
ot

damage)
appearance of new cases of alcohol abuse
Carbohydrate vitamin-C, vitamin-B, B
N

by reducing the consumption of alcohol

B, supplementation.
*Provide calm, safe environment
Administer anti-convulsants
Disulfiram Therapy:
This drug produces headache, severe
flushing, nausea, vomiting, palpitations,|
nypotension, dyspnoea and blurred vision when
alcohol is consumed by the person.
Aversion Therapy:
Patient is subjected to pain inducing stimuli
at the time of drinking to establish alcohol
ejection behaviour and antacids for gastritis.
through health promotion and health
education.
Secondary Prevention: Early to detect the
cases and treat them before serious
complications.
3 Tertiary Prevention: Aim to avoid further
disabilities and to reintegrate individuals into
society.

5.65
VIJAYAMIS MENTAL HEALTH NURSING

5.10B. TOBACCO
ISEZTESEDANUE

Smoking:
Smoking and tabacco use are significant risk factors for a variety of chronic disorders,
*According to American Health Association, Cigarette smoking is the most important
preventable cause of premature death in US, accounting for 4,40,000 of the more than 24
million annual deaths.

In
h.
la
al
W

Fig. 5.25 Cigarette Smoking

es

Nicotine:
ot

(From Nicotiana tabacum) is important in the context of smoking or chewing tobacco,

but there
is no clinical application of ganglionic stimulants, because no useful purpose
can be served by
N

stimulating sympathetic and parasympathetic ganglia concurrently.

Smoking-related Diseases:
Lung cancer.
*Heart disease, heart attacks and stroke.
Cancer ofthe mouth, larynx, esophagus, lips andtongue.
*Cancer of pancrease, kidney bladder, stomach, colon and liver.
Peripheral vascular disease (poor circulation).
Asthma in children.
*Low birth weight babies
*Early menopause. *Osteoporosis.
* Cataract macular degeneration. * Peptic ulcers.
Uterine and cervical cancer. * Premature wrinkles.
*Decreased sense of smell. Infertility/impotence.

5.66
 nit-5 :: Mental Disorders and Nursing Interventions VIJAYAM'S
Dangerous chemicals in tobacco:

-Acetone

Mercury

Lead

0 Nicotine

Cadmium

Dangerous chemicals in tobacco Carbon monoxide

In
Hydrogen cyanide
h.
la
Urethane
al

Arsenal
W

Phenol

Formaldehyde
es

DDT
ot
N

Fig. 5.26

Treatment:
Use of combination of medication and behavioural therapy. Latest tabacco treatment medications
Such as bupropion and nicotine replacement therapies leg. Nicotine gum or the patch.
Behaviour therapy includes walking, reading materials, web based programme and individual
and group counselling.
*
The tobacco treatment specialist follows up on clients' progress, offers tips and celebrates
his success.
Prepare: Patient need a little time before he quits; 14-30 days is usually optimal to prime his
mind and body for success.

5.67
 MENTAL HEALTH NURSING
VIJAYAM'S

Over the counter medications (Nicotine Pheochromocytoma (pcc).

based medicines):
Over the counter medicines that contain
nicotine can be very helpful in fighting off
cravings. These products will not remove
all cravings, but you can use them instead
of smoking to reduce your nicotine intake
gradually and ease of its addictive efects.
When you give your body a steady dose
of nicotine all the time and then stop
suddenly, you will have more side effects
(withdrawal symptoms) that usually make
quitting a lot harder.
Over the counter treatments are typically
used for up to 12 weeks as part of
smoking cessation programme.
Additional things to consider when taking
nicotine-based medicines.
Do not smoke while you are using the
nicotine medicines. You could risk
overdosing on Nicotine.
Tell your doctor about any medicines
you are taking or any allergies you
have.

Withdrawal symptoms include: Irritability, Do not use the nicotine-based

In
headache and the craving to smoke, go medicines if you are breast feeding or
slow and lower the dose gradually with pregnant. Keep this and all medicines
nicotine-based products until you feel are
able to resist the cravings on your own.
h. out of the reach of children and pets.
la
Common brand names of nicotine patch,
You will still have cravings, but theywill gum, and lozeng include:
al

be weaker. It is very important to have

some form of social support when you
W

decide to quit, no matter if you use Nicorelief (gum)

products or not. Support can come from
es

Nicorette (gum)
your doctor, counsellor, support group
Common brand
close friend, or a family member. names Nicotine
Nico
ot

derm (patch)
When considering a nicotine-based product
N

to help you quit, be sure to tell your doctor about Commit (lozenges)
many conditions you might have, especially
Asthma or breathing problems. Fig. 5.27

Heart or blood vessel disease.

T Quiting smoking in 5 stages:
High blood pressure.
i. Precontemplation: The person does not
Stomach ulcer.
want to quit smoking but may try to quit
Diabetes mellitus. because he or she feels pressured.
Kidney disease. ii. Contemplation: The person wants to quit
Liver disease. someday. He or she has not taken stepts to
quit but wants to quit.
Overactive thyroid.

5.68
5: Mental Disorders and Nursing Interventions
Preperation: The person takes small steps
iti.
to quit such as cutting back on smoking or
Switches toa lighter brand.
Action: The person puts a plan for quitting
i: into action. He or she makes changes
in his
or her actions and environment to help cope
to
with urges smoke. The person copes with
urges to smoke by following the plan and
remains smoke-tree for six months.
Maintainance: The person has not smoked
for one year. Smoking again (relapse) is
common. 75% of those who quit smoke|
again. Most smokers tried 3 times before
successfully quitting, don't give up.
Advantages of quiting smoking:
Prolong your life.
Improve your health.
Feel healthier.
Look better.
al
* Improve your sense of táste and smell.
W
Save money.
es
5.10C. OTHER PSYCHOACTIVE
ot
SUBSTANCE
N
Cocaine use disorder:
Common street name is 'Crack'. It can be
administered orally, intranasally by smoking
orsynthesized in 1938. Itpresumably produces its
parentrally.
Acute Intoxication: Characterized by
pupillary dilatation, tachycardia,
hypertension, sweating nausea and
vomiting.
Withdrawal Syndrone: Agitation,
Depression, Anorexia, Fatigue,
Sleepiness.
Complications: Acute anxiety reaction,
uncontrolled impulsive behaviour,
ISERRISRO 5.69
VIJAYAM'S
scizures, respiratory depression, cardiac
arrhythmias.
Treatment: Management of intoxication
Amyl nitrate is an antidote, diazepam
-
or propronalol are also used for
withdrawal symptoms-Antidepressants
imipramine (or) Amitriptyline and
psychotherapy.
Amphetamine use disorder:
Amphetamines are powerful CNS stimulants
with peripheral sympathetic effects. Commonly
used amphetamines are pemoline and methyl
phenidate.
*
Acute Intoxication: Characterized by
In
Tachycardia, Hypertension Cardiac
failure, Seizures, Tremors, hyperpyrexia,
h.
pupillary dilation, panic, insomnia,
restlessness, irritability, paranoid
la
hallucinatory syndrome anti amphetamine
-inducedpsychosis.
Withdrawal Symptoms: Characterized
by depression, apathy, fatigue,
hypersomnia, or insomnia, agitation and
hyper phobia.
*
Complications: Seizures, delirium,
arrhythmias, aggressive behaviour, coma.
disorder
LSD Use (Lysergic and
Diethylamide):
LSD is apowerful hallucinogen, and was first
effects by acting on 5 HT levels in brain. A
-
common pattern of LSD use is like a trip.
Intoxication: Characterized by
perceptual changes occurring in clear
consciousness, e.g. Depersonalize
derealization, illusions, synesthesias
(colours are heard, sounds are felt),
autonomic hyperactivity, marked anxiety,
paranoid ideation and impairment of
judgement.
SISNU

VIJAYAM'S5
Withdrawal Syndrome: Flashbacks
(brief experiences of the hallucinogenic
state).
* Complications: Anxiety, Depression,
for Intoxication.
Psychosis or usual halluciasions.
*Treatment: Symptomatic treatment with| Nursing Management with
antianxiety, antidepressants or
antipsychotic medications.
Barbiturate use disorder:
are
The commonly abused barbiturates
secobarbitol, pentobarbital, and anobarbital,
*Intoxication: Acute intoxication
characterized by irritability, lability of
mood, disinhibited behaviour, slurring of
speech, incardination, attention and
memory 1mpairment.
Complications: Intravenous use can lead
to skin abscesses, cellulitis, infections,
embolism and hypersensitivity reactions
Withdra wal Syndrome: It is
al
characterized by marked restlesSness
tesntremors, and seizures, in severe cases
W
resembling delirium tremers.
*Treatment: If the patient is conscious,
es
induction of Vomiting and use of activated
charcoal can reduce the absorption.
ot
Treatment is symptamatic.
Inhalants or Volatile solvent use disorder:
N
The Commonly used Volatile solvents include
petrol, aerosols, thinners, varnish, remover and
industrial solvents.
*Intoxication: Inhalation of a volatile
solvent leads to euphoria, excitement,
belligerence, slurring of speech, apathy,
impaired judgment and neurological signs.
Withdrawal Symptoms: Anxiety,
Depression.
*Complications: Ireversible damage to
the liver and kidneys, peripheral
neuropathy, perceptual disturbances and
brain damage.
5.70
MENTAL HEALTH NURSING
Irreversible damage to the liver
and
kidneys, peripheral neuropathy, perceptu
disturbances and brain damage.
Treatmnent: Reassurance and diazepam
substance uUse
Jse
Disorder:
Nursing Assessment:
Collect the brief history of the client
regarding developmental aspects.
milestones Educational states, Scholastic
environment and any problems associated
with it.
Marital history, sexual history, social
In
history etc.
Physical Examination: Head to foot
h.
physical examination is important to rule oüt
somatic complaints associated with
la
psychiatric problems.
Mental Status Examination:
*General appearance andbehaviour.
*Psychomotor activity.
Thought, Content, Mood, Perception.
Cognitive function-Orientation, Memory,
Intelligence, Abstractibility, Judgement,
Insight.
General Information.
Nursing Diagnosis:
1. Riskfor injury related to hallucinosis, acute
intoxication evidenced by confusion,
disorientation inability to identify potentially
harmful situations.
Goal: Client will not harm self.
Interventions:
*Place the client in a room nearthenurse's
station or where the staff can observe
the client closely.
Monitor the client's sleep pattern. He may
need to be restrained at night if confused
tnit-5: Mental Disorders and Nursing Interventions VIUAYAWS

or if he wanders or attempts to climb out Identify recent maladaptive behavioure

of bed.
Decrease environmental stimuli.
Institute Scizure precautions.
Re orient the client to person, time, place
and situation as needed.
Altered health maintenance related to
2.
inability to identity, manage or seek out help
to maintain health, evidenced by various
physical symptoms, exhaustion, sleep
disturbance.
situations that have occured in the
patient's life and discuss how to use of
drugs, alcohol may bea contributing
factor.
* Do not allow patient to rationalize or
blame others for behaviours associated
with substance use.
* Provide positive reinforcement when the
client shows insight into his behaviour.
4. In effective individual coping related to

Goal: Client will maintain optimum health. impairement of adaptive behaviour and
problem-solving abilities, evidenced by use
Interventions:
of substances as coping mechanisms.
Monitor the client's health status,

In
Goal: Patient will be able to use adoptive
administer medications as prescribed by
coping Mechanisms.
physician.

Maintain fluid and electrolyte balance.

h.
Interventions:
la
Encourage clients to explore options
Provide food or nourishing fluids as soon available to deal with stress,
al

as the client can tolerate eating.

*Give positive reinforcement for ability to
Ensure that amount of protein in diet is
delay gratification andrespond to stress
W

correct for individual patient condition.

with adaptive coping strategies.
Provide small frequent feedings and
es

Teach client and family that alcoholism is

favourite foods to patient. Supplement
a disease that requires long-term
with vitamins and minerals.
treatment and follow-up.
ot

Assist the client in self-care activities. It

Maintain frequent contact with the client.
may be necessary to provide complete
N

physical care.
3. In effective denial related to weak,
underdeveloped ego, evidenced by lack of
insight, rationalizations ofproblems, blaming
others, failure to accept responsibility for his
behaviour.
Goal: Patient will understand the effect
his behaviour on others.
Interventions:
Develop trust, convey an attitude of
acceptance ensure that patient
understands, it is not him but his behaviour
that is acceptable.
*Assist the patient to plan weekly or even
daily schedules of purposeful activities
such as appointments taking, walking
5. Imbalanced nutrition less than body
requirement related to use of substances
instead of eating evidenced by loss of weight,
pale conjunctiva and mucus membrane.
of
Goal: Client will be free from signs and
symptoms of malnutrition.
Interventions:
* Parental support may be required initially.
*Encourage cessation of smoking.

5.71
VIJAYAM'S
*Consult dietician, determine the number
of calories required based on body size
and level of activity.
*Document the intake and output and
weigh them daily.
* Ensure that amount of protein in the diet
is correct for the individual client's
condition.
*Sodium may need to be restricted.
*Provide foods that are non-iritating to
clients with oesophageal varices.
* Provide small frequent feeding of client's
Favourite foods.
Evaluation: The following questions can be
useful in evaluating the Nursing care.
*Has detoxification occured without
*
complications?
Has correlation been made between
personal problems and the use of
al
substances?
Does he accept responsibility for own
W
behaviour?
Prevention of Subtance use Disorder:
es
I. Primary Prevention:
*Reduction of overprescribing of drugs by
ot
the doctors especially Benzodiazepines
N
and other anxiolytics.
Identification and treatment of family
members who may be contributing to the
drug abuse.
*Health educationto college students and
the youth about the dangers of drug abuse
through the curriculum and mass media.
*Health education should also include
certain specific groups where a substance
like alcohol may be culturally accepted
for e.g. Certain tribal communities such
as the Lambanis group.
5.72
MENTAL HEALTH NURSING
An overall improvement in the
socio.
economic condition of the population.
2. Secondaury Prevention:
*Early detection and counselling.
Motivational interviewing which involves
providing feedback to the patient on the
personal risks that alcohol poses, together
with a number of options for change.
*A full assessment including an appraisal
of current medical, psychological and
social problems,
* Detoxification with Benzodiazepines
e-g. Diazepam.
3. Tertiary Prevention:
In
Alcohol deterrent therapy.
*Othertherapies include assertiveness
h. training, teaching coping skills, behaviour,
counselling, supportive psychotherapy,
la
and individual psychotherapy.
*Some practical issues under relapse
prevention include motivation
enhancement including education about
health consequences of alcohol use.
*Identifying high-risk situations and
developing strategies to deal with them.
Drink refusal skills.
Hand limp Negative mood states.
Recreation and spirituality.
Primary Prevention
Prevention of
Subtance Secondary Prevention
use disorder
Tertiary Prevention
Fig. 5.28
 Unit Mental Disorders and Nursing Interventions
VIJAYAM'SS

Physical damage and disorders:

11,CHILD AND ADOLESCENT
Y PSYCHIATRIC DISORDER
* Injury.

5.11A. MR *Hypoxia.
INTRODUCTION Intoxication:

Mental Retardation is not a diseasebut a *Lead.

condition in which the intellectual facilities Certain drugs.
are never manifested
Environ mental and Socio-cultural
Institutionalizationandspecial schooling Factors:
are required for a number of mentally
*Low socio-economic status.
handicapped children.
Definition: *Inadequate core takers.
Mental retardation is defined by deficits in Postnatal Factors:

In
general intellecthual functioning and adoptive *Infections.
functioning (APA, 2000).
Encephalitis.
Mental retardation refers to significantly sub
average general intellectual functioning resulting
h.
Classification of Mental Retardation:
la
in or associated with concurrent impairments in Mild Retardation: (50-70) 1Q:
al

adaptive behaviour and manifested during the

This is commonest type of Mental
developmental period (American Association on
Retardation accountly for 85-90% of all cases.
W

Mental Deficiency, 1983).

These individuals have minimum retardation in
Etiology:
es

sensory motor areas.

Chromosomal Abnormalities:
Moderate Retardation: (35-50) 1Q:
Down's syndrome.
ot

About 10% ofmentally retarded come under

Fragile syndrome.
this group.
N

Metabolic Disorders:
Phenylketonuria. Severe Retardation: (20-35) IQ:
Wilson's disease. Severe mental retardation is oftenrecognized
early in life with poor motor development and
Cranial Malformation:
absent or markedly delayed speech and
Hydro cephaly. communication skills.
*Miorocephaly. Profound Retardation: (<20) 1Q:
Infections:
This group accounts for 1-2% ofallmentally
Rabella. retarded. The achievement of developmental
Cytomegalovirus. mile stones is markedly delayed. They require
Endocrain Disorders: constant nursing care and supervision.
Hypothyroidism.
Hypoporathyroidism.

RRERENESIER 5.73 E32

 MENTAL HEALTH NURSING
VIJAYAM'S
Table: Classification of Mental Retardation:
Psychomotor Economic
Self-care Education Social Skills
Ability Level Skills Skills
child can The child can
Mild Thechild The child may | The child canThe
learn and use develop perform a job
may be able achieve
social skills in average to under close
to live reading skills
up to the level structured good skills but supervision
somewhat
settings. may and manage
independetly| of primry Cxperience money with
with school master
vocational minor proper
monitoringor
coordination guidance.
assistance training.
problems.
with life
changes,
challenges,or
stressors
(such as
.
In
personal
ilness or the
death of a
loved one).
h.
la
The child can The child has The child may The child may
Moderate The child
certain speech have difficulty learm to handle
requires close achieve skills
al

supervision up to second limitations and with gross a small amount

and must be class and may difficulty motor skills of pocket
W

supervised be trained in following and may have money as well

when skills to expected social| limited as how to
es

performing participate in a | norms. vocational make changes.

certain work shopp opportunities.
independence settings.ets
ot

activities.
Severe The child May learn a The child has The child has The child may
N

rquires few simple limited verbal poor be taught how

complete skills. skills and psychomotor to use money
supervision tends to skills, with and supervised
may be able communicate limited ability while
to perfom i: te needs non- to perform shopping.
simple verbally or by simple tasks
hygiene acting them even under
skills, súch as Ou. direct
brushing supervision.
teeth, and
washing
hands.
Profound The child The child The child has The child lacks The child must
requires cannot benefit little speech both fine and depend on
constant from academic developments gross motor others for
assistance and | training. andlack social skills. money
Supervision. skills. mánagement.

5.74 ne
Unit- Mental Disorders and Nursing Interventions
VIJAYAM'S
and Symptoms:
signs Diagnosis:
Failure to achieve developmental
milestones. *llistory: Familyhistory, abnormalities in
Deficiencies in cognitive functioning. pregnancy and delivery, developmental
milestones and associated behavioural
Such as inability to follow commands or disorder.
directions.
Reduced ability to learn or to meet General Physical Examination: Height,
academic demands. weight, head circumference
Expressive or receptive language Neurological: Vision, hearing and
problems.
specific signs.
Psychomotor skill deficits.
Difficulty in performing self-care *MentalStatus Examination: Level of
intelligence.
activities.
*Neurologic impairment. Investigation: Stanford binet intelligence
Medical problemssuch as seizures. scale, Wechsler Intelligence Scale for

In
Low self-esteem, depression and labile Children (WISC).
mood. Treatment Modalities:
*Iritability when frustrated or upset. h.
*BehaviourManagement.
la
Acting out behaviour.
Lack of curiosity. *Environmental supervision. is
al

Signs: Mouth small mouth and teeth,

-
*Monitoring the child's developmental
W

Furowed tongue, high arched palate. needs and problems.

Eyes: Oblique palpebral fissures, eg * Family therapy to help partents develop
es

Cantie folds.
coping skills and deal with guilt and anger.
Head: Flat occiput.
Provide dayschoolsto train the child in
ot

Hands: Short and broad, curved.

5oh Finger: Single transverse crease. basic skills, such as bathing and feeding.
N

Joints: Hypertensibility or hyper Vocational training.

flexibility, hypotonia, poor mororeflex.
Prevention:
*Others: Congenital heart disease, small
dysplastic ears, etc. Primary Prevention:
i. Preconception: Genetic counselling,
Immunization.

i. During gestation:
Prenatal care:Adequate nutrition, fetal
monitoring and protection from disease.
ii. Delivery: Conducted by expert doctors
and staff especially in case of high-risk
pregnancy.

5.75
 MENTAL HEALTH NURSING
VIJAYAM'S
iv. Childhood: Proper nutrition First 6 Frequently the disorder is not recognized
months. until the child enters school.

Secondary Prevention: Early detection and More common in boys than girls
girls (<4
(4
times).
treatment of preventable disorders.
e.g. Phenylketonuria. A prevalence of 1.7% was found amone
Tertiary Prevention: Rehabilitation in school children.
vocational, physical and social areas Definition:
according to the level of handicap.
Hyperkinetic disorder (attension deficit
Role of Nurse: Hyper activity disorder or ADHD in DSM I
* Encourage child to dress himself. is a persistent pattern of inattention and/or
urine.yperactivity. More frequent and severe than is
*Maintain incontinence of stool and typical of children at a similer level of
*Acceptable socialbehaviour. development. Sreevani.

In
Adolescent participates in a structured Etiology:
work programme.
Identify child's strengths and potential
h.
Genetic factors:
la
*Greater in mono zygotic than dizygotic
abilities are emphasized rather than
twins.
al

deficits.
Sliblings ofhyperactivity children.
Participate inself-care skills, activities of
W

daily living. *Biological parents of children.

es

* Learning social skills and adaptive Biochemical theory:

behaviour.
Deficit dopamine and norepinephrine.
ot

0lder children prepare them for Pre, peri, and postnatal Factors:
productive work life.
N

Prenatal toxic exposure.

* Close collaboration with all members of
health team and family members.
5.11B. ADHA (ATTENTION DEFICIT
HYPERACTIVITY DISORDER)
INTRODUCTION
These children are highly distractable and
unableto contain stimuli. Motor activity
is excessive and movements are randam
and impulsive.
Prematurity, fetal distress.
Perinatal asphyxia.
*Low Apger scores.
Postnatal infections.
Environmental Influences:
Environmental lead - effect on cognitive
and behavioural development in children.
*Food additives, colouring preservatives
and sugar causes of hyperactive
behaviour.

5.76
 it-5: Mental Disorders and NursingInterventions
Psyehosocial Factors:
Prolonged emotional deprivation.
Stressful psychic events.
Disruption of family cquilibrium.
Symptoms:
1. Symptoms of Inattention:
Fails to give close attention, makes
careless mistakes in school work or other
activities.
*Difficulty in sustaining attention in tasks
or play activities.
Not seemtolisten when spoken to directly.
Failure to understand instructions.
*Difficulty in organizing tasks and
activities.
* Avoids, dislikes engage in tasks.
Easily distracted by extraneous stimuli.
W
Forgetful in daily activities.
es
2. Symptoms of hyper activity impulsivity:
*Runs about or climbs excessively.
ot
Has difficulty in playing or engaging
N
leisure activities quietly.
Talks excessively.
Answers before questions have been
completed.
*Difficulty in awaiting turn.
Interrupts on others games.
Diagnosis:
Complete medical evaluation with
emphasis on neurologic examination,
hearing and vision.
anst
VIJAYAM'S
*A psychiatric evaluation to assess
intellectual ability, academic achievement,
and potential learning disorder problem.
*Detailed Prenatal history and early
development history.
*Direct observation, obtain report from
School Teachers, and a reliable report
from the parents.
Treatment:
Pharmaco Therapy:
*Amphetamines (Dextroamphetamine,
Metamphetamine).
Tricyclic Antidepressants.
In
Antipsychotics.
h.
Serotonin specific reuptake inhibitors.
la
*Clonidine.
al
Psychological Therapy:
Behaviour modification techniques.
Cognitivebehaviour therapy.
*Social skilltraining.
Family education.
"Nursing Intervention:
* Develop a trusting relationship with the
child. Convey acceptance of the child.
Separate from the unacceptable
behaviour.
Safe environment, remove objects from
immediate area. Provide supervision for
potentially dangerous situations.
*Provide an environment that is as free of
distractions as possible.
Ensure the child's attention by calling his
name and establishing eye contact, before
instructions.
5.77
 MENTAL HEALTH NURSING
VIJAYAM'S

the patient to repeat instructions Commoner in upper socio-economic

Ask classes. Recent studies have failed to
before beginning a task.
confirm this finding.
*Establish goals that allow patient to
complete a part of the task, rewarding *Onset occurs before the age of 2
each step completion with a break for
years, though in some cases, the onset
physical activity.
may occur later in childhood.
Provide assistance on a one-to-one basis
*Such cases are called childhood onset
beginning with simple concrete
instructions. autism or childhood onset pervasive
developmental disorder.
*Gradually decrease the amount of
assistance givent to task performance. Clinical Features:

Often recognition for successful attempts The characteristic features are:

and positive reinforcement for attempt . Autism (nmarked impairment in reciprocal
social and interpersonal interaction):

In
made.
Provide quiet environment, self-contained * Absent social smile.
classrooms, and small group activities,
avoid over-stimulating places such as
h.
*Lack of eye-to-eye-contact.
la
cinema halls, bus stops and other crowded Lack of awareness of others existence
of feelings, treats people as furniture.
al

places.
*Help him to learn how to take hi turn, Lack of attachment to parents and
W

wait in line and follovw rules. absence of separation anxiety.

No or abnormal social play; prefers
es

solitary games
ot

5.11C. AUTISM
* Marked impairment in making friends.
*Lack ofimitative behaviour.
N

Definition:
*Absence of fear in presence of danger.
Infantile autism was described for the first
2. Marked impairment in language and non
time by Leo Kanner in 1943 as "autistic
verbal communication:
disturbance of affective contact'.
This syndrome has variously been described *Lack of verbal or facial response to
as autistic disorder, pervasive developmental sounds or voices; might be thought as
disorder, childhood autism, childhood psychosis deaf initially.
and pseudo defective psychosis. *In infancy, absence of communicative
Prevalence: sounds like babbling.
Absent or delayed speech (about half of
*This syndrome is more common (3-4
times) in males and has a prevalence rate autistic children never develop useful
speech).
of0.4-0.5 per 1000 population.

5.78
 t-5: Mental Disorders and NursingInterventions VIJAYAM'S

Abnormal specch patterns and content. |

Treatment:
Presence ofecholalia, perseveration, poor
1. Behaviour Therapy:
articulation and pronominal reversal
(1-you) is common. *Development ofa regular routine with as
few changes as possible.
Remote memory is usually good.
Abstract thinking is impaired. *Structured class room training, aiming at
learning new material and maintenance
Abnormal Behavionral Characteristics:
3. of acquired learning
Mannerisms. * Positive reinforcements to teach self-care
Stereotyped behaviours such as head - skills.
banging, body-spinning, hand - flicking,
lining up objects, rocking , clapping,
Speech therapy and/or sign language
teaching.
twirling, etc.
Ritualistic and compulsive behaviour.
*Behavioural techniques to encourage
interpersonal interactions.

In
Resistance to even the slightest change
2. Psychotherapy: Parental counselling and
in the environment.

Attachment may develop to inanimate h.

supportive psychotherapy can be very useful
in allaying parental anxiety and guilt, and
la
objects.
helping their active involvement in therapy.
However, overstimulation of child should be
al

Hyperkinesis is commonly associated.

avoided during treatment.
4. Mental Retardation: Only about 25% of all
W

children with autism have an 1Q ofmore than 3. Pharmacotherapy: Drug treatment can be
70.A large majority (more than 50%) of these used for treatment of autism and as well as
es

children have moderate to profound mental for treatment ofco-morbid epilepsy.

retardation. There appears to be a correlation
Haloperidol decreases dopamine levels in
ot

between severity of mental retardation, brain.

absence of speech and epilepsy in autism.
N

*Risperidone.
5. Other Features:
SSRIs, chlorpromazine, amphetamines.
*Many children with autism particularly
enjoy music. Imipramine, multi-vitamins and
triiodothyronine.
*Epilepsy is common in children with an
IQ of less than 50. Anticonvulsant medication.
Aetiology:

*EEG abnormalities.
Epilepsy.
*Ventricular dilatation on brain imaging.
Increased serotonin (5-HT) levels in brain.

ES5.79
 MENTAL HEALTH NURSING
VIJAYAM'S
evidence that they are over-anxious or
over - protective about the child They
5.11D. SEPARATIONAL ANXIETY should be persuaded to allow the child
DISORDER more autonomy.

Family Therapy: It is often needed

In these disorders, there is excessive anxiety when the child's disorder appears to be
concerning separation from those individuals to related to the family system. Treatment
whom the child is attached. is designed to promote healthy functioning

Clinical Features: of the family system.

An unrcalistic worry about possible harm

* Pharmacological Management:
Anxiolytic drugs such as diazepam may
befalling major attachment figures or
fears that they will leave and not return. be needed occasionally when anxiety is
extremely severe, but they should be used
Persistent reluctance or refusal to go to for short periods only.

In
sleep, without being near or next to a major
attachment figure.
Persistent inappropriate fear of being
h.
la
alone.
al

*Repeated nightmares. 5.11E. CONDUCT DISORDER

W

*Repeated occurence of physical

symptoms, for example, nausea, Conduct disorder is characterised by a
es

stomachache, headache etc. on Bpersistent and significant pattern of

occasions that involve separation from a conduct, in which the basic rights of
ot

major attachment figure, such as leaving others are violated or rules of society are
home to go to school. not followed.
N

*Excessive tantrums, crying and apathy *The diagnosis is only made when the
immediately following separation from a
conduct is far in excess of the routine
major attachment figure.
mischief of children and adolescents.
Treatment: The onset occurs much before 18 years
*Individual Counselling: This is often of age, usually even before puberty.
useful to give the child an opportunity to
understand the basis for anxiety and also
*The disorder is much more (about 5-10
times) common in males.
to teach the child some strategies for
anxiety management. *According to ICD-10, there are four
subtypes of conduct disorder.
Parental Counselling: Parental
counselling is needed when there is

5.80
Unit-5 Mental Disorders and Nursing Interventions VIJAYAM'S

Conduct disorder confined

to the family context

Unsocialised conduct disorder

Sub Types of Conduct
Disorder
Socialised conduct disorder

Oppositional defiantdisorder

Fig. 5.29

In the more common socialised (group) * Physical violence such as rape, fire
type of conduct disorder, the person setting, assault or breaking-in, use of

In
claims loyalty to his or her group. weaponS.
The unsocialised (solitary) type is a more
serious disorder with usually a severe
h.
Cruelty towards other people and
animals.
la
underlying psychopathology. Earlier, the
patients with conduct disorder were called
Treatment of Conduct Disorder:
al

juvenile delinquents. * Corrective institution.

W

Many patients of conduct disorder, Behavioural Therapy.

especially socialised (group) type, go on
es

Educational and psychotherapeutic

to improve markedly and may lead well
measures are usually employed for the
adjusted lives.
behaviour modification.
ot

Some others, especially those with severe

Drug treatment may be needed in
N

symptomatology, have a more chronic

presence of epilepsy (anticonvulsants),
course and may be diagnosed with hyperactivity (stimulant medication),
antisocial personality disorder (or traits) impulse control disorder and episodic
after 18 years of age.
aggressive behaviour (lithium,
Secondary Complications: carbamazepinc), and psychotic symptoms
(antipsychotics).
Substance misuse or dependence, unwanted
pregnancies, criminal record, suicidal and
homicidal behaviour.

Clinical Manifestations:
5:12LEEP DISORDER
Frequent lying.
Sleep can be regarded as a physiological1
Stealing or robbery.
reversible reduction of conscious awareness.
Running away from home and school.

5.81
 MENTAL HEALTH NURSING
VIJAYAM'S
Periodic movements in sleep.
Sleep disorders are divided into subtypes: age.
Old
-Dyssomnias
Alcohol and Drug Use:
aInsomnia Delirium tremens.
6. Hypersomnia Amphetamines or other stimulants
- schedule.
CDisorders of sleep wake
Chronic alcoholism.
2Parasomnias
Psychiatric Disorders:
a Stage IV disorders
(due to decreased need for
b. Other disorders Mania
sleep).

Sleep Disorders
Major depression (early morning
awakening or late insomnia).
Dysthymia or neurotic depression

In
Parasomnias (difficulty in initiating sleep or early
Dyssomnias
insomnia).
a. Insomnia a. Stage IV disorders
b. Other disorders
h.
Schizophrenia and other psychosis
la
b. Hypersomnia
c. Disorder of sleep (due to psychotic symptoms).
wake schedule
al

Anxiety disorder (difficulty in initiating

Fig. 5.30 sleep due to worrying thoughts).
W

Social Causes:
es

1. Dyssomnias: Financial loss.

a. Insomnia: Insomniarefers to disorder of Separation or divorce.
ot

initiationand maintenance of sleep. This

includes frequent awakening during the Death of spouse or a close relative.
N

night and early morning awakening. Retirement.

Causes: Stressful life situations.
Medical lnesses Behavioural Causes:
7
Any painful or uncomfortable illness. Naps during the day
Heart disease. Irregular sleeping hours.
Respiratory diseases.
3Lack of physical exercise.
Brain stem or hypothalamic lesions. Excessive intake of beverages in the
Delirium evening, for example, coffee.

Rheumatic and other musculoskeletal *Disturbing environment (heat, cold,

diseases. noise).

5.82
Unit-5 :: Menta Disorders and Nursing Interventions VIJAYAM'S

Mental
Illness

Behavioural Alcohol and

causes Causes drug and use
of
Dyssomnias

In
Social Psychiatric
causes disorders

h.
la
al

Fig. 5.31
W
es

Treatment:
A thorough medical and psychiatric assessment; polysomnography may be needed in
ot

some cases.

Treatment of underlying physical or psychiatric disorder.

N

Withdrawal of current medications, if any.

Transient insomnia can be treated initially with hypnotics.
Non-drug Treatment for Insomnia:
Progressive relaxation.
Autosuggestion.
Meditation, yoga.

Stimulus control therapy: Do not use the bed for reading or chatting -go to bed for sleep
only.

E5.83
 MENTAL HEALTH NURSING
VIJAYAM'S
Sleep Hygiene:

111

EXERCISE
+|
REGULAR
+ Zzzz

SCHEDUJLE

Fig. 5.32 Sleep Hygiene Methods

In
*Regular, daily physical exercises in the evening.
h.
Avoid fluid intake and heavy meals just before bedtime.
la
*Avoid caffeine intake (for example, tea, coffee, cola drinks) before sleeping
hours.
al

*Avoid reading or watching television while in bed.

W

Back rubs, warm milk and relaxation exercises.

Sleep inacomfortableenvironment.
es

b. Hypersomnia: Hypersomnia is known as Disorder of Excessive Somnolence (DOES). It

includes excessive daytime sleepiness, sleep attacks during daytime, sleep drunkenness
ot

(person needs much more time to awaken, and during this period he is confused or disoriented).
N

Causes
i Narcolepsy: Excessive daytime sleepiness characterized by:
Ti,

Sleep attacks.
*Cataplexy -Sudden decrease or loss of (sleep paralysis) muscle tone, often generalized
and may lead on to sleep.
*Sleep paralysis - It occurs either at awakening in morning or at sleep onset. The
person is conscious but unable to move his body.
* Hypnagogic hallucinations."
Hl
Ai. Sleep apnea: Repeated episodes of apnea during sleep.
ii. Kleine- Levin syndrom: Periodic episodes of hypersomnia.

R 5.84
 Mental Disorders and Nursing Interventions VIJAYAM'S
nit-5
cDisorder of Sleep- wake schedule: /h/0ther Sleep Disorders:
The person with this disorder is not able
to sleep when he wishes to, although at
Nocturnal angina.
other time he is able to sleep adequately. Nocturnal asthma.
Causes: Nocturnal seizures.
*Workshifts. Sleep paralysis.
*Unusual sleep phases.

2. Parasommas: 5.13. EATING DISORDERS

a. Stage IV sleep Disorders:
Anorexia Nervosa:
Sleep walking (somnambulism).
* Anorexia nervosa is characterized by
Night terrors. highly specific behavioural and

In
Sleep related enuresis. psychopathological symptoms and
Bruxism (tooth-grinding). h.
significant somatic signs.
*Majority are females.
la
Sleep talking(somniloquy)
* Onset is during adolescence.
al
W
es
ot
N

Fig. 5.33 Feeling of becoming Faut

5.85 rsnens

VJAYAM'S
Psychopathological Feature:
* The dread of fatness.
Weightphobia.
* A drive for thinness.
Etiology:
A disturbance of body image, a struggle
for control and a sense of identify are
important.
*Traits of low self - esteem.
*Perfectionism.
*Disturbance in family relationships.
MENTAL HEALTH NURSING
Diagnosis:
Complete physical examination.
*Laboratory tests to rule out endocrine,
metabolic and central nervous system
abnormalities; cancer; malabsorption
syndrome and other disorders that cause
physical wasting.
Complete blood testing hemoglobin
levels, platelet count, cholesterol level,
total protein, sodium, potassium, chloride,
calcium and fasting blood glucose and
serum amylase levels and blood urea
nitrogen.

ECG readings irregular.

In
* Over-protection.
*Family members having an unusual Differential diagnosis to rule out other
interest in food and physical appearance. h.
psychiatric disorders like substance abuse,
anxiety disorder, body dysmorphic
la
Clinical Features:
disorder, mood disorders, schizophrenia.
al

*Intense fear of becoming obese.

*Based on ICD10 criteria.
This fear does not decrease even if the
W

person loses weight grossly and becomes

Treatment Modalities:
very thin. Pharmacotherapy:
es

* The pursuit of thinness may take several * Neuroleptics.

forms. Patients generally eat little and set
ot

themselves daily calorie limits. *Appetite stimulants.

Antidepressants.
N

Some try to achieve weight loss by

inducing vomiting, excessive exercise, and Psychological Therapies:
misusing laxatives. *Individual Psychotherapy.
Other Signs and Symptoms: *Behaviouraltherapy.
*Vomiting and abuse oflaxatives may lead
to a variety of electrolyte disturbances,
*Cognitive behaviour therapy.
the most serious being hypokalemia. Family therapy.
Hormonal abnormalities also may be Nursing Interventions:
seen. *
Maintain a strict intake and output chart.
*Psychological findings Preoccupation
Monitor status of skin and oral mucous
with body size, distorted body image, membranes.
description of herself as fat.

5.86
 VIJAYAM'S
Unit-5 Mental Disorders and Nursing Interventions

Encourage the patient to verbalize feclings Bulimia Nervosa:

of fear and anxiety related to
achievement, family relationships and
intense need for independence.
Encourage family to participate in
education regarding connection between
family process and the patient's disorder.
Avoid discussions that focus on food and
weight.
Short-term management is focused on
ensuring weight gain and correcting
Bulimia nervosa is characterized by episodes
of binge-eating föllowed by feelings of guilt,
humiliation, depression, and self-condemnation.
frequent binging severe cases,
Includes
can have several binge episodes in one
day.
*Involves recurrent use of compensatory
measures to prevent weight gain (such
as self-induced vomiting, diuretic or
laxative use, dieting, fasting, or a

nutritional deficiencies. Maintaining combination of these measures.

normal weight and preventing relapses

In
are long-term goals to be achieved.
Hospitalization is usually required and
successful treatment depends on good
nursing care, with clear aims and
h.
la
understanding on the part of the patient
al

as well as the nurse.

Eating must be supervised by the nurse
W

and a balanced diet of at least 3000

calories should be provided in 24 hours.
es

*In the early stages oftreatment, it is best

for the patient to remain in bed in a single
ot

room while the nurse maintains close

observation. The goal should be to
N

achieve a weight gain of 0.5 to kg per

1

week.
Fig. 5.34 Inducing Self Vomiting
*Weight should be checked regularly.
Monitor serum electrolyte levels and signs
and symptoms like amenorrhea, Etiology:
constipation, hypoglycemia, hypotension,
etc. *More common in first- degree, biological
relatives of people with bulimia.
Control vomiting by making the bathroom
inaccessible for at least 2 hours after *Specific area of chromosome 10p linked
food. to families with history of bulimia.

In extreme cases, when the patient * Possible role of altered serotonin levels
refuses to eat and comply with the in brain.
treatment, gavage feedings may need to
be instituted.

RERG5.87
VIJAYAM'S MENTAL HEALTH NURSING

*Society's emphasis on appearance and Abdominal and epigastric pain.

thinness. Amenorrhea.
Family disturbances or conflict. Fluid and electrolyte imbalances.
*Sexual abuse. Perfectionism.
Learncd maladaptive behaviour. Distorted body image.
Struggle for control or self-identity. Exaggerated sense of guilt.
Clinical Features: Feelings ofalienation.
*Persistent sore throat, heartburn. Poor impulse control.
Callused or scarring on back of hands and Low tolerance for frustration.
knuckles.
Peculiar eating habits or rituals.
*Tooth staining or discolouration, loss of Excessive exercise regimen.
dental enamel, and increased dental
caries. Withdrawal from friends and usual

In
activities.

h.
.*Frequent weighing.
Complications:
la
*Gastric rupture during periods of binge
al

eating.
Dental caries, erosion of tooth enamel,
W

parotitis, and gum infections.

es

Dehydration or electrolyte imbalances.

Chronic, irregular bowel movements and
ot

constipation from laxative use.

Increased risk of suicide and
N

psychoactive substance abuse.

Fig. 5.35 Tooth Staining and

Diagnosis:
Discoloration
History of cating amount of food larger
than what most people would eat.
During binge-eating episodes, sense of
.
lack of control.
*Thin, normal, or slightly overweight
appearance, with history of frequent
weight fluctuations.
Medical evaluation to rule out upper
gastrointestinal disorder.
Psychological evaluation and Beck
depression Inventory.
History.
*Laboratory tests (Serum electrolytes,
blood glucose, baseline ECG).
Confirmed, ifICD 10 criteriamet.

5.88
Unit-5:: Men
ental Disorders and Nursing Interventions VIJAYAM'S

Treatment Modalities: Explain risks of laxative, emetic, and

Psychotherapy. diuretic abuse.
TCAs or SSRIs." Provide assertiveness training.
Self-help groups. * Assess and monitor patient's suicide
Hospitalization. potential.

Nursing Interventions:
Engage patientin therapeutic alliance to
obtain commitment to treatment.
Establish contract with patient
that5.SEXUALDISORDERS
specities amount and type of food she5SEXUAL
must eat at cach meal.
atime limit for each meal. In ICD10 gender identity disorders, disorders
Set
of sexual preference and sexual development
Identify patient's elimination patterns. and orientation disorders are listed under

In
Teach patient to keepjournal to monitor disorders of Adult personality and Behavior (F6),
high-risk situations that cue binging and
purging behaviours. h.
while sexual dysfunctions are listed undér
behavioural syndromes associated with
la
Encourage patient to recognize and physiological Disturbances and physical Factors
verbalize her feelings about her eating | (F5).
al

behaviour.
W
es
ot
N

o Fig. 5.36 Sexual Problems

5.89

VJAYAM'S
Classification:
Gender identity disorders.
Psychological and behavioural disorders
associated withsexual development and
maturation.
Disorders of sexual preference
paraphilias).
Sexual dysfunctions.
Gender Identity Disorders (F6);
In these disorders, the sense of one's
masculinity or femininity is disturbed. They
include;
a. Transsexualism.
b. Gender identity disorder of childhood.
c. Dual-role transvestism.
d. Intersexuality.
Transsexualism: In this, there is a persistent
and Significant sense of discomfort regarding
al
one's anatomic sex and a feeling that it is
W
inappropriate to one's perceived gender. The
person will be preoccupied with the wish to
es
get rid of one's genitals and secondary sex
characteristics and to adopt the sex
characteristics of the other sex.
ot
Treatment:
N
*Counselling to help the individual reconcile
with the anatomic seX.
Sex change to the desired gender (sex
reassignment surgery (SRS) in selected
cases.
Gender identity disorder of childhgod:
Thisis adisorder similar to transsexualism, b.
with a very early age of onset.
cDual-role transvestism: It is characterizedC.
by wearing clothes of the opposite sex in
order to enjoy the temporary experience of
membership of the opposite sex but without
any desire for permanent sex change.
B 5.90
MENTAL HEALTH NURSING
dIntersexuality: The patients have gross
natomical or physiological features of the
other sex. For example, pseudoherma.
phroditism, Turner's syndrome, congenital
adrenal hypoplasia.
Psychological and Behavioural Disorders
Associated with sexual Development and
Maturation (F6):
Homosexuality: In this, sexual relationships
aremaintained between persons of the same
sex. Female homosexuals are called
lesbians' and male homosexuals are called
gay
In
Treatment:
Behaviour Therapy: Aversion therapy,
h.covert sensitization,
desensitization.
systematic
la
Supportive psychotherapy.
*Psychoanalytic psychotherapy.
Disorders of Sexual Preference (ICD10-F6)
orParaphilias (DSMV):
occurs
Inparaphilias, sexual arousal
persistently and significantly in response to
objects, which are not a part of normal sexual
arousal. These disorders include:
a. Fetishism: Sexual arousal occurs with a
non-living object which is usually intimately
associated with the human body. The fetish
object may include bras, underpants, shoes,
gloves, etc.
Transvestism: Sexual arousal occurs by
wearing clothes of the opposite sex.
Sexual Sadism: The person is sexually
aroused by physical and psychological
humiliation, suffering or injury of the sexual
partner.
 Mental
Unit-5: Me Disorders and Nursing Interventions
ual Masochism: Here, the person is ePremature.ejaculation:
cexually arousedby physical
or psychological
humiliation or injury intlicted on selfby
others.
Ehibitionism: In this, the person is sexually
Non-organic
aroused by the exposure of one's genitalia d: spasm of lowervaginismus: An involuntary
to an unsuspecting stranger.
Voyeurisn: This is a persistent orrecurrente Non-organic dyspareunia:.Pain
Tendency to observe unsuspecting persons
naked (usually of the other sex) and engaged
in sexual activity.
Frotteuris: This is a persistent or recurrent
involvement in the act of touching and
rubbing
against an unsuspecting, non-consenting
person.
Jh Pedophilia: It is characterized by persistent
or recurrent involvement ofan adult in sexual
activity with prepubertal children.
iZoophilia(Beastiality):Involving in sexual
activity with animals.
Other Paraphilias: Sexual arousal occurs
with urine, feces,enemas, etc.
W
Treatment:
es
*Behaviour therapy: Aversion therapy.
Psychoanalysis.
ot
Drug therapy: Antipsychoties have been
used for severe aggression associated
N
with paraphilias
Sexual Dysfunctions
(F5)
Sexual dysfunction is a significant disturbance
in the sexual response cycle, which is not due to
an underlying organic cause.
The common dysfunctions are:
atrigidity: Absence of desire for sexual
activity
mpotence: This disorder is characterized
by an inability to have or sustain penile
erection till the completion of satisfactory
Sexual activity.
5.91 R
VIJAYAM'S
Ejaculation before
the completion of satisfactory sexual activity
for both partners.
1/3rd of vagina, Interfering
with coitus.
in the
genital area of either male or female during
coitus.
Treatment:
*Psychoanalysis.
*Hypnosis.
* Group psychotherapy.
*Behaviourtherapy.
In
Nursing Intervention for Patient with
h.
Sexual Disorder:
Assess patient's sexual history and
la
previous 1level of satisfaction in sexual
al
relationships; also assess patient's
perception of the problenm.
*Note cultural, social, ethnic, racial and
religious factors that may contribute to
conflicts regarding variant sexual
practices.
JAssess for any medications which might
be affecting libido.
Provide information regarding sexuality
and sexual functioning, correct any
misconceptions if necessary. Teach
patient that sexuality is a normal human
response and that it involves complex
inter-relationships among one's self-
concept, body image, family and cultural
influences.
Both the patient and his/her partner may
need additional assistance if problems in
sexual relationship are severe or remain
unresolved.
 MENTA HEALTH NURSING
VIJAYAM'S
additional counselling or sex therapy if required.
Refer fortherapist as necessary in plan of behaviour modification
to help decrease varian
variant
Assist
behaviour.
hiphl
In all cascs, an accepting and non -judgemental attitude on the part of the nurse is
essential for successful resolution of these problems as these are highly sensitive issues and
may be causing significant distress to the patient.

5.15. Nursing Management: Nursing process and process recording in caring for patients with
and
various psychiatric disorders are detailed in the pre paras and the suggestions, indications
other norms are to be followed scrupulously by the nurse.

COverview

In
Pathophysiology of human behaviour involves three things. They are knowing
h.
(cognition) feeling (affection) and doing (conation).
la
Continuum of behaviour is in between normal (Adaptive response) or abnormal
(maladaptive responses).
al

Etiological theories are Biological factors, psychologicalfactors and socio-cultural

W

factors.
Classification of mental disorder can be done by using ICD 10 (International
-
es

Classification of Disease), DSM IV (Diagnostic Statistical Manual) and followed by

-

Indian classification.
ot

Disorders of thoughs are delusions, obsessions. Disorders of motor activity are

posturing, Negativism, Echopraxia, Ecolalia.
N

Disorders of perception are illusions and Hallucination, Disorders of mood are apathy,
blant, labile and emotional incontinence. Disorders of speech are palilalia, Echolalia.
Disorders of memory are confabulation, immediate, recent and remote memory. Disorders
of judgement and insight composed of 6 point scale.
Prognosis of mental illness is influenced by Type and duration of problem, person
strength and weakness and support system. Early Treatment and Interventions formenta
illness can improve lives.
Personality is a quality ofindividual. Types inchuded are paranoid personality schizoid
schizotypal, Anti social, Border line, Histronic personality and Narcissistic personaliy
disorder
In Delirium cognitive impairment and disturbances of consciousness are seen. Main
symptoms are like changes in orientation, mood, language. Treatment includes physica
and psycho therapy and medications.

5.92