Case Presentation

CASE PRESENTATION
ON
BIPOLAR AFFECTIVE
DISORDER
SUBMITTED TO: SUBMITTED BY:
Mrs. Mr.MAHANTESH.K
1st Yr MSc Nursing

EAST WEST COLLEGE OF NURSING EAST WEST COLLEGE OF NURSING
BANGALORE. BANGLORE
PATIENT PROFILE
Name of patient : Mr. Santosh Mane.
Age : 40 years
Date of Admission : 26/01/10
Marital Status : Married & divorced after 6 months.
Education : 10th Standard
Occupation : Farmer
Income : Rs.200/-
Address : #35, Neharu nagar Belgaum.
Ward : open psychiatric ward.

Religion : Hindu
Socio Economic Status: Low Income Group
Diagnosis : BPAD mania
INFORMANT: Client’s brother is the informant. He is staying along with patient from birth
itself. He had good intellectual and observation ability. He had moderate degree of concern
regarding the patient.
PRESENTING CHIEF COMPLAINTS
According to patient he had no problem for admitting him.
According to informant, patient had reduced sleep, increased physical activity, using abusive
words, assaultive behavior, talking with him self and aloud. The onset of illness was one month
before. Precipitating and aggravating factor is reduced sleep.
HISTORY OF PRESENT ILLNESS
This is the 5th episode of illness. Patient was last well before one month. Symptoms of illness
was reduced sleep, increased talk and talking aloud, using abusive words, increased
psychomotor activity, poor personal hygiene, increased food intake, assaultive behavior etc. On
examination he had persecutory delusion, grandiose delusion, poor dry compulsion and mood
labile. On admission Inj.Phenergan 25 mg 1M and Inj. Haloperiol 5mg 1M stat ordered and
administered. He had no history of head injury before illness.
PAST PSYCHIATRIC & MEDICAL HISTORY
Client had history of similar illness in past. This disease was started on his 18 year of age
and was treated in a private hospital. No treatment history available and was admitted here on
20/1/98 and discharge on 12/2/98. Other episodes are:
2nd episode -> 10/3/01 – 21/4/01
3rd Episode -> 28/3/05 – 29/5/05
4th episode - > 6/2/07 – 1/3/07
On each admission he had got Inj.Phenergan and Inj.Serenase and he was on T.clozapine
25 mg HS & T.valproate 200mg bd. But he had poor drug complaints. He had history of
cigarette smoking before 2 years and now he had no habit of smoking. He had no history of any
serious medical illness like CAD, HTN, DM, asthma etc and surgical history of any head injury,
trauma etc.
TREATMENT HISTORY
Client was treated in a private hospital first. No treatment history available. After the
treatment from NIMHANS he was on
Tab.clozapine 25 mg HS
Tab. Valproate 200mg tds
Tab. Diazepam 2mg ½ HS
He had no habit of taking medicine at correct time (poor drug complaints).
FAMILY HISTORY
Client’s father and mother died because of old age and CA stomach respectively. He was
married and divorced after 6 months. He had no children. Now he is living with his younger
brother. He had positive family history of mental illness. His younger brother had mental illness
and he was committed suicide on his 18 years of age.
FAMILY TREE
KEY
: MALE : MALE DIED
: FEMALE
: CLIENT : FEMALE DIED
PERSONAL HISTORY
Perinatal history
No history of any febrile illness, medications, drugs, alcohol use, trauma to abdomen and
any physical or psychiatric illness during pregnancy. He was a wanted child. No history about
breast feeding and weaning available. The delivery was normal vaginal delivery. He had history
of measles during prenatal period. He had no birth defects.
Childhood history
Patient was brought up by his mother and father. No history available regarding breast
feeding and weaning. No history of maternal deprivation. He had temper tantrum during his
childhood period.
Educational history
Age of beginning school age on 6 years and was studied up to 6 th standard. He had good
relationship with peers and teachers. He had learning problems and absenteeism in school. He
terminated his study because he was poor in study and financial problems.
Play history: Client was very happy to engage in play. He had good relationship with peer
groups.
Occupational history
Client started for going to work at his 15 year of life. He was a farmer. He had good job
satisfaction. He head good relationship with authority. But easily become angry. His present
income is around Rs.200/-
Sexual & Marital History
Client was married and divorced after 6 months because of his illness. He had no
extramarital and pre marital sexual relationship. He had no gender identity disorder. The
duration of marriage was up to 6 months. Marriage was arranged by parents with consent.
Premorbid personality: Cyclothymic personality
Interpersonal relationship
i. He had good IPR with family members, friends and superiors. He was introverted.
ii. Use of leisure time: he had no specific hobbies and interest.
iii. He had good attitude towards work. He had good decision making skill. He was not take
responsibilities effectively.
iv. Family life – Not interested in family life. He was prone to anxiety and poor reaction to
stressful life events.
v. Habit – He had no habit of day dreaming. He had no specific food fads and habits.
Environmental history
House is tiled. Disposal of waste is through dumping and open drainage.
PHYSICAL & PHYSIOLOGIC ASSESSMENT

Vital Signs: Temperature – Normal
Pulse – 72/mt
Respiration – 20/mt
BP – 120/80 mm of Hg
General appearance: Poor hygiene and grooming. Over dressed, hairs are spangling, not taken
bath for 1 week. Hyperactive, steady giant and erect posture.
BODY PARTS OBSERVATION
Skin Color is normal. Dry skin

Dry Texture. Good Teerger, no edema and lecious
Pink in color. Normal shape. Capillary refill good
Equal distribution of hair. No presence of aloperia and dandruff
Nails
Normal Size
Hair & Scalp
No puffiness, moon face etc
Normal visual a . no double vision, ocular movements are not
Head & Skull
normal. No infection & discharges.
Face
No infections and discharge. Good hearing capacity. No ringing in the
Eye & vision
ears. He had not using hearing aids.
Had no frequent colds, no DNS and injury to nose or face
Ears
No halitosis, gum bleeding & hyperplasie, sore throat etc
Good range of motion. No pain and neck rigidity. Ho thyroid
Nose
enlargement.
Mouth and throat
Normal size and shape.
Neck
Chest expansion is equal and symmetric
Pale color. Soft and distended. No tenderness.
Thorax and chest
Good range of motion. No complaints of pain and stiffness of joints.
Abdomen
No deformities. Good range of motion. No complaints of pain and
Upper extremities
stiffness of joints.
Lower extremities
No specific deformities or abnormalities found during physical
examination. He had poor personal care and appearance. He was worn
Interference
shirts and 2 pants at a time during admission. No specific medical
disorders find out.
MENTAL STATUS EXAMINATION

General appearance
Facial expression – apathetic
Posture – stiff
Mannerism – absent
Dress – overdressed
Hygiene – very poor
Motor disturbance: present (hyperactivity and negativism present. Sometime patient will do
exactly opposite when asking to do something)
Disorder of thought
A. Form of thought
a) Circumstantialities present (Patient always giving answer after telling some related
topics)
b) Tangential thinking (sometimes patient will fails to answer to question after telling
related topics).
c) Ambivalence present ( Patient is interacting effectively sometimes and then he
become very angry towards me)
B. Disorder of content of thought.
a) Delusion present -> grandiosity (Patient says “ I am the God”)
-> Persecution (Patient says “Somebody is trying to harm me”)
b) Obsession – Present
c) Phobia – Present ( Fear of death)
d) Preoccupation – absent
e) Fantasy – absent
Remark -> delusion of grandiosity and persecution and phobia present
Disorder of speech
1. Pressure of speech – accelerated
2. Flight of ideas – present
3. Thought block – absent
4. Intensity – loud
5. Pitch – abnormal variation
6. Speed – increased
7. Manner – inappropriate
8. Reaction time - fast
Disorder of perception
1. Illusion – absent
2. Hallucination – present ( hearing voices )
Remarks – auditory hallucinations present
Disorder of affect
1. Affect – inappropriate
Subjective – Patient says “I am Happy”
Objective – facial expression reveals sadness
2. Pleasurable affect – present i.e, euphoric
3. Un pleasurable affect – present
Remarks -> in appropriate affect, euphoric and moor swing present
Disorder of memory
a. Immediate memory
Q: what you have for your breakfast?
A: Tea
b. Recent memory
Q: when did you slept during night?
A: Not answering (Looking sharply)
c. Remote memory
Q: Where did you studied/
A: Not Answering
Remarks: Patient is not responding, so it can not be assessed.
Disorder of orientation
a. Orientation to time
Q: what is the time now? (10:00AM)
A: afternoon
b. Orientation to place
Q: which place is this?
A: NIMHANS
c. Orientation to person
Q: who am I?
A: you are coming for disturbing me
Remark: Oriented to time, place and person
Insight
Q: How are you?
A: nothing. You are coming for disturb me?
Q: for what reason you came here?
A: I don’t know.
Remark: insight grade I.
Disorder of concentration
Q: Count from 100 to 10 by subtracting 10 to each
A: 100, 90, 91, 92, 93 …
Q: Count from 1 to 10
A: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12…
Remark: Concentration is impaired
Disorder of judgment
Q: what you will do when you are in a house on firing
A: Oh, I will look and see (laughing)
Remark: Judgment is impaired.
Intelligence
Q: Who is the president of India
A: I don’t know
Q: add 19 with 49
A: 68
Q: subtract 23 from 64
A: 41
Remark: Intelligence is intact.
Abstract thinking
Proverb
Q: tell me the meaning of “barking dog seldom bite”
A: not responding (looking sharply)
Similarities
Q: what is the similarity between a table and a bed?
A: not responding (become angry)
Differences
Q: what is the difference between a apple and orange
A: apple is soft and orange is juice
Remark: abstract thinking is not elicited effectively
Disorder of sleep
Present (complaints of reduced sleep since 1 week)
Summary: Eye to eye contact was developed from the beginning itself.
General remarks
Client had delusion of grandiosity and delusion of persecution. He also had disturbance in
speech, affect and thought. He is hyperactive, over talkative and easily become angry. He had
impaired concentration and abstract thinking. His orientation is not affected. He had reduced
sleep.
Diagnosis – Mania
Investigation – Nil
BIPOLAR AFFECTIVE DISORDER

INTRODUCTION
Mood disorders are the most frequent serious mental disorder. This group of disorder is
characterized by a disturbance of mood, accompanied by a full or partial manic or depressive
syndrome that is not due to any other physical or mental disorders. The term abnormal mood is
used when it is accompanied by physiological psychomotor and cognitive changes or its
duration and severity exceed normal expectations.
DEFINITION
Affective disorders are characterized by a severe disturbance of mood manifested as
elation or excitement and depression. Affective disorders are illness in which mood change is
relatively persistent and is associated with characteristic changes in thinking, attitude and
behavior.
Classification of mood disorder

The classification of mood disorders in an area which is fraught with multiple controversies.
According to ICD – 10, the mood disorders are classified as follows.
1. F30 – Manic Episode
2. F31 – Bipolar mood (affective) disorder
3. F32 – depressive episode
4. F33 – Recurrent depressive episode
5. F34 – Persistent mood disorder (including cyclothymia and dysthymia)
6. F38 – other mood disorders (including mixed affective episode and recurrent brief
depressive disorders)
7. F39 – Unspecified mood disorders
2. Unipolar & Bipolar mood disorder
3. By symptom culture
a) Anxious depressive
b) Psychotic depression
c) Hostile depressive
d) Younger depressive with personality disorders
4. psychotic Versus Neurotic
5. Endogenous Versus Exogenous ( reactive)
6. Mood – congruent Versus mood – in congruent psychotic depression
7. physiological classification (Pollit ) Type S and Type J
8. Bio chemical classification Type 1 & Type 2.
9. Melancholic / Nonmelancholic psychotic depression
10. Other subtypes.
i. Acute versus chronic
ii. Agitated or retarded
iii. Reactive or endomorphagenic
iv. Masked or apparent depression
v. Neurasthenic or paranoil depression
vi. Early life versus late life (involvement)
vii. Seasonal or non seasonal
viii. Typical / atypical
ix. Others: milel versus severe, depressive opectrum disorder Vs pure depressive.
Somatogenic Vs psychogenic etc
Epidemiology
1. Life time prevalence 0.6 – 2%
2. Male: Female ratio equal
3. Age at onset late teens to early 20s
4. Social class slight increase in upper class
5. Race no difference
6. Family history positive and genetically linked
7. In relatives
a) % major depression 15%
b) % of BPAD 8%
8. Life events unknown
9. Marital status married people have lesser episodes than
unmarried. Widowhood increases the episode of MDF
10. Professionals 4 times higher in Professionals
ETIOLOGY
Book picture Patient picture
1. Genetic predisposition Genetic predisposition (his
15% of brothers, sisters, parents and children of younger brother had mental
manic depressive psychosis were also suffering from illness and was committed
this ail , whereas expectancy in the general suicide)
population was 0.5%. Identical twins develop a
similar type of MDP reactions. Neurophysiologic factors
2. Neurophysiologic factors: imbalance in excitatory
and inhibitory process may predispose MDP.
Excitatory functions may cause mania and inhibitory
functions may cause depression
3. Bio chemical factors: increased or decreased
catecholamine may cause mania or depression
respectively. There may be sleep disturbance also.
4. Psychological and interperso9nal factors
predisposing family and personality factors : mood
swings in parents will lead to maladaptive learning in Severe stress (death of mother
children and divorce from wife)
5. Severe stress : Patient who have experienced severe Feeling of helplessness & use of
stress in their life time may be predispose to MDP defenses
6. Feeling of hopelessness and use of defenses
7. Psychodynamics: psychoanalytical theory explains Socio cultural factors.

that a child is placed in a dependent position and ego
development is disturbed. The child develops
punitive superego or anger turned inward or into
depression
8. Social – cultural factors
BIPOLAR DISORDER
It has 2 poles, manic episode and depressive episode.
Manic episode
The essential features is a distinct period when the predominant mood is either elevated,
expansive or irritable and there are associated symptoms such as hyperactivity, pressure of
speech, flight of ideas, inflated self – esteem, decreased need for sleep, distractability and
excessive involvement in activities that have potential for painful consequences which is not
recognized.
Classification
Emil Kraepelin described the following types of mania.
a. Hypomania
This is a mild condition, but it may be long lasting. It is characterized by predominant
euphoria, over activity and disinhibition. Patient may not come for treatment in this
phase.
b. Acute mania
This is severe condition, showing transient grandiose delusions, a labile mood and
sometimes incoherent talk.
c. Delusional mania
Characterized by less excitement, more persistent grandiose delusions and even
occasional hallucinations.
d. Delirious mania
There is frenzied over activity, labile mood (depression, panic to excitement variable
delusions, vivid hallucinations, disorientation for time and place together with
dehydration and lack of drinking and eating
e. Secondary mania
Due to drugs (tricycle anti depressant , MAO inhibitors, steroids, amphetamines, L-dopa
& INH) organic metal disorders, multiple sclerosis etc.
f. Chronic mania
g. Triple classification
CLINICAL FEATURES

1. Mood is usually elevated and may be euphoric 1. Mood – elated, euphoric and
usually good, cheerful or high, expansive, irritable
irritable or infectious (makes the observer laugh ) - Mood swing present
or labile (common bipolar disorder) - Easily become angry
2. Psychomotor activity -> often increased. It is 2. Increased psychomotor
reflected from planning of and participation in activity.
multiple activities, increased sociality and
intrusive domineering or demanding nature of
interactions. Often the activities are disorganized,
flamboyant or leizarree behavior etc
3. Speech -> speech is typically loud, rapid, difficult 3. Speech -> flight of ideas,
to interrupt (i.e,. pressure of speech ). Often it is loud, rapid and difficult to
full of jokes, funs, plays on words or amusing interpret
irrelevances.
4. Thinking: there is flight of ideas, loosening of 4. Flight of ideas present
association and incoherence may be present.
Ideas or delusion of grandiosity persecution or
self reference may occur.
5. Attention: distractibility is usually present and 5. Distractibility present
manifests itself as rapid changes in speech or
activity as a result of responding to various
irrelevant external stimuli such as background
noise or signs or pictures on the wall.
6. Sleep: almost invariably there is decreased need 6. Reduced need for sleep
for sleep; the individual awakens several hours
before the usual time, full of energy.
7. Self worth: there is self esteem, ranging from 7. Increased self esteem
uncritical self confidence to marked delusional
grandiosity.
8. Lability of mood: euphoric mood may shift to 8. Euphoric mood shift to
anger or depression, expression by tearfulness,
suicidal threats, lasting movements, hours or anger.
rarely days. There may be mixed symptoms.
Hallucinations may rarely occur.
9. Libido: it is often increased and make a patient
prone to sexual promiscuity, extra marital affairs,
illegitimate , pregnancies or ever rape.
DIAGNOSIS
A reliable detailed history, MSE and clinical - Detailed history
response usually with full remission help in diagnosing - Mental status examination
an affective disorder.
MANAGEMENT
The developing a treatment plan for a patient with a mood disorder, the factors , which need
consideration are – patients’ lethality, resources, past treatment successes and failures and the
specific diagnosis.
A. Hospitalization A. Hospitalization
The main indication for hospitalization are : Indication for
i. Depression hospitalization was
Risk for suicidal or homicide abnormal behavior.
Depressive stupor
Depression with agitation or panic attack
Presence of concomitant physical or other
psychological problems
Non – responders to drugs.
Poor support system
ii. Mania
Abnormal behavior
Delirious mania
B. Medication
a) Depression
Tricyclic (heterocyclic) antidepressants B. Medication
MAO inhibitors
Combined antidepressants
Tetracyclines and newer antipressants
b) Mania
Neuroleptic (Phenothazines and
butyrophenones)
Lithium carbonate T. clozapine 25 mg 1-0-3
Carbonazepine T. Sodium valproate 300 mg
Clonazepam -> patient not respond to litiium 2HS
Other drugs -> Ex: Sodium valproate, T. Lorazepam 2mg
calcium channel blockers, amoxapine, Inj. Serenase 5mg 1M SOS
phenytoin, flupenthixol. Inj Phenergan 25mg 1M SOS
C. Electroconvulsive therapy (ECT)

Main indications are :
Depressive with suicidal tendancies or in
stupor
Patient who do not respond to conventional
drugs.
Those with rapid cycles of mania and
depression
Those patients who can not tolerate drugs or
where drugs are contraindicated
D. Sleep deprivation (in depressive)
Total sleep deprivation causes rapid clinical
improvement in about 30% cases.
E. High intensity light
F. Psychotherapy & behavior therapy
Interpersonal therapy (IPT)
Cognitive behavior therapy (CBT)
Behavioral therapy - Psychotherapy
Short term psychodynamic psychotherapies.
G. Transcranial magnetic stimulation (TMS)
It is a non – invasive means of stimulating nerve
cells in superficial areas of brain and has been tried
in a variety of psychiatric and neurological
disorders for treatment and diagnosis.
LIST OF NURSING DIAGNOSIS
1. Fatigue related to hyperactivity secondary to manic state of bipolar disorder

2. Disturbed sleep pattern related to hyperactivity secondary to manic state of bipolar
disorder
3. Impaired verbal communication related to inability to concentrate secondary to
depression.
4. Imbalanced nutrition, less than body requirement related to anorexia secondary to manic.
5. Self care deficit, dressing & grooming related to mixed episodes of depressed mood and
manic mood as evidenced by over dressing and poor hygiene.
6. Ineffective individual coping related to poor impulse control secondary to manic disorder.
7. Risk for injury related to hyperactivity.
8. Risk for violence related to hyperactivity loosening of association and manic episode.
9. Knowledge deficit regarding the importance of taking medication regularly.
10. Non compliance related to refusal to take prescribed psychotropic medication.
11. Social isolation related to fear of rejection secondary to low self – concept.
PSYCHO EDUCATION & REHABILITATION
Explained the patient regarding various measures to do at home
DIET
 Explained him about the importance of balanced diet & explained to him about the diet
pattern which should be followed
 Explained to his relatives to give diet according to the choice of the patient and if he is
unable to take food help him to eat
DRUG
 Explain to him and to his family members regarding the importance of drug therapy
 Explained to the relatives about the drug how often it should be given and about the
action of each drug
 Explain to him and to his relatives not to stop the drug without the prescription of doctor
and to continue drug as prescribed by doctors.
FAMILY SUPPORT
 Explain to family members about the king of illness the patient is suffering from and
about his social productive abilities
 Educate the relatives to persuade the patient to maintain his personal hygiene, take diet,
participate in daily care activities and to accept the treatment
 Explain about the types of jobs the client can perform
 Encouraged the relatives to keep supportive the patient and not to over protect and show
rejection towards patient
SOCIALIZATION
 Encourage him to go day care center and to interact with others

 Allowed him to sit with others and encouraged him to talk to neighbor patients
 Encourage his good performance in the group
 Encourage him to spend more time with others
FOLLOW UP
Explain to the patient that the disease can’t be cured completely. Only we have to control this.
So you must continue drugs as prescribed by doctor and come for follow up regularly as
prescribed by doctor.
BIBLIOGRAPHY
1. Shives LR. “Basic concept of psychiatric mental health nursing. 6 th edition. Philadelphia;
Lippincott: 2005.
2. Ahuja N. “Text book of psychiatry”. 5th edition; New Delhi. Jaypee; 2002.
3. Bhatia MS. “Essentials of psychiatry”. 4th edition. New Delhi; CBS publishers: 2004.
4. Sreevani R. “A guide to mental health and psychiatric nursing”. New Delhi, Jaypee:
2004.
5. Stuart GW. “Principles and practice of psychiatric nursing”. 7 th edition; Mosby;

Harcourt:2001.
EAST WEST COLLEGE OF NURSING BANGALORE

CASE PRESENTATION
ON
SEVERE DEPRESSION WITH PSYCHOTICS SYMPTOMS
Mrs. Mr.MAHANTESH.K
1st Yr MSc Nursing

BANGALORE. BANGLORE
INTRODUCTION
During our clinical postings we are posted to NIMHANS as per our rotation plan I posted to pev -1 I
selected patient by name of Miss.Roopali. with multiple suicidal attempts diagnosed as a case of
“severe depression with psychotics symptoms”. I took this case for my presentation.
PATIENT PROFILE
Patient Name : Miss.Roopali
Age : 22 yrs
Sex : female
Religion :Hindu
Marital status : Unmarried / single
Educational status : PUC 2nd yr
Admitted on : 17/02/08
Ward : Pavilion – IV
IP Number : P1256512
Unit : V
Informants : Patients parents.
Adequate and reliable.
Diagnosis : severe depression with psychotics symptoms
Address : d/o devegouda. Harugeri Belgaum.
CHIEF COMPLAINTS
1) Fearfullness
2) Social withdrawal/2 months
3) 2 attempts of suicide 1 ½ month back.
4) Decreased food intake.
5) Decreased speech output/for 1 month.
HISTORY PRESENT ILLNESS

Patient was apparently normal 2 month back. When she doing a computer course in her town,
she had joined the course 1 ½ month back after studying at an orthodox modarana which taught her
to be away from males, not to see, speak, touch them etc.
So when she joined this computer course which had both genders studying and interacting with each
other, she felt very uncomfortable, guilty, sad and frightened, so she thought that “Allah” would not
forgive her, for the sins she committing. She was teased constantly at her class for not interacting with
others, as a result of this she felt further sad. One day in the class she sat in the corner, frightened and
shivering. Upon asking by the teacher, did not speak, but continued to sit silently. She was brought to
home and then did not continue her classes. She spent most of the time at home. Not interested to
talking with friends, going out and also not interested on family members. Initially she used to spent
most of time with Kuran, then gradually stopped reading Kuran. She reported feeling sad had feelings
of guilt and about 1 ½ month back tried to attempt suicide by consuming 10-15 tabs of PCT and
antibiotics twice in a year, but nor succeded in those attempts was seen by family members and
survived.
Since then, she was not interested in her personal hygiene, not taking food regularly., not taking with
anyone at family, sitting alone and crying and feeling sad as she did sin was also noticed spending long
hours in a corner, sitting in some position, starting at space, not responding to commands.
ASSOCIATED DISTURBANCES
Not interested to socialize with others.

Decreased food intake.
Decreased sleep. (Sound sleep)
Not going for class.
NEGATIVE HISTORY
 No H/o Head Injury
 No H/o memory loss.
 No H/o trauma, disorientation.
 No H/o seizure or convulsion.
PAST HISTORY
Nil significant past history, no significant medical history.
PERSONAL HISTORY
 Full term normal vaginal delivery.
 No delay in milestones.
 Good scholastic performance.
 Menarchy- at 15 years. Regular cycles, until 3 months back.
 Since 3 months – Polymenorrhoea
FAMILY HISTORY
No history of mental illness in the family.

No family history of diseases like DM, HTN, Cancer etc
FAMILY TREE
PREMORBID PERSONALITY
 Well adjusted.
 Shy religious, friendly and responsible.
 Independent and ambitious.
Moves reluctantly, after lot of pressuring by family members.
Sits with down cast eyes, frowns, grunts, and moves spontaneously, which increases if spokes to her.
Mannerisms- continuous picking up fingers and finger nails.
Doesn’t respond verbally to any questions.
Negativism
Staving
Posturing
Rigidity
Near mutism
Vocal stereotypes.
Speech : Not responding.

Near mutism
Thought : Not co-operative.

Could not assess.
Insight : Poor.
Mood
Subjective : I feel sad.
Objective : Depressed.
INVESTIGATION
SL TEST PATIENT VALUE NORMAL VALUE REMARKS

NO
1. B Glucose 76 mg/dl 60-10 mg/dl Normal
2. B. Urea 20 mg/dl 10-50 mg/dl Normal
3. B. Creatinine 0.7 mg/dl 0.3 – 1.2 MG/dl Normal
4. T. Bilirubin 0.3 mg/dl Less than 1 Normal
5. ALP 72 u/L 40-129 U/L Normal
6. SCIOT 22 gm/Dl 8-40 U/l Normal
7. Sodium 147 mcg/L 135-148 MCG/L Normal
8. Potassium 4.5 mcg/l 3.5-5.2 mcg/l Normal
9. Chloride 110 mcg/l 95-106 mcg/l Increased
Treatment
SL DRUGS DOES FREQ/ROUT ACTION SIDE EFFECTS

NO
1. TRSPN 4 mg Od/oral Its antipsyxholic activity may Somnolence,
be medicated through a crtrapyramidal symptoms,
combination of dopamine type headache, insomnia,
2 and serotonin type 2 agitation, anxiety.
antagonism.
2. T. 25 Od/oral It is thoughto exert its Drowsiness, dizziness
Imipramin mg antidepressant effects by excitation, tremor,
inhibiting reuptale of confusion, hallucination,
norepineaphrine and serotonin anxiety, ataxia,
in CNS nerve terminals paresthesia, EEG changes.
3. T. 100 BD/oral It exert antipsychotic activity Dizziness, head ache,
Quietiapine mg through antagonism f somnolence, hypertonai,
dopamine type 2 and aphasia, dysarthria etc.
serotonin type 2 reception.
MOOD DISORDERS – DEPRRESSION
INTRODUCTION
Mood disorder encompass a large group of disorders involving pathological mood and related
disturbances. The diagnostic and stastical manual of mental disorders, divides mood idsordors into two
main categories, depressive disorders and bipolar disorders. Mood disorders are one of the most
commonly occurring psychiatric mental health disorders. Only alcoholism and phobias are common.
Mood disorders impose an enormous burden on the individual, the family and society as a whole.
(current and morrson, 2001, sadock and sadock, 2003)
According ot the National Institute of Mental Health (NIMH, 2001) approximately 18.8 million
American adults 18 years of age or older have a mood disorder in a given year. Additionally, women
are at greatest risk for mood disorder than are men and are more likely to seek treatment (sadock and
sadock, 2003). By thte year 2020, mood disorders are estimated to be the second most important
cause of disability world wide (Murray and Lopee, 1996)
Mood disorders can occur in any age group. Infants may exhibits signs of anaclitic depression or failure
to thrive when separated from their mothers. School aged children may experience a mood disorders
along with anxiety, exhibiting behavior such as hyperactivity, school phobia, or excessive clinging to
parents. Adolescents experiencing depression mahy exhibit poor academic performance, abuse
substances, display antisocial behavior or attempt suicide.
Although mood disorders are less common in the older adult than in younger individuals , symptoms of
depression are present in approximately 15 to 25% of all older community residents, particularly those
living in long term care facilities. In recent years, marked progress has been made in the diagnosis ad
treatmrnt of mood disorders in nursing home residents. In 1987, only 10% nursing home residents
were receiving antidepressant medication for clinical symptoms of mood disorders. By 1999, 25% of all
residents were receiving antidopressants as af result of more com-prehensive assessments and better
diagnosis of mood disorders.
ETIOLOGY OF MOOD DISORDERS
In the past, causes of mood disorder were classified as genetic, biochemical and environmental. In
addition, several medical illness are highly correlated with mood disrorders. More over, individuals of
any age may experience changes in mood or affect as an adverse effect of medication. However, older
adults are more likely than younger adults to experience medication related mood disorders. Risk
factors for the development of mood disorders have been identified as clinical practice guideline for
primary care practitioners by the Agency for Health Care Policy and Research.
GENETIC THEORY
According to statistics from the National Institute Of Mental Health (2001), studies involving adoptes
revealed higher correlations of mood disorders between depressed adoptees and biologic. Parents
than adoptive parents studies of twins have shown that of an identical twin develops a mood disorder,
the twin has a 70% chance of developing the disorder, too. The risk decreases to about 15% with
siblings, parents or children of the person with the mood disorder. Grand parents, aunts or uncles
have about a 7% chance of developing a mood disorder.
BIOCHEMICAL THEORY
Biogenic amines, or chenica compounds known as norepinephrine, and serotonin have been shown to
regulate mood and control drives such as hunger, sex and thrist. Increased amounts of these
neurotransmitters at receptors sites in the brain cause an elevation in mood whereas decreased can
lead to depression. Although nrepinaphrine and serotonin are the biogenic amines most often
associated with the development of a mood disorder, dopamine has also been theorized to play a role.
As with norpinephrine and serotonin, dopamine activity may be reduced in depressed mood and
increased in mania, the two phases of bipolar disorder. These explanations are termed as biogenic
amine hypothesis.
PSYCHODYNAMIC THEORY
The psychodynamic theory of depression, based ln the work of sigmoud Freud Karl Abraham, Melanic
Klein and others begins with the observations that b------------- normally produces symptoms
resembling a mood disorder. That is people with a depressed mood are likely morness who do not
make a realistic adjustments to living without the loved person. In childhood, they are be---- of parents
or other loved person, usually the result of the absence or withdrawal of affection Any loss or
disappointment late in life reactivates a delayed grief reaction that is accompanied by self criticism,
guilt and anger turned inward. Because the source and object of the grief are unconscious, symptoms
are not resolved, but rather persist and return later in life.
BEHAIVOR THEORY: LEARNED HELPLESSNESS
Behavioral theorist regard mod is orders as a form of acquired or learned behavior for one reason or
another people who receive little positive a perception promtes feelings of helplessness and
hopelessness, both hallmarks of depressed states.
COGNITIVE THEORY
Cognitive or cognitive behavior theories believe that thoughts are maintained by reinforcement, thus
contributing to a mood disorder. People with a depressed mood are convinced that they are worthless,
that the world is hostile, that the future offers no hope and that every accidental misfortune is a
judgmental of them, such reactions are the result of assumption early in life and brought into play by
disappointment, or rejection.
LIFE EVENTS AND ENVIRONMENTAL THEORY
Stressful life events such as the loss of a parent or spouse, financial hardship, illness, perceived r real
failure, and midlife crises are all examples of environmental factors contributing to the development of
depression.
COMPARISON OF ETIOLOGY WITH PATIENT
SL BOOK PICTURE PATIENT PICTURE

NO
1. Genetic theory There is a family history of psychosis. But not sure about mood
disorder. History of psychosis in paternal side.
2. Biochemical theory As with norpinephrine and serotonin, dopamine activity mahy be
reduced in depressed mood.
3. Psychodynamic theory Nil significant
4. Behavior theory She hs been teased and criticized by his classmates for not talking with
boys. This perception promotes feeling of helplessness and
hopelessness, both hallmarks of depressed states.
5. Cognitive theory She was depressed mood are convinced that she is worthless, that he
world is hostile that the future offers no hope.
6. Life events and Change of study place, made her to depressed, withdrawn and isolated
environmental theory behavior.
CLINICAL SYMPTOMS

NO
1. Depressed mood Depressed mood present.
2. Significant loss of interest or pleasure Not interested in talking with others and watching
TV.
3. Marked changes in weight or significant Loss of appetite, pre----- of weight loss, about 2
increase or decrease in appetite. legs, within a month.
4. Insomnia or hypersomnia Presence of insomnia.
5. Pshychomotor agitation or retardation Psychomotor retardation. She used sat in same
place for longer time.NO much movements.
6. Fatigue or loss of energy Presence of fatigue, especially in the morning.

NO
7. Feelings of worthlessness or excessive or Feelings guilt, that she was studies with
inappropriate guilt. boys.
8. Reduced ability to concentrate or think or Present
indescisiveness.
9. Recurrent thoughts of death, suicidal idea. Twice tried for suicide but not
succeded.
DIAGNOSTIC CHARACTERISTICS

NO
1. Evidence of at least five clinical symptoms in conjuction Presence of almost all the symptoms.
with depressed mood or loss of interest or pleasure.
2. Symptoms occurring most of the day and nearly every Symptoms are present almost more
day during the same two weak period representing an than two weeks and disturbance in
actual change in person’s previous level of functioning.her functioning also present.
3. Significant distress or marked impairment in person’s She was withdrawn from all the
functioning, such as in social or occupational areas. activities at home and not going for
class.
4. Symptoms not related to a medical condition or use of a It is not related to medical condition
substance. or use of a substance.
A CONTINUUM OF DEPRESSION
Transiet depression Mild depression Moderate Severe depression

depression
Life’s every day Natural grief Dysthmic disorder Major depressive
disappointment response disorder
PRIMARY RISK FACTORS FOR DEPRESSION
1.History of prior episode of depression.

2.Family history of depressive disorders.
3. History of suicide attempts and or family history of suicide.
4. Female gender.
5. Age 40 year or above.
6. Post partum peiod.
7. Medical illness.
8. Absence of social support.
9. Negative, stressful life events.
10. Active alcohol or substance abuse.
MAJOR DEPRESSIVE DISORDER
According to the World Health Organization major depressive disorder has been identified as the
fourth leading cause of world wide disease in 1990, causing more disability than either ischemic heart
disease or cerebral vascular disease. According to the DSM-IV-TR, person with a major depressive
disorder do not experience momentary shifts from one unpleasant mood or another. During a 2 week
period, the individual exhibits five or more of the nine clinical symptoms of a major depressive episode
in conjuction with a depressed mood or loss of interest or pleasure. The clinical symptoms interfere
with social, occupational or other important areas of functioning. Symptoms are not due to effects of a
substance nor are they due to a general medical condition.
Major depressive disorder may be coded as mild, moderate or severe, with or without psychotic
features, and as in partial or full remission. Reference also is made to identify it as a single or recurrent
episode The specified “with seasonal pattern” can be applied to the pattern of major depressive
episodes if the clinical symptoms occurs at characteristics times of the year.
DYSTHYMIC DISORDER
The Client with the diagnosis of dysthymic disorder typically exhibit symptoms that are similar to those
of major depressive disorder r severe depression. However , they are not as severe and do not include
symptoms such as delusions, hallucinations, impaired communication, or incoherence. Clinical
symptoms usually persists for 2 years or more and may occur continuously or intermittently with
normal moodswings for a few days or weeks. Persons who develops systhymic disorder are usually
overly sensitive often have intense guilt feelings and may experience chronic anxiety.
According to DSM-IV_-TR, criteria, the individual while depressed must exhibit two or more of six
clinical symptoms of a major depressive episode, including poor appetite or over reacting insomnia or
hypersomnia, low energy or fatigue, low self decisions, and feelings of hopelessness. Clinical symptoms
interfere with functioning and are not due to a medical condition or the physiologic effects of a
substance.
TREATMENT
PHARMACOTHERAPY
Antidepressants are the treatment of choice for a vast majority of depressive episodes.
1. Tricyclic antidepressants.
2. Selective serotonin receptor. Inhibitorrs (SSRI)
3. Dopaminergic antidepressants.
4. Antypical antidepressants.
5. Monoamine oxidase, Inhibitors (MAOI)
6. Non selective serotonin reuptake inhibition.
ELECTRO CONVULSIVE THERAPY (ECT)
Severe depression with suicidal risk is the most important indication for ECT.
PSYCHOLOGICAL TREATMENT
COGNITIVE THERAPY
It aims at correcting the depressive negative cognitions like hopelessness, worthlessness, helplessness
and pessimistic ideas, and replacing with new cognitive and behavioral response.
SUPPORTIVE PSYCHOTHERAPY
Various techniques are employed to support the patient. They are reassurance, ventilation,
occupational therapy, relaxation, and other activity therapies.
GROUP THERAPY
Group therapy is useful for mild cases of depression. In group therapy negative feelings such as
anxiety anger, guilt, despair are recognized and emotional growth is improved through expression of
their feelings.
FAMILY THERAPY
Family therapy is used to decrease intra familiar and interpersonal difficulties and to reduce or modify
stressors, which may help in faster and more complete recovery.
BEHAVIOR THERAPY
It includes social skills training, problems solving techniques, ---------- training, self control therapy,
activity scheduling and decision making techniques.
COURSE AND PROGNOSIS OF MOOD DISORDERS

Depressive episode lasts for 4 to 9 months.
GOOD PROGNOSTIC FACTORS

 Abrupt or acute onset.
 Severe depression.
 Typical clinical features.
 Well adjusted pre-morbid personality.
 Good response to treatment.
POOR PROGNOSTIC FACTORS
 Double depression.
 Co-morbid physical disease, personality disorder, or alcohol dependence.
 Chronic ongoing stress.
 Poor drug compliance.
 Marked hypo chondrial features or mood incongruent psychotic features.
NURSING DIAGNOSIS
1. High risk for self harm related to depressed mood, feelings of worthlessness, anger turned
inward to self.
2. Dysfunctional grieving related to real or perceived loss, bereavement over loads.
3. Low self esteem related to learned helplessness, feelings of abandonment by significant others.
4. Powerlessness related to dysfunctional grieving process, life style of helplessness.
5. Alteration in nutrition less than body requirement related to loss of appetite.
6. Spiritual distress related to dysfunctional grieving over loss of valued objects.
7. Self care deficit (personal hygiene- bath, un----- care of clothes and hair)
8. Improved communication.
9. Impaired socialization.
10. Reduced attention and concentration.
FOLLOW-UP AND HOME CARE AND REHABILITATION
1. Educate the family about the impact of treated mood disorders on the individual life and
functional ability.
2. Tell the Client and family to report any worsening of depression or suicidal thoughts.
3. Educate the family and Client about mood disorders as illness that are not their “fault”.
4. Teach Clients and families about the “lay time” between starting anti-depressants and on set of
therapeutic effects.
5. Explain that self esteem is influenced by mood disorders and suggests steps to develop ending
self-esteem.
6. Teach the Client and family about the effects of major depression and episodes.
7. Help the Client and family identify community resources such as suicide ---------.
CONCLUSION
Depression is one of the oldest recognized psychiatric illness that is still prevalence today. It is so
common in fact that it has called as a “common cold of psychiatric disorder”.
By providing comprehensive care to Ms. Shireen I was able to gain confidence with caring patient with
a severe depression with psychotic symptoms. She has improved remarkably during the period of the
study.
BIBLIOGRAPHY
1. Lippincott’s Mannual of psychiatric nursing care plans, 5th edition, Pp. 361-365.
2. Dr. (Mrs) K Lalitha- Mental Health and Psychiatric Nursing. An Indian Perspective. VMG Book
house, Bengaluru, 2008. Pp-311 to 345.
3. Sreevani. R. A guide to Mental Health and Psychiatric Nursing. Jaypee Brothers, New
Delhi.2004, pp-54 to 55.
4. Louise Rebraca Shives,- Basic concepts of psychiatric mental health nursing. 6 th Edition,
Lippincott Williams and Wilkins. New York. Pp 271-276.
INTRODUCTION
During our clinical postings we are posted to NIMHANS as per our rotation plan I posted to male
general ward I selected patient by name of Mr Anand. with multiple suicidal attempts diagnosed as a
case of “anxiety neurosis ”. I took this case for my presentation.
IDENTIFICATION DATA
Name : Mr. Anand

Age : 31 years
Sex : Male
Qualification : Uneducated
Occupation : Car driver
Income : Rs. 3000 per month
Mother tongue : Kannada
Religion : Hindu
Nationality : Indian
Diagnosis : Anxiety Neurosis
Brought to the hospital by : Wife
Source of referral : Client is a case of anxiety neurosis
RELIABILITY OF THE INFORMANT
Client had admission with his wife because of her request. He has good relationship with his wife. She was
uneducated and her observation was good. She has not much intelligent. At present she is with her husband for
the past 10 years. Mrs. Adhilakshmi was very loving with her husband. She gave reliable information of the
client.
CHIEF COMPLAINTS DURING ADMISSION
 Anxiety
 Fear
 Hear some voice
 Increased psychomotor activity
 Sleep disturbance
 Loss of appetite
 Feels worried
 Not aware to urinate
 Want to die
 Palpitation, frightened and confused
 Experiencing fear and hopeless.
SYMPTOMS OBSERVED
 Anxiety temperament
 Fear
 Palpitation
 Confusion
 Twisting of ----- frequency.
PRECIPITATING FACTORS
There is presence of physical illness hypertension which was diagnosed back, no family history of psychological
illness. Patients social factors is affected because of his worries.
PAST MEDICAL AND SURGICAL HISTORY

Patient has the past medical history of hypertension before 10 years and has undergone treatment. There is no
relevant surgical history and no history of blood trasnsfusion.
PAST PSYCHIATRIC HISTORY

There is no relevant past psychiatric history of the patient.
PRESENT PSYCHIATRIC HISTORY

Patient had two episodes of psychiatric illness since the year 1999. At present he is under follow-up treatment
and taking mediations regularly.
FAMILY HISTORY
Mr.Anand belongs to a nuclear family. He has the habit of alcohol intake early. His grand parents died due to
ageing. Mr. Anand’s monthly income is Rs. 3000 per month. He is head of the family. Mr. sudeer had two
episodes of psychiatric illness since the year 1999. He has no properties and the house facilities are adequate
and good. Mr. Anand had the attempts of commiting suicide and expressed his ideas to his family members
because he was upset that he got married earlier. He has so wandering behavior. Patient has good religious
belief and he lacks social support. His wife and children was loving to him.
Client is a hypertensive person. He had suicidal ideas before 10 years because of his dislike of early marriage at
the age of 21 years. All are healthy in his family except Mr. Kumar.
PERSONAL HISTORY
PRE-BIRTH HISTORY OR PERINATAL HISTORY
Mr. Anand was not born to blood related parents and his mother’s condition was good during pregnancy. He
was a full term baby and was breast fed adequately febrile, illness, medications, drugs use but alcohol are rarely
not trauma to abdomen and nay physical or psychiatric illness during pregnancy of the mother. He was a
wanted child and his date of birth is 10/2/1972 and was home delivered. APGAR score was normal and birth cry
was present soon after birth.
CHILD HOOD HISTORY

Mr. Anand was brought up by his mother and was breast fed adequately. The age of passing each important
developmental milestone was normal and toilet training was also normal. There was no occurrence of neurotic
traits.
EDUCATIONAL HISTORY
Mr. sudeer was a follower and not a leader among his classmates. The age of his begging formal education was
normal but stopped from his schooling when he was in 1st standard. He does not had nay school phobia. The
reason for stopping from school is due to poverty and he had no interest school.
ADOLESCENT HISTORY
Mr. Anand adolescent history shows that he had normal secondary sexual characters and his attitude towards
opposite sex is also normal. He does not have any abnormal behavior towards others.
OCCUPATIONAL HISTORY
Mr. Anand started going for his job at the age of 20 years. He does not have any change in his job. He is a auto
driver. He does not have job satisfaction because he has no enough earning. He lacks financial support.
PLAY HISTORY
Mr. Anand played all the games and he was interested in playing cards. His attitude towards peer group and his
teachers and peer group was good and normal.
SEXUAL AND MARITAL HISTORY

Mr. Anand was love married at the age of 21 years. At present he is living together with his wife and his
children. His sexual life was satisfactory but sometimes felt impotent. He got examined for this and he was
assured by the doctors, so he has confidence and how his sexual life is normal.
PREMORBID PERSONALITY
Mr. Anand has good interpersonal relationship with his family members and superiors. He is extraverted
character. His hobby is playing cards and he has the habit of alcohol intake rarely and smoking.
He is a cheerful person and has many friends. His attitude to self and others are he has self-confidence,
thoughtful of others and has good achievements in life like earning money and getting good name. He gets
easily irritable and he is sensitive. He has good decision making in facing problem and has good religious and
moral beliefs.
I GENERAL DESCRIPTION
 Mr. sudeer is a young man moderately body built man and looks comfortable.
 GROOMING AND HYGEINE
Mr. sudeer is clean and tidy. Nails are short and clean. He met his self care and hygiene activity. His hair
is short and healthy. There is perspiration in his face while talking.
 FACIES: There is no non-verbal expression of mood.
 ATTITUDE TOWARDS THE EXAMINER
Mr. sudeer was attentive, co-operative, showed interest in answering to my questions. He is irritated
sometimes but has control over it.
 COMPREHENSION: Intact (fully)
 BEHAIVIOUR AND PSYCHOMOTOR ACTIVITY

Gait : Unstable, often pulling his shirt.
Psychomotor activity : Increased.
CATATONIC SIGNS: Mannerism, roll shin eyes often upwards, twisting his arms frequently.
Sterothypes : Absent.
Posturing : Absent.
Wax flexibility : Absent.
Negativism : Absent
Ambitendering : Absent
Ecopraxia : Absent
Conversion and dissociative signs : Absent.
SOCIAL MANNER AND BEHAIVIOR

Mr. sudeer has appropriate social manner and eye contact is good.
RAPPORT
A good working and empathic relationship could be established with the patient.
HALLUCINATORY BEHAVIOR
Mr. suseer had hallucination (auditory) behavior ie he says that he heard a male voice in the right time irritating
him that he is impotent and his life is completed.
II SPEECH
RATE AND QUANTITY OF SPEECH
Mr.sudeer’s speech was spontaneously, coherent and relevant. Rate of production of speech, normal.
VOLUME AND TONE OF SPEECH

Pitch normal. He does not have flight of ideas, circumstantially, tangentiality, ------------- and ------- association.
FLOW AND RHYTHM OF SPEECH

Normal
III MOOD AND AFFECT

A MOOD:
Nurse : How are you now?
Patient : ------------------------------------------------
B AFFECT
Inappropriate
IV THOUGHT
STREAM AND FORM OF THOUGHT
There is no loosening of association, circumstantiality, illogical thinking and verbigeration.
CONTENT OF THOUGHT
Delusion of grandeur was absent. He says that he has belief in Christ. Mr. sudeer has no delusion, obsession and
compulsion, phobia, poverty but had suicidal ideas.
V PERCEPTION
A HALLUCINATIONS:
Nurse : Do you have any voice in ears?
 AUDITARY
Patient : That he have a male voice in the right irritating him that he is impotent and his
life is completed.
Olfactory : Absent
Visual : Absent
Tactile : Absent
Gustatory : Absent
B ILLUSIONS AND MISINTERPRETATIONS : Absent
C DEPERSONALIZATION/DEREALIZATION
1. NURSE : What do you think of yourself?
Patient : I am fine and alright.
2. Nurse : Do you find any change in the external world?
Patient : No, I don’t find any change.
D SOMATIC PHENOMENOM : Absent.
IV COGNITION
A ALERTNESS AND LEVEL OF CONSCIOUSNESS:client is very cuscious, while asking questions. He is

answering well and responding to all the questions. He is alert.
B ORIENTATION
Mr. client is very causcious while asking questions. He is answering well and he is responding to all questions.
He is very alert.
Client has good orientation to time, place, and person.

 TIME: Oriented to time.
NURSE: What is the time now?
PATIENT: 9:45 am
 PLACE : Oriented to person.
NURSE : Who are we?
PATIENT: Training nurses.
C ATTENTION: Mr. client’s attention is good.

1. Nurse : Can you repeat 5 digits forwards starting form 10?
Patient : 10, 11, 12, ----
2. Nurse : Can you repeat 3 digits backwards starting from 100?
Patient : 200, 99, 98,
D CONCENTRATION
Patient has good concentration.
Nurse : Can you substract serial----------- from 90?

Patient : 83, 76, 69-----
E MEMMORY
Mr. Kumar has good recall to remote and immediate memory and abstract recall to recent memory.
 Remote memory recall was good.

Nurse : Can you tell me your date of birth?
Patient : 10/2/1972
 Recent past memory is not good.

Nurse : When did you come for first admission?
Patient : I don’t know, I think before 1 month.
 RECENT
Nurse : What do you have in the morning?
Patient : Nothing (but client actually ate iddli)
 IMMEDIATE
Nurse : Can you tell numbers from 10 to backwards?
Patient : Repeated 10, 9, 8, 7, --------
INTELLIGENCE
Mr. Kumar has the ability to think logically, act rationally and deal effectively with the environment.
1. Nurse : Who is the chief minister of Tamil Nadu?

Patient : Selvi. Jayalalitha
2. Nurse : Which is the capital of India?
Patient : New Delhi
ABSTRACT THINKING
Abstract thinking is good.
 PROVERB TESTING
Nurse : Can you say a proverb which you know, and tell its meaning?
Patient : ---------------------------------------------------------------------------------------------------------------------
SIMILARITIES
Nurse : What is the similarity between chair and table?
Patient : Both has four legs.
DIFFERENCES
Nurse : What is the difference between ball and apple?
Patient : We use play with the ball and can eat the apple.
H INSIGHT : Present.
Nurse : What is your problem?
Patient : --------------------------------------------
I JUDGMENT
* PERSONAL JUDGMENT : Good
Nurse : If a snake comes close to you, what will you do?
Patient : I will run and don’t know what to do.
 SOCIAL JUDGEMENT : Good.
Nurse : If you find two patients fighting each other in the ward, what will you do?\
Patient : I will try to compromise them.
J RELIABILITY
All the information given by the patient was reliable to the case sheet.
SUMMARY
To summarize, assessment of mental status examination sums up totally his mental status is good and he had
abnormalities in memory, judgment, and hallucination (auditory).
Client has increased psychomotor activity and has disturbed mannerism, his mood is anxious and fearful, and his
talk is emotional and sometimes very quiet.
DIAGNOSIS
With the above findings by mental status examination and with the history client was diagnosed as a case of
“Anxiety Neurosis”.
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Cousciousness : Causcious
General condition : Fair
Body built : Thin
Nourishment : Under nourished
Activity : Has normal activity and works hard.
HEAD
Scalp : The hair is clean and there is no dandruff as hair loss.
EYES
Eyes contact is good. Conjunctiva and sclera are pink. Eye movements are normal. Pupils react to light.
NOSE
There is no crust formation and no septal deviation.
EARS
Hearing acuity is normal and there is no waxy formation.
TEETH
Client’s teeth is slightly discolored and there is no dentures and dental carries and no tooth fall.
MOUTH AND PHARYNX

There is no angular stomatitis and no infections or bleeding from the teeth.
NECK
No lymph nodes enlargement and no thyroid gland enlargement.
CHEST
Chest movements are normal. Breathing pattern is also normal.
ABDOMEN
The abdomen is normal and there is no abdominal distension. He has normal peristaltic movements. There is no
presence of fluid organs.
SPINAL CURVE
The spinal curve is normal. There is no kyphosis, lordosis, or scoliosis.
EXTREMITIES
Extremities are normal, but has tremors in his arms. Range of motion is normal.
ANUS AND GENITALIA

There is no hemorrhoids and no enlargement of inguinal gland.
VITAL SIGNS : Normal
Temperature : 98.8 degree Fahrenheit.

Pulse : 82 beats per minute.
Respiration : 24 breaths per minute
Blood pressure : 120/90 mmHg.
CEREBRAL FUNCTION
Client has good communication with others. His pattern of emotional behavior is normal. He also has good social
interaction.
MENTAL STATUS
Patient’s appearance is good. His dress is clean and tidy. He has good personal hygiene. Mr. Kumar’s facial
expression shows that he is very worried and sad.
INTELLECTUAL FUNCTION
Patient has good orientation to time, place and person and his recent memory is slightly impaired. His
immediate and remote memory is normal.
MOTOR ABILITY
Client is easily understanding and he performs the activity according to his desire with his normal motor
strength.
MUSCLE STRENGTH
Client has good muscle strength ie he is able to flex and extend the extremities against resistance. He has
tremors of his arms.
BALANCE AND CO-ORDINATION

client’s hand is shivering while asked to extend the arms and counting the numbers. His balance is normal and
co-ordination has slightly abnormality.
CRANIAL NERVES FUNCTIONN CLINICAL SYMPTOMS

I. Olfactory Sense of smell Normal
II. optic Visual activity Normal
III. occulomotor Regulation of eye, movements, eyelid. Normal
IV. Trochlear Pupilary reaction Normal
V. Abducens Pupilary reaction Normal
VI. Tryeminal Facial sensation Normal
VII. Facial Facial muscle movement, facial Normal
expression, tear and saliva secretion.
Taste: anterior 2/3rd of tongue.
VIII. Vestibulo cochlear Hearing and equilibrium Hear some male voices like,
saying that client is impotent.
IX. Glosso pharyngeal Taste: Posterior third of tongue Normal
CRANIAL NERVES FUNCTIONN CLINICAL SYMPTOMS

X. Vagus Pharyngeal contraction, movements of Normal
vocal cords, soft palate.
XI. Spinal accessory Movement of sternogledo mastoid and Normal
trapezes muscle
XII. Hypoglossal Movement of tongue Normal
PROCESS RECORDING
CONVERSATION COMMENTS
Nurse: Good morning! Gait normal.
Patient: Good morning sister. Immediate memory intact.
Nurse: What is your name?

Patient: Mr. Kumar
Nurse: Did you have your breakfast?

Patient: No sister.
Nurse: What is the problem with you? Affect is inappropriate.

Patient: I am feared without reason and feel
anxious.
Nurse: Did you take treatment any where

other than this hospital?
Patient: No, I am taking treatment here
only.
Nurse: Do you take treatment regularly? Copies to treatment and shows interest in
Patient: yes, I will come every month to get recovery.
medicines and if I get excess anxiousness I
immediately approach the doctor.
Nurse: Do you hear any voices or sounds

when you are alone? Has auditory hallucination.
Patient: Yes, I can hear a male voice saying
that I am impotent and my life is over.
Nurse: When did you get married? Remote memory intact.

Patient: Ten years back.
Nurse: Can you tell the similarity between

chair and table?
Patient: Both has four legs.
Nurse: Can you please tell the difference Abstract thinking is normal.
between ball and apple?
Patient: We can eat the apple and play with
the ball.
Nurse: You are walking alone, on the way

you are seeing a envelop with address, what Judgment is good.
will you do?
Patient: I will post the envelop.
Nurse: Tell me something about your
children?
Patient: I am having 4 children. 3 boys and 1 Patient is attached with his children and wife.
girl.
Nurse: Do you love your children and wife?
Patient: yes, I love my wife and children.
Nurse: Does anyone in your family affected

with psychiatric illness? Accept his psychiatric problem.
Patients: No one, except me.
Nurse: What is your plan for future?
Patient: I want to earn more money and
spend for my wife and children.
Concentration is good.
Nurse: Will you follow your plan?
Children: Yes! I am going sister.
Nurse: Where are you going?

Patient: I want to see the doctor, so I am
going.
Nurse: OK, Thank you.
SL NO INVESTIGATIONS PATIENT’S NAME NORMAL VALUE INFERENCE

1. Blood 12.2 gms% 13-18gm% Normal
Hemoglobin
2. Total WBC count 6,600 cu mm 4,000 – 11,000 cu mm Normal
3. Polymorph 59% 60-70% Normal
4. Lymphocyte 40% 20-30% Normal
5. Eosinophil 4% 1-4% Normal
6. Serum creatinine 0.8 mg/dL 0.7-1.4 mg /dL Normal
Drug Name Pharmacological Dose Route Action Side effects Nurses

name responsibility
Tab Elavil 75- Oral Tricyclic Postural Administer
Amitriphylline 300 Antidepresant hypotension, correctly in
mg / It exist its tachycardia, sufficient
day antidepressant cardiac doses.
action by blocking arrhythmias, Check BP.
normal ---- take of urinary retension,
nor---- adrenaline fatigue, dizziness,
and --------. It also confusion weight
has significant gain and sexual
anticholinergic disturbances.
activity.
Tab. Imipramine 75 Oral Tricyclic Sinus, tachycardia, Check vital
Imipramine mg antidepressant postural signs.
Inhibits --- adrenaline hypotension, Administer
----- and to be lesser urinary retension, correct doses.
extend that of -------, liver dysfunction,
it reduces RSM sleep weight gain,
and increases stage 4 eosionphilia,
sleep. tremors.
Tab BC BC 320 Oral Vit B and C complex Hyper vitaminosis, See for side
mg supplement. GI disturbances. effects.
Yellow colored Explain about
urine. ---- color
change.
Tab. Diazepam 5 mg Oral Benzodiazepine Psychological and Check vital
Diazepam ------------- Has typical physical signs.
activity spectrum of dependence with Monitor vision
benzodiazepine withdrawal and value for
encomparing syndrome, visual eye check ups.
anxiolysis, sleep disturbance,
modifying and ------- mental chang.
effects.
CASE STUDY
INTRODUCTION
Anxiety is the commonest psychiatric symptom in clinical practice.
Anxiety is a normal phenomena which is characterized by a state of apprehension or uncare arising out of
anticipation of danger.
Normal anxiety becomes pathological when it causes significant subjective distress and for impairment in
functioning of individuals.
DEFINITION
Anxiety reaction is a neurotic state of chronic apprehension with recurrence of acute anxiety symptoms.
TYPES
TRAIT ANXIETY
This is a habitual tendency to be anxious in general and is exemplified by I often feel anxious.
STATE ANXIETY
This is the anxiety felt at the present moment exemplified by I feel anxious now. Persons with trait anxiety often
have episodes of state anxiety.
BOOK STUDY PATIENT’S STUDY
ELIOLOGY
BIOLOGICAL FACTORS
 Heredity
 Constitution
 Endocrine disturbances, metabolic and biochemical abnormalities.
There are not considered as significant causes in the illness.
ENVIRONMENTAL FACTORS
There are more important causes.
AGE
Childhood, adolescence, and involution periods are more susceptible.
SEX
Incidence equal in both sexes, it may be more in one sex than another at different ages.
PERSONALITY
Persons with anxious, inadequate and obsessive personalities are more susceptible.
FRUSTRUATION IN SEXUAL AIM
 Physical, physiological or psychosocial stress of a moderate to severe degree.
 Difficult family situation.
 Occupational and financial difficulties.
 Heavy responsibilities without adequate support.
 Prolonged or debilitating physical illness.
Example: Influenza.
THEORIES OF ANXIETY DISORDERS

PSYCHODYNAMIC THERAPY
According to this theory, anxiety is a signal that something is disturbing the
internal psychological equilibrium. This is called as signal anxiety. This signal
anxiety arouses the ego to take defensive action which is usually in the form
of repression, a primary defense mechanism, like conversion, isolation, are
called ie to function adequately and the secondary defense mechanisms are
not activated. Hence, anxiety come to the
for front.
Develop mentally , p------ anxiety is manifested as ------- symptomatology

while develop mentally advanced anxiety is signal anxiety.
Panic anxiety according to this theory is closely related to the separation

anxiety of childhood.
BEHAVIORAL THEORY
According to this theory, anxiety is viewed as an unconditioned inherent
response of the organism to painful or dangerous stimuli. In anxiety and
phobias, this becomes attached to relatively neutral stimuli by conditioning.
Behavioral approach is more helpful in treatment rather than in explaining the

cause of anxiety.
COGNITIVE BEHAIVOR THEORY(CBT)

According to cognitive behavioral theory, in anxiety disorder, there is
evidence of selection information processing (with more attention paid to
threat related information), cognitive distortions, negative automatic
thoughts (NATs) and perception of decreased control over internal and
external stimuli.
BIOLOGICAL THEORY
i) GENETIC EVIDENCE
15-20% of the first degree relatives of patients with anxiety disorder exhibits
anxiety disorder

Themselves. The concordance rate in the monozygotic twin of patients with
panic disorders in as high as 80% (4 times more than dizygotic twins).
ii) CHEMICALLY INDUCED ANXIETY STATES
Infusion of sodium lactate, isoproterenol and caffeine, ingestion of
yohimbine and inhalation of 5% CO2 can produce panic episodes in
predisposed individuals. Administration l(oral) of HAOIs before lactate
infusion protects the individual form panic attach, thus providing a
probable clue to the biological model of anxiety.
I) GABA BENZODIAZEPINE RECEPTORS
This is one of the most recent advances in the search for etiology of anxiety
disorders. Benzodiazepine receptors are disturbed widely in the central
nervous system. Presently, two types have been identified. The type I is
GABA and chloride independent, while type II is GABA and chloride
dependent.
GABA is the most prevalent inhibitory neurotransmitter in the central
nervous system. It has been suggested that an alteration in GABBA levels
may lead to production of clinical anxiety. The fact that the
bencodiazepenin relieve anxiety and inverse antagonists cause anxiery,
lends heavy support to this hypothesis.
II) OTHER NEUROTRANSMITTERS

Norepinephrine, 5-HT, dopamikne, opioid receptor and neuro endrocrine
dysfunction have also been implicated in the causation of anxiety
disorders.
III) NEUROANATOMICAL BASIS
Locus -----, ------- system and prefrontal cortex are some of the areas
implicated in the etiology of anxiety disorders. Regional cuebral blood flow
is increased in anxiety, though vasoconstriction occur in severe anxiety.
IV) ORGANIC ANXIETY DISORDER
This disorder is characterized by the presence of anxiety which is secondary
to the various medical disorder. If anxiety can occur secondary to medical
disorders it is possible that anxiety has a biological basis.

PSYCHOLPATHOLOGY
Early emotional conflicts in life interfere with the normal development of personality
and contribute to the development of anxious or dythymic types of personality which
under the influence of st---- fo life breakdown in ot attacks of anxiety state. The usual
defense mechanism which helps in the handling of anxiety become too inadequate
resulting in an anxiety state.
CLASSIFICATION
 Generalized anxiety disorder.
 Panic disorder. Client belongs to the
classification of
GENERALISED ANXIETY DISORDER generalize disorder.
It is characterized by a generalized persistent anxiety of at least six month duration, and
manifested by signs of motor tension, autonomic hyper activity, ---------tensive
expectation and vigilance. It is the most common neurotic disorder.
EPIDEMIOLOGY
 3-17 PER 1000 among men.
 1-38 per 1000 among women.
PANIC DISORDER
Panic disorder is defined as a sudden attack of intense discomfort, fear, or tremor. Panic
disorder is characterized by fear and subsequent attempt to avoid of specific objects or
situation, which the person thinks are unreasonable.
ETIOLOGY OF GAD AND PANIC DISORDERS

GENETIC: Anxiety disorder is more frequent among relatives of patients with their
condition.
BIOCHEMICAL
Disturbance in nuro-transmitter especially nor-adrenaline , serotonin and GABA may
cause anxiety of disorder.
PSYCHOLOGICAL
As a result of intra psychic conflict, as a conditioned response a ---------- learning.

CLINICAL SYMPTOMS : PHYSICAL
SYMPTOMS IN GAD
1. CARDIOVASCULAR SYSTEM
 Tachycardia
 Chest pain
 Palpitations Client has the symptoms of palpitation, abdominal pain, hesitation
 Dropped beats to urination, tremors, sweating, aches and pain.
 Flushing
 Fainting
2. RESPIRATORY SYSTEM
 Sighing
 Choking
 Yawning
 Dyspnoea
3. ALIMENTARY SYSTEM
 Dry mouth’
 Dysphagia
 Dyspepsia
 Butterflies in stomach
 Nausea
 Abdominal pain
 Diarrhoea
4. GENITO-URINARY SYSTEM
 Frequency
 Hesitation
 Sexual dysfunction

5. Nervous system
 Tension headaches
 Blurring of vision
 Tinnitus
 Sweating
 Tremor
 Dilated pupils
6. MUSCULO SKELETAL SYSTEM
 Aches and pain
 Teeth clinching
 Chronic terks.
PSYCHOLOGICA SYMPTOMS OF ANXIETY

1. CONGNITIVE SYMPTOMS Client has the symptoms f fearfulness, irritability and
Poor concentration. worries.
Dis--------
Hyperarousal
Vigilance or scanning.
2. PERCEPTUAL SYMPTOMS
 Derealization.
 Depersonalization.
AFFECTIVE SYMPTOMS
 Diffuse , unpleasant, vague sense of
apprehension.
 Fearfulness.
 Inability to relax.
 Feeling of impoding doom.
 Worries.

OTHER SYMPTOMS
 Insomnia (initial) Client has the symptoms of insomnia, reduction in efficiency and
 Exaggerated startle response. feeling fatigue and tired.
 Vague somatic symptoms.
 Reduction in efficiency,
 Feeling fatigued and tired.
COMMON SIGNS ARE
 Elevation of blood pressure
 Tachycardia
 Increased respiratory rate
 Sweating
 Hyper reflexia
PHYSICAL SYMPTOMS OF PANIC
DISORDER Client has the physical symptoms of sweating and trembling.
 Increased heart rate.
 Dizziness
 Sweating
 Trembling
 Dyspnoea
 GI disorder and others.
PSYCHOLOGICAL SYMPTOMS OF PANIC

DISORDER
 Intense anxiety.
 Fear of dying or losing control.
 Depersonalization.
 Derealization.
TYPES
Some authors separated anxiety in to two
types.
TRAIT ANXIETY
This is a habitual tendency to be anxious in
general.

STATE ANXIETY
This is the anxiety felt at the present moment.
PRESENT MOMENT
According to the duration of anxiety, it is divided into two.
ACUTE ANXIETY REACTIONS

It is also known as panic physiological symptoms are most mark. Patient may be Client has acute anxiety
bewildered, confused and agitated. reactions.
CHRONIC ANXIETY NEUROSIS

Psychological symptoms are more marked resulting in physical and mental
exhaustion (neuroasthenia)
LEVELS OF ANXIETY
Anxiety has four levels
 Mild +
 Moderate ++
 Severe +++
 Panic +++
Changes in attention and concentration during levels or forms of anxiety. Client has mild level of
anxiety.
MILD
 Increased alertness.
 Concentration poor.
 Appears confident.
MODERATE
 Misperception of stimuli.
 Concentration very poor.
 Paces up and down.
 May irritate others.

SEVERE
Decreased and distorted perception.
PANIC
Attention and concentration highly affected.
DIFFERENTIAL DIAGNOSIS
In acute attacks of anxiety should be differentiated from p------ chromocytoma In case of client history of
and chronic anxiety state should be differentiated from thyrotoxicosis. The emotional conflict and
personality type, history of emotional conflicts, absence of exapthalmous, personality type show his
abence cold moist hands are more in favor of diagnosis of anxiety state. anxiety disorder and hence
diagnosed.
TREATMENT
The treatment is usually multimodal.
PSYCHOTHERAPY
This is the principal treatment usually supportive psychotherapy is used either
alone, when anxiety is mild or in combination with drug therapy. Deep
analytical psychotherapy is needed of chronic mal adjusted personalities since
the modification of basic psychic structure is important to set lasting benefit.
RELAXATION TECHNIQUES
In patient with mild to moderate anxiety relaxation techniques are used. It is
used by the patient himself as a routine exercise everyday and also whenever
anxiety provoking situation is at hand.
The technique include.

 Progressive relaxation technique.
 Yoga.
 Pranayama.
 Self-hypnosis.
 Meditation (TM- transcendental medication)
OTHER BEHAVIOR THERAPY
There include

 Cognitive behavioral therapy (BT) In case of client he gets drug therapy
 Bio feed back. such as transquilisers.
 Hyper ventilation control.
DRUGS
Drugs used are
 Sedatives
 Hypnotics
 Transquilisers (anxiolytics)
 Neuroleptics
TRANQUILLISERS
Example
- T.Meprobamate 200 mg t.d.s
- T. Chlordiazepoxide 5-10 mg t.d.s
- T.Alprzolam 0.25 to 1 mg t.d.s
- Buspirone 5-10 mg t.d.s given for symptomatic relief.
NEUROLEPTICS
Example:
T.Chloropromazine hydrochloride 25 mg t.d.s
T.Trifluoperazine 1 to 2 mg t.d.s
T.Haloperidol 0.25 mg t.d.
The tranguillisers and neuroleptics also be given parenterally.

Beta blockers like propanalol. (Eg – ciplar) are useful in the
management of anticipatory anxiety.
SEMINARCOSIS THERAPY
It is useful for acute reactions. Patients is put to sleep for 16 to 20
hours per day with the help of drugs.

ABREATIVE THERAPY
INDICATIONS
Definite psychological trauma feelings of guilt.
TREATMENT
Intravenous injections of sodium peritothal hypnosis.
Small doses (10 to 40 volts) of electric current passed bitemporally.
SOCIAL CASE WORK AND COUNSELLING In case of client

It is vey useful in cases where the conflicts are extra psychic and the environmental counselling was given.
stress is responsible for the illness. The goal is to modify the environment more
specially the psychosocial situations so as to reduce the unhealthy and abnormal
interactions between the patient and his family members, relatives, friends,
colleagues etc.
PSYCHOPHSIOLOGICAL THERAPY (PPT)

A very distinct advantage of this therapy is that it involves active participation and
training in the part of the patient and avoids the use of anxiolytic drugs which are
known to be habit forming. In case client prognosis
is good in both
MODIFIED INSULIN TREATMENT personality and
It is useful in relieving anxiety and in improving the physical health which will precipitating factors.
produce a sense of well-being.
PROGNOSIS
This is determined by,
DURATION OF ILLNESS: Shorter duration carries better prognosis.
PERSONALITY: Well adjusted personalities recover more easily than the neumotic,
mal adjusted personalities.
Possibility of environmental manipulation to make it as stressful for the person
ensures quicker and long lasting remission of symptoms.
NURSING MANAGEMENT
 Provide calm and quiet environment. All the nursing management are carried out with the
 Speak slowly and calmly. patient correctly.
 Provide reassurance and comfort.
 Encourage to take rest.
 Don’t leave the patient alone.
 Limit intake of caffeinated drinks.
 Give relaxation technique.
 Encourage to come for follow-up care.
 Give counseling to him and also to the family
members.
PSYCHO EDUCATION
HEALTH EDUCATION GIVEN ABOUT :
 PERSONAL HYGEINE
1) Instructed the patient to take bath daily, to brush daily, to wash hands before and after defecation
and before eating.
2) Instructed to cut short the nails once in a week, to comb hair properly and to wear the cloths after
washing and drying in sunlight.
FAMILY THERAPY
Encouraged the client and the family members to cope with the patient’s disease condition and take special care
of him without any avoidance of him.
Notified the patient carefully and encouraged him to do his works correctly.
BEHAVIOR THERAPY
Encourage the client to change his behavior by improving his activities of daily living, maintaining his personal
care and to make him to be socialized with others.
INDIVIDUAL PSYCHO THERAPY

Encouraged supportiveness for disease condition and to be confidence in his life.
GROUP PSYCHOTHERAPY
Group psychotherapy was given by forming a group in the hospital ad detailing the disease condition and the
methods of treatment.
FOLLOW UP CARE
Instructed the patient to take medications regularly.
Avoid discontinuing the drugs once he felts better without doctor’s order and to come for a regular check up.
CONCLUSION
Client showed improvement after his starting of treatment. H showed interest and coped with the treatment.
His symptoms were reduced which was severe during admission. At present this under follow-up treatment.
BIBLIOGRAPHY
1. NIRAJ AHUJA - A short text book of psychiatry 5th edition. Jay Pee -2002 page no : 91- 95.
2. S. NAMBI: Psychiatry for Nurses, first edition Jay Pee Company – 1998, Page No: 46 to 52.
3. BIMLA KAPOOR - “TEXT BOOK OF PSYCHIATRIC NURSING” 1st edition – volume II, Delhi-1994.
4. LYNDA JUALL CARPENTIO - “ Handbook of Nursing Diagnosis. 7th edition- Lipincott – New York
1997.
5. CIMS – Current Index of Medical specialities.
EAST WEST COLLEGE OF NURSING BANGALORE
CASE PRESENTATION
ON
SCHIZOPHRENIA
Mrs. Mr.MAHANTESH.K
1st Yr MSc Nursing

BANGALORE. BANGLORE
INTRODUCTION:
During our clinical postings we are posted to NIMHANS as per our rotation plan I posted to male
general ward I selected patient by name of Mrs Anu . with multiple suicidal attempts diagnosed as a
case of “schizophrenia”. I took this case for my presentation.
IDENTIFICATION DATA
Name of patient : Miss. Anu
Age : 30 years
Sex : Female
Ward : pavilion 4
Address : Bapuji Nagar. Hubli
Religion : Hindu
Marital Status : Unmarried.
Education : 7th STD
Occupation : Nil.
Date of admission : 14/01/10
Diagnosis : Schizophrenic – undifferentiated
INFORMANT
Client’s mother is the informant. She is the mother of patient and she is living
together with her daughter. She had good intellectual and observation ability. She
had higher degree of concern regarding the patient.
PRESENTING CHIEF COMPLIANT
According to patient she had no problem. She is absolutely alright.
According to informant this is the fourth episode of Miss. Kamashis illness. She had
complaints of fearfulness, reduced sleep, increased activity, talk with herself and
increased talk, hallucination and reduced food intake also present.
HISTORY OF PRESENT ILLNESS
This is the fourth episode of illness. Miss. Anu was admitted to this hospital with
complaints of reduced sleep, increased talk, tremors, and assaultive behavior for 1
week. On examination she has bradykinesia, increased talk, delusion of grandiosity
and delusion of persecution and reference, apathetic and tremor present. During
admission Inj.Haloperidol 1amp 1M & Inj.phenergan 25mg 1M stat administered.
Now her condition has improved. Now she is oriented euphoric, increased activity,
delusion of grandiosity thought block etc present. She was maintained good rapport
and she had good memory and insight.
PAST PSYCHIATRIC AND MEDICAL HISTORY
Miss. Anu is a known case of schizophrenia since 3 years. This is the fourth episode of
disease. Initially she was treated in medical college hospital, Manipal and was on
T.Clozapin, T.Pentril and T.Sodium valproate. Then she was referred to mental health
center, perroorkada. She was on same drugs since 9/9/06. Possible precipitating
factor was beating from her mother. During first episode she was depressed; crying
behavior and reduced sleep was present. 1 st episode was 3 years back and each year
he was developing disease. Now the disease I in severe form
Miss.Anu had no history of any medical or surgical history. No history of head injury
prior to illness.
TREATMENT HISTORY
This is the fourth episode of illness. During the previous episode and follow up she
was on: T.Petril, Tab. Valproate & T.Clozapin. No further history is available.
FAMILY HISTORY
Miss. Anu is living with her mother. She is living with her mother and younger sister.
No history of mental illness in the family. No family history of diseases like DM, HTN,
Cancer etc.
FAMILY TREE
PERSONAL HISTORY
1. Personal history
No history of any febrile illness, drug, alcoholism etc during pregnancy. She is
born by normal vaginal delivery. No complications present during perinatal
period.
2. Childhood history
Miss. Anu is brought up by her mother. She is a wanted child. She had no
history of any illness and behavioral disorder during childhood.
3. Education history
Miss. Anu started her formal education at her 7 year of age. She was not very
interested in study.
4. Play history
She was engaged in play and she was very happy to participate in play. She
had good relationship with peers of same and opposite sex.
5. Puberty
She attained menarche during her 14 years of age. No behavior changes
present during menarche.
6. Menstrual history
Miss. Anu menstrual cycle is regular and it is 28 days cycle. She had abdominal
pain and back pain during menstruation.
7. Marital & sexual history
Miss Anu is unmarried. She had no sexual relationship with others.
8. Occupational history: Nil.
9. Interpersonal relationship
 Miss. Anu had good interpersonal relationship with family members,
friends and superiors.
 Use of leisure time – no specific hobbies as use of leisure time.
 She had good attitude towards self and she had poor self confidence. She
is only concerned with herself
 Family life – she is very happy in her home
 Habit – she had no specific habits and food fads.
10. Environmental history
Miss. Anu house is hatched. The source of water supply is from well. Disposal of
excreta is through sanitary latrine.
11. Nutritional history
Miss. Anu had no specific likes and dislikes. She is a on – vegetarian. She used
to eat 3 times a day. Now she had reduced intake of food because of illness.
12. Socioeconomic status
Miss. Anu’s family belongs to low class family. Her mother have the monthly
income of around Rs.500/-. Her father is not with them. He has left their
family.
PHYSICAL AND PHYSIOLOGIC ASSESSMENT
a. Vital signs
Temperature – Normal
Pulse – 82/mt
Respiration – 26/mt
BP – 110/80 mmHg
b. Head to foot examination.
Body parts Observations

Skin condition Skin color is paler, scaling present, rough texture. Good
skin turgor. No lesions and edema.
Nails Pale in color, normal shaped, capillary refill is good
Hair and scalp Equal distribution of hair. No complaints of alopecia.
Infestation with the present
Skull Normal size. No exophthalmoses
Eyes and vision Good vision, normal ocular movement, no infection,
redness etc. star looking present.
Ears No infection. Good hearing capacity. No pain and use of
hearing aids.
Nose No frequent colds. No changes in sense of smell. No
DNS and discharges.
Mouth & throat Pink mucosa, dry mouth, no halitosis, no gum
hyperplasia and dental ache.
Neck Good range of motion, no thyroid enlargement and
distension of lymph nodes present.
Thorax and chest Chest expansion on breathing is symmetric and
bilaterally equal. No adventitious breath sounds
present. No palpable masses present.
Abdomen Normal color, soft, not tender and no distension present
Upper extremities Good range of motion. No tenderness, frequent hand
movement present.
Lower extremities Good range of motion. No tenderness. She used to walk
too frequently. So walking had some instability.
Inference Miss. Kamashi had no specific physical impairments.
She had only symptoms associated with schizophrenia.
GENERAL APPEARANCE:
Facial expression is apathetic
Posture – relaxed
Mannerism – present i.e., frequent walking present
Hygiene - poor
Grooming – satisfactory
Physical deformities - absent
Remark : apathetic, relaxed posture, mannerism of walking and poor hygiene and
grooming present.
MOTOR DISTURBANCE:
Present i.e., hyperactivity
DISORDER OF THOUGHT
a. Form of thought disorder – thought retardation present

b. Disorder of content of thought
Delusion – Present i.e., delusion of grandiosity and delusion of reference
(Patient says that she know all things and all of the people are talking about
her)
Phobic – absent
Fantasy – absent
Remark : she had delusion of grandiosity and reference.
DISORDER OF SPEECH:
1. Pressure of speech – decelerated

2. Flight of ideas – present (Patient says many things at same
time)
3. Thought block – present
EVALUATION OF SPEECH
1. Intensity – low
2. Pitch – abnormal variation
3. Speed – decreased
4. Manner – inappropriate
5. Reaction time - slow
DISORDER OF PERCEPTION
Illusion – absent
Hallucination – present. Auditory hallucination all times she is talking with herself
DISORDER AFFECT
1. Affect – inappropriate
Subjective – patient says “I am happy”
Objective – anxious, depressed and sometimes laughing
2. Pleasurable effect – present , euphoric
3. Un pleasurable effect – absent
4. Mood swing – present
DISORDER OF MEMORY
1. Immediate memory
Q: what you had for your breakfast?
A: wheat conjee
2. Recent memory
Q: when did you slept yesterday?
A: 9 O’ clock
3. Remote memory
Q: who was your best friend?
A: Rema
4. Any disorder in memory – absent
Remark: immediate, recent and remote memory are unaffected.
DISORDER OF ORIENTATION
1. Orientation to time
Q: what is the time now? (10:00AMP
A: 7am
2. Orientation to place
Q: which place is this?
A: NIMHANS
3. Orientation to person?
Q: who am I?
A: Sister
Remark: oriented to time, place and person.
DISORDER OF CONCENTRATION
Q: tell me the days of week in descending order
A: Saturday, Friday, Thursday, Wednesday, Tuesday, Monday, Sunday
Remark: Concentrates well
INSIGHT
Q: how are you?
A: fine, I have no problem
Q: for what reason you were admitted here?
A: I don’t know.
Remark: insight grade II
DISORDER OF JUDGMENT
Q: What will you do when you see a dog for biting you?
A: No response
Remark: judgment is impaired.
INTELLIGENCE
Q: add 19 with 29
A: 48
Q: subtract 22 from 52
A: 30
Remark: Intelligence is intact
ABSTRACT THINKING
Proverb
Q: Tell me the meaning of “Barking dog seldom bites”
A: no response
Similarities
Q: What are the similarities between these two pens? (Blue and Black
Pens)
A: Both are pen
Differences
Q: What are the differences between these two pens?
A: no response.
Remark: Abstract thinking is impaired.
DISORDER OF SLEEP
Present she had poor sleep in night. She woke up intermittently.
SUMMARY
Eye to eye contact developed from beginning itself.
GENERAL REMARKS
Miss. Anu had delusion of grandiosity, delusion of reference, auditory hallucination,

inappropriate affect and impaired judgment and abstract thinking.
SCHIZOPHRENIA
INTRODUCTION
Schizophrenic disorder is a group of mental disturbances essentially characterized by
a. One or more psychotic features during the active phase, including a bizarre or
abort delusion such as being controlled.
b. Somatic grandiose, religious or nihilistic delusions
c. Delusion of persecution or jealousy with hallucination, blund, flat or
inappropriate affect.
d. Hallucination
e. grossly disorganized behavior such as in catatonic
A common term for schizophrenic disorder is schizophrenia.
DEFINITION
The American psychiatric association defines schizophrenia as “A group of disorders

manifested by characteristic disturbance of thinking, mood and behavior”.
Disturbance in thinking is marked by alteration of concept formation which may lead
to misinterpretation of reality and sometimes to delusions and hallucinations. Mood
changes include ambivalent constituted or inappropriate emotional responsiveness
and loss of empathy with others. Behavior may be withdrawn, are regressive and
bizarre.
CLASSIFICATION
The classification of schizophrenia according to ICD – 10 are
1. paranoid schizophrenia (F20-0 )

2. hebephrenic schizophrenia (F20-1)
3. catalonie schizophrenia (F20-2)
4. undifferentiated schizophrenia (F20-3)
5. post schizophrenic depression (F20-4)
6. residual schizophrenia (F20-5)
7. simple schizophrenia (F20-6)
8. other schizophrenia (F20-8)
9. schizophrenia unspecified (F20-9)
Etiology of Schizophrenia
Recent research suggests that schizophrenia involves problems with brain
chemistry and brain structure. However, no single cause has been identified to
account for all cases of schizophrenia. Scientists are currently investigating possible
factors contributing to the development of schizophrenia. These factors include viral
infections occurring early in life, abnormalities in the developing fetus, middle-brain
damage due to birth complications, and genetic predisposition.
Genetic Predisposition Theory

The genetic, or hereditary, predisposition theory suggests that the risk of
inheriting schizophrenia is 10% in those who have one immediate family member
with the disease, and approximately 40% if the disease affects both parents or an
identical twin. About 60% of people with schizophrenia have no close relatives with
the illness
Biochemical and Neurostructural Theory

The biochemical and neurostructural theory includes the dopamine
hypothesis: that is, that an excessive amount of the neurotramsmitter dopamine
allows nerve impulses to bombard the mesolimbic pathway, the part of the brain
normally involved in arousal and motivation. Normal cell communication is
disrupted, resulting in the development of hallucinations and delusions, symptoms of
schizophrenia
Environmental or Cultural Theory

Proponents of the environmental or cultural theory state that the person who
develops schizophrenia has a faulty reaction to the environment, being unable to
respond selectively to numerous social stimuli. Theorists also believe that persons
who come from low socioeconomic areas or single-parent homes in deprived areas are
not exposed to situations in which they can achieve or become successful in life.
Thus they are at risk for developing schizophrenia. Statistics are likely to reflect the
alienating effects of this disease rather than any causal relationship or risk factor
associated with poverty or lifestyle (Kolb, 1977).
Perinatal Theory
Experts suggest that the risk of schizophrenia exists if the developing fetus or
newborn is deprived of oxygen during pregnancy or if the mother suffers from
malnutrition or starvation during the first trimester of pregnancy. The development of
schizophrenia may occur during fetal life at critical points in brain development,
generally the 34th or 35th week of gestation. The incidence of trauma and injury
during the second trimester and birth has also been considered in the development of
schizophrenia (Well-Connected, 1999a).
Psychological or Experiential Theory

Although genetic and neurologic factors are believed to play major roles in the
development of schizophrenia, researchers also have found that the prefrontal lobes
of the brain are extremely responsive to environmental stress. Individuals with
schizophrenia experience environmental stress when family members and
acquaintances respond negatively to the individual's emotional needs. These negative
responses by family members can intensify the already vulnerable neurologic state,
possibly triggering and exacerbating existing symptoms.
ETIOLOGY IN GENERAL AND IN PATIENT
There is no specific etiology of schizophrenia. In general, the

theories of schizophrenia can be described as follows:
A. Genetic factors: Monozygotic twins have four times

higher chances of developing schizophrenia than the
dizygotic, the chances of other twin being affected is
85.8%. children of schizophrenia patients are more
prone to develop schizophrenia than children of other
person. 40% of children born to both the
schizophrenia patients will be affected. 10% of
children will be psychotic if one parent have
schizophrenia
B. Psychosocial factors
1. Impaired ego functioning:- reality testing and

judgment is affected. The intensity of schizophrenia
will depend upon the intense impairement of ego
function
2. Mother infant relationship:- there may be defect in

the mother baby relationship. Deprivation of early
mothering reduces child’s capacity to socialize. Lack
Mother infant
of effective mother – child relationship does with draw
relationship was
the child from socialization.
impaired.
3. Pathologic communication: It has a significant role to
play in a child whether to withdraw from the
communication or continue. EX: in double bound
communication the child is not discriminate the sort
of message conveyed.
4. Pathologic family interaction: Transaction between

parents or significant people who relate with the
child. Parent may be maintaining superficial
relationship.
C. Socio cultural factors : Persons who live in low socio –

economic families and areas are prone to
schizophrenia. Ex: a child at a very young age goes
for work and is deprived of affection from parents,
schooling, play mates. This cause a lot of anger and Poor socio – economic
frustration in the child. status, belongs to low
income group.
D. Organic theory: Theories believe that schizophrenia is
caused due to infection , poison, trauma or metabolic
disorders.
1. Biochemical theory:- Schizophrenia is due to

functional increase of dopamine at the post –
synaptic receptor, through other neuro
transmitters like serotonin (5 HT 2 receptor) , GABA
& acetyl chlonie are also presumably involved.
2. Brain imaging: CT &MRI scan shows ventricular

hypertrophy and mild cortical atrophy. PET scan
shows hypofraontality and decreased glucose
citilization in the dominant temporal lobe.
E. Vitamine deficiency theory
A patient with vitamin B 1, B6, B12 & Vitamin C

deficiency may become schizophrenia.
PSYCHODYNAMICS
The bio-chemical, and neuro-structural theory includes the dopamine hypothesis:

i.e., that an excessive amount of neurotransmitter dopamine allows nerve impulses to
bombard the mesolimbic path way. The part of the brain normally involved in arousal
and motivation. Normal cell communication is disturbed resulting in the development
of hallucinations and delusions, symptoms of schizophrenia. The cause of the release
of high levels of dopamine has not yet been found, but the administration of
neuroteplic medication supposedly blocks the excessive release.
Abnormalities of brain shape and brain circuitry are being researched as well. A
circuit filters information to other parts of the brain for determining action. A
defective circuit results in the bombardment of unfiltered information, possibly
causing both negative and positive symptoms. Overwhelmed, the mind makes errors
in perception and hallucinates, draws incorrect conclusions and becomes delusional.
To compensate for this barrage, the mind withdraws negative symptoms develop.
CLINICAL FEATURES
Schizophrenia is characterized by disturbance in thought

and verbal behavior, pereption , affect, motor behavior
and relationship to external world.
Bleuler’s fundamental symptom of schizophrenia (4 A’s of
Bleuler )
1. Ambivalence -> two opposite emotion toward same

object or things or event
2. Autism -> withdrawal into self

Autism
3. Affect disturbance -> inappropriate affect
In appropriate affect
4. Association disturbance -> loosening of association ,
thought disorder
Bleler’s accessory symptoms include:
1. Delusions
Delusion
2. Hallucinations
Hallucinations
3. Negativism
CLINICAL FEATURES
1. THOUGHT & SPEECH DISORDERS
 Autistic thinking is most important features of

Autism
schizophrenia
 Loosening of association
 Thought blocking
Thought blocking
 Neologisms are newly formed works or phrases
whose derivation can not be understood
 Complete mutism, poverty of speech, poverty of

ideation, echolalia, preservation or
verbigeneration (senseless repetition of same
words or phrases over and over again )
 Delusion
 Primary delusion and secondary delusion.

 Delusion of persecution
Delusion of persecution
 Delusion of reference
 Delusion of grandeur and grandiosity
 Delusion of control
 Somatic delusion
2. DISORDER OF PERCEPTION
 Hallucination (3rd person )
3. DISORDER OF AFFECT
 Apathy Hallucination
 Emotional blunting
Apathy emotional
 Emotional shallowness
blunding
 Anhedonia
 Inappropriate emotional response
4. DISORDER OF MOTOR BEHAVIOR
 Decreased activity
 Increased activity
 Mannerism, grimacing, stereotypes, decreased
self care and poor grooming Increased activity
5. NEGATIVE SYMPTOMS
 Affective flattening or blunding, attention

impairment , avolition apathy, anheclonia,
associality, and alogia ( lack of speech output) Blund affect apathy
alogia.
6. OTHER FEATURES
 Decreased functioning
 Loss of ego boundaries
 Multiple somatic symptoms
 Insight is absent
 Suicide can occur Insight grade I
 No disturbance of consciousness
 No underlying organic disorder and prominent
mood disorder.
CLINICAL FEATURES OF EACH TYPES
1. Paranoid schizophrenia
- Delusion of persecution, reference grandeur, control
or infidelity
- Hallucination usually have persecutory or
grandeurs content
- Disturbance of affect, volition speech and motor
behavior
2. Disorganized or hebephrenic s schizophrenia
- Marked thought disorder
- Emotional disturbances mannerism
- Mirror, gazing, inhabited behavior , poor self care
and hygiene etc.
3. Catatonic schizophrenia
Disturbance of motor behavior.
It can present in three forms; excited catatonia,
stuporous catatonia, and catatonia alternating
between excitement and stupor.
4. Residual and latent schizophrenia
- Negative symptoms
- Absence of dementia or other organic brain disease
or disorder and chronic depression or
institutionalism sufficient to explain the negative
impairements.
5. Undifferentiated schizophrenia
Common type. No features of one subtype is
exhibited.
6. Simple schizophrenia
- Negative symptoms Undifferentiated
- Delusion and hallucination are absent schizophrenia
7. Post schizophrenic depression

Develops with in 12 months of an acute episode.
They are associated with increased risk of suicide.
Diagnostic measures

According to 1CD- 10 for the diagnosis of schizophrenic ,
a minimum of one very clear symptom (and usually or
more if less clear out) belonging to any one of group
referred to as
a. Thought echo or thought broadcasting

b. Delusion of control, influence or passivity delusional
of perception
c. Hallucinatory voice giving running commentary
behavior
Persistent delusion
d. Persistent delusion.
At least two from :
1. Persistent hallucination Persistent hallucination

2. Thought block
Thought block
3. Catotonie behavior Catatonic behavior
Bood examination on
4. Negative symptoms
30/6/06
These should have been clearly present for most of the TC – 7200/cmm
time during a period of one month or more ( Required a Need rophils – 42%
minimum period of one month) Lymphocyte – 50%
Eosinophils – 8%
MANAGEMENT
1. Somatic treatment T. Haloperidol 5mg 1M sos

(antipsychoties)
a. Pharamacological treatment
 Antipsychotics like resperidone, olanzapine, T.Phenergan 25mg 1M sos
trifluoperazine, haloperidol, ziprasidone and (sedative)
chlorpromazine T.Clozepine 0-0- ½ (atypical
 A typical antipsychoties like resperidone, antipsychoties)
clozapine, olenzepine etc T.Valproate bol (Mood
 In presence of acute episode Inj.Haloperidol stabilizer)
10-20mg 1V or 1M with or without10mg T.Librium 10 mg 0-0-1
diazepam CPZ 50-100 mg also can be given. ( antianxiety)
 Maintenance treatment with antipsychoties to
prevent relapse
 To ensure drug compliance, depot
preparations with long term action can be
used ex: haloperidol deconate 100-200mg 1M
for every 4 week.
2. Electroconvulsive therapy: 8-12 ECTs are
ECT tried for 2 times.
needed. Give three times a week
3. Miscellaneous treatment
 Limbie leucotomy ( a small subceudate
lesion with a cingulated lesion)
 Others are megavitamin theory dialysis,
malaria therapy, high dose propandol
and insulin coma therapy
4. Psychosocial treatment
a. Psychoeducation
Psycho education
b. Group psychotherapy
- Teaching problem solving,
- communication skill etc
c. family therapy Family therapy
d. millies therapy (Therapecitic community
include treatment in a living , learning or
working environment ranging from 1p
psychiatric unit to day care hospitals and
half way homes.
e. Individual psychotherapy supportive in
nature
f. Psychosocial rehabilitation
Includes activity therapy, training in a new
vocation or retraining previous skills,
vocational guidance, sheltered employment
or self employment and occupational
therapy.
LIST OF NURSING PROBLEMS

1. Disturbed thought process related to presence of delusions
2. Disturbed sensory perception related to presence of hallucination as evidenced
by talking with herself, always whispering, laughing etc
3. Disturbed motor activity related to hyperactivity
4. Impaired nutritional status, less than body requirement related to reduced food
intake
5. Impaired verbal communication related to thought disturbance as evidenced by
though block & thought retardation
6. Self care deficit in physical need cleaning, bathing , eating etc
7. Ineffective individual coping related to fear
8. Noncompliance related to refusal to take prescribed psychotropic medication
9. Potential for violence
10. Impaired socialization related to fear of rejection secondary to low self concept.
BIBLIOGRAPHY
6. Shives LR. “Basic concept of psychiatric mental health nursing. 6 th edition.

Philadelphia; Lippincott: 2005.
7. Ahuja N. “Text book of psychiatry”. 5th edition; New Delhi. Jaypee; 2002.
8. Bhatia MS. “Essentials of psychiatry”. 4th edition. New Delhi; CBS publishers:
2004.
9. Sreevani R. “A guide to mental health and psychiatric nursing”. New Delhi,
Jaypee: 2004.
10. Stuart GW. “Principles and practice of psychiatric nursing”. 7 th edition;
Mosby; Harcourt:2001.
11. Lippincott’s Mannual of psychiatric nursing care plans, 5th edition,
12. Dr. (Mrs) K Lalitha- Mental Health and Psychiatric Nursing. An Indian
Perspective. VMG Book house, Bengaluru, 2008..

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SUBMITTED TO: SUBMITTED BY:

1st Yr MSc Nursing

Ward : open psychiatric ward.

PHYSICAL & PHYSIOLOGIC ASSESSMENT

BODY PARTS OBSERVATION

Skin Color is normal. Dry skin

MENTAL STATUS EXAMINATION

BIPOLAR AFFECTIVE DISORDER

Classification of mood disorder

6. Feeling of hopelessness and use of defenses

7. Psychodynamics: psychoanalytical theory explains Socio cultural factors.

Book picture Patient picture

C. Electroconvulsive therapy (ECT)

LIST OF NURSING DIAGNOSIS

1. Fatigue related to hyperactivity secondary to manic state of bipolar disorder

PSYCHO EDUCATION & REHABILITATION

Explained the patient regarding various measures to do at home

 Encourage him to go day care center and to interact with others

5. Stuart GW. “Principles and practice of psychiatric nursing”. 7 th edition; Mosby;

EAST WEST COLLEGE OF NURSING BANGALORE

SEVERE DEPRESSION WITH PSYCHOTICS SYMPTOMS

SUBMITTED TO: SUBMITTED BY:

1st Yr MSc Nursing

Address : d/o devegouda. Harugeri Belgaum.

HISTORY PRESENT ILLNESS

Not interested to socialize with others.

No history of mental illness in the family.

Mannerisms- continuous picking up fingers and finger nails.

Doesn’t respond verbally to any questions.

Speech : Not responding.

Thought : Not co-operative.

SL TEST PATIENT VALUE NORMAL VALUE REMARKS

SL DRUGS DOES FREQ/ROUT ACTION SIDE EFFECTS

MOOD DISORDERS – DEPRRESSION

ETIOLOGY OF MOOD DISORDERS

LIFE EVENTS AND ENVIRONMENTAL THEORY

COMPARISON OF ETIOLOGY WITH PATIENT

SL BOOK PICTURE PATIENT PICTURE

SL BOOK PICTURE PATIENT PICTURE

SL BOOK PICTURE PATIENT PICTURE

SL BOOK PICTURE PATIENT PICTURE

Transiet depression Mild depression Moderate Severe depression

PRIMARY RISK FACTORS FOR DEPRESSION

1.History of prior episode of depression.

MAJOR DEPRESSIVE DISORDER

COURSE AND PROGNOSIS OF MOOD DISORDERS

GOOD PROGNOSTIC FACTORS

FOLLOW-UP AND HOME CARE AND REHABILITATION

Name : Mr. Anand

RELIABILITY OF THE INFORMANT

CHIEF COMPLAINTS DURING ADMISSION

PAST MEDICAL AND SURGICAL HISTORY

PAST PSYCHIATRIC HISTORY

PRESENT PSYCHIATRIC HISTORY

CHILD HOOD HISTORY

SEXUAL AND MARITAL HISTORY

MENTAL STATUS EXAMINATION

 COMPREHENSION: Intact (fully)

 BEHAIVIOUR AND PSYCHOMOTOR ACTIVITY

SOCIAL MANNER AND BEHAIVIOR

VOLUME AND TONE OF SPEECH

FLOW AND RHYTHM OF SPEECH