Mental Health and Psychiatric Nursing

SECOND EDITION
R Sreevani
Foreword
K Reddemma
JAYPEE
A Guide to
MENTAL HEALTH
AND
PSYCHIATRIC NURSING
R Sreevani
MSc (Psychiatric Nursing)
Associate Professor, Sri Devaraj Urs College of Nursing
Tamaka, Kolar
Karnataka
Contributing Editor
Prasanthi N
Research Scholar in Nursing
NTMHANS
Bengaluru
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
New Delhi
Contents
1. Mental Health and Mental Illness 1

2. Principles and Concepts of Mental Health Nursing 14
3. Personality Development and Theories 29
4. Conceptual Models 48
5. Nursing Process in Psychiatric Nursing 57
6. The Therapeutic Nurse-Patient Relationship 66
7. The Individual with Functional Psychiatric Disorder 77
8. Organic Mental Disorders 104
9. The Individual with Neurotic Disorder 110
10. Behavioral Syndromes Resulting from Physiological Disturbances 124
11. Disorders due to Psychoactive Substance Use 129
12. Disorders of Adult Personality and Behavior 144
13. Childhood Psychiatric Disorders 150
14. Therapeutic Modalities in Psychiatry 171
15/Crisis Intervention 201
16. Legal Aspects of Mental Health Nursing 215
17. Community Mental Health Nursing 224
18./Psychiatric Emergencies 240
19. Psychosocial Issues Among Special Population 245
Appendix I-Glossary 253
Appendix II-Mental Mechanisms 260
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Further Reading 263
Index 2
265
Mental Health and
Mental Illness
D MENTALHEALTH and to each other with a maximum of
Definitions effectiveness and happiness."
Components of Mental Health
Criteria for Mental Health The American Psychiatric Association (AP A
Indicators of Mental Health - Jahoda (1958) 1980) defines mental health as: "Simultaneous
Characteristics of a Mentally Healthy
Person success at working, loving and creating with the
D MENTALILLNESS capacity for mature and flexible resolution of
Definition conflictsbetween instincts, conscience,important
Characteristics of Mental Illness
Features of Mental Illness
other people and reality".
Common Signs and Symptoms of Mental
Thus mental health would include not only
Illness
D CONCEPTSOF NORMALANDABNORMAL the absence of diagnostic labels such as schizo-
BEHAVIOR phrenia and obsessive compulsive disorder, but
D PROBLEMSOF MENTALDISORDERS also the ability to cope with the stressors of daily
D BURDENOF MENTALDISORDERS
D MENTALHEALTHFACTS living, freedom from anxieties and generally a
D MENTALHEALTHISSUES positive outlook towards life's vicissitudes and
D MINIMUMACTIONSREQUIRED to cope with those.
D MAGNITUDEOFTHE PROBLEMININDIA
D ETIOLOGYOF MENTALILLNESS
D MISCONCEPTIONSABOUTMENTALILLNESS Components of Mental Health
General Attitude Towards The Mentally Ill The components of mental health include:
D MENTALHEALTHTEAM
D CLASSIFICATIONOF MENTALDISORDERS The ability to accept self: A mentally healthy
ICD10 individual feelscomfortable about himself. He
DSMIV feels reasonably secure and adequately
Indian Classification
accepts his shortcomings. In other words, he
has self-respect.
MENTAL HEALTH The capacity to feel right towards others :An
It is a state of balance between the individual and individual who enjoys good mental health is
the surrounding world, a state of harmony bet- able to be sincerely interested in other's
ween oneself and others, a co-existence between welfare. He has friendships that are satisfying
the realities of the self and that of other people and lasting. He is able to feel a part of a group
and the environment. without being submerged by it. He takes
responsibility for his neighbors and his fellow
Definitions members.
Karl Menninger (1947) defines mental health as The ability to fulfill life's tasks : The third
"An adjustment of human beings to the world important component of mental health is that
2 A Guide to Mental Health and Psychiatric Nursing
it bestows on an individual the ability to meet 5. Perception of reality
the demands of life.A mentally healthy person This includes perception of the environment
is able to think for himself, set reasonable goals without distortion, as well as the capacity for
and take his own decision. He does something empathy and social sensitivity- a respect and
about the problems as they arise.He shoulders concern for the wants and needs of others.
his daily responsibilities, and is not bowled 6. Environmental mastery
over by his own emotions of 'ear, anger, love This indicator suggests that the individual
or guilt. has achieved a satisfactory role within the
group, society or environment. He is able to
Criteria for Mental Health love and accept the love of others.
Adequate contact with reality Characteristics of a Mentally Healthy Person
Control of thoughts and imagination
He has an ability to make adjustments.
Efficiency in work and play
He has a sense of personal worth, feels
Social acceptance
worthwhile and important.
Positive self-concept
He solves his problems largely by his own
A healthy emotional life effort and makes his own decisions.
He has a sense of personal security and feels
Indicators of Mental Health secure in a group, shows understanding of
other people's problems and motives.
Jahoda (1958) has identified six indicators of
He has a sense of responsibility.
mental health which include:
He can give and accept love.
1. A positive attitude towards self
He lives in a world of reality rather than
This includes an objective view of self,
fantasy.
including knowledge and acceptance of
He shows emotional maturity in his behavior,
strengths and limitations. The individual feels and develops a capacity to tolerate frustration
a strong sense of personal identity and security and disappointments in his daily life.
within the environment. He has developed a philosophy of life that
2. Growth, development and the ability for self gives meaning and purpose to his daily
actualization activities.
This indicator correlates with whether the He has a variety of interests and generally
individual successfully achieves the tasks lives a well-balanced life of work, rest and
associated with each level of development. recreation.
3. Integration
Integration includes the ability to adaptively MENTAL ILLNESS
respond to the environment and the develop-
Mental illness is maladjustment in living. It
ment of a philosophy of life, both of which
produces a disharmony in the person's ability to
help the individual maintain anxiety at a
meet human needs comfortably or effectivelyand
manageable level in response to stressful function within a culture.
situations. A mentally ill person loses his ability to
4. Autonomy respond according to the expectations he has
Refers to the individual's ability to perform, for himself and the demands that society has for
in an independent self-directed manner; the him.
individual makes choices and accepts In general an individual may be considered
responsibility for the outcomes. to be mentally ill if:
Mental Health and Mental Illness 3
the person's behavior is causing distress and Boweland bladdermovement: Diarrhea or consti-
suffering to self and I or others pation, increased micturition, bed-wetting.
the person's behavior is causing disturbance Sexual desireand activity: Decreased interest in
in his day-to-day activities, job and inter- sex, premature ejaculation, impotence or lack
personal relationships. of sexual satisfaction. In some conditions
there can be excessive sexual desire or lack of
Definition social inhibitions.
Mental and behavioral disorders are understood
as clinically significant conditions characterized 2. Disturbances in Mental Functions
by alterations in thinking, mood (emotions) or Behavior:The patient may exhibit over activity,
behavior associated with personal distress and/ restlessness, irritability, may be abusive to
or impaired functioning. (WHO, 2001) others for trivial or no reasons at all, or the
patient may become dull, withdrawn and not
Characteristics of Mental Illness respond to external or internal cues. At times
Changes in one's thinking, memory, percep- the patient may behave in a bizarre way which
tion, feeling and judgment resulting in the family members may find irritating. Some-
changes in talk and behavior which appear times the patient's behavior can be dangerous
to be deviant from previous personality or from to self or others.
the norms of community Speech: Patient talks excessively and unneces-
These changes in behavior cause distress and sarily or talks very little or stays mute. The
suffering to the individual or others or both talk becomes irrelevant and un-understand-
Changes and the consequent distress cause able (incoherent).
disturbance in day-to-day activities,work and Thought: Patient expresses peculiar and wrong
relationship with important others (socialand beliefs which others do not share.
vocational dysfunction). Emotions: Patient may exhibit excessive emo-
tions like excessive happiness, anger, fear or
Features of Mental Illness sadness. Sometimes emotions can be
inappropriate to situations. He may laugh to
The features of mental illness are classified under self or weep without any reason.
four headings Perception: The patient may perceive without
1. Disturbances in bodily functions any stimulus. There can be misinterpretation
2. Disturbances in mental functions of perception. For example a mentally ill
3. Changes in individual and social activities person can see things or hear sounds or feel
4. Somatic complaints objects which do not exist or which others do
not see. This is known as hallucinations. A
1. Disturbances in Bodily Functions patient who is hallucinating is seen talking to
Sleep: Disturbed sleep throughout the night, self, laughing or weeping to self, wandering
or no sleep at all, or difficulty in falling asleep, in the streets and behaving in a manner which
or waking up in the middle of night and others may find abnormal.
failing to fall asleep again. In addition, the Attention and concentration: Patient may have
individual may experience lethargy and lack decreased attention and concentration; he
of freshness in the morning. may get distracted easily, or have selective
Appetite and food intake: Increased appetite or inattention.
decreased appetite, weight loss or weight gain, Memory: Patient may lose his memory and start
nausea, vomiting. forgetting important matters.
Intelligence and judgment: In some mental Disorders of emotion
illnesses, intelligence and the ability to take Blunt affect, labile affect, elated mood, euphoria,
decisions deteriorate. Patient loses reasoning ecstasy, dysphoric mood, depression, anhedonia.
skills and abilities, may not be able to perform Disturbances of consciousness
simple arithmetic, or commits mistakes in Clouding of consciousness, delirium and coma.
routine work.
Level of consciousness: In some mental illnesses Disturbances in attention
due to possible brain damage there may be Distractibility, selective inattention.
changes in the level of consciousness. Patient Disturbances in orientation
fails to identify his relatives. He can be Disorientation of time, place or person.
disoriented to time and place. He may remain
confused or become unconscious. Disturbances of memory
Amnesia, confabulation.
3. Changes in Individual and Social Activities Impaired judgment
Patients may neglect their bodily needs and
personal hygiene. The patient may also lose social
Disturbances in biologicalfunction
Persistent deviations in temperature, pulse and
sense. They behave in an inappropriate manner
respiration, nausea, vomiting, headache, loss of
in social situations and embarrass others. They
appetite, increased appetite, loss of weight, pain,
behave strangely with their family members,
fatigue, weight gain, insomnia, hypersomnia and
friends, colleagues and others. They may insult,
sexual dysfunction.
abuse/ assault them.
CONCEPTS OF NORMAL AND
4. Somatic Complaints
ABNORMAL BEHAVIOR
Patient may complain of aches and pains in
Psychiatry as evident from the above is concerned
different parts of the body, fatigue, weakness,
with abnormal behavior in its broadest sense, but
involuntary movements, etc. defining the concepts of normal and abnormal
behavior as such has been found to be difficult.
Common Signs and Symptoms of Mental These concepts are much under the influence of
Illness sociocultural factors.
Disturbances in Motor Behavior Severalmodels have been put forward in order
Motor retardation, stupor, stereotypes, negati- to explain the concept of normal and abnormal
vism, ambitendence, waxy flexibility,echopraxia, behavior. Some of them are:
restlessness, agitation and excitement.
Medical Model
Disorders of thought, language and communication Medical model considers organic pathology as
Pressure of speech, poverty of speech, dysarthria, the definite cause for mental disorder. According
flight of ideas, circumstantiality, loosening of to this model abnormal people are the ones who
association, tangentiality, incoherence, persevera- have disturbances in thought, perception and
tion, neologism, clang association, thought block, psychomotor activities. The normal are the ones
thought insertion, thought broadcasting, echo- who are free from these disturbances.
lalia, delusions, obsessions and phobias.
Statistical Model
Disorders of perception
Illusions, hallucinations, depersonalization, It involves the analysis of responses on a test or a
derealization. questionnaire or observations of some particular
behavioral variables.The degree of deviation from their lives. They are also universal, affecting
the standard norms arrived at statistically, people in all countries and societies, individuals
characterizes the degree of abnormality. of all ages, women and men, the rich and the poor,
Statistically normal mental health falls within from urban and rural environments. They have
two standard deviations (SDs) of the normal an economic impact on societies and on the
distribution curve. quality of life of individuals and families.
Mental disorders at any point of time are
Sociocultural Model present in about 10 percent of the adult
The beliefs, norms, taboos and values of a society population. Around 20percent of all patients
have to be accepted and adopted by individuals. seen by primary health care professionalshave
Breaking any of these would be considered as one or more mental disorders.
abnormal. Normalcy is defined in context with During the last two decades many
social norms prescribed by the culture. Thus epidemiological studies have been conducted
cultural background has to be taken into account in India, which show that mental disorders
when distinguishing between normal and prevail in 18 to 207 per 1000, with median
abnormal behavior. 65.4per1000 at any given time. About 2.3%of
the population suffers from seriously
Behavior Model incapacitating mental disorders or epilepsy.
A large number of adult patients (10.4% to
Behavior that is adaptive, is normal, maladaptive
53.0%) coming to the general out patient
is abnormal. Abnormal behavior is a set of faulty
department are diagnosed as mentally ill.
behaviors acquired through learning.
It is estimated that in 2000,mental disorders
accounted for 12% of the total Disability
PROBLEMS OF MENTAL DISORDERS
Adjusted Life Years (DALYs)lost due to all
Self-care limitations or impaired functioning diseases and injuries. Common disorders,
related to mental illness which usually cause severe disability, include
Significant deficits in biological, emotional depressive disorder, substance use disorders,
and cognitive functioning schizophrenia, epilepsy, Alzheimer's disease,
Disability, life-process changes mental retardation and disorders of childhood
Emotional problems such as anxiety, anger, and adolescence.
sadness, loneliness and grief More than 450 million people today suffer
Physical symptoms that occur along with from mental and behavioral disorders. Within
altered psychological functioning the next 20 years depression will have the
Alteration in thinking, perceiving, communi- dubious distinction of becoming the second
cating and decision making biggest cause for global burden of disease.
Difficulties in relating to others Worldwide 70 million people suffer from
Patient's behavior may be dangerous to self alcohol dependence, 50million from epilepsy,
or others 24 million from schizophrenia and another
Adverse effects on the well-being of the 20 million people attempt suicide every year.
individual, family and community Global Burden of Disease (GBD) 2000
Financial, marital, family, academic and estimates show that mental and neurological
occupational problems. conditions account for 30.8%of all YearsLived
with Disability (YLD).Depression causes the
BURDEN OF MENTAL DISORDERS largest amount of disability, accounting for
Mental disorders are common, affecting more almost 12% of all disabilities. Six neuro-
than 25percent of all people at some time during psychiatric conditions figured in the top
twenty causes of disability worldwide which MENTALHEALTHFACTS
include: One in four patients visiting a health service
Unipolar depressive disorders has at least one mental, neurological or
Alcohol use disorders behavioral disorder but most of these disorders
Schizophrenia are neither diagnosed nor treated.
Bipolar affective disorders Barriers to effectivetreatment of mental illness
Alzheimer's and other dementias include lack of recognition of the seriousness
Migraine of mental illness and lack of understanding
Mental illnesses cause massive disruption in about the benefits of services. Policy makers,
the lives of individuals, families and commu- insurance companies, health and labor poli-
nities. Individuals suffer the distressing symp- cies and the public at large-all discriminate
toms of disorders. They also suffer because between physical and mental health prob-
they are unable to participate in work and lems.
leisure activities often as a result of discrimi- Most middle and low-income countries devote
nation. They worry about not being able to less than 1% of their health expenditure to
shoulder their responsibilities towards their mental health. Consequently, mental health
family and friends and are fearful of being a policies, legislation, community care facilities,
and treatment for people with mental illness
burden to others. Mental illnesses are common
are not given the priority they deserve.
to all countries and cause immense suffering.
More than 40% of countries have no mental
People with these disorders are often subjected
health policy and over 30% have no mental
to social isolation, poor quality of life and
health program. Over 90% of countries have
increased mortality. These disorders are thus
no mental health policy that includes children
the cause of staggering economic and social
and adolescents. In addition health plans
costs. frequently do not cover mental and
It is estimated that one in four families has at behavioral disorders at the same level as other
least one member currently suffering from a illnesses, creating significant economic
mental illness. These families are required not difficulties for patients and their families.
only to provide physical and emotional sup- Therefore, the suffering continues and difficul-
port, but also to bear the negative impact of ties grow.
stigma and discrimination present in all parts There is a wide gap between availability and
of the world. implementation of effective interventions, e.g.
Families in which one member is suffering in India, treatment rates for schizophrenia and
from a mental disorder make a number of epilepsy are reported to be 20% of all cases in
adjustments and compromises that prevent need of treatment, compared to 80% for the
other members of the family from achieving same disorders in the west.
their full potential in work, social relation- There is an urgent need to sensitize govern-
ships and leisure. These are the human ments on the importance of mental health and
aspects of the burden of mental disorders that clearly define the goals and objectives of
are difficult to assess and quantify. community-based health programs. Mental
The impact of mental disorders in commu- health services should be integrated into the
nities is large and manifold. There is the cost overall primary health care system. Innovative
of providing care, the loss of productivity and community-based health programs which are
certain legal problems associated with some culturally and gender appropriate and reach
mental disorders. out to all segments of the population need to
be developed. Well-organized community- Assessing and monitoring mental health in
based care is urgently required besides communities
increasing the number of psychiatric beds in Promoting healthy lifestylesand reducing risk
the general hospitals; governments must take factors for mental disorders
the responsibility for ensuring that mental Supporting stable family life, social cohesion
health policies are developed and implemen- and human development
ted. Strategies like including the integration Continuing research in related areas
of mental health treatment and services into Introducing mental health care activities in
the general health system, particularly into workplace and schools
primary health care, must be pursued. Use of mass media to promote mental health,
foster positive attitude, and help prevent
MENTAL HEALTH ISSUES disorders.
(Source:Syed Amin Tabish, JK-practitioner
There are a number of new issues that have come
2005, 12 (1) : 34 - 38).
up in the country with implications for mental
health. The most notable are alcohol policies,
MAGNITUDE OF THE PROBLEM IN INDIA
violence in society, the growing population of
elderly persons, urbanization, mental health of The common psychiatric illnesses encountered
women, disaster care,migrants and refugees,street in a clinic of a General Hospital are-Neurotic
children, and stress at the work place. These new disorders (e.g. anxiety neurosis, obsessive-
problems pose serious challenges to existing compulsive disorder and reactive depression),
mental health services and infrastructure. psychosomatic disorders (e.g. hypertension,
diabetes mellitus, peptic ulcer, tension headaches,
The National Rural Health Mission (NRHM)
etc.), functional psychosis (e.g. schizophrenia,
has overlooked various ground realities related
mania and depression) and organic psychosis.
to mental health. There is a shortage of manpower,
In a child guidance clinic,the common mental
and training programs are not able to meet the
illnesses include mental retardation, conduct
demands in providing training to all medical
disorder, hyperkinetic syndrome, enuresis, etc.
private practitioners and medical officers. In a geriatric clinic the common disorders are
Appropriate mental health can be provided at the depression, dementia, delusional disorders, etc.
sub centre and village level by minimum training In a psychosexual clinic the common problems
of the health workers that will help in providing include Dhat syndrome, premature ejaculation,
comprehensive health care at the most peripheral erectile impotence and so on.
level. It is necessary to integrate National Mental The prevalence of psychiatric disorders is 58.2
Health Program and District Mental Health per thousand which means that there are about
Program and include mental health in National 5.7 crore people suffering from some sort of
Rural Health Mission to achieve health for all. psychiatric disturbance. Out of this 4 lakh people
have organic psychoses, 26 lakh people have
MINIMUM ACTIONS REQUIRED schizophrenia and 1.2crore people have affective
Formulating policies designed to improve the psychosis; thus there are about 1.5 crore people
mental health of populations suffering from severe mental disorders, besides
Assuring universal access to appropriate and 12,000patients in government mental hospitals
cost-effective services (including mental in the country (Reddy et al, 1996).
health promotion and prevention services)
ETIOLOGY OF MENTAL ILLNESS
Ensuring adequate care and protection of
human rights for institutionalized patients Many factors are responsible for the causation of
with most severe mental disorders mental illness. These factors may predispose an
individual to mental illness, precipitate or brain is found to play an important role in the
perpetuate the mental illness. etiology of certain psychiatric disorders.
Predisposing Factors Brain Damage

These factors determine an individual's suscep- Any damage to the structure and functioning of
tibility to mental illness. They interact with the brain can give rise to mental illness. Damage
precipitating factors resulting in mental illness. to the structure of the brain may be due to one of
These are: the following causes:
Genetic make up Infection:E.g.Neurosyphilis, encephalitis,HIV
infection, etc.
Physical damage to the central nervous system
Injury: Loss of brain tissue due to head injury
Adverse psychosocial influence
Intoxication: Damage to brain tissue due to
toxins such as alcohol, barbiturates, lead, etc.
Precipitating Factors
Vascular: Poor blood supply, bleeding (intra-
These are events that occur shortly before the cranial hemorrhage, subarachnoid hemor-
onset of a disorder and appear to have induced it. rhage, subdural hemorrhage)
These are: Alteration in brain function: Changes in blood
Physical stress chemistry that interfere with brain functioning
Psychosocial stress such as disturbance in blood glucose levels,
hypoxia, anoxia, and fluid and electrolyte
Perpetuating Factors imbalance
These factors are responsible for aggravating or Tumors: Brain tumors
prolonging the diseases already existing in an Vitamin deficiency and malnutrition, in
individual. Psychosocial stress is an example. particular deficiency of vitamin Bcomplex
Thus etiological factors of mental illness can Degenerative diseases: Dementia
be: Endocrine disturbances: Hypothyroidism,
thyrotoxicosis etc.
Biological factors
Physical defects and physical illness: Acute
Physiological changes
physical illness as well as chronic illnesses
Psychological factors
with all their handicapping conditions may
Social factors
result in loss of mental capacities
Biological Factors
Physiological Changes
Heredity It has been observed that mental disorders are
What one inherits is not the illness or its symp- more likely to occur at certain critical periods of
toms, but a predisposition to the illness, which is life namely-puberty, menstruation, pregnancy,
determined by genes that we inherit directly. delivery, puerperium and climacteric. These
Studies have shown that three-fourths of mental periods are marked not only by physiological
defectives and one-third of psychotic individuals (endocrine) changes, but also by psychological
owe their condition mainly to unfavorable issues that diminish the adaptive capacity of the
heredity. individual. Thus the individual becomes more
susceptible to mental illness during this period.
Biochemical Factors
Biochemical abnormalities in the brain are Psychological Factors
considered to be the cause of some psychological It is observed that some specific personality
disorders. Disturbance in neurotransmitters in the types are more prone to develop certain
psychological disorders. For example those Mental illness is caused by supernatural power
who are unsocial and reserved (schizoid) are and is the result of a curse or possession by evil
vulnerable to schizophrenia when they face spirit: Many people do not consider mental
adverse situations and psychosocial stresses. illness as an illness, but possession by spirits
Psychological factors like strained inter- or curse that has befallen on the patient or
personal relationships at home, place of work, family because of past sins or misdeeds in
school or college, bereavement, loss of previous life.
prestige, loss ofjob, etc. Mentally ill people show bizarre behavior:
Childhood insecurities due to parents with Patients in mental hospitals and clinics are
pathological personalities, faulty attitude of often picturised as a weird lot, who spend
parents (over-strictness,over leniency),abnor- their time exhibiting useless bizarre behavior
mal parent-child relationship (over- like twisting of hands, etc.
protection, rejection,unhealthy comparisons), Mentally ill people are dangerous: People who
have or had a mental illness are viewed with
deprivation of child's essential psychological
suspicion and as dangerous persons.
and social needs, etc.
Mental illness is something to beashamed of This
Socialand recreational deprivations resulting
idea arouses an unsympathetic, cruel attitude
in boredom, isolation and alienation.
towards a mentally ill person. This is the
Marriage problems like forced bachelorhood, reason why many people hide mental illness
disharmony due to physical, emotional, social, in the family.
educational or financial incompatibility, Mental illnessisnot curable:People objectto have
childlessness, too many children, etc. normal relationship with mentally ill people,
Sexual difficulties arising out of improper sex or to give them employment even after being
education, unhealthy attitudes towards sexual cured, or even to accept them as neighbors.
functions, guilt feelings about masturbation, Mental illness is contagious: The fear that it is
pre and extra-marital sex relations, worries contagious is the main false notion which
about sexual perversions. leads people to view suspiciously, or object to
Stress, frustration and seasonal variations are marital relations with a person belonging to
sometimes noted in the occurrence of mental the household of the mentally ill.
diseases. Mental illness is hereditary: It is not a rule that
children of mentally illpatients should become
Social Factors mentally ill.
Poverty, unemployment, injustice, insecurity,
Marriage can cure mental illness: A mentally ill
person can get worse if he gets married when
migration, urbanization
he is ill, as marriage can become an additional
Gambling, alcoholism, prostitution, broken
stress. A patient who has recovered can get
homes, divorce, very big family, religion,
married and live a normal life like any other
traditions, political upheavals and other person.
social crises Mental hospitals areplaces where only dangerous
mentally ill individuals are treated and restraint
MISCONCEPTIONS ABOUT MENTAL ILLNESS
is a majorform of treatment: People hesitate to
Beliefs about mental illness have been characte- take their relatives to mental hospitals for
rized by superstition, ignorance and fear. treatment because of fear. Further, as ex-
Although time and advances in scientific patient of a mental hospital, he, as well as his
understanding of mental illness have dispelled family members are often isolated. Therefore,
many false ideas, there remain a number of people seek help from mental hospitals only
popular misconceptions. Some of them are: as a last resort.
General Attitude toward the Mentally Ill Conducting individual and family therapy
Participatingininterdisciplinaryteammeetings
In general the community responds to the
Owing to their legal power to prescribe and to
mentally ill through denial, isolation and
write orders, psychiatrists often function as
rejection. There is also a lack of understanding
leaders of the team.
of mental illness as any other illness, and a
lack of tendency to rejectboth the patients and A Psychiatric nurse is a registered nurse with
those who treat them. specialized training in the care and treatment of
Mentally ill are viewed as people with no psychiatric patients; she may have a Diploma,
capacity for understanding. MSc.,M.Phil. or Ph.Din psychiatric nursing. She
People feelmental illness cannot be cured, and is accountable for the bio-psychosocial nursing
even ifthe patient getsbetter, completephysical care of patients and their milieu. Other functions
rest is considered essential. include:
The mentally ill are by and large perceived as Administering and monitoring medications
aggressive, violent and dangerous. Assisting in numerous psychiatric and
An individual's values and personal beliefs physical treatments
affect his attitude about mental illness, the Participate in interdisciplinary team meetings
mentally ill and treatment of mental illness. There Teach patients and families
still exists a stigma surrounding individuals who Take responsibility for patient's records
need or use psychiatric mental health services. Act as patient's advocate
The need continues for public education to Interact with patients' significant others
modify or alter misconceptions about mental
A Clinical psychologist should have a Masters
illness and people with mental disorders.
Degree in Psychology or Ph.Din clinical psycho-
logy with specialized training in mental health
MENTAL HEALTH TEAM OR
settings. He is accountable for psychological
MULTIDISCIPLINARY TEAM
assessments, testing, and treatments. He offers
Multidisciplinary approach refers to collabora- direct services such as individual, family or
tion between members of different disciplineswho marital therapies.
provide specific services to the patient.
The multidisciplinary team includes: A Psychiatric social worker should have a
Masters Degree in Social Work or Ph.D degree
A Psychiatrist
with specialized training in mental health
A Psychiatric nurse
settings. He is accountable for family case work
A Clinical psychologist
and community placement of patients. He
A Psychiatric social worker
conducts group therapy sessions. He emphasizes
An Occupational therapist or an Activity
intervention with the patient in social
therapist environment in which he will live.
A Pharmacist and a dietitian
A Counselor An Occupational therapist or an Activity
therapist is accountable for recreational,
A Psychiatrist is a medical doctor with special occupational and activity programs. He assists
training in psychiatry. He is accountable for the the patients to gain skills that help them cope
medical diagnosis and treatment of patient. Other more effectively to gain or retain employment, to
important functions are: use leisure time.
Admitting patient into acute care setting
Prescribing and monitoring psychopharma- A Counselor provides basic supportive
cologic agents counseling and assists in psycho educational and
Administering electroconvulsive therapy recreational activities.
CLASSIFICATION OF MENTAL DISORDERS F13 Mental and behavioral disorders due

Classification is a process by which complex to use of sedatives or hypnotics
phenomena are organized into categories, classes F14 Mental and behavioral disorders due
or ranks so as to bring together those things that to use of cocaine
most resemble each other and to separate those Fl6 Mental and behavioral disorders due
that differ. to use of hallucinogens
Like any growing branch of medicine, psy- F20-F29 Schizophrenia, schizotypal and
chiatry has seen rapid changes in classification delusional disorders
to keep up with a conglomeration of growing F20 Schizophrenia
research data dealing with epidemiology, sympto- F20.0 paranoid schizophrenia
matology, prognostic factors, treatment methods F20.1 hebephrenic schizophrenia
and new theories for causation of psychiatric F20.2 catatonic schizophrenia
disorders. F20.3 undifferentiated schizophrenia
At present there are two major classifications F20.4 post-schizophrenic depression
in psychiatry, namely, ICDlO (1992)and DSM IV F20.5 residual schizophrenia
(1994). F20.6 simple schizophrenia
I. ICDlO (International Statistical Classification of F21 Schizotypal disorder
Disease and Related Health Problems) -1992 F22 Persistent delusional disorders
This is WHO's classification for all diseases and F23 Acute and transient psychotic dis-
related health problems. The chapter 'F' classifies orders
psychiatric disorders as mental and behavioral F24 Induced delusional disorders
disorders and codes them on an alphanumeric F25 Schizoaffective disorders
system from FOOto F99. F30-F39 Mood (affective) disorders
F30 Manic episode
The main categories in ICDlO F31 Bipolar affective disorder
FOO-F09 Organic, including symptomatic, F32 Depressive episode
mental disorders F33 Recurrent depressive disorder
FOO Dementia in Alzheimer's disease Persistent mood disorder
F34
FOl Vascular dementia F40-F49 Neurotic, stress-related and somato-
F04 Organic amnestic syndrome
form disorders
FOS Delirium
F40 Phobic anxiety disorders
F06 Other mental disorders due to brain
F41 Other anxiety disorders
damage and dysfunction and to
F42 Obsessive-compulsive disorder
physical disease
F43 Reaction to severe stress, and adjust-
F07 Personality and behavioral disorders
ment disorders
due to brain disease, damage and
F44 Dissociative (conversion) disorders
dysfunction
F45 Somatoform disorders
F10-Fl9 Mental and behavior disorders due
to psychoactive substance use F50-F59 Behavioral syndromes associated
FlO Mental and behavioral disorders due with physiological disturbances and
to use of alcohol physical factors
Fl 1 Mental and behavioral disorders due FSO Eating disorders
to use of opioids F51 Non-organic sleep disorders
F12 Mental and behavioral disorders due F52 Sexual dysfunction, not caused by
to use of cannabinoids organic disorder or disease
F60-F69 Disorders of adult personality and F98 Other behavioral and emotional dis-
behavior orders with onset usually occurring in
F60 Specific personality disorders childhood and adolescence
F60.0 paranoid personality disorder F99 Unspecified mental disorder
F60.1 schizoid personality disorder
II. DSMIV (Diagnostic and Statistical Manual)-1994
F60.2 dissocial personality disorder
This is the classification of mental disorders by
F60.3 emotionally unstable personality dis-
the American Psychiatric Association (APA). The
order
pattern adopted by DSM IV is of multiaxial
F60.4 histrionic personality disorder
systems.
F60.5 anankastic personality disorder
A multiaxial system that evaluates patients
F60.6 anxious personality disorder
along several versatiles contains five axes. Axis I
F60.7 dependent personality disorder
and II make up the entire classification which
F61 Mixed and other personality disorders
contains more than 300 specific disorders.
F62 Enduring personality changes, not
attributable to brain damage and The five axes of DSM IV are
disease
AXIS I: Clinical psychiatric diagnosis
F63 Habit and impulse disorders
F64 Gender identity disorders AXISII: Personality disorder and mental retar
F65 Disorders of sexual preference dation
F70-F79 Mental retardation
AXISIII:General medical conditions
F70 Mild mental retardation
F71 Moderate mental retardation AXISIV: Psychosocial and environmental pro
F72 Severe mental retardation blems
F73 Profound mental retardation
AXISV: Global assessment of functioning in
F80-F89 Disorders of psychological develop-
current and past one year
ment
F80 Specific developmental disorders of Differences between ICDlO and DSM IV
speech and language
ICD-10 DSM-IV
F81 Specific developmental disorders of
scholastic skills Origin International American Psychiatric
F82 Specific developmental disorder of Association
Presentation Different versions A single version
motor function for clinical work,
F83 Mixed specific developmental disor- research and
ders primary care
F84 Pervasive developmental disorders Language Available in all English version only
widely spoken
F90-F98 Behavioral and emotional disorders languages
with onset usually occurring in child- Structure Single axis Multiaxial
hood and adolescence Content Diagnostic criteria Diagnostic criteria
F90 Hyperkinetic disorders do not include social usually include
consequences occupational or
F91 Conduct disorders of the disorder other areas of
F93 Emotional disorders with onset specific functioning
to childhood
F94 Disorders of social functioning with
onset specificto childhood and adoles- Ill. Indian Classification
cence In India Neki (1963),Wig and Singer (1967),Vahia
F95 Tic disorders (1961) and Varma (1971) have attempted some
modifications of ICD8 to suit Indian conditions. Moderate
They are broadly grouped as follows: Severe
A. Psychosis Profound
j, In everyday practice classification is made
after the history and examination of mental state
Functional Affective Organic have been completed.
a. Schizophrenia a. Mania a. Acute
Simple schizophrenia b. Depression b. Chronic REVIEW QUESTIONS
Hebephrenic schizophrenia Concepts of normal and abnormal behavior
Catatonic schizophrenia
(Nov 2001,0ct 2006)
Paranoid schizophrenia
Components of mental health (Nov 2003)
B. Neurosis Meaning of mental illness (Feb2001,Oct 2004)
Anxiety neurosis Features of mental illness
Depressive neurosis Mental health issues
Hysterical neurosis Characteristics of a mentally healthy person
Obsessive compulsive neurosis (Nov 1999,Apr 2003,Nov 2003)
Phobic Neurosis Misconceptions about mental illness
(Nov 2003)
C. Special disorders
Community attitude towards mentally ill (Nov
Childhood disorders
2002)
conduct disorders
Etiology of mental illness (Feb 2001,Apr 2002,
emotional disorders
Apr 2005, Oct 2006)
Personality disorders
sociopath Classification of mental disorders (Apr 2006)
psychopath International classification of diseases (Oct
Substance abuse 2004, Apr 2006)
alcohol abuse DSMIV(Nov 2003)
drugabuse Multidisciplinary team or mental health team
Psycho physiological disorders Defence mechanisms- rationalization, pro-
asthma jection, identification, reaction formation,
psoriasis undoing, negativism, repression (Oct 2000),
Mental retardation regression, suppression (Oct 2000),fantasy or
Mild day dreaming.
Principles and Concepts of
Mental Health Nursing
D PSYCHIATRY DEVELOPMENT OF PSYCHIATRY
D PSYCHIATRIC NURSING Historically, mental illness was viewed as a
D DEVELOPMENT OF PSYCHIATRY
D DEVELOPMENT OF MODERN PSYCHIATRIC NURSING
demonic possession, the influence of ancestral
D CURRENT ISSUES AND TRENDS IN CARE spirits, the result of violating a taboo or neglecting
D PSYCHIATRIC NURSING SKILLS a cultural ritual and spiritual condemnation. As
D STANDARDS OF MENTAL HEALTH NURSING a result, the mentally illwere often starved, beaten,
D GENERAL PRINCIPLES OF PSYCHIATRIC NURSING
D FUNCTIONS OF A PSYCHIATRIC NURSE
burnt, amputated and tortured in order to make
D QUALITIES OF A PSYCHIATRIC NURSE the body an unsuitable place for the demon.
D THERAPEUTIC ROLES OF A PSYCHIATRIC Gradually, man began the quest for scientific
MENTALHEALTH NURSE knowledge and truth, which can be traced as
Health is a state of complete physical, mental, follows:
social and spiritual well-being and not merely Pythagoras (580-510BC) developed the con-
the absence of disease or infirmity. Both physical cept that the brain is the seat of intellectual
and mental healths are interdependent. A nurse activity.
who is responsible for total health care of a person Hippocrates (460- 370 BC) described mental
must take care of both physical and emotional illness as hysteria, mania and depression.
needs; therefore she should develop a basic Plato (427- 347BC)identified the relationship
understanding and skill in psychiatric nursing between mind and body.
to achieve total health care. Asciepiades, who is referred to as the Father
of Psychiatry, made use of simple hygienic
PSYCHIATRY measures, diet, bath, massage in place of
It is a branch of medicine that deals with the diag- mechanical restraints.
nosis, treatment and prevention of mental illness. The Greeks were the first to study mental
illness scientifically and separate the study of
PSYCHIATRIC NURSING mind from religion.Aristotle, a Greek philoso-
pher, emphasized on the release of repressed
It is a specialized area of nursing practice,
emotions for the effective treatment of mental
employing theories of human behavior as it is a
science, and the purposeful use of self as it is an illness. He suggested catharsis and music
art, in the diagnosis and treatment of human therapy for patients with melancholia.
responses to actual or potential mental health During the middle ages the mentally ill were
problems. (American Nurses Association, 1994) not considered as outcasts, but as people to be
Thus psychiatric nursing deals with the helped. One of the great figures during this
promotion of mental health, prevention of mental time was St. Augustine, who believed that
illness, care and rehabilitation of mentally ill although God acted directly in human affairs,
individuals both in hospital and community. people were responsible for their own actions.
Principles and Concepts of Mental Health Nursing 15
Renaissance in Europe (1300-1600 AD):This National Institute of Mental Health and
represented the saddest chapter in the history Neurosciences or NIMHANS).
of psychiatry when it was believed that 1949 Lithium was first used for the treatment of
demons were the cause of hallucinations, mania.
delusions and sexual activity, and the 1952 Chlorpromazine was introduced which
treatment was torture and even death. brought about a revolution in psychophar-
macology and changed the whole picture
Some Important Milestones
of mental health care.
1773 The first mental hospital in the US was 1963 The 'Community Mental Health Centers'
built in Williamsburg, Virginia. Act was passed.
1793 Phillip Pinel removed the chains from 1978 The Alma-Ata declaration of "Health for
mentally ill patients confined in Bicetre,a All by 2000 AD." posed a major challenge
hospital outside Paris, thus bringing about to Indian mental health professionals. In
the first revolution in psychiatry. order to achieve mental health for all (as a
1812 The first American textbook in psychiatry part of the achievement of Health for All
was written by Benjamin Rush, who is by 2000 AD.), in 1980 the Government of
referred to as the Father of American
India called for experts in the field for
Psychiatry.
assessing the mental health needs of the
1908 Clifford Beers, an ex-patient of a mental
people and recommended steps for
hospital, wrote the book, 'The Mind That
providing mental health care.
Found Itself' based on his bitter
1981 Community psychiatric centers were set
experiences in the hospital. He founded
up to experiment with primary mental
the American Mental Health Association,
health care approach at Raipur Rani,
which made a major contribution towards
the improvement of conditions in mental Chandigarh and Sakalwara, Bangalore.
hospitals. 1982 The Central Council of Health, India's
1912 Eugene Bleuler, a Swiss psychiatrist highest health policy making body
coined the term 'schizophrenia'. accepted the National Mental Health
-The Indian Lunacy Act was passed. Policy and brought out the National
1927 Insulin shock treatment was introduced Mental Health Program in India.
for schizophrenia. 1987 The Indian Mental Health Act was passed.
1936 Frontal lobotomy was advocated for the 1990 TheGovernment ofIndia formed an Action
management of psychiatric disorders. Group at Delhi to pool the opinions of
1938 Electro Convulsive Therapy (ECT) was mental health experts about the National
used for the treatment of psychoses. Mental Health Program. National Institute
1939 Development of psychoanalytical theory of Mental Health and Neurosciences
by Sigmund Freud led to new concepts in (NIMHANS), Bangalore,has taken up the
the treatment of mental illness. leadership in orienting health care profes-
1946 The Bhore Committee presented the sionals about the mental health programs
situation with regard to mental health of our country. A number of innovative
services. Based on its recommendations, 5 approaches for the treatment and rehabi-
mental hospitals were set up at Amritsar litation of mental illness have been
(1947),Hyderabad (1953),Srinagar (1958), initiated, and the most important ones are:
Jamnagar (1960) and Delhi (1966). An All Integration of mental health care with
India Institute of Mental Health was also general health care.
set up at Bangalore (currently known as School mental health programs.
Promotion of child mental health skills of the nurses and increased the demand for
through the involvement of anganwadis improved psychological treatment for patients
(ICDSprogram). who did not respond well. As the nurses
Crisis intervention for suicide pre- collaboratedwith the doctors in carrying out these
vention. therapies they struggled to define their role as
Halfway homes for mentally ill indi- psychiatric nurses.
viduals for social skills training, Major growth of psychiatric nursing occurred
vocational training. after World War II because of the emergence of
Education and involvement of the services related to psychiatric problems. The
general public through the activities of content ofpsychiatric nursing became an integral
non-governmental organizations. part of general nursing curriculum.
Media materials for public education. 1943 Psychiatric nursing course was started for
Training for non-professionals to work male nurses.
with mentally ill individuals. 1946 Health Survey Committee's report recom-
mended preparation ofnursing personnel
DEVELOPMENT OF MODERN in psychiatric nursing also. The existing
PSYCHIATRICNURSING institutions like,mental hospitals in Banga-
Psychiatricnursing in general arose from the need lore and Ranchi should start the training.
for hospitals to provide socially acceptable levels 1952 Dr. Hildegard Peplau defined the the-
of care for patients. rapeutic roles that nurses might play in
the mental health setting. She described
Some Important Milestones the skills and roles of the psychiatric nurse
in her book 'Interpersonal Relations in
1872 First training school for nurses, based on
Nursing'. It was the first systematic
the Nightingale system was established
theoretical framework developed for
by the New England Hospital for Women
psychiatric nursing.
and Children, USA. Linda Richards, the
1953 Maxwell Jones introduced therapeutic
first nurse to graduate from the one-year
community.
course, developed 12 training schools in
1956 One year post-certificate course in
the USA.
psychiatric nursing was started at
1882 First school to prepare nurses to care for
NIMHANS, Bangalore.
the mentally ill was opened at Mc Lean
1960 The focus began to shift to primary
Hospital in Waverly. A two-year program
prevention and implementing care and
was started but few psychological skills
consultation in the community. The name
were addressed and much importance was
'psychiatric nursing' was changed to
given to custodial care such as personal
'psychiatric and mental health nursing,'
hygiene, medication, nutrition, etc.
and a second change was made in the
1913 Johns Hopkins became the first school of
1970s when it was known as
nursing to include a fully developed
'psychosocial nursing'.
course for psychiatric nursing in the
1963 Journal of PsychiatricNursing and Mental
curriculum.
Health Services was published.
The important factor in the development of 1964 Mudaliar committee felt the need for
psychiatric nursing was the emergence ofvarious preparing a large number of psychiatric
somatic therapies like, insulin shock therapy nurses and recommended inclusion of
(1927), psychosurgery (1936), and ECT (1938). psychiatry in the nursing curriculum (as
These therapies required the medical surgical per International Council of Nursing).
1965 The Indian Nursing Council included collaboration, social accountability, legal and
psychiatric nursing as a compulsory ethical obligations.
course in the B.ScNursing program.
1973 Standards of Psychiatric and Mental CURRENT ISSUES AND TRENDS IN CARE
Health Nursing practice were enunciated (SCOPE)
to provide a means of improving the A psychiatric nurse faces various challenges
quality of care. because of changes in patient care approach. Some
1975 Psychiatric Nursing was offered as an of these changes that affecther role are as follows:
elective subject in M.Sc Nursing at the
Rajkumari Amrit Kaur College of Nursing, Demographic Changes
New Delhi. Now various colleges offer
Type of family (increased number of nuclear
psychiatric nursing as an elective subject
families)
in M.ScNursing. These are SNDT College
Increasing number of the elderly group
of Nursing, Mumbai; NIMHANS, Banga-
lore; College of Nursing, Ludhiana;
Social Changes
College of Nursing, CMC, Vellore; Father
Muller's College of Nursing, Mangalore; The need for maintaining intergroup and
College of Nursing, Thiruvananthapuram; intragroup loyalties
MAHE, Manipal; MV Shetty Institute of Peer pressure
Health Sciences, Mangalore.
Economic Changes
1980 Scientific advances in the area of psycho-
biology, brain imaging techniques, know- Industrialization
ledge about neurotransmitters and neuro- Urbanization
nal receptors, molecular genetics related Raised standard of living
to psychiatry, etc, emerged. These contri-
buted to the shift from psychodynamic Technological Changes
models to more balanced psychobiological Mass media
models of psychiatric care. Electronic systems
1986 The Indian Nursing Council (INC) made Information Technology
psychiatric nursing a component of
General Nursing and Midwifery course. Mental Health Care Changes
1990 During these years integration of neuro- Increased awareness in the public regarding
sciences into holistic biopsychosocial mental health
practice of psychiatric nursing occurred. Need to maintain mental stability
Advances in understanding the inter- Increased mental health problems
relationships of brain, behavior, emotions
and cognition offered many new oppor- The above changes set the current trends in
tunities for psychiatric nurses. mental health care. Some of these are:
1994 The above mentioned changes led to the
revision of Standards of Psychiatric and Educational Programs for the Psychiatric Nurse
Mental Health Nursing. Diploma in Psychiatric Nursing (The first
The professional psychiatric nursing role program was offered in 1956 at NIMHANS,
has grown in complexity. In contemporary Bangalore).
psychiatric nursing practice the role includes the M.Scin PsychiatricNursing (Thefirst program
parameters of clinical competence, patient was offered in 1976at Rajkumari Amrit Kaur
advocacy, fiscal responsibility, professional College of Nursing, New Delhi).
M.Phil in Psychiatric Nursing (1990, M.G. health field through innovations in theory and
University, Kottayam). practice and participation in research.
Doctorate in Psychiatric Nursing (offered at
MAHE, Manipal; RAK College of Nursing, Cost Effective Nursing Care
Delhi; NIMHANS, Bangalore). Studies need to be conducted to find out the
Short-term training programs for both the viability in terms of cost involved in training a
degree and diploma holders in nursing. nurse and the quality of output in terms ofnursing
care rendered by her.
Standards of Mental Health Nursing
The development of standards for nursing prac- Focus of Care
tice is a beginning step towards the attainment of A psychiatric nurse has to focus care on certain
quality nursing care. The adoption of standards target groups like the elderly, children, women,
helps to clarify nurses' areas of accountability, youth, mentally retarded and chronic mentally
since the standards provide the nurse, the health ill.
agency, other professionals, clients, and the
public, with a basis for evaluating practice. New Trends in Role of a Psychiatric Nurse
Standards also define the nursing profession's
Primary Mental Health Nursing
accountability to the public. These standards are
therefore a means for improving the quality of Psychiatric nurses are moving into the domain of
care for mentally ill people. primary care and working with other nurses and
physicians to diagnose and treat psychiatric
Development of Code of Ethics illness in patients with somatic complaints.
Cardiovascular, gynecological, respiratory, and
This is very important for a psychiatric nurse as
she takes up independent roles in psychotherapy, gastrointestinal and family practice settings are
behavior therapy, cognitive therapy, individual appropriate for assessing patients for anxiety,
therapy, group therapy, maintains patient's depression and substance abuse disorders.
confidentiality, protects his rights and acts as
Collaborative Psychiatric Nursing Practice
patient's advocate.
Patients who are having difficultybeing stabilized
Legal Aspects in Psychiatric Nursing on their medications or who have co-morbid
Knowledge of the legal boundaries governing medical illnesses are seen in a psychiatric nursing
psychiatric nursing practice is necessary to protect clinic where nurses and physicians collaborate
the public, the patient, and the nurse. The practice to provide high quality patient care.
of psychiatric nursing is influenced by law,
particularly in its concern for the rights of patients Registered Psychiatric Nurse (RPN)
and the quality of care they receive. A Registered Psychiatric Nurse provides psy-
The client's right to refuse a particular treat- chiatric mental health nursing care to individuals,
ment, protection from confinement, intentional families, and groups to enable them to function at
torts,informed consent,confidentiality,and record an optimal level of psychological wellness
keeping are a few legal issues in which the nurse through more effective adaptive behaviors and
has to participate and gain quality knowledge. increased resilience to stress. She must be able to
provide safe, basic physical care, have a wide
Promotion of Research in understanding of psychological and develop-
Mental Health Nursing mental problems and their treatment and have a
The nurse contributes to nursing and the mental highly developed level of communication skills.
She works with children, adolescents, adults and mental illness to lead more independent and
elderly with dysfunctional behavior patterns, and satisfactory lives in the community.
developmental handicaps. A registered psychia-
tric nurse works as an independent entity. She Child Psychiatric Nursing
works in various kinds of inpatient facilities and In child psychiatric nursing the nurse identifies
community settings. emotional and behavioral problems of the
children and provides comprehensive care.
Clinical Nurse Specialist (CNS)
The Clinical Nurse Specialist provides consul- Gerontological and Geriatric Nursing
tative services to nursing personnel. She attends Gerontological nursing provides emotional
clinical teaching programs, demonstrates thera- support to those people who have retired from
pies, conducts in-service education programs, services,who have no financial sources and helps
initiates and participates in curriculum revision/ them in understanding the situation, and
changes and nursing research. developing new coping mechanisms.
Geriatric nursing is expanding the psychiatric
Case Management nursing practice to aged people who have been
Using case management a psychiatric mental affected by emotional and behavioral disorders
health nurse is responsible for assessing needs, such as dementia, chronic schizophrenia,
identifying services, and monitoring and eva- delirium, etc.
luating client status. A case manager coordinates
care through collaboration with all involved Deaddiction Nursing
health professionals ensuring accessibility and A psychiatric nurse in these units identifies
availability of care. psychosocial problems and maintaining factors
in addicts. She also provides various therapies to
Nurse Psychotherapist the addicts and their family members.
The psychiatric nurse can take up psychotherapy
Neuropsychiatric Nursing
roles as in individual therapy, group therapy,
counseling, etc. Psychiatric nursing practice is extended to
patients who are suffering from neuropsychiatric
Psychiatric Nurse Educator disorders such as dementia, epilepsy,brain tumor,
head injury with behavioral problems, HIV
The main function of psychiatric nurse educator
infection with behavioral problems, etc.
is planning and changing the curriculum accor-
ding to the needs of the society and learner. The
Community Mental Health Nursing
Indian Nursing Council included psychiatric
nursing as compulsory for the qualifying Community mental health nursing is the
examination in B.Sc Nursing program in 1965, application of knowledge of psychiatric nursing
and from 1986it became a component in General in preventing mental illness, promoting and
Nursing and Midwifery course as well. maintaining mental health of the people. It
The number of nurses in the field of teaching includes early diagnosis, appropriate referrals,
psychiatric nursing needs to be enhanced. care and rehabilitation of mentally ill people.
This is a big challenge for nursing curriculum
planners. Advanced Practice Roles
These include: Nursing leadership in forensic
Psychosocial Rehabilitation Nursing health units, crisis intervention, risk assessment
It is concerned with helping people with chronic and management in community settings.
PSYCHIATRIC NURSING SKILLS Working within personal and ethical
Mental health nursing is the practice of promoting boundaries.
mental health as well as caring for people who
have mental illness, potentiating their indepen- Counseling Skills
dency and restoring their dignity. In order to fulfill These include:
this arduous occupation, a mental health nurse Unconditional positive regard/non-judge-
must possess a sound knowledge base and the mental approach
requisite skills for good nursing practice. Empathy
Warmth and genuineness
Prerequisites for a Mental Health Nurse Confidentiality
Non-verbal sensitivity, non-verbal attending,
Personal Skills
non-verbal responding
Self-awareness It is a key component of psychia- Other interpersonal skills required are para-
tric nursing experience. It is an answer to the phrasing, reflecting, clarifying, summarizing.
question, "who am I". The nurse must be able to
examine personal feelings, actions and reactions Behavioral Skills
as a provider of care. A firm understanding and
These are based on Pavlovian principles and
acceptance by the nurse allows acknowledging a
Skinner's principles. They include:
patient's differences and uniqueness.
1. To increase adaptive behavior
Adaptability A mental health nurse needs to be Positive reinforcement
adaptable to different settings and cultures. Negative reinforcement
Working within residential settings, for example, Tokeneconomy
may demand attitudes and roles which are 2. To decrease maladaptive behavior
different from working in a community, as in a Extinction
residential setting the nurse may have an authori- Timeout
tative or a supervisory role which she necessarily Restraining
does not have in a community. Over correction
A mental health nurse also needs to cope with 3. To teach new behavior
a variety of social and cultural settings. Social Modeling
settings involve the class and status of the Shaping
individuals while cultural settings involve race, Chaining
ethnicity and gender. Therefore she may need to Cueing.
be familiar with the issues that arise in cross-
cultural mental health nursing. Supervisory Skills
Carevalues and attitudes Supervision is an integral necessityfor any worker
These include: in the caring profession, to ensure the best quality
Self-awareness and self-esteem service for clients and best quality developmental
Respecting the person's rights opportunities for workers. A good supervisor
Listening requires interpersonal and professional skills,
Responding with care and respect technical knowledge, leadership qualities and
Supporting with trust and confidence human skills.
Reassuring with explanation and honesty
Physically nursing the helpless with compas- Crisis Skills
sion Aggressive and assaultive behavior of violent
Carrying out procedures skillfully patients, self-harm, acute alcohol intoxication are
some of the cases a nurse is likely to encounter in interviewing, behavioral observation, physical
the course of her practice. Such situations may and mental health assessment enable the nurse
cause the nurse to feeloverwhelmed with feelings to reach sound conclusions and plan appropriate
of helplessness, powerlessness and inadequacy. interventions with the client.
Exercise of self-control, calm, rational thinking
and identifying ways of obtaining help from the Standard Ill: Diagnosis
other people are some of the skills to be cultivated The nurse utilizes nursing diagnoses and/ or
by the psychiatric nurse when confronted with standard classification of mental disorders to
such crises situations. express conclusions supported by recorded
assessment data and current scientific premises.
Teaching Skills Nursing' s logicalbasis for providing care rests
This relates to the nurse's ability to explain, on the recognition and identification of those
enabling full understanding on the part of the actual or potential health problems that are within
client. It also involves enhancing the client's the scope of nursing practice.
environment in order to maximize his awareness
of the things around him. It is necessary for the Standard IV: Planning
nurse to be enthusiastic about activities and The nurse develops a nursing care plan with
choicesof the clients and also give the client every specific goals and interventions delineating
opportunity to use his power ofjudgment in order nursing actions unique to each client's needs.
to make decisions. The nursing care plan is used to guide
therapeutic intervention and effectively achieve
STANDARDS OF MENTAL HEALTH NURSING the desired outcomes.
The purpose of Standards of Psychiatric and
Mental Health Nursing practice is to fulfill the Standard V: Intervention
profession's obligation to provide a means of The nurse intervenes as guided by the nursing
improving the quality of care. The standards care plan to implement nursing actions that
presented here are a revision of the standards promote, maintain or restore physical and mental
enunciated by the Division on Psychiatric and health, prevent illness and effect rehabilitation.
Mental Health Nursing Practice in 1973.
(a) Psychotherapeutic interventions The nurse
uses psychotherapeutic interventions to assist
Professional Practice Standards
clients in regaining or improving their previous
Standard I: Theory coping abilities and to prevent further disability.
The nurse applies appropriate theory that is (b) Health teaching The nurse assists clients,
scientifically sound as a basis for decisions families and groups to achieve satisfying and
regarding nursing practice. Psychiatric and productive patterns of living through health
mental health nursing is characterized by the teaching.
application of relevant theories to explain (c) Activities of daily living The nurse uses the
phenomena of concern to nurses and to provide a activities of daily living in a goal directed way to
basis for intervention. foster adequate self-care and physical and mental
well being of clients.
Standard II: Data Collection (d) Somatic therapies The nurse uses knowledge
The nurse continuously collects data that are of somatic therapies and applies related clinical
comprehensive, accurate and systematic.Effective skills in working with clients.
(e) Therapeutic environment The nurse provides, Standard XI: Research
structures and maintains a therapeutic environ- The nurse contributes to nursing and the mental
ment in collaboration with the client and other health field through innovations in theory and
health care providers. practice and participation in research.
(f) Psychotherapy The nurse utilizes advanced GENERAL PRINCIPLES OF PSYCHIATRIC
clinical expertise in individual, group and family NURSING
psychotherapy, child psychotherapy and other
The following principles are general in nature
treatment modalities to function as a psychothe- and form guidelines for emotional care of a
rapist and recognizes professional accountability patient. These principles are based on the concept
for nursing practice. that each individual has an intrinsic worth and
dignity and has potentialities to grow.
Standard VI: Evaluation
The nurse evaluates client responses to nursing 1. Patient is Accepted Exactly as He is
actions in order to revise the database, nursing Accepting means being non-judgmental. Accep-
diagnoses and nursing care plan. tance conveys the feelingofbeing loved and cared.
Acceptance does not mean complete permissi-
Professional Performance Standards veness but setting of positive behaviors to convey
to him the respect as an individual human being.
Standard VII: Peer Review A nurse should be able to convey to the patient
The nurse participates in peer review and other that she may not approve everything what he
means of evaluation to assure quality of nursing does, but he will not be judged or rejected because
of his behavior.
care provided for clients.
Acceptance is expressed in the following
ways:
Standard VIII: Continuing Education
The nurse assumes responsibility for continuing (a) Being Non-judgmental and Non-punitive
education and professional development and The patient's behavior is not judged as right or
contributes to the professional growth of others. wrong, good or bad. Patient is not punished for
his undesirable behavior. All direct (chaining,
Standard IX: Interdisciplinary Collaboration restraining, putting him in a separate room) and
indirect (ignoring his presence or withdrawing
The nurse collaborates with other health care attention) methods of punishment must be
providers in assessing, planning, implementing avoided. A nurse who shows acceptance does
and evaluating programs and other mental health not reject the patient even when he behaves
activities. contrary to her expectations.
Standard X: Utilization of Community Health (b) Being Sincerely Interested in the Patient
Systems Being sincerely interested in another indivi-
The nurse participates with other members of the dual means considering the other individual's
community in assessing, planning, implementing interest.
and evaluating mental health services and This can be demonstrated by:
community systems that include the promotion Studying patient's behavior pattern.
Allowing him to make his own choices and
of the broad continuum of primary, secondary
decisions as far as possible.
and tertiary prevention of mental illness.
Being aware of his likes and dislikes.
Being honest with him. own feelings,attitudes and responses. Her ability
Taking time and energy to listen to what he is to be aware and to accept her own strengths and
saying. limitations should help her to see the strengths
Avoiding sensitive subjects and issues. and limitations in other people too. Self-
understanding helps her to be assertive in life
(c) Recognizing and Reflecting on Feelings situations without being aggressive and feeling
which Patient may Express guilty.
When patient talks, it is not the content that is
important to note, but the feeling behind the 3. Consistency is used to Contribute to
conversation, which has to be recognized and Patient's Security
reflected. This means that there should be consistency in
the attitude of the staff, ward routine and in
(d) Talking with a Purpose defining the limitations placed on the patient.
The nurse's conversation with a patient must
revolve around his needs, wants and interests. 4. Reassurance should be given in a Subtle
Indirect approaches like reflection, open-ended and Acceptable Manner
questions, focusing on a point, presenting reality Reassurance is building patient's confidence. To
are more effective when the problems are not give reassurance, the nurse needs to understand
obvious. and analyze the situation as to how it appears to
Avoid evaluative, hostile, probing questions the patient. False reassurance can also reflect a
and use understanding responses, which may lack of interest and understanding or unwilling-
help the patient to explore his feelings. ness on the part of the nurse to empathize with
the patient's life situation.
(e) Listening
Listening is an active process. The nurse should 5. Patient's Behavior is Changed through
take time and energy to listen to what the patient Emotional Experience and not by
is saying. She must be a sympathetic listener and Rational Interpretation
show genuine interest.
Major focus in psychiatry is on feelings and not
on the intellectual aspect. Advising or rationa-
(D Permitting Patient to Express Strongly-held lizing with patients is not effective in changing
Feelings
behavior. Role-play and socio-drama are a few
Strong emotions bottled up are potentially avenues of providing corrective emotional
explosive and dangerous. It is better to permit the experiences to a patient and facilitating insight
patient to express his strong feelings without into his own behavior. Such experiences can truly
disapproval or punishment. Expression of bring about the desired behavioral changes.
negative feelings (anxiety, fear, hostility and
anger) may be encouraged in a verbal or symbolic 6. Unnecessary Increase in Patient's
manner. The nurse must accept the expression of Anxiety should be Avoided
patient's strong negative feelings quietly and The following approaches may increase the
calmly. patient's anxietyand should, therefore,be avoided:
Showing nurse's own anxiety.
2. Use Self-understanding as a Showing attention to the patient's deficits.
Therapeutic Tool Making the patient to face repeated failures.
A psychiatric nurse should have a realistic self- Placing demands on patient which he
concept and should be able to recognize one's obviously cannot meet.
Direct contradiction of patient's psychotic anxiety and level of ability to decide. But expla-
ideas. nation should never be withheld on the basis that
Passing sharp comments and showing psychiatric patients are not having any contact
indifference. with reality or have no ability to understand.
7. Objective Observation of Patient to 12. Many Procedures are Modified but Basic
Understand his Behavior Principles Remain Unaltered
Objectivity is an ability to evaluate exactly what In psychiatric nursing field, many methods are
the patient wants to say and not mix up one's adapted to individual needs of the patients, but
own feelings, opinion or judgment. the underlying nursing scientific principles
To be objective, the nurse should indulge in remain the same. Some nursing principles to be
introspection and make sure that her own kept in mind are: safety, comfort, privacy,
emotional needs do not take a precedence over maintaining therapeutic effectiveness, economy
patient's needs. of time, energy and material.
8. Maintain Realistic Nurse-Patient FUNCTIONSOF A PSYCHIATRICNURSE

Relationship Assessing the client and planning nursing
Realistic or professional relationship focuses care.
upon the personal and emotional needs of the Providing safe nursing care, including
patient and not on nurse's needs. To maintain medication administration and participation
professional relationship the nurse should have in various therapies, individual interactions,
a realistic self-concept and should be able to formal and informal group situations, role-
empathize and understand the feelings of the playing, advocating on behalf of the client,
patient and the meaning of behavior. and so forth.
Providing a safe environment, including
9. Avoid Physical and Verbal Force as protecting the client and others from injury.
Much as Possible Accurately observing and documenting the
All methods of punishment must be avoided. If client's behavior.
the nurse is an expert in predicting patient Providing feedback to the client based on
behavior, she can mostly prevent an onset of observations of his behavior.
undesirable behavior. Teaching the client and significant others.
Involving the client and the client's significant
10.Nursing Care is Centered on the Patient others in the nursing process.
as a Person and not on the Control of Providing opportunities for the client to make
Symptoms his own decisions and to assume responsi-
Analysis and study of symptoms is necessary to bility for his emotions and life.
reveal their meaning and their significanceto the Cooperating with other professionals in
patient. Two patients showing the same symp- various aspects of the client's care; thereby,
toms may be expressing two different needs. facilitating an interdisciplinary approach to
care.
11.All Explanations of Procedures and Continuing nursing education and the explo-
other Routines are Given According to ration of new ideas, theories, and research.
the Patient's Level of Understanding
QUALITIES OF A PSYCHIATRICNURSE
The extent of explanation that can be given to a
patient depends on his span of attention, level of Certain attitudes are necessary for a psychiatric
nurse to deal with psychiatric patients. These 4. Being Sincerely Interested in Patient Care
include: Being sincerely interested in patient care means
considering the patients interest.
1. Self-awareness
This can be demonstrated by:
A Psychiatric nurse should have a realistic self
Studying patient's behavior pattern
concept and should be able to recognize her own
Allowing him to make his own choices and
feelings, fantasies and fears. She should analyze
decisions as far as possible
her own professional strengths and limitations.
Being aware of his likes and dislikes
Her ability to be aware and to accept her own
Being honest with him
strengths and limitations should help her see the
Active listening.
strengths and limitations in other people.
She should have her own beliefs and values
5. Being Available
related to life and should be able to acknowledge
and accept her own feelings and their influence Being available means nurse should be appro-
on her behavior. achable all the time to the patient. She should
She should have the ability to recognize when convey to the patient that she is available not only
she is under stress and the influence of the stress to meet his physical needs, but also to assist him
on her physical and mental performance, and in dealing with his psychological needs.
should be able to find ways to get adequate release
from the stress. 6. Empathizing with the Patient
Until the nurse is able to cope with personal Empathy is an important tool in understanding
fears and anxieties in relation to psychiatric nur- others' feelings. Empathy is a process when a
sing, it is unlikely that she can have a therapeutic person gets into another person's situation and
influence in the patient's environment. experiences what the other person feels and then
is able to step back and analyze the situation. The
2. Self-acceptance nurse need not necessarily have to experience it,
The nurse should not only be aware, but also but has to be able to imagine the feelings asso-
accept her strengths as well as her limitations. ciated with the experience.
Self-understanding helps her to be assertive in To be able to empathize with the patient the
life situations without being aggressive and nurse must be willing to get involved enough to
feeling guilty. feel what the other person feels and at the same
time avoiding over-involvement, projection of her
3. Accepting the Patient own feelings and over-identification.
Accepting means, being non-judgmental. Accep-
7. Reliability
tance conveys the feeling ofbeing loved and cared.
The nurse should accept the patient as he is, as a The nurse must demonstrate honesty, truthful-
sick person, regardless of caste, color, race or ness, resourcefulness and competence in her
behavior. dealings with the patients and their families. She
Theabilitytotalktherapeuticallywithpatients must prove herself to be trustworthy and as a
requires an attitude of acceptance, tolerance and person who can be relied upon in any situation.
genuine interest in the patient. The basis of all
helping relationships is acceptance which implies 8. Professionalism
that the nurse treats the patient as an important Developing the professional skills of a psychiatric
person and not as a diagnostic entity or a set of nurse is dependent upon learning as much as
psychiatric symptoms. possible about the patient, his illness and the
helping role of the nurse as it specifically applies 2. Provider of Therapeutic Environment for
to the patient. the Patient
The psychiatric nurse has always had a central
9. Accountability role in maintaining a therapeutic environment.
According to Peplau (1980),the need for personal The nurse assesses potentially stressful charac-
accountability and professional integrity are teristics of the environment and develops
greater in psychiatric practice than in any other strategies to eliminate or decrease these stresses
type of health care. Patients in mental health in the environment.
settings are usually more vulnerable and As protector the nurse helps maintain a safe
defenseless than patients in other health care environment for the client and takes steps to
settings, particularly because their conditions prevent injury and protect the clientfrom possible
hinder their thinking processes and their adverse effects of diagnostic or treatment
relationships with others. Mental health nurses measures.
are accountable for the nature of the effort they
make on behalf of patients and answerable to 3. Teacher I Educator
patients for the quality of their efforts. It is one of the primary intervention strategies the
nurse uses in improving mental health.
10.The Ability to Think Critically Some topics that nurses address in their
The ability to think critically is crucial for mental education include the following:
health nurses. A critical thinker analyzes Medication management
information before drawing conclusions about it. Illness management
It is purposeful, reasonable, reflective thinking Communication skills
that drives problem solving and decision making Coping skills
and aims to make judgments based on evidence. Handling of stress and anxiety
Dealing with emergencies
THERAPEUTIC ROLES OF A PSYCHIATRIC The teaching role requires skills to assess the
MENTALHEALTHNURSE patient's learning needs, level of learning ability
Psychiatric nurses have many roles that will and designing a teaching plan that encompasses
continue to change and evolve as the health care cultural, socio-economic and personal needs.
environment changes. The roles of the nurse meet Psychiatric nurses act as both advisors to
client and family needs, guide, assist, and teach people on health matters which are in essence
,the clientand family;and provide an environment teaching on a one-to-onebasis,and engage in more
that facilitates client and family growth and formal teaching activities.
development.
4. Coordinator
1. Direct Care Provider Nurse as a coordinator, cooperates with other
A Psychiatric nurse provides nursing care to professionals in various aspects of the client's
individuals, families and groups to enable them care; thereby facilitating an inter disciplinary
to function at an optimal level of psychological approach to care.
wellness. As a direct care provider the nurse The psychiatric nurse plans and supervises
assists the client to regain health through the the care given by auxiliary nursing personnel. In
healing process. The nurse provides a holistic addition, she consults with other professionals
approach to care, including assisting the client/ regarding the care given to the patient. She
family in coping with the physical, emotional consults with the psychiatrist about his plan of
social and spiritual impacts of the illness. treatment; she may need to talk with the

behavioral therapist about the psychological Providing information about mental health
management, with the occupational therapist issues, such as communication skills,
about his rehabilitation, with the social worker parenting, stress reduction, coping strategies
and the community agency about plans for his and relaxation techniques and counseling
home care. In a nutshell, it is the nurse, who Making appropriate referrals as indicated to
establishes a plan for the patient's care and serves prevent occurrence of mental illness (primary
as the coordinator for all activitiesconcerned with prevention)
him. Working with community groups on issues
related to mental health
5. Patient Advocate Secondary prevention involves those nursing
activities directed at reducing actual illness
As the health care system has become more
by early detection and treatment of the
complex with a number of different agencies and
problem. Example: screening for anxiety and
an increasing variety of care providers concerned
depression
with different aspects of the patient's care, the
Tertiary prevention involves those nursing
need for someone who can speak on the patient's
activities that focus on reducing the residual
behalf and intercede in his interests has become impairment or disability resulting from an
essential. This speaking for the patient and illness.
interceding on his behalf is an important aspect
of nursing care. 7. Collaborator
A patient needs at least one person to whom
As members of the health care team, nurses must
he can relate in a meaningful way and who can
work with other team members to ensure that
act as his spokesman with other members of
patients receive the highest quality of care
health team. In this connection, the nurse is res-
possible. In psychiatry, every patient must have
ponsible for defining, defending and promoting an individualized treatment plan that reflects the
the rights of the patient. A nurse is the logical collaborative efforts of nursing, psychiatry, social
person to interpret the different services offered work, occupational therapy, recreational therapy
by other professional health staff and to explain and other specialties that are involved in the
the types of and need for, various prescriptions patient's care. Nurses can effectively work with
and treatments as ordered by the physician. As other members ofthe health care team to deal with
an advocate, the nurse is compelled to work on patient care problems.
behalf of the patient.
The advocacy role involves: 8. Case Manager
Educating patients about their rights and In case management the nurse co-ordinates the
responsibilities activities of the other health care providers in
Negotiating for mental health services collaboration with the direct care providers. The
Reporting abuse of client's rights, unethical, casemanager focuseson moving the clientthrough
incompetent and illegal practices the health care environment, assisting with
Protecting the patient and family members scheduling oftests and procedures and interacting
from unethical practices. with various care providers. Many times case
managers follow a client across all settings,
6. Provider of Preventive Care including ambulatory care and home care.
Preventive care includes health promotion, illness
prevention, and protection against diseases. 9. Professional Role
The following activities are carried out by a Nurses have a responsibility to contribute to the
psychiatric nurse for prevention of mental growth of self and of the profession. The nurse
illnesses: participates in continuing professional educa-
tional activities and promotes activities designed Scope of psychiatric nursing (Nov 2001, Oct
to improve psychiatric nursing practice and care. 2002, Nov 2003)
Current trends in mental health nursing (Nov
10. Researcher 2002, Nov 2003, Oct 2006)
A Psychiatric nurse utilizes therapeutic principles Qualities of a psychiatric nurse
and research to understand and interpret the Therapeutic roles of a psychiatric nurse
client's emotions, thoughts and behaviors. She Standards of mental health nursing (Nov
also involves in research activities to incorporate
2001, Nov 2002)
new research findings into practice and monitor
Principles of psychiatric nursing (Feb 2000,
the protection of human subjects.
Feb 2001, Apr 2004, Oct 2004, Oct 2005, Apr
REVIEW QUESTIONS 2006)
Functions of psychiatric nurse
Historical development of psychiatric nursing
Methods of psychiatric assessment (Nov 1999)
(Nov 1999, Oct 2006)
Personality Development
and Theories
:J DEFINITIONOF PERSONALITY height, weight, eye and skin color, the complex
:J PSYCHOSOCIALFACTORSINFLUENCING patterns of social and intellectual behavior, are
PERSONALITY
Role of Heredity influenced by a person's genetic endowment.
Environmental Factors
:J DEVELOPMENTOF PERSONALITY II. Environmental Factors
:J THEORIESOF PERSONALITYDEVELOPMENT
Psychoanalytic Theory 1. Family
Interpersonal Theory
Theory of Psychosocial Development
Among environmental factors, the most
Cognitive Development Theory important is the family environment. The
Theory of Moral Development reaction of the family environment towards
Humanistic Approach an individual, and the role ofparents, are very
Trait and Type Theories of Personality
Behavior Theory important in the molding of personality.
Parents serve as a model whom the child
/IEFINITION OF PERSONALITY imitates, and their influence is considerable
on the child. Parents influence the develop-
"Personality refers to deeply ingrained patterns
- ofbehavior, which include the way one relates to, ment of a child's personality in a wide variety
perceives, and thinks about the environment and of ways. Children learn the moral values, code
one self". of conduct, social norms and methods of
'----f American Psychiatric Association (APA) 1987 interacting with others from parents.
On the whole friendly and tolerant fathers
PSYCHOSOCIAL FACTORS INFLUENCING help children to have greater emotional
PERSONALITY stability and selfconfidence.Domineering and
rigid fathers will only foster the development
I. Role of Heredity of submissive and frightened dependent
At conception when the egg cell of the female is children.
fertilized by the sperm cell of the male, each new Over-protective mothers will influence
human being receives a genetic inheritance that children in the direction of dependence and a
provides potentialities for development and total disregard for others. Nagging mothers
behavioral traits throughout a lifetime. will cause children to be shy, submissive and
The principal raw materials of personality - emotionally unstable.
physique, intelligence and temperament are the Besidesthe role of the parents, the atmosphere
result of heredity. How they will develop will in the family is greatly influencing. A peaceful
depend on environmental influences. Many and loving atmosphere results in children
aspects of human behavior and development being orderly, peace-loving and very affectio-
ranging from physical characteristics such as nate. Without undue strain they develop
mature and pleasant personalities. In a family The parathyroid gland regulates calcium
where there is tension, constant quarrels and metabolism. Excitabilityof the nervous system
incompatibility among parents, the child is is directly dependent on the amount of calcium
likely to develop strong feelings of insecurity in the blood. Deficient working of this gland
and inferiority. leads to the development of an irritable,
Birth order: This is another familial factor that distracted, nervous and a tense person.
can have an important influence on Similarly other glands namely pituitary, the
personality development. Every child has a adrenal and the gonads have their tremendous
unique position in the family, such as the impact on various personality traits.
eldest, youngest, second or third. This position
has a definite influence on personality. The 4. School
eldest child is very often overburdened with The children spend much of their time in the
responsibility, hence he grows up to be very schools and hence it can play a very large part
independent, while the youngest being the in the formation of the personality of the child.
baby of the family is petted and spoilt. The The following factors of schoolwill have direct
common view of an only child would be that role on child personality:
he will be pampered and spoilt. the friendships and acquaintances which
are made among the children themselves
2. Physique the type of curriculum in the schools,
An individual's size, strength and general which affects the habitual responses of
appearance determines to a large extent the way children
in which he behaves towards others and how well-furnished laboratories, adequate
others react towards him. An individual with an playground, etc.
imposing body-build and a healthy appearance A nurturant school atmosphere that provides
definitely influences those around him. Even if for all-round development, consistency,
he has not proved himself,yet he gains recognition structure, warmth and responsiveness, can do
and status through his physical appearance. a great deal to help children develop a
Contrary to this is the small lean person; even if favorable personality and cope with changing
he has some merits, these are over-looked because life circumstances.
of his physique. People are apt to judge him
according to his appearance. 5. Teacher
3. Endocrine Glands A teacher is the most important person in the
school who can help in modifying children's
The secretions of endocrine glands affect
personalities. He is the most powerful source of
physical growth, emotional growth and
stimulation for the child. If he/she possesses
mental growth. These will have an impact on
desirable personal and social modes or reactions,
the total personality of an individual.
he will inculcate them among his students. On
The thyroid gland secretes a hormone called
thyroxin, and the main function of this the other hand, effectsof prejudicial treatment on
hormone is regulation of body metabolism. If the part of teachers can make the child lose self-
the thyroid gland is under-active, the result is confidence and develop low self-esteem.
usually mental dullness, inactivity, depres-
sion, fatigue and poor appetite. Hypersec- 6. Peer Group
retion of these glands leads to extreme over- Developmental psychologists believe that inter-
activity. actions with peers are criticalto many of the social
Personality Development and Theories 31
skills and advances that occur during childhood. 8. Mass Media

Peer group refers to other children of the same Mass media includes films, television, radio,
age who study with or play with the child. Peer printed literature, etc. Mass media has a
group is much more influential than siblings or considerable impact on attitudes, values, beliefs
parents. and behavior patterns. Baron and Bryne (1986)
Even at preschool age, playmates are highly have shown that individuals, especially children,
influential. Children imitate peers and try to be imitate specific aggressive acts of models. They
like them in many respects. The peer group serves have proposed that human personality formation
as an important reference group in shaping is a result of modeling and imitating the behavior
personality traits and characteristics of the of significant others. Many abnormal forms of
growing child. As the child grows up peers behavior can be learned by imitating models from
become progressively more influential in molding the mass media.
the child's self concept. Children learn many
forms of behavior, some socially appropriate and 9. Culture
others socially undesirable, from their peers. Culture influences personality because every
For example, by striving to be accepted and culture has a set of ethical and moral values,
liked by their peers, they gain new insights into beliefs .and norms which considerably shapes
the meaning of friendship. Through give and take behavior. Cross-cultural studies have pointed out
with peers, they learn the importance of sharing, the importance of cultural environment in
reciprocity and cooperation. Bytrying to get peers shaping our personality. Individuals of certain
to understand their thoughts and feelings, they cultures are more generous, open-hearted and
learn to communicate more effectively.Within the warm whereas individuals of some other cultures
peer group, children also learn sex-role norms. In are suspicious, introverted and self-centered. It
general, boys become rougher, boisterous, more has also been found that certain cultural
compulsive, and form larger groups, while girls communities are more prone to develop certain
tend to form more intimate,more exclusivegroups. abnormal behaviors as compared to others,
Feelings of masculine superiority, sex bias and probably due to the influence of geographical,
other attitudes and behavior develop with gender dietary, hormonal or genetic influences within
identification. the community.
7. Sibling Relationships
The number of siblings as well as their sex "Personality consists of distinctive patterns of
and age has a considerable influence on the behavior (including thoughts and emotions) that
development of both favorable and unfavorable characterize each individual's adaptation to the
personality traits like cooperativeness, sharing, situations of his or her life".
aggressiveness, jealousy, etc. Although sibling (Walter Mischel, 1976)
rivalry is common, older siblings invariably teach
the infant a great deal and they can even function Babyhood (Birth - 2 years of life)
as a source of security. On the other hand, This period is the true foundation period of
unhealthy comparisons can also develop, for life because many behavioral patterns, atti-
instance, an athletic child who is favored by an tudes and patterns of emotional expressions
athletic father over a less active sibling,may suffer are being established. These have a lifelong
from an inferiority complex or develop low self- influence on the child's personal and social
esteem. adjustments.
The term 'infant' suggests extreme helpless- growth in infancy. Body proportions change
ness. The infant is truly a dependent markedly. The muscles become longer, stronger
individual, and his total existence depends and heavier. The average annual increase in
on resources outside himself. It is a time of height is 3 inches and the average annual increase
rapid growth and development, and a time of in weight is 3-5 lbs.
radical adjustments. Emotions are especially intense, and they are
An average infant weighs 7 lbs and measures easily aroused to emotional outbursts such as
18-19 inches in length. Common responses temper tantrums, fears, and unreasonable
like spontaneous eye movements, yawning, outbursts ofjealousy. Other emotions of curiosity,
turning and lifting the head, etc. are present. joy, and affection also develop.
Gradually dentition, bowel and bladder
control develop. The baby grows rapidly and Personality Traits
masters some common skills such as self-
The most important psychosocial achieve-
feeding, self-dressing, walking alone,
ment at this time is the development of
climbing stairs, etc.
autonomy or independence. If trust and
The baby's vocalization includes crying,
security do not develop at an early age,
cooing, gurgling, which gradually develop
autonomy will fail to develop. There is
into babbling, and later, speech.
heightened awareness and curiosity of the self,
Emotional reactions are intense and sudden,
termed as narcissism. The issue of sexuality
whatever the stimulus. These reactions may
also overtly develops.
be described as states of pleasantness
The child also begins to know the difference
(characterized by relaxing of the body) and
between right and wrong, and laid down
unpleasantness (characterized by tensing of
the body). Later on, emotions such as anger, standards of behavior and rules of conscience
fear, curiosity, joy, affection are exhibited. which will thereafter guide much of his
Babies who experience more of pleasant behavior.
emotions are laying the foundation for good In this phase specific crisis is between
personal and social adjustments later on in initiative and guilt. If the child successfully
life. passes through this stage, it leads to inter-
Personality traits nalization of values and social sanctions, and
Children are born with characteristic tempe- from this time onwards, he is able to
ramental differences,and it is these differences differentiate between right and wrong and to
from which the individual personality patterns lay down standards of behavior and rules of
develop. The infant develops self-trust by conscience that will thereafter guide much of
trusting in what he sees and hears. The his behavior.
beginning feelings of confidence and faith The child with faulty autonomy traits will be
develop ifhe receiveswhat is needed. Feelings clinging and dependent. Phase related adult
of distrust develop if the baby's needs are not characteristics include stubbornness, over
met. This leads to personality problems such compensatory control, compulsive cleanliness
as clinging and demanding behavior, greed, and extreme selfcontrol. He may also develop
giving up easily, taking rather than giving, intense anxiety or guilt or an antisocial
etc. personality.
Early Childhood (2-6 years) Late Childhood (6-11 years)

Growth during early childhood proceeds at a Late childhood is a period of slow and uniform
slow rate as compared with the rapid rate of growth. The average annual increase in height
is 2-3 inches, and the average annual weight establishing meaningful relationships with
increase is 3-5 lbs. peers of both sexes, and making decisions
Emotional expressions are usually pleasant about life work and goals.
ones, although outbursts of anger, anxiety and Parent-adolescent conflict is very common, as
frustration may continue to occur. adolescents seek independence from their
parents. The approval of their own age group
Psychosocial Development is much more important to them than the
It is during this stage there is increased ego approval of adults. Intense conflictscan occur
control over basic drives. Behavioral if the values of the group conflictwith those of
characteristics like sympathy and concern for the parents. Beinga member of the peer group
others, cleanliness,modesty, co-operation and has a strong influence on the self-identity and
willingness to share develop. The child now self-esteem of the adolescent.
looks beyond the family and begins to interact The issues of the period of later adolescence
with the social system. (15-19years) are related to career, marriage
Developmental tasks during this period are and parenthood. This is the period when there
the acquisition of social skills, incorporating is a consolidation of the personality and a
social values and patterns, and competition beginning sense of identity as a mature person.
and interaction with peers and authority Characteristic troubles of the adolescent
figures. Failure in mastery of the tasks results identity crisis may include psychosis,
in emotional instability,low self-esteem,social neurosis, delinquency (breaking rules of
inferiority and inability to assume expected society),etc.
responsibilities.
Early Adulthood (20-40 years)
Adolescence (12-19 years) The term' adult' is derived from the Latinword
The period of adolescenceis a period of" storm 'adulius', which means' grown to full size and
and stress," an action-oriented phase of life strength'. Adults are therefore individuals
in which feelings and thoughts are primarily who have completed their growth and are
expressed through behavior. ready to assume their status in society along
The important physical changes which occur with other adults.
during this period include changes in body During this stage, the physical and
size and proportion, and the development of psychological changes which accompany the
primary and secondary sex characteristics. beginning of reproductive capacity appear.
The BasalMetabolicRate (BMR)slowly begins
Psychosocial Development to come down, when compared to adolescence,
A major change from the childhood to the so excess body weight is easily gained.
adolescent is the development of self-
consciousness. Adolescents become very Psychosocial Development
aware of how others see them and react to The four major social expectations or tasks for
them, and this awareness makes teenagers feel the adult include choice of career, sexual
apprehensive and extremely self-conscious. mutuality (marriage/ choosing a life partner),
This is the period when there is a conso- generativity and child-rearing, participation
lidation of personality and a beginning sense in social processes and work.
of identity as a mature person. Phase specific If the young adult has been over-protected by
tasks for the adolescent may be identified as parents, difficulties arise in forming intimate
gaining independence from the family, relationships with another person and coping
integrating new found sexual maturity, with responsibilities in the working world.
Middle Adulthood (41-60 years) loss of spouse, post-child rearing period
Physical changes related to ageing become more (empty nest syndrome), grand parenthood
prominent, such as wrinkled skin,muscular pains If favorable factors such as satisfaction of
and impaired sensory capacities. Faulty lifestyles needs, retention of old friendships, positive
may bring on diseases such as hypertension, social attitudes, etc. are present, they foster
heart disease, cancer, etc. A very major physical ego integrity of the person. However without
change is menopause or the male climacteric. adequate support to sustain and bear the
Many physical discomforts and mood changes losses the older adult is vulnerable to a
may accompany menopause, and they may profound sense of insecurity. Despair and
become depressed, hostile and self-critical and disgust can take over the person, including
have wide mood swings. All these usually the feeling, time is running out and there are
disappear once endocrine balance is restored. no alternatives possible at this late date.
How successfully women make the adjustment Seriouspersonality breakdown in old age may
to the physical and psychological changes that lead to criminal behavior or suicidal tende-
accompany menopause is greatly influenced by ncies, as in demen~.j
their past experiences, and especially the social
THEORIES OF PERSONALITY DEVELOPMENT
support available to them.
Developmental theories identify behaviors asso-
Psychosocial Issues ciated with various stages through which indivi-
During this age,people becomemore and more duals pass, thereby specifyingwhat is appropriate
occupied with their work and family. The or inappropriate at each developmental level.
major adjustments to be made during this Nurses must have a basic knowledge of human
period include adjusting to physical and personality development to understand mal-
mental changes, occupational responsibilities, adaptive behavioral responses commonly seen
approaching retirement and old age. in the mentally ill. Knowledge of the appropria-
Failure to master these developmental tasks teness ofbehavior at each developmental level is
may lead to marital, social or occupational vital to the planning and implementation of
conflicts and failures. quality nursing care.
Late Adulthood (Old age- 60 years and above) Psychoanalytic Theory
Physical changes include wrinkling of skin, Freud (1939),who has been called the father of
stooped posture, flabbiness of muscles, psychiatry, is credited as the first to identify
decreased vision and hearing, a decreased development by stages. He believed that an
efficiency of cardiovascular system individual's basic character is formed by age 5.
Freud categorized his personality theory accor-
Psychosocial issues
The theme of this age period is loss, which ding to structure, dynamics, and development.
may be identified as follows: Structure of the Personality
Loss of physical abilities
Loss of intellectual processes Freud organized the structure of personality
Loss ofwork role and occupational identi- into three major components : the id, ego, and
fication (retirement) superego.
Loss of intimate ties, such as death of
spouse, friends and other acquaintances Id
The major adjustments to be made include The id contains all our biologically based drives
adjustment to physical changes, retirement, - the urge to eat, drink, eliminate, and especially,
to be sexually stimulated. The sexual energy that the superego. If an excessive amount of
underlies these urges is called the libido. The id psychic energy is stored in one of these
operates according to the "pleasure principle." personality components, behavior will reflect
That is, it desires to satisfy its urges immediately, that part of the personality. For instance,
without regard to rules, realities of life or morals impulsive behavior will prevail when
of any kind. Id present at birth, it endows the excessive psychic energy is stored in the id.
infant with instinctual drives that seek to satisfy Overinvestment in the ego will reflect self-
needs and achieve immediate gratification. Id absorbed or narcissistic behaviors and an
driven behaviors are impulsive and may be excesswithin the superego will result in rigid,
irrational. self-deprecating behaviors.
The human personality functions on three
Ego levels of awareness: conscious, preconscious
The ego functions on the basis of "reality and unconscious.
principle", and begins to develop between ages 4 Consciousness refers to the perception,
and 6 months. The ego experiences the reality of thoughts and feelings existing in a person's
the external world, adapts to it, and responds to immediate awareness.
it. It delays satisfying id, and channels our Preconscious content on the other hand, is not
behavior into socially acceptable way. A primary immediately accessible to awareness. Unlike
function of the ego is that of mediator, that is to conscious and preconscious, content in the
maintain harmony between the external world, unconscious remain inaccessible for the most
the id, and the superego. part.
The unconscious affects all the three perso-
Superego nality structures - id, ego and the superego.
Although the id's content resides totally in
The superego is referred to as the "perfection
the unconscious, the superego and the ego
principle" or the "moral principle". The superego
have aspects in all the three levels of
which develops between ages 3 and 6,
consciousness.
internalizes the values and morals set forth by
Some ideas, memories, feelings or motives
primary caregivers. The superego is important in
which are disturbing, forbidden, and un-
the socialization of the individual as it assists the
acceptable and anxiety producing are repres-
ego in the control of id impulses. When the
sed from consciousness.The process ofrepres-
superego becomes rigid and punitive, problems
sion itself is unconscious and automatic, it
with low self-confidenceand low self-esteemarise.
just happens without our knowledge. This
repressed material continuous to operate
Dynamics of the Personality
underground and converts the repressed
Freud believed that "psychic energy" is the conflicts into disturbed behavior and
force or impetus required for mental func- unexplained signs and symptoms. According
tioning. Originating in the id, it instinctually to Freud this repressed material is also
fulfillsbasic physiological needs. As the child responsible for some of our dreams, accidental
matures, psychic energy is diverted from the slips of tongue, etc.
id to form the ego and then from the ego to
form the superego. Freud's Stages of Personality Development
Psychic energy is distributed within these Freud described formation ofpersonality through
three personality components, largest share five stages of psychosexual development. Freud
to maintain a balance within impulsive placed much emphasis on the first 5 years of life
behavior of id and the idealistic behavior of and believed that characteristics developed
during these early years bore heavily on one's organs. The development of Oedipus complex
adaptation patterns and personality traits in occurs during this stage of development. Freud
adulthood. Fixation in an early stage of described this as the child's unconscious desire
development will almost certainly result in to eliminate the parent of the same sex and to
psychopathology. posses the parent of the opposite sex. Guilt feelings
result with the emergence of the superego during
1. Oral stage: Birth to 18 months these years. Resolution of this internal conflict
The major developmental tasks during this stage occurs when the child develops a strong
are "relief from anxiety through oral gratification identification with the parent of the same sex and
of needs". During this stage behavior is directed that parent's attitudes, beliefs and value system
by the id. The focus of energy is the mouth. The are subsumed by the child.
baby obtains pleasure from sucking, biting, and
chewing. The infant feels a sense of attachment 4. Latency stage: 6 to 12years
and is unable to differentiate the self from the The major developmental task during this stage
person who is providing the mothering. At the is "repressed sexuality with focus on relation-
age of 4-6 months the development of ego will ships with same sex peers". Sexuality is not absent
begin, the infant starts to view the self as separate during this period, but remains obscure and
from the mothering figure. A sense of security and imperceptible to others. Children of this age show
the ability to trust others is derived out of a distinct preference for same-sex relationships,
gratification from fulfillment of basic needs during even rejecting members of the opposite sex.
this stage.
5. Genital stage: 13 to 20 years
2. Anal stage : 18 months to 3 years
The major developmental tasks during this stage
The major developmental tasks in this stage are are: Libido is reawakened as genital organs
gaining independence and control, with focus on mature; focus is on relationships with members
the excretory function. During this stage the id is of the opposite sex. The development of sexual
slowly brought under the control of ego. Freud maturity evolves from self-gratification to
believed that the manner in which the parents behaviors that have been deemed acceptable by
and other primary caregivers approach the task societal norms.
of toilet training may have long term effects on
the child in terms of values and personality Interpersonal Theory
characteristics. When toilet training is strict and
Sullivan (1953) believed that an individual's
rigid, the child may choose to retain the feces,
behavior and personality development are the
becoming constipated. Adult retentive personality
direct result of interpersonal relationships and
traits influenced by this type of training include
that personality development is determined
stubbornness, stinginess and miserliness.
within the context of interactions with other
Toilet training that is more permissive and
humans.
accepting attaches the feeling of importance and
desirability to feces production. The child becomes Sullivan's major concepts include:
extroverted, productive and altruistic. 1. Anxiety
A central theme of Sullivan's theory is anxiety
3. Phallic stage : 3 to 6 years and its relationship to the formation of
The major developmental task during this stage personality. He viewed anxiety as a primary
is identification with parents of the same sex and motivator of behavior, a builder of self-esteem
development of sexual identity; focus is on genital and the great educator in life. It arises out of
one's inability to satisfy needs or achieve Sullivan's Stages of Personality Development

interpersonal security. He also believed that Sullivan described six stages of personality
anxiety is the chief disruptive force in the development from birth to maturity, which he
development of serious difficulties in living. divided according to the capacity for communi-
2. The self system cation and integration of new interpersonal
It is a significant aspect of the personality that experiences. Experiences during each stage are
develops in response to anxiety.Disapproving
influenced by those of the previous one. The
and forbidding gestures during interactions
personality achieves some degree of stability at
with significant others help to develop the
the end of the juvenile era (see below), but
self-system. Sullivan identified three compo-
continues to develop beyond this time and has
nents ofthe self-system,which are based upon
the potential for corrective experiences.
interpersonal experiences early in life.
A The "good me" - the part of the personality
that develops in response to positive 1. Infancy: Birth to 18 months
feedback from the primary caregiver. The major developmental task during this stage
Feelings of pleasure and gratification are is "relief from anxiety through oral gratification
experienced. of needs". This is accomplished around activity
B. The"badme" -partofthepersonalitythat associated with the mouth, such as crying and
develops in response to negative feedback thumb sucking.
from the primary caregiver and experien-
ces related to increased anxiety states. 2. Childhood: 18months to 6 years
Feelings of discomfort and distress are The major developmental task during this stage
experienced. is "learning to experience a delay in personal
C. The "not me" - the part of the personality gratification without undo anxiety". Tools of this
that develops in response to situations that stage include the mouth, language, the anus,
produce intense anxiety in the child. experimentation, manipulation, and identifi-
Feelings of horror and dread are experien-
cation.
ced. The child may develop emotional
withdrawal.
3. Juvenile: 6 to 9 years
3. Security operations
Security operations become a part of the self The major developmental task during this stage
system to help the individual avoid or is "learning to form satisfactory peer relation-
minimize anxiety. The security operations ships". This is accomplished through the use of
include sublimation, selective inattention and competition, co-operation and compromise.
dissociation.
Sublimation is an unconscious process of 4. Preadolescence: 9 to 12years
substituting a socially acceptable activity The major developmental task during this stage
pattern to partially satisfy a need for an is "learning to form satisfactory relationships
activity that would give rise to anxiety. with persons of same sex";the initiation offeelings
Selective inattention is an unconscious of affection for another person.
substitute process that allows many
meaningful details of one's life that are
5. Early adolescence: 12 to 14years
associated with anxiety to go unnoticed.
Dissociation is a system of process that The major developmental task during this stage
minimizes or avoids anxiety by keeping is "learning to form satisfactory relationship with
parts of the individual's experiences called persons of the opposite sex;developing a sense of
'not me' out of consciousness. identity". The emergence of lust in response to
biological changes is a major force occurring gratification of needs and desires and hope
during this period. for the future.
Distrust can develop if the infant's world is
6. Late adolescence: 14 to 21 years filled with insecurity due to unmet needs,
The major developmental task during this stage caused by lack of caring on the part of parents
is "establishing self identity; experiencing and significant others.
satisfying relationship; working to develop a Non-achievement results in emotional dissa-
lasting, intimate opposite-sex relationship." The tisfaction with the self and others, suspicious-
genital organs are the major developmental focus ness, and difficulty with interpersonal
of this stage. relationship.
Theory of Psychosocial Development 2. Early Childhood (2- 3 years) -Autonomy vs

Shame and Doubt
Erikson (1963) studied the influence of social
processes on the development of the personality. The major developmental task during this
Erikson tried to revise psychoanalytic theory by stage is "to gain some self-control and
giving a greater role to ego processes. He independence within the environment".
expanded Freud's theory to cover the whole life As the child attempts to gain independence,
cycle of man as the Eight Stages of Man. At each parents need to encourage him, which will
of these 8 stages, the individual is faced with a help him gain autonomy. Achievement of the
psychosocial crisis, which must be successfully task results in a sense of self-control and the
resolved, if healthy development must take place ability to delay gratification, and a feeling of
at a later stage. self-confidence in one's ability to perform.
If he is not allowed freedom or if he is
1. Infancy (0 - 1year) Trust vs Mistrust overprotected or criticized for what he does,
The major developmental task during this shame, doubt and uncertainty about himself
stage is "to develop a basic trust in the and his capabilities will result.
mothering figure and be able to generalize it
to others". 3. Middle Childhood (4 to 5 years)- Initiative vs
The infant learns to trust if all his needs are Guilt
met. Achievement of the task results in self The major developmental task during this
confidence, optimism and faith in the stage is "to develop a sense of purpose and
SI.No. Stage Psuchosocial Crisis Virtue
1 Infancy (Birth to 1 year) Basic Trust vs Mistrust Hope

2 Early Childhood (2-3 years) Autonomy vs Shame and Doubt Will power
3 Middle Childhood (4-5 years) Initiative vs Guilt Purpose
4 Late Childhood (6-11 years) Industry vs Inferiority Competence
5 Adolescence (12-19 years) Ego Identity vs Role Confusion Fidelity
6 Early Adulthood (20-25 years) Intimacy vs Isolation Love
7 Middle Adulthood (26-64 years) Generativity vs Stagnation Care
8 Late Adulthood or Old Age Ego Integrity vs Despair Wisdom
(65 years and above)
..
the ability to initiate and direct own activities. Achievement of the task results in a sense of
Initiative is achieved when creativity is confidence, emotional stability, and a view of
encouraged and performance is recognized the self as a unique individual.
and positively reinforced. When independence is discouraged by the
Achievement of the task results in the ability parents, and the adolescent is nurtured in the
to exercise restraint and self-control of dependent position, it may cause a lack of self-
inappropriate social behaviors. confidence. Non-achievement results in a
If his initiative and curiosity are discouraged, sense of self-consciousness, doubt and con-
the child may be prevented from setting future fusion about one's role in life.
goalsby a sense of guilt and shame for holding
such ambitions. 6. Early Adulthood (20 - 25 years) - Intimacy
vs Isolation
4. Late Childhood (6 - 11years) - Industry vs The major developmental task during this
Inferiority stage is "to form an intense, lasting relation-
The major developmental task during this ship or a commitment to another person".
stage is "to achieve a sense of self-confidence Intimacy is achieved when an individual has
by learning, competing, performing success- developed the capacity for giving of oneself to
fully, and receiving recognition from signi- another. This is learned when one has been
ficant others, peers and acquaintances. the recipient of this type of giving within the
If parents praise the children's efforts, a sense family unit. Achievement of the task results in
ofesteem and industry develops. Achievement the capacity for mutual love and respect
of the task results in a sense of satisfaction between two people.
and pleasure in the interaction and involve- If there is extreme fear of being rejected or
ment with others. disappointed, the individual may withdraw
When parents set unrealistic expectations for or isolate himself.
the child, when discipline is harsh and tends
to impair self esteem, and when accomp- 7. Middle Adulthood (26-64 years) -
lishments are consistently met with negative Generativity vs Stagnation
feedback, the individual may become a The major developmental task during this
workaholic with unrealistic expectations, non- stage is "to achieve the life goals established
achievement results in difficulty in interper- for oneself, while also considering the welfare
sonal relationships due to feelings of personal of future generations.
inadequacy. For Erikson, generativity includes marriage,
parenthood and the sense of working
5. Adolescence (12- 19 years) - Ego Identity productively for the good of others.
vs Role Confusion The generative individual enjoys work and
The major developmental task during this family and is continuously ready to come to
stage is "to integrate the tasks mastered in the the aid of others.
previous stages into a secure sense of self". When earlier developmental tasks are not
Childhood comes to an end during this stage fulfilled he becomes withdrawn, isolated, and
and youth begins. Puberty brings on a highly self-indulgent.
"physiological revolution" with which adole-
scents must learn to cope. 8. Old age (65 years and above)- Ego integrity
Identity is achieved when adolescents are vs Despair
allowed to experience independence by The major developmental task during this
making decisions that influence their lives. stage is "to review one's life and derive
meaning from both positive and negative cannot be linked to existing schema, the child
events, while achieving a positive sense of self must learn to develop new mental images or
worth". patterns through the process of accommo-
Ego integrity is achieved when individuals dation. As long as the child is able to assimilate
have successfully completed the develop- or accommodate adequately to new know-
mental tasks of the previous stages. ledge, the child is able to achieve equilibrium
Achievement of the task results in a sense of or mental balance. When schemas are inade-
self-worth and self-acceptance. quate to facilitate learning, disequilibrium
When earlier tasks are unresolved he feels may occur.
worthless and helpless to change. Non-
achievement results in a sense of selfcontempt Major Cognitive Development Stages
and disgust with how life has progressed.
Stage I: Sensorimotor (Birth to 2 years)
Cognitive Development Theory The major developmental tasks during this
stage are increased mobility and awareness,
Jean Piaget (1896-1980)a Swiss philosopher
and psychologist dedicated his life work to developing a sense of selfas separate from the
observing and interacting with children to external environment.
determine how their thinking processes During this stage the child is concerned only
differed from adults. with satisfying basic needs and comforts.
According to Piaget's theory of personality The child develops a greater understanding
development, the developing child passes regarding objects within the external
through four main discrete stages: the environment and their effectsupon him or her.
sensorimotor stage, the preoperational stage, Knowledge is gained regarding the ability to
the stage of concrete operations, and the stage manipulate objectsand experienceswithin the
of formal operations. Each stage reflects a environment.
range of organizational patterns that occur in Stage II: Preoperational (2 to 6 years)
definite sequence and within an approximate The major developmental tasks during this
age span. stage are "Learning to express self with
Development is influenced by biological language, develops understanding of
maturation, socialexperiences, and experien- symbolic gestures, achievement of object
ces with the physical environment. During permanence".
cognitive development the individual strives Uses language and can represent objects by
to find equilibrium between self and images and words.
environment. Remains egocentric: Unable to think from
Cognitive theory explains how thought another's point of view. Cannot distinguish
processes are structured, how they develop reality from fantasy.
and their influence on behavior. Structuring Acquires language: Only intuitively guesses
of thought processes occurs through the about cause and effect.
development of schema (i.e.mental images or
cognitive structures). Thought processes Stage III: Concrete operations (6 to 12 years)
develop through assimilation and accommo- The major developmental tasks during this
dation. When the child encounters new infor- stage are: learning to apply logic to thinking;
mation that is recognized and understood develops understanding of reversibility and
within existing schema, assimilation of that spatiality; learning to differentiate and
new information occurs. If new information classify.
Able to think about past and present events authority role; the child is responsive to cultural
but not future. The child is able to acknow- guidelines of good and bad, right and wrong, but
ledge the viewpoints of others and appreciate primarily in terms of the known related
feelings. consequences.
Stage IV: Formal operations period (12 to 15 years) 3. Instrumental relativist orientation
The major developmental tasks during this During this stage moral decisions are motivated
stage are: learning to think and reason in by desire for rewards rather than avoiding
abstract terms; makes and tests hypotheses. punishment, and belief that by helping others they
Logical thinking and reasoning ability expand will get help in return. Behaviors of this stage are
and are refined. guided by egocentrism and concern for self.There
Can think of future events and develops is an intense desire to satisfy one's own needs,
strategies for solving complex problems. but occasionally the needs of others are consi-
Cognitive maturity is achieved during this dered.
stage.
Level II: Conventional Level
Theory of Moral Development (Able to see victim's perspective-ages 10 to 13
Moral development encompasses moral years)
judgment or reasoning processes and involves
4. Interpersonal concordanceorientation
making decisions about right or wrong actions
Moral decisions are based on desire for approval
in a particular situation (Stroufe, Cooper and
from others and on avoiding guilt experienced by
Dettart, 1992).
not doing the right thing. Behavior at this stage is
Piaget examined the concept of moral develop-
guided by the expectations of others.
ment; according to him moral judgment is first
based on consequences and later on motives. 5. Law and order orientation:
Lawrence Kohlberg built on Piaget's work in In this stage moral decisions are defined by rights,
the area of moral development. Kohlberg assigned duty, rules of the community and respect
believes that each stage is necessary and basic for authority.
to the next stage and that all individuals must
progress through each stage sequentially. He Level Ill: Post-conventional Level
defined three major levels of moral (Underlying ethical principles are considered that
development. take into account societal needs - Ages 13 years
and above)
Level I: Pre-conventional Level
6. Social contract legalistic orientation:
(Self-centered orientation-Ages 4to10 years)
Moral decisions are based on a sense of
This stage consists of 3 substages:
community respect and disrespect. This stage
1. Egocentricjudgment: focuses on the legal point of view but is also open
In which children make decisions based on what to considering what is moral and good for society.
they like or wish with no obligations to obey Individuals who reach this stage have developed
authority figures. a system of values and principles that determine
for them what is right or wrong.
2. Punishment and obedienceorientation:
Moral decisions are based on avoidance of 7. Universal ethical principle orientation:
punishment. Children realize that there are This stage deals with abstract and ethical moral
physical consequences in the form of punishment values, rather than concrete moral rules. These
for bad behaviors. In this stage, children learn the include universal principles such as equality,
justice and beneficence. Behavior is motivated by Maslow's Hierarchy of Needs
internalized principles of honor, justice, and Maslow proposed that our human motives are
respect for human dignity and guided by the arranged in a hierarchy, with the most basic
conscience. needs at the bottom. At the top are the more
highly developed needs like self esteem needs
Humanistic Approach and finally self-actualization.
In contrast to the pessimism of the psycho- Maslow's hierarchy proposes that our needs
dynamic perspective, the humanistic approach must be fulfilled in a specified order, from
optimistically argues that people have enormous physiological, safety, and love to the higher
potential for personal growth. When personality needs of esteem and selfactualization;Maslow
development focuses upon the development of also specified a list of characteristics descrip-
self, it is called humanism. Humanists like Carl tive of self-actualized people.
Rogers and Abraham Maslow reject the internal One of the basic themes underlying Maslow' s
conflicts of Freud's view and the mechanistic theory is that motivation affects the person as
nature of behaviorism. They believe that each a whole, rather than just in part. Maslow
person is creative and responsible, free to choose believed that people are motivated to seek
and each strives for fulfillment or self personal goals which make their lives
actualization. rewarding and meaningful.
Humanistic theories emphasize the impor- Abraham Maslow suggested that 5 basic
tance of people's subjectiveattitudes, feelings,and classes of needs or motives influence human
beliefs, especially with regard to the self. Carl behavior. According to Maslow, needs at the
Rogers's theory focuses on the impact of disparity lowest level of the hierarchy must be satisfied
between a person's ideals, self and perceived real before people can be motivated by higher-level
self. Maslow focuses on the significance of self goals.
actualization.
Schematic Representation of Maslow's
Rogers' Person-Centered Approach Hierarchy of Needs
Rogers' emphasized that each of us interprets the
same set of stimuli differently,so there are as many
different 'real worlds' as there are people on this
planet. (Rogers, 1980)
Self-Actualization
Carl Rogers used the term self-actualization to
capture the natural, underlying the tendency of Self esteem needs
(need for achievement
humans to move forward and fulfill their true and recognition)
potential. He argued that people strive towards Love and belongingness
growth, even in less-than favorable surroundings. (need for affection, acceptance)
Safety and security needs
Personality Development (need for safety, security, stability, law and order)
Carl Rogers proposed that even young children Physiological need
need to be highly regarded by other people. (need for water, oxygen, sex, food, rest, etc.)
Children also need positive self regard to be
esteemed by selfas well as others. Rogersbelieved
that everyone should be given unconditional From the bottom to the top of the hierarchy,
positive regard, which is a nonjudgmental and the five levels of motives according to Maslow
genuine love, without any strings attached. are:
Physiological Needs presses toward the full use of his talents, capaci-
The physiological needs are most basic, powerful ties and potentialities. In short, the self-actualized
and urgent of all human needs that are essential person is someone who has reached the peak of
to physical survival. Even if one of these needs his potential.
remains unsatisfied the individual rapidly
becomesdominated by it,so allother needs become Trait and Type Theories of Personality
secondary. Included in this group are the need Two major themes underlie trait and type theories
for food, water, oxygen, sex, activity and sleep. of personality:
People possess broad predispositions or traits
Safety and Security Needs to respond in certain ways in diverse situa-
Once the physiological needs are fairly well- tions; what this suggests is that people display
satisfied, safety and security needs predominate. consistency in their actions, thoughts and
Included here are the needs for structure, stability, emotions across time, events and experiences.
law and order, and freedom from such threa- No two individuals are alike.
tening forces as illness and fear.
Gordon Allporl's Theory (1937)
Love and Belongingness Needs 1. Allport's theory asserts that no two indivi-
These needs become prominent when the duals are alike. Allport regarded 'traits' as
physiological and safety I security needs have being responsible for these individual diffe-
been met. The person at this level longs for rences. According to Allport, trait is a
affectionate relationship with others, for a place predisposition to act in the same way in a wide
in his family and social groups. Accordingly a range of situations.
person experiences feelings of loneliness, friend- 2. Allport distinguished between common traits
lessness and rejection, especially when caused and individual traits. Common traits are
by the absence of friends and loved ones. shared by several people within a given
culture. Individual traits are peculiar to the
Self-Esteem Needs person and do not permit comparisons among
Maslow divided these needs into two types: people. They guide, direct and motivate an
Selfrespect and respect from others. Self-respect individual's adjustment. Therefore, they accu-
includes a person's desire for competence, confi- rately reflect the distinctiveness or uniqueness
dence, achievement and independence. Respect of his personality.
from others includes his desire for prestige, 3. Allport was deeply committed to the study of
reputation, status, recognition, appreciation and individual traits. He started calling them as
acceptance from others. Satisfactionof self-esteem 'personal' dispositions. Common traits were
needs generates feelings of self-confidence, self- simply called as 'traits'. Allport proposed that
worth and a sense of being useful and necessary there are three types of personal dispositions.
in the world. Cardinal disposition: A cardinal disposition
Dissatisfaction of self-esteem needs in con- is so dominant that all actions of the
trast, generate such feelings as inferiority, weak- person are guided by it. Very few people
ness, passivity and dependency. possess cardinal dispositions. For
example: Ms. Nightingale whose actions
Self-Actualization were driven by compassion for people.
According to Maslow self-actualization is the Central disposition: These are not as domi-
person's desire to become everything he is capable nant as cardinal dispositions, but they
of. The person who has achieved this highest level influence the person's behavior in a very
prominent way. Therefore they are called reserved; stable-emotional; self-sufficient,

the building blocks of personality. For group dependent, etc.).He constructed a scale
example: A person may have such central to measure these source traits, which came to
dispositions as punctuality, responsibility, be known as 'Sixteen Personality Factor
attentiveness, honesty, loyalty, etc. Questionnaire' (16PF Questionnaire).
Secondary disposition: These are not very
consistent and are thus less relevant in Hans Eysenck's Theory
reflectingthe personality of the individual. (Trait-type theory of personality)
Food and clothing preferences, specific The essence of Eysenck's theory is that the
attitudes etc. may be considered as secon- elements of personality can be arranged
dary dispositions. hierarchically. In this scheme certain super
traits and types such as extroversion exert a
Raymond Cattell's Theory (1965) powerful influence over behavior.
Cattell spoke of the multiple traits that Accordingly, Eysenck's focus has been on a
comprise the personality, the extent to which small number of personality types, defined by
these traits are genetically and environ- two major dimensions: introversion-extro-
mentally determined and the ways in which version, stability- instability (neuroticism).
genetic and environmental factors interact to Based on these personality types, Eysenck
influence behavior. proposed four separate categories of people:
According to Cattell, personality is that which
permits us to predict what a person will do in Stable Unstable
a given situation. In line with his mathe- Introvert Calm Moody
matical analysis of personality, prediction of Reliable Anxious
behavior can be made by means of a Controlled Rigid
specification equation: Peaceful Pessimistic
R= f (S, P)
Careful Reserved
According to this formula the response ( R) of Extrovert Leadership Restless
the person is a function (f)of the stimulus (S)
Easygoing Aggressive
at a given moment in time, and of the existing
Talkative Impulsive
personality structure (P). This equation
Outgoing Optimistic
conveys Cattell's strong belief that human
Sociable Active
behavior is determined and can be predicted.
Traits are a major part of Cattell's theory, Later on, he added a third type dimension of
which he defined as the individual's stable personality called as psychoticism-superego
and predictable characteristics. strength. People belonging to this category are
Cattell divided traits into surface traits and selfish, impulsive and opposed to social
source traits. Surface traits are not consistent customs.
over time and do not have much value in Based on his categorization of personality
accounting for the individual's personality. types, Eysenck constructed an inventory
Source traits are the basic building blocks of called Personality Questionnaire (EPQ). It
personality, which determine the consisten- covers items from each of the personality types
cies of each person's behavior over an identified by him.
extended period of time. Throughout his writings, Eysenckconsistently
Based on extensive research, Cattell identified emphasized the role of genetic factors and
16source traits that constitute the underlying neurophysiological factors,role of the cerebral
structure of personality (such as outgoing- cortex, autonomous nervous system, limbic
system, Reticular Activating System (RAS)in tion was elicited only by the conditioned sti-
explaining individual differences in behavior. mulus. This phenomenon was called classical
Because of the use of statistical techniques and conditioning.
the assumption that there is a hierarchial He demonstrated that a conditioned stimulus
organization to basic personality dimensions, could be paired with an unconditioned
Cattell and Eysenck have been called as factor stimulus to elicit a conditioned response or
analytic trait theorists. behavior change. When the unconditioned
stimulus was removed, the conditioned sti-
Behavior Theory mulus continued to result in the same
Behavior theory is based on the premise that conditioned response.
all behavior, adaptive and maladaptive is a This experiment may be represented as :
Unconditioned Stimulus _________,
Unconditioned Response
product of learning. (UCS) (Food) (UCR) (Salivation)
Learning isa change in behavior resulting from Conditioned Stimulus (CS) _________,
Conditioned Response
reinforcement. A related assumption is that, (Bell) (CR) (Salivation)
since behavior is learned, it can be unlearned
B. John B.Watson
and adaptive behavior can be substituted.
John B.Watson introduced behaviorism, belie-
Behavioral theories attempt to explain how
ved that all learning was classical condi-
people learn and act. tioning and that people are born with certain
Unlike psychodynamic theories, behavioral
stimulus response connections called reflexes.
theories never attempt to explain the cause of
Examples are sneezing in response to an
mental disorders, but focus on normal human
irritation and the knee-jerk response to a sharp
behavior.
tap on the knee.
Stimulus - response theories He developed two principles: Frequency and
recency. The principles of frequency states
1. CLASSICAL CONDITIONING
that the more frequently a given response is
A. Ivan Pavlov made to a given stimulus, the more likely the
The theory of classicalconditioning was given response to that stimulus will be repeated. The
by Ivan Pavlov (1849-1936)a Russian physio- principle of recency states that the more
logist. Pavlov noticed that stomach secretions recently a given response to a particular
of dogs were stimulated by other triggers stimulus is made, the more likely it will be
besides food reaching stomach. He found that repeated.
the sight and smell of food triggered stomach
2. REINFORCEMENT THEORIES
secretions. Thus, a clear connection was made
between thought processes and physiologic A. Edward L.Thorndike
responses. Thorndike believed in the importance of the
In Pavlov's model, there is Un Conditioned effects that followed the response or the
reinforcement of the behavior. According to
Stimulus (UCS), i.e. food (not dependent on
Thorndike, the individual's behavior is shaped
previous training) that elicits an Un Condi-
through the stamping of the correct responses and
tional Response (UCR), i.e. salivation (a
stamping out of incorrect responses through trial
specific response). Pavlov would then select
and error. Thorndike was thus the first
other stimuli such as a bell, large cue card,
reinforcement theorist.
etc., presenting this conditioned stimulus just
before the food, the unconditioned response. B. B.F.Skinner
If the conditioned stimulus was repeatedly BasicallySkinner revolted against the concept
presented before the food, eventually saliva- of classical conditioning. He said that man is
an active organism, and not a victim of his Schedules of Reinforcement
environment. He does not wait for the Objects or events which provide reinforcement
stimulus; instead, he acts or operates on the are called as reinforcers. There are two types of
environment, so as to change it in some way. reinforcers :Primary and Secondary reinforcers.
Thus he called it as operant behavior. Primary reinforcers are those which possess
According to Skinner, operant behavior is inherent reinforcing properties. Examples include
determined by the events or consequences that food, water, physical comfort, etc. Secondary or
follow the response. If the consequences are Conditioned reinforcers are those which acquire
favorable, then the organism will repeat the their reinforcing qualities through close associa-
same behavior. In this case, the consequences tion with a primary reinforcer. Examples of
are said to have provided positive reinforce- secondary reinforcers include money, attention,
ment and caused repetition of behavior. affection and good grades. Skinner put forward
Alternatively, if the consequences are unfavo- the idea of planning of schedules of reinforcement
rable, then they reduce the chances of the same in order to condition the operant behavior of the
behavior from getting repeated. In such a case, organism. The important schedules are as
the consequences are said to have provided follows:
negative reinforcement and reduced the 1. Continuous Reinforcement schedule (CR)
chances of the behavior from recurring again. This is 100%reinforcement schedule, where every
Thus, operant conditioning is called as Type - correct response of the individual is rewarded or
R conditioning, to emphasize the effect of the reinforced. For example, the learner is rewarded
response of future behavior. In this way for every correct answer he gives to the questions
Skinner said that learning is shaped and put by his teacher.
maintained by its consequences.
The following is one of the experiments 2. Fixed-Interval reinforcement schedule (FI)
carried out by Skinner to support his concept In this schedule, the individual is rewarded for a
of operant conditioning: response only after a set interval of time. What is
important here is the fixed responses during this
A hungry rat was placed in a box designed by
interval. For example:
Skinner which was called as the Skinner box or
Paying salaries for the work done on a weekly
operant chamber. The chamber contained a lever,
or monthly basis
which would drop food pellets into the chamber
Conducting examinations periodically for the
if pressed.
students
In the beginning the experimenter himself Giving a person a periodic allowance, etc.
dropped the food pellets into the box, and later
stopped. The rat, being hungry, began to explore 3. Fixed-Ratio reinforcement schedule (FR)
the box and pressed the lever accidentally. The In this schedule, the individual is reinforced
food pellet was released into the box, and the rat following a 'fixed' number of correct responses.
ate it up. After a while, it pressed the lever again, This schedule usually generated extremely high
and ate the food pellet which got released. After operant levelsin the individuals, because the more
the third or fourth time, the rat began to press the they respond, the more reinforcement they receive.
lever more rapidly. Thus, the food is said to have For example: Paying employees depending on the
number of units they produce or sell.
provided positive reinforcement to the rat, and
operant behavior got established, i.e. the rat 4. Variable-Ratio reinforcement schedule (VR)
continued to press the lever, in order to obtain the In this schedule, reinforcement is intermittent and
food pellets. irregular. The individual does not know when he
is going to be rewarded, and so he remains outgrowth of different theoretical perspectives

motivated throughout the learning process. The including the behavioral and the psychodynamic,
most common example of this schedule in human attempted to link the internal thought processes
behavior is gambling. Here rewards are with human behavior.
unpredictable and keep the players motivated,
Albert Bandura's Social Cognitive Theory
though returns are occasional.
Even though he was mostly concerned with Acquiring behaviors by learning from other
positive reinforcers, Skinner recognized that people is the basis of social cognitive theory.
negative reinforcers also exist. According to Bandura believes that important behaviors are
Skinner,negative reinforcersare differentfrom learned by internalizing behaviors of others.
punishment. In negative reinforcement, According to Bandura learning by observation is
something negative is taken away or avoided. achieved through four necessary components:
Positive and negative reinforcement have attention, retention, production and motivation.
similar consequences; they both strengthen or Attention occurs when events are selectively
reinforce the behavior they follow and noticed.
increase the changes that the behavior will be Retention is remembering what is learned.
repeated. An example of negative reinforce- Production-the actual performance of the
ment would be ifthe childwas told by a parent, behavior.
"if you eat all your salad, you won't have to Motivation involves the reinforcement for
eat your bean's - thereby taking away imitating an individual.
something unpleasant. An important concept of Bandura's is self-
Punishment can involve adding something efficacy,a person's ability to dealeffectively with
negative; punishment can also involve taking the environment. Efficacy beliefs influence how
away or preventing something positive. people feel, think, motivate themselves, and
Punishment tends to decrease the probability behave. The stronger the self-efficacy,the higher
of the response that it follows, making that the goals people set for themselves and the firmer
response less likely in the future. For example: is their commitment to them. Cognitive processes
If a patient regularly watches television at 10 shape most courses of action, that is, if people
pm and the television is removed suddenly believe in positive outcomes. If they have doubts
because the patient violated a smoking policy, about their efficacy,people view failure scenarios
this is punishment. and dwell on things that can go wrong.
Skinner also developed the concept of
"shaping" behavior, which has been used in REVIEW QUESTIONS
the process of learning how to perform
Personality development (Nov 2002,Oct 2006)
complex tasks.
What are the factors influencing personality
3. COGNITIVETHEORIES development
The initial behavioral studies focused attention Psychoanalytical theory
on human actions without much attention to the Oedipus complex (Oct 2006)
internal thinking process. Cognitive theories, an Theories of psychosocial development.
Conceptual Models
0 PSYCHOANALYTICALMODEL associated with physiological or instinctual
0 BEHAVIORALMODEL drives (e.g., hunger, thirst, elimination and
0 INTERPERSONALMODEL
sex). Release of these drives results in the
0 COMMUNICATION MODEL
0 MEDICALMODEL reduction of tension and experience of
0 NURSINGMODEL pleasure. Hence, the pleasure principle
Peplau's Theory becomes operative when pleasure seeking
Orem's Theory
behaviors are used.
Roger's Theory
Roy's Theory The personality of the human being can be
0 HOLISTICMODEL understood by way of three majorhypothetical
structures, viz. id, ego and superego. Id
A model is a means of organizing a complexbody represents the most primitive structure of the
of knowledge. For example, the linkage between human personality. It houses the physiolo-
the various concepts related to human behavior gical drives. Human behavior originating
may be represented in the form of a model, which from the id is impulsive, pleasure-oriented,
can now be referred to as a conceptual model. and disconnected from reality.
The treatment of the mentally 'm depends The ego represents that part of the human
mainly on the philosophy related to mental health personality, which is in closest contact with
and mental illness. The various models or theore- reality. Unlike the id, ego is capable of
tical approaches influencing current practice are: postponing pleasure until an appropriate
time, place or object is available. Unlike the
PSYCHOANALYTICAL MODEL superego, the ego is not driven to blind
Psychoanalytical model has been derived from conformitywith rules and regulations. Rather,
the work of Sigmund Freud and his followers. the ego acting as mediator between the id and
Basicassumptions of psychoanalytical model superego, gives rise to a much more mature
are: and adaptive behavior.
All human behavior is caused and thus is The superego is the personality structure
capable of explanation. Human behavior, containing the values, legal and moral
however insignificant or obscure, does not regulations and social expectations that
occur randomly or by chance. Rather, all thwart free expression of pleasure-seeking
human behavior is determined by prior life behaviors. The superego thus functions to
events. oppose the id.
All human behavior from birth to old age is Understandably, humans occasionally expe-
driven by an energy called the libido. The goal rience anxiety when confronted with situa-
ofthe libido is the reduction oftension through tions that challenge the tenuous balance
the attainment ofpleasure. The libido is closely between the id and the superego. At these
Conceptual Models 49
times, the ego uses defense mechanisms that also able to relate to others uninhibited by neurotic
include repression, denial, regression, conflicts.
rationalization, reaction formation, undoing,
projection, displacement, sublimation, isola- Roles of the Patient and the Psychoanalyst
tion, and fixation. The patient is to be an active participant, freely
The human personality functions on three revealing all thoughts exactly as they occur and
levels of awareness: conscious, preconscious describing all dreams. The psychoanalyst is a
and unconscious. Consciousness refers to the shadow person; while the patient is expected to
perception, thoughts and feelings existing in a reveal all his thoughts and feelings, the analyst
person's immediate awareness. Preconscious
reveals nothing personal.
content on the other hand, is not immediately
accessibleto awareness. Unlike conscious and
Application to Nursing
preconscious, content in the unconscious
remain inaccessible for the most part. This theoretical perspective has helped mental
The unconscious affects all the three health professionals to understand psychopatho-
personality structures-id, ego and the logy and stress related behaviors. More impor-
superego. Although the id's content resides tantly, this theory illustrates the importance of
totally in the unconscious, the superego and not taking human behavior at face value. That is,
the ego have aspects in all the three levels of it helps the psychiatric-mental health nurse to
consciousness. The ego maintains contact discern and explore the meaning behind human
with reality, the id and the superego. behavior.
Human personality development unfolds
through five innate psychosexual stages- BEHAVIORAL MODEL
oral, anal, phallic, latent and genital.
Prominent theorists of behavioral theory include
Although these stages extend throughout the
Ivan Pavlov, John Watson, BFSkinner, etc.
lifespan, the first 6 years of life determine the
individual's long-term personality charac- Basic assumptions of behavioral model are:
teristics. All behavior is learnt (adaptive and mal-
adaptive).
Psychoanalytical Process All behavior occurs in response to a stimulus.
Human beings are passive organisms that can
Psychoanalysis, described by Freud, makes use
be conditioned or shaped to do anything if
of free association and dream analysis to affect
correct responses are rewarded or reinforced.
reconstruction of personality. Free association
Maladaptive behavior can be unlearnt and
refers to the verbalization of thoughts as they
replaced by adaptive behavior if the person
occur, without any conscious screening. Analysis
receives exposure to specific stimuli and rein-
of the patient's dreams helps to gain additional
forcement for the desired adaptive behavior.
insight into his problem and the resistances. Thus
dreams symbolically communicate areas of Deviations from behavioral norms occur when
intrapsychic conflict. The therapist then attempts undesirable behavior has been reinforced.
to assist the patient to recognize his intrapsychic This behavior is modified through application
conflicts through the use of interpretation. of learning theory.
The patient is an active participant, freely Therapeutic Approaches
revealing all thoughts exactly as they occur and
describing all dreams. Bytermination of therapy, Systematic desensitization
the patient is able to conduct his life according to Tokenreinforcement
an accurate assessment of external reality and is Shaping
Chaining Human personality is determined in the
Prompting contextof socialinteractions with other human
beings.
Flooding
Anxiety plays a central role in the formation
Aversion therapy
of human personality by serving as a primary
Assertiveness and social skills training motivator of human behavior. Especially,
(Refer chapter 14for details). anxiety is important in building self-esteem
and enabling a person to learn from their life
Roles of the Patient and the Behavioral experiences.
Therapist Self-esteem is an important facet of human
The approach is that of a learner and a teacher. personality that forms in reaction to the
experience of anxiety. Interactions with signi-
Therapist ficant others conveying disapproval or other
The therapist is an expert in behavior therapy such negative meanings contribute to self-
who helps the patient unlearn his symptoms system formation.
and replace them with more satisfying Security mechanisms are used to reduce or
behavior. avoid the experience of anxiety.These security
The therapist uses the patient's anxiety as a mechanisms include sublimation, selective
motivational force towards learning. inattention and dissociation.
The therapist teaches the patient about Early life experiences with parents, especially
behavioral approaches and helps him develop the mother, influence an individual's develop-
behavioral hierarchy. ment throughout life.
The therapist reinforces desired behaviors. Human development proceeds through six
stages of development: infancy, childhood,
Patient juvenility, pre-adolescence, early adolescence
and late adolescence. According to inter-
As a learner the patient is an active participant
personal theory, juvenile and preadolescent
in the therapy process.
stages hold the greatest potential for correction
Patient practises behavioral techniques.
of previous behavior and personality diffi-
Does homework and reinforcement exercises.
culties.
Therapy is considered to be complete when
the symptoms subside. Interpersonal Therapeutic Process
The interpersonal therapist, like the psycho-
analyst, explores the patient's life history.
Nurses commonly use behavioral techniques in Components of self-esteem are identified,
a wide variety of mental health settings. including the security operations that are used to
Additionally, nurses who work with clients defend the self.
having physical disability, chronic pain, chemical The process of therapy is essentially a process
dependency and rehabilitation centers also apply of re-education as the therapist helps the patient
these techniques. identify interpersonal problems and then
encourages him to try out more successful styles
INTERPERSONALMODEL of relating.
Harry S Sullivan is the originator of interpersonal Therapy is terminated when the patient has
relations theory. developed the ability to establish satisfying
Basic assumptions of interpersonal model are: human relationships thereby meeting his basic
Human being are essentially social beings. needs.
Roles of the Patient and the Interpersonal All behavior is communication, whether
Therapist verbal or non-verbal.
Sullivan describes the therapist as a participant Disruptions in behavior may then be viewed
observer, who should not remain detached from as a disturbance in the communication
the therapeutic situation. The therapist's role is process, and as an attempt to communicate.
to actively engage the patient to establish trust
and to empathize. He will create an atmosphere Communication Therapeutic Process
of uncritical acceptance to encourage the patient Therapists locate the disruptions within the com-
to speak openly. munication process and also the interventions
The patient's role is to share his concerns with made in the patterns of communication.
the therapist and participate in the relationship This may take place in individuals, groups or
to the best of his ability. families. The communication pattern is first
The relationship itself is meant to serve as a assessed and the disruption diagnosed. The
model of interpersonal relationships. As the patient is then helped to recognize his own
patient matures in his ability to relate, he can then disrupted communication.
improve and broaden his other life experiences
with people outside the therapeutic situation. Roles of Patient and Therapist
Therapist
Sullivan's interpersonal theory has been the The communication therapist induces chan-
cornerstone of psychiatric-mental health nursing ges in the patient by intervening in the com-
curricula in the undergraduate and graduate munication process. Feedback is given about
evels. the person's success at communicating.
Nurse-client one-to-one interaction or inter- The therapist demonstrates how to relate to
ersonal process is based on Sullivan's interper- others clearly.
sonal theory. The use of interpersonal process Non-verbal communication is also empha-
recordings in the clinical aspect of psychiatric- sized, particularly in terms of congruence with
mental health nursing courses is also derived from verbal behavior.
Sullivan's interpersonal theory. The therapist teaches principles of good com-
munication.
COMMUNICATIONMODEL
Patient
Communication refers to the reciprocal exchange
oi information, ideas, beliefs, and feelings among The patient must be willing to become
:;.group of persons. The theorists who particularly involved in an analysis of his style of
anphasized the importance of communication are communicating.
Eric Berne (founder of transactional analysis), The responsibility for changing rests with the
?aul Watzlawick and his associates. patient. Significant others often are included
3asic assumptions of communication model in communication therapy to bring change in
are: the patient.
The understanding of the meaning ofbehavior
is based on the clarity of communication bet- Application to Nursing
ween the sender and receiver. This theory helps mental health nurses to
Breakdown in successful transmission of understand communication process and to correct
information causes anxiety and frustration. communication disturbances.
MEDICAL MODEL psychosurgery, are important components of the

treatment process.
The medical model dominates much of modern
psychiatric care. Other health professionals may Roles of the Patient and the Medical Therapist
be involved in interagency referrals, family
The physician as the healer identifies the
assessment and health teaching, but physicians
patient'sillnessandinstitutesa treatmentplan.
are viewed as the leaders of the team when this
Physician admits the patient in a psychiatric
model is in effect. A positive contribution of the
institution.
medical model has been the continuous explo-
The role of the patient involves admitting that
ration for causes of mental illness using the
he is ill.
scientific process.
Patient practices prescribed therapy regimen
Basic assumptions of medical model are:
and reports the effects of therapy to the
Medical model believes that deviant behavior
is a manifestation of a disorder of the central physician.
nervous system.
It suspects that psychiatric disorders involve
an abnormality in the transmission of neural Psychiatric-mental health nurse uses this model
impulses, difficulty at the synaptic level, and for assessment, diagnosis, planning and imple-
neurochemicals such as dopamine, serotonin menting nursing care to the patient.
and norepinephrine. This model helps psychiatric-mental health
It focuses on the diagnosis of a mental illness nurses to understand the physiological changes
and subsequent treatment based on this occurring due to psychiatric disorders.
diagnosis.
Environmental and social factors are also NURSING MODEL
considered in the medical model. They may Nursing focuses on the individual's response to
be either predisposing or precipitating factors potential or actual health problems. Under the
in an episode of illness. nursing model, human behavior is viewed from a
Another branch of research focuses on holistic perspective.
stressors and the human response to stress.
These researchers suspect that humans have Nursing View of Behavioral Deviations
a physiological stress threshold that may be Behavior is viewed on a continuum from
genetically determined. healthy adaptive responses to maladaptive
responses that indicate illness.
Medical Therapeutic Process Each individual is predisposed to respond to
The physician's examination of the patient life events in unique ways. These predis-
includes history of the present illness, past positions are biological, psychological,
history, socialhistory, medical history and review sociocultural, and the sum of the person's
of systems, physical examination and mental heritage and past experiences.
status examination. Additional data may be Behavior is the result of combining the pre-
collected from significant others, and past disposing factors with precipitating stressors.
medical records are reviewed if available. A Stressors are life events that the individual
preliminary diagnosis is then formulated pending perceives as challenging, threatening or
further diagnostic studies and observation of the demanding. The nature of the behavioral
patient's behavior. After the diagnosis is made response depends on the person's primary
treatment is instituted. appraisal of the stressor and his secondary
Somatic treatments including pharmacothe- appraisal of the coping resources available to
rapy, electroconvulsive therapy and occasionally him.
A stressor that has primary impact on physio- psychiatric-mental health nursing in particular.
logical functioning also affects the person's It focuses primarily on the nurse-client relation-
psychological and sociocultural behavior. For ship. Peplau's theory describes, explains, predicts
instance, a man who had a myocardial infarc- and to some extent,permits control of the sequence
tion may also become severely depressed, of events occurring in the nurse-client relation-
because he fears he will lose his ability to work ship.
On the other hand, the patient who enters the Peplau describes the interpersonal aspects of
psychiatric inpatient unit with major depres- nursing as a process consisting of four phases.
sion may be suffering from malnutrition and These are orientation, identification, exploitation
dehydration because of his refusal to eat or and resolution phases.
drink The holistic nature of nursing encom- While working with the client through these
passes all of these facets of behavior and phases, the nurse assumes six roles: resource
incorporates them into patient care planning. person, technical expert, teacher, leader, surro-
gate parent and a counselor.
Nursing Process Peplau's theory continues to apply to today's
_.ursing intervention may take place at any point nursing scene, especially with respect to long-
on the continuum. Nursing diagnosis may focus term psychiatric care in outpatient and home
on behavior associated with a medical diagnosis health settings.
or other health behavior that the patient wishes
Orem's Theory
to change.
A nurse may practice primary prevention by Dorothea E.Orem' s theory isbased on the premise
intervening in a potential health problem, that people need a composite of self-care actions
secondary prevention by intervening in an actual to survive. Self-care actions consist of all
acute health problem or tertiary prevention by behaviors performed by people to maintain life
mtervening to limit the disability caused by actual and health. The capacity of the client and the
chronic health problems. The nursing assessment client's family to perform self-care is called self-
of the patient includes presenting complaints, care agency. Orem states that a need for nursing
~ast history, family history, personal history, care exists if the client's self-care demand exceeds
occupational history, sexual history, physical the client's self-care agency. Thus the goal of
examination and mental status examination. nursing is to meet the client's self-care demands
_-"i.dditional
data may be collected from significant until the client and his family are able to do so.
Jai.ers and by reviewing the systems. A nursing Orem's theory describes three types of self-
.iiagnosis is then formulated and based on this care:
iiagnosis, planning and interventions are carried 1. Universal self-carebehaviors, required to meet
ut. Finally, evaluation will be done to find out physiological and psychosocial needs.
::ie effectiveness of nursing interventions. 2. Developmental self-care behaviors, required
Providing nursing care is a collaborative effort, to undergo normal human development.
ith both the nurse and the patient contributing 3. Health deviation self-carebehaviors, required
-=easand energy to the therapeutic process. to meet client's needs during health
deviations.
SUMMARY OF SELECTED The classification of self-carebehaviors in this
RSING THEORIES manner helps to ensure complete assessment of
the client's self-care agency.
~eplau's Theory Assessment focuses on the client's self-care
~2Plau proposed an interpersonal theory appli- demand, self-care agency and self-care deficits. A
-=-...,leto nursing practice in general, and to plan is formulated from the information obtained
in the assessment, that indicates the nursing The nursing process used in Roy's theory
approach needed to meet the client's needs, involves two levels of assessment. The first level
which can be categorized as follows: includes observation of behavior related to the
Wholly compensatory, in which the client four adaptive modes: physiologic, self-concept,
does not participate behaviorally in self-care. role function and interdependence. These four
Partially compensatory, in which the client modes represent methods used by the client to
and nurse participate behaviorally in meeting adapt. The second level of assessment consists of
the client's self-care needs. identifying focal,contextual and residual stimuli.
Educative-developmental, in which the client
The focal stimulus represents the immediate
meets self-care needs with minimal nursing
dominant stimulus affecting the client, such as
assistance.
injury, stress or illness.Contextual stimuli include
To implement the required nursing approach, the environment, the client's family and all other
the nurse uses one of five behaviors: acting or background factors related to the focal stimulus.
doing for the client, guiding, supporting, Residual stimuli consist of the client's previous
providing and teaching. background, beliefs, attitudes and traits.
According to Roy's theory, a person's adapta-
Roger's Theory
tion level is a function of focal, contextual and
Roger's model focuses on the individual as a residual stimuli. When a person encounters
unified whole in constant interaction with the stresses from these stimuli that surpass innate
environment. The unitary person is viewed as an and acquired mechanisms to cope effectively,the
energy field that is more than as well as different
person behaves ineffectively as demonstrated by
from the sum of the biological, physical, social
one or more of the adaptive modes. At this point,
and psychological parts. In Roger's model,
nursing is concerned with the unitary person as nursing intervention is required. This emphasizes
a synergistic phenomenon. on the client's behavior, stimuli determining the
Nursing science is devoted to the study of client's behavior, and the nurse intervening in
nature and direction of unitary human develop- some way to interfere with the stimuli.
ment. Nursing practice helps individuals achieve
maximum well-being within their potential. HOLISTIC MODEL
The holistic view of the patient, with the body
Roy's Theory and soul seen as inseparable, and the patient
According to Callista Roy's theory, the goal of viewed as a member of a family and community,
nursing is to promote the client's adaptation in was central to Nightingale's view of nursing. The
health and illness. This goal is achieved through primary goal of nursing is to help clients develop
the nurse's efforts to change, manipulate or block strategies to achieve harmony within themselves
stress-producing stimuli that may impinge on the and with others, nature and the world. Integrative
client. The theory assumes that this kind of functioning of the client's physical, emotional,
nursing intervention assists the client to cope intellectual, social and spiritual dimensions is
more effectively through reducing stress. emphasized. Each person is considered as a
Roy's theory assumes that all human beings
whole, with many factors contributing to health
are having adaptive systems, and change in
and illness.
response to stimuli. If the change is viewed as a
positive one that promotes the person's integrity
then the change can be considered adaptive. If Major Concepts
the change does not promote the person's integrity Five major concepts are generally accepted as
then the change can be considered maladaptive. premises of holistic health care philosophy:
First, each person is multidimensional; one's health and illness. Any event or circumstance
physical, emotional, intellectual, social and can act as a stressor. Regardless of the source,
spiritual dimensions are in constant inter- stress has an impact on the whole person.
action with each other: Examples of stressors directly affecting the
the physical dimension involves every- physical dimension include stressors
thing associated with one's body, both associated with genetic factors, physiological
internal and external processes, and body image. Emotional stress
the emotional dimension consists of may result from any experience or situation.
affective states and feelings, including Examples include poor physical conditions,
motor behavior associated with emotion, perceived social inequities, a significant loss,
the experienced aspect of emotion, and the
intellectual incompetence, and a sense of
physiological mechanisms that underlie
meaninglessness. Stressors affecting the
emotion
intellectual dimension may include factors
the intellectual dimension includes
that interferewith receptivefunctions,memory
receptive functions; memory and learning,
cognition and expressive functions and learning, cognitive functions, and
the social dimension is based on social expressive functions. Social stressors may
interaction and relationships, more so the arise from interactions and relationships with
global concept of culture other people, as well as from more general
the spiritual dimension is that aspect of a societaland cultural factors.Stressorsaffecting
person from which meaning in life is the spiritual dimension may be any factors
determined through which transcendence that interfere with one's ability to meet
over the ordinary is possible spiritual needs.
The second premise of holisticcare philosophy Fifth,people are ultimately responsible for the
is that the environment makes significant directions their lives take and the lifestyles
contributions to the nature of one's existence. they choose. Within a holistic framework,
Each person's environment consists of many people are viewed as active participants in
factors that are influential in that person's and contributors to their health status; they
quality of life. Consequently, people cannot are willing to learn from illness and strive
be fully understood without consideration of towards healthier choices.
environmental factors such as family relation- The following is a diagrammatic representa-
ships, culture, and physical surroundings. tion of the clientviewed from a holisticperspective:
Individuals interact with their unique
environments through all dimensions, based Physical
on subjective experience as well as external Genetics
Sleep-wake cycle Emotional
stimuli. Body image Affect
Feelings
The third premise is that each person ~----~~
experiences development across his life cycle; Spiritual CLIENT Intellectual
Philosophy (PERSON) Expressive functions
in each stage of life,the individual experiences Transcendence Memory
and confronts different issues or similar issues Relatedness to God, Learning
in different ways. One's experience of each other power, or nature Social Cognition
Self-actualization Interactions Receptive functions
stage of life, forms the basis for further Relationships
development as one moves through the life Culture
Socialization
cycle. Self-concept
Fourth, the holistic health care model Sexuality
maintains that stress is a primary factor in Environment
Recognizing all human dimensions encour- REVIEW QUESTIONS
ages a balanced and whole view of a person. Each
Psychoanalytical model (Feb 2000,
facet of an individual is important and contributes
Oct 2004)
to the quality of life experience. All dimensions
are intricately interwoven, and the person as a Dream analysis
whole functioning organism is more than the Behavioral model
simple combination of dimensions. The holistic Interpersonal model
model emphasizes that all the dimensions of the Self care model (Oct 2004)
individual should be considered when planning Nursing model
and instituting care. Holistic model (Apr 2002)
Nursing Process in
Psychiatric Nursing
0 HISTORICAL OVERVIEW OF NURSING PROCESS Contd ...
IN PSYCHIATRIC NURSING
0 NURSING PROCESS
1960s Orlando was among the first to describe
nursing as deliberative process with a
Definition
focus on the interpersonal relationship.
Nursing Assessment
Nursing Diagnosis 1970s Psychiatric nursing texts included the
Planning nursing process as a method for orga-
Implementation nizing nursing care within a conceptual
Evaluation framework.
0 METHODS OF ASSESSMENT IN PSYCHIATRY
1980s Mental health- psychiatricnurses continue
History Taking
to refine their use of the nursing process.
Mental Status Examination
Physical Investigations for Psychiatric 1990s With increased understanding, the
Patients mental health-psychiatricnurse more deli-
Psychological Assessment in Psychiatric berately applies the nursing process.
Nursing
Future Psychiatric nurses will engage in more
0 CHILD AND ADOLESCENT PSYCHIATRY
research to systematically examine the
ASSESSMENT FORMAT
effectof the nursing process on the nurse-
0 HISTORY COLLECTION INALCOHOL DEPENDENCE
client relationship.
0 GERIATRIC HISTORY COLLECTION FORMAT
HISTORICAL OVERVIEW OF NURSING NURSING PROCESS

PROCESS IN PSYCHIATRIC NURSING
Definition
Dates Events Nursing process is an orderly, systematic manner
Before World Mental health-psychiatric nurses depen- of determing the client's problems, making plans
War II ded mainly on experience, rote to solve them, initiating the plan or assigning
procedure, and intuitive judgment as a others to implement it and evaluating the extent
basis for nursing care. to which the plan was effective in resolving the
1940s Mental health-psychiatric nurses had problems identified.
some awareness of theory but still - Yura and Walsh, 1978
provided primarily custodial care with
The nursing process provides a scientific
no attention to systemic approach to
nursing care. framework for the delivery of professional nursing
care.
1950s Psychiatric nurses were using nursing
care plans as a tool for communicating
Nursing process consists of five steps:
their practice. Peplau developed a model 1. Assessment
of nursing care that emphasized a 2. Nursing diagnosis or Analysis
systemic approach to the nurse-client 3. Nursing goal or Planning or Objectives
relationship. 4. Implementation or Intervention
Contd ... 5. Evaluation
(Re) Assessment
- Sexual and marital history
Physical examination
- Body system review
- Neurological status
- Laboratory results
Nursing Physical functions
Evaluation
diagnosis - Activity I Exercise
-Sleep
-Appetite and nutrition
-Hydration
- Sexuality
-Self care
Pharmacological assessment
Planning
II. Psychological Dimension
NURSING ASSESSMENT General appearance and behavior
- Psychomotor activity
In this step information is gathered to establish -Attitude
a database for best possible care of the patient. Speech
Mood
The nursing assessment is deliberate and
- Affect and emotions
systematic collectionofbio-psychosocial informa-
Thought
tion or data is done to determine current and past Perception
health and functional status and to evaluate past Cognitive functions
and present coping patterns. Insight
Judgment
Techniques of Data Collection in Abstract reasoning and comprehension
Psychiatric Nursing Memory
1. Patient observation Behavioral responses
2. Patient interview (Process recording) Selfconcept
3. Family interview -Body image
4. Physical examination - Selfesteem
- Personal identity
5. Mental status examination
Present and past coping patterns
6. Records and diagnostic reports
Risk assessment
7. Collaboration with colleagues. - Suicidal ideation
-Assault or homicidal ideation
BIOPSYCHOSOCIAL ASSESSMENT IN
PSYCHIATRIC NURSING III. Social Dimension
Functional status
I. Biologic Dimension
Social systems
Present history - Cultural assessment
Past psychiatric and medical history - Family assessment
Personal history - Community support and resources
- Perinatal history Spiritual assessment
- Childhood history Occupational status
- Educational history Economic status
- Play history Legal status
- Obstetrical history Quality oflife
Nursing Process in Psychiatric Nursing 59
NURSING DIAGNOSIS Coordination and delegation of responsi-
Nursing diagnoses are defined as clinical bilities.
judgments about individual, family or community In this nurse will choose nursing interventions
responses to actual and potential health problems. appropriate to an individual's identified problem
Nursing diagnoses are used to describe an indi- with specific expected outcomes.
vidual patient's condition, to prescribe nursing Once the nursing diagnoses are identified, the
interventions, and to delineate the parameters for next step is the prioritization of the problems in
developing outcome criteria. order of importance. Highest priority is given to
The basic level psychiatric nurse identifies those problems that are life threatening. Next in
nursing problems by using the nomenclature the priority are those problems that are likely to
specified by the North American Nursing cause destructive changes. Lowest in priority are
Diagnoses Association (NANDA). those issues that are related to normative or
A nursing diagnosis describes an existing or developmental experiences. Psychiatric nurses
high-risk problem and requires a three-part often use Maslow's hierarchy of needs to prioritize
statement. nursing diagnoses.
1. The health problem (Problem, 'P')
2. The etiological or contributing factors Outcome Identification
(Etiology, 'E') Outcomes can be defined as a patient's response
3. The defining characteristics (Signs and to the care received. Outcomes are the end result
symptoms, 'S'). of the process. Measuring outcomes not only
For example: demonstrates clinical effectiveness but also helps
High risk for self directed violence related to promote rational clinical decision- making on
to depressed mood, feeling of worth- the part of the nurse.
lessness, anger turned inward on the self.
Powerlessness related to dysfunctional Outcome identification should be:
grieving process, lifestyle of helplessness, Patient centered
evidenced by feelingsof lackof controlover Singular
life situations, over dependence on others Observable
to fulfill needs. Measurable
Time limited
PLANNING Mutual
The planning phase consists of the total planning Realistic
of the patient's overall treatment to achieve quality Diagnosis Outcome Intervention
outcomes in a safe, effective, and timely manner. Impaired social Patient will attend Using a contract
interaction (Isolates group sessions format explain the
Nursing interventions with rationales are selected self from others) everyday role and responsibility
in the planning phase based on the client's ofpatients.
identified risk factors and defining characteris-
tics. The process of planning includes: Correct and Incorrect Outcome Statements
-------- --------------
Collaboration by the nurse with patients, Nursingdiagnosis Correctoutcome Incorrect outcome
significant others, and treatment team
Anxiety Verbalizes feeling calm, Exhibitsdecreased
members relaxed, with absence anxiety, engages in
Identification of priorities of care of muscle tension and stress reduction
diaphoresis; practices
Critical decisions regarding the use of deep breathing.
psychotherapeutic principles and practices Ineffectivecoping Makes own decisions to Demonstrates effective!
(Identify the most appropriate nursing attend groups; seeksstaff coping abilities
for interaction.
intervention)
IMPLEMENTATION Conclusion
In the implementation phase nurse sets inter- Psychiatric treatment is a team effort; basic
ventions prescribed in the planning phase. outcomes often reflect the combined effects of the
Nursing interventions (also known as interventions of nurses, physician, occupational
nursing orders or nursing prescriptions) are the therapist, psychologists and social workers.
most powerful pieces of the nursing process. Inter-
ventions are selected to achieve patient outcome METHODS OF ASSESSMENT IN
and to prevent or reduce problems. Implemen- PSYCHIATRY
tation serves as a blueprint of plan. History Taking
Nursing interventions are classified as Mental Status Examination
independent, interdependent and dependent. Physical Investigations
Psychological Assessment
Nursing Intervention in Psychiatric Nursing
Interventions for biologicaldimension History Taking in Psychiatric Nursing
Self care activities I. Identification data
Name Age Sex
Activity and exercise
Father I Spouse
Nutritional interventions Address
Relaxation interventions Education Occupation Income
Hydration interventions Marital status Religion
Thermoregulation intervention II. Informant
Pain management III. Presenting chief complaint
Medication management (with duration in chronological order)
Interventions for psychological dimension IV. History of present illness

Duration (weeks/months/years):
Counseling interventions
Mode of onset: abrupt/ acute/ subacute/insidious
Conflict resolutions (<48 hrs)/ <1 wk I (l-2 wks)
Bibliotherapy Course: continuous I episodic I fluctuating I
Reminiscence therapy deteriorating I improving I unclear
Behavior therapy Precipitating factors:
Cognitive therapy Description of present illness (chronologicaldescription
of abnormal behavior, associated problems like
Psycho-education suicide, homicide, disruptive behavior; thought
Spiritual interventions content, speech, mood states, abnormal perception,
biological functioning, social functioning, occupational
Intervention for social dimensions functioning, changes in ADLs)
Group interventions
V. Treatment history
Family intervention Drugs (name of the drug, dose, route, side-effects, if
Milieu therapy any)
ECT
Psychotherapy
EVALUATION Family therapy
Evaluation is the process of determining the value Rehabilitation
of an intervention. Nurses determine the effecti- VI. Past psychiatric and medical history
veness of interventions with particular patients. Hospitalization (psychiatric):
Nurses evaluate selected interventions by judging Substance use:
Surgical procedures I accidentsI head injury I convulsionsI
the patients progress towards the outcome set unconsciousness/DM/HTN I CAD/venereal disease/
down in the nursing care plan. HIV positivity/any other
VII. Family history (H) Occupational history
Genogram (family of origin) Age at starting work:
Description (describe each family member briefly: age, Jobs held in chronological order:
education, occupation, health status, relationship with Reasons for changes:
the patient, age at death, mode of death) Current job satisfaction:
(including relationships with authorities, colleagues,
VIII. Personal history subordinates)
(A) Perinatal history Whether job is appropriate to client's background:
Antenatal period: uneventful/ eventful (specify)
(I) Sexual and marital history
Birth : full-term I premature I postmature
Genogram (family of procreation):
Delivery : normal I instrumental I cesarean
Type of marriage: self-choice/arranged
Birth cry : immediate/delayed
Duration of marriage:
Birth defects:
Interpersonal and sexual relations: satisfactory I
Postnatal complications: cyanosis/convulsions jaundice
unsatisfactory
Any other
Details of spouse and children:
(B) Childhood history
(J) Premorbid personality
Primary caregiver:
(a) Interpersonal relationships:
Feeding: breastfed/ artificial
Extrovert/introvert
Age at weaning:
Family and social relationships
Developmental milestones: normal I delayed
(b) Use of leisure time:
Behavior and emotional problems: thumb sucking/
(c) Predominant mood:
temper tantrums/ stuttering
Optimistic/ pessimistic; stable I fluctuating;
head-banging/body rocking/nail biting
enuresis/morbid fears/night terrors cheerful/ despondent
Usual reaction to stressful events
somnambulism
(d) Attitude to self and others:
C) Educational history Self-appraisal of abilities, achievements and
Age at beginning of formal education: failures
Academic performance: General attitudes towards others
Academic and extracurricular achievements, if any: (e) Attitude to work and responsibility:
Relationships with peers and teachers: () Religious beliefs and moral attitudes:
School phobia : yes/no Truancy: yes/no (g) Fantasy life:
Reason for termination of studies: Daydreams ___,frequency and content.
(h) Habits:
D) Play history
Eating pattern regular I irregular
Games played (at what stage and with whom):
Elimination regular I irregular
Relationships with playmates:
Sleep regular I irregular
B Emotional problems during adolescence Use of drugs, tobacco, alcohol:
Running away from home/ delinquency I smoking/
drug-taking/ any other (specify) Mental Status Examination
TI Puberty [A] General Appearance and Behavior
Age at appearance of secondary sexual characteristics:
Anxiety R/T puberty changes: Appearance: looking one's age I older I younger
Age at menarche:
Reaction to menarche: Level of grooming: normal/ shabbilydressed/ over-
Regularity of cycles, duration of flow: dressed/idiosyncratically dressed
Abnormalities, if any (menorrhagia, dysmenorrhea,
etc): Level of cleanliness: adequate/ inadequate/ overtly
G) Obstetrical history clean
LMP:
Number of children: Level of consciousness: fully conscious and alert/
Any abnormalities associated with pregnancy, drowsy I stuporous I comatosed
delivery, puerperium:
Termination of pregnancy, if any Mode of entry: came willingly I persuaded/brought
Menopause (including any associated problems): using physical force
Cooperativeness: normal/more than so/less than Sample of speech (in response to open-ended
so questions):
Eye-to-eye contact: maintained/ difficult/not main- [C]Mood
tained
Subjective:
Psychomotor activity: normal/increased/ dec-
Objective:
reased
(Predominant mood state/appropriate/inappropriate/
Rapport: spontaneous/ difficult/not established irritable/labile/blunted/lattened)
Gesturing: normal/ exaggerated/ odd [D]Thought
Posturing: normal posture/ catatonic posture Stream: normal/racy thoughts (pressure of
thought) I retarded thinking (poverty of thought) I
Other movements: stereotypesI tremors/EPS I AIMs thought block/muddled or unclear thinking/
(abnormalinvoluntarymovements) flight of ideas
Other catatonic phenomena: automatic obedience/ Form: normal/formal thought disorder (specify
negativism/ excessive cooperation/waxy flexi- with a sample of speech)
bility I echopraxia/ echolalia
Content: (a) Ideas/ delusions of:
Conversion and dissociative signs: worthlessness /helplessness /hopelessness I
Compulsive acts or rituals: guilt/hypochondriacal/poverty /nihilistic/
death wishes I suicidal I grandiose I referenceI
Hallucinatory behavior: control/ persecution/bizarre
(Smiling and talking to self, odd gesturing) (b) Thought alienation phenomena:
[B] Speech thought insertion/ thought withdrawal/
thought broadcasting
Initiation: spontaneous I speaks when spoken to I (c) Obsessional/compulsive phenomena:
minimal/ mute thoughts I images I rum in ati ons I doubts I
impulsive rituals
Reaction time: normal/ delayed/ shortened/ diffi-
cult to assess [E] Perception
Hallucinations: Auditory
Rate: normal/ slow I rapid
Visual
Productivity: monosyllabic/ elaborate replies/ Olfactory
pressured Gustatory
Tactile
Volume: normal/ increased/ decreased
Somatic passivity:
Tone: normal variation/monotonous
Deja vu Ijamais vu:
Relevance: fully relevant/ sometimes off target/ [F]Cognitive Function (neuropsychiatric
irrelevant
assessment)
Stream: normal/ circumstantial/ tangential Consciousness
Coherence: fully coherent/loosening of associa- conscious/ cloudy I comatosed
tions Orientation
Others: rhyming/punning/echolalia persever- Time:appropriate time/ day/night/ date/month/
ation /neologism year
Place: kind of place/ area/ city [HJ Judgment
Person: self/ close associates /hospital staff Personal: intact I impaired
Social: intact I impaired
_-tttention
Test: intact I impaired
normally aroused/ aroused with difficulty
digit forward Diagnostic formulation
digit backward
Physical Investigations for Psychiatric
Concentration Patients
normally sustained/ sustained with difficulty I (A)Routine: general screening
distractible e.g. hemogram, urinalysis
100-7 (Additional investigations may be ordered in
40-3 special populations)
20-1 (B)Routine: specific
Name of months (backwards) Based on diagnosis-e.g. liver function tests in
Name of weekdays (backwards) alcoholics
Based on treatment-e.g, pre-lithium, pre-ECT
_.1emory work-up investigations
a) Immediate (same test as for attention): Based on ongoing management-e.g. blood
1) Recent: (recent happenings - last meal, visitors counts in patients on clozapine treatment
etc) (C) Non-routine:
verbal recall - 3 unrelated objects Based on need and index of suspicion
5 unrelated objects, or imaginary e.g. thyroid function tests in suspected hypo-
address of 5 items thyroidism during lithium therapy; pregnancy
c) Remote: tests in amenorrhea during treatment with
personal events: potential teratogens.
impersonal events: (D) Common neuropsychiatry investigations
illness-related events: Electroencephalogram (EEG)
Computed tomographic (CT) scanning
.-ueitigence Magnetic resonance imaging
General fund of information: The sleep EEG (polysornnogram)
.Arithmetic ability: mental arithmetic /written
s.ums Psychological Assessment in Psychiatric
_-bstraciion Nursing
_.ormal/ concrete Psychological testing of patients is ideally conduc-
interpretation of proverbs: ted by a clinical psychologist who has been
Similarities between paired objects: trained in the administration, scoring and
:Jissimilarities between paired objects: interpretation of these procedures.
1. To assist in diagnosis:
:GJ Insight E.g. Rorschach inkblot test
Awareness of abnormal behavior I experience: 2. To assist in the formulation of psycho-
:-es I maybe I no pathology and in the identification of areas of
Attribution to physical causes: yes I maybe I no stress and conflict:
Recognition of personal responsibility: yes I E.g. Thematic apperception test
maybe I no 3. To determine the nature of the deficits that are
-.illingness to take treatment: yes I maybe I no present:
-Cognitive neuropsychological assessments J. Mental Status Examination
Attention & concentration
4. To assess severity of psychopathology and Activity level
response to treatment: Motor behavior
-Hamilton rating scale for depression Speech and language ability
-Brief psychiatric rating scale General intelligence
Mood and affect
5. To assess general characteristics of the Thought processes
individual: Perception
-Assessment of intelligence K. Summary
-Assessment of personality
HISTORY COLLECTION IN ALCOHOL
CHILD AND ADOLESCENT PSYCHIATRY DEPENDENCE
ASSESSMENT FORMAT A. Demographic Data
Name: Age: Sex:
A. Demographic Data
Occupation: Income:
Name: Address:
Marital status - Married I Single I Widow
Age: Sex:
Urban I Semi-Urban I Rural LP.No. : Address:
Income:
Education :
Hospital No.:
Informant :
Informant: Mother I Father I Others
B. Chief complaints (in chronological order with duration)
B. Chief complaints (with duration in brief):
C. History of present illness
C. History of present illness:
1. First drink causes
D. Family History:
1. Mental illness 2. First experience with alcohol
1. Nuclear 1. Consanguinous
3. The type and volume of first drink - Hard drink/
2. Non-nuclear 2. Non-consanguinous 2. Epilepsy
3. Mentally Regular drink
retarded 4. History of tolerance
4. Others 5. History of craving
6. History of loss of control
Genogram:
7. History withdrawal features - when abstinent
E. Personal History:
from alcohol
Antenatal history
8. History of blackouts
Perinatal history
9. History of salience
Postnatal history
(Restricting all the activities and concentrating
Milestones
Current schooling :Yes I No only on alcohol seeking behavior, not even going
Habits, interest and talents, sexual history to work)
10. What are the reasons for excessive consumption
F. Past history:
1. Psychiatric of alcohol
2. Neurotic 11. Maintaining factors/reasons
3. Others 12. Previous history of abstinence
G. Current functioning 13. Money spent for alcohol
1. Intelligence 14. Medical problems associated with alcoholism
a. Average b. Below c. Above d. Not known 15. Psychiatric problems associated with alcoholism
2. School Performance Cognitive deficits
a. Average b. Below c. Not appropriate d. Not History of dementia
known 16. Co-morbidity
3. Self-Help: Age appropriate 17. History of any other substance abuse
a. Toilet - Yes I No D. Family history
b. Dressing - Yes I No Family history of similar problems
c. Eating - Yes I No Interpersonal relationship in the family
d. Bathing I Washing - Yes I No Family history of psychiatric disorders
H. Physical examination - Psychosis
Vision Mood disorders
Hearing Neurotic disorders
CNS Substance abuse
Chest Epilepsy
I. Treatment history till date Genogram
E. Personal history Socio economic status
F. Marital history Genogram
Role reversal IX. Personal History
Emotional disorders in children a) Developmental history
History of exposure to extra marital relationship b) Educational history
Sexual dysfunction c) Occupational history pre-retirement
G. Premorbid personality d) Source of income
Dependence Employment I pension I assistance from familyI
Anankastic other financial problems if any
Passive aggressive e) Residence
Anti-social Living at home/ alone/with spouse/with children
Own I rented house
Any problems with living situation
GERIATRIC HISTORY COLLECTION FORMAT
X. Marital History
I. Demographic Data Sexual I menstrual history
Name: Age: Sex: Genogram
Occupation: Income: Family history of mental or physical history
Marital Status: Married/Single/Widow XI. Premorbid personality
LP. No.: Address: Specific traits
Education Social functioning
Informant: Occupational functioning
II. Chief Complaints Biological functioning
III. Precipitating Factors Interest I hobbies, alcohol and other drug abuse
Head injury XII. Community involvement
Infection Members of organization I club I political activities/
Sensory handicaps voluntary work
Retirement XIII. Social support
Bereavement XIV. Attitude towards ageing and death
Any other XV. Summary
IV. History of Present Illness XVI. Investigations
Stress XVII.Treatment
Qualitative or quantitative changes in routine
activities REVIEW QUESTIONS
Cognitive function
Habits and others Describe nursing process in psychiatric
v. Past Medical History nursing
vt. Past Psychiatric History Describe various methods of assessment in
-.11. Mental Status Examination
"Tll. Family History
psychiatry
Joint or nuclear family Mental status examination (Nov 2003,
Monthly income of the family Oct 2004)
The Therapeutic Nurse-
P atient Relationship
0 TYPES OF RELATIONSHIPS Social Relationships
0 DIFFERENCES BE1WEEN THERAPEUTIC AND
SOCIAL RELATIONSHIP
A social relationship can be defined as a
0 GOALS OF THERAPEUTIC RELATIONSHIP relationship that is primarily initiated with the
0 COMPONENTS OFTHERAPEUTIC RELATIONSHIP purpose of friendship, socialization, enjoyment
Rapport or accomplishing a task. Mutual needs are met
Empathy
Warmth during social interaction. For example,
Genuineness participants share ideas, feelingsand experiences.
0 CHARACTERISTICS OF THERAPEUTIC NURSE-
PATIENT RELATIONSHIP Intimate Relationships
D PHASES OF THERAPEUTIC RELATIONSHIP
Pre-interaction Phase An intimate relationship occurs between two
Introductory Phase individuals who have an emotional commitment
Working Phase
to each other. Those in an intimate relationship
Termination Phase
0 THERAPEUTIC COMMUNICATION TECHNIQUES usually react naturally with each other. Often the
D PROCESS RECORDING relationship is a partnership wherein each
member cares about the other's need for growth
A relationship is defined as a state ofbeing related and satisfaction.
or a state of affinitybetween two individuals. The
nurse and client interact with each other in the Therapeutic Relationships
health care system with the goal of assisting the The therapeutic relationship between nurse and
/ client to use personal resources to meet his or her client differs from both a social and an intimate
unique needs. relationship in that the nurse maximizes inner
In a therapeutic relationship the nurse and communication skills, understanding of human
client work together towards the goal of assisting behavior and personal strengths, in order to
the client to regain the inner resources to meet life enhance the client's growth. The focus of the
challenges and facilitate growth. The interaction relationship is on the client's ideas, experiences
is purposefully established, maintained and and feelings.
carried out with the anticipated outcome of
helping the client gain new coping and GOALS OF THERAPEUTIC RELATIONSHIP
adaptation skills.
Facilitating communication of distressing
thoughts and feelings.
TYPES OF RELATIONSHIPS
Assisting the client with problem solving.
Social relationships. Helping clients examine self-defeating
Intimate relationships. behaviors and test alternatives.
Therapeutic relationships. Promoting self-care and independence.
The Therapeutic Nurse-Patient Relationship 67
DIFFERENCES BETWEEN THERAPEUTIC AND SOCIAL RELATIONSHIP
Therapeutic relationship Social relations/zip

Technique A planned therapeutic Just happens with mutual interests
relationship
Objective Helping the patient Satisfying the needs of each other
Duration Usually time is limited Varies, may last for years
Accountability Nurse is accountable for the Both are responsible and
goals of the relationship accountable
Acceptance Nurse accepts patient as Personal/ emotional
"here and now", without attachment and interest
any personal or emotional involved
attachments and interests
Termination An important part of the Relationship may exist
relationship, it is planned lifelong or terminate
and discussed with the gradually
patient
COMPONENTS OF THERAPEUTIC It is the ability to put oneself in another

RELATIONSHIP person's circumstances and feelings. The nurse
need not necessarily have to experience it, but
Rapport
has to be able to imagine the feelings associated
Rapport is a relationship or communication with the experience.
especially when useful and harmonious. It is the In empathy process the nurse receives
crux of a therapeutic relationship between the information from the patient with an open, non-
nurse and the p~ judgemental acceptance, and communicates this
It is: understanding of the experience and feelings so
a willingness to become involved with another that the patient feels understood. This serves as a
person basis for the relationship.
growth towards mutual acceptance and Sympathy is often confused with empathy. In
understanding of individuality sympathy, the nurse actually feels what the
the end result of one's care and concern for patient feels but in the process objectivity is lost,
another. and the nurse becomes focused on relief of
The nurse establishes rapport through demon- personal distress rather than on assisting the
stration of understanding, warmth and non- patient to resolve the problem. With empathy
judgmental attitude. A skilled nurse will be able while understanding the patient's thoughts and
to establish rapport that will alleviate the patient's feelings, the nurse is able to maintain sufficient
problems. When rapport develops, the patient objectivityto allow the patient to achieve problem
feelscomfortablewith the nurse and finds it easier resolution with minimal assistance.
to self-disclose. The nurse also feels comfortable
and recognizes that an interpersonal bond or Warmth
alliance is developing.
Warmth is the ability to help the client feel cared
for and comfortable. It shows acceptance of the
Empathy
client as a unique individual. It involves a
Empathy is an ability to feelwith the patient while non-possessive caring for the client as a person
retaining the ability to critically analyze the and a willingness to share the client's joys and
situation. sorrows.
Genuineness Pre-interaction Phase

Genuineness involves being one's own self. This This phase begins when the nurse is assigned to
implies that the nurse is aware of her thoughts, initiate a therapeutic relationship and includes
feelings, values and their relevance in the all that the nurse thinks, feelsor does immediately
immediate interaction with a client. The nurse's prior to the first interaction with the patient. The
nurse's initial task is one of self-exploration. The
response to the client is sincere and reflects her
nurse may have misconceptions and prejudices
internal response. It is also important that the
about psychiatric patients and may have feelings
nurse's verbal and non-verbal communication
and fears common to all novices. Many nurses
correspond with each other. express feelings of inadequacy and fear of hurting
or exploiting the patient. Another common fear of
CHARACTERISTICS OF THERAPEUTIC nurses is related to the stereotyped psychiatric
NURSE-PATIENT RELATIONSHIP patients' abusive and violent behavior.
The therapeutic relationship is the corner- The nurse should also explore feelings of
stone of psychiatric-mental health nursing, inferiority,insecurity, approval-seeking behaviors
where observation and understanding of etc. This self-analysis is a necessary task because,
behavior and communication are of great to be effective,she should have a reasonably stable
importance. It is a mutual learning experience, self-concept and an adequate amount of self-
and a corrective emotional experience for the esteem.
patient ~ Nurse's tasks in the pre-interaction phase
The nature of the therapeutic relationship is Explore own feelings, fantasies and fears
characterized by the mutual growth of Analyze own professional strengths and
individuals who "dare" to become related to limitations
discover love, growth and freedom. Gather data about patient whenever possible
The therapeutic relationship is based on the Plan for first meeting with patient
belief that the patient has potential, and as a Problems Encountered
result of the relationship, "will grow to his Difficulty in self-analysis and self-acceptance:
fullest potential". Promoting a patient's self-realization and self-
In a therapeutic relationship the nurse and acceptance is facilitated by the nurse's
client work together towards the goal or assis- acceptance of herself and behaving in ways
ting the client to regain the inner resources in congruent with her own personality. Also, the
order to meet life challenges and facilitate nurse should have enough sources of
growth. The interaction is purposefully esta- satisfaction and security in her non-
blished, maintained and carried out with the professional life to avoid the temptations or
using her patient for the pursuit of her
anticipated outcome of helping the patient to
personal satisfaction or security. If she does
gain new coping and adaptation skills.
not have sufficient personal fulfillment she
should realize it and the source of dissatis-
PHASES OF THERAPEUTIC RELATIONSHIP
faction clarified, so that it does not interfere
Four phases of relationship process have been with the success of the therapeutic relation-
identified ship.
Pre-interaction phase Anxiety: Quite frequently, the nurse may
Introductory or orientation phase experience anxiety ofvarying intensity during
Working phase the pre-interaction phase due to role threat,
Termination phase feelings of incompetence, fear of being hurt or
of causing distress, fear of losing control and Gather data, including the client's feelings,
fear of rejection. The nurse needs to become strengths and weaknesses
aware of what is being experienced, identify Define client's problems; set priorities for
the threat, and decide what needs to be done nursing intervention
about it. This is important, so that the patient Mutually set goals
is not unduly affected by the nurse's anxiety.
Apart, from anxiety, the nurse may also Problems Encountered
experience boredom, anger, indifference, and The major problem encountered during this
depression. The cause of such feelings must be phase is related to the manner in which the
identified, which is the first step in devising nurse and patient perceive each other. A nurse
ways to cope with them.
may react to a patient not in terms of his
uniqueness, but in terms of the nurse's
Ways to Overcome stereotyped view of a "psychiatric patient,"
The nurse needs help from her supervisor and or she may because of her theoretical
peers in self-analysis and facing reality in background read in terms of diagnostic
order to help patients do likewise. This categories. Sometimes the nurse may relate to
provides opportunity to explore feelings and a patient as if he were a significant individual
fears and develops useful insight into one's from the past. The nurse may then displace to
professional role. the patient the feelings she has for the
It is also helpf~~lto onceptualize in advance significant individual. Since interaction is a
what she wishes o accomplish during the reciprocal process, the patient also perceives
relationship. nurse may in consultation the nurse in his own idiosyncratic manner.
with her supervisor identify in writing goals Thus, perception of each other as unique
for the initial interaction, and decide the individuals may not take place.
methods to be used in achieving the goals. Problems related to establishing an agreement or
The nurse also needs to be consciously aware pact between the nurse and patient: The patient
of the reasons for choosing a particular may feel that since the nurse is here only for a
patient. She may also attempt to assess the few weeks much help cannot be expected from
patient's anxiety level as well as her own. The her in the short span of time. The same feelings
nurse who is able to analyze herself and may be experienced by the nurse, in that she
recognize her assets and limitations, is able to feels she cannot do much for the patient
use this information in relating to patients in during his stay in the hospital due to factors
a natural, congruent and relaxed manner. like limited time, overwork or the nurse's
opinion that the patient is suffering from a
troductory or Orientation Phase 'major psychiatric problem'. Because the
-ris during the introductory phase that the nurse establishment of an agreement or pact to work
znd patient meet for the first time. One of the together is a mutual process, such misper-
rairse's primary concerns is to find out why the ceptions can greatly hinder it.
?ltient sought help. This forms the basis of the
-msing assessment and helps the nurse to focus Ways to Overcome
,~ the patient's problem and to determine The nurse must be willing to relate honestly
7-atient's level of motivation. to her perceptions, thoughts and feelings, and
to share the data collected during the nurse-
_:urse's tasks in the orientation phase patient interaction with her supervisors. The
Establish rapport, trust and acceptance supervisor must provide an atmosphere in
Establish communication; assist in the verbal which the nurse feels free to reveal self
expression of thoughts and feelings without any fear of criticism.
Difficulties may be faced in assisting a nurse common for the patient to show desirable
who perceives a patient as if he were someone behavioral changes in the beginning, and then
from her past life. She is usually not aware of remain fixed, neither progressing nor regres-
doing so, since most of this behavior is sing. A nurse who was enthusiastic about the
unconsciously determined. An alert super- patient's improvement may then become
visor can usually detect that the nurse is discouraged when he does not progress at a
distorting the patient by viewing him as steady state.
someone else. It may be necessary to bring the The nurse's fear of closeness: If the nurse fears
problem to the nurse's attention so that she closeness too much, she may react by being
can examine her behavior. Gradually, with indifferent, rejectingor being cold towards the
assistance the nurse is able to audit her patient. She must learn to interact with
behavior, and then to change it. kindness and concern,but with objectivityand
professional interest.
Working Phase
Life stresses of the nurse: A nurse who has
Most of the therapeutic~ork is carried out during
difficultyin coping with her own lifeproblems
the working phase. Th nurse and the patient
cannot help a patient in making appropriate
explore relevant stresso and promote the
behavioral changes.
development of insight in the patient. By linking
Resistance behaviors:Resistance is the patient's
perceptions, thoughts, feelings and actions, the
attempt to remain unaware of anxiety-
nurse helps the patient to master anxieties,
producing aspects within him. Resistancemay
increase independence and coping mechanisms. take different forms and some of them were
Actual behavioral change is the focus of attention identified by Wolfberg as follows:
in this phase of the relationship. Suppression and repression of relevant
Nurse's tasks in the working phase information
Gather further data; explore relevant stressors Intensification of symptoms
Promote patient's development of insight and A helpless outlook on the future
use of constructive coping mechanisms Breaking appointments, coming late to his
Facilitate behavioral change; encourage him sessions, being forgetful, silent and sleepy
to evaluate the results of his behavior during the interactions
Provide him with opportunities for indepen- Acting out or irrational behavior
dent functioning Expressing an excessive liking for the
Evaluate problems and goals and redefine as nurse and claiming that nobody can
necessary replace her
Reporting physical symptoms which may
Problems Encountered occur only during the time the clientis with
Testing of the nurse by the patient: The patient the nurse
may test the nurse in a number of ways, and Hostility, dependence, provocative
for a number of reasons. For example, he may remarks, sexual interest in the nurse
wish to checkher ability to set limits and abide Transference and counter transference reactions:
by them. A patient with problems related to These are in fact a form of resistance behavior.
aggression may deliberately attempt to Transference is the unconscious transfer of
provoke the nurse to determine whether or not qualities or attributes originally associated
she will become punitive. with another individual by the patient.
Progress of the patient: Another barrier is the Transferenceoccursbecause the patient brings
nurse's unrealistic assumption as to the frustrations, conflicts and feelings of depen-
progress the patient should be making. It is dence from a past relationship into the
therapeutic relationship. The patient may her own needs and problems that she cannot
express feelings of aggression, rejection or clearly perceive what is happening.
hostility that are too intense for the current The first thing the nurse must do in
situation. These responses are often not handling resistance is to listen. When she
appropriate for the nurse-patient relationship. recognizes the resistance, she then uses
Counter transference is the reverse of trans- clarification and reflection of feelings;
ference. The nurse may have unresolved clarification helps to give the nurse a more
problems from an earlierrelationship.Shemay focused idea of what is happening, while
unconsciously transfer inappropriate attribu- reflection of content helps the patient to
tes to a client that was experienced in that become aware of what has been going on
earlier relationship. The client's transference in his own mind.
It is not sufficient to merely identify that
provokes the nurse's counter transference
resistance.is occurring; the behavior must
reactions.
be explored:' and possible reasons for its
Ways to Overcome occurrence analyzed. Ignoring transfe-
Conferences with the supervisors and group rence can perpetuate the pattern. Also,
discussions with other members of the staff being overly critical of the patient, with-
are the ways in which the nurse can best be holding information or being over invol-
assisted to overcome the barriers encountered ved in making decisions for the patient can
during the working phase. It is during this encourage the dysfunctional behavioral
phase that the supervisor helps the nurse to pattern. It is important that the nurse
increase her ability to collect and interpret maintains open communication with her
supervisor, who can then guide her in
data, apply concepts and synthesize the data
making adequate progress in handling
obtained.
such resistance reactions.
There will be times when the nurse believes
she is making little or no progress, either in Termination Phase
helping the patient or in gaining knowledge. This is the most difficult, but most important
It is at such times that emotional support is phase of the therapeutic nurse-patient relation-
needed, and it is the task of the supervisor to ship. The goal of this phase is to bring a
encourage the nurse to persevere. therapeutic end to the relationship.
At one time or another, most nurses may Criteria for determining patient's readiness for
exhibit a reluctance to write and analyze termination:
process records or to engage in a discussion Patient experiences relief from presenting
with the supervisor about the content of problems
records, due to many reasons. For instance Patient's social function has improved and
fatigue, boredom, discouragement or an isolation has decreased
apparent impasse in interacting with a patient Patient's ego functions are strengthened and
may cause reluctance. A discussion of the he has attained a sense of identity
meaning ofbehavior and ofways to overcome Patient employs more effectiveand productive
it is essential. defense mechanisms
Handling resistances: The nurse may find the Patient has achieved the planned treatment
experience of transference and counter trans- goals
rerenceparticularly difficult. The relationship Nurse's tasks in the termination phase:
can become stalled and non-beneficial if the Establish reality of separation
nurse is not prepared for the patient's Mutually explore feelings of rejection, loss,
zxpression of feelings or is so preoccupied by sadness, anger and related behavior
Review progress of therapy and attainment of plans and implement them. Plans for
goals termination are essential and the nurse needs
Formulate plans for meeting future therapy to conceptualize these plans in advance. A
needs nurse who does not discuss frankly the
reasons for termination or elicit from the
Problems Encountered
patient his thoughts and feelings about the
It is the task of the nurse to prepare the patient impending termination cannot help to
for termination of the relationship. prepare him psychologically. Similarly, a
However, patients differ in their reactions to the nurse who cannot explore her own thoughts
nurse's attempts to prepare them for termination. and feelings about separation from the patient
An ill person who has experienced trust, support is also unable to accomplish the goals related
and the warmth of caring may be reluctant to to termination.
discontinue the nurse-patient contact.
Ways to Overcome
Some behaviors exhibited in this regard can be: The nurse should be aware of the patient's
Patients may perceive termination as deser- feelings and be able .to deal with them
tion and may demonstrate angry behavior appropriately. The nurse can assist the patient
Some patients attempt to punish the nurse for by openly eliciting his thoughts and feelings
this desertion by not talking during the last about termination. For some patients,
few interactions or by ignoring termination termination is a critical experience, because
completely; they may act as if nothing has many of their past relationships were
changed and the interactions will go on as terminated in a negative way that left them
before with unresolved feelings of abandonment,
Other patients react to the threatened loss by rejection,hurt and anger. Learning to bear the
becoming depressed or assuming an attitude sorrow of the loss while incorporating positive
of not caring aspects of the relationship into one's life is
Fault-finding is another behavior; the client the goal of termination in the therapeutic
may state that the therapy is not beneficial or nurse patient relationship.
not working; he may refuse to follow through During this phase, the supervisor may notice
on something that has been agreed upon before that the nurse is showing less interest in the
Resistance often comes in the form of "flight patient than shown earlier and may be
to health", which is exhibited by a patient who disengaging self from the patient several days
suddenly declares that there is no need for before the final interaction. This may be a
therapy; he claims to be all right and wants to psychological defense mechanism by which
discontinue the therapeutic relationship; this she tries to decrease or delay the anxiety she
may be a form of denial or fear of the is experiencing as a result of the impending
anticipated grief over separation termination of relationship. The task of the
"Flight to illness" occurs when a client supervisor is to discuss frankly with the nurse
exhibits sudden return of symptoms; this is the meaning of the behavior. The supervisor
an unconscious effort to show that termination then initiates action to assist the nurse to
is inappropriate and that the nurse is still persevere and intensify her efforts to prepare
needed; the client may disclose new both self and patient for his eventual release
information about him or more problems or from the hospital.
even threaten to commit suicide in an attempt
to delay parting THERAPEUTIC COMMUNICATION
The barriers to goal accomplishment during TECHNIQUES
this phase also seem to be related to the nurse's 1. Listening: It is an active process of receiving
inability or unwillingness to make specific information. Responses on the part of the
nurse such as maintaining eye-to-eye contact, Therapeutic value Can promote insight by
nodding, gesturing and other forms of making repressed material conscious, reso-
receptive non-verbal communication convey lving paradoxes, tempering aggression and
to the patient that he is being listened to and revealing new options, and is a socially
understood. acceptable form of sublimation.
Therapeutic value Non-verbally communicates 7. Informing: The skill of information giving.
to the patient the nurse's interest and accep- For example, "I think you need to know more
tance. about your medications."
2. Broad openings: Encouraging the patient to Therapeutic value Helpful in health teaching
select topics for discussion. For example, or patient education about relevant aspects
"What are you thinking about?" of patient's well-being and self-care.
8. Focusing: Questions or statements that help
Therapeutic value Indicates acceptance by the
the patient expand on a topic of importance.
nurse and the value of patient's initiative.
For example, "I think that we should talk more
3. Restating: Repeating the main thought
about your relationship with your father."
expressed by the patient. For example, "You
Therapeutic value Allows the patient to
say that your mother left you when you were discuss central issues and keeps the
five years old." communication process goal-directed.
Therapeutic value Indicates that the nurse is 9. Sharing perceptions: Asking the patient to
listening and validates, reinforces or calls verify the nurse's understanding of what the
attention to something important that has patient is thinking or feeling. For example,
been said. "Youare smiling,but I sense that you are really
4. Clarification: Attempting to put vague ideas very angry with me."
or unclear thoughts of the patient into words Therapeutic value Conveys the nurse's
to enhance the nurse's understanding or understanding to the patient and has the
asking the patient to explain what he means. potential for clearing up confusing com-
For example,"! am not sure what you mean. munication.
Could you tell me about that again?" 10. Theme identification: This involving identi-
Therapeutic value It helps to clarify feelings, fication of underlying issues or problems
ideas and perceptions of the patient and experienced by the patient that emerge
provides an explicitcorrelation between them repeatedly during the course of the nurse-
and the patient's actions. patient relationship. For example, "I noticed
:J. Reflection: Directing back the patient's ideas, that you said you have been hurt or rejected
feelings, questions and content. For example by the man. Do you think this is an underlying
"You are feeling tense and anxious and it is issue?"
related to a conversation you had with your Therapeuticvalue It allows the nurse to promote
the patient's exploration and understanding
husband last night."
of important problems.
Therapeutic value Validates the nurse's under-
11. Silence: Lack of verbal communication for a
standing of what the patient is saying and
therapeutic reason. For example, sitting with
signifies empathy, interest and respect for the
a patient and non-verbally communicating
patient. interest and involvement.
6. Humor: The discharge of energy through Therapeuticvalue Allowsthe patient timeto think
comicenjoymentofthe imperfect.Forexample, and gain insight, slows the pace of the
"That gives a whole new meaning to the word interaction and encourages the patient to
'nervous'," said with shared kidding between initiateconversationwhile enjoyingthe nurse's
the nurse and the patient. support, understanding and acceptance.
7 4 A Guide to Mental Health and Psychiatric Nursing
12. Suggesting: Presentation of alternative ideas helps to increase observational skills, as there
for the patient's consideration relative to is a conscious process involved in thinking,
problem solving. For example, "Have you sorting and classifying the interaction under
thought about responding to your boss in a the various headings;
different way when he raises that issue with helps to increase the ability to identify
you? You could ask him if a specific problem problems and gain skills in solving them;
has occurred." After a few exercises these skills will become
Therapeutic value Increases the patient's so in-built that she will keep using them auto-
perceived notions or choices. matically even when it is not specificallyrequired
or when she does not have the time to do it.
PROCESS RECORDING Thus process recording is a/ an
Educative tool
Recording is an important and necessary func-
Teaching tool
tion of any organization whether it is an industry,
Diagnostic tool
a business enterprise, a hospital or for that matter
Therapeutic tool, and a pre-requisite for
even farming. Recording is done in different ways
nursing process
in different organizations and situations. Process
recording is the method of recording used in
Pre-requisites for Process Recording
psychiatric wards by nurses.
Physical setting
Definition: Process recording is a written account Getting consent of the patient for the possibility
or verbatim recording of all that transpired, during of cassette recording
and immediately following the nurse-patient Confidentiality
interaction. In other words, it is the recording of
the conversation during the interaction or the Suggested Outlines for Process Recording
interview between the nurse and the patient in
Introductory Material
the psychiatric setup with the nurse's inference.
It may be written during the interaction or This should include a short description of the
immediately after the one-to-one interaction. patient, his name, age, educational level, health
problems and length of stay in the hospital. The
Purpose and uses: The aim of process recording date, time, place of interaction and a short
is to improve the quality ofthe interactionforbetter description of the milieu of the ward immediately
effect to the patient and as a learning experience prior to the interaction will be helpful in
for the nurse to continuously improve her clinical understanding the thoughts and feelings of the
interaction pattern. When correctly used, it patient. It is also helpful to record the thoughts
assists the nurse or student to plan, structure and feelingsof the nurse just before the interaction.
and evaluate the interaction on a conscious Reason for choosing the patient and the duration
rather than an intuitive level; of the nurse-patient relationship should also be
assists her to gain competency in interpreting included. To understand the patient in a better
and synthesizing raw data under super- way, process recording also includes personal
vision; history, family history, socio-economic history,
helps to consciously apply theory to practice; medical history, present complaints, past psy-
helps her to develop an increased aware- chiatric history if any, and provisional diagnosis.
ness of her habitual, verbal and non-verbal
communication pattern and the effectof those Objectives
patterns on others; They can be different on different days of the
helps the nurse to learn to identify thoughts interview. For example, in the beginning, setting
and feelings in relation to self and others; short-term goals may be more appropriate. In the
VERBATIM
PLACE
DATE AND TIME
SITUATION
DATE OF ADMISSION
OBJECTIVESOF THE INTERVIEW
(1)
(2)
(3)
Person Verbatim Non-verbal Inference

Communication
Conclusion- Fixing the time and place for the next interview.
Summary-s- List of inferences
Care plans made according to inference
Any special difficulties faced during the inference
Techniques used to overcome difficulties
SIGNATURE
second stage (working phase) the objectives the nurse said and did and what the patient said
can be more long-term in nature, focusing on cor- and did, including any non-verbal behavior of
rective psychodynamics, including rehabilita- the patient, such as changing the position,
::ion,follow-up and preparing the family for future looking at various things, eye contact, biting the
olans.
nails, pacing, etc. What the nurse did also means
all her non-verbal behavior. The nurse's thoughts
=?ecordof Interaction between Nurse and feelings also should be recorded so that a
end the Patient self-evaluation can be made as to how these
This should include truthful recording of what influence her behavior.
Analysis of the Interaction Difference between therapeutic and social
An analysis of the interaction should include relationship
the interpretation of the verbal and non-verbal Goals of therapeutic relationship (Apr 2004)
behavior and patient's thoughts and feelings as Nurse-patient relationship (Apr 2002)
evident from the process. The communication List the characteristics of therapeutic nurse-
techniques used by the nurse and evaluation of
patient relationship (Nov 2003)
the technique in terms of its effect on the patient
Phases of therapeutic relationship and the role
and in terms of the planned objectives also should
be included. The nurse's thoughts and feelings at during each phase (Feb 2000, Feb 2001, Apr
the end of the interaction and the plans made for 2006, Oct 2006)
further interactions should be stated. Explain the problems commonly encountered
Process recording can be written as short notes by the nurse while developing such relation-
duringtheinteractionandrewrittenimmediately ship (Nov 2003)
after it. Total time spent on the recording can be Working phase (Oct 2005)
around 30 minutes. The active time can be 20 Counter transference (Apr 2005)
minutes, with 10 minutes for conclusion and Therapeutic communication techniques
recording. Although video or tape recorders give Listening as a tool of communication (Apr
more accurate recording, the impact of this 2002)
equipment on the interaction will make an Process recording (Nov 1999, Feb 2000, Nov
unnatural influence.
2002, Nov 2003, Apr 2004, Oct 2004, Oct 2005,
Apr 2006)
REVIEW QUESTIONS
Rapport and resistance (Oct 2000, Oct 2006)
Types of relationship Empathy and Sympathy (Oct 2000, Nov 2003)
The Individual
with Functional
Psychiatric Disorder
0 SCHIZOPHRENIA from the Greek words skhizo (split) and phren
Definition (mind).
Epidemiology In ICDlO, schizophrenia is classified under
Etiology
codeF2.
Schneider's First-Rank Symptoms of
Schizophrenia (SFRS)
Clinical Features Definition
Clinical Types
Schizophrenia is a psychotic condition charac-
- Paranoid Schizophrenia
- Hebephrenic (Disorganized) Schizophrenia terized by a disturbance in thinking, emotions,
- Catatonic Schizophrenia volitions and faculties in the presence of clear
- Residual Schizophrenia consciousness, which usually leads to social
- Undifferentiated Schizophrenia
withdrawal.
- Simple Schizophrenia
- Post-Schizophrenic Depression
Course and Prognosis Epidemiology
Treatment
Nursing Management Schizophrenia is the most common of all psy-
0 NURSINGMANAGEMENTFOR APATIENTWHO chiatric disorders and is prevalent in all cultures
I EXHIBITSWITHDRAWNBEHAVIOR across the world. About 15%of new admissions
0 MOODDISORDERS
Classification of Mood Disorders
in mental hospitals are schizophrenic patients. It
Etiology has been estimated that patients diagnosed as
Manic Episode having schizophrenia occupy 50% of all mental
- Classification of Mania hospital beds.
- Clinical Features
About three to four per 1000 in every
- Symptoms of Hypomania
- Treatment community suffer from schizophrenia. About one
- Nursing Management for Mania percent of the general population stands the risk
- Nursing Management for Hypomania of developing this disease in their lifetime.
Depressive Episode
Schizophrenia is equally prevalent in men and
- Classification of Depression
- Clinical Features women. The peak ages of onset are 15to 25 years
- Treatment for men and 25 to 35 years for women.
Course and Prognosis of Mood Disorders About two-thirds of cases are in the age group
0 OTHERMOODDISORDERS of 15 to 30 years.
Differences between Somatic and Neurotic
Depression The disease is more common in lower socio-
Nursing Managementof Major Depressive Episode economic groups.
SCHIZOPHRENIA Etiology
The word 'Schizophrenia' was coined in 1908by The cause of schizophrenia is still uncertain.
the Swiss psychiatrist Eugen Bleuler.It is derived Some of the factors involved may be:
Genetic Factors Psychological Factors
The disease is more common among people born Family relationships act as major influence in the
of consanguineous marriages. Studies show that development of illness:
relatives of schizophrenics have a much higher
probability of developing the disease than the Mother-child relationship: Early theorists charac-
general population. The prevalence rate among terized the mothers of schizophrenics as cold,
family members of schizophrenics is as follows: over-protective, and domineering, thus retarding
Children with one schizophrenic parent: 12% the ego development of the child.
Children with both schizophrenic parents: Dysfunctional family system: Hostility between
40% parents can lead to a schizophrenic daughter
Siblings of schizophrenic patient: 8% (marital skew and schism).
Second-degree relatives: 5-6%
Double-bind communication (Bateson et al, 1956):
Dizygotic twins of schizophrenic patients:
Parents convey two or more conflicting and
12%
incompatible messages at the same time.
Monozygotic twins of schizophrenic patients:
47%
Social Factors
Stress-DiathesisModel Studies have shown that schizophrenia is more
prevalent in areas of high social mobility and
According to the stress-diathesis model for the
disorganization, especially among members of
integration of biological, psychosocial and
very low social classes. Stressful life events also
environmental factors, a person may have a can precipitate the disease in predisposed
specificvulnerability (diathesis) that, when acted individuals.
on by a stressful influence, alows the symptoms
of schizophrenia to develop. In the most general Schneider's First-Rank Symptoms of
stress-diathesis model, the diathesis or the stress Schizophrenia (SFRS)
can be biological, environmental or both. The
Kurt Schneider proposed the first rank symptoms
environmental component again can be either
of schizophrenia in 1959. The presence of even
biological (e.g.an infection) or psychological (e.g.
one of these symptoms is considered to be strongly
stressful family situation). The biological basis of
suggestive of schizophrenia. They include:
a diathesis can be further shaped by epigenetic Hearing one's thoughts spoken aloud
influences such as substance abuse, psychosocial (audible thoughts or thought echo).
stress and trauma. Hallucinatory voices in the form of statement
and reply (the patient hears voices discussing
Biochemical Factors him in the third person).
Dopamine hypotheses: This theory suggests that an Hallucinatory voices in the form of a running
excess of dopamine-dependent neuronal activity commentary (voices commenting on one's
in the brain may cause schizophrenia. action).
Thought withdrawal (thoughts cease and
Other biochemicalhypotheses: Various other bioche-
subject experiences them as removed by an
micals have been implicated in the predisposition external force).
to schizophrenia. These include abnormalities in Thought insertion (subject experiences
the neurotransmitters norepinephrine, serotonin, thoughts imposed by some external force on
acetylcholine and gamma-aminobutyric acid his passive mind).
(GABA), and neuroregulators such as prostag- Thought broadcasting (subject experiences
landins and endorphins. that his thoughts are escaping the confines of
The Individual with Functional Psychiatric Disorder 79
his self and are being experienced by others understood by others).

around). Poverty of speech (decreased speech pro-
Delusional perception (normal perception has duction).
a private and illogical meaning). Poverty ofideation (speechamount is adequate
Somatic passivity (bodily sensations espe- but content conveys little information).
cially sensory symptoms are experienced as
Echolalia (repetition or echo by patient of the
imposed on body by some external force).
words or phrases of examiner).
Made volition or acts (one's own acts are
experienced as being under the control of some Perseveration (persistent repetition of words
external force, the subject being like a robot). or themes beyond the point of relevance).
Made impulses (the subjectexperiences impul- Verbigeration (senseless repetition of some
ses as being imposed by some external force). words or phrases over and over again).
Made feelings or affect(the subjectexperiences Delusions of various kinds i.e., delusions of
feelings as being imposed by some external persecution (being persecuted against); delu-
force). sions of grandeur (beliefthat one is especially
very powerful, rich, born with a special
Clinical Features mission in life); delusions of reference (being
Thepredominant clinicalfeatures in acute schizo- referred to by others); delusions of control
phrenia are delusions,hallucinations and interference (being controlled by an external force);somatic
ioiih. thinking. Features of this kind are often called delusions.
positive symptoms or psychotic features while Other thought disorders are over inclusion
most of the patients recover from acute illness, (tending to include irrelevant items in speech),
some progress to the chronic phase, during which impaired abstraction, concreteness and
rime the main features are affective flattening or ambivalence.
blunting, avolition-apathy (lack of initiative),
attentional impairment, anhedonia (inability to Disorders of Perception
experience pleasure), asociality, alogia (lack of speech Auditory hallucinations (described under
output). These are called as negative symptoms. SFRS).
Once the chronic syndrome is established, few Visual hallucinations may sometimes occur
?atients recover completely. along with auditory hallucinations; tactile,
The signs and symptoms commonly encoun- gustatory and olfactory types are far less
rered in schizophrenic patients may be grouped common.
- follows:
Disorders of Affect
nought and Speech Disorders These include apathy, emotional blunting, emo-
Autistic thinking (preoccupations totally tional shallowness, anhedonia and inappro-
removing a person from reality). priate emotional response. The incapacity of the
Loosening of associations (a pattern of patient to establish emotional contact leads to lack
spontaneous speech in which the things said of rapport with the examiner.
in juxtaposition lack a meaningful relation-
ship with each other). Disordersof Motor Behavior
Thought blocking (a sudden interruption in There can be either an increase or a decrease in
the thought process). psychomotor activity. Mannerisms, grimacing,
Neologism (aword newly coined, or an every- stereotypes, decreased self-care and poor
day word used in a special way, not readily grooming are common features.
Other Features Delusions of grandiosity: Individuals with

Decreased functioning in work, social rela- grandiose delusions have irrational ideas
tions and self-care,as compared to earlier life. regarding their own worth, talent, knowledge
Loss of ego boundaries. or power. They may believe that they have a
Loss of insight. special relationship with famous persons, or
Poor judgment. grandiose delusions of a religious nature may
Suicide can occur due to the presence of asso- lead to assumption of the identity of a great
ciated depression, command hallucinations, religious leader.
impulsive behavior, or return of insight that Hallucinatory voices that threaten or com-
causes the patient to comprehend the devas- mand the patient, or auditory hallucinations
tating nature of the illness and take his life. without verbal form, such as whistling,
There is usually no disturbance of conscious- humming and laughing.
ness, orientation, attention, memory and Other features include disturbance of affect
intelligence. (though affectiveblunting is less than in other
There is no underlying organic cause. forms of schizophrenia), volition, speech and
motor behavior.
Clinical Types Paranoid schizophrenia has a good prognosis
if treated early. Personality deterioration is
Schizophrenia can be classifiedinto the following minimal and most of these patients are productive
subtypes: and can lead a normal life.
1. Paranoid
2. Hebephrenic (disorganized) Hebephrenic (disorganized) Schizophrenia
3. Catatonic
4. Residual It has an early and insidious onset and is often
5. Undifferentiated associated with poor premorbid personality. The
6. Simple essential features include marked thought dis-
7. Post-schizophrenic depression order, incoherence, severe loosening of associa-
tions and extreme social impairment. Delusions
Paranoid Schizophrenia and hallucinations are fragmentary and chan-
geable. Other oddities of behavior include
The word 'paranoid' means 'delusional.' Para-
senseless giggling, mirror-gazing, grimacing,
noid schizophrenia is at present the most common
mannerisms and so on. The course is chronic and
form of schizophrenia. It is characterized by the
progressively downhill without significant
following features (in addition to the general
remissions. Recoveryclassicallynever occurs and
features already described).
it has one of the worst prognoses among all the
Delusions of persecution: In persecutory
subtypes.
delusions, individuals believe that they are
being malevolently treated in some way.
Catatonic Schizophrenia
Frequent themes include being conspired
against, cheated, spied upon, followed, Catatonic (Cata-disturbed) schizophrenia is
poisoned or drugged, maliciously maligned, characterized by marked disturbance of motor
harassed or obstructed in the pursuit of long- behavior. This may take the form of catatonic
term goals. stupor, catatonic excitement and catatonia
Delusions of jealousy: The content of jealous alternating between excitement and stupor.
delusions centers around the theme that the Clinicalfeatures of excited catatonia:
person's sexual partner is unfaithful. The idea Increase in psychomotor activity (ranging
is held on inadequate grounds and is from restlessness, agitation, excitement,
unaffected by rational judgment. aggressiveness to at times violent behavior).
Increase in speech production. Ambitendency: A conflict to do or not to do,

Loosening of associations and frank e.g., on asking to put out tongue, it is slightly
incoherence. protruded but taken back again.
Sometimes excitement becomes very severe Automatic obedience: Obeys every command
and is accompaniedby rigidity,hyperthermia and irrespective of their nature.
dehydration and can result in death. It is then
known as acute lethal catatonia or pernicious Residual Schizophrenia
catatonia. Symptoms of residual schizophrenia include
Clinical features of retarded catatonia (catatonic emotional blunting, eccentric behavior, illogical
stupor): thinking, social withdrawal and loosening of
Mutism: Absence of speech. associations. This category should be used when
Rigidity:Maintenance ofrigid posture against there has been at least one episode of schizo-
effortsto be moved. phrenia in the past but without prominent
Negativism: A motiveless resistance to all psychotic symptoms at present.
commands and attempts to be moved, or doing
just the opposite. Undifferentiated Schizophrenia
Posturing: Voluntary assumption of an This category is diagnosed either when features
inappropriate and often bizarre posture for ofno subtype are fully present or features ofmore
long periods of time. than one subtype are exhibited.
Stupor: Does not react to his surroundings
and appears to be unaware of them. Simple Schizophrenia
Echolalia:Repetition or mimicking of phrases It is characterized by an early and insidious onset,
or words heard. progressive course, presence of characteristic
Echopraxia: Repetition or mimicking of negative symptoms, vague hypochondriacal
actions observed. features, wandering tendency, self-absorbed
Waxy flexibility: Parts of body can be placed idleness and aimless activity. It differs from
in positions that will be maintained for long residual schizophrenia in that there never has
periods of time, even if very uncomfortable been an episode with all the typical psychotic
(flexiblelike wax). symptoms. The prognosis is very poor.
Prognostic Factors in Schizophrenia
Good prognostic factors Poor prognostic factors
1. Abrupt or acute onset 1. Insidious onset

2. Later onset 2. Younger onset
3. Presence of precipitating factor 3. Absence of precipitating factor
4. Good premorbid personality 4. Poor premorbid personality
5. Paranoid and catatonic subtypes 5. Simple, undifferentiated subtypes
6. Short duration: (<6 months) 6. Long duration: (>2 years)
7. Predominance of positive symptoms 7. Predominance of negative symptoms
8. Family history of mood disorders 8. Family history of schizophrenia
9. Good social support 9. Poor social support
10. Female sex 10. Male sex
11. Married 11. Single, divorced or widowed
12. Out-patient treatment 12. Institutionaliza tion
Post-schizophrenic Depression Schizophrenia refractory to all other forms of
Depressive features develop in the presence of treatment
residual or active features of schizophrenia and Usually 8-12 ECTs are needed
are associated with an increased risk of suicide.
Psychological Therapies
Course and Prognosis Group therapy The social interaction, sense of
The classic course is one of exacerbations and cohesiveness, identification, and reality testing
remissions. In general, schizophrenia has been achieved within the group setting have proven to
described as the most crippling and devastating be highly therapeutic for these individuals.
of all psychiatric illnesses. Several studies have Behavior therapy Behavior therapy is useful in
found that over the 5-10 years period after the reducing the frequency of bizarre, disturbing and
first psychiatric hospitalization for schizophrenia, deviant behavior, and increasing appropriate
only about 10 to 20% of patients can be described behaviors.
as having a good outcome. More than 50% of
patients have a poor outcome, with repeated Social skills training Social skills training
hospitalizations. addresses behaviors such as poor eye contact, odd
facial expressions and lack of spontaneity in
Treatment social situations through the use of videotapes,
role playing and homework assignments.
Pharmacotherapy
Cognitive therapy Used to improve cognitive
An acute episode of schizophrenia typically
distortions like reducing distractibility and
responds to treatment with classic antipsychotic
correcting judgment.
agents, which are most effective in its treatment.
Some commonly used drugs include: Family therapy Family therapy typically consists
of a brief program of family education about
Chlorpromazine: 300-1500 mg/ day PO; 50-100
schizophrenia. It has been found that relapse rates
mg/day IM
of schizophrenia are higher in families with high
Fluphenazine decanoate: 25-50 mg IM every 1-3 expressed emotions (EE),where significant others
weeks make critical comments, express hostility or show
emotional over-involvement. The significant others
Haloperidol: 5-100 mg/day PO; 5-20 mg/day
are, therefore, taught to decrease expectations and
IM
family tensions, apart from being given social
Trifluoperazine: 15- 60 mg/day PO; 1-5 mg/ skills training to enhance communication and
day IM problem solving.
Clozapine: 25-450 mg/ day PO
Psychosocial Rehabilitation
Risperidone: 2-10 mg/ day PO This includes activity therapy to develop the work
Olanzapine: 10-20 mg/day PO habit, training in a new vocation or retraining in
(Refer chapter 14for a detailed description of these a previous skill, vocational guidance and inde-
drugs). pendent job placement.
Electroconvulsive Therapy (ECT)

Nursing Management
Indications for ECT in schizophrenia include:
Catatonic stupor Nursing Assessment
Uncontrolled catatonic excitement Assessment of the schizophrenic patient may be
Severe side-effects with drugs a complex process, based on information gathered
Table 7.1: Nursing interventions for delusional behaviour
Interventions Rationale
(a) Convey acceptance of the patient's The client must understand that you do not
need for the false belief, but that view the idea as real.
you do not share the belief.
(b) Do not argue or deny the belief. Arguing or denying serves no useful purpose as
delusional ideas are not eliminated by this approach;
further, this may adversely affect the development of a
trusting relationship.
(c) Reinforce and focus on reality. Discussions that focus on the false ideas are
Discourage long discussions about purposeless and useless and may even
the irrational thinking. Instead talk aggravate the condition.
about real events and real people.
(d) If the client is highly suspicious, the
following interventions may help:
* use same staff as far as possible; To promote trust
be honest and keep all promises
* avoid physical contact in the form To prevent the client from feeling threatened
of touching the patient etc;
* avoid laughing, whispering or
talking quietly where the client -do-
can see but cannot hear what is
being said;
* avoid competitive activities; use
assertive, matter-of-fact yet friendly -do-
approach
from a number of sources. Schizophrenic patients evidenced by inappropriate responses, disor-

in an acute episode of the illness are seldom able dered thought process, poor concentration and
to make a significant contribution to their history. disorientation.
Data may be obtained from family members if
possible, old records if available, or from other Objective: Patient will be able to define and test
individuals who are in a position to report on the reality, eliminating the occurrence of halluci-
progression of the patient's behavior. nations.
Intervention: See Table 7.2.
Nursing Diagnosis
Alteration in thought processes related to inability Nursing Diagnosis Ill
to trust, panic anxiety, evidenced by delusional Social isolation related to inability to trust, panic
thinking, inability to concentrate, impaired anxiety, delusional thinking, evidenced by
volition, extreme suspiciousness of others. withdrawal, sad, dull affect, preoccupation with
Objective: Patient will eliminate patterns of delu- own thoughts, expression of feelings of rejection
sional thinking and demonstrate trust in others of aloneness imposed by others.
Objective:Patient will voluntarily spend time with
Nursing Diagnosis II other patients and staff members in group
Sensory-perceptual alteration: Auditory /visual, activities on the unit.
related to panic anxiety, withdrawal into self, Intervention: SeeTable 7.3.
Table 7.2: Nursing interventions for hallucinatory behaviour
(a) Observe the client for signs of Early intervention may prevent aggressive
hallucinations (listening pose, response to command hallucinations.
laughing or talking to self, stopping
in mid-sentence).
(b) Avoid touching the client without The client may perceive touch as threatening and
warning. may respond in an aggressive manner.
(C) An attitude of acceptance will This is important to prevent possible injury
encourage the patient to share the to the patient or others from command
content of the hallucination with you. hallucinations.
(d) Do not reinforce the hallucinations. The client should know that you do not
Use "the voices" instead of words share the false perception.
like "they" that imply validation.
Say "Even though I realize the voices
are real to you, I don't hear any
voices speaking."
(e) Help the client understand the If the client can learn to interrupt rising
connection between anxiety and anxiety, hallucinations may be prevented.
hallucinations.
(f) Try to distract the client away from This is to bring the client back to reality.
the hallucinations and involve him
in interpersonal activities and actual
situations.
Table 7.3: Nursing interventions for withdrawn behaviour
(a) Convey an accepting attitude by This increases feelings of self-worth and

making brief, frequent contacts. facilitates trust.
Show unconditional positive regard.
(b) Offer to be with the client during group The presence of a trusted individual
activities that he finds frightening or provides emotional security for the client.
difficult. Involve the client gradually
in different activities on the unit.
(C) Give recognition and positive re- Positive reinforcement enhances self-esteem
inforcement for the client's voluntary and encourages repetition of acceptable
interaction with others. behavior.
Nursing Diagnosis IV Nursing Diagnosis V

Potential for violence, self-directed or directed at Impaired verbal communication related to panic
others, related to extreme suspiciousness, panic anxiety, disordered, unrealistic thinking, evi-
anxiety, catatonic excitement, rage reactions, denced by loosening of associations, echolalia,
command hallucinations, evidenced by physical verbalizations that reflect concrete thinking, and
violence,destruction of objectsin the environment, poor eye contact.
self-destructive behavior or active aggressive Objective: Patient will be able to communicate
suicidal acts. appropriately and comprehensibly by the time of
Objective: Patient will not harm self or others. discharge.
Intervention: See Table 7.4. Intervention: See Table 7.5.
Table 7.4: Nursing interventions for violent behaviour
(a) Maintain low level of stimuli in the Anxiety level rises in a stimulating
client's environment (low lighting, environment and may trigger off aggression.
low noise, few people, simple
decoration, etc.)
(b) Observe client's behavior Close observation is necessary so that
frequently. intervention can occur if required, to ensure
client's and others' safety.
Do this while carrying out To avoid creating suspicion in the
routine activities. individual.
(c) Remove all dangerous objects To prevent the client from using them
from the client's environment. to harm self or others in an agitated,
confused state.
(d) Redirect violent behavior with Physical exercise is a safe and effective way
physical outlets for the anxiety. of relieving pent-up tension.
(e) Staff should maintain a calm attitude Anxiety is contagious and can be transmitted
towards the client. from staff to client.
(f) Have sufficient staff available to This shows the client evidence of control
indicate a show of strength to the over the situation and provides some
client if it becomes necessary. physical security for the staff.
(g) Administer tranquilizers If the client is not calmed by "talking down"
as prescribed. Use of mechanical or the use of medications, restraints may
restraints may become necessary in have to be used as a last resort.
some cases.
Table 7.5: Nursing interventions for impaired verbal communication

(a) Attempt to decode incomprehensible These techniques reveal how the

communication pattern. Seek validation patient is being perceived by others,
and clarification by stating "Is it what while the responsibility for not
you mean ... ?"or "I don't understand what understanding is accepted by the
you mean by that. Would you please nurse.
clarify it for me?"
(b) Facilitate trust and understanding by This approach conveys empathy and
maintaining staff assignments as encourages the client to disclose
consistently as possible. painful issues.
The techniques of VERBALIZING
THE IMPLIEDis used with the client
who is mute (either unable or unwilling
to speak).
For example, "That must have been a very
difficult time for you when your
mother left. You must have felt all alone."
(c) Anticipate and fulfill client's needs Self-care ability may be impaired in some
until functional communication pattern patients who may need assistance initially.
returns.
Nursing Diagnosis VI Nursing Diagnosis VII

Self-care deficit related to withdrawal, panic Ineffective family coping related to highly ambi-
valent family relationships, impaired family
anxiety, perceptual or cognitive impairment,
communication, evidenced by neglectful care of
evidenced by difficulty in carrying out tasks
the client, extreme denial or prolonged over-
associated with hygiene, dressing, grooming, concern regarding his illness.
eating and toileting.
Objective: Family will identify more adaptive
Objective: Patient will demonstrate ability to meet coping strategies for dealing with patient's illness
self-care needs independently. and treatment regimen.
Intervention: SeeTable 7.6. Intervention: SeeTable 7.7.
Table 7.6: Nursing interventions to improve self-care activities
(a) Provide assistance with self-care needs Patient safety and comfort are
as required. Some patients who are nursing priorities.
severely withdrawn may require total
care.
(b) Encourage client to perform independen- Independent accomplishment and
tly as many activities as possible. Provide reinforcement enhance self-esteem
positive reinforcement for independent and promote repetition of desirable
accomplishments. behavior.
(c) Creative approaches may need to be To ensure that self-care needs are
used with the client who is not eating met.
because he is suspicious of being
poisoned (e.g., allow client to open own
canned or packaged foods, etc.) If
elimination needs are not being met,
establish structured schedule to help
the client fulfill these needs until he is
able to do so independently.
Table 7.7: Nursing interventions to improve family coping skills
(a) Identify role of the client in the family These factors will help to identify
and how it is affected by his illness. how successful the family is in
Identify the level of family functioning. dealing with stressful situations
Assess communication patterns, inter- and areas where assistance is
personal relationships between the required.
members, problem solving skills and
availability of support systems.
(b) Provide information to the family Knowledge and understanding about
about the client's illness, the what to expect may facilitate the
treatment regimen, long-term prognosis. family's ability to successfully
integrate the schizophrenic patient
into the system.
(c) Practice with family members, how A plan of action will assist the
to respond to bizarre behavior and family to respond adaptively in the
communication patterns and when the face of what they may consider to be
client becomes violent. a crisis situation.
Evaluation Regression is another process predominant

A few questions that may facilitate the process of in a withdrawn patient. When it becomes
evaluation can be: severe,physicalneeds like sleep,rest, nutrition
Has the patient established trust with at least and hygiene may be interfered with.
one staffmember?
Is delusional thinking still prevalent? Interventions
Are hallucinations still evident? In taking care of a withdrawn patient, the
Is the patient able to interact with others nurse might be faced with many problems.
appropriately? Communication and interpersonal relation-
Is the patient able to carry out all activities of
ships are the biggest difficulties because the
daily living independently?
withdrawn patient tends to use symbolized
language, or may prefer to rely on non-verbal
NURSING MANAGEMENT FOR A PATIENT
behavior completely. Establishing initial con-
WHO EXHIBITS WITHDRAWN BEHAVIOR
tact using calm, non-threatening and consis-
The term withdrawn behavior is used to describe tent approaches is important. It necessitates a
a client's retreat from relating to the external
lot of hard work and patience from the nurse
world. Withdrawn behavior can occur in
as the patient needs a long period of testing
conjunction with a number of mental health
out before he finally trusts her.
problems, including schizophrenia, mood
Dealing with hallucinations and delusions
disorders and suicidal behavior.
may be a problem as this happens in accor-
Characteristics of Withdrawn Behavior dance with his own self-created world. Any-
Pattern body who is trying to destroy that comfortable
world may be seen by the patient as a threat to
Withdrawn behavior pattern may present the
him and to his security. Disintegration in
picture of a lonely individual who does not
thinking is what makes the withdrawn
respond to the environment. He may walk up
patient the worst of the mentally ill. As this
and down talking to himself, or may stand or
sit in thecorner assuming unusual and most process can go on for a long time before it is
uncomfortable positions. noticed by others, it is often very late when it
He has difficulty in expressing his feelings, is identified. This makes it more difficult for
so he may present the picture of a totally the nurse in her efforts to bring the patient
apathetic person, or he may express them in back to reality. A lot of tact and expert skill is
inappropriate ways. important, and opportunities should be
Ambivalence is another characteristic that created for the client to recognize the nurse as
might be seen in a withdrawn patient. For a safe contact with present reality and to begin
example, he may love and hate a person at the to respond.
same time. Regression in the patient causes a difficult
Disordered thought process is another feature practical problem, as the patient has to be
in this patient. The outward expression of this considered and taken care of as a child. At the
disorganization can be a meaningless jumble same time he has to be treated as an adult,
of words/sentences, or making up of new fostering his adult characteristics. Providing
words. The patient may also experience sensory stimulation, meeting the client's phy-
sudden thought block. As he creates his own siologic and hygienic needs, and promoting
world, the world becomes filled with his own the client's physical activity and interactions
projected ideas and thoughts. with others are important interventions.
Certain general principles in working with Classification of Mood Disorders
these patients are:avoid change ofstaff,reduce According to ICDlO (F3) mood disorders are
the number of staffwho works with them, and classified as follows:
be available when the patient really needs the Manic episode
nurse. He may perceive the unavailability of Depressive episode
the nurse as another disappointment in his Bipolar mood (affective)disorders
relationship with people in general. Recurrent depressive disorder
A one-to-one relationship with the patient is Persistent mood disorder (including cyclo-
considered most beneficial and least anxiety- thymia and dysthymia)
producing to the patient. It is necessary to Other mood disorders
encourage reality contact whenever possible
Etiology
and to discourage him from living in the
unreal world. This may be achieved by The etiology of mood disorders is currently
providing opportunities for interaction with unknown. However, several theories have been
propounded which include:
the real environment.
Give the client positive feedback for any
Biological Theories
response to your attempted interaction or to
the external environment. Gradually increase Genetic hypothesis Geneticfactorsare very impor-
tant in predisposing an individual to mood
the amount of time the client spends with
disorders. The lifetime risk for the first-degree
others and the number of people with whom
relatives of patients with bipolar mood disorder
the client interacts. is 25%and of normal controls is 7%.The lifetime
Active friendliness: As the patient is with- risk for the children of one parent with mood
drawn and does not approach anybody, the disorder is 27% and of both parents with mood
approach has to be made from the nurse's side disorder is 74%. The concordance rate for
and many attempts will have to be made to monozygotic twins is 65%and for dizygotic twins
initiate any conversation or communication. is 15%.
Kind firmness: This is another attitude that is
Biochemical theories A deficiency of norepineph-
to be considered essential. The nurse assumes rine and serotonin has been found in depressed
firmness in expecting the patient to behave in patients and they are elevated in mania.
certain ways but should expect the behavior Dopamine, GABA and acetylcholine are also
in a kind manner without being authoritative presumably involved.
and demanding, showing kindness and
understanding while listening to the patient, Psychosocial Theories
and helping him handle any difficult Psychoanalytic theory According to Freud (1957)
situations. depression results due to loss of a "loved object",
and fixation in the oral sadistic phase of
MOOD DISORDERS development. In this model, mania is viewed as a
Mood disorders are characterized by a distur- denial of depression.
bance of mood, accompanied by a full or partial Behavioral theory This theory of depression
manic or depressive syndrome, which is not due connects depressive phenomena to the experience
to any other physical or mental disorder. of uncontrollable events. According to this model,
The prevalence rate of mood disorders is 1.5 depression is conditioned by repeated losses in
percent, and it is uniform throughout the world. the past.
Cognitive theory According to this theory depres- Ecstasy (Stage IV):Severe elevation of mood,
sion is due to negative cognitions which includes: intense sense of rapture or blissfulness seen
Negative expectations of the environment in delirious or stuporous mania.
Negative expectations of the self Expansive mood is unceasing and unselective
Negative expectations of the future enthusiasm for interacting with people and
These cognitive distortions arise out of a defect surrounding environment.
in cognitive development and cause the indivi- Sometimes irritable mood may be predomi-
dual to feel inadequate, worthless and rejected by nant, especially when the person is stopped from
others. doing what he wants.
There may be rapid, short-lasting shifts from
Sociological theory Stressfullife events, e.g. death, euphoria to depression or anger.
marriage, financial loss before the onset of the
disease or a relapse probably have a formative Psychomotor Activity
effect. There is an increased psychomotor activity
ranging from over activeness and restlessness to
Manic Episode manic excitement. The person involves in cease-
Mania refers to a syndrome in which the central less activity.These activities are goal-oriented and
features are over-activity, mood change (which based on external environment cues.
may be towards elation or irritability) and self-
important ideas. Speech and Thought
The lifetime risk of manic episode is about 0.8- Flight of ideas: Thoughts racing in mind,
1%. This disorder occurs in episodes lasting rapid shifts from one topic to another
usually 3 to 4 months, followed by complete Pressure of speech: Speech is forceful, strong
recovery. and difficult to interrupt. Uses playful
language with punning, rhyming, joking and
Classification of Mania (ICD10) teasing and speaks loudly
Hypomania Delusions of grandeur
Mania without psychotic symptoms Delusions of persecution
Mania with psychotic symptoms Distractibility
Manic episode unspecified
Other Features
Clinical Features Increased sociabilities
Impulsive behavior
An acute manic episode is characterized by the
Disinhibition
following features which should last for at least
Hypersexual and promiscuous behavior
one week: Poor judgment
High-risk activities (buying sprees, reckless
Elevated, Expansive or Irritable Mood driving, foolish business investments, distri-
Elevated mood in mania has four stages depen- buting money or articles to unknown persons)
ding on the severity of manic episodes: Dressed up in gaudy and flamboyant clothes
Euphoria (StageI):Increased sense of psycho- although in severe mania there may be poor
logical well-being and happiness not in self-care
keeping with ongoing events. Decreased need for sleep (< 3 hrs)
Elation (StageII):Moderate elevation of mood Decreased food intake due to over-activity
with increased psychomotor activity. Decreased attention and concentration
Exaltation(StageIII):Intense elevation ofmood Poor judgment
with delusions of grandeur. Absent insight
Symptoms of Hypomania 4. The disturbance in mood and the change in
Hypomania is a lesser degree of mania. There is a functioning are observable by others.
persistent mild elevation of mood and increased 5. The episode is not severe enough to cause
sense of psychological well being and happiness marked impairment in social or occupational
not in keeping with ongoing events. In some cases functioning, or to necessitate hospitalization,
irritability,conceit,and boorish behavior may take and there are no psychotic features.
the place of the more usual euphoric sociability.
Concentration and attention may be impaired, Treatment
thus diminishing the abilityto settledown to work Pharmacotherapy
or to relaxation and leisure, but this may not
Lithium: 900-2100 mg/ day.
prevent the appearance of interests in quite new Carbamazepine: 600-1800 mg/day.
ventures and activities. In fact, the ability to Sodium valproate: 600-2600 mg/ day.
function becomes better in hypomania, and Other drugs: Clonazepam, calcium channel
there's a marked increase in productivity and blockers, etc.
creativity; many artists and writers have (referchapter 14formore detailson thesedrugs)
contributed significantly during such periods.
The features of hypomania may be specified Electroconvu/sive Therapy (ECT)
as follows:
ECT can also be used for acute manic excitement
1. A distinct period of persistently elevated, if not adequately responding to antipsychotics
expansive, or irritable mood, lasting and lithium.
throughout 4 days, that is clearlydifferentfrom
the usual non-depressed mood. Psychosocial Treatment
2. During the period of mood disturbance, three
Family and marital therapy is used to decrease
(or more) of the following symptoms are
intrafamilial and interpersonal difficulties and
persistent (four, if the mood is only irritable)
to reduce or modify stressors. The main purpose
and present to a significant degree:
is to ensure continuity of treatment and adequate
a) inflated self-esteem or grandiosity drug compliance.
b) decreased need for sleep (e.g. feels rested
after only 3 hours of sleep) Nursing Management for Mania
c) more talkative than usual
d) flight of ideas or subjectiveexperience that Nursing Assessment
thoughts are racing Nursing assessment of the manic patient should
e) distractibility (i.e. attention too easily include assessing the severity of the disorder,
drawn to unimportant or irrelevant forming an opinion about the causes, assessing
external stimuli) the patient's resources and judging the effects of
f) increase in goal-directed activity (either patient's behavior on other people. As far as
socially, at work or school, or sexually) or possible all relevant data should be collectedfrom
psychomotor agitation the patient as well as from his relatives, because
g) excessiveinvolvement in pleasurable acti- the patient may not always recognize the extent
vities that have a high potential for painful of his abnormal behavior.
consequences (e.g. the person engages in
unrestrained buying sprees, foolish busi- Nursing Diagnosis I
ness investments or sexual indiscretions) High risk for injury related to extreme hyper-
3. The episode is associated with an unequivocal activity and impulsive behavior, evidenced by
change in functioning that is uncharacteristic lack of control over purposeless and potentially
of the person when not symptomatic. injurious movements.
Objective: Patient will not injure self. weapon (throwing water in the patient's face,
yelling, etc.).
Intervention: See Table 7.8. Give prescribed antipsychotic medications
Nursing Diagnosis II Nursing Diagnosis Ill

High risk for violence; self-directed or directed at Altered nutrition, less than body requirements
others related to manic excitement, delusional related to refusal or inabilityto sit stilllong enough
thinking and hallucinations. to eat, evidenced by weight loss, amenorrhea.
Objective: Patient will not harm self or others. Objective: Patient will not exhibit signs and
Intervention: See Table 7.9. symptoms of malnutrition.
The following are some guidelines for self- Intervention: See Table 7.10.
protection when handling an aggressive patient:
Never see a potentially violent person alone. Nursing Diagnosis IV
Keep a comfortable distance away from the Impaired social interaction related to egocentric
patient (arm length). and narcissistic behavior, evidenced by inability
Beprepared to move, violent patient can strike to develop satisfying relationships and mani-
out suddenly. pulation of others for own desires.
Maintain a clear exit route for both the staff Objective: Patient will interact with others in an
and patient. appropriate manner.
Besure that the patient has no weapons in his Intervention: See Table 7.11.
possession before approaching him.
If patient is having a weapon ask him to keep Nursing Diagnosis V
it on a table or floor rather than fighting with Self-esteem disturbance related to unmet depen-
him to take it away. dency needs, lack of positive feedback, unrealistic
Keep something like a pillow, mattress or self-expectations.
blanket wrapped around arm between you Objective: Patient will have realistic expectations
and the weapon. about self.
Distract the patient momentarily to remove the Intervention: See Table 7.12.
Table 7.8: Nursing interventions for hyperactive behaviour

~---~
(a) Keep environmental stimuli to a minimum; Patient is extremely distractible and
assign single room; limit interactions with responds to even the slightest
others; keep lighting and noise level low. stimuli.
Keep his room and immediate environment
minimally furnished.
(b) Remove hazardous objects and substances, Rationality is impaired and patient
caution the patient when there is possibility may harm self inadvertently.
of an accident.
(c) Assist patient to engage in activities, such To bring relief from pent-up tension
as writing, drawing and other physical and dissipate energy.
exercise.
(d) Stay with patient as hyperactivity increases. To offer support and provide feeling of security.
(e) Administer medication as prescribed by For providing rapid relief from symptoms of
physician. hyperactivity.
Table 7.9: Nursing interventions for manic violent behaviour
(a) Maintain low level of stimuli in patient's To minimize anxiety and
environment, provide unchallenging suspiciousness.
environment.
(b) Observe patient's behavior at least every Early intervention must be taken
15 minutes. to ensure patient's and others' safety.
(c) Ensure that all sharp objects, glass or These may be used to harm
mirror items, belts, ties, matchboxes self or others.
have been removed from patient's
environment.
(d) Redirect violent behavior with physical outlet. For relieving pent-up tension and hostility.
(e) Encourage verbal expression of feelings. -do-
(f) Engage him in some physical exercises
like aerobics -do-
(g) Maintain and convey a calm attitude to the Anxiety is contagious and can be
patient. Respond matter-of-factly to verbal transmitted from staff to patient.
hostility. Talk to him in low, calm voice, use
clear and direct speech.
(h) Have sufficient staff to indicate a show of This conveys control over the
strength to patient if necessary. State situation and provides physical
limitations and expectations. security for the staff.
(i) Administer tranquilizing medication; if Explaining why the restriction is
patient refuses, use of restraints may be imposed may ensure some
necessary. In such a case, explain the control over his behavior.
reason to the patient.
(j) Following application of restraints observe To ensure that needs for nutrition,
patient every 15 minutes. hydration and elimination are met
(k) Remove restraints gradually once at a time To minimize potential for injury to
patient and staff.
Table 7.10: Nursing interventions to improve nutritional status of manic patient

(a) Provide high-protein, high caloric, nutritious Patient has difficulty sitting
finger foods and drinks that can be consumed still long enough to eat a meal.
'on the run.'
(b) Find out patient's likes and dislikes and To encourage the patient to eat.
provide favorite foods.
(c) Provide 6 - 8 glasses of fluids per day. Have Intake of nutrients is required on
juice and snacks on unit at all times. regular basis to compensate for
increased caloric requirements
due to hyperactivity.
(d) Maintain accurate record of intake, output These are useful data to assess
and calorie count. Weigh the patient patient's nutritional status.
regularly.
(e) Supplement diet with vitamins and minerals. To improve nutritional status.
(f) Walk or sit with patient while he eats. To offer support and to encourage
patient to eat.
Table 7.11: Nursing interventions for manipulative behaviour
(a) Recognize that manipulative behavior helps Understanding the rationale behind
to decrease feelings of insecurity by increasing the behavior may facilitate greater
feelings of power and control. acceptance of the individual.
(b) Set limits on manipulative behavior. Explain Consequences for violation of limits
the consequences if limits are violated. must be consistently administered.
Terms of the limits must be agreed upon
by all the staff who will be working with
the patient
(c) Ignore attempts by patient to argue or bargain Lack of feedback may decrease
his way out of the limit setting. these behaviors.
(d) Give positive reinforcement for non- To enhance self-esteem and promote
manipulative behaviors. repetition of desirable behavior.
(e) Discuss consequences of patient's Patient must accept responsibility for
behavior and how attempts are made to own behavior before adaptive change
attribute them to others. can occur.
(f) Help patient identify positive aspects As self-esteem increases patient
about self, recognize accomplishments and will experience a lesser need to manipulate
feel good about them. others for own gratification.
Table 7.12: Nursing interventions to improve self-esteem among manic patient
(a) Ask how client would like to be addressed. Grandiosity is thought actually to
Avoid approaches that imply different reflect low self-esteem.
perception of the client's importance.
(b) Explain rationale for requests by staff unit Nursing approaches should reinforce
routine etc; strictly adhere to courteous patient's dignity and worth;
approaches, matter-of-fact style and friendly understanding reasons enhances
attitudes. co-operation with regimen.
(c) Encourage verbalization and identification Problem solving begins with
of feelings related to issues of chronicity, agreeing on the problem.
lack of control over self, etc.
(d) Offer matter-of-fact feedback regarding Unrealistic goals will increase
unrealistic plans. Help him to set realistic failures and lower self-esteem
goals for himself. even more.
(e) Encourage client to view life after discharge Role rehearsal is helpful in returning
and identity aspects over which control is patient to the level of independent
possible. Through role play, practice how functioning. When the individual is
he will demonstrate that control. functioning well, sense of self-esteem is enhanced.
Nursing Diagnosis VI own actions.

Altered family processes related to euphoric - Objective: The family members will demonstrate
mood and grandiose ideas, manipulative coping ability in dealing with the patient.
behavior, refusal to accept responsibility for Intervention: See Table 7.13.
Table 7.13: Nursing interventions to improve family coping skills
(a) Determine individual situation and feelings Living with a family member having
of individual family members like guilt, bipolar illness fosters a multitude of
anger, powerlessness, despair and alienation. feelings and problems that can affect
interpersonal relationships and may
result in dysfunctional responses and
family disintegration.
(b) Assess patterns of communication. For Provides clues to the degree of
example: Are feelings expressed freely? problem being experienced by
who makes decisions? What is the individual family members and
interaction between family members? coping skills used tp handle the crisis.
(c) Determine patterns of behavior displayed These behaviors are typically used
by patient in his relationships with others, by the manic individual to manipulate
e.g. manipulation of self-esteem of others, others. The result is alienation, guilt,
limit testing, etc. ambivalence and high rates of divorce.
(d) Assess the role of patient in the family, like When the role of an ill person is not
provider etc, and how the illness affects filled family disintegration can occur.
the roles of other members.
(e) Provide information about behavior patterns Assists family to understand the various aspects of
and expected course of the illness. bipolar illness. This may relieve guilt and promote
family discussions of the problems and solutions.
Evaluation The patient's resources and effect on other

In this step, the nurse assesses if the goals of care people should be assessed. The patient's
are achieved. The plan may need to be revised or responsibilities in the care of dependent
modified in the light of this evaluation. children or at work should be considered
carefully.
Nursing Management for Hypomania
Interventions
Assessment
NURSING DIAGNOSIS I
Assessment includes judging the severity of the
Risk of injury related to inability to perceive
symptoms, forming an opinion about the causes,
potentially harmful situations evidenced by
assessing the patient's social resources, and
impulsive behavior.
gauging the effect of the disorder on other people.
In assessing the severity of symptoms, the Objective: To reduce risky behavior and avert
patient's capacity to work or engage in family injury.
life and social activities should be noted. This Intervention: See Table 7.14.
is important to prevent the patient from
causing himself long-term difficulties due to NURSING DIAGNOSIS II
ill-judged decisions and unjustified extra- Impaired social interaction related to short
vagance. attention span, high level of distractibility and
Usually the causes may be endogenous, but it labile mood, evidenced by insufficient or excessive
is important to identify any life events that quantity or ineffective quality of social exchange.
may have provoked the onset. Sometimes the
episode may follow physical illness, treatment Objective: Patient will demonstrate acceptable
by drugs (especially steroids), or surgical interaction with others.
operations. Intervention: See Table 7.15.
Table 7.14: Nursing interventions to reduce risky behaviour and avert injury among hypomanic patients
Talk with the client about safe and unsafe This provides the client with
behavior. clear expectations.
Assess the frequency and severity of It is necessary for baseline
accidents. data.
Provide supervision for potentially dangerous This is necessary, because the client's
situations. Limit the client's participation ability to perceive harmful conse-
in activities when safety cannot be ensured. quences of a behavior is impaired.
State expectations for behavior in clear The client may be unable to process
terms. social cues to guide reasonable
behavior choices.
Make correct feedback as specific as Specificfeedback will help the
possible. For example, "Do not jump down client understand expectations.
the stairs. Walk down one step at a time."
Set limits that are directly related to the The client will be better able to
undesirable behavior. Institute them as draw the correlation between
soon as possible after the occurrence of undesirable behavior and conse-
the behavior. Continuous supervision is quences if the two are related to
needed to prevent the patient from each other.
developing full-blown manic symptoms.
Table 7.15: Nursing interventions to improve social interaction among hypomanic patients
Identify the factors that aggravate and External stimuli that exacerbate
alleviate the client's performance. the client's problems can be
identified and minimized.
Provide an environment as free from The client's ability to deal with
distractions as possible. Gradually external stimulation is impaired.
increase the amount of environmental
stimuli.
Give instructions slowly, using simple The client's ability to comprehend
language and concrete directions. complex instructions is reduced.
Provide positive feedback for completion Positive feedback increases the
of each step of desirable activity /behavior. likelihood of desirable behavior.
Protect other clients from being drawn into Clients with hypomania have
the client's influence, especially those who manipulative behavior.
might be non-assertive or vulnerable.
NURSING DIAGNOSIS Ill Objective: Patient will demonstrate adequate

Ineffective coping skills related to poor impulse cognitive function.
control evidenced by acting out behavior. Intervention: See Table 7.17.
Objective: Patient will not harm self or others. EVALUATION

Intervention: See Table 7.16. In this step the nurse assesses if the goals of care
are achieved. The plan may need to be revised or
modified in the light of this evaluation.
NURSING DIAGNOSIS IV
Disturbed thought process related to disorien- Depressive Episode
tation and decreased concentration evidenced by Depression is a widespread mental health prob-
disruption in activities. lem affecting many people. The lifetime risk of
Table 7.16: Nursing interventions to increase self-control among hypomanic patients
State rules, expectations and responsibilities Clear expectations give the client
clearly to the client, including consequences limits to which his behavior must
for exceeding limits. conform, and what to expect if he
exceeds those limits.
Use time out when the client begins to lose Time out period is not a punishment
behavioral control. but an opportunity for the client to
regain control.
Encourage the client to verbalize his feelings. It is an initial step towards resolving
difficulties.
Teach the client a simple problem solving The client's ability to think, judge or
process : describe the-problem, list alter- solve problems is impaired.
natives, evaluate choices, and select and
implement an alternative.
Table 7.17: Nursing interventions to improve cognitive function in hypomanic patients
Use a firm yet calm, relaxed approach. The nurse's presence and manner
will help to communicate her interest.
Set and maintain limits on behavior Limits must be established by others
that is destructive or adversely affects when the client is unable to use
others. internal controls effectively.
Decrease environmental stimuli when- The client's ability to deal with
ever possible. Respond to cues of stimuli is impaired.
increased restlessness or agitation by
removing stimuli and perhaps isolating
the client, to single or private occupancy
room may be beneficial.
Provide a consistent structured environment. Consistency and structure can
Let the client know what is expected of him. reassure the client and foster
Set goals with the client as soon as possible. desirable behavior.
depression in males is 8 to 12%and in females it Depressed mood: Sadness of mood or loss of

is 20to 26%.Depression occurs twice as frequently interest and loss of pleasure in almost all activities
in women as in men. (pervasive sadness), present throughout the day
(persistent sadness).
Classification of Depression (ICD10)
Depressive cognitions: Hopelessness (a feeling of
Mild depression 'no hope in future' due to pessimism), help-
Moderate depression lessness (the patient feels that no help is possible),
Severe depression worthlessness (a feeling of inadequacy and
Severe depression with psychotic symptoms inferiority), unreasonable guilt and self-blame
over trivial matters in the past.
Clinical Features
Suicidal thoughts: Ideas of hopelessness are often
A typical depressive episode is characterized accompanied by the thought that life is no longer
by the following features, which should last worth living and that death had come as a
for at least two weeks in order to make a dia- welcome release. These gloomy preoccupations
gnosis: may progress to thoughts of and plans for suicide.
Psychomotor activity: Psychomotor retardation Electroconvulsive therapy (ECT)

is frequent. The retarded patient thinks, walks Severe depression with suicidal risk is the most
and acts slowly. Slowing of thought is reflected important indication for ECT (SeeChapter 14,pg
in the patient's speech; questions are often 182,).
answered after a long delay and in a monotonous
voice. In older patients agitation is common with Psychosocial Treatment
marked anxiety, restlessness and feelings of
uneasiness. Cognitive therapy: It aims at correcting the dep-
ressive negative cognitions like hopelessness,
Psychotic features: Some patients have delusions worthlessness, helplessness and pessimistic
and hallucinations (the disorder may then be ideas, and replacing them with new cognitive
termed as psychotic depression); these are often and behavioral responses.
mood congruent, i.e.they are related to depressive Supportive psychotherapy: Various techniques
themes and reflect the patient's dysphoric mood. are employed to support the patient. They are
For example, nihilistic delusions (beliefs about reassurance, ventilation, occupational the-
the non-existence of some person or thing), delu- rapy, relaxation and other activity therapies.
sions of guilt, delusions of poverty, etc. may be Group therapy: Group therapy is useful for
present. mild cases of depression. In group therapy
Some patients experience delusions and hallu- negative feelings such as anxiety anger, guilt,
cinations that are not clearly related to depressive despair are recognized and emotional growth
themes(mood incongruent), for example, delusion is improved through expression of their
of control. The prognosis then appears to be much feelings.
worse.
Family therapy: Family therapy is used to
Somatic symptoms of depression, according to decrease intrafamilial and interpersonal diffi-
ICDlO (these are called as 'melancholicfeatures' in culties and to reduce or modify stressors,
DSMIV): which may help in faster and more complete
Significant decrease in appetite or weight. recovery.
Early morning awakening, at least 2 or more Behavior therapy: It includes social skills train-
hours before the usual time of waking up. ing, problem solving techniques, assertiveness
Diurnal variation, with depression being training, self-control therapy, activity schedu-
worst in the morning. ling and decision making techniques.
Pervasive lack of interest and lack of reactivity
to pleasurable stimuli. Course and Prognosis of Mood Disorders
Psychomotor agitation or retardation.
An average manic episode lasts for 3-4 months,
while a depressive episode lasts for 4-9 months.
Other Features
Difficulties in thinking and concentration. Good Prognostic Factors
Subjectivepoor memory.
Abrupt or acute onset
Menstrual or sexual disturbances.
Vague physical symptoms such as fatigue, Severe depression
aching discomfort, constipation, etc. Typical clinical features
Well-adjusted premorbid personality
Treatment Good response to treatment
Pharmacotherapy
Poor Prognostic Factors
Antidepressants are the treatment of choice for a
Double depression
vast majority of depressive episodes (SeeChapter
Co-morbid physical disease, personality dis-
14, pg 175).
orders or alcohol dependence
Chronic ongoing stress Cyclothymia refers to a persistent instability in
Poor drug compliance mood in which there are numerous periods of
Marked hypochondriacal features or mood- mild elation or mild depression.
incongruent psychotic features Dysthymia (neurotic/ reactive depression) is a
chronic,mild depressive statepersisting formonths
OTHER MOOD DISORDERS or years. It is more common in females with an
averageageofonsetinlatethirddecade.Anepisode
Bipolar Mood Disorder
ofmajordepressionmaysometimes become super-
This is characterized by recurrent episodes of imposed on an underlying neurotic depression.
mania and depression in the same patient at This is known as 'double depression.'
different times. (see Table 7.18 for differences between somatic
Bipolarmood disorder is further classifiedinto and neurotic depression).
bipolar I and bipolar II disorder (DSMIV).
Bipolar I: Episodes of severe mania and severe Nursing Management of Major
depression. Depressive Episode
Bipolar II: Episodes of hypomania and severe
depression. Nursing Assessment
Nursing assessment should focus on judging the
Recurrent Depressive Disorder severity of the disorder including the risk of
This disorder is characterized by recurrent depres- suicide, identifying the possible causes, the social
sive episodes. The current episode is specified as resources available to the patient, and the effects
mild, moderate, severe, severe with psychotic of the disorder on other people. Although there is
symptoms. a risk of suicide in every depressed patient, the
risk is much more in the presence of the following
Persistent Mood Disorder factors:
(Cyclothymia and Dysthymia) Presence of marked helplessness
These disorders are characterized by persistent Male sex
mood symptoms that last for more than 2 years. More than 40 years of age
Table 7.18: Differences between somatic (major/endogenous depression/ melancholia)
and neurotic depression (reactive)
Endogenous Reactive
(a) Caused by factors within the Caused by stressful events.
individual.
(b) Premorbid personality: cyclothymic Premorbid personality:
or dysthymic. anxious, or obsessive.
(c) Early morning awakening Difficultyin falling asleep
(late insomnia). (early insomnia).
(d) Patient feels more sad in the morning. Patient feels more sad in the evening.
(e) Feels better when alone. Feels better when in a group.
(f) Psychotic features Iike psychomotor Usually psychomotor agitation
retardation, suicidal tendencies, delusions and no other psychotic
etc are common. features.
(g) Relapses are common. Relapses are uncommon.
(h) ECT and antidepressants are used Psychotherapy and
for management. antidepressants are used
for management.
(i) Insight is absent. Insight is present.
Unmarried, widowed or divorced self, evidenced by expression of worthlessness,

Written or verbal communication of suicidal sensitivity to criticism, negative and pessimistic
intent or plan outlook.
Early stages of depression
Recovery from depression(at the peak of Objective: Patient will be able to verbalize positive
depression the patient is usually either too aspects about self and attempt new activities
depressed or too retarded to commit suicide) without fear of failure.
Period of three months from recovery Intervention: See Table 7.22.
The nurse should routinely enquire about
Nursing Diagnosis V
the patient's work, finances, family life, social
activities, general living conditions and physical Altered communication process related to depres-
health. It is also important to consider whether sive cognitions, evidenced by being unable to
the patient could endanger other people, parti- interact with others, withdrawn, expressing fear
cularly if there are depressive delusions and the of failure or rejection.
patient may act on them. Objective: Patient will communicate or interact
with staff or other patients in the unit.
Nursing Diagnosis I
High risk of self-directed violence related to
depressed mood, feelings of worthlessness and Nursing Diagnosis VI
anger directed inward on the self.
Altered sleep and rest, related to depressed mood
Objective: Patient will not harm self. and depressive cognitions evidenced by difficulty
Intervention: See Table 7.19. in falling asleep, early morning awakening, verbal
complaints of not feeling well-rested.
Nursing Diagnsois II
Objective:Patient will sleep adequately during the
Dysfunctional grieving related to real or perceived night.
loss, bereavement, evidenced by denial of loss, Intervention: See Table 7.24.
inappropriate expression of anger, inability to
carry out activities of daily living. Nursing Diagnosis VII
Objective: Patient will be able to verbalize normal Altered nutrition, less than body requirements
behaviors associated with grieving. related to depressed mood, lack of appetite or
Intervention: See Table 7.20. lack of interest in food, evidenced by weight loss,
poor muscle tone, pale conjunctiva, poor skin
Nursing Diagnosis Ill turgor.
Powerlessness related to dysfunctional grieving
Objective:Patient's nutritional status will improve.
process, life-style of helplessness, evidenced by
feelings of lack of control over lifesituations, over-
dependence on others to fulfil needs.
Nursing Diagnosis VIII
Objective: The patient will be able to take control Self-care deficit related to depressed mood,
of life situations. feelings of worthlessness, evidenced by poor
Intervention: See Table 7.21. personal hygiene and grooming.
Nursing Diagnosis IV Objective:Patient will maintain adequate personal
Self-esteem disturbance related to learned help- hygiene.
lessness, impaired cognition, negative view of Intervention: See Table 7.26.
Table 7.19: Nursing interventions for suicidal behaviour
(a) Ask the patient directly "Have you thought The risk of suicide is greatly
about harming yourself in any way? If so, what increased if the patient has
do you plan to do? Do you have the means to developed a plan and if means
carry out this plan?" exist for the patient to execute the plan.
(b) Create a safe environment for the patient. Patient's safety is nursing priority.
Remove all potentially harmful objects from
patient's vicinity (sharp objects, straps, belts,
glass items, alcohol, etc.), supervise closely
during meals and medication administration.
(c) Formulate a short-term verbal or written A degree of the responsibility for his
contract that the patient will not harm self. safety is given to the patient.
Secure a promise that the patient will seek Increased feelings of self-worth may
out staff when feeling suicidal. be experienced when patient feels accepted
unconditionally regardless of behavior.
(d) It may be desirable to place the client near Patient's safety is nursing priority.
the nursing station. Do not leave the
patient alone. Observe for passive
suicide - the patient may starve or fall
asleep in the bath-tub or sink.
(e) Close observation is especially required At the peak of depression the patient
when the patient is recovering from the is usually too retarded to carry out
disease. his suicidal plans.
(f) Do not allow the patient to put the bolt on his Patient's safety is nursing priority.
side of the door of bathroom or toilet.
(g) If the patient suddenly becomes unusually -do-
happy or gives any other clues of suicide,
special observation may be necessary.
(h) Encourage the patient to express his feelings, Depression and suicidal behavior
including anger. may be viewed as anger turned inward on the
self. If the anger can be verbalized in a non-
threatening environment, the patient may be able
to eventually resolve these feelings.
Table 7.20: Nursing interventions for grief reaction

(a) Assess stage of fixation in grief process. Accurate baseline data is required to
plan accurate care.
(b) Be accepting of patient and spend time with These interventions provide the basis
him. Show empathy, care and for a therapeutic relationship.
unconditional, positive regard.
(c) Explore feelings of anger and help patient Until patient can recognize and
direct them towards the intended object or accept personal feelings regarding
person. the loss, grief work cannot progress.
(d) Provide simple activities which can be Physical activities are safe and an
easily and quickly accomplished. effective way of relieving anger.
Gradually increase the amount and
complexity of activities.
Table 7.21: Nursing interventions for over dependence behaviour

(a) Allow the patient to take decisions Providing patient with choices will
regarding own care. increase his feelings of control.
(b) Ensure that goals are realistic and that To avoid repeated failures which
patient is able to identify life further increase his sense of
situations that are realistically under his powerlessness.
control.
(c) Encourage the patient to verbalize feelings Verbalization of unresolved issues
about areas that are not in his ability to may help the patient to accept
control. what cannot be changed.
Table 7.22: Nursing interventions to improve self-esteem in depressed patients

(a) Be accepting of patient and spend time These interventions contribute
with him, even though pessimism and towards feeling of self-worth.
negativism may seem objectionable.
(b) Focus on strengths and accomplishments -do-
and minimize failures.
(c) Provide him with simple and easily
achievable activity. Encourage the patient Success and independence promote
to perform his activities without feelings of self-worth.
assistance.
(d) Encourage patient to recognize areas of To facilitate problem solving.
change and provide assistance toward this
effort.
(e) Teach assertiveness and coping skills. Their use can serve to enhance self-
esteem.
Table 7.23: Nursing interventions to improve communication skills in depressed patients

i Interventions Rationale
(a) Observe for non-verbal communication.
The patient may say that he is happy but To facilitate better response and
looks sad. Point out this discrepancy in communication.
what he is saying and actually feeling.
(b) Use short sentences. Ask questions
in such a way that the patient will have to -do-
answer in more than one word.
(c) Use silence appropriately without Using silence when the situation
communicating anxiety or discomfort demands can be therapeutic.
in doing so.
(d) Introduce the patient to another patient There is less anxiety in relating to a
who is quiet and possibly convalescing person other than staff.
from depression.
(f) As he improves, take him to other Group support is important in
patients and see that he is actually included facilitating communication.
as part of the group.
Table 7.24: Nursing interventions to improve sleeping pattern
Interoentions Rationale
(a) Plan daytime activities according to To improve sleep during night.

the patient's interests, do not allow
him to sit idle.
(b) Ensure a quiet and peaceful
environment when the patient
is preparing for sleep. -do-
(c) Provide comfort measures -do-
(back rub, tipid bath, warm milk, etc).
(d) Do not allow the patient to sleep for long -do-
time during the day.
(e) Give p.r.n. sedatives as prescribed. -do-
(f) Talk to the patient for a brief period Talking to the patient helps to
at bedtime. Do not enter into lengthy relieve his anxiety, but engaging in
conversations. long talks may increase depressive thinking .
Table 7.25: Nursing interventions to improve nutritional status in depressive patients

(a) Closely monitor the client's food and fluid These are useful data for
intake; maintain intake and assessing nutritional status.
output chart.
(b) Record patient's weight regularly. -do-
(c) Find out the likes and dislikes of the person before To encourage eating and
he was sick and serve the best preferred food. improve nutritional status.
(d) Serve small amounts of a light -do-
or liquid diet frequently that is nourishing.
(e) Record the client's pattern of bowel To assess for constipation.
elimination.
(h) Encourage more fluid intake, roughage For relief of constipation if
diet and green leafy vegetables. present.
Table 7.26: Nursing interventions to improve self-care for depressed patients

(a) Ensure that he takes his bath regularly. Depressive patient will not have any
interest for self-care and may need assistan,ce.
(b) Do not ask the patient's permission for a
wash or bath. For instance, do not ask
"Do you want to have a bath?" Instead Positive suggestions will usually
lead the patient to the action with positive enhance patient's cooperation.
suggestions, e.g. "The water is ready,
let me take you for a bath."
(c) When the patient has taken care of himself, Positive reinforcement will improve
express realistic appreciation. desirable behavior.
Evaluation Thought block (Apr 2004)

Evaluation is facilitated by using the following Neologism (Nov 2003, Apr 2004)
types of questions: Discuss the concepts of schizophrenia and
Has self-harm to the individual been avoided? identify predisposing factors in the deve-
Have suicidal ideations subsided? lopment of schizophrenia (Nov 2003)
Schizophrenia (Apr 2002, Apr 2004, Oct 2005)
Does patient set realistic goals for self?
Dynamics of schizophrenia (Feb 2002)
Is he able to verbalize positive aspects about
Types of schizophrenia (Feb 2000)
self, past accomplishments and future
Excited catatonia (Oct 2000)
prospects? Catatonic stupor (Nov 2002)
Clinical features of catatonic stupor (Oct 2000)
REVIEW QUESTIONS Nursing management of a patient with
Types of hallucinations (Feb 2000, Apr 2002) paranoid schizophrenia (Oct 2004)
Types of delusions (Feb 2000, Oct 2004) Withdrawn behavior (Nov 1999)
Mutism (Nov 2003) Aggressive behavior (Oct2000, Nov 2003, Oct
Echolalia (Oct 2000, Apr 2002) 2004, Apr 2006)
Echopraxia (Oct 2000) Mood disorders (Nov 2002, Nov 2003)
Ambivalence, anhedonia, nihilism, Clinical features of mania (Oct 2000,Apr 2004)
confabulation, circumstantiality, tangen- Triad of mania (Oct 2004)
tiality, clang associations, flight of ideas (Oct Nursing management of patient with mania
2000), poverty of thought, loosening of (Oct 2000, Nov 2003, Apr 2006)
Psychomotor retardation (Oct 2004)
association, perseveration, verbigeration,
Nursing management of patient with
formal thought disorder, thought alienation
depression (Feb 2001, Oct 2004, Apr 2006)
phenomena, deja vu, jamais vu.
Cyclothymia-dysthymia
Pseudo hallucinations (Oct 2006) Differences between endogenous and reactive
Pressure of thought (Oct 2000, Oct 2006) depression
Disorders of thought (Nov 2003) Hypomania
Apathy (Nov 2003) Endogenous depression (Nov 2003,Apr 2006)
Organic Mental Disorders
0 CLASSIFICATIONOF ORGANICMENTAL 0.1percent in those below 60years of age to 15to
DISORDERS 20 percent in those who are 80 years of age.
0 DEMENTIA
0 DELIRIUM
0 ORGANICAMNESTICSYNDROME
Etiology
0 MENTALDISORDERSDUETO BRAINDAMAGE, Untreatable and irreversible causes:
DYSFUNCTIONAND PHYSICALDISEASE Degenerating disorders of CNS
0 PERSONALITYAND BEHAVIORALDISORDERS
DUETO BRAIN DISEASE,DAMAGEAND Alzheimer's disease (this is the most
DYSFUNCTION common of all dementing illnesses)
Pick's disease
Organic mental disorders are behavioral or psy-
Huntington's chorea
chological disorders associated with transient or
Parkinson's disease
permanent brain dysfunction. These disorders
have a demonstrable and independently diagno- Treatable and reversible causes:
sable cerebral disease or disorder. They are Vascular-multi-infarct dementia
classified under Fo in ICDlO. Intracranial space occupying lesions
Metabolic disorders-hepatic failure, renal
CLASSIFICATION OF ORGANIC MENTAL failure
DISORDERS Endocrine disorders-myxedema, Addison's
Dementia disease
Delirium Infections-AIDS, meningitis, encephalitis
Organic amnestic syndrome Intoxication-alcohol, heavy metals (lead,
Mental disorders due to brain damage, arsenic), chronic barbiturate poisoning
dysfunction and physical disease Anoxia-anemia, post-anesthesia, chronic
Personality and behavioral disorders due to respiratory failure
brain disease, damage and dysfunction Vitamin deficiency, especially deficiency of
thiamine, and nicotine
DEMENTIA (CHRONIC ORGANIC BRAIN Miscellaneous-heatstroke, epilepsy, electric
SYNDROME) injury
Dementia is an acquired global impairment of
Stages of Dementia
intellect, memory and personality but without
impairment of consciousness. Stage I: Early stage (2 to 4 years)
Forgetfulness
Incidence Declining interest in environment
Dementia occurs more commonly in the elderly Hesitancy in initiating actions
than in the middle-aged. It increaseswith age from Poor performance at work
Organic Mental Disorders 105
Stage II: Middle stage (2 to 12 years) Course and Prognosis
Progressive memory loss Insidious onset but slow progressive deterioration
Hesitates in response to questions occurs.
Has difficulty in following simple instructions
Irritable, anxious Treatment
Wandering
Until now no specificmedicine is available to treat
Neglects personal hygiene
Alzheimer's disease. A drug called 'Tacrine' is
Social isolation
being used in western countries. Tacrine (Tetra
Stage III: Final stage (up to a year). hydro amino acridine) is a long-acting inhibitor
Marked loss of weight because of inadequate of acetylcholine and also delays the progression
intake of food of the illness.
Unable to communicate The following drugs may be of some use in
Does not recognize family causing symptomatic relief:
Incontinence of urine and feces benzodiazepines for insomnia and anxiety
Loses the ability to stand and walk antidepressants for depression
Death is usually caused by aspiration antipsychotics to alleviate hallucinations and
pneumonia delusions
anticonvulsants to control seizures
Clinical Features (for Alzheimer's Type) Nursing care for patients of Alzheimer's
Personality changes: lack of interest in day- disease is most important. Whether at home, in
to-day activities,easy mental fatiguability,self- an acute hospital environment, a day-care center
centered, withdrawn, decreased self-care or in a long-term stay institution. Care givers must
Memory impairment: recent memory is pro- be trained to promote the patient's remaining
minently affected intellectual abilities; help them maintain their
Cognitive impairment: disorientation, poor independence in attending to their usual
judgment, difficulty in abstraction, decreased functions and avoid injuries; and provide for a
attention span good quality of life.
Affective impairment: labile mood, irritable-
ness, depression Nursing Interventions
Behavioralimpairment: stereotyped behavior,
Daily Routine
alteration in sexual drives and activities,
neurotic/psychotic behavior Maintaining a daily routine includes drawing up
Neurological impairment: aphasia, apraxia, a fixed timetable for the patient for waking up in
agnosia, seizures, headache the morning, toilet, exerciseand meals. This gives
Catastrophic reaction: agitation, attempt to the patient a sense of security.
compensate for defects by using strategies to Patients often deteriorate after dark, a pheno-
avoid demonstrating failures in intellectual menon known as 'sun downing'. Additional care
performances, such as changing the subject, must be taken during the evening and at night.
cracking jokes or otherwise diverting the Orient the patient to reality in order to decrease
interviewer confusion; clockwith large faces aid in orientation
Sundowner syndrome: It is characterized by to time. Use calendar with large writing and a
drowsiness, confusion, ataxia; accidental falls separate page for each day. Provide newspapers
may occur at night when external stimuli such which stimulate interest in current events.
as light and interpersonal orienting cues are Orientation of place, person and time should be
diminished given before approaching the patient.
Nutrition and Body Weight established in healthy years must be maintained

Patient should be provided a well-balanced diet, as long as possible by gently persuading the
rich in protein, high in fiber, with adequate patient to go to the toilet and use it. When the first
amount of calories.Allow plenty of time for meals. sign of incontinence appears doctor should check
Tell the patient which meal it is and what is there for an underlying cause if any, such as urinary
to eat; food served should be neither too hot nor infection or urinary tract damage.
too cold. Many patients have sugar craving. Care Constipation is a frequent cause of discomfort
should be taken that such patients do not gain to the patient. The quantity of faeces passed each
weight. The diet should take into account other morning should be checked to ensure that the
medical illnesses which require diet modification, patient is not constipated. Constipation can be
such as diabetes or high blood pressure. Semi- avoided by adding fiber supplements and
solid diet is the safest while liquids are the most roughage to the diet on a daily basis.
dangerous as these can be easily aspirated into
Accidents
the lungs.
Great care should be taken to avoid accidents
Personal Hygiene caused by tripping over furniture, falling down
Particular care should be taken about the patient's the stairs or slipping in the bathroom. The reasons
personal hygiene including brushing of teeth, for falling include loose and poorly fitting
bathing, keeping the skin clean and dry, footwear and wrinkled carpets. Ideally, patients
particularly in areas prone to perspiration, such should be made to wear soft slip-on shoes with
as the armpits and groin. Caustic substances such straps which fit securely. Any floor covering must
as spirit or antiseptic solutions should not be used be firmly secured.
routinely on the skin. Remember to check finger Older people have been driving for years and
and toe nails regularly, cut them if the person in modem cities many people are dependent on
cannot do it by himself. their personal cars for transportation. Once early
People with dementia may have problem with signs of the disease appear, patients should be
the lock on the bathroom door; if this happens it gently persuaded to stop driving as this can pose
is advisable to remove the lock. Compliment the a hazard to them and others.
patient when he/ she looks good. Make sure that lights are bright enough. Keep
matches, bleach, and paints out of reach. Do not
Toilet Habits and Incontinence allow the patient to take medication alone.
Toilet habits should be established as soon as
possible and maintained as a rigid routine. This Fluid Management
includes conditioned behavior such as going for The patients require as much fluid as normal
bowel movement immediately after a cup of tea. people and this depends on the season. Ideally,
The patient should be taken to urinate at fixed sufficient fluid should be given during the day
interval, depending on the season and amount of and only the minimum essential amount of fluid
fluid intake. Prostate trouble common in elderly (some water with dinner) after 6 pm. The last cup
men leads to discomfort as it causes urgency and of tea should be given around 5 pm. After that no
frequency of urination particularly in winters. A beverages including tea, coffee,cocoa or any other
doctor should check this. caffeine containing drinks should be given, as all
Incontinence is very distressing to the patient these promote urination. Proper fluid management
and family. Once incontinence sets in, the under- will reduce bed-wetting and also reduce the
garments, pants of the patient and the house in number of times the patient will need to get up
general start reeking of foul smell. Toilet habits, during the night.
Moods and Emotions Interpersonal Relationship

Some patients of Alzheimer's disease have abrupt Verbal communication should be clear and
change in their moods and emotions. These unhurried. Questions that require 'yes', or 'no'
changes can be unpredictable. Mood changes are answers are best. Reinforce socially acceptable
best controlled by keeping a calm environment skills. Give necessary information repeatedly.
with fixed daily routine. The patients should not Focus on things the person does well rather than
be questioned repeatedly or given too many on mistakes or failures. Try to make sure that each
choices, such as what they want to eat or what day has some thing of interest for the patient- it
they want to wear. Mood changes are also might be going for a walk, listening to music; talk
about the day's activities. Try to involve him with
amenable to distraction, particularly if topics
old friends for a chat, reminiscing about the past.
related to the past are discussed or favorite pieces
Family members should be aware of early
of music played. For example, if music that
warning signs which may suggest that one of the
reminds the patients of their childhood is played,
older members may be on the verge of developing
the pleasant associations put them in a nostalgic Alzheimer's disease. Early diagnosis and early
mood. If patient behavior and emotions are intervention can be beneficial both to the patient
distressing to the family members the doctor may and the family.
prescribe some medications to calm the patient. As the disease progresses, the family remains
the main pillar of support for the patient.
Wandering Alzheimer's associations around the world
Patients of Alzheimer's disease often lose their provide practical and emotional help and
geographic orientation and can get lost even in information to families, health care professionals
familiar surroundings. They may be found and the community. Alzheimer's and Related
wandering aimlessly either in the neighborhood Disorders Societyof India (ARDSI)started in 1992,
or far away. It is advisable to have some identi- a national organization dedicated to dementia
fication bracelet or card always in their posses- care, support and research.
sion. The doors of the house should be securely
DELIRIUM (ACUTE ORGANIC BRAIN
locked so that the patients cannot leave unnoticed.
SYNDROME) It:
The patient should always be accompanied while
going for walks or for simple chores outside the Delirium is an acute organic mental disorder
house. characterized by impairment of consciousness,
disorientation and disturbances in perception
Disturbed Sleep
and restlessness.
Sleep disturbances are extremely distressing to Incidence

the family. If the patient is restless at night or Delirium has the highest incidence among
wanders and talks at night, the entire family is organic mental disorders. About 10 to 25%
disturbed. Sleep patterns must be maintained. of medical-surgical inpatients, and about 20 to
Napping during the day should be avoided. 40% of geriatric patients meet the criteria for
Sleeping pills are best avoided as their effect is delirium during hospitalization. This percentage
temporary and frequently unpredictable in is higher in post-operative patients.
patients of Alzheimer's disease. Causes of
discomfort at night, such as pain, uncomfortable Etiology
temperature or prostate trouble, should be Vascular: hypertensive encephalopathy, cere-
checked. bral arteriosclerosis, intracranial hemorrhage
Infections: encephalitis, meningitis Treatment
Neoplastic: space occupying lesions Identification of cause and its immediate
Intoxication: chronic intoxication or with- correction, e.g., 50 mg of 50% dextrose IV for
drawal effect of sedative-hypnotic drugs hypoglycemia, 02for hypoxia, 100mg ofB1 IV
Traumatic: subdural and epidural hematoma, for thiamine deficiency, IV fluids for fluid and
contusion, laceration, post-operative, heat- electrolyte imbalance.
stroke Symptomatic measures: benzodiazepines (10
Vitamin deficiency, e.g. thiamine mg diazepam or 2 mg lorazepam IV) or
Endocrine and metabolic: diabetic coma and antipsychotics (5 mg haloparidol or 50 mg
shock, uremia, myxedema, hyperthyroidism, chlorpromazine IM) may be given.
hepatic failure
Metals: heavy metals (lead, manganese,' mer- Nursing Intervention
cury), carbon monoxide and toxins
Anoxia: anemia, pulmonary or cardiac failure
1. Providing safe environment:
restrict environmental stimuli, keep unit
Clinical Features
calm and well-illuminated
there should always be somebody at the
Impairment of consciousness: clouding of patient's bedside reassuring and sup-
consciousness ranging from drowsiness to porting
stupor and coma. as the patient is responding to a terrifying
Impairment of attention: difficulty in shifting, unrealistic world of hallucinatory illusions
focusing and sustaining attention. and delusions, special precautions are
Perceptual disturbances: illusions and hallu- needed to protect him from himself and to
cinations, most often visual. protect others
Disturbance of cognition: impairment of 2. Alleviating patient's fear and anxiety:
abstract thinking and comprehension, impair- remove any object in the room that seems
ment of immediate and recent memory, to be a source of misinterpreted perception
increased reaction time. as much as possible have the same person
Psychomotor disturbance: hypo or hyper- all the time by the patient's bedside
activity, aimless groping or picking at the bed keep the room well lighted especially at
clothes (flocculation), enhanced startle night
reaction. 3. Meeting the physical needs of the patient:
Disturbance of the sleep-wake cycle:insomnia appropriate care should be provided after
or in severe cases total sleep loss or reversal physical assessment
of sleep-wake cycle, daytime drowsiness, use appropriate nursing measures to
nocturnal worsening of symptoms, disturbing reduce high fever, if present
dreams or nightmares, which may continue maintain intake and output chart
as hallucinations after awakening. mouth and skin should be taken care of
Emotional disturbances: depression, anxiety, monitor vital signs
fear, irritability, euphoria, apathy or wonder- observe the patient for any extreme
ing perplexity. drowsiness and sleep as this may be an
indication that the patient is slipping into
Course and Prognosis a coma
The onset is usually abrupt. The duration of 4. Facilitateorientation:
an episode is usually brief , lasting for about a repeatedly explain to the patient where he
week is and what date, day and time it is
introduce people with name even if the Systemic diseases: Hypothyroidism, Cushing's
patient misidentifies the people disease, hypoxia, hypoglycemia, systemic lupus
have a calendar in the room and tell him erythematosis and extracranial neoplasms.
what day it is
when the acute stage is over take the patient Drugs: Steroids, antihypertensives, antimalarials,
out and introduce him to others alcohol and psychoactive substances.
The following mental disorders come under
ORGANIC AMNESTIC SYNDROME this category:
Organic amnestic syndrome is characterized by Organic hallucinosis
impairment of memory and global intellectual Organic catatonic disorder
functioning due to an underlying organic cause. Organic delusional disorder
There is no disturbance of consciousness. Organic mood disorder
Organic anxiety disorder.
Etiology
Thiamine deficiency, the most common cause PERSONALITY AND BEHAVIORAL
being chronic alcoholism. It is also called as DISORDERS DUE TO BRAIN DISEASE,
"Wernicke-Korsakoff syndrome." Wernicke's DAMAGE AND DYSFUNCTION
encephalopathy is an acute phase of delirium These disorders are characterized by significant
preceding amnestic syndrome, while Korsa- alteration of the premorbid personality due to
koff's syndrome is a chronic phase of amnestic underlying organic cause. There is no disturbance
syndrome. of consciousness and global intellectual function.
Head trauma The personality change may be characterized by
Bilateral temporal lobectomy emotional lability, poor impulse control, apathy,
Hypoxia hostility or accentuation of earlier personality
Brain tumors traits.
Herpes simplex encephalitis
Stroke.
Etiology
Clinical Features Complex partial seizures (temporal lobe

seizures)
Recent memory impairment
Cerebral neoplasms
Anterograde and retrograde amnesia
There is no impairment of immediate memory Cerebrovascular disease
Head injury.
Management
Treatment for underlying cause. Management
Treatment for the underlying cause.
MENTAL DISORDERS DUE TO BRAIN Symptomatic treatment with lithium, carba-
DAMAGE, DYSFUNCTION AND PHYSICAL mazepine or with antipsychotics.
DISEASE
These are mental disorders, which are causally REVIEW QUESTIONS
related to brain dysfunction due to primary cere- Classification of organic mental disorders
bral disease, systemic disease or toxic substances. Dementia (Feb 2000,Feb 2001,Nov 2001,Apr
Primary cerebral diseases: Epilepsy, encephalitis, 2002,Nov 2003,Oct 2004,Oct 2005,Oct 2006)
head trauma, brain neoplasms, vascular cerebral Delirium (Oct 2004)
disease and cerebral malformations. Amnestic syndrome
The Individual with
Neurotic Disorder
0 DIFFERENCESBETWEENPSYCHOTICAND either excessiveor prolonged emotional reaction
NEUROTICDISORDERS to any given stress. These disorders are not
0 CLASSIFICATION
caused by organic disease of the brain and,
0 PHOBICANXIETYDISORDER
0 GENERALIZEDANXIETYDISORDER however severe, do not involve hallucinations
0 PANICDISORDER and delusions. They are classified under F4 in
0 OBSESSIVE-COMPULSIVEDISORDER(OCD)
0 REACTIONTO STRESSANDADJUSTMENT
ICDlO.
DISORDER For differences between psychotic and
0 DISSOCIATIVEDISORDERS neurotic disorder SeeTable 9.1.
0 SOMATOFORMDISORDERS
Neurotic disorder (neurosis) is a less severe form CLASSIFICATION [ICD1 O]

of psychiatric disorder where patients show Phobic anxiety disorder
Table 9.1: Differences between psychotic disorder (psychosis) and neurotic disorder (neurosis)
Psychotic disorder Neurotic disorder
Etiology
Genetic factors more important less important
Stressful life events less important more important
Clinicalfeatures
Disturbances of thinking common rare
and perception
Disturbances in cognitive common rare
function
Behavior markedly affected not affected
Judgment impaired intact
Insight lost present
Reality testing lost present
Treatment
Drugs major tranquil- minor tranquilizers
izers commonly used and anti-depressants are
commonly used
ECT very useful not useful
Psychotherapy not much useful very useful;
Prognosis difficult to treat; relatively easy to treat;
relapses are relapses are
common; uncommon;
complete recovery complete recovery is
may not be possible possible
The Individual with Neurotic Disorder 111
Other anxiety disorders Examples of some specific phobias:

Obsessive-compulsive disorder Acrophobia-fear of heights
Reaction to severe stress and adjustment Hematophobia-fear of the sight of blood
disorders Claustrophobia-fear of closed spaces
Dissociative (conversion) disorders Gamophobia-fear of marriage
Somatoform disorder Insectophobia-fear of insects
Other neurotic disorders AIDSphobia-fear of AIDS
Social phobia Social phobia is an irrational fear
PHOBIC ANXIETY DISORDER
of performing activities in the presence of other
Anxiety is a normal phenomenon, which is people or interacting with others. The patient is
characterized by a state of apprehension or afraid of his own actions being viewed by others
uneasiness arising out of anticipation of danger. critically, resulting in embarrassment or humilia-
Normal anxiety becomes pathological when it tion.
causes significant subject distress and impair-
ment of functioning of the individual. Agoraphobia It is characterized by an irrational
Anxiety disorders are abnormal states in fear of being in places away from the familiar
which the most striking features are mental and setting of home, in crowds, or in situations that
the patient cannot leave easily.
physical symptoms of anxiety, which are not
As the agoraphobia increases in severity, there
caused by organic brain disease or any other
is a gradual restriction in normal day-to-day
psychiatric disorder.
activities. The activity may become so severely
A phobia is an unreasonable fear of a specific
restricted that the person becomes self-imprisoned
object, activity or situation. This irrational fear is
at home.
characterized by the followingfeatures: In all the above mentioned phobias, the indi-
It is disproportionate to the circumstances that vidual experiences the same core symptoms as in
precipitate it. generalized anxiety disorders. These are listed
It cannot be dealt with by reasoning or on page 114.
controlled through will power.
The individual avoids the feared object or Etiology
situation.
In phobic anxiety disorders, the individual
Psychodynamic theory According to this theory,
anxiety is usually dealt with repression. When
experiences intermittent anxiety which arises in
repression fails to function adequately, other
particular circumstances, i.e. in response to the
secondary defense mechanisms of ego come into
phobic object or situation.
action. In phobia, this secondary defence mecha-
nism is displacement. By displacement anxiety is
Types of Phobia
transferred from a really dangerous or frightening
Simple phobia object to a neutral object. These two objects are
Social phobia connected by symbolic associations. The neutral
Agoraphobia object chosen unconsciously is the one that can
be easily avoided in day-to-day activities, in
Simple phobia (Specific phobia) Simple phobia is
contrast to the frightening object.
an irrational fear of a specific object or stimulus.
Simple phobias are common in childhood. By Learning theory According to classical condi-
early teenage most of these fears are lost, but a tioning a stressful stimulus produces an
few persist till adult life. Sometimes they may unconditioned response - fear. When the stressful
reappear after a symptom-free period. Exposure stimulus is repeatedly paired with a harmless
to the phobic object often results in panic attacks. object, eventually the harmless object alone
produces the fear, which is now a conditioned Antidepressants (e.g. imipramine, sertraline,
response. If the person avoids the harmless object phenelzine)
to avoid fear, the fear becomes a phobia.
Behavior therapy
Cognitive theory Anxiety is the product of faulty Flooding
cognitions or anxiety-inducing self-instructions. Systematic desensitization
Cognitive theorists believe that some individuals Exposure and response prevention
engage in negative and irrational thinking that Relaxation techniques
produce anxiety reactions. The individual begins
to seek out avoidance behaviors to prevent the Cognitive therapy
This therapy is used to break the anxiety patterns
anxiety reactions and phobias result.
in phobic disorders.
Course Psychotherapy Supportive psychotherapy is a
The phobias are more common in women with helpful adjunct to behavior therapy and drug
an onset in late second decade or early third treatment.
decade. Onset is sudden without any cause. The (ReferChapter 14 for details of these therapies)
course is usually chronic. Sometimes phobias are
spontaneous remitting. Nursing Management
Treatment Nursing Assessment

Pharmacotherapy Assessment parameters focus on physical symp-
Benzodiazepines (e.g. alprazolam, clonaze- toms, precipitating factors, avoidance behavior
pam, lorazepam, diazepam) associated with phobia, impact of anxiety on
Table 9.2: Nursing interventions to reduce anxious behaviour
(a) Reassurethe patient that he is safe. At the panic levelof anxietypatient

may fear for his own life.
(b) Explorepatient's perceptionof the It is important to understand
threat to physicalintegrity or threat to patient's perceptionof the phobic
selfconcept. objector situation to assistwith
the desensitizationprocess.
(c) Includepatient in makingdecisions Allowingthe patient to choose
related to selectionof alternativecoping provides a measure of controland
strategies(e.g.patient may choose servesto increasefeelingsof self-
either to avoid the phobicstimulus or worth.
attempt to eliminatethe fear associated
with it.)
(d) If the patient electsto work on eliminating Fear decreasesas the physicaland
the fear, techniquesof desensitization psychologicalsensationsdiminish
or implosiontherapy may be employed. in responseto repeated exposureto
the phobicstimulus under non-
threatening conditions.
(e) Encouragepatient to exploreunderlying Facingthese feelingsrather than
feelingsthat may be contributingto suppressing them may result in more
irrational fears. adaptivecopingabilities.
The Individual with Neurotic Disorder 11 3
Table 9.3: Nursing interventions to reduce social isolation behaviour in anxious patients
(a) Convey an accepting attitude and These interventions increase feelings
unconditional positive regard. Make brief, of self-worth and facilitate a
frequent contacts. Be honest and keep all trusting relationship.
promises.
(b) Attend group activities with the patient that The presence of a trusted individual
may be frightening for him. provides emotional security.
(c) Administer anti-anxiety medications as Anti-anxiety medications help to
ordered by the physician, monitor for reduce the level of anxiety in most
effectivenessand adverse affects. individuals, thereby facilitating
interactions with others.
(d) Discuss with the patient signs and symptoms Maladaptive behavior such as
of increasing anxiety and techniques to withdrawal and suspiciousness
interrupt the response.(e.g. relaxation are manifested during times of
exercises,thought stopping) increased anxiety.
(e) Give recognition and positive reinforcement To enhance self-esteem
for voluntary interactions with others. encourage repetition of acceptable
behaviors.
physical functioning, normal coping ability, achieving the objectives of care. Following
thought content and social support systems. questions are helpful in evaluation:
Does the patient face phobic object/ situation
Nursing Diagnosis I without anxiety?
Fear related to a specific stimulus (simple phobia), Does the patient voluntarily participate in
or causing embarrassment to self in front of others, group activities?
evidenced by behavior directed towards Is the patient able to demonstrate techniques
avoidance of the feared object/ situation. that he may use to prevent anxiety from
escalating to the panic level?
Objective: Patient will be able to function in the
presence of a phobic object or situation without GENERALIZED ANXIETY DISORDER
experiencing panic anxiety. Generalized anxiety disorders are those in which
Intervention: See Table 9.2. anxiety is unvarying and persistent (unlike phobic
anxiety disorders where anxiety is intermittent
Nursing Diagnosis II and occurs only in the presence of a particular
Social isolation related to fear of being in a place stimulus). It is the most common neurotic disorder,
from which one is unable to escape, evidenced by and it occurs more frequently in women. The
staying alone, refusing to leave the room/home. prevalence rate of generalized anxiety disorders
is about 2.5-8%.
Objective: Patient will voluntarily participate in
group activities with peers. Clinical Features
Intervention: See Table 9.3. Generalized anxiety disorder (GAD) is manifested
by the following signs of motor tension, auto-
Evaluation
nomic hyperactivity, apprehension and vigilence,
Reassessment is conducted to determine if the which should last for at least 6 months in order to
nursing interventions have been successful in make a diagnosis:
Psychological: Fearful anticipation, irritability, Depersonalization or derealization
sensitivity to noise, restlessness, poor concen- Numbness or tingling sensations
tration, worrying thoughts and apprehension. Flushes or chills
Trembling or shaking
Physical:
Fear of dying
Gastrointestinal-dry mouth, difficulty in
Fear of going crazy or doing something
swallowing, epigastric discomfort, frequent or
uncontrolled
loose motions
Respiratory=-constriction in the chest,
Course
difficulty inhaling, overbreathing
Cardiovascular-palpitations, discomfort in The onset is usually in early third decade with
chest often a chronic course. It occurs recurrently every
Genitourinary-frequency or urgent mic- few days. The episode is usually sudden in onset
turition, failure of erection, menstrual dis- and lasts for a few minutes.
comfort, amenorrhea
Neuromuscular system-tremor, prickling Etiology of Anxiety Disorders (both GAD and
sensations, tinnitus, dizziness, headache, panic disorder)
aching muscles Genetic theory: Anxiety disorder is most
Sleep disturbances-insomnia, night terror frequent among relatives of patients with this
Other symptoms: depression, obsessions, condition. About 15to 20%of the first-degree
depersonalization, derealization relatives of patients with anxiety disorder
exhibit anxiety disorders themselves. The
Course concordance rate in monozygotic twins of
It is characterized by an insidious onset in the patients with panic disorder is 80 percent.
third decade and usually runs a chronic course. Biochemical factors: Alteration in GABA levels
may lead to production of clinical anxiety.
PANIC DISORDER Psychodynamic theory: According to this theory
Panic disorder is characterized by anxiety, which anxiety is usually dealt with repression. When
is intermittent and unrelated to particular repression fails to function adequately, other
circumstances (unlike phobic anxiety disorders secondary defense mechanisms of ego come
where, though anxiety is intermittent, it occurs into action. In anxiety repression fails to
only in particular situations). The central feature function adequately and the secondary
is the occurrence of panic attacks, i.e. sudden defense mechanisms are not activated. Hence
attacks of anxiety in which physical symptoms anxiety comes to the forefront.
predominate and are accompanied by fear of a Behavioral theory: Anxiety is viewed as an
serious consequence such as a heart attack. The unconditional inherent response of the
lifetime prevalence of panic disorder is 1.5 to 2 organism to a painful stimulus.
percent. It is seen 2 to 3 times more often in females. Cognitive theory: According to this theory
anxiety is related to cognitive distortions and
Clinical Features negative automatic thoughts.
Shortness ofbreath and smothering sensations
Choking, chest discomfort or pain Treatment
Palpitations Pharmacotherapy
Sweating, dizziness, unsteady feelings or Benzodiazepines (e.g. alprazolam, clonaze-
faintness pam)
Nausea or abdominal discomfort Antidepressants for panic disorder
Betablockers to control severe palpitations autonomic nervous system stimulation. Specific

that have not responded to anxiolytics (e.g. symptoms should be noted, along with statements
propranolol) made by the client about subjective distress. The
nurse must use clinical judgment to determine
Behavioral therapies
the level of anxiety being experienced by the client.
Bio-feedback
Hyperventilation control
Nursing Diagnosis I
Other psychological therapies Panic anxiety related to real or perceived threat to
Jacobson's progressive muscle relaxation biological integrity or self-concept, evidenced by
technique, yoga, pranayama, meditation and various physical and psychological manifes-
self-hypnosis tations.
Supportive psychotherapy
Objective: Patient will be able to recognize symp-
Nursing Management toms of onset on anxiety and intervene before
reaching panic level.
Nursing Assessment Intervention: SeeTable 9.4.
Assessment should focus on collectionof physical,
psychological and social data. The nurse should Nursing Diagnosis II
be particularly aware of the fact that major Powerlessness related to impaired cognition,
physical symptoms are often associated with evidenced by verbal expression of lack of control
Table 9.4: Nursing interventions to reduce panic anxiety

(a) Stay with the patient and offer reassurance Presence of trusted individual
of safety and security. provides feeling of security and
assurance of personal safety.
(b) Maintain a calm, non-threatening matter- Anxiety is contagious and may be
of-fact approach. transferred from staff to patient or
vice-versa.
(c) Use simple words and brief messages, In an intensely anxious situation,
spoken calmly and clearly to explain patient is unable to comprehend
hospital experiences. anything but the most elementary
communication.
(d) Keep immediate surroundings low in A stimulating environment may
stimuli (dim lighting, few people). increase of anxiety level.
(e) Administer tranquilizing medication Anti-anxiety medication provides
as prescribed by physician. Assess for relief from the immobilizing effects
effectiveness and for side-effects. of anxiety.
(f) When level of anxiety has been reduced, Recognition of precipitating factors
explore possible reasons for occurrence. is the first step in teaching patient to
interrupt escalating anxiety.
(g) Teach signs and symptoms of escalating The first three of these activities
anxiety and ways to interrupt its progression result in physiologic response
(relaxation techniques, deep-breathing opposite of the anxiety response,
exercises and meditation, or physical i.e. a sense of calm, slowed heart
exercise like brisk walks and jogging. rate, etc. The latter activities
discharge energy in a healthy manner.
Table 9.5: Nursing interventions to improve self-control in anxious patients
(a) Allow patient to take as much Providingchoiceswillincrease

responsibilityas possiblefor self-care patient's feelingof control.
activities,provide positivefeedback
for decisionsmade.
(b) Assistpatient to set realisticgoals. Unrealisticgoalsset the patient
up for failureand reinforcefeelings
of powerlessness.
(c) Help identifylifesituationsthat are Patient'semotionalcondition
within patient's control. interfereswith the abilityto solve
problems.
(d) Help patient identifyareas of lifesituation Assistanceis required to perceivethe
that are not within his abilityto control. benefitsand consequencesof
Encourageverbalizationof feelingsrelated availablealternativesaccurately,to
to this inability. dealwith unresolvedissuesand
accept what cannotbe changed.
over life situations and non-participation in ruminate on an abstract topic. Unwanted

decision-making related to own care or significant thoughts, which include the insistency of words
life issues. or ideas are perceived by the patient to be
inappropriate or nonsensical. The obsessional
Objective: Patient will be able to effectively solve urge or idea is recognized as alien to the
problems and take control of his life. personality, but as coming from within the self.
Intervention: See Table 9.5. Obsessional rituals are designed to relieve
anxiety, e.g. washing the hands to deal with
Evaluation contamination. Attempts to dispel the unwelcome
Identified objectives serve as the basis for eva- thoughts or urges may lead to a severe inner
luation. In general, evaluation of objectives for struggle, with intense anxiety."
clients with anxiety disorders deals with From the above, obsessions and compulsions
questions such as the following: should have the following characteristics:
Is the client experiencing a reduced level of They are ideas, impulses or images, which
anxiety? intrude into conscious awareness repeatedly.
Does the clientrecognizesymptoms as anxiety- They are recognized as the individual's own
related? thoughts or impulses.
Is the client able to use newly learned beha- They are unpleasant and recognized as
vior to manage anxiety? irrational.
Patient tries to resist them but is unable to.
OBSESSIVE-COMPULSIVE DISORDER (OCD) Failure to resist leads to marked distress.
Rituals (compulsions) are performed with a
Definition sense of subjective compulsion (urge to act).
According to ICD9, obsessive-compulsive dis- They are aimed at either preventing or
order is a state in which "the outstanding neutralizing the distress or fear arising out of
symptom is a feeling of subjective compulsion - obsessions.
which must be resisted - to carry out some action, The disorder may begin in childhood, but
to dwell on an idea, to recall an experience, or more often begins in adolescence or early
adulthood. It is equally common among men and acts and they become stable learned behavior. This
women. The course is usually chronic. theory is more useful for treatment purposes.
Classification (ICD10) Clinical Picture

OCD with predominantly obsessive thoughts Obsessional thoughts These are words, ideas and
or ruminations. , beliefs that intrude forcibly into the patient's
OCD with predominantly compulsive acts. mind. They are usually unpleasant and shocking
OCD with mixed obsessional thoughts and to the patient and may be obscene or
acts. blasphemous.
Etiology Obsessional images These are vividly imagined

scenes, often of a violent or disgusting kind
Genetic Factors involving abnormal sexual practices.
Twin studies have consistently found a signifi-
Obsessional ruminations These involve internal
cantly higher concordance rate for monozygotic
debates in which arguments for and against even
twins than for dizygotic twins. Family studies of
the simplest everyday actions are reviewed
these patients have shown that 35% of the first-
endlessly.
degree relatives of obsessive-compulsive disorder
patients are also affected with the disorder. Obsessionaldoubts These may concern actions that
may not have been completed adequately. The
Biochemical Influences obsession often implies some danger such as
A number of studies suggest that the neuro- forgetting to turn off the stove or not locking a
transmitter serotonin (5-HT)may be abnormal in door. It may be followed by a compulsive act such
individuals with obsessive-compulsive disorder. as the person making multiple trips back into the
house to check if the stove has been turned off.
Psychoanalytic Theory Sometimesthese may take the form of doubting
the very fundamentals ofbeliefs,such as, doubting
The psychoanalytic concept (Freud) views
the existence of God and so on.
patients with obsessive-compulsive disorder
(OCD) as having regressed to developmentally Obsessional impulses These are urges to perform
earlier stages of the infantile superego, whose acts usually of a violent or embarrassing kind,
harsh exacting punitive characteristics now such as injuring a child, shouting in church etc.
reappear as part of the psychopathology.
Obsessionalrituals These may include both mental
Freud also proposed that regression to the pre-
activities such as counting repeatedly in a special
oedipal anal sadistic phase combined with the
way or repeating a certain form of words, and
use of specific ego defense mechanisms like
repeated but senseless behaviors such as washing
isolation, undoing, displacement and reaction
hands 20 or more times a day. Sometimes such
formation, may lead to OCD.
compulsive acts may be preceded by obsessional
thoughts; for example, repeated handwashing
Behavior Theory
may be preceded by thoughts of contamination.
This theory explains obsessions as a conditioned These patients usually believe that the
stimulus to anxiety. Compulsions have been contamination is spread from object to object or
described as learned behavior that decreases the person to person even by slight contact and may
anxiety associated with obsessions. This decrease literally rub the skin off their hands by excessive
in anxiety positively reinforces the compulsive hand washing.
Obsessive slowness: Severe obsessive ideas or As soon as the thought forms, give the
extensive compulsive rituals characterize command 'Stop!' Follow this with calm and
obsessional slowness in the relative absence of deliberate relaxation of muscles and diversion
manifested anxiety.Thisleads to marked slowness of thought to something pleasant.
in daily activities. Repeat the procedure to bring the unwanted
thought under control.
Course and Prognosis (ReferChapter 14for desensitization and aversive
Course is usually long and fluctuating. About conditions)
two-thirds of patients improve by the end of a
year. A good prognosis is indicated by good social Other Therapies
and occupational adjustment, the presence of a Supportive psychotherapy.
precipitating event and an episodic nature of ECT-for patients refractory to other forms of
symptoms. treatment.
Prognosis appears to be worse when the onset
is in childhood, the personality is obsessional, Nursing Management
symptoms are severe, compulsions are bizarre, or
there is a coexisting major depressive disorder. Nursing Assessment
Assessment should focus on the collection of
Treatment physical, psychological and social data. The
Pharmacotherapy nurse should be particularly aware of the impact
Antidepressants (e.g.fluvoxamine, sertraline, of obsessions and compulsions on physical
etc.) functioning, mood, self-esteemand normal coping
Anxiolytics (e.g.benzodiazepines) ability. The defense mechanisms used, thought
content or process, potential for suicide, ability to
Behavior Therapy function and social support systems available
should also be noted.
Exposure and response prevention
Thought stoppage
Nursing Diagnosis I
Desensitization
Aversive conditioning Ineffective individual coping related to under-
developed ego, punitive superego, avoidance
Exposure and response prevention This is vivo learning, possible biochemical changes, eviden-
exposure procedure combined with response ced by ritualistic behavior or obsessive thoughts.
prevention techniques. For example compulsive
handwashers are encouraged to touch Objective: Patient will demonstrate ability to cope
contaminated objects and then refrain from effectively without resorting to obsessive-
washing in order to break the negative reinfor- compulsive behaviors.
cement chain (hand washing reducing the Intervention: See Table 9.6.
anxiety i.e. negative reinforcement).
Nursing Diagnosis II
Thought stoppage Thought stopping is a
technique to help an individual to learn to stop Altered role performance related to the need to
thinking unwanted thoughts. Following are the perform rituals, evidenced by inability to fulfil
steps in thought stopping: usual patterns of responsibility.
Sit in a comfortable chair, bring to mind the Objective:Patient willbe able to resume role-related
unwanted thought concentrating on only one responsibilities.
thought per procedure. Intervention: See Table 9.7.
Table 9.6: Nursing interventions to reduce obsessive compulsive behaviour

(a) Work with patient to determine types Recognition of precipitating factors

of situations that increase anxiety and is the first step in teaching the patient
result in ritualistic behaviors. to interrupt escalating anxiety.
(b) Initially meet the patient's dependency Sudden and complete elimination of
needs. Encourage independence and all avenues for dependency would
give positive reinforcement for create intense anxiety on the part of
independent behaviors. the patient. Positive reinforcement
enhances self-esteem and encourages
repetition of desired behaviors.
(c) In the..beginning of treatment, allow Denying patient this activity may
plenty of time for rituals. Do not be precipitate panic anxiety.
judgmental or verbalize disapproval
of the behavior.
(d) Support patient's efforts to explore the Patient may be unaware of the relationship between
meaning and purpose of the behavior. emotional problems and compulsive behaviors.
Recognition is important before change can occur.
(e) Provide structured schedule of activities Structure provides a feeling of
for patient, including adequate time for security for the anxious patient.
completion of rituals.
(f) Gradually begin to limit amount of Anxiety is minimized when patient
time allotted for ritualistic behavior as is able to replace ritualistic behaviors
patient becomes more involved in unit with more adaptive ones.
activities.
(g) Give positive reinforcement for non- Positive reinforcement encourages
ritualistic behaviors. repetition of desired behaviors.
(h) Help patient learn ways of interrupting These activities help in interruption
obsessive thoughts and ritualistic behavior of obsessive thoughts.
with techniques such as thought stopping,
relaxation and exercise.
Table 9.7: Nursing interventions to improve role-related responsibilities in OCD patients

(a) Determine patient's previous role within This is important assessment data
the family and the extent to which this role for formulating an appropriate plan
is altered by the illness. Identify roles of of care.
other family members.
(b) Encourage patient to discuss conflicts Identifying specific stressors, as well
evident within the family system. Identify as adaptive and maladaptive
how patient and other family members have responses within the system, is
responded to this conflict. necessary before assistance can be
provided in an effort to facilitate change.
(c) Explore available options for changes Planning and rehearsal of potential
or adjustments in role. Practice through role transitions can reduce anxiety.
role play.
(d) Give patient lots of positive reinforcement Positive reinforcement enhances
for ability to resume role responsibilities self-esteem and promotes repetition
by decreasing need for ritualistic behaviors. of desired behaviors.
Evaluation Adjustment Disorders
Evaluation of client with obsessive-compulsive It is characterized by predominant disturbance
disorder may be done by asking the following of emotions and conduct. This disorder usually
questions: occurs within one month of a significant life
Does the client continue to display obsessive- change.
compulsive symptoms?
Is the client able to use newly learned Treatment for Stress and Adjustment Disorders
behaviors to manage anxiety? Drug treatment
Can the client adequately perform self-care Antidepressants
activities? Benzodiazepines
Psychological therapies
REACTION TO STRESS AND Supportive psychotherapy
ADJUSTMENT DISORDER Crisis intervention
Stress management training
This category includes:
Acute stress reaction
DISSOCIATIVE (CONVERSION) DISORDERS
Post-traumatic stress disorder (PTSD)
Adjustment disorders Conversion disorder is characterized by the
presence of one or more symptoms suggesting the
presence of a neurological disorder that cannot
Acute Stress Reaction be explained by any known neurological or
It is characterized by symptoms like anxiety, medical disorder. Instead, psychological factors
despair and anger or over activity. These like stress and conflicts are associated with onset
symptoms are clearly related to the stressor. If or exacerbation of the symptoms. Patients are
removal from the stressful environment is unaware of the psychological basis and are thus
possible, the symptoms resolve rapidly. not able to control their symptoms.
Some features of the disorder include:
Post-traumatic Stress Disorder (PTSD) The symptoms are produced because they
Post-traumatic stress disorder is characterized by reduce the anxiety of the patient by keeping
hyperarousal, re-experiencing of images of the the psychological conflict out of conscious
awareness, a process called as primary gain.
stressful events and avoidance of reminders.
These symptoms of conversion are often
Post-traumatic stress disorder is of a reaction
advantageous to the patient. For example, a
to extreme stressors such as floods, earthquackes,
woman who develops psychogenic paralysis
war, rape or serious physical assault. The main
of the arm may escape from taking care of an
symptoms are persistent anxiety, irritability,
elderly relative. Such an advantage is called
insomnia, intense intrasive imagery (flashbacks)
as secondarygain.
recurring distressing dreams, inability to feel
The patient does not produce the symptoms
emotion and diminished interest in activities. intentionally.
The symptoms may develop after a period of The patient shows less distress or shows lack
latency, within 6 months after the stress or may of concern about the symptoms, called as belle
be delayed. The general approach is to provide indifference.
emotional support, to encourage recall of the Physical examination and investigations do
traumatic events. Benzodiazepine drugs may be not reveal any medical or neurological
needed to reduce anxiety. abnormalities.
Conversion disorders were formerly called as correct answer. Hallucinations are usually visual
'hysteria.' The term is now changed because the and may be elaborate.
word 'hysteria' is used in everyday speech when
referring to any extravagant behavior, and it is Multiple Personality Disorder (Dissociative
confusing to use the same word for a different Identity Disorder)
phenomena that falls under this syndrome. In this disorder, the person is dominated by two
or more personalities ofwhich only one is manifest
Dissociative Amnesia at a time. Usually one personality is not aware of
Most often, dissociative amnesia follows a the existence of the other personalities. Each
traumatic or stressful life situation. There is personality has a full range of higher mental
sudden inability to recall important personal functions and performs complex behavior pat-
information particularly concerning the stressful terns. Transition from one personality to another
lifeevent. The extent of the disturbance is too great is sudden, and the behavior usually contrasts
to be explained by ordinary forgetfulness. The strikingly with the patient's normal state.
amnesia may be localized, generalized, selective
or continuing in nature. Trance and Possession Disorders
This disorder is very common in India. It is
Dissociative Fugue characterized by a temporary loss of both the
Psychogenic fugue is a sudden, unexpected travel sense of personal identity and full awareness of
the person's surroundings. When the condition
away from home or workplace, with the
is induced by religious rituals, the person may
assumption of a new identity and an inability to
feel taken over by a deity or spirit. The focus of
recall the past. The onset is sudden, often in the
attention is narrowed to a few aspects of the
presence of severe stress.Followingrecovery there
immediate environment, and there is often a
is no recollection of the events that took place
limited but repeated set of movements, postures
during the fugue. The course is typically a few
and utterances.
hours to days and sometimes months.
Dissociative Motor Disorders
Dissociative Stupor
It is characterized by motor disturbances like
In this, patients are motionless and mute and do paralysis or abnormal movements. Paralysis may
not respond to stimulation, but they are aware of be a monoplegia, paraplegia or quadriplegia. The
their surroundings. It is a rare condition. abnormal movement may be tremors, choreiform
movements or gait disturbances which increase
Ganser's Syndrome when attention is directed towards them. Exami-
Canser's syndrome is a rare condition with four nation reveals normal tone and reflexes.
features: giving 'approximate answers' to
questions designed to test intellectual functions, Dissociative Convulsions (hysterical fits or
psychogenic physical symptoms, hallucinations pseudo-seizures)
and apparent clouding of consciousness. The It is characterized by convulsive movements and
term 'approximate answers' denotes answers (to partial loss of consciousness. Differential diag-
simple questions) that are plainly wrong, but are nosis with true seizures is important. Some
clearly related to the correct answers in a way differences are illustrated in Table 9.8.
that suggest that the latter is known. For example,
when asked to add three and three a patient might Dissociative Sensory Loss and Anesthesia
answer seven and when asked four and five,might It is characterized by sensory disturbances like
answer ten; each answer is one greater than the hemianesthesia, blindness, deafness and glove
Table 9.8: Differences between epileptic seizures and dissociative convulsions
Clinical points Epileptic seizures Dissociative convulsions
Aura (warning) usual unusual

Attack pattern stereotyped known purposive body movements;
clinical pattern absence of any established
clinical pattern
Tongue bite present absent
Incontinence of urine can occur very rare
and feces
Injury can occur very rare
Duration usually about 20-800 sec (prolonged)
30-70 sec
Amnesia complete partial
Time of day anytime; can occur during never occurs during sleep
sleep also
Place of occurrence anywhere usually indoors or in safe places
Post-ictal confusion present absent
Neurological signs present absent
and stocking anesthesia (absence of sensations Hypnosis

at wrists and ankles). Abreaction therapy
The disturbance is usually based on patient's Supportive psychotherapy
knowledge of that particular illness whose Behavior therapy (aversion therapy, operant
symptoms are produced. A detailed examination conditioning, etc.)
does not reveal any abnormalities. Drug therapy: Drugs have a very limited
role. A few patients have anxiety and may
Etiology of Conversion Disorders need short-term treatment with benzodiaze-
pines
Psychodynamic Theory
In conversion disorder, the ego defense mecha- Nursing Intervention
nisms involved are repression and conversion.
Monitor physician's ongoing assessments,
Conversion symptoms allow a forbidden wish or
laboratory reports and other data to rule out
urge to be partly expressed, but sufficiently
disguised so that the individual does not have to organic pathology.
face the unacceptable wish. The symptoms are Identify primary and secondary gains.
symbolically related to the conflict. Do not focus on the disability; encourage
patient to perform self-care activities as
Behavior Theory independently as possible. Intervene only
According to this theory the symptoms are learnt when patient requires assistance.
from the surrounding environment. These symp- Do not allow the patient to use the disability
toms bring about psychologicalreliefby avoidance as a manipulative tool to avoid participation
of stress. Conversion disorder is more common in in the therapeutic activities.
people with hystrionic personality traits. Withdraw attention if the patient continues
to focus on physical limitations.
Treatment Encourage patient to verbalize fears and
Free association anxieties.
Positive reinforcement for identification or tions, hiccoughs, hyperventilation, irritable bowel,

demonstration of alternative adaptive coping dysuria, etc.
strategies.
Identify specific conflicts that remain unre- Persistent Somatoform Pain Disorder
solved and assist patient to identify possible The main feature in this disorder is severe,
solutions. persistent pain without any physical basis. It may
Assist the patient to set realistic goals for the be of sufficient severity so as to cause social or
future. occupational impairment. Preoccupation with the
Help the patient to identify areas of life pain is common.
situation that are not within his ability to
control. Encourage verbalization of feelings
related to this inability. Treatment
Drug therapy
SOMATOFORM DISORDERS Antidepressants
Benzodiazepines
These disorders are characterized by repeated
presentation with physical symptoms which do
Psychological treatment.
not have any physical basis, and a persistent
Supportive psychotherapy
request for investigations and treatment despite
Relaxation therapy
repeated assurance by the treating doctors.
These disorders are divided into following
REVIEW QUESTIONS
categories:
Somatization disorder Differences between psychotic and neurotic
Hypochondriasis disorders (Feb 2001, Oct 2006)
Somatoform autonomic dysfunction Classification of neurotic disorders
Persistent somatoform pain disorder Neurotic disorders (Nov 2002, Apr 2005)
Phobia (Nov 2002, Apr 2003, Nov 2003, Apr
Somatization Disorder 2004)
Agoraphobia (Oct 2004)
Somatization disorder is characterized by chronic
Panic disorder (Oct 2006)
multiple somatic symptoms in the absence of
Anxiety neurosis (Apr 2006)
physical disorder. The symptoms are vague,
Nursing management for a patient with acute
presented in a dramatic manner and involve
anxiety state (Feb 1999, Nov 2001, Apr 2002,
multiple organ systems.
Nov 2003, Apr 2004, Oct 2004)
Obsession (Apr 2002, Apr 2003)
Hypochondrias is
Obsessive compulsive disorders (Oct 2000,
Hypochondriasis is defined as a persistent pre- Nov 2002, Nov 2003, Oct 2005)
occupation with a fear or belief of having a serious Ritualistic behavior (Nov 2003)
disease despite repeated medical reassurance. Dissociative (conversion) disorders (Oct 2000,
Apr 2006)
Somatoform Autonomic Dysfunction Differences between epileptic seizures and
In this disorder, the symptoms are predominantly pseudo-seizures (Oct 2000)
under autonomic control, as if they were due to a Somatoform disorders
physical disorder. Some of them include palpita- Multiple personality (Nov 2002)
Behavioral Syndromes
Resulting from
.___
__ ~Physiological Disturbances
D PSYCHOPHYSIOLOGICAUPSYCHOSOMATIC Common Examples of Psychophysiological
DISORDERS Disorders
Common Examples of
Psychophysiological Disorders Franz Alexander, the father of psychosomatic
Nursing Management of Patient With medicine, described seven classical psychoso-
Psychophysiological Disorder matic illnesses.
D EATINGDISORDERS
Anorexia Nervosa
Bulimia Nervosa Cardiovascular Disorders
D SLEEPDISORDERS Essential hypertension
Insomnia
Hypersomnia
Coronary artery disease
Disorders of Sleep-Wake Schedule Post-cardiac surgery delirium
Stage IV Sleep Disorders Migraine
Other Sleep Disorders Mitral valve prolapse syndrome
Endocrine Disorders
PSYCHOPHYSIOLOGICALJPSYCHOSOMATIC
DISORDERS
Diabetes mellitus
Hyperthyroidism
The word 'psychosomatic' means mind and body.
Cushing' s syndrome
Psychosomatic disorders are those disorders in Pre-menopausal syndrome
which the psychic elements are significant for
Amenorrhea
initiating chemical, physiological or structural
Menorrhagia
alterations, which in turn create the physical
symptoms in the person. Gastrointestinal Disorders
The term 'psychosomatic' has now been
replaced with 'psychophysiologic '. Esophagealreflux
There are three factors which must be present Peptic ulcer
simultaneously for a person to develop a Ulcerative colitis
psychosomatic disorder: Crohn' s disease
, 1. The individual must have "biological predis-
position". Immune Disorders
2. The individual must have "personality vulner- Autoimmune disorders, e.g. systemic lupus
ability". erythematosus
3. The individual must experience a significant Allergic disorders, like bronchial asthma and
psychosocial stress in his/her susceptible hay fever
personality area. Viral infections
Behavioral Syndromes Resulting from Physiological Disturbances 12 5
Muscu/oskeletal Disorders Knowledge deficit related to psychological

Rheumatoid arthritis factors affectingphysical condition, evidenced
by various physical problems.
Respiratory Disorders
Interventions
Bronchial asthma
Hayfever Encourage patient to discuss current life
Rhinitis situations that he perceives as stressful, and
the feelings associated with each.
Skin Disorders Provide positive reinforcement for adaptive
coping mechanisms identified or used.
Psoriasis
Suggest alternative coping strategies but allow
Pruritus
patient to determine which can most appro-
Urticaria
priately be incorporated into his life style.
Acne vulgaris
Help patient to identify a resource person
Warts
within the community (friend or significant
others) to use as a support system for the
Treatment
expression of feelings.
1. Relaxation techniques: This is one of the most Have patient keep a diary of appearance,
important methods aimed at reducing anxiety duration, and intensity of physical symptoms.
or restlessness. They include: A separate record of situations that the patient
Jacobson's progressive relaxation techni- finds especially stressful should be kept.
que Help patient identify needs that are being met
Yoga through the sick role. Together, formulate
Auto hypnosis more adaptive means for fulfillingthese needs,
Meditation practice by role-playing.
Bio-feedback Provide instruction in assertive techniques,
2. Behavior modification techniques especially the ability to recognize the diffe-
3. Individual therapy rences among passive, assertive, and
4. Group therapy aggressive behaviors and the importance of
respecting the rights of others while protecting
Nursing Management one's own basic rights.
Assessment Discuss adaptive methods of stress
management, such as relaxation techniques,
Perform thorough physical assessment.
physical exercises, meditation and breathing
Monitor laboratory values, vital signs, intake
exercises.
and out put and other assessments necessary
to maintain an accurate ongoing appraisal.
EATING DISORDERS
Assess patient's level of anxiety.
Assess patient's level of knowledge regarding The two most important eating disorders are:
effectsof psychological problems on the body. Anorexia nervosa, and
Bulimia nervosa
Nursing Diagnoses
Ineffectiveindividual coping related to repres- Anorexia Nervosa
sed anxiety and inadequate coping methods, Anorexia nervosa is characterized by highly
evidenced by initiation or exacerbation of specific behavioral and psychopathological
physical illness. symptoms and significant somatic signs. Majority
are females and the onset is during adolescence. blood pressure, bradycardia, hypothermia
The core psychopathological feature is the dread and amenorrhea in females.
of fatness, weight phobia and a drive for thinness. Vomiting and abuse of laxatives may lead to a
variety of electrolyte disturbances, the most
Etiology serious being hypokalemia.
a. Genetic causes: Among female siblings of Hormonal abnormalities also may be seen.
patients with established anorexia nervosa,
6-10 percent suffer from the condition Course and Prognosis
compared to the 1-2 percent found in the Anorexia nervosa often runs a fluctuating course
general population of the same age(Strober, with periods of exacerbations and partial remis-
1995). sions. Outcome is very variable.
b. A disturbance in hypothalamic function.
c. Social factors: There is a high prevalence of Treatment
anorexia nervosa among female students and Pharmacotherapy
in occupational groups particularly concer- Neuroleptics
ned with weight (for example, dancers). Appetite stimulants
Influence of mass media, beauty contests are Antidepressants
other important social causes.
d. Individual psychological factors: A distur- Psychological therapies
bance of body image, a struggle for control Individual psychotherapy
and a sense of identity are important factors Behavioral therapy
in the causation of anorexia nervosa. Traits of Cognitive behavior therapy
low self-esteem and perfectionism are often Family therapy
found.
e. Causes within the family: Disturbance in Nursing Interventions
family relationships, over-protection, family Short-term management is focused on ensu-
members having an unusual interest in food ring weight gain and correcting nutritional
and physical appearance. deficiencies. Maintaining normal weight and
preventing relapses are long-term goals to be
Clinical Features achieved.
There is an intense fear of becoming obese. Hospitalization is usually required and
This fear does not decrease even if the person successful treatment depends on good nursing
loses weight grossly and becomes very thin. care, with clear aims and understanding on
The body weight is 15 percent below the the part of the patient as well as the nurse.
standard weight. Eating must be supervised by the nurse and a
There is a body image disturbance. The patient balanced diet of at least 3000 calories should
is unable to perceive the body size accurately. be provided in 24 hours.
The pursuit of thinness may take several In the early stages of treatment, it is best for
forms. Patients generally eat little and set the patient to remain in bed in a single room
themselves daily calorie limits (often between while the nurse maintains close observation.
600 and 1000 calories). Some try to achieve The goal should be to achieve a weight gain of
weight loss by inducing vomiting, excessive 0.5 to 1 kg per week.
exercise, and misusing laxatives. Weight should be checked regularly. Monitor
Other signs and symptoms are secondary to serum electrolyte levels and signs and symp-
starvation and include sensitivity to cold, toms like amenorrhea, constipation, hypogly-
delayed gastric emptying, constipation, low cemia, hypotension, etc.
Behavioral Syndromes Resulting from Physiological Disturbances 12 7
Control vomiting by making the bathroom nance of sleep. This includes frequent awakening
inaccessible for at least 2 hours after food. during the night and early morning awakening.
In extreme cases when the patient refuses to
Causes
eat and comply with the treatment, gavage
Medical illnesses
feedings may need to be instituted.
Any painful or uncomfortable illness
Heart disease
Bulimia Nervosa
Respiratory diseases
Bulimia nervosa is described as repeated bouts of Brain stem or hypothalamic lesions
overeating and a preoccupation with control of Delirium
weight that leads to self-induced vomiting. Rheumatic and other musculoskeletal
diseases
Clinical Features Periodic movements in sleep
An irresistible craving for food: There are Oldage
episodes of overeating in which large amount Alcohol and drug use
of food are consumed within short periods of Delirium tremens
time (eating binges) Amphetamines or other stimulants
Attempt to counteract the effects of overeating Chronic alcoholism
by self-induced vomiting
There is usually no significant weight loss Psychiatric disorders
Mania (due to decreased need for sleep)
Treatment Major depression (early morning awakening
or late insomnia)
Antidepressants, carbamazepine and lithium
Dysthymia or neurotic depression (difficulty
for patients with co-morbid mood disorders
in initiating sleep or early insomnia)
Group therapy
Schizophrenia and other psychoses (due to
Family therapy
psychotic symptoms)
Cognitive behavior therapy Anxiety disorder (difficulty in initiating sleep
due to worrying thoughts)
SLEEP DISORDERS
Sleep can be regarded as a physiological reversible
Social causes
Financial loss
reduction of conscious awareness.
Separation or divorce
Sleep disorders are divided into subtypes:
Death of spouse or a close relative
Retirement
1. Dyssomnias
Stressful life situations
Insomnia
Hypersomnia Behavioral causes
Disorders of sleep-wake schedule Naps during the day
Irregular sleeping hours
2. Parasomnias Lack of physical exercise
Excessive intake of beverages in the evening,
Stage IV disorders e.g. coffee
Other disorders Disturbing environment (heat, cold, noise)
DYSSOMNIAS Treatment
A thorough medical and psychiatric assess-
Insomnia ment; polysomnography may be needed in
Insomnia is disorder of initiation and mainte- some cases.
Treatment of underlying physical or psy- in morning or at sleep onset. The person is
chiatric disorder. conscious but unable to move his body.
Withdrawal of current medications, if any. Hypnagogic hallucinations
Transient insomnia can be treated initially 2. Sleep apnea: repeated episodes of apnea
with hypnotics. during sleep.
3. Kleine-Levin syndrome: periodic episodes of
Non-drug treatment for insomnia
hypersomnia.
Progressive relaxation.
Autosuggestion.
Disorder of Sleep-wake Schedule
Meditation, yoga.
Stimulus control therapy: do not use the bed The person with this disorder is not able to sleep
for reading or chatting - go to bed for sleep when he wishes to, although at other time he is
only. able to sleep adequately.
Sleep hygiene Causes

Regular, daily physical exercises in the
Work shifts
evening.
Unusual sleep phases
Avoid fluid intake and heavy meals just before
bedtime.
PARASOMNIAS
Avoid caffeine intake (e.g. tea, coffee, cola
drinks) before sleeping hours. In this the person frequently wakes during sleep.
Avoid reading or watching television while
in bed. Stage IV Sleep Disorders
Backrubs, warm milk and relaxation exercises. Sleep walking (somnambulism)
Sleep in a comfortable environment. Night terrors
Sleep-related enuresis
Hypersomnia Bruxism (tooth-grinding)
Hypersomnia is known as Disorder Of Excessive Sleep talking (somniloquy)
Somnolence (DOES).It includes excessivedaytime
sleepiness, sleep attacks during daytime, sleep Other Sleep Disorders
drunkenness (person needs much more time to Nocturnal angina
awaken, and during this period he is confused or Nocturnal asthma
disoriented). Nocturnal seizures
Sleep paralysis
Causes
Narcolepsy-excessive daytime sleepiness cha- REVIEWQUESTIONS
racterized by: Psychophysiological disorders (Feb2001,Nov
Sleep attacks. 2002)
Cataplexy-sudden decreased or loss of (sleep Dynamics of psychophysiologic disorders
paralysis) muscle tone, often generalized and (Apr 2006)
may lead on to sleep. Anorexia nervosa (Apr 2006)
Sleep paralysis-it occurs either at awakening Insomnia (Nov 1999,Oct 2004)
Disorders due to
Psychoactive
Substance Use
DETIOLOGICALFACTORSINSUBSTANCEUSE Difficult in controlling substance taking
DALCOHOLDEPENDENCESYNDROME behavior
Medical and Social Complications of
A physiological withdrawal state
Alcohol Dependence
Psychiatric Disorders due to Alcohol Development of tolerance
Dependence Progressive neglect of alternative pleasures or
Acute Intoxication interests
Withdrawal Syndrome Persisting with substance use despite clear
Alcohol Induced Amnestic Disorder
evidence of harmful consequences
Alcohol Induced Psychiatric Disorder
Treatment Tolerance: It is a state in which after repeated
Agencies Concerned With Alcohol-
Related Problems
administration, a drug produces a decreased
D OTHERSUBSTANCEUSEDISORDERS effect,or increasing doses are required to produce
Opioid Use Disorders the same effect.
Cannabis Use Disorder
Cocaine Use Disorder Withdrawal state: A group of signs and symptoms
Amphetamine Use Disorder recurring when a drug is reduced in amount or
LSD Use Disorder withdrawn, which last for a limited time. The
Barbiturate Use Disorder nature of the withdrawal state is related to the
Inhalants Or Volatile Solvent Use Disorder
D PREVENTION
class of substance used.
D REHABILITATION The major dependence producing drugs are:
D NURSINGMANAGEMENTFORSUBSTANCEUSE Alcohol
DISORDER Opioids
Cannabis
Disorders due to psychoactive substance use refer Cocaine
to conditions arising from the abuse of alcohol, Amphetamines and other sympathomimetics
psychoactive drugs and other chemicals such as Hallucinogens, e.g. LSD,phencyclidine
volatile solvents. These are classified under FI in Sedatives and hypnotics, e.g. barbiturates
ICDlO. Inhalants, e.g. volatile solvents
Nicotine
Abuse: It refers to maladaptive pattern of substance Other stimulants, e.g. caffeine
use that impairs health in a broad sense.
Dependence: It refers to certain physiological and ETIOLOGICAL FACTORS IN PSYCHOACTIVE
SUBSTANCE USE
psychological phenomena induced by the repea-
ted taking of a substance. The criteria for Biological Factors
diagnosing dependence include (ICDlO): Genetic vulnerability: family history of sub-
A strong desire to take the substance stance use disorder, e.g. twin studies suggest
that genetic mechanisms might account for Taking drugs that can be bought legally
alcohol consumption. without prescription (e.g. nicotine, opioids ).
Biochemical factors: for example, role of Taking drugs that can be obtained from illicit
dopamine and norepinephrine have been sources (e.g. street drugs).
implicated in cocaine, ethanol and opioid
dependence. Abnormalities in alcohol dehy- Psychiatric disorders Substance use disorders
drogenase or in the neurotransmitter are more common in depression, anxiety dis-
mechanism are thought to play a role in orders (particularly social phobias), personality
alcohol dependence. disorder (especially antisocial personality) and
Withdrawal and reinforcing effects of drugs occasionally in organic brain disease and
(they serve as maintaining factors). schizophrenia.
Co-morbid medical disorder (e.g. to control
chronic pain) .
ALCOHOL DEPENDENCE SYNDROME
Psychological Factors Alcoholism refers to the use of alcoholicbeverages

to the point of causing damage to the individual,
General rebelliousness
Sense of inferiority society or both.
Poor impulse control
Low self-esteem Properties of Alcohol
Inability to cope with the pressures of living Alcohol is a clear colored liquid with a strong
and society (poor stress management skills)
burning taste. The rate of absorption of alcohol
Loneliness, unmet needs
into the blood stream is more rapid than its
Desire to escape from reality
elimination. Absorption of alcohol into the blood
Desire to experiment, a sense of adventure
Pleasure-seeking stream is slower when food is present in the
Machoism stomach. A small amount is excreted through
Sexual immaturity urine and a small amount is exhaled.
A concentration of 80 to 100mg of alcohol per
Social Factors 100 ml of blood is considered intoxication. A
Religious reasons person with 200mg to 250mg will be toxic,sleepy,
Peer pressure confused and his thought process will be altered.
Urbanization Ifblood level is 300mg/100 ml ofblood the person
Extended periods of education may lose consciousness. A concentration of 500
Unemployment mg /100 ml is fatal. All the symptoms change
Overcrowding according to tolerance.
Poor social support
Effects of television and other mass media
Epidemiology
Occupation: substance use is more common
in chefs,barmen, executives, salesmen, actors, The incidence of alcohol dependence is 2%. In
entertainers, army personnel, journalists, India 20 to 40% of subjects aged above 15 years
medical personnel, etc are current users of alcohol, and nearly 10% of
them are regular or excessive users. Nearly 15 to
Easy Availability of Drugs 30% of patients are developing alcohol-related
Taking drugs prescribed by doctors (e.g. problems and seeking admission in psychiatric
benzodiazepine dependence). hospitals.
Disorders due to Psychoactive Substance Use 131
Medical and Social Complications of 1. Acute intoxication: Acute intoxication deve-
Alcohol Dependence lops during or shortly after alcohol ingestion. It is
A Medical characterized by clinically significant maladap-
Gastrointestinal system tive behavior or psychological changes, e.g.
Gastritis, peptic ulcer, reflux esophagitis, inappropriate sexual or aggressive behavior,
carcinoma of stomach and esophagus mood lability, impaired judgment, slurred speech,
Fatty liver, cirrhosis of liver, hepatitis, liver incoordination, unsteady gait, nystagmus,
cell carcinoma impaired attention and memory finally resulting
Acute and chronic pancreatitis in stupor or coma.
Malabsorption syndrome
2. Withdrawal syndrome: In persons who have
Cardiovascular system been drinking heavily over a prolonged period of
Alcoholic cardiomyopathy time, any rapid decrease in the amount of alcohol
High risk for myocardial infarction in the body is likely to produce withdrawal
Central nervous system symptoms. These are:
Peripheral neuropathy Simple withdrawal syndrome
Epilepsy Delirium tremens
Head injury
Cerebellar degeneration Simple withdrawal syndrome: It is characterized
by mild tremors, nausea, vomiting, weakness,
Miscellaneous irritability, insomnia and anxiety.
Protein malnutrition
Vitamin deficiency disorder Delirium tremens: It occurs usually within 2-4
Peripheral muscle weakness days of complete or significant abstinence from
Acne heavy alcohol drinking. The course is short, with
Sexual dysfunction in males, failure of recovery occurring within 3-7 days.
ovulation in females It is characterized by:
Damage to thefetus A dramatic and rapidly changing picture of
Fetal alcohol syndrome (facial abnormality, low disordered mental activity, with clouding of
birthweight, low intelligence), increased consciousness and disorientation in time and
stillbirths. Alcohol dependence is responsible for place
3 percent of all cases of mental retardation Poor attention span
B. Social Vivid hallucinations which are usually visual;
Marital disharmony tactile hallucinations can also occur
Occupational problems Severe psychomotor agitation, shouting and
Financial problems evident fear
Criminality Grossly tremulous hands which sometimes
Accidents pick up imaginary objects; truncal ataxia
Autonomic disturbances such as sweating,
PSYCHIATRIC DISORDERS DUE TO fever, tachycardia, raised blood pressure,
ALCOHOL DEPENDENCE pupillary dilatation
1. Acute intoxication Dehydration with electrolyte imbalances
2. Withdrawal syndrome Reversal of sleep-wake pattern or insomnia
3. Alcohol induced amnestic disorders Blood tests reveal leukocytosis and impaired
4. Alcohol induced psychiatric disorders liver function
Death may occur due to cardiovascular f) Pathological jealousy: Excessive drinkers may
collapse, infection, hyperthermia or self- develop an overvalued idea or delusion that
inflicted injury the partner is being unfaithful.
g) Alcoholic seizures (rum fits): Generalized
3. Alcohol- induced amnestic disorders tonic clonic seizures occur usually within 12-
Chronic alcohol abuse associated with thiamine 48 hours after a heavy bout of drinking. Some-
(vitamin 'B') deficiency is the most frequent cause times, status epilepticus may be precipitated.
of arnnestic disorders. This condition is divided h). Alcoholic hallucinosis: This is characterized
into: by the pi;esence of hallucinations (auditory)
a) Wernicke's syndrome: This is characterized during abstinence, following regular alcohol
by prominent cerebellar ataxia, palsy of the intake. Recovery occurs within one month.
6th cranial nerve, peripheral neuropathy and
mental confusion. Treatment
b) Korsakoff' s syndrome: The prominent symp- 1. A full assessment, including an appraisal of
tom in Korsakoff' s syndrome is gross memory current medical, psychological and social
disturbance. Other symptoms include: problems.
Disorientation 2. Goal setting: Setting up of short-term goals that
Confusion deal with any accompanying problems in
Confabulation health, marriage, job and social adjustments;
Poor attention span and distractibility long-term goals can be set as treatment
Impairment of insight progresses, which are concerned with trying
4. Alcohol- induced psychiatric disorders to change factors that precipitate or maintain
a) Alcohol-induced dementia: It is a long term excessive drinking, such as tensions in the
complication of alcohol abuse, characterized family.
3. Treatment of withdrawal from alcohol
by global decrease in cognitive functioning
a. Detoxification: Detoxification is the treat-
(decreased intellectual functioning and
ment for alcohol withdrawal symptoms.
memory). This disorder tends to improve with
The drugs of choice are benzodiazepines.
abstinence, but most of the patients may have
The most commonly used drugs from this
permanent disabilities. class are chlordiazepoxide 80-200 mg/
b) Alcohol-induced mood disorders: Excess day and diazepam 40-80 mg/ day, in
drinking may induce persistent depression or divided doses.
anxiety b. Others:
c) Suicidal behavior: Suicidal rates are higher in For vitamin B deficiency a preparation
alcoholics when compared to non-alcoholics of vitamin B containing 100 mg of
of the same age. The risk factors for suicidal thiamine should be administered
behavior are continued drinking, co-morbid parenterally, twice daily for 3 to 5 days.
major depression, serious medical illness, This should be followed by oral
unemployment and poor social support. administration of vitamin B for at least
d) Alcohol-induced anxiety disorder: Alcohol 6months.
persons report panic attacks during acute Administration of anticonvulsants as
withdrawal, similarly during the first 4 to 6 necessary, maintaining fluid and
weeks of abstinence. electrolyte balance, strict monitoring of
e) Impaired psychosexual function: Erectile vitals, level of consciousness and orien-
dysfunction and delayed ejaculation are tation. Close observation is essential,
common in chronic alcoholics especially during the first five days.
Disorders due to Psychoactive Substance Use 13 3
4. Alcohol deterrent therapy: Deterrent agents are Contraindications
those which are given to desensitize the Pulmonary and cardiovascular disease.
individual to the effects of alcohol and Disulfiram should be used with caution
maintain abstinence. The most commonly in patients with nephritis, brain damage,
used drug is disulfiram (tetraethyl thiuram hypothyroidism, diabetes, hepatic disease,
disulfide) or antabuse. seizures, poly-drug dependence or an
abnormal electroencephalogram.
Disulfiram: Disulfiram is used to ensure
Patients at high risk of alcohol ingestion.
abstinence in the treatment of alcohol
dependence. Its main effect is to produce a Dosage Disulfiram is supplied in tablets of
rapid and violently unpleasant reaction in a 250and 500mg. The usual initial dose is 500
person who ingests even a small amount of mg/ day orally for the first 2 weeks, followed
alcohol while taking disulfiram. by a maintenance dosage of 250mg/ day. The
dosage should not exceed 500mg/ day.
Mechanism of action Disulfiram is an
aldehyde dehydrogenase inhibitor that Nurse's responsibility
interferes with the metabolism of alcohol and An informed consent should be taken
produces a marked increase in blood acetal- before starting treatment.
dehyde levels. The accumulation of acetal- Ensure that at least 12hours have elapsed
dehyde (to a level of 10 times more than that since the last ingestion of alcohol before
which occurs in the normal metabolism of administering the drug.
alcohol) produces a wide array of unpleasant Patient must be instructed that ingestion
reactions called the disulfiram-ethanol of even the smallest amount of alcohol
reaction (DER), characterized by nausea, brings on a disulfiram-ethanol reaction
throbbing headache, vomiting, hypotension, with all its unpleasant effects ; he should
flushing, sweating, thirst, dyspnea, therefore be strictlywarned not to take any
tachycardia, chest pain, vertigo, blurred vision alcohol whatever.
and a sense of impending doom associated The patient should also be warned against
ingestion of any alcohol-containing
with severe anxiety.Thereactionoccursalmost
preparations such as cough syrups, drops
immediately after the ingestion of even one
of any kind, and alcohol-containing foods
alcoholicdrink and may last up to 30minutes.
and sauces. Advise not to use alcohol
Therapeutic indications The primary indica- based aftershave lotions and advise
tion for disulfiram use is as an aversive con- against inhalation of paints, warnishes,
ditioning treatment for alcohol dependence. etc., containing alcohol. Any topical
Side-effects The adverse effects of disulfiram applications containing alcohol should
also be avoided.
in the absence of alcoholconsumption include
Caution patient against taking CNS
fatigue, dermatitis, impotence, optic neuritis,
depressants or any OTC(over-the-counter)
mental changes, acute polyneuropathy and
medications during disulfiram therapy.
hepatic damage.
Instruct patient to avoid driving or other
With alcohol consumption the intensity activitiesrequiring alertness until response
of the disulfiram-alcohol reactions varies with to drug is known.
each patient. In extreme cases it is marked by Patients should be warned that the
convulsions, respiratory depression, cardio- disulfiram-alcohol reaction may continue
vascular collapse, myocardial infarction and for as long as 1 to 2 weeks after the last
death. dose of disulfiram.
Patients should carry identification cards and Bill Wilson, a stockbroker on the 10th of
describing disulfiram-alcohol reaction June,1935. It has since then spread to many
and listing the name and telephone countries in the world. AA considers alcoholism
number of the physician to be called. as a physical, mental and spiritual disease, a
Emphasize the importance of follow-up progressive one, which can be arrested but not
visits to the physician to monitor progress cured. Members attend group meetings usually
in long-term therapy. twice a week on a long-term basis. Each member
5. Psychological treatment is assigned a support person from whom he may
Motivational interviewing: This involves seek help when the temptation to drink occurs. In
providing feedback to the patient on the crisishe can obtain immediate help by telephone.
personal risks that alcohol poses, together Once sobriety is achieved he is expected to help
with a number of options for change. others.
Group therapy: Group therapy enables the The organization works on the firm belief that
patients to observe their own problems abstinence must be complete. The only require-
mirrored in others and to work out better ways ment for membership is a desire to stop drinking.
of coping with them. There is no authority, but only a fellowship of
Aversive conditioning: This therapy is based imperfect alcoholicswhose strength is formed out
on classical conditioning. In alcoholism the of weakness. Their primary purpose is to help
behavior patterns are self-reinforcing and each other stay sober and help other alcoholics to
pleasurable, but are maladaptive for reasons achieve sobriety.
outside the control of the client. In this
"Twelve Steps" of A.A.
technique the client is exposed to chemically-
The "Twleve Steps" are the core of the A.A.
induced vomiting or shock when he takes
program of personal recovery from alcoholism.
alcohol.
They are not abstract theories; but are based on
Cognitive therapy: This involves reduction in
the trial-and-error experience ofearly members of
alcohol intake by identifying and modifying
A.A.They describe the attitudes and activitiesthat
maladaptive thinking patterns.
these early members believe were important in
Relapse prevention technique: This technique
helping them to achieve sobriety. Acceptance of
helps the patient to identify high-risk relapse
the "Twelve Steps" is not mandatory in any sense.
factors and develop strategies to deal with
1. We admitted we were powerless over
them. It also enables the patient to learn
alcohol-that our lives had become
methods to cope with cognitive distortions.
unmanageable.
Cue exposure technique: This technique aims 2. Came to believe that a Power greater than
through repeated exposure to desensitize drug ourselves could restore us to sanity.
abusers to drug effects,and thus improve their 3. Made a decision to turn our will and our
ability to remain abstinent. lives over to the care of God as we understood
Other therapies include assertiveness training, Him.
behaviorcounseling, supportive psychotherapy and 4. Made a searching and fearless moral
individual psychotherapy. inventory of ourselves.
5. Admitted to God, to ourselves and to
Agencies Concerned with Alcohol- another human being the exact nature of
related Problems our wrongs.
6. Were entirely ready to have God remove all
Alcoholics Anonymous (AA) these defects of character.
This is a self-help organization founded in 7. Humbly asked Him to remove our short-
the USA by two alcoholic men, Dr. Bob Smith comings.
8. Made a list of all persons we had harmed, 6. An A.A.group ought never endorse, finance,
and became willing to make amends to them or lend the A.A. name to any related facility
all. or outside enterprize, lest problems of
9. Made direct amends to such people money, property, and prestige divert us
wherever possible, except when to do so from our primary purpose.
would injure them or others. 7. Every A.A. group ought to be fully self-sup-
10. Continued to take personal inventory and porting, declining outside contributions.
when we were wrong promptly admitted it. 8. Alcoholics Anonymous should remain
11. Sought through prayer and meditation to forever non-professional, but our service
improve our conscious contact with God, centers may employ special workers.
as we understood Him, praying only for 9. A.A.,as such ought never be organized; but
knowledge of His will for us and the power we may create serviceboards or committees
to carry that out. directly responsible to those they serve.
12. Having had a spiritual awakening as the 10. Alcoholics Anonymous has no opinion on
result of these steps, we tried to carry this outside issues; hence the A.A. name ought
message to alcoholics, and to practice these never be drawn into public controversy.
principles in all our affairs. 11. Our public relations policy is based on
attraction rather than promotion; we need
"Twelve Traditions" of A.A.
always maintain personal anonymity at the
The "Twelve Traditions" of A.A. are suggested
level of press, radio, and films.
principles to ensure the survival and growth of
12. Anonymity is the spiritual foundation of all
the thousands of groups that make up the
our traditions, ever reminding us to place
Fellowship. They are based on the experience of
principles before personalities.
groups themselves during the critical early years
of the movement.
Al-Anon
The Traditions are important to both oldtimers
and newcomers as reminders of the true Al-Anon is a group started by Mrs.Anne, wife of
foundations of A.A. as a society of men and Dr.Bob to support the spouses of alcoholics.
women whose primary concern is to maintain
their own sobriety and help others to achieve Al-A teen
sobriety: Provides support to their teenage children.
1. Our common welfare should come first;
personal recovery depends upon A.A.unity. Hostels
2. For our group purpose there is but one These are intended mainly for those rendered
ultimate authority- a loving God as He may homeless due to alcohol-related problems. They
express Himself in our group conscience. provide rehabilitation and counseling. Usually
Our leaders are but trusted servants; they abstinence is a condition of residence.
do not govern. [Refer p. 139 and 140 for rehabilitation and
3. The only requirement for A.A. membership nursing management]
is a desire to stop drinking.
4. Each group should be autonomous except OTHER SUBSTANCE USE DISORDERS
in matters affecting other groups or A.A. as
a whole. Drug Addiction in India: UN Report (The
5. Each group has but one primary purpose to Indian Express Feb.1999)
carry its message to the alcoholic who still Of the 4 million registered drug addicts in South
suffers. Asia, 1.25lakh are in India.
Distribution: appetite, irritability, tremors, sweating, cramps,
Alcohol: 42% (including social drinkers) nausea, diarrhea, insomnia, raised body tempe-
Opium:20% rature, piloerection and anorexia.
Heroin: 13% Withdrawal symptoms begin within 12hours
Cannabis: 6.2% of the last dose, peak in 24 to 36 hours and
Others: 1.8% disappear in 5 to 6 days.
Heroin abusers are now estimated to be
around 40,000. Complications
The majority of drug addicts are aged between Complications due to illicit drug use:
16 and 30 years. Parkinsonism, peripheral neuropathy,
These drug abusers are mostly unmarried, and transverse myelitis.
from the lower socio-economic strata; 33 Complications due to intravenous use: Skin
percent of them are engaged in antisocial infection,thrombophlebitis, pulmonary embo-
activities. lism, endocarditis, septicemia, AIDS, viral
hepatitis and tetanus.
Opioid Use Disorders Involvement in criminal activities.
In the last few decades, the use of opioids has
increased markedly world over. India, sur- Treatment
rounded on both sides by routes of illicittransport, Treatment of opioid overdose: Opioid overdose can
namely Golden Triangle (Burma, Thailand, Laos) be treated with narcotic antagonists, e.g.naloxone,
and Golden Crescent (Iran, Afghanistan, naltrexone
Pakistan), is particularly affected. The most Detoxification: Withdrawal symptoms can be
important dependence producing derivatives are managed by methadone, clonidine, naltrexone,
morphine and heroin. buprenorphine, etc.
The commonly abused opioids (narcotics) in
our country are heroin (brown sugar, smack) and Maintenance therapy: After the detoxification phase
synthetic preparations like pethidine, fortwin is over, the patient is maintained on one of the
following regimens:
(pentazocine) and tidigesic (buprenorphine).The
Methadone maintenance
drugs that are injected through needle are heroin,
Opioid antagonists
buprenorphine and pentazocine. Though most
Psychological methods like individual psy-
opiate users had begun chasing (inhaling the
chotherapy, behavior therapy, group therapy
smoke or chasing the dragon) heroin they gradually
and family therapy
shifted to needle use. These injecting drug users
have become a high risk group for HIV infection. Cannabis Use Disorder
Cannabis is derived from hemp plant, Cannabis
Acute Intoxication sativa. The dried leaves and flowering tops are
It is characterized by apathy, bradycardia, often referred to as ganja or marijuana. The resin of
hypotension, respiratory depression, subnormal the plant is referred to as hashish. Bhang is a drink
temperature and pinpoint pupils. Later delayed made from cannabis.
reflexes, thready pulse and coma can occur. Cannabis is either smoked or taken in liquid
form.
Withdrawal Syndrome
Narcotic withdrawal rarely produces a life-threa- Acute Intoxication
tening situation. Common symptoms include Mild intoxication is characterized by mild impair-
watery eyes, running nose, yawning, loss of ment of consciousness and orientation, tachy-
cardia, a sense of floating in the air, euphoria, Treatment
dream-like states, 'flashback' phenomena, altera- Management of intoxication: Amyl nitrite is an
tion in psychomotor activity, tremors, photo-
antidote; diazepam or propranolol are also used.
phobia, lacrimation, dry mouth and increased
appetite. For withdrawal symptoms: Antidepressants (imi-
Severe intoxication causes perceptual distur- pramine or amitriptyline) and psychotherapy.
bances like depersonalization, derealization,
synesthesias and hallucinations. Amphetamine Use Disorder
Amphetamines are powerful CNS stimulants
Withdrawal Symptoms
with peripheral sympathomimetic effects.
They are mostly found in the first 72-96 hours Commonly used amphetamines are pemoline and
and include increased salivation, hyperthermia, methylphenidate.
insomnia, decreased appetite, loss of weight and
insomnia. Acute Intoxication
Characterized by tachycardia, hypertension,
Complications
cardiac failure, seizures, tremors, hyperpyrexia,
Transient or short-lasting psychiatric disor- pupillary dilation, panic, insomnia, restlessness,
ders such as acute anxiety,paranoid psychosis,
irritability, paranoid hallucinatory syndrome and
hysterical fugue-like states, hypomania,
amphetamine-induced psychosis .
schizophrenia-like state.
Amotivational syndrome.
Withdrawal Syndrome
Memory impairment.
Characterized by depression, apathy, fatigue,
Treatment hypersomnia or insomnia, agitation and hyper-
Supportive and symptomatic treatment phagia.
Cocaine Use Disorder Complications
Common street name is 'crack'. It can be admi- Seizures, delirium, arrhythmias, aggressive
nistered orally, intranasally by smoking, or behavior, coma.
parenterally.
LSD Use Disorder (Lysergic acid diethylamide)
Acute Intoxication LSD is a powerful hallucinogen, and was first
Characterized by pupillary dilatation, tachy- synthesized in 1938.It presumably produces its
cardia, hypertension, sweating and nausea and effectsby actingon 5-HTlevelsin brain. A common
hypomanic picture. pattern of LSD use is 'trip' (occasional use
followed by a long period of abstinence).
Withdrawal Syndrome
Intoxication
Agitation, depression, anorexia, fatigue and
sleepiness. Characterized by perceptual changes occurring
in clear consciousness, e.g.depersonalization,
Complications derealization, illusions, synesthesias (colors are
Acute anxiety reaction, uncontrolled compulsive heard, sounds are felt), autonomic hyperactivity,
behavior, seizures, respiratory depression, marked anxiety, paranoid ideation and
cardiac arrhythmias. .impairmenf ofjudgment.
Withdrawal Syndrome apathy, impaired judgment and neurological

Flashbacks (brief experiences of the hallu- signs.
cinogenic state).
Withdrawal Symptoms
Complications Anxiety, depression.
Anxiety, depression, psychosis or visual
hallucinosis. Complications
Irreversible damage to the liver and kidneys,
Treatment
peripheral neuropathy, perceptual disturbances
Symptomatic treatment with antianxiety, anti- and brain damage.
depressant or antipsychotic medications.
Treatment
Barbiturate Use Disorder
Reassurance and diazepam for intoxication.
The commonly abused barbiturates are seco-
barbital, pentobarbital and amobarbital.
PREVENTION OF SUBSTANCE USE
Intoxication DISORDER
Acute intoxication characterized by irritability, Primary Prevention

lability of mood, disinhibited behavior, slurring Reduction of over prescribing by doctors
of speech, incoordination, attention and memory (especially with benzodiazepines and other
impairment. anxiolytic drugs).
Identification and treatment of family
Complications
members who may be contributing to the drug
Intravenous use can lead to skin abscesses, cellu- abuse.
litis, infections, embolism and hypersensitivity
Introduction of socialchanges is likelyto affect
reactions.
drinking patterns in the population as a whole.
Withdrawal Syndrome
This is made possible by:
Putting up the price of alcohol and
It is characterized by marked restlessness,
alcoholic beverages
tremors, and seizures in severe cases resembling
Controlling or abolishing the advertising
delirium tremens.
of alcoholic drinks
Treatment Controls on sales (by limiting hours or
banning sales in supermarkets)
If the patient is conscious, induction of vomiting
and use of activated charcoal can reduce the Restrictingavailabilityand lessening social
absorption. Treatment is symptomatic. deprivation (Governmental measures)
Other approaches are to strengthen the indi-
Inhalants or Volatile Solvent Use Disorder vidual's personal and social skills to increase
The commonly used volatile solvents include self-esteem and resistance to peer pressure.
petrol, aerosols, thinners, varnish remover and Health education to college students and the
industrial solvents. youth about the dangers of drug abuse
through the curriculum and mass media.
Intoxication Health education should also include certain
Inhalation of a volatile solvent leads to euphoria, specificgroups where a substance like alcohol
excitement, belligerence, slurring of speech, may be culturally accepted. For instance,
certain tribal communities such as the Some practical issues under relapse
Lambani group manufacture arrack, and its prevention include:
intake is considered normal. Some commu- Motivation enhancement, including
nities use it in the postnatal period, as alcohol education about health consequences of
is believed to strengthen the pelvic muscles alcohol use
and also speed up retroversion of the uterus. Identifying high-risk situations and
Such attitudes should be addressed and developing strategies to deal with them
corrected. (craving management)
An overall improvement in the socioeconomic Drink refusal skills (assertiveness training)
condition of the population. Dealing with faulty cognitions
Handling negative mood states
Secondary Prevention Time management
Anger control
Early detection and counseling.
Financial management
Brief intervention in primary care (simple
Developing the work habit
advice by a general practitioner plus an
Stress management
educational leaflet).
Sleep hygiene
Motivational interviewing which involves
Recreation and spirituality
providing feedback to the patient on the
Family counseling, to reduce interpersonal
personal risks that alcohol poses, together
conflicts, which may otherwise trigger
with a number of options for change.
relapse
A full assessment including an appraisal of
current medical, psychological and social
REHABILITATION
problems. Assessment also includes ascer-
taining whether alcoholism is the primary or The aim of rehabilitation of an individual
secondary problem. For example, a patient deaddicted from the effects of alcohol/ drugs, is
to enable him to leave the drug sub-culture and to
with diabeticneuropathy may be using alcohol
develop new social contacts. In this, clients first
to numb pain. Alcohol is also used by some to
engage in work and social activities in sheltered
relieve asthmatic symptoms. In such instances,
surroundings and then take greater responsi-
treatment of the medical problem can help to
bilities for themselves in conditions increasingly
control alcoholism.
like those of everyday life. Continuing social
Detoxification with benzodiazepines (diaze-
support is usually required when the person
pam, chlordiazepoxide).
makes the transition to normal work and living.
Tertiary Prevention
NURSING MANAGEMENT FOR SUBSTANCE
Specific measures include: USE DISORDER
Alcohol deterrent therapy (Disulfiram or
Antabuse). Nursing Assessment
Other therapies include assertiveness training 1. Recognitionof alcoholabuse: The CAGEques-
(toprevent yielding to peer pressure), teaching tionnaire may be adopted for this purpose:
coping skills (some take drugs to combat C: Have you ever feltyou ought to CUTdown
stress), behavior counseling, supportive psy- on your drinking?
chotherapy and individual psychotherapy. A: Have people ANNOYED you by criticizing
Agencies concerned with alcohol-related your drinking?
problems: Alcoholics Anonymous (AA), Al- G: Have you ever felt GUILTY about your
Anon, Al-Ateen, etc. drinking?
Table 11.1: Nursing interventions during acute intoxication
(a) Place the client in a room near Client's safety is nursing priority.
the nurse's station or where the staff
can observe the client closely.
(b) Monitor the client's sleep pattern;
he may need to be restrained at
night if confused or if he wanders - do-
or attempts to climb out of bed.
(c) Decrease environmental stimuli (bright Too many stimuli in the environment
lights, television, visitors) when the may increase misperceptions and
client is restless, irritable or tremulous. restlessness.
(d) Institute seizure precautions (padded Seizures can occur during with-
tongue blade and airway at bedside, drawal, precautions can minimize
raised side-rails, etc.) chances of injury.
(e) Reorient the client to person, time, The client is often confused and
place and situation as needed. needs to be reoriented.
(f) Talk to the client in simple, direct, Patient's ability to deal with complex
concrete language. or abstract ideas is limited.
E: Have you ever had a drink first thing in Blood alcohol concentration.
the morning (an EYE-OPENER)to steady Most drugs can be detected in urine, the
your nerves or get rid of a hangover? notable exception being LSD.
2. Besuspicious about' at-risk' factors:Problems
in the marriage and family, at work, with
Nursing Diagnosis I
finances or with the law; at risk occupations;
withdrawal symptoms after admission; Risk for injury related to hallucinosis, acute into-
alcohol-related physical disorders; repeated xication evidenced by confusion, disorientation,
accidents; deliberate self-harm. inabilitytoidentifypotentiallyharmfulsituations.
3. If at-risk factors raise suspicion, the next step
Objective: Client will not harm self.
is to ask tactful but persistent questions to
confirm the diagnosis.
4. Certain clinical signs lead to the suspicion
Nursing Diagnosis II
that drugs are being injected: needle tracks
and thrombosed veins, wearing garments Altered health maintenance related to inability to
with long sleeves, etc. IV use should be identify, manage or seek out help to maintain
suspected in any patient who presents with health, evidenced by various physical symptoms,
subcutaneous abscesses or hepatitis. exhaustion, sleep disturbances, etc.
5. Behavioral changes: Absence from school or
work, negligence of appearance, minor crimi- Objective:The clientwill maintain optimum health
nal offences,isolation from former friends and status.
adoption of new friends in a drug culture. Intervention: See Table 11.2.
6. Laboratory tests:
Raised Gamma-Glutamyl Transpeptfdase Nursing Diagnosis Ill
(GGT). Ineffective denial related to weak, underdevelo-
Raised mean corpuscular volume. ped ego, evidenced by lack of insight, rationa-
Table 11.2: Nursing interventions to improve health status of alcoholics
(a) Monitor the client's health status. To evaluate the client's progress
Administer medications as prescribed accurately.
by physician. Observe the client for any
behavioral changes and inform
physician when necessary.
(b) Maintain fluid and electrolyte balance. Patients with alcohol abuse problems
are at high risk for fluid and
electrolyte ,.imbalances.
(c) Provide food or nourishing fluids as Many patients who use alcohol
soon as the client can tolerate eating heavily experience gastritis,
(bland food usually is tolerated best anorexia and so forth. Therefore
at first). bland foods are tolerated most
easily. It is important to re-establish
nutritional intake as soon as possible.
(d) Ensure that amount of protein in the Diseased liver may be incapable of
diet is correct for individual patient properly metabolizing proteins,
condition. resulting in an accumulation of
ammonia in the blood that circulates
to the brain and can result in altered
consciousness.
(e) Provide small frequent feedings of To correct malnutrition.
patient's favorite foods. Supplement
with vitamins and minerals.
(f) Assist the client in self-care activities; The level of client independency
it may be necessary to provide is determined by the severity of
complete physical care, depending on the withdrawal symptoms. The client's
severity of the client's withdrawal. needs should be met with the
greatest degree of independence
he can attain.
Table 11.3: Nursing interventions to improve adaptive behaviour

(a) Develop trust, convey an attitude of Unconditional acceptance promotes

acceptance. Ensure that patient dignity and self-worth.
understands it is not him but
his behavior that is unacceptable.
(b) Identify recent maladaptive behaviors The first step in decreasing
or situations that have occurred in the denial and rationalization is for patient
patient's life and discuss how use of to see the relationship between
drugs/alcohol may be a contributing substance use and personal problems.
factor.
(c) Do not allow patient to rationalize or This only serves to prolong the
blame others for behaviors associated ' denial.
with substance use.
(d) Provide positive reinforcement when the Enhances repeytion of desirable
client shows insight into his behavior. behavior.
Table 11.4: Nursing interventions to improve adaptive coping skills among alcoholics
(a) Encourage client to explore options To develop desirable ways of coping
available to deal with stress, rather with stress.
than resorting to substance use.
Practice these techniques.
(b) Give positive reinforcement for Because of weak ego, patient needs
ability to delay gratification and a lot of positive feedback to
respond to stress with adaptive coping enhance self-esteem.
strategies.
(c) Teach client and family that alcoholism Family and significant others are ~!so
is a disease that requires long-term treatment affected by the client's substance
and followup. Refer to AA, Al-Anon use and need help.
and other support groups as indicated.
(d) Teach the client about the Patients with alcohol/ drug use may
prevention of HIV transmission. involve in high risk behaviors which
increase the risk of HIV transmission
(e) Maintain frequent contact with the Patient will not feel left alone
client, even if it is only by a brief telephone to deal with his problems.
call.
(f) If drinking occurs, discuss the events The client may be able to see the
that led to the incident with the patient relatedness of the event or a pattern
in a non-judgmental manner. Discuss of behavior while discussing the
ways to avoid similar circumstances in situation. Anticipatory planning may
the future. prepare the client to avoid similar
circumstances in future.
(g) Assist the patient to plan weekly, or even Scheduled events provide the patient
daily, schedules of purposeful activities, with something to look forward to.
such as appointments, talking walks, etc.
lization of problems, blaming others, failure to Evaluation

accept responsibility for his behavior. The following questions can be useful in
Objective: Patient will understand the effect of evaluating the nursing care:
his behavior on others and verbalize acceptance Has detoxification occurred without compli-
of responsibility and desire for change. cations?
Intervention: See Table 11.3. Has a correlation been made between personal
problems and the use of substances?
Nursing Diagnosis IV Does he accept responsibility for own
Ineffective individual coping related to behavior?
impairment of adaptive behavior and problem-
solving abilities, evidenced by use of substances REVIEW QUESTIONS
as coping mechanisms. Drug addiction (Oct 2000)
Objective: Patient will be able to use adaptive Drugs commonly used for addiction (Nov
coping mechanisms, instead of abusing drugs/ 2003)
alcohol, in response to stress. Drug abuse (Apr 2002, Apr 2004), dependence
Intervention: See Table 11.4. (Nov 2003), tolerance and withdrawal state
What are the dependency producing drugs Opioid use disorders
(Oct 2000) Prevention of drug abuse (Feb 2000)
Etiology of substance use (Nov 1999) Nursing management for substance use
Complications of alcohol dependence disorder (Oct 2000, Nov 2001, Nov 2002, Nov
Delirium tremens (Nov 1999, Oct 2005) 2003, Oct 2004)
Korsakoff's syndrome (Apr 2006) Out line rehabilitation program for an
Prevention of alcohol abuse (Feb 2000) alcoholic patient who is on anatabuse therapy
Treatment of alcohol dependence (Nov 2003)
Alcohol anonymous (Oct 2000, Oct 2005, Apr Esperol (Apr 2002)
2006)
Disorders of Adult
Personality and
Behavior
D PERSONALITYDISORDER mixed personality disorders is more common
Definition (ICD9) than a single personality disorder in an
Incidence individual.
Classification
Clinical features of abnormal personalities
Etiology
Classification
Treatment
Nursing Intervention
A. ICD10
D SEXUALDISORDERS Paranoid personality disorder
Classification Schizoid (schizotypal) personality disorder
Dissocial personality disorder
Emotionally unstable (impulsive and border-
PERSONALITYDISORDER
line type) personality disorder
The term personality refers to enduring qualities Histrionic personality disorder
of an individual that are shown in his ways of Anankastic (obsessive-compulsive perso-
behaving in a wide variety of circumstances. nality disorder)
Personality disorders result when personality Anxious (avoidant) personality disorder
traits become abnormal, i.e.become inflexibleand Dependent personality disorder
maladaptive and cause significant social or Other disorders
occupational impairment or significant subjective
distress. B. OSMIV
In ICDlO,they are listed under the section on
In DSMIV,personality disorders are coded on axis
Disorders of Adult Personality and Behavior (F6).
II and have been divided into three clusters:
a. Cluster A (odd and eccentric): paranoid,
Definition (ICD9)
schizoid, schizotypal personality disorders
The definition of abnormal personality given by b. Cluster B (dramatic, emotional and erratic):
ICD9 is as follows: antisocial, histrionic, narcissistic personality
An abnormal personality is one in which there disorders
are "deeply ingrained maladaptive patterns of c. Cluster C (anxious and fearful): avoidant,
behavior recognizable by the time of adolescence
dependent and obsessive-compulsive perso-
or earlier and continuing through most of adult
nality disorders
life. Because of this, the patient suffers or others
have to suffer, and there is an adverse affect on
Clinical Features of Abnormal Personalities
the individual or on society."
a. Paranoid Personality Disorder
Incidence Suspicious
The prevalence of personality disorders in the Mistrustful
general population is 5 to 10%. Occurrence of Sensitive
Disorders of Adult Personality and Behavior 145
Argumentative j. Borderline Personality

Stubborn Unstable relationships
Self-important Impulsive behavior
Variable moods
b. Schizoid Personality Disorder Lack of control on anger
Emotionally cold Recurrent suicidal threats or behavior
Aloof Uncertainty about personal identity
Detached Chronic feelings of emptiness
Humourless Efforts to avoid abandonment
Introspective Transient stress-related paranoid or dissocia-
tive symptoms
c. Schizotypal Disorder
Inappropriate affect h. Anxious (Avoidant) Personality Disorder
Odd beliefs or magical thinking Persistent feeling of tension and apprehension
Social withdrawal Inferiority complex
Odd, eccentric or peculiar behavior Fear of criticism, disapproval or rejection
Unwillingness to become involved with
d. Antisocial (Dissocia/) Personality Disorder people
(Sociopath, Psychopath) Excessivepreoccupation with being criticized
Failure to sustain relationships or rejected in social situations
Disregard for the feelings of others
Impulsive actions i. Dependent Personality
Low tolerance to frustration Subordination of one's own needs
Tendency to cause violence Unwillingness to make even reasonable
Lack of guilt demands on other people
Failure to learn from experience Inability to take decision
Feeling uncomfortable or helpless when alone
e. Histrionic Personality Disorder
This disorder is more common in females j. Obsessive-compulsive (anankastic)
Dramatic emotionality (Emotional blackmail, Personality Disorder
angry scenes, demonstrative suicide attempts, Feeling of excessive doubt and caution
etc.) Preoccupation with details, rules, lists, order
Craving for novelty and excitement or schedule
Shallow and labile affectivity Perfectionism
Attention-seeking behavior Rigidity and stubbornness
Over concern with physical attractiveness High standards.
f. Narcissistic Personality Disorder Etiology

Inflated sense of self-importance A Hereditary factors: Chromosomal abnormality
Attention-seeking, dramatic behavior or genetic predisposition can be responsible
Unable to face criticism for a psychopathic personality.
Lack of empathy B. Relation of personality disorder to mental disorder:
Exploitative behavior For example, schizoid personalities are
considered to be partial expressions of schizo- Explore with patient alternative ways of
phrenia. handling frustration to relieve pent-up
C. Personality disorder and upbringing: e.g. tensions (e.g. large motor skills that channel
disturbed parent-child relationships. hostile energy into socially acceptable
D. Other causes: behavior).
Maternal deprivation, especially in Staff should maintain a calm attitude. Have
antisocial personality. sufficient staff available to present a show of
Borderline personalities are more likely to strength to patient ifnecessary.It alsoprovides
report physical and sexual abuse in some physical security for the staff.
childhood. Administer tranquilizing medications as
Histrionic personality is said to occur as a prescribed.
result of failure to resolve oedipal complex Mechanical restraints may be neeessary if the
and excessive use of repression as a client is not calmed by 'talking down' or by
mechanism of defense. medication.
Dependent personality may be due to Explain consequences if limits are violated.
fixation in the oral stage of development. A consequence must involve something of
Paranoid personality is due to absence of value to the client, and all staff must be
trust, which results from lack of parental consistent in enforcing these limits.
affection in childhood and persistent Provide positive feedback for acceptable
rejection by parents leading to low self- behavior which will encourage repetition of
esteem. desirable behaviors.
Help client to gain insight into his own
Treatment behavior. He must understand that certain
Personality disorder is often difficult to treat. behaviors will not be tolerated within the
Drug treatment has a very limited role and may society and that severe consequences will be
be used if associated mental illness like depres- imposed upon those individuals who refuse
sion or psychosis is present. Individual and group to comply.
psychotherapy, therapeutic community and beha- Talk about his past behaviors. Help him
vioral therapy may be beneficial. Manipulation identify ways in which he has exploited
of the social environment can be tried. others. Encourage him to explore how he
would feelif the circumstances were reversed.
B. BorderlinePersonalityDisorder
A. Antisocial Personality Disorder Observe patient's behavior frequently. Do this
Convey an accepting attitude towards the during routine activities and interaction;
patient. Be honest, keep all promises and avoid appearing watchful and suspicious.
convey the message that it is not him but his Secure a verbal contract from patient that he
behavior which is unacceptable. will seek out staffmembers forhelp when urge
Maintain low level of stimuli in the environ- for self-mutilation is felt.
ment to decrease agitation and aggressive If self-mutilation occurs, care for patient's
behavior; remove all dangerous objects from wounds in matter-of-factmanner. Do not give
the environment. positive reinforcement to this behavior by
Help the patient to identify the true object of offering sympathy or additional attention.
his hostility and encourage him to gradually Assign staffon a one-to-onebasis ifneed arises.
verbalize hostile feelings. This may help him Encourage patient to talk about feelings he
to come to terms with unresolved issues. was having just prior to this behavior. Act as
Disorders of Adult Personality and Behavior 14 7
a role model for appropriate expression of Treatment

angry feelings. Give positive reinforcement Counseling to help the individual
when attempts to conform are made. reconcile with the anatomic sex.
Set limits on acting out behavior. Sexchange to the desired gender [sexreas-
Rotate staff who work with the patient to signment surgery (SRS)]in selected cases
prevent the patient from developing depen- b. Gender identity disorder of childhood: This is a
dence on particular staff members. disorder similar to transsexualism, with a very
Explore feelings that relate to fears of aban- early age of onset.
donment. Help client understand that these c. Dual-role transvestism: It is characterized by
fears are causing his clinging and distancing wearing clothes of the opposite sex in order to
behaviors. Help patient understand how these enjoythe temporary experienceofmembership
behaviors interfere with satisfactory relations. of the opposite sex but without any desire for
permanent sex change.
SEXUAL DISORDERS d. Intersexuality: The patients have gross anato-
mical or physiological features of the other
In ICDlO gender identity disorders, disorders of
sex. For example, pseudohermaphroditism,
sexual preference and sexual development and
Turner's syndrome, congenital adrenal
orientation disorders are listed under Disorders
hypoplasia.
of Adult Personality and Behavior (F6), while
sexual dysfunctions are listed under Behavioral
Psychological and Behavioral Disorders
Syndromes Associated With Physiological Associated with Sexual Development
Disturbances and Physical Factors (FS). and Maturation (F6)
Classification Homosexuality
Gender identity disorders. In this, sexual relationships are maintained be-
Psychological and behavioral disorders asso- tween persons of the same sex. Female homo-
ciated with sexual development and sexuals are called as 'lesbians' and male
maturation. homosexuals are called 'gay.'
Disorders of sexual preference (paraphilias).
Sexual dysfunctions. Treatment
Behavior therapy: aversion therapy, covert
Gender Identity Disorders (F6) sensitization, systematic desensitization.
In these disorders, the sense of one's masculinity Supportive psychotherapy.
or femininity is disturbed. They include: Psychoanalytic psychotherapy
Transsexualism.
Gender identity disorder of childhood. Disorders of Sexual Preference (ICD10 - F6)
Dual-role transvestism. or Paraphilias (DSMIV)
Intersexuality. In paraphilias sexual arousal occurs persistently
a. Transsexualism: In this, there is a persistent and significantly in response to objects, which
and significant sense of discomfort regarding are not a part of normal sexual arousal. These
one's anatomic sex and a feeling that it is disorders include:
inappropriate to one's perceived gender. The a. Fetishism: Sexual arousal occurs with a non-
person will be preoccupied with the wish to living object which is usually intimately
get rid of one's genitals and secondary sex associated with the human body. The fetish
characteristics and to adopt the sex object may include bras, underpants, shoes,
characteristics of the other sex. gloves, etc.
b. Transvestism: Sexual arousal occurs by c. Premature ejaculation: Ejaculation before the
wearing clothes of the opposite sex. completion of satisfactory sexual activity for
c. Sexual sadism: The person is sexually aroused both partners.
by physical and psychological humiliation, d. Non-organic vaginismus: An involuntary
suffering or injury of the sexual partner. spasm of lower l/3rd of vagina, interfering
d. Sexual masochism: Here the person is sexually with coitus.
aroused by physical or psychological humi- e. Non-organic dyspareunia: Pain in the genital
liation or injury inflicted on self by others. area of either male or female during coitus.
e. Exhibitionism: In this the person is sexually
aroused by the exposure of one's genitalia to Treatment
an unsuspecting stranger. Psychoanalysis
f. Voyeurism: This is a persistent or recurrent Hypnosis
tendency to observe unsuspecting persons Group psychotherapy
naked (usually of the other sex) and engaged Behavior therapy
in sexual activity.
g. Frotteurism: This is a persistent or recurrent Nursing Intervention for Client with Sexual
involvement in the act of touching and rubbing Disorder
against an unsuspecting, non-consenting Assess client's sexual history and previous
person. level of satisfaction in sexual relationships;
h. Pedophilia: It is characterized by persistent or also assess client's perception of the problem.
recurrent involvement of an adult in sexual Note cultural, social, ethnic, racial and
activity with prepubertal children. religious factors that may contribute to
conflicts regarding variant sexual practices.
i. Zoophilia (Beastiality): Involving in sexual
Assess for any medications which might be
activity with animals.
affecting libido.
j. Other paraphilias: Sexual arousal occurs with
Provide information regarding sexuality and
urine, feces, enemas, etc. sexual functioning, correct any misconcep-
tions if necessary. Teach patient that sexuality
Treatment is a normal human response and that it
Behavior therapy: aversion therapy . involves complex inter-relationships among
Psychoanalysis. one's self-concept, body image, family and
Drug therapy: Antipsychotics have been used cultural influences.
for severe aggression associated with Both the client and his /her partner may need
paraphilias. additional assistance if problems in sexual
relationship are severe or remain unresolved.
Sexual Dysfunctions (F5) Refer for additional counseling or sex therapy
if required.
Sexual dysfunction is a significant disturbance
Assist therapist as necessary in plan of
in the sexual response cycle, which is not due to behavior modification to help decrease
an underlying organic cause variant behavior.
The common dysfunctions are: In all cases, an accepting and non-judgmental
a. Frigidity: Absence of desire for sexual activity. attitude on the part of the nurse is highly
b. Impotence: This disorder is characterized by essential for successful resolution of these
an inability to have or sustain penile erection problems as these are highly sensitive issues
till the completion of satisfactory sexual and may be causing significant distress to the
activity. patient.
Disorders of Adult Personality and Behavior 149
REVIEW QUESTIONS Histrionic personality

Define abnormal personality Borderline personality
Classification of personality disorders (Nov Etiology of personality disorders (Feb 2000)
1999) Nursing management for antisocial
Paranoid personality disorder personality (Feb 2000)
Schizoid personality disorder Sexual disorder (Nov 2002)
Antisocial personality disorder (Feb 2000, Oct Classification of sexual disorders (Feb 2000)
2004) Transsexualism (Oct 2005)
Sociopathic reactions (Oct 2005) What is voyeurism (Apr 2004)
Psychopathic personality (Nov 2003) Paraphilias (sexual perversions) (Nov 2003)
Childhood Psychiatric
Disorders
0 CLASSIFICATION realized. In 1954 the first graduate program in
0 MENTALRETARDATION child psychiatric nursing was opened. Advocates
0 DISORDERSOF PSYCHOLOGICALDEVELOPMENT for Child Psychiatric Nursing (ACPN), the
Specific Developmental Disorders of
Speech and Language
professional organization for this nursing
Specific Developmental Disorders of specialty was established in 1971, and the first
Scholastic Skills ANA certificationof child psychiatric nurses took
Specific Developmental Disorders of place in 1979.The ANA's Standards of child and
Motor Function
Pervasive Developmental Disorder- adolescent psychiatric and mental health nursing
Childhood Autism practice were published in 1985.
0 BEHAVIORALAND EMOTIONALDISORDERS The child psychiatric nurse uses a wide range
WITHONSETUSUALLYOCCURRINGIN
of treatment modalities, including milieu therapy,
CHILDHOODANDADOLESCENCE
Hyperkinetic Disorder behavior modification, cognitive behavior
Conduct Disorders therapy, therapeutic play, group and family
Emotional Disorders With Onset Specific therapy and pharmacological agents.
to Childhood
- Separation Anxiety Disorder of
Child psychiatric nursing is different from
Childhood adult psychiatric nursing in the following ways:
Phobic Anxiety Disorder of Childhood It is seldom that children initiate a consultation
Social Anxiety Disorder of Childhood with the clinician. Instead, they are brought
- Sibling Rivalry Disorder
Disorders of Social Functioning With Onset by adults, usually the parents, who think that
Specific to Childhood and Adolescence some aspect of behavior or development is
Tic Disorders abnormal.
Other Behavioral and Emotional Disorders
The child's stage of development determines
With Onset Usually Occurring In Childhood
and Adolescence whether behavior is normal or abnormal. For
Non-Organic Enuresis instance, bedwetting is normal at the age of 3
Non-Organic Encopresis years but abnormal when the child is 7. Thus
Feeding Disorder of Infancy and
greater attention should be paid to the stage
Childhood
Pica of development of the child and duration of
Stereotyped Movement Disorders the disorder.
Stuttering (Stammering) Children are generally less able to express
themselves in words; therefore evidence of
disturbance is based more on observations of
The field of child psychiatry is new to the behavior made by parents, teachers and
twentieth century, and child psychiatric nursing others.
evolved gradually as the therapeutic value of The treatment of children makes less use of
nurses' relationship with children began to be medications or other methods of individual
Childhood Psychiatric Disorders 151
treatment. Main emphasis is on changing the 'General intellectual functioning' is defined as

attitudes of parents, reassuring and retraining the result obtained by the administration of
children, working with family and coordi- standardized general intelligence tests developed
nating the efforts of others who can help for the purpose, and adopted to the conditions of
children especially at school. the region/ country.
'Significant subaverage' is defined as an
CLASSIFICATION (ICD10) Intelligence Quotient (IQ) of 70 or below on
Mental retardation (F7) standardized measures of intelligence.The upper
Disorders of psychological development (FS) limit is intended as a guideline and could be
Specific developmental disorders of speech extended to 75 or more, depending on the
and language reliability of the intelligence test used.
Specificdevelopmental disorders of scholastic 'Adaptive pehavior' is defined as the degrees
skills with which the individual meets the standards
Specific developmental disorders of motor of personal independence and social responsi-
function bility expected of his age and cultural group. The
Pervasive developmental disorders expectations of adaptive behavior vary with the
Behavioral and emotional disorders with onset chronological age. The deficits in adaptive
usually occurring in childhood and adolescence behavior may be reflected in the following areas:
(F9)
During infancy and childhood in:
Hyperkinetic disorders
Sensory and motor skill development
Conduct disorders
Communication skill (including speech and
Emotional disorders
language)
Separation anxiety disorder of childhood
Self-help skills
Phobic anxiety disorder of childhood
Socialization
Social anxiety disorder of childhood
Sibling rivalry disorder During childhood and adolescence in:
Disorders of social functioning Application of basic academic skill to daily
Electivemutism life activities
Tic disorders Application of appropriate reasoning and
Other behavioral and emotional disorders in judgment in the mastery of the environment
childhood and adolescence Social skills.
Non-organic enuresis
During late adolescence in:
Non-organic encopresis
Feeding disorders of infancy and child- Vocational and social responsibilities and
hood performance.
Stereotyped movement disorders 'Developmental period' is defined as the period
Stuttering of time between conception and the 18th birth-
day.
MENTAL RETARDATION (F7)
Epidemiology
Definition
About 3%of the world population is estimated to
"Mental retardation refers to significantly sub- be mentally retarded. In India, 5 out of 1000
average general intellectual functioning resulting children are mentally retarded (The Indian Express,
in or associated with concurrent impairments in 13th March 2001). Mental retardation is more
adaptive behavior and manifested during the common in boys than girls. With severe and
developmental period" (American Association on profound mental retardation mortality is high due
Mental Deficiency, 1983). to associated physical diseases.
Etiology Placental dysfunction
Toxemia of pregnancy
Genetic Factors
Placenta previa
Chromosomal abnormalities Cord prolapse
Down's syndrome Nutritional growth retardation
Fragile Xsyndrome
Trisomy Xsyndrome Perinatal Factors
Turner's syndrome
Birth asphyxia
Cat-cry syndrome
Prolonged or difficult birth
Prader-willi syndrome
Prematurity (due to complications)
Metabolic disorders Kernicterus ,
Phenylketonuria Instrumental delivery (resulting in head
Wilson's disease injury, intraventricular hemorrhage)
Galactosemia
Postnatal Factors
Cranial malformation
Hydrocephaly Infections
Microcephaly Encephalitis
Measles
Gross diseases of brain Meningitis
Tuberous scleroses Septicemia
Neurofibromatosis Accidents
Epilepsy Lead poisoning
Prenatal Factors Environmental and Sociocultural Factors

Infections Cultural deprivation
Rubella Low socioeconomic status
Cytomegalovirus Inadequate caretakers
Syphilis Child abuse
Toxoplasmosis, herpes simplex
Endocrine disorders Classification
Hypothyroidism Intelligence Quotient (IQ)
Hypoparathyroidism Mild (Educable) 50-70
Diabetes mellitus Moderate (Trainable) 35-50
Severe (Dependent retarded) 20-35
Physical damage and disorders
Profound (Lifesupport) <20
Injury
Hypoxia
Behavioral Manifestations
Radiation
,.;
Hypertension Mild Retardation (l.Q. 50-70)
Anemia This is commonest type of mental retardation
Emphysema accounting for 85 to 90% of all cases. These
Intoxication individuals have minimum retardation in
Lead sensory-motor areas. They often progress upto VI
Certain drugs standard in school and can achieve vocational
Substance abuse and social self-sufficiency with a little support.
They can develop social and communication CTscanorMRibrain,e.g.intuberoussclerosis.

skills, but have deficits in cognitive function like Thyroid function tests when cretinism is
poor ability for abstraction and egocentric suspected.
thinking. Psychological tests like Stanford Binet
Intelligence Scale and Wechsler Intelligence
Moderate Retardation (l.Q. 35-50) Scale For Children (WISC), for categorizing
About 10% of mentally retarded come under this the child's level of disability.
Through psychological testing the mental age
group. Communication skills develop much
of the child is estimated. The Intelligence Quotient
slowly in these individuals. They can be trained
is then determined using the formula:
to support themselves by performing semiskilled
or unskilled work under supervision. Mental Age (M.A.)
---------- x 100
Chronological Age (C.A.)
Severe Retardation (l.Q. 20-35)
Severemental retardation is often recognized early Prognosis
in life with poor motor development and absent The prognosis for children with mental retar-
or markedly delayed speech and communication dation has improved and institutional care is no
skills.There is a possibility of teaching some skills longer recommended. These children are
in AOL skills with long-term consistent behavior mainstreamed whenever feasible and are taught
modification. Butmost of them require a great deal survival skills. A multidimensional orientation
of assistance and structured living arrangements. is used when working with these children,
considering their physiological, cognitive, social
Profound Retardation (1.0.< 20) and emotional development.
This group accounts for 1to 2 percent of all men-
Prevention
tally retarded. The achievement of developmental
milestones is markedly delayed. They require Primary Prevention
constant nursing care and superv1s1on. Preconception
Associated physical disorders are common. Genetic counseling, which is an attempt to
determine risks of occurrence or recurrence of
Diagnosis specific genetic or chromosomal disorders;
History collection from parents and care- parents can then make an informed decision
takers. as to the risks of having a retarded child.
Physical examination. Immunization for maternal rubella.
Neurological examination. Blood tests for marriage licenses can identify
Assessing milestones development. the presence of venereal diseases.
Investigations Adequate maternal nutrition can lay a sound
urine and blood examination for metabolic metabolic foundation for later childbearing.
disorders Family planning in terms of size, appropriate
culture for cytogenic and biochemical spacing, and age of parents can also affect a
studies variety of specific causal agents.
amniocentesis in infant chromosomal During Gestation
disorders Two general approaches to prevention are
chorionic villi sampling. associated with this period:
Hearing and speech evaluation. a. Prenatal care
EEG, especially if seizures are present. b. Analysis of fetus for possible genetic disorders.
a. Prenatal care Tertiery Prevention
Adequate nutrition, fetal monitoring and This includes rehabilitation in vocational,
protection from disease. physical and social areas according to the level
Avoidance of teratogenic substances like of handicap. Rehabilitation is aimed at reducing
exposure to radiation and consumption of disability and providing optimal functioning in
alcohol and drugs. a child with mental retardation.
b. Analysis of fetus
Byamniocentesis, fetoscopy, fetal biopsy and
Care and Rehabilitation of the
ultrasound. Mentally Retarded
At delivery The main elements in a comprehensive service
Delivery conducted by expert doctors and for mentally retarded individuals and their
staff, especially in cases of high-risk preg- families include:
nancy (e.g. maternal conditions of diabetes, The prevention and early detection of mental
hypertension etc). handicaps.
Apgar scoring done at 1 and 5 minutes after Regular assessment of the mentally retarded
the birth of the child. person's attainments and disabilities.
Close monitoring of mother and child. Advice, support, and practical measures for
Injection of gamma globulin, which can families.
prevent Rh-negativemothers from developing Provision for education, training, occupation,
antibodies that might otherwise affect or work appropriate for each handicapped
subsequent children. person.
Housing and socialsupport to enable self-care.
Childhood Medical, nursing, and other services for those
Proper nutrition throughout the developmen- who require them as outpatients, day patients,
tal period and particularly during the first 6 or inpatients.
months after birth. Psychiatric and psychological services.
Dietary restrictions for specific metabolic
disorders until no longer needed. General provisions: The general approach to care
Avoidance of hazards in the child's environ- is educational and psychosocial. The family
ment to avert brain injury from causes such as doctor and pediatrician are mainly responsible
lead poisoning, ingestion of chemicals, or for the early detection and assessment of mental
accidents. retardation. The team providing continuing
health care also includes psychologists, speech
therapists, nurses, occupational therapists and
Secondary Prevention
physic-therapists.
Early detection and treatment of preventable
disorders. For example, phenylketonuria and The mildly retarded: A few mildly retarded children
hypothyroidism can be effectively treated at require fostering, boarding schools placements
an early stage by dietary control or hormone or residential care, but usually specialist services
replacement therapy. are not required. Mildly retarded adults may need
Early recognition of presence of mental help with housing, employment, or with the
special problems of old age.
retardation. A delay in diagnosis may cause
unfortunate delay in rehabilitation. The severely retarded: In case of children some
Psychiatric treatment for emotional and require special services throughout their lives,
behavioral difficulties. which may include a sitting service, day respite
Childhood Psychiatric Disorders 15 5
during school holidays, or overnight stays in a Remember, a mentally retarded child learns
foster family or residential care. In case of adults, very slowly. Tellthe parents not to be dejected
provisions are required for work, occupation, at the slow progress, nor feel threatened by
housing, adult education, etc. The main principle the child's failure.
now guiding the provision of resources is that
Vocational training: The activities included in
the retarded person should be given sufficient
vocational training are work preparation,
help to be able to use the usual community ser-
selective placement, post placement and follow
vices, rather than to provide specialist segregated up.
services. For example, MITRA Special School and
Education and training: The aim is that as many Vocational Training Center for the Mentally
mentally retarded children as possible are Retarded.
educated in ordinary schools either in normal Help for families: Help for families is needed from
classes or in special classes. There is now an the time that the diagnosis is first made; adequate
increasing use of more specialist teaching and a time must be allowed to explain the prognosis;
variety of innovative procedures for teaching indicate what help can be provided, and discuss
language and other methods of communication. the part that the parents can play in helping their
Before leaving school, these children require child to achieve full potential.
reassessment and vocational guidance. When the child starts school, the parents
Hints for successful skill training: should not only be kept informed about his
Divide each training activity into small steps progress, but should feelinvolved in the planning
and demonstrate. and provision of care.
Give the mentally retarded person repeated Families are likely to need extra help when
training in each activity. their child is approaching puberty or leaving
Give the training regularly and systematically. school; both day and overnight cares are often
Do not let parents get impatient. required to relieve caregivers and to encourage
Start the training with what the child already the retarded person to become more independent.
knows and then proceed to the skill that needs Stages in parent counseling:
to be trained. By this the child will have a Stage 1: Impart information regarding condition
feeling of success and achievement. of the mentally retarded child. Avoid giving
Reward his effort even if the child attains near misleading information or building false hopes
success, by appreciation or with something in the parents.
that he likes.
Stage 2: Help the parents develop right attitude
Reduce the reward gradually as he masters a
towards their mentally retarded child (to prevent
skill and takes up another skill for training.
overprotection, rejection, pushing the child too
Use the training materials which are
hard). Handle guilty feelings in parents.
appropriate, attractive and locally available.
Remember, children learn better from children Stage 3: Create awareness in parents regarding
of the same age. Therefore, try and involve their role in training the child. The parents should
normal children of the same age in training be made to realize that training a mentally
the mentally retarded child, after orienting the retarded child does not need complex skills and
normal child appropriately. with repeated training in simple steps, the child
Remember, there is no age limit for training a can learn.
mentally retarded person. Parents are taught behavior modification
Assess the child periodically, preferably once techniques to decrease or eliminate problematic
in four or six months. behavior, increase adaptive behavior and develop
new skills. Some of these techniques include 6. Is it true that the mentally retarded persons
positive reinforcement, shaping, prompting, cannot be taught anything?
modeling,extinctionprocedures etc(ReferChapter No. Mentally retarded persons can be taught
14, p. 187 and 188 for a detailed description). many things, but they need to be trained
Parents should be demonstrated how their systematically. They can perform many jobs
training has helped their child to acquire new under supervision.
skills.This will give them a sense of achievement, 7. Isit true that mental retardation is due to karma
thus making them more involved in the care. and hence nothing can be done about it?
No. Believing that mental retardation is due
Some questions parents ask to their karma helps the parents to be free from
1. Is mental retardation same as mental illness? the feelings of guilt. Parents must be told that
No. Mentally retarded persons are not whatever may be the cause, training the child
mentally ill. The mentally retarded persons will improve his condition. The earlier the
are just slow in their development. training is started, the better the chances of
2. Is mental retardation curable? improvement.
No. Mental retardation is a condition which
cannot be cured. But timely and appropriate Residential care: Parents should be supported in
intervention can help the mentally retarded caring for their retarded children at home, or if
person learn several skills. they are too heavy a burden for their parents, the
3. Can marriage solve the problems of mental child should be cared for in day care centers,
retardation? halfway homes, etc.
No. Many people think that after marriage, Specialist medical services: Retarded children and
the mentally retarded person will become adults often have physical handicaps or epilepsy
active and responsible, or sexual satisfaction for which continuing medical care is needed.
will cure the person. That is not so. Marriage
will only further complicate the"problem. Psychaitric sevices: Expert psychiatric care is an
essential part of a comprehensive community
When it is known that a mentally retarded
service for the mentally retarded.
person cannot be totally independent, it will
not be possible for him to look after his family.
Nursing Management
4. Do mentally retarded persons become normal,
as they grow older? Assessment
No. The mentally retarded person's mental Assessment of early infant behavior for
development is slower than that of a normal cognitive disability among high risk children
person. Therefore, when their actual age should be closely done (e.g. children born to
increases with time, the mental development elderly primiparas, birth trauma, etc.); Early
does not occur at the same pace to catch up infant behaviors that may indicate a cognitive
with the actual age. disability include non-responsiveness to
5. Is mental retardation an infectious disease? contact, poor eye contact during feeding, slow
No. Many people think that on allowing feeding, diminished spontaneous activity,
normal children to mix, eat or play with decreased responsiveness to surroundings,
mentally retarded children, the normal decreased alertness to voice or movement, and
children also develop mental retardation. This irritability.
is wrong. Interaction between mentally Documentation of daily living skills.
retarded children and normal children on the A careful family assessment for information
other hand, helps in the improvement of on:
mentally retarded children. the family's response to the child
presence of other members with impaired by reinforcing certain desirable patterns of

cognition in the family behavior or eliminating undesirable patterns.
degree of independence encouraged at In addition, learning socialskillsand adaptive
home behavior assists the child in building a
stability of the family unit. positive self-image. For older children and
Psychological assessment: This is directed at adolescents assistance is needed to prepare
the interaction between the individual and them for a productive work life.
people who are closely involved in care, and Sexuality becomes a major concern, as these
determining the correct needs and wishes for children may form emotional attachment to
the future. It should examine opportunities those of the opposite sex and have normal
for learning new skills, making relationships, sexual desires. However, their decision-
and achieving maximum choice about the making skills are limited. Teaching contra-
way of life. ceptive methods are important to emphasize
with both the child and family.
In all instances it is important for the nurse to
Intervention
maintain a non-threatening approach. Very
The long-term goals for these children are often these children do not understand why
highly individualized and are dependent on physical assessment, therapeutic approaches
the level ofmental retardation. Parents should and evaluative measures are needed. Proper
be involved in establishing realistic goals for explanation and relevant information should
their child. Some of these goals can be: be given to the parents and their help should
the child dresses himself be enlisted in bringing out the best out of the
the child maintains continence of stool child. Close collaboration with all members
and urine of the team involved in the care of the child is
the child demonstrates acceptable social highly essential for a successful outcome. To
behavior a large extent the nurse is responsible for the
the adolescent participates in a structured emotional climate of the setting in which she
work program is employed.
Early intervention programs are essential to (Alsorefer 'Care and rehabilitation ofthe mentally
maximize the children's potential develop- retarded' on p. 154)
ment. This necessitates early recognition and
DISORDERS OF PSYCHOLOGICAL
referral. Nurses have an opportunity to
DEVELOPMENT (F8)
evaluate children in the nursery, in the clinic
during well-baby health care, in schools, and Specific Developmental Disorders of
during acute management. The potential of Speech and Language
each child will vary according to the degree of These are disorders in which normal patterns of
mental retardation. The key for success is that language acquisition are disturbed from the early
the child's strengths and potential abilities stages of development. The conditions are not
are emphasized rather than deficits. directly attributable to neurological or speech
The nurse can participate in programs that mechanism abnormality or mental retardation.
teach infant stimulation, activities of daily It includes developmental language disorder
living and independent self-care skills. A or dysphasia, developmental articulation dis-
successful technique in treatment of the order or phonological disorder or dyslalia,
mentally retarded is called operant con- expressive language disorder, receptive language
ditioning. It focuses on changing or modifying disorder and other developmental disorders of
the individual's response to the environment speech and language.
Specific Developmental Disorders of Epidemiology
Scholastic skills Prevalence is 4-5/10,000 in children under 16
Specific developmental disorders of scholastic years of age. Male to female ratio is 4 or 5 to I.The
skills are divided further into specific reading disorder is evenly distributed across all socio-
disorder, specific spelling disorder and specific economic classes.
arithmetic disorder.
Specific reading disorders (dyslexia) should be Childhood Autism
clearly distinguished from general backwardness In 1908,Heller from Austria reported 6 cases of a
in scholastic achievement resulting from low disintegrative psychosis with onset in the 3rd or
intelligence or inadequate education. It is charac- 4th year of life in children whose previous deve-
terized by a slow acquisition of reading skills, lopment was normal. LeoKenner (1943)identified
slow reading speed, impaired comprehension, a relatively homogenous group of children with
word omissions and distortions and letter onset of psychosis in the 1st and 2nd year of life
reversals. whom he designated early "infantile autism" and
The main feature of specific spelling disorder is "autistic disturbance of affect contact." Lauretta
significantimpairment in development of spelling Bender first used the term "childhood schizo-
skillsin the absence of a history of specificreading phrenia" to characterize psychotic children. Now
disorder. The ability to spell orally and to write all these terms have been replaced and the
out words correctly are both affected. condition is currently known as Childhood
Specific arithmetic disorder involves deficit in Autism in ICDIO,or Autistic Disorder in DSMIV.
basic computational skills of addition, subtrac-
tion, multiplication and division. Etiology
Genetic factors The higher concordance in
Specific Developmental Disorders of monozygotic than dizygotic twins (36% vs 0%)
Motor Function suggests a genetic factor. Siblings of autistic
Children with this disorder have delayed motor children show a prevalence of autistic disorder
development, which is below the expected level of 2 percent (50times over expected prevalence).
on the basis of their age and general intelligence. Biochemicalfactors At least 1I3rd of patients with
The main feature of this disorder is a serious
autistic disorder have elevated plasma serotonin.
impairment in the development of motor co-
ordination, which results in clumsiness in school Medical factors There is an elevated incidence of
work or play. early developmental problems such as post-natal
neurological infections (meningitis, encephalitis),
Pervasive Developmental Disorder congenital rubella and cytomegalovirus, phenyl-
The term Pervasive Developmental Disorder ketonuria and rarely perinatal asphyxia. The other
(PDD)refers to a group of disorders characterized inborn errors of metabolism associated with
by abnormalities in communication and social autism are tuberous sclerosis and neurofibromo-
interaction and by restricted repetitive activities tosis. About 2 to 5% appear to have Fragile X
and interests. These abnormalities occur in a wide chromosome syndrome. Neurological abnormali-
range of situations, usually development is abnor- ties are present in about one-quarter of cases.
mal from infancy and most cases are manifest Perinatal factors During gestation, maternal
before the age of 5 years. bleeding after the first trimester and meconium in
PDD includes childhood autism, atypical the amniotic fluid have been reported in the
autism, Rett's Syndrome, Asperger's syndrome, histories of autistic children. There is also a high
childhood disintegrative disorder, and other incidence of medication usage during pregnancy
pervasive developmental disorders. in the mothers of autistic children.
Psychodynamic and parenting influences and social Gaze avoidance or lack of eye-to-eye contact.
environment Some of the specificcausative factors Dislikes being touched or kissed.
proposed in these theories are parental rejection, No separation anxiety on being left in an
child responses to deviant parental personality unfamiliar environment with strangers.
characteristics, family break-up, family stress, No or abnormal social play. Failure to play
insufficient stimulation and faulty communi- with peers and unable to make friends.
cation patterns (Schreibman and Charlop, 1989). Failure to develop empathy.
Kanner (1973) in his studies, described the Marked lack of awareness of the existence or
parents of autistic children as well educated feelings of others.
upper class individuals, involved in career and Anger or fear without apparent reason and
intellectual pursuits, who were aloof, obsessive absence of fear in the presence of danger.
and emotionally cold. The term "refrigerator
parents" was coined to describe their lack of Communication and language
warmth and affectionate behavior. Gross deficits and deviances in language
Mahler and associates (1975)suggested that development.
the autistic child is fixed in the presymbiotic phase No mode of communication such as babbling,
of development. In this phase, the child creates a facial expression, gestures, mime, etc.
barrier between self and others. The normal Absence of imaginative activity such as play
symbiotic relationship between mother and child acting of adult roles, fantasy characters of
followed by the progression to separation/ indivi- animals, lack of interest in imaginative stories.
dualization does not occur. Ego development is Marked abnormality in the production of
inhibited and the child fails to achieve a sense of speech (volume,pitch, stress,rhythm, rate etc).
self. Marked abnormalities in the form or content
of speech including stereotyped or repetitive
Theory-of-mind in autism Theory-of-mind descri- use of speech, use of "you" when "I" is meant,
bes the developmental process whereby the child idiosyncratic use of phrases.
comes to understand others' minds or to Marked impairment in the ability to initiate or
anticipate what others may be thinking, feeling, sustain a conversation with others despite
or intending. Children with autistic disorder are adequate speech.
sometimes said to be "mind-blind," in that they
lack the ability to put themselves in the place of Activities
another person. Marked restricted, repertoire of activities and
interests.
Electrophysiological changes Brain stem Auditory Stereotyped body movements e.g. hand flick-
Evoked Responses (BAERs)of autistic children ing or twisting, spinning, head banging, etc.
showed impairment in sensory modulation at Persistent preoccupation with parts of objects
brain stem level. (e.g.spinning wheels of toy cars)or attachment
Neuroanatomical studies These studies have to unusual objects.
shown an enlargement of lateral ventricles and Marked distress over changes in trivial aspects
cerebellar degeneration. of environment.
Markedly restricted range of interests and a
Clinical Picture preoccupation with one narrow interest.
Behavioral characteristics Other features
Autistic aloofness (unresponsiveness to More than half of autistic children have mode-
parent's affectionate behavior, by smiling or rate to profound mental retardation, whereas
cuddling). about 25%have mild mental retardation.
Autistic children are resistant to transition and and lithium. Antiepileptic medication is used
change. for generalized seizures.
Over-responsive or under-responsive to Behavioral methods: Contingency management
sensory stimuli. may control some of the abnormal behavior of
May have a heightened pain threshold or an autistic children. The term contingency mana-
altered response to pain. gement refers to a group of procedures based
Other behavioral problems like hyperkinesis, on the principle that, if any behavior persists,
aggression, temper tantrums, self-injurious certain of its consequences are reinforcing it.
behavior, head banging, biting, scratching If these consequences can be altered, the
and hair pulling are common. behavior will change. The parents instructed
Idiot Savant Syndrome: Inspite of a pervasive and supervised by a clinical psychologist
or abnormal development of functions, certain
often carry out this method at home.
functions may remain normal, e.g. calculating
Contingency management has the following
ability, prodigious remote memory, musical
stages:
abilities, etc.
First the behavior to be changed is defined,
Absence of hallucinations, delusions, loosen-
ing of associations as in schizophrenia. and another person (usually a nurse,
Kanner's "Autistic triad"- Kanner said auti- spouse or parent) is trained to record it; for
stic aloofness, speech and language disorder example, a mother might count the number
and obsessive desire for sameness constitute of times a child with learning difficulties
a triad characteristic of infantile autism. shouts loudly.
Second,the events that immediately follow
Course and Prognosis (and therefore are presumed to reinforce
Autistic disorder has a long course and the behavior) are identified; for example,
guarded prognosis. the parents may pay attention to the child
About 10 to 20% autistic children begin to when he shouts, but ignore him at other
improve between 4 and 6 years of age and times.
eventually attend on ordinary school and Third, reinforcements are devised for
obtain work. alternative behaviors, for example, being
10to 20%can live at home, but need to attend approved or earning points by refraining
a special school or training center and cannot from shouting for an agreed time. Staff or
work. relatives are trained to provide the chosen
60% improve little and are unable to lead an reinforcements immediately after the
independent life, mostly needing long-term desired behavior, and to withhold them at
residential care. other times.
Those who improve may continue to show As treatment progresses, records are kept
language problem, emotional coldness and of the frequency of the problem behaviors
odd behavior. and of the desired behaviors.
Although treatment is mainly concerned
Treatment with the consequences of behavior, atten-
Pharmacotherapy is a valuable treatment for tion is also given to changing any events
associated symptoms like aggression, temper that might be provoking the behavior. For
tantrums, self-injurious behavior, hyperacti- example, in a psychiatric ward, the abnor-
vity and stereotypic behaviour. Some drugs mal behavior of one child may be provoked
that have been used are risperdone, serotonin on each occasion by the actions of another
specific reuptake inhibitors, clomipramine child.
Special schooling: Most autistic children require Give positive reinforcement for eye contact
special schooling and older adolescents many with something acceptable to the child (e.g.
need vocational training. food, familiar object).Gradually replace with
Counseling and supportive therapy: The family social reinforcement (i.e.touch, hugging).
of an autistic child needs considerable help to Anticipate and fulfill the child's needs until
cope with the child's behavior, which is often communication can be established.
distressing. Slowly encourage him to express his needs
Others: Development of a regular routine, verbally. Seek clarification and validation.
positive reinforcements to teach self-care Give positive reinforcement when eye contact
skills, speech therapy or sign language is used to convey nonverbal expressions or
teaching, behavior techniques to encourage when the child tries to speak.
interpersonal interactions. Teach simple self-careskillsby using behavior
modification techniques.
Nursing Management Language training plays a big part in teaching
autistic children. At first they have to learn
Assessment The following factors need to be the names of things by linking the name with
considered in assessing an autistic child (Lord the actual object. When teaching the word
and Rutter, 1994): 'table' they must see and feel a real table, and
Cognitive level lots of different tables, otherwise they may
Language ability think that table refers to only that particular
Communication skills, social skills and play object. Look at child's face and pronounce
and repetitive are other abnormal behavior simple words. Ask the child to repeat the
Stage of social development in relation to age, words. Show picture books and name the
mental age and stage of language develop- objects. Verbs like sitting, walking, running
ment can be acted to show the child what these
Associated medical conditions words mean.
Psychosocial factors Autistic children have personal identity dis-
Intervention turbance and need to be assisted to recognize
separateness during self-care activities, such
Work with the child on a one-to-one basis.
as dressing and feeding. The child should be
Protect the child when self-mutilativebehavior
helped to name own body parts. This can be
occurs. Devices such as a helmet, padded
facilitated with the use of mirrors, drawings
mittens or arm covers may be used.
and pictures ofhimself.Encourage appropriate
Try to determine if self-mutilative behavior
touching of, and being touched by others.
occurs in response to increasing anxiety, and
The role of the parent is crucial for any
if so, to what the anxiety may be attributed. intervention with the autistic child; the parent
Intervene with diversion or replacement generally acts as a co-therapist and plays an
activities as anxiety level starts to rise. These integral role in treatment. Thebehavior of their
activities may provide needed feelings of autistic child is often very distressing and
security and substitute for self-mutilative parental counseling begins with clarification
behavior. of the diagnosis and an explanation of the
Assign limited number of caregivers to the characteristics of the disorder. To effectively
child. Ensure that warmth, acceptance and participate in the treatment program, the
availability are conveyed. parents must have acknowledged the extent
Provide child with familiar objects such as of their child's handicap and be able to work
familiar toys or a blanket. Support child's with him at the appropriate developmental
attempts to interact with others. level.
Atypical Autism Etiology
A pervasive developmental disorder that differs Biological influences
from autism in terms of either age of onset or
Geneticfactors
failure to fulfill diagnostic criteria i.e. disturbance
There is greater concordance in monozygotic
in reciprocal social interactions, communication
than in dizygotic twins
and restrictive stereotyped behavior. Atypical
Siblings of hyperactive children have about
autism is seen in profoundly retarded individuals.
twice the risk of having the disorder as does
the general population
Rett's Syndrome
Biological parents of children with the
A condition of unknown cause, reported only in disorder have a higher incidence of ADHD
girls. It is characterized by apparently normal or than do adoptive parents
near-normal early development which is followed
by partial or complete loss of acquired hand skills Biochemical theory
and of speech, together with deceleration in head A deficit of dopamine and norepinephrine has
growth, usually with an onset between 7 and 24 been attributed in the overactivity seen in ADHD.
months of age. This deficit of neurotransmitters is believed to
lower the threshold for stimuli input
Asperger's Syndrome Pre, peri and postnatal factors
The condition is characterized by severe and Prenatal toxic exposure, prenatal mechanical
sustained abnormalities of socialbehavior similar insult to the fetal nervous system
to those of childhood autism with stereotyped and Prematurity, fetal distress, precipitated or
repetitive activities and motor mannerisms such prolonged labor, perinatal asphyxia and low
as hand and finger-twisting or whole body Apgar scores
movements. It differs from autism in that there is Postnatal infections, CNS abnormalities resul-
no general delay or retardation of cognitive ting from trauma, etc
development or language. Environmental influences
Environmental lead
BEHAVIORAL AND EMOTIONAL DISORDERS Food additives, coloring preservatives and
WITH ONSET USUALLY OCCURRING IN sugar have also been suggested as possible
CHILDHOOD AND ADOLESCENCE (F9) causes of hyperactive behavior but there is no
Hyperkinetic Disorder definite evidence
Hyperkinetic disorder (Attention-Deficit Hyper- Psychosocial factors
activity Disorder or ADHD in DSMIV)is a persis- Prolonged emotional deprivation
tent pattern of inattention and or hyperactivity Stressful psychic events
more frequent and severe than is typical of Disruption of family equilibrium
children at a similar level of development. The
syndrome was first described by Heinrich Hoff Clinical Features
in 1854. Sensitiveto stimuli, easily upset by noise, light,
temperature and other environmental
Epidemiology changes.
A prevalence of 1.7 percent was found among At times the reverse occurs and the children
primary school children ( Taylor et al, 1991). are flaccid and limp, sleep more and the
ADHD is four times more common in boys than growth and development is slow in the first
in girls. month oflife.
More commonly active in crib, sleep little. Serotonin specific re-uptake inhibitors
General coordination deficit. Clonidine
Short attention span, easily distractable.
Psychological therapies
Failure to finish tasks.
Behavior modification techniques
Impulsivity.
Cognitive behavior therapy
Memory and thinking deficits .
Social skills training
Specific learning disabilities
In school Nursing Intervention
Often fidgets with hands or feet or squirms in Develop a trusting relationship with the child.
seat. Convey acceptance of the child separate from
Answers only the first two questions ; often the unacceptable behavior.
blurts out answers to questions before they '
Ensure that patient has a safe environment.
have been completed. Remove objectsfrom immediate area in which
Unable to wait to be called on in school and
patient could injure self due to random
may respond before everyone else.
hyperactive movements. Identify deliberate
Has difficultyawaiting turn in games or group
behaviors that put the child at risk for injury.
situations.
Institute consequences for repetition of this
Often loses things necessary for tasks or
behavior. Provide supervision for potentially
activities at school.
dangerous situations.
Home Since there is non-compliance with task
Explosive or irritable. expectations, provide an environment that is
Emotionallylabileand easily set offto laughter as free of distractions as possible.
or tears. Ensure the child's attention by calling his
Mood is unpredictable. name and establishing eye contact, before
Impulsiveness and an inability to delay giving instructions.
gratification. Ask the patient to repeat instructions before
Often talks excessively. beginning a task.
Often engages in physically dangerous acti- Establish goals that allow patient to complete
vities without considering possible conse- a part of the task, rewarding each step
quences (forexample, runs into street without completion with a break for physical activity.
looking). Provide assistance on a one-to-one basis,
beginning with simple concrete instructions.
Diagnosis Gradually decrease the amount of assistance
Detailed prenatal history and early develop- given to task performance, while assuring the
mental history. patient that assistance is still available if
Direct observation, teacher's school report deemed necessary.
(often the most reliable), parent's report Offer recognition of successful attempts and
positive reinforcementfor attempts made. Give
Treatment immediate positive feedback for acceptable
Pharmacotherapy behavior.
CNS stimulants: Dextroamphetamine, met- Provide quiet environment, self-contained
hylphenidate, pemoline classrooms, and small group activities. Avoid
Tricyclic antidepressants over stimulating places such as cinema halls,
Antipsychotics bus stops and other crowded places.
Assess parenting skill level, considering Organicfactors Children with brain damage and
intellectual, emotional and physical strengths epilepsy are more prone to conduct disorders.
and limitations. Be sensitive to their needs as
there is often exhaustion of parental resources
Psychosocial factors
Parental rejection.
due to prolonged coping with a disruptive
child. Inconsistent management with harsh discip-
line.
Provide information and materials related to
Frequent shifting of parental figures.
the child's disorder and effective parenting
Large family size.
techniques. Give instructional materials in
Absent father.
written and verbal form with step-by-step
Parents with antisocial personality disorder
explanations.
or alcohol dependence.
Explain and demonstrate positive parenting
Parental permissiveness.
techniques to parents or caregivers, such as
Marital conflict and divorce in parents.
time-in for good behavior, or being vigilant
Associations with delinquent subgroups.
in identifying the child's behavior and
Inadequate/inappropriate communication
responding positively to that behavior.
patterns in the family.
Educate child and family on the use of psycho-
stimulants and anticipated behavioral
Clinical Features
response.
Coordinate overall treatment plan with Frequent lying.
schools, collateral personnel, the child and Stealing or robbery.
the family. Running away from home and school.
Deliberate fire-setting.
Conduct Disorders Breaking someone else's house articles, car,
etc.
Conduct disorders are characterized by a
Deliberately destroying other's property.
persistent and significant pattern of conduct in
Cruelty towards other people and animals.
which the basic rights of others are violated or
Physical violence like rape, assaultive beha-
rules of society are not followed. The diagnosis is
vior and use of weapons, etc.
only made when the conduct is far in excess of
In addition to the typical symptoms of conduct
the routine mischief of children and adolescents.
disorder, secondary complications often deve-
The onset occurs much before 18 years of age,
lop like, drug abuse and dependence, unwan-
usually even before puberty. The disorder is much
ted pregnancies, syphilis, AIDS, criminal
more (about 5to10 times) common in boys.
record, suicidal and homicidal behavior.
Etiology
Treatment
Genetic factors Studies with monozygotic and
The treatment is difficult. The most common
dizygotic twins as well as with non-twin siblings
mode of management is placement in a corrective
have revealed a significantly higher number of
institution. Behavioral, educational and psycho-
conduct disorders among those whose family
therapeutic measures are employed for changing
members are affected with the disorder (Baum,
the behavior.
1989).Alcoholism and personality disorder in the
Drug treatment may be indicated in the
father is reported to be strongly associated with
conduct disorders. presence of epilepsy (anticonvulsants), hyper-
activity (stimulant medication), impulse control
Biochemicalfactors Various studies have reported disorder and episodic aggressive behavior
a possible correlation between elevated plasma (lithium, carbamazepine) and psychotic
levels of testosterone and aggressive behaviors. symptoms (antipsychotics).
Nursing Intervention vioral responses and areas where continued

The nurse should bear in mind that there is work is needed. Encourage client to continue
always the risk of violence in these children. the log after discharge.
She should therefore observe the child's Social skills training: Some views of aggres-
behavior frequently during routine activities sion emphasize the aggressive child's limited
and interactions. She should be aware of repertoire of cognitive and behavioral skills
behavior that indicates a rise in agitation. related to successful peer and adult inter-
Redirectviolent behavior with physical outlets action. This perspective has led to social skills
for suppression of anger and frustration. training programs in the context of individual
Ensure that a sufficient number of staff is child or family therapy. The key steps for
available to indicate a show of strength if teaching social skills are:
necessary. Administer tranquilizing medica- presenting the target skill to the child by
tion as prescribed. Use of mechanical describing it and discussing when it is
restraints or isolation should be used only if relevant;
the situation cannot be controlled by less demonstrating the skill by modeling;
restrictive means. asking the child to rehearse the skill and
Explain to the client the correlation between providing feedback;
role playing example situations that call
feelings of inadequacy and the need for accep-
for use of the skill; and
tance from others, and how these feelings
giving the child an assignment involving
provoke aggression or defensive behavior
practice of the skill in real life situations
such as blaming others for own faulty beha-
outside the clinical setting
vior. Practice more appropriate responses
Guidance and support for parents: In parent
through role play.
training programs, the nurse should empha-
Set limits on manipulative behavior, and iden-
size to the parents that reconnecting with their
tify the consequences of manipulative beha- children as positive, nurturing caregivers,
vior. Administer the consequences matter-of- comes first.However, management of difficult
factly and in a non-threatening manner if such behavior is a key component in the program,
behavior occurs. and certain guidelines for discipline include:
Provide immediate positive feedback for Develop disciplinary alternatives (such as
acceptable behavior. time out or removal of privileges) to span-
Encourage the child to maintain a log book king.
and make daily entries of his behavior. The Spend scheduled time with your child that
entry should consist of a brief statement of an would foster a more positive relationship
incident when the client was angry or with him.
disagreed with another person, what the client Agree on the rules about behavior and
thought about the incident afterwards (in his consequences, make them clear and stick
own words), what the client thought about with them.
doing, and what he actually did, and the Don't give a direction unless you are
outcome. This provides opportunity for the willing to make sure it is followed.
child to identify his predominant patterns of Encourage parents to verbalize feelings of
thinking and behaving in different situations, guilt and helplessness in dealing with the
and recognize new and acceptable ways of child. Involve siblings in family discus-
responding in situations which provoke such sions and planning for more effective
behaviors. family interactions.
Reviewthe log with the clientbefore discharge. Working with the school:Aggressive children
Provide feedback regarding improved beha- often display problems across settings, inclu-
ding school, or even only in a particular Psychological causes Personality characteristics,
classroom. The nurse should emphasize on (emotional instability, immaturity), emotional
close collaboration between parents and insecurity and mental illness.
school personnel likely to come into contact
with the child (principal, assistant principal, Economic causes Poverty, leading to stealing,pro-
guidance counselors, school psychologists, stitution and other antisocial activities to satisfy
etc.). Children who see their parents and unfulfilled desires.
teachers working together find it easier to
control their behavior in home and in school. Refor0atory Measures
Truancy requires separate consideration. Probation, where the juvenile delinquent is
Pressure should be brought upon the child to kept under the supervision of a probation
return to school, and if possible, the support of officer,whose job is to help him get established
the family should be enlisted. At the same time an in normal life.
attempt should be made to resolve educational or Institutions like reformatory schools, remand
other problems at school. In all this, it is essential homes, certified schools, auxiliary homes.
to maintain good communication between the These institutions provide for all-round
nurse, parents and teachers. progress of the delinquent.
Psychological therapies like play therapy,
Juvenile Delinquency finger-painting, psychodrama.
According to Dr. Sethna, Juvenile delinquency Governmental measures: The Children's Act
involves wrongdoing by a child or a young person of 1977 under which remand homes and
who is under an age specified by the law of the borstal schools were made available;
place concerned. vocational training and follow-up services.
From the legal point of view, a juvenile Under the Care Program sponsored by the
delinquent is a person who is below 16 years of Central Government, 5 borstal schools, 15
age (18 years, in case of a girl) who indulges in boy's clubs and 5 probation hostels have been
antisocial activity. established.
Recently there was a clarification made by the
Supreme Court in the existingJuvenileJusticeAct, Separation Anxiety Disorder
that a regular court would try a juvenile if he is
arrested after crossing the age of 16 though he In these disorders there is excessive anxiety con-
might have committed the crime when he was cerning separation from those individuals to
under the age of 16 (The Hindu, 15th May 2000). whom the child is attached.
Causes Clinical Features
Social causes An unrealistic worry about possible harm

Defects of the family, like broken families, befalling major attachment figures or fear that
uncaring attitude of parents, bad conduct of they will leave and not return.
parent, etc. Persistent reluctance or refusal to go to sleep,
Defects of the school, like harsh punishment without being near or next to a major
by teachers, weakness in some subjects,a level attachment figure.
of education that is above the child's capacity. Persistent inappropriate fear of being alone.
Children living in crime-dominated areas Repeated nightmares.
Absent or defective recreation Repeated occurrence of physical symptoms
War and post-war conditions e.g. nausea, stomachache, headache, etc., on
occasionsthat involve separation from a major treatment. Other methods are implosion or
attachment figure, such as leaving home to go flooding which involves persuading the child to
to school. remain in the feared situation at maximum inten-
Excessive tantrums, crying and apathy imme- sity from the start (the reverse of desensitization).
diately following separation from a major
attachment figure. Social Anxiety Disorder
Children with this disorder show a persistent or
Treatment recurrent fear and avoidance of strangers which
Individual counseling This is often useful to give interferes with social functioning. Treatment
the child an opportunity to understand the basis includes simple behavioral methods, combined
for anxiety and also to teach the child some with reassurance and support.
strategies for anxiety management.
Sibling Rivalry Disorder
Parental counseling Parental counseling is Siblingrivalry /jealousy may be shown by marked
needed when there is evidence that they are over- competition with siblings for the attention and
anxious or over-protective about the child. They affection of parents, associated with unusual
should be persuaded to allow the child more pattern of negative feelings. Onset is during the
autonomy. months following the birth of the younger sibling.
In extreme cases there is over-hostility, physical
Family therapy It is often needed when the
trauma towards and undermining of the sibling,
child's disorder appears to be related to the family
regression with loss of previously acquired skills
system. Treatment is designed to promote healthy
(such as bowel and bladder control) and a
functioning of the family system. tendency to babyish behavior. There is an increase
Pharmacological management Anxiolytic drugs in oppositional behavior with the parents, temper
such as diazepam may be needed occasionally tantrums, and dysphoria exhibited in the form of
when anxiety is extremely severe, but they should anxiety, misery or social withdrawal.
be used for short periods only.
Management
Phobic Anxiety Disorder Parents should be helped to divide their atten-
Minor phobic symptoms are common in child- tion appropriately between the two children.
Help the older child feel valued. At the same
hood and usually concern animals, insects,
time, limits should be set as appropriate.
darkness, school and death. The prevalence of
Preventive interventions such as preparing the
more severe phobias varies with age. In most cases,
child mentally for the arrival of the sibling
all fears decline by early teenage years.
during pregnancy itself, and involving him
in the care of the sibling.
Treatment
Most childhood phobias improve without specific Elective Mutism
treatment, provided the parents adopt a firm and This condition is characterized by a marked,
reassuring approach. For phobias that do not emotionally determined selectivity in speaking
improve, behavioral treatment combined with such that the child demonstrates his language
reassurance and support are most helpful. competence in some situations, but fails to speak
Systematic desensitization (gradual introduction in other situations. Most typically the child speaks
of the phobic object or situation while the subject at home or with closefriends, and is mute at school
is in a state of relaxation), is an established or with strangers.
Management Simple Vocal Tics

Management includes a combination of beha- Simplevocal ticsinclude coughing,barking, throat
vioral and family therapy techniques to promote clearing, sniffing, and clicking.
communication and the use of speech. Individual
psychotherapy may also help. Complex Vocal Tics
Tic Disorders These include echolalia (repetition of heard

phrases), palilalia (repetition of heard words)
Ticis an abnormal involuntary movement, which
coprolalia (use of obscene words), and mental
occurs suddenly, repetitively, rapidly and is
coprolalia (thinking of obscene words).
purposeless in nature. It is of two types:
1. Motor tics, characterized by repetitive motor Etiology of Tourette' s syndrome The etiology of
movements. Tourette's syndrome isnot known but the presence
2. Vocal tics, characterized by repetitive vocali- of learning difficulties, neurological soft signs,
zations. hyperactivity, abnormal EEG record, abnormal
Ticdisorders can be either transient or chronic. evoked potentials and abnormal CTbrain findings
A special type of chronic tic disorder is Gilles de in some patients points towards a biological
la Tourette's syndrome or Tourette's disorder. basis. There is some evidence to suggest that
This is characterized by: multiple motor and vocal Tourette's syndrome may be inherited as
tics, with duration of more than 1year. Onset is autosomal dominant disorder with variable
usually before 11years of age and almost always penetrance.
before 21years of age.
The disorder is more common (about 3 times) Treatment Pharmacotherapy is the preferred
in males and has a prevalence rate of about 0.5 mode of treatment. The drug of choice is
per 1000. haloperidol. In resistant cases or in case of severe
side effects, pimozide or clonidine can be used.
Motor Tics Behavior therapy may be used sometimes, as an
adjunct.
Motor tics can be simple or complex.
Simple Motor Tics Non-organic Enureses

These may include eye blinking, grimacing, It is a disorder characterized by involuntary
shrugging of shoulders, tongue protrusion. voiding of urine by day and/ or night which is
abnormal in relation to the individuals mental
Complex Motor Tics age and which is not a consequence of a lack of
These are facial gestures, stamping, jumping, bladder control due to any neurological disorder,
hitting self, squatting, twirling, echokinesis epileptic attacks or any structural abnormality of
(repetition of observed acts), and copropraxia urinary tract. Enuresis would not ordinarily be
(obscene acts). diagnosed in a child under the age of 5 years or
Motor tics are often the earliest to appear, with a mental age less than 4 years.
beginning in the head region and progressing In most cases, enuresis is primary (the child
downwards. These are followed by vocal tics. has never attained bladder control). Sometimes it
may be secondary (enuresis starting after the
Vocal Tics child achieved continence for a certain period of
Vocal tics also can be simple or complex. time).
Factors Associated with Enuresis Belland pad technique: It is based on classical

Faulty training: If toilet training is started too conditioning principle. A bell is attached to
early, and especially if coercive, produces the napkin or panties and when the child
confusion and resentment rather than passes urine, the alarm goes off,the child then
compliance. Also, if it is begun too late, loss of has to wake up, change his napkin, bed sheets,
bladder control can result. etc. Reinforcement is given for dry nights.
Emotional disturbances: Emotional problems Medications: Tricyclic antidepressants like
or conflicts can manifest in the form of imipramine or amitriptyline,25-50mg at night.
disturbed bladder control. These conflictsmay The mechanism of action is unknown, but
be due to such factors like dominating parents, results have demonstrated its effectiveness.
harsh punishments and other problems in the The parents should be instructed not to blame
family, causing the child to feel neglected and the child in any way. On no account should
isolated. As the children grow older, they the child be embarrassed or humiliated, which
become sensitive about their habit of bed- will only serve to aggravate the problem.
wetting. They develop feelings of inferiority
and a sense of being different from other Non-organic Encopresis
children, which aggravates the problem even
It is the repeated voluntary or involuntary pas-
further.
Physical diseases and anatomic defects (e.g. sage of feces, usually of normal or near normal
congenital anomalies of the genitourinary consistency, in places not appropriate for
tract, diseases involving the central nervous that purpose in the individual's socio-cultural
system) are relatively rare causes for enuresis. setting.
Management
Management
Exclude any physical basis for enuresis by Family tensions regarding the symptoms must
be reduced and a non-punitive atmosphere
history, examination and if necessary,
must be created. Parental guidance and family
investigation of the renal tract.
therapy often is needed.
Explain the parents and child about the
Behavioral techniques, e.g. star charts, in
maturational basis of the problem and the
which the child places a star on a chart for
likelihood of spontaneous improvement.
dry or continent nights.
The child should be encouraged to keep a
Individual psychotherapy to gain the co-
diary of the pattern of night time dryness/ operation and trust of the child.
wetness, which can be done with a star chart.
This consists of a record of dry nights with a Feeding Disorder of Infancy and Childhood
star placed on the sheet for each dry night.
It generally involves refusal of food and extreme
The star chart system has 3 functions:
faddiness in the presence of an adequate food
it provides an accurate record of the
supply and reasonably competent caregiver and
problem;
the absence of organic disease. There may or may
it tests motivation and cooperation of the
not be associated rumination (repeated regurgi-
child and the family; and
tation without nausea or gastrointestinal illness).
it acts as a positive reinforcement for the
desired behavior.
Pica
Fluid restriction after 6O' clockin the evening.
Interruption of child's sleep and emptying Pica of infancy and childhood is characterized
by eating non-nutritive substances (soil, paint
bladder in the toilet.
chipping, paper etc). Treatment consists of Definition and etiology of mental retardation
common-sense precautions to keep the child away (Feb 2000, Oct 2004,Apr 2006)
from abnormal items of diet. Pica usually Classification of mental retardation (Feb2001,
diminishes as the child grows older. Nov 2003)
Profound mental retardation (Oct 2005)
Stereotyped Movement Disorders Mental retardation (Nov 2002)
These disorders are characterized by voluntary, Role of a nurse in the prevention of mental
repetitive, stereotyped, nonfunctional, often retardation
rhythmic movements that do not form part of any Nursing management of a mentally retarded
recognized psychiatric or neurological condition. child (Nov 2002)
The movements include body rocking, head Habilitation of mentally retarded child (Nov
rocking, hair plucking hair twisting, finger 2001)
flicking, mannerisms and hand flapping. Nursing management of an autistic child
Infantile autism (Oct 2000)
Management Autism (Nov 2003,Oct 2004)
Attention deficit hyperactive disorder (Nov
Individual and family interventions
2002, Apr 2003)
Behavioral strategies
Nursing management of a child with
hyperkinetic disorder
Stuttering (Stammering)
Conduct disorder (Nov 2001,Apr 2002)
It refers to frequent hesitation or pauses in speech Juvenile delinquency (Feb 2000,Apr 2006)
characterized by frequent repetition or prolon- Enuresis (Feb 2001, Apr 2002, Apr 2004, Oct
gation of sounds or syllables or words, disrupting 2004)
rhythmic flow of speech. The usual treatment is Mutism (Nov 2001)
speech therapy. Tic disorder (Apr 2002)
Nursing management of childhood psy-
REVIEW QUESTIONS chiatric disorders (Apr 2006)
Classification of childhood psychiatric Behavioral disorders in children (Oct 2004)
disorders (Feb 2001) Neurotic disorders of childhood (Nov 2003)
Therapeutic Modalities
in Psychiatry
D SOMATICTHERAPIES one treatment. These treatment methods vary from
Psychopharmacology patient to patient. Some patients do not want
Antipsychotics treatment and may not cooperate with the doctors
Antidepressants
Lithium and Other Mood Stabilizing
and nurses. Some do not realize that they are ill
Drugs and may actively resist all forms of treatment.
Anxiolytics and Hypnosedatives The nurse has an extremely important role to
Antiparkinsonian Agents play in the treatment of the mentally ill. She is the
Antabuse Drugs
Drugs Used In Child Psychiatry
one who has closer contact with the patient than
Electroconvulsive Therapy any other members of the hospital team. She also
Psychosurgery has a greater opportunity to get to know him and
D PSYCHOLOGICALTHERAPIES report on his improvement.
Psychoanalytic Therapy
Behavior Therapy The various treatment modalities in psychia-
Cognitive Therapy try are broadly divided as:
Hypnosis Somatic (physical) therapies
Abreaction Therapy Psychological therapies
Relaxation Therapies
Individual Psychotherapy Other therapies included in this unit are:
Supportive Psychotherapy Milieu therapy
Group Therapy Therapeutic community
Family and Marital Therapy
Activity therapy
D MILIEUTHERAPY
D THERAPEUTICCOMMUNITY
D ACTIVITYTHERAPY SOMATIC (PHYSICAL) THERAPIES
Occupational Therapy
Recreational Therapy Psychopharmacology
Educational Therapy
The understanding of the biological regulation of
Biblio Therapy
Play Therapy thought, behavior and mood is the basis of all
Music Therapy somatic therapies used in modern psychiatry.
Dance Therapy Psychopharmacological agents are now the first-
Art Therapy
Implications of Activity Therapies For
line treatment for almost every psychiatric
Nursing Practice ailment. With the growing availability of a wide
range of drugs to treat mental illness, the nurse
Patients suffering from physical illnesses are practicing in modern psychiatric settings needs
given specific treatment because the causes are to have a sound knowledge of the pharma-
specific and the signs and symptoms are specific. cokinetics involved , the benefits and potential
In a psychiatric setting the treatment may not be risks of pharmacotherapy, as well as her own role
so specific and most patients are given more than and responsibility.
The various drugs used in psychiatry are worker to clean the drug cupboard. The drug
called as psychotropic (or psychoactive) drugs. cupboard keys should not be given to patients.
They are so called because of their significant
effecton higher mental functions. There are about Classification of Psychotropic Drugs
seven classes of psychotropic drugs. Beforegoing 1. Antipsychotics
into a detailed description of each, a few 2. Antidepressants
guidelines are given below regarding the 3. Mood stabilizing drugs
administration of drugs in psychiatry in general.
4. Anxiolytics and hypnosedatives
The specific responsibilities are mentioned
5. Antiepileptic drugs
separately under each class.
6. Antiparkinsonian drugs
7. Miscellaneous drugs which include stimu-
General Guidelines Regarding Drug
lants, drugs used in eating disorders, drugs
Administration in Psychiatry
used in deaddiction, drugs used in child psy-
The nurse should not administer any drug chiatry,vitamins,calciumchannelblockers,etc.
unless there is a written order. Do not hesitate
to consult the doctor when in doubt about any Antipsychotics
medication.
All medications given must be charted on the Antipsychotics are those psychotropic drugs,
patient's case record sheet. which are used for the treatment of psychotic
In giving medication: symptoms. These are also known as neuroleptics
always address the patient by name and (as they produce neurological side-effects), major
make certain of his identification tranquilizers, D2-receptor blockers and anti-
do not leave the patient until the drug is schizophrenic drugs.
swallowed
do not permit the patient to go to the Classification: See Table 14.1
bathroom to take the medication Indications
do not allow one patient to carry medicine Organic psychiatric disorders
to another. Delirium
If it is necessary to leave the patient to get Dementia
water, do not leave the tray within the reach Delirium tremens
of the patient. Drug-induced psychosis and other organic
Do not force oral medication because of the
mental disorders
danger of aspiration. This is especially
important in stuporous patients. Functional disorders
Check drugs daily for any change in color, Schizophrenia
odor and number. Schizoaffectivedisorders
Bottles should be tightly closed and labeled. Paranoid disorders
Labels should be written legibly and in bold
Mood disorders
lettering.Poison drugs are to be legiblylabeled
Mania
and to be kept in separate cupboard.
Make sure that an adequate supply of drugs Major depression with psychotic symptoms
is on hand, but do not overstock. Childhood disorders
Make sure no patient has access to the drug Attention-deficit hyperactivity disorder
cupboard. Autism
Drug cupboards should always be kept locked Enuresis
when not in use. Never allow a patient or Conduct disorder
Therapeutic Modalities in Psychiatry 173
Table 14.1: Classification of antipsychotic drugs
Class Examples of Oral dose Parenteral

drugs mg/day dose (mg)
Phenothiazines Chlorpromazine Megatil 300-1500 50-100

Largactil IM only
Tranchlor
Triflupromazine Siquil 100-400 30-60IM only
Thioridazine Thioril,Melleril 300-800
Ridazin
Trifluoperazine Espazine 15-60 1-5IM
Fluphenazine Prolinate 25-50IM
decanoate every 1-3
weeks
Thioxanthenes Flupenthixol Fluanxol 3-40
Butyrophenones Haloperidol Senorm, Serenace 5-100 5-20IM
Relinace
Diphenylbutyl Pimozide Orap 4-20
Piperidines Penfluridol Flumap 20-60weekly
Indolic derivatives Molindone Mobarn 50-225
Dibenzoxazepines Loxapine Loxapac 25-100
Atypical anti- Clozapine Sizopin,Lozapin 50-450
psychotics Risperidone Sizodon, Sizomax 2-10
Olanzapine Oleanz 10-20 mg
Quetiapine Qutan 150-750 mg
Ziprasidone Zisper 20-80 mg
Others Reserpine Serpasil 0.5-50
Neurotic and other psychiatric disorders centration is higher than plasma concentration.
Anorexia nervosa They are metabolized in the liver, and excreted
Intractable obsessive-compulsive disorder mainly through the kidneys. The elimination half-
Severe, intractable and disabling anxiety life varies from 10 to 24 hours.
Most of the antipsychotics tend to have a
Medical disorders
Huntington's chorea therapeutic window. If the blood level is below
Intractable hiccough this window, the drug is ineffective. If the blood
Nausea and vomiting level is higher than the upper limit of the window,
Tic disorder there is toxicity or the drug is again ineffective.
Eclampsia
Heat stroke Mechanism of Action
Severe pain in malignancy Antipsychotic drugs block D2 receptors in the
Tetanus mesolimbic and mesofrontal systems (concerned
with emotional reactions).Sedation is caused by
Pharmacokinetics alpha-adrenergic blockade. Anti dopaminergic
Antipsychotics when administered orally are actions on basal ganglia are responsible for
absorbed variably from the gastrointestinal tract, causing EPS (Extra Pyramidal Symptoms).
with uneven blood levels. They are highly bound Atypical antipsychotics have antiserotonergic
to plasma as well as tissue proteins. Brain con- (5-hydroxytryptamine or 5-HT) antiadrenergic
and antihistaminergic actions.These are therefore pyrexia develops with evidence of autonomic
called as serotonin-dopamine antagonists. disturbances in the form of unstable blood
pressure, tachycardia, excessive sweating,
Adverse Effects of Antipsychotic Drugs salivation, and urinary incontinence. In the
I. Extrapyramidal symptoms (EPS) blood, Creatinine Phospho Kinase [CPK]levels
1. Neurolepiic-induced parkinsonism: Symptoms may be raised to very high levels, and the
include rigidity, tremors, bradykinesia, white cell count may be increased. Secondary
stooped posture, drooling, akinesia, ataxia, features may include pneumonia, thrombo-
etc. The disorder can be treated with embolism, cardiovascular collapse, and renal
anticholinergic agents. failure.
2. Acute dystonia: Dystonic movements results The syndrome lasts for one to two weeks
after stopping the drug.
from a slow sustained muscular spasm that
(SeeChapter 18,p. 244 for management).
lead to an involuntary movement. Dystonia
IL Autonomic side-effects: Dry mouth, constipa-
can involve the neck, jaw, tongue and the
tion, cycloplegia,mydriasis, urinary retention,
entire body (opisthotonos). There is also
orthostatic hypotension, impotence and
involvement of eyes leading to upward lateral
impaired ejaculation.
movement of the eye known as oculogyric Ill. Seizures
crisis. Dystonias can be prevented by anticho- N. Sedation
linergics, antihistaminergics, dopamine V. Other effects
agonists, beta-adrenergic antagonists, benzo- Agranulocytosis (especiallyfor clozapine)
diazepines, etc. Sialorrhea or increased salivation (espe-
3. Akathisia: Akathisia is a subjective feeling of cially for clozapine)
muscular discomfort that can cause patients Weight gain
to be agitated, restless and feel generally Jaundice
dysphoric. Akathisia can be treated with Dermatological effects(contact dermatitis,
propranolol, benzodiazepines and clonidine. photosensitive reaction)
4. Tardivedyskinesia:It is a delayed adverse effect
of antipsychotics. It consists of abnormal, Nurse's Responsibility for a Patient
irregular choreoathetoid movements of the Receiving Antipsychotics.
muscles of the head, limbs and trunk. It is Instruct the patient to take sips of water fre-
characterized by chewing, sucking, grimacing quently to relieve dryness of mouth. Frequent
and peri-oral movements. mouth washes, use of chewing gum, applying
5. Neuroleptic malignant syndrome: This is a rare glycerine on the lips are also helpful.
but serious disorder occurring in a small A high-fiber diet, increased fluid intake and
minority of patients taking neuroleptics, laxatives if needed, help to reduce consti-
especially high-potency compounds. pation.
The onset is often, but not invariably, in Advise the patient to get up from the bed or
the first 10 days of treatment. The clinical chair very slowly. Patient should sit on the
picture includes the rapid onset (usually over edge of the bed for one full minute dangling
24-72hours) of severe motor, mental and auto- his feet, before standing up. Check BPbefore
nomic disorders. The prominent motor symp- and after medication is given. This is an
tom is generalized muscular hypertonicity. important measure to prevent falls and other
Stiffnessof the muscles in the throat and chest complications resulting from orthostatic
may cause dysphasia, and dyspnea. The hypotension.
mental symptoms include akinetic mutism, Differentiate between akathisia and agitation
stupor or impaired consciousness. Hyper- and inform the physician. A change of drug
may be necessary if side-effects are severe. Antidepressants

Administer antiparkinsonian drugs as pres- Antidepressants are those drugs, which are used
cribed. for the treatment of depressive illness. These are
Observe the patient regularly for abnormal also called as mood elevators or thymoleptics.
movements.
Take all seizure precautions. Classification: See Table 14.2
Patient should be warned about driving a car Indications
or operating machinery when first treated with
Depression
antipsychotics. Giving the entire dose at
Depressive episode
bedtime usually eliminates any problem from Dysthymia
sedation. Reactive depression
Advise the patient to use sunscreen measures Secondary depression
(use of full sleeves, dark glasses etc) for Abnormal grief reaction
photosensitive reactions.
Teach the importance of drug compliance, Childhood psychiatric disorders
Enuresis
side-effectsof drugs and reporting iftoo severe,
Separation anxiety disorder
regular follow-ups. Give reassurance and
Somnambulism
reduce unfounded fears and anxieties. School phobia
A patient receiving clozapine is at risk for Night terrors
developing agranulocytosis. Monitor TC, DC
essentially in the first few weeks of treatment. Other psychiatric disorders
Panic attack
Stop the drug if the WBC count drops to less
Generalised anxiety disorder
than 3000/mm3 of blood. The patient should Agoraphobia, social phobia
also be told to report if sore throat or fever OCD with or without depression
develop, which might indicate infection. Eating disorder
Seizure precautions should also be taken as Borderline personality disorder
clozapine reduces seizure threshold. The dose Post-traumatic stress disorder
should be regulated carefully and the patient Depersonalization syndrome
may also be put on anticonvulsants such as Medical disorders
eptoin. Chronic pain
Table 14.2: Classification of antidepressants
Class Examples of drugs Trade names Oral dosage (mg/day)

Tricyclic antidepressants Imipramine Antidep 75-300
(TCAs) Amitriptyline Tryptomer 75-300
Clomipramine Anafranil 75-300
Dothiepin Prothiaden 75-300
Mianserin Depnon 30-120
Selective serotonin reuptake Fluoxetine Fludac 10-80
Inhibitors (SSRis) Sertraline Serena ta 50-200
Dopaminergic antidepressants Fluvoxamine Faverin 50-300
Atypical antidepressants Amineptine Survector 100-400
Monoamine oxidase Trazodone Trazalon 150-600
inhibitors (MAOis) Isocarboxazid Marplan 10-30
Migraine 4. Allergic side-effects: Agranulocytosis, cholesta-
Peptic ulcer disease tic jaundice, skin rashes, systemic vasculitis.
5. Metabolic and endocrine side-effects:Weight gain.
Pharmocokinetics 6. Special effects of MAOI drugs: Hypertensive
Antidepressants are highly lipophilic and crises, severe hepatic necrosis, hyperpyrexia.
protein-bound.The half-life is long and usually Nurse's Responsibility for a Patient Receiving
more than 24 hours. It is predominantly meta- Antidepressants
bolized in the liver.
Most of the nurse's responsibilities for a patient
Mechanism of Action on antidepressants are the same as for a patient
receiving antipsychotics (seep. 174).In addition:
The exact mechanism is unknown. The predo- Patients on MAOis should be warned against
minant action is by increasing catecholamine the danger of ingesting tyramine-rich foods
levels in the brain. which can result in hypertensive crisis. Some
TCAs are also called as Mono Amine of these foods are beef liver, chicken liver, fer-
Reuptake Inhibitors (MARls). The main mode of mented sausages, dried fish, overriped fruits,
action is by blocking the reuptake of chocolate and beverages like wine, beer and
norepinephrine(NE) and/ or serotonin (5-HT)at coffee.
the nerve terminals, thus increasing the NE and Report promptly ifoccipitalheadache, nausea,
5-HT levels at the receptor site. vomiting, chest pain or other unusual
MAOis instead act on MAO (monoamine symptoms occur ; these can herald the onset
oxidase), which is responsible for the degradation of hypertensive crisis.
of catecholamines after re-uptake. The final effect Instruct the patient not to take any medication
is the same, a functional increase in the NE and without prescription.
5-HT levels at the receptor site. The increase in Caution the patient to change his position
brain amine levels is probably responsible for the slowly to minimize orthostatic hypotension.
antidepressant action. It takes about 5 to 10 days Strict monitoring of vitals, especially blood
for MAOis and 2 to 3 weeks for TCAs to bring pressure is essential.
down depressive symptoms.
SSRis act by inhibiting the re-uptake of Lithium and Other Mood Stabilizing Drugs
serotonin and increasing its levels at the receptor Mood stabilizers are used for the treatment of
site. bipolar affectivedisorders. Some commonly used
mood stabilizers are:
Side Effects Lithium
1. Autonomic side-effects: Dry mouth, constipa- Carbamazepine
tion, cydoplegia, mydriasis, urinary retention, Sodium valproate
orthostatic hypotension, impotence, impaired
Lithium
ejaculation, delirium and aggravation of
glaucoma. Lithium is an element with atomic number 3 and
2. CNS effects: Sedation, tremor and other extra- atomic weight 7. It was discovered by FJ Cade in
pyramidal symptoms, withdrawal syndrome, 1949,and is a most effective and commonly used
seizures, jitteriness syndrome, precipitation drug in the treatment of mania.
of mania.
Indications
3. Cardiacside-effects: Tachycardia, ECGchanges,
arrhythmias, direct myocardial depression, Acute mania
quinidine-like action (decreased conduction Prophylaxis for bipolar and unipolar mood
time). disorder.
Schizoaffective disorder tion is done after a loading dose of 600mg or 900
Cyclothymia mg of lithium to determine the pharmacokinetics.
Impulsivity and aggression
Blood Lithium Levels
Other disorders:
premenstrual dysphoric disorder Therapeutic levels = 0.8 - 1.2 mEq/L (for
bulimia nervosa treatment of acute mania)
borderline personality disorder Prophylactic levels = 0.6 - 1.2 mEq/L (for
episodes of binge drinking prevention of relapse in bipolar disorder)
trichotillomania Toxic lithium levels > 2.0 mEq/L
cluster headaches Side Effects
1. Neurological: Tremors, motor hyperactivity,
Pharmacokinetics
muscular weakness, cogwheel rigidity,
Lithium is readily absorbed with peak plasma seizures, neurotoxicity (delirium, abnormal
levels occurring 2-4hours after a single oral dose involuntary movements, seizures, coma).
of lithium carbonate. Lithium is distributed 2. Renal: Polydipsia, polyuria, tubular enlarge-
rapidly in liver and kidney and more slowly in ment, nephrotic syndrome.
muscle, brain and bone. Steady state levels are 3. Cardiovascular: T -wave depression.
achieved in about 7 days. Elimination is 4. Gastrointestinal: Nausea, vomiting, diarrhea,
predominantly via kidneys. Lithium is reabsorbed abdominal pain and metallic taste.
in the proximal tubules and is influenced by 5. Endocrine: Abnormal thyroid function, goiter
sodium balance. Depletion of sodium can and weight gain.
precipitate lithium toxicity. 6. Dermatological: Acneiform eruptions, papular
eruptions and exacerbation of psoriasis.
Mechanism of Action 7. Side-effects during pregnancy and lactation:
The probable mechanisms of action can be: Teratogenic possibility, increased incidence
It accelerates presynaptic re-uptake and des- of Ebstein's anomaly (distortion and down-
truction of catecholamines, like norepinep- ward displacement of tricuspid value in right
hrine ventricle)when taken in firsttrimester.Secreted
It inhibits the release of catecholamines at the in milk and can cause toxicity in infant.
synapse. 8. Signs and symptoms of lithium toxicity (serum
It decreases postsynaptic serotonin receptor lithium level >2.0 mEq/L):
sensitivity. ataxia
All these actions result in decreased cate- coarse tremor (hand)
cholamine activity, thus ameliorating mania. nausea and vomiting
impaired memory
impaired concentration
Dosage
nephrotoxicity
Lithium is available in the market in the form of muscle weakness
the following preparations: convulsions
Lithium carbonate: 300mg tablets (e.g. muscle twitching
Licab); 400mg sustained release tablets dysarthria
(e.g.Lithosun-SR) lethargy
Lithium citrate: 300mg/ 5ml liquid. confusion
The usual range of dose per day in acute coma
mania is 900-2100mg given in 2-3divided doses. hyperreflexia
The treatment is started after serial lithium estima- nystagmus
Management of Lithium Toxicity When lithium therapy is initiated, mild side-
Discontinue the drug immediately. effects such as fine hand tremors, increased
For significant short-term ingestions, residual thirst and urination, nausea, anorexia etc may
gastric content should be removed by induc- develop. Most of them are transient and do
tion of emesis, gastric lavage and adsorption not represent lithium toxicity.
with activated charcoal. Serious side-effectsof lithium that necessitate
If possible instruct the patient to ingest fluids. its discontinuance include vomiting, extreme
Assess serum lithium levels, serum electro- hand tremors, sedation, muscle weakness and
lytes,renal functions, ECGas soon as possible. vertigo. The psychiatrist should be notified
Maintenance of fluid and electrolyte balance. immediately if any of these effects occur.
In a patient with serious manifestations of Since polyuria can lead to dehydration with
lithium toxicity, hemodialysis should be the risk of lithium intoxication, patients
initiated. should be advised to drink enough water to
compensate for the fluid loss.
Contraindications of Lithium Use Various situations may require an adjustment
Cardiac, renal, thyroid or neurological in the amount of lithium administered to a
client, such as the addition of a new medicine
dysfunctions
Presence of blood dyscrasias to the client's drug regimen, a new diet or an
During first trimester of pregnancy and illnesswith fever or excessivesweating. In this
lactation connection,people involved in heavy outdoor
Severe dehydration labor are prone to excessive sodium loss
Hypothyroidism through sweating. They must be advised to
History of seizures consume large quantities of water with salt,
to prevent lithium toxicity due to decreased
Nurse's Responsibilities for a sodium levels. If severe vomiting or
Patient Receiving Lithium gastroenteritis develops, the patient should
be told to report immediately to the doctor.
The pre-lithium work up: A complete physical
These are the conditions that have a high
history, ECG,blood studies (TC,DC, FBS,BUN,
potential for causing lithium toxicity by
creatinine, electrolytes) urine examination
lowering serum sodium levels..
(routine and microscopic) must be carried out. It
Frequent serum lithium level evaluation is
is important to assess renal function as renal side-
important. Bloodfor determination of lithium
effectsare common and the drug can be dangerous
levels should be drawn in the morning
in an individual with compromised kidney
function. Thyroid functions should also be approximately 12-14hours after the last dose
assessed, as the drug is known to depress the was taken.
thyroid gland. The patient should be told about the
To achieve therapeutic effect and prevent lithium importance of regular followup. In every six
toxicity, thefollowing precautions should be taken: months, blood sample should be taken for
Lithium must be taken on a regular basis, estimation of electrolytes, urea, creatinine, a
preferably at the same time daily (forexample, full blood count, and thyroid function test.
a client taking lithium on TID schedule, who
forgets a dose should wait until the next Carbamazepine
scheduled time to take lithium and not take It is available in the market under different trade
twice the amount at one time, because lithium names like Tegretol, Mazetol, Zeptol and Zen
toxicity can occur). Retard.
Indications Sodium Valproate (Encorate chrono,
Seizures-complex partial seizures, GTCS, valparin, Epilex, Epival)
seizures due to alcohol withdrawal . Indications
Psychiatric disorders- rapid cycling bipolar
Acute mania, prophylactic treatment of bipo-
disorder, acute depression, impulse control lar I disorder, rapid cycling bipolar disorder.
disorder, aggression, psychosis with epilepsy, Schizoaffectivedisorder.
schizoaffectivedisorders, borderline persona- Seizures.
lity disorder, cocaine withdrawal syndrome. Other disorderslikebulimianervosa, obsessive-
Paroxysmal pain syndromes - trigeminal compulsive disorder, agitation and PTSD.
neuralgia and phantom limb pain.
Mechanism of Action
Dosage The drug acts on gamma-aminobutyric acid
(GABA) an inhibitory amino acid neurotrans-
The average daily dose is 600-1800mg orally, in
mitter. GABAreceptor activation serves to reduce
divided doses. The therapeutic blood levels are 6-
neuronal excitability,
12g/ml. Toxicblood levels are attained at more
than 15 g/ml.
Dosage
The usual dose is 15mg/kg/ day with a maxi-
Mechanism of Action mum of 60mg/kg/ day orally.
Its mood stabilizing mechanism is not clearly
established. Its anticonvulsant action may Side Effects
however be by decreasing synaptic transmission Nausea, vomiting, diarrhea, sedation, ataxia,
in the CNS. dysarthria, tremor, weight gain, loss of hair,
thrombocytopenia, platelet dysfunction.
Side Effects
Nurse's Responsibilities
Drowsiness, confusion, headache, ataxia, hyper-
Explain to the patient to take the drug
tension, arrhythmias, skin rashes, Steven-Johnson
immediately after food to reduce GI irritation.
syndrome, nausea, vomiting, diarrhea, dry mouth,
Advise to come for regular follow-up and
abdominal pain, jaundice, hepatitis, oliguria, periodic examination of blood count, hepatic
leukopenia, thrombocytopenia, bone marrow function and thyroid function. Therapeutic
depression leading to aplastic anemia. serum level of valproic acid is 50-100
micrograms Iml.
Since the drug may cause dizziness and Anxiolytics (Anti-anxiety drugs) and
drowsiness advise him to avoid driving and Hypnosedatives
other activities requiring alertness. These are also called as minor tranquilizers. Most
Advise patient not to consume alcohol when of them belong to the benzodiazepine group of
he is on the drug. drugs.
Emphasize the importance of regular follow-
up visits and periodic examination of blood Classification
count and monitoring of cardiac, renal, 1. Barbiturates: Example, phenobarbital, pento-
hepatic and bone marrow functions. barbital, secobarbital and thiopentone.
2. Non-barbiturate non-benzodiazepine anti-anxiety Side Effects
agents: Example, Meprobamate glutethimide, Nausea, vomiting, weakness, vertigo, blurring of
ethanol, diphenhydramine and methaqualon. vision, body aches, epigastric pain, diarrhea,
3. Benzodiazepines: Presently benzodiazepines impotence, sedation, increased reaction time, ata-
are the drugs of first choice in the treatment of xia, dry mouth, retrograde amnesia, impairment
anxiety, and for the treatment of insomnia. of driving skills, dependence and withdrawal
Very short-acting: Example, Triazolam, symptoms (the drug should be withdrawn slowly,
Midazolam. as a result).
Short-acting: Example, Oxazepam
(Serepax), Lorazepam (Ativan, Trapex, Nurse's Responsibility in the Administration of
Larpose), Alprazolam (Restyl, Trika, Benzodiazepines
Alzolam, Quiet, Anxit) . Administer with food to minimize gastric
Long-acting: Example, Chlordiazepoxide irritation.
(Librium), Diazepam(Valium,Calmpose), Advise the patient to take medication exactly
Clonazepam (Lonazep), Flurazepam as directed. Abrupt withdrawal may cause
(Nindral), Nitrazepam (Dormin). insomnia, irritability and sometimes even
seizures.
Indications for Benzodiazepines Explain about adverse effects and advise him
Anxiety disorders to avoid activities that require alertness.
Insomnia Caution the patient to avoid alcohol or any
Depressibn other CNS depressants along with benzo-
Panic disorder and social phobia diazepines ; also instruct him not to take any
Obsessive-compulsive disorder over-the-counter (OTC)medications.
Post-traumatic stress disorder If IM administration is preferred give deep
Bipolar I disorder IM.
Other psychiatric indications include alcohol For IV administration do not mix with any
withdrawal, substance-induced and psy- other drug. Give slow IV as respiratory or
chotic agitation cardiac arrest can occur; monitor vital signs
during IV administration. Prevent extravasa-
Dosage (mg/day) tions since it can cause phlebitis and venous
Alprazolam: 0.5 - 6 PO thrombosis.
Oxazepam: 15-120PO
Lorazepam: 2-6PO/IV /IM Antiparkinsonian Agents
Diazepam: 2-10PO/IM/ slow IV In clinical practice anticholinergic drugs,
Clonazepam: 0.5-20PO/IM amantadine and the antihistamines have their
Chlordiazepoxide: 15-100PO ; 50-100slow IV primary use as treatments for medication-induced
Nitrazepam: 5-20PO movement disorders, particularly neuroleptic-
induced parkinsonism, acute dystonia and
Mechanism of Action medication-induced tremor.
Benzodiazepines bind to specific sites on the
GABAreceptors and increase GABAlevel. Since Anticholinergics
GABA is an inhibitory neurotransmitter, it has a Trihexyphenidyl
calming effecton the central nervous system, thus Benztropine
reducing anxiety. Biperiden
Dopaminergic Agents Antabuse Drugs

Bromocriptine Disulfiram is an important drug in this class and
Carbidopa/Levodopa is used to ensure abstinence in the treatment of
alcohol dependence. Its main effect is to produce
Monoamine Oxidase Type B Inhibitors a rapid and violently unpleasant reaction in a
Selegiline person who ingests even a small amount of
alcohol while taking disulfiram.
Trihexyphenidyl (Artane, Trihexane, Trihexy,
(ReferChapter 11p. 133for a detailed description
Pacitane)
on disulfiram)
Indications
Drug-induced parkinsonism. Drugs Used in Child Psychiatry
Adjunct in the management of parkinsonism. Clonidine
Mechanism of Action Indications

It acts by increasing the release of dopamine from Control ofwithdrawal symptoms from opioids
presynaptic vesicles, blocking the re-uptake of Tourette's disorder
dopamine into presynaptic nerve terminals or by Control of aggressive or hyperactive behavior
exerting an agonist effect on postsynaptic in children
dopamine receptors. Autism
Trihexyphenidyl reaches peak plasma con-
centrations in2-3 hours after oral administration Mechanism of Action
and has a duration of action of upto 12 hours.
Alpha 2 - adrenergic receptor agonist.
Dosage The agonist effectsof clonidine on presynaptic
alpha 2-adrenergic receptors result in a
1-2 mg per day orally initially. Maximum dose
decrease in the amount of neurotransmitter
up to 15 mg/ day in divided doses.
released from the presynaptic nerve terminals.
Side Effects This decrease serves generally to reset the
sympathetic tone at a lower level and to
Dizziness, nervousness, drowsiness, weakness,
decrease arousal.
headache, confusion, blurred vision, mydriasis,
tachycardia, orthostatic hypotension, dry mouth,
Dosage
nausea, constipation, vomiting, urinary retention
and decreased sweating. Usual starting dosage is O.lmg orally twice a day;
the dosage can be raised by 0.3 mg a day to an
Nurse's Responsibilities appropriate level.
Assess parkinsonian and extrapyramidal
symptoms. Medication should be tapered Side Effects
gradually. Dry mouth, dryness of eyes, fatigue, irritability,
Caution patient to make position changes sedation, dizziness, nausea, vomiting, hypo-
slowly to minimize orthostatic hypotension. tension and constipation.
Instruct the patient about frequent rinsing of
mouth and good oral hygiene.
Caution patient that this medication decreases Nurse's Responsibility
perspiration, and over-heating may occur Monitor BP, the drug should be withheld if the
during hot weather. patient becomes hypotensive.
Advise frequent mouth rinses and good oral weekly) during hospitalization and at home
hygiene for dry mouth. while on therapy with CNS stimulants, due
to the potential for anorexia/weight loss and
Methylphenidate (Ritalin) temporary interruptions of growth and
Methylphenidate, dextroamphetamine and pemo- development.
line are sympathomimetics. To prevent insomnia administer last dose at
least 6 hours before bedtime ..
Indications In children with behavioral disorders a drug
'holiday' should be attempted periodically
Attention-deficit hyperactivity disorder
under the direction of the physician to
Narcolepsy
determine effectiveness of the medication and
Depressive disorders
the need for continuation.
Obesity
Ensure that parents are aware of the delayed
effects of Ritalin. Therapeutic response may
Mechanism of Action
not be seen for 2-4 weeks; the drug should not
Sympathomimetics cause the stimulation of be discontinued for lack of immediate results.
alpha and beta-adrenergic receptors directly as Inform parents that OTC (over-the-counter)
agonists and indirectly by stimulating the release medications should be avoided while the
of dopamine and norepinephrine from pre- child is on stimulant medication. Some OTC
synaptic terminals. Dextroamphetamine and medications, particularly cold and hay fever
methylphenidate are also inhibitors of catecho- preparations contain certain sympathomi-
lamine reuptake, especially dopamine reuptake metic agents that could compound the effects
and inhibitors of monoamino oxidase. The net of the stimulant and create drug interactions
result of these activities is believed to be the that may be toxic to the child.
stimulation of several brain regions. Ensure that parents are aware that the drug
should not be withdrawn abruptly. With-
Dosage drawal should be gradual and under the
Starting dose is 5-10 mg per day orally, maximum direction of the physician.
daily dose is 80 mg/ day.
Electroconvulsive Therapy
Side Effects Electroconvulsive therapy is a type of somatic
Anorexia or dyspepsia, weight loss, slowed treatment first introduced by Bini and Cerletti in
growth, dizziness, insomnia or nightmares, April 1938. From 1980 onwards ECT is being
dysphoric mood, tics and psychosis. considered as a unique psychiatric treatment.
Electroconvulsive therapy is the artificial
Nurse's Responsibilities induction of a grandma! seizure through the
Assess mental status for change in mood, level application of electrical current to the brain. The
of activity, degree of stimulation and aggres- stimulus is applied through electrodes that are
siveness. placed either bilaterally in the fronto-temporal
Ensure that patient is protected from injury. region, or unilaterally on the non-dominant side
Keep stimuli low and environment as quiet as (right side of head in a right-handed individual).
possible to 'discourage over stimulation.
To decrease anorexia, the medication may be Parameters of Electrical CurrentApplied
administered immediately after meals. The Standard dose according to American Psychiatric
patient should be weighed regularly (at least Association, 1978:
Voltage - 70-120 volts. melancholia with psychotic features with
Duration - 0.7-1.5 seconds unsatisfactory response to drugs or where
drugs are contraindicated or have serious
Typeof Seizure Produced side-effects .
grandma! seizure-tonic phase lasting for 10 b. Severe catatonia (functional): With stupor; with
- 15 seconds. poor intake of food and fluids; with
clonic phase lasting for 30-60 seconds unsatisfactory response to drug therapy, or
when drugs are contraindicated or have
Mechanism of Action serious side-effects.
c. Severe psychosis (schizophrenia or mania): With
The exact mechanism of action is not known. One
risk of suicide, homicide or danger of physical
hypothesis states that ECT possibly affects the
assault; with depressive features; with
catecholamine pathways between diencephalon
unsatisfactory response to drug therapy, or
(from where seizure generalization occurs) and
when drugs are contraindicated or have
limbicsystem (which may be responsible for mood
serious side-effects.
disorders), also involving the hypothalamus.
d. Organic mental disorders:
organic mood disorders.
TypesofECT
organic psychosis
Direct ECT: In this, ECT is given in the absence of e. Other indications: ECT is preferred to anti-
anesthesia and muscular relaxation. This is not a depressant therapy in some cases, such as for
commonly used method now. clients with cardiac disease; when tricyclics
Modified ECT: Here ECT is modified by drug- are contraindicated because of the potential
induced muscular relaxation and general for dysarrythmias and congestive heart
anesthesia. failure; and for pregnant women, in whom
antidepressants place the fetus at risk for
congenital defects.
Frequency and TotalNumber of ECT
Frequency: Three times per week or as indicated. Contraindications
Total number: 6 to 10; upto 25 may be preferred as
A Absolute:
indicated.
raised ICP (intracranial pressure)
B. Relative:
Application of Electrodes
cerebralaneurysm
Bilateral ECT: Each electrode is placed 2.5-4 cm cerebral hemorrhage
(1-1V:zinch) above the midpoint, on a line joining brain tumor
the tragus of the ear and the lateral canthus of the acute myocardial infarction
eye. congestive heart failure
pneumonia or aortic aneurysm
Unilateral ECT: Electrodes are placed only on one retinal detachment
side of head, usually non-dominant side (right
side of head in a right-handed individual). Complications of ECT
Unilateral ECTis safer, with much fewer side-
Life-threatening complications of ECT are rare.
effects particularly those of memory impairment.
ECT does not cause any brain damage.
Fractures can sometimes occur in elderly
Indications
patients with osteoporosis. In patients with a
a. Major depression: With suicidal risk; with history of heart disease, dysrhythmias and
stupor; with poor intake of food and fluids; respiratory arrest may occur.
Side Effects of ECT Withhold oral medications in the morning.
Memory impairment. Head shampooing in the morning since oil
Drowsiness, confusion and restlessness. causes impedance of passage of electricity to
brain.
Poor concentration, anxiety.
Any jewellery, prosthesis, dentures, contact
Headache, weakness/fatigue, backache,
lens, metallic objects and tight clothing should
muscle aches.
be removed from the patient's body.
Dryness of mouth, palpitations, nausea,
Empty bladder and bowel just before ECT.
vomiting.
Administration of 0.6 mg atropine IM or SC
Unsteady gait.
30 minutes before ECT, or IVjust before ECT.
Tongue bite and incontinence.
b. Intra-procedure care
ECTTeam Place the patient comfortably on the ECT table
Psychiatrist, anesthesiologist, trained nurses and in supine position.
aides should be involved in the administration of Stay with the patient to allay anxiety and fear.
ECT. Assist in administering the anesthetic agent
(thiopental sodium 3-5 mg/kg body weight)
TreatmentFacilities and muscle relaxant (1 mg/kg body weight of
succynylcholine).
There should be a suite of three rooms:
Since the muscle relaxant paralyzes all
1. A pleasant, comfortable waiting room (pre-
muscles including respiratory muscles, patent
ECT room).
airway should be ensured and ventilatory
2. ECT room, which should be equipped with
support should be started.
ECT machine and accessories ,an anesthetic
Mouth gag should be inserted to prevent
appliance, suction apparatus, face masks,
possible tongue bite.
oxygen cylinders with adjustable flow valves,
The place(s) of electrode placement should be
curved tongue depressors, mouth gags,
cleaned with normal saline or 25 percent
resuscitation apparatus and emergency drugs.
bicarbonate solution, or a conducting gel
There should be immediate access to a
applied.
defibrillator.
Monitor voltage, intensity and duration of
3. A well-equipped recovery room.
electrical stimulus given.
Monitor seizure activity using cuff method.
Role of the Nurse 100 percent oxygen should be provided.
a Pre-treatment evaluation During seizure monitor vital signs, ECG,
Detailed medical and psychiatric history, oxygen saturation, EEG, etc.
including history of allergies. Record the findings and medicines given in
Assessment of patient's and family's know- the patient's chart.
ledge of indications, side-effects, therapeutic
effects and risks associated with ECT. c. Post-procedure care
An informed consent should be taken. Allay Monitor vital signs.
any unfounded fears and anxieties regarding Continue oxygenation till spontaneous
the procedure. respiration starts.
Assess baseline vital signs. Assess for post-ictal confusion and restless-
Patient should be on empty stomach for 4-6 ness.
hours prior to ECT. Take safety precautions to prevent injury (side-
Withhold night doses of drugs, which lying position and suctioning to prevent
increase seizure threshold like diazepam, aspiration of secretions, use of side rails to
barbiturates and anticonvulsants, prevent falls).
If there is severe post-ictal confusion and rest- Psychoanalytic Therapy

lessness, IV diazepam may be administered. Psychoanalysis was first developed by
Reorient the patient after recovery and stay Sigmund Freud at the end of the 19th century.
with him until fully oriented. The most important indication for psycho-
Document any findings as relevant in the analytical therapy is the presence of long-
patient's record. standing mental conflicts, which may be
unconscious but produce symptoms. The aim
Psychosurgery of the therapy is to bring all repressed material
Psychosurgery is defined by APA's Task Force as to conscious awareness so that the patient can
"a surgical intervention, to sever fibers connecting work towards a healthy resolution of his
one part of the brain with another, or to remove, problems, which are causing the symptoms.
destroy, or stimulate brain tissue, with the intent Psychoanalysis makes use of free association
of modifying behavior, thought or mood distur- and dream analysis to affect reconstruction of
bances, for which there is no underlying organic personality. Free association refers to the ver-
pathology." balization of thoughts as they occur, without
any conscious screening. The psychoanalyst
Indications searches for patterns in the material that is
verbalized and in the areas that are uncons-
Severe psychiatric illness.
Chronic duration of illness of about 10years. ciously avoided (such areas are identified as
Persistent emotional distress. resistances).
Failure to respond to all other therapies. Analysis of the patient's dreams helps to gain
High risk of suicide. additional insight into his problem and the
resistances. Thus dreams symbolically
Major Surgical Procedures communicate areas of intrapsychic conflict.
The therapist then attempts to assist the
Stereotactic subcaudate tractotomy.
patient to recognize his intrapsychic conflicts
Stereotactic limbic leucotomy.
through the use of interpretation ..
Stereotactic bilateral amygdalotomy
The process is complicated by the occurrence
Nursing care for a patient undergoing psycho- of transference reactions. This refers to the
surgery is the same as for any neurosurgical patient's development of strong positive or
procedure. negative feelings towards the analyst, and
they represent the patient's past response to a
PSYCHOLOGICAL THERAPIES significant other, usually a parent. The
There are several kinds of psychological therapist's reciprocal response to the patient
therapies: is called countertransference. Such reactions
Psychoanalytic therapy must be handled appropriately before
Behavior therapy progress can be made.
Cognitive therapy The roles of the patient and psychoanalyst
Hypnosis are explicitly defined by Freud. The patient is
Abreaction therapy an active participant, freely revealing all
Relaxation therapies thoughts exactly as they occur and describing
Individual psychotherapy all dreams. He is frequently in a recumbent
Supportive psychotherapy position on a couch during therapy to induce
Group therapy relaxation, which facilitates free association.
Family and marital therapy The psychoanalyst is a shadow-person. He
reveals nothing personal, nor does he give receives exposure to specific stimuli and
any directions to the patient. His verbal reinforcement for the desired adaptive
responses are for the most part brief and behavior.
noncommittal, so as not to interfere with the Behavioral assessment is focused more on the
associative flow. He departs from this style of current behavior rather than on historical
communication when an interpretation of antecedents.
behavior is made to the patient. . Treatment strategies are individually tailored.
By termination of therapy, the patient is able Behavior therapy is a short duration therapy,
to conduct his life according to an accurate therapists are easy to train and it is cost-effective.
assessment of external reality and is also able The total duration of therapy is usually 6-8weeks.
to relate to others uninhibited by neurotic Initial sessions are given daily but the later
conflicts. sessions are spaced out. Unlike psychoanalysis
Psychoanalytical therapy is a long-term where the therapist is a shadow person, in
proposition. The patient is seen frequently, behavior therapy both the patient and therapist
usually five times a week. It is therefore time-
are equal participants. There is no attempt to
consuming and expensive.
unearth an underlying conflict and the patient is
(Also Refer Chapter 4 p. 48 Psychoanalytical not encouraged to explore his past.
model).
(Refer 'Behavior model' on p. 49 for further
details)
Behavior Therapy
It is a form of treatment for problems in which a Behavior Techniques
trained person deliberately establishes a profes-
(A)Systematic desensitization It was developed by
sional relationship with the client, with the
Joseph Wolpe, based on the behavioral principle
objective of removing or modifying existing
of counter conditioning. In this patients attain a
symptoms and promoting positive personality, state of complete relaxation and are then exposed
growth and development.
to the stimulus that elicits the anxiety response.
Behavior therapy involves identifying
The negative reaction of anxiety is inhibited by
maladaptive behaviors and seeking to correct
the relaxed state, a process called reciprocal
these by applying the principles of learning inhibition.
derived from the following theories: It consists of three main steps:
Classical conditioning model by Ivan Pavlov 1. Relaxation training
(1936)
2. Hierarchy construction
Operant conditioning model by BF Skinner 3. Desensitization of the stimulus
(1953)
1. Relaxation training: There are many methods
Major Assumptions of Behavior Therapy which can be used to induce relaxation, some of
Based on the above-mentioned theories, the themare:
following are the assumptions of behavior Jacobson's progressive muscle relaxation
therapy: Hypnosis
All behavior is learned (adaptive and Meditation or yoga
maladaptive). Mental imagery
Human beings are passive organisms that can Biofeedback
be conditioned or shaped to do anything if 2. Hierarchy construction: Here the patient is
correct responses are rewarded or reinforced. asked to list all the conditions which provoke
Maladaptive behavior can be unlearned and anxiety. Then he is asked to list them in a
replaced by adaptive behavior if the person descending order of anxiety provocation.
Therapeutic Modalities in Psychiatry 18 7
3. Desensitization of the stimulus: This can token can later be exchanged for other
either be done in reality or through imagination. rewards. For example on inpatient hospital
At first,the lowest item in hierarchy is confronted. wards, patients receive a reward for perfor-
The patient is advised to signal whenever anxiety ming a desired behavior, such as tokens which
is produced. With each signal he is asked to relax. they may use to purchase luxury items or
After a few trials, patient is able to control his certain privileges.
anxiety gradually.
Indications: E. Operant conditioning procedures to teach new
Phobias behavior
Obsessions 1. Modeling: Modeling is a method of teaching
Compulsions by demonstration, wherein the therapist
Certain sexual disorders shows how a specific behavior is to be
performed. In modeling the patient observes
B. Flooding:The patient is directly exposed to the
other patients indulging in target behaviors
phobic stimulus, but escape is made impossible.
and getting rewards for those behaviors. This
By prolonged contact with the phobic stimulus,
will make the patient repeat the same be-
the therapist's guidance and encouragement and
havior and earn rewards in the same
his modeling behavior reduce anxiety.
Indications: Specificphobias manner.
2. Shaping: In shaping the components of a
C. Aversion therapy: Pairing of the pleasant particular skill,the behavior is reinforced step
stimulus with an unpleasant response, so that by step. The therapist starts shaping by
even in absence of the unpleasant response the reinforcing the existing behavior. Once it is
pleasant stimulus becomes unpleasant by
established he reinforces the responses which
association. Punishment is presented imme-
are closestto the desired behavior, and ignores
diately after a specific behavioral response and
the other responses.
the response is eventually inhibited.
For example, to establish eye-to-eye
Unpleasant response is produced by electric
stimulus, drugs, social disapproval or even contact, the therapist sits opposite the patient
fantasy. and reinforces him even if he moves his
Indications: upper body towards him. Once this is
Alcohol abuse established, he reinforces the person's
Paraphilias head movement in his direction and this
Homosexuality procedure continues till eye-to-eye contact is
Transvestism. established.
3. Chaining: Chaining is used when a person
D. Operant conditioning procedures for increasing
fails to perform a complex task. The complex
adaptive behavior
1. Positive reinforcement: When a behavioral task is broken into a number of small steps
response is followed by a generally rewarding and each step is taught to the patient. In
event such as food, praise or gifts, it tends to forward chaining one starts with the first step,
be strengthened and occurs more frequently goes on to the second step, then to the third
than before the reward. This technique is used and so on. In backward chaining, one starts
to increase desired behavior. with the last step and goes on to the next step
2. Token economy:Thisprogram involvesgiving in a backward fashion. Backward chaining is
token rewards for appropriate or desired found to be more effective in training the
target behaviors performed by the patient. The mentally disabled.
F. Operant conditioning proceduresfor decreasing G. Assertiveness and socialskill training: Assertive
maladaptive behavior training is a behavior therapy technique in which
1. Extinction/Ignoring: Extinction means the patient is given training to bring about change
removal of attention rewards permanently, in emotional and other behavioral pattern by
following a problem behavior. This includes being assertive. Client is encouraged not to be
actions like not looking at the patient, not afraid of showing an appropriate response,
talking to the patient, or having no physical negative or positive, to an idea or suggestion.
contact with the patient etc, following the Assertive behavior training is given by the
problem behavior. therapist, first by role play and then by practice
This is commonly used when patient in a real life situation. Attention is focused on
exhibits odd behavior. more effective interpersonal skills.
2. Punishment: Aversive stimulus (punishment) Social skills training helps to improve social
is presented contingent upon the undesirable manners like encouraging eye contact, speaking
response. The punishment procedure should appropriately, observing simple etiquette, and
be administered immediately and consistently relating to people.
following the undesirable behavior with clear
explanation.
Cognitive Therapy
Differential reinforcement of an adaptive
or desirable behavior should always be added Cognitive therapy is a psychotherapeutic
when a punishment is being used for approach based on the idea that behavior is
decreasing an undesirable behavior. Other- secondary to thinking. Our moods and feelings
wise the problem behaviors tend to get are influenced by our thoughts. Self-defeatingand
maintained because of the lack of adaptive self-depreciating patterns of thinking result in
behaviors and skill defect. depressed mood. The therapist helps the patient
3. Timeout: Timeout method includes removing by correcting this distorted way of thinking,
the patient from the reward or the reward from feelings and behavior.
the patient for a particular period of time The cognitive model of depression includes
following a problem behavior. This is often the cognitive triad:
used in the treatment of childhood disorders. 1. A negative view about self
For example, the child is not allowed to go out 2. A negative view about the environment and
of the ward to play if he fails to complete the 3. A negative view about the future
given work.
These negative thoughts are modified to
4. Restitution (Over-correction): Restitution
improve the depressive mood. Cognitive therapy
means restoring the disturbed situation to a
state that is much better than what it was before is used for the treatment of depression, anxiety
the occurrence of the problem behavior. disorder, panic disorder, phobic disorder and
For example, if a patient passes urine in eating disorders.
the ward he would be required to not only
clean the dirty area but also mop the entire/ Hypnosis
larger area of the floor in the ward. The word 'hypnotism' was first used by James
5. Response cost: This procedure is used with Braid in the 19th century. Hypnosis is an
individuals who are on token programs for artificially induced state in which the person is
teaching adaptive behavior. When undesir- relaxed and unusually suggestible. Hypnosis can
able behavior occurs, a fixed number of tokens be induced in many ways, such as by using a
or points are deducted from what the fixed point for attention, rhythmic monotonous
individual has already earned. instructions, etc.
Changes that occur during Hypnosis safe method is the use of thiopentone sodium i.e.
The person becomes highly suggestible to the 500 mg dissolved in 10 cc of normal saline. It is
commands of the hypnotist. infused at a rate no faster than 1 cc/minute to
There is an ability to produce or remove prevent sleep as well as respiratory depression.
symptoms or perceptions.
Dissociation of a part of body or emotions. Relaxation Therapies
Amnesia for the events that occurred during Relaxation produces physiological effects oppo-
the hypnotic state. site those of anxiety: slowed heart rate, increased
peripheral blood flow and neuromuscular
Techniques stability.
Patient is either made to lie down on a bed or sit There are many methods which can be used
in a chair. He is asked to gaze fixedly on a spot. to induce relaxation.
Therapist makes monotonous suggestions of
relaxation and sleep. The patient however is not Jacobson's Progressive Muscular Relaxation
asleep and can hear what is being said, answer Patients relax major muscle groups in fixed order,
questions and obey instructions. beginning with the small muscle groups of the
This therapy is useful in: feet and working cephalad or vice versa.
Abreaction of past experiences.
Psychosomatic disorders. Hypnosis
Conversion and dissociative disorders.
Eating disorders. Mental Imagery
Habit disorders and anxiety disorders. It is a relaxation method in which patients are
instructed to imagine themselves in a place
Abreaction Therapy associated with pleasant relaxed memories. Such
Abreaction is a process by which repressed images allow patients to enter a relaxed state or
material, particularly a painful experience or experience a feeling of calmness and tranquility.
conflict is brought back to consciousness. The
person not only recalls but also relives the Use of Tape-recorded Exercises or Instructions
material, which is accompanied by the Which allows patients to practice relaxation on
appropriate emotional response. It is most useful their own.
in acute neurotic conditions caused by extreme
stress (Post-traumatic stress disorder, hysteria Yoga or Meditation
etc).
It is concentrating on the spirit by using certain
Although abreaction is an integral part of
postures to prepare the body to sit motionless,
psychoanalysis and hypnosis, it can also be used
independently. remain alert and focus on one particular point.
Yoga is highly useful in reducing stress and
Method treating anxiety.
Abreaction can be brought about by strong
Bio-feedback
encouragement to relive the stressful events. The
procedure is begun with neutral topics at first, Bio-feedback is based on the idea that the auto-
and gradually approaches areas of conflict. nomic nervous system can come under voluntary
Although abreaction can be done with or without control through operant conditioning. Thus it
the use of medication, the procedure can be facili- helps people to control usually involuntary
tated by giving a sedative drug intravenously. A physiological functions so as to change them, for
instance,by relaxing.People learn to control these Re-education: Education to the patient
functions by hearing or seeing signals from regarding his problems, ways of coping, etc.
instruments that produce information about Reassurance
various measures such as muscle tension, blood
pressure, etc. This feedback helps the patient to Group Therapy
control such responses. Group psychotherapy is a treatment in which
Uses of bio-feedback include treatment of carefully selected people who are emotionally ill
enuresis, and treatment of a host of ailments meet in a group guided by a trained therapist,
brought on by stress such as migraine headaches, and help one another effect personality change.
tension headaches, idiopathic hypertension,
cardiac problems, etc.
Selection
Individual Psychotherapy Homogeneous groups

Adolescents and patients with personality
Psychotherapy can be defined as the treatment
disorders
for problems of an emotional nature, in which a
Families and couples where the system needs
trained person deliberately establishes a pro-
change
fessional relationship with the patient to remove,
modify or retard existing symptoms, mediate
Contraindications
disturbed patterns of behavior and promote
positive personality growth and development. Antisocial patients
Individual psychotherapy is conducted on a Actively suicidal or severely depressed
one-to-onebasis, i.e. the therapist treats one client patients
at a time. The patient is encouraged to discover Patients who are delusional and who may
for himself the reasons for his behavior. The incorporate the group into their delusional
therapist listens to the patient and offers system
explanation and advice when necessary. By this
he helps the patient to come to a greater Group Size
understanding of himself and to find a way of Optimal sizefor group therapy is 8to 10members.
dealing with his problems.
Indications: Stress-related disorders, alcohol and Frequency and Length of Sessions
drug dependence, sexual disorders and marital Most group psychotherapists conduct group
disharmony. sessions once a week; each session may last for
45 minutes to 1 hour.
Supportive Psychotherapy
In this, the therapist helps the patient to relieve Approaches to Group Therapy
emotional distress and symptoms without pro- The therapist's role is primarily that of a
bing into the past and changing the personality. facilitator; he should provide a safe,
He uses various techniques such as: comfortable atmosphere for self-disclosure
Ventilation: It is a free expression of feelingsor Focus on the "here and now"
emotions. Patient is encouraged to talk freely Use any transference situations to develop
whatever comes to his mind. insight into their problems
Environmental modification/manipulation: Protect members from verbal abuse or from
Improving the well-being of mental patients scapegoating
by changing their living condition. Whenever appropriate, provide positive
Persuasion: Here the therapist attempts to reinforcement, this gives ego support and
modify the patient's behavior by reasoning. encourages future growth
Handle circumstantial patients, hallucinating If the group is run well, patients imitate the
and delusional patients in a manner that adaptive behaviors of other group members.
protects the self-esteem of the individual and
Interpersonal learning: It refers to learning about
also sets limits on the behavior so as to protect difficulties in relationships by examining the
other group members interaction of individuals with the other members
Develop ability to recognize when a group of the group.
member is" fragile"; he should be approached
in a gentle, supportive and non-threatening Some Techniques Useful in Group Therapy
manner
Reflecting or rewarding comments of group
Use silence effectively to encourage intro- members
spection and facilitate insight Asking for group reaction to one member's
Laughter and a moderate amount of joking statement
can act as a safety valve and at times can Askingforindividual reactionto one member's
contribute to group cohesiveness statement
Role-playing may help a member develop Pointing out any shared feelings within the
insight into the ways in which he relates to group
others Summarizing various points at the end of
session
Therapeutic Factors Involved in Group Therapy In conclusion,one may say that group therapy
Theseinvolve sharing experiences,support to and plays a major role in the rehabilitation of the
from group members, socialization,imitation and mentally ill individual. Group therapy gives an
interpersonal learning. opportunity for immediate feedback from a
patient's peer and a chance for both patient and
Sharing experience: This helps the patients to therapist to observe the patient's psychological,
realize that they are not isolated and that others emotional and behavioral response towards a
also have similar experiences and problems. variety of people. Thus it helps the patient to
Hearing from other patients that they have shared master communication and interpersonal skills,
experiences is often more convincing and helpful problem solving, decision making and
than reassurance from the therapist. assertiveness skills, thus enabling him to re-enter
the society's mainstream with a greater degree of
Support to andfrom group members: Receiving help confidence.
from other group members can be supportive to
the person helped. The sharing action of being Psychodrama
mutually supporting is an aspect of group
Psychodrama is a specialized type of group
cohesivenessthat can provide a sense ofbelonging
therapy that employs a dramatic approach in
for patients who feel isolated in their everyday which patients become actors in life-situation
lives. scenarios. The goal is to resolve interpersonal
Socialization: It is acquisition of social skills (for conflicts in a less threatening atmosphere than
e.g. maintaining eye contact) within a group the real-life situation would present.
through comments that members provide about In psychodrama the patient is brought directly
one another's deficiencies in social skills. This into the situation as an active participant. The
process can be helped by trying out new ways of director co-ordinates the process so that the group
interacting within the safety of the group. and the protagonist receivemaximalbenefit.Other
group members act as auxiliary egos and play
Imitation: It is learning from observing and the roles of significant others with whom
adapting the behaviors of other group members. relationships are being explored.
The primary advantage of psychodrama is its Family therapy is the treatment of choicewhen
direct access to reenacting painful situations so there is a marital problem or sibling conflict;
that the painful emotions associated with them family therapy may also be indicated when
can be reworked, with the potential for spon- problems are caused by using one child as the
taneously learning new responses in a safe scapegoat.
therapeutic environment. Situational crises such as the sudden death of
a family member, and maturational crises
Family and Marital Therapy such as birth of the first child, may cause
Family therapy is that branch of psychiatry which sufficient stress to warrant family therapy.
sees an individual's psychiatric symptoms as
inseparably related to the family in which he lives. Types of Family Therapy
Thus the focus of treatment is not the individual, Individual Family Therapy
but the family. Today, most family theorists
identify the individual's problems as a symptom In individual family therapy each family member
of trouble within the family. has a single therapist. The whole family may meet
occasionally with one or two of the therapists to
Indications see how the members are relating to one another
and work out specific issues that have been
Family therapy is indicated whenever there are
defined by individual members.
relational problems within a family or marital
unit, which can occur in almost all types of
Conjoint Family Therapy
psychiatric problems, including psychoses, reac-
tive depression, anxiety disorders, psychosomatic The most common type of family therapy is the
disorders, substance abuse and various childhood single-family group, or conjoint family therapy.
psychiatric problems. The nuclear family is seen, and the issues and
problems raised by the family are the ones
Components of Therapy addressed by the therapist. The way in which the
Assessment of family structure, roles, boun- family interacts is observed and becomes the focus
daries, resources, communication patterns of therapy. The therapist helps the family deal
and problem solving skills more effectively with problems as they arise and
Teaching communication skills are defined.
Teaching problem solving skills
Couples Therapy
Writing a behavioral marital contract
Homework assignments Couples are often seen by the therapist together.
The couple may be experiencing difficulties in
Client Selection their marriage, and in therapy they are helped to
Families may be referred for treatment by, work together to seek a resolution for their prob-
private physicians, and agencies such as the lems. Family patterns, interaction and communi-
school system, welfare board, parole officers, cation styles, and each partner's goals, hopes and
and judges. expectations are examined in therapy. This exami-
Some families are referred for therapy from nation enables the couple to find a common ground
emergency room psychiatric services after a for resolving conflicts by recognizing and respec-
visit caused by a crisis in the family, such as a ting each other's similarities and differences.
drug overdose.
Multiple Family Group Therapy
On discharge from a psychiatric hospital, a
client and his family may be referred for family In multiple family group therapy, four or five
therapy, as part of follow up services. families meet weekly to confront and deal with
problems or issues they have in common. Ability development and effective management in the
or inability to function well in the home and evolution of the problem resolution.
community, fear of talking to or relating to others,
abuse, anger, neglect, the development of social MILIEU THERAPY
skills, and responsibility for oneself are some of The therapeutic milieu is an environment that is
the issues on which these groups focus. The structured and maintained as an ideal, dynamic
multiple family group becomes the support for setting in which to work with clients. This milieu
all the families.The network also encourages each includes safe physical surroundings, all the
person to reach out and form new relationships treatment team members, and other clients. It is
outside the group. supported by clear and consistently maintained
limits and behavioral expectations.
Multiple Impact Therapy A therapeutic setting should minimize
In multiple impact therapy, several therapists environmental stress such as noise and confu-
come together with the families in a community sion, and physical stress. It provides a chance for
setting. They live together and deal with pertinent rest and nurturance of self, a time to focus on the
issues for each family member within the context development of strengths, and an opportunity to
of the group. Multiple impact therapy is similar learn to identify alternatives or solutions to
to multiple family group therapy except that it is problems and to learn about the psychodynamics
more intense and time- limited. Like multiple of those problems.
family group therapy, it focuses on developing A therapeutic milieu is a "safe space," a non-
skills or working together as a family and with punitive atmosphere in which caring is a basic
other families. factor. In this environment, confrontation may be
a positive therapeutic tool that can be tolerated
Network Therapy by the client.Nurses and treatment team members
Network therapy is conducted in people's homes. should be aware of their own roles in this
All individuals interested or invested in a environment, maintaining stability and safety,but
problem or crisis that a particular person or minimizing authoritarian behavior. Clients are
persons in a family are experiencing take part. expected to assume responsibility for themselves
This gathering includes family, friends, within the structure of the milieu as much as
neighbors, professional groups or persons, and possible. Feedback from other clients and the
anyone in the community who has an investment sharing of tasks or duties within the treatment
in the outcome of the current crisis. People who program facilitate the client's growth.
form the network generally know each other and The various components of therapeutic milieu
interact on a regular basis in each other's lives. include:
Thus a network may include as many as 40 to 60
people. Maintaining Safe Environment
The rewards are great when all the people The nursing staff should follow the facility's
involved mobilize energy for management of the policieswith regard to prevention of routine safety
problem. The power is in the network itself. The hazards and supplement these policies as
answers to each problem come from the network necessary. For example:
and how people in the network decide to manage Dispose of all needles safely and out of reach
each issue as it arises. The therapists serve as a of clients.
guide to clarify issues, reinforce the importance Restrict or monitor the use of matches and
of and need for the network toward its members lighters.
collectively and individually, and assist in the Do not allow smoking.
Remove mouthwash, aftershave lotions and therapeutic relationship, and limit-setting and
so forth, if substance abuse is suspected. consistency are its building blocks.
Listed below are the most restrictive measures
to be used on a unit on which clients who are Building Self-esteem
exhibiting behavior directly threatening or Strategies to help build or enhance self-esteem
harmful to themselves or others may be pre- must be individualized and built on honesty and
sent. These measures may be modified based on the client's strengths. Some general sugges-
on the assessment of the client's behavior: tions are:
immediately on the client's admission, Set and maintain limits.
search the client and all of the client's Accept the client as a person.
belongings and remove potentially Benon-judgmental at all times.
dangerous items, such as wire, clothes Structure the client's time and activities.
hangers, ropes, belts, safety pins, scissors Have realistic expectations of the client and
and other sharp objects, weapons, and make them clear to the client.
medications; keep these belongings in a Initially provide the client with tasks,
designated place inaccessible to the client, responsibilities and activitiesthat can be easily
be sure mirrors, if glass, are securely accomplished; advance the client to more
fastened and not easily broken difficult tasks as he progresses.
keep sharp objects (e.g. scissors, pocket Praise the client for his accomplishments
knives, knitting needles) out of reach of however small, giving sincere appropriate
clients and allow their use only with feedback for meeting expectations,completing
supervision; use electric shavers when tasks, fulfilling responsibilities, and so on.
possible (disposable razors are easily Never flatter the client.
broken to access blades) Use confrontation judiciously and in a
identify potential weapons (e.g. mop supportive manner; use it only when the client
handles, hammers) and dangerous can tolerate it.
equipment (e.g.electrical cords, scalpels), Allow the client to make his own decisions
and keep them out of the client's reach whenever possible. If the clientis pleased with
do not leave cleaning fluids, bleach, mops the outcome of his decision, point out that he
and tools, unattended in clie~t care areas was responsible for the decision and give
do not leave medicines unattended or positive feedback.
unlocked If the client is not pleased with the outcome,
keep keys (tounit door, medicines) on your point out that the client like everyone can
person at all times make and survive mistakes, then help the
be aware of items that are harmful if inges- client identify alternative approaches to the
ted, for example, mercury in manometers problem; give positive feedback for the client's
search packages brought in by visitors, taking responsibility for problem solving and
explain the reason for such rules briefly, for his efforts.
and do not make any exceptions
Limit-setting
The Trust Relationship Setting and maintaining limits are integral to a
One of the keys to a therapeutic environment is trust relationship and to a therapeutic milieu.
the establishment of trust. Both the client and the Beforestating a limit explain the reasons for limit-
nurse must trust that treatment is desirable and setting. Somebasic guidelines for effectivelyusing
productive. Trust is the foundation of a limits are:
Therapeutic Modalities in Psychiatry 19 5
State the expectations or the limit as clearly, To increase their independence and gain con-
directly and simply as possible. trol over many of their own personal activities.
The consequence that will follow the client's To enable the patients become aware of how
exceeding the limit also must be clearly stated their behavior affects others.
at the outset.
The consequences should immediately follow Elements of Therapeutic Community
the client's exceeding the limit and must be Free communication
consistent, both over time (each time the limit Shared responsibilities
is exceeded) and among staff (each staff Active participation
member must enforce the limit). Involvement in decision making
Consequences are essential to setting and Understanding of roles, responsibilities,
maintaining limits, they are not an oppor- limitations and authorities
tunity to be punitive to a client.
In conclusion, the nurse works with other Components of Therapeutic Community
health professionals in an interdisciplinary team; Daily Community Meetings
The interdisciplinary team works within a milieu
These meetings are composed of 60-90
that is constructed as a therapeutic environment, patients. All levels of unit staff are involved,
with the aim of developing a holistic view of the including administrative personnel. Acute
client and providing effective treatment. patients are not involved in the meetings.
Meetings should be held regularly for 60
THERAPEUTICCOMMUNITY minutes.
The concept of therapeutic community was first Discussion should focus mainly on day-to-
developed by Maxwell Jones in 1953.He wrote a day life in the unit.
book entitled "SocialPsychiatry" which was first During discussions patients' feelings and
published in England. Later on when it was behaviors are examined by other members.
published in the United States, its title was Frank discussions are encouraged, these may
changed to "Therapeutic Community." take place with much outpouring of emotions
and anger
Definition
Stuart and Sundeen defined therapeutic com- Patient Government or Ward Council
munity as "a therapy in which patient's social The purpose of patient government is to deal
environment would be used to provide a with practical unit details such as house-
therapeutic experiencefor the patient by involving keeping functions, activity planning and
him as an active participant in his own care and privileges.
the daily problems of his community." A group of 5-6patients will have specific res-
ponsibilities, such as house keeping, physical
Objectives exercise, personal hygiene, meal distribution,
To use patient's socialenvironment to provide a group to observe suicidal patients, etc. Staff
a therapeutic experience for him. members should be available always.
Toenable the patient to be an activeparticipant All decisions should be fedback to the
in his own care and become involved in daily community through the community meetings
activities of his community.
To help patients to solve problems, plan Staff Meetings or Review
activities and to develop the necessary rules A staff meeting should be held following each
and regulations for the community. community meeting (Patients are excluded and
only staff are present). In this meeting the staff In conclusion, therapeutic community is an
would examine their own responses, expecta- approach which is:
tions, and prejudices. Democratic as opposed to hierarchial.
Rehabilitative rather than custodial.
Living and Learning Opportunities Permissive instead of limited and controlled.
Learning opportunities are to be provided within
the social milieu, which should provide realistic ACTIVITYTHERAPY
learning experiences for the patients. Activity therapies include occupational therapy,
recreational therapy, educational therapy, play
Advantages of Therapeutic Community therapy, music therapy, dance therapy, and art
Patient develops harmonious relationships therapy.
with other members of the community.
Gains self-confidence. Aims
Develops leadership skills. To assist the client in making a transition from
Learns to understand and solve problems of sick role to becoming a contributing member
self and others. of society.
Becomes socio-centric. To assist in diagnostic and personality
Learns to live and think collectively with the evaluation.
members of the community. To enhance psychotherapy and other
Lastly therapeutic community provides psychotherapeutic measures (the activity
opportunities to participate in the formulation prescribed for the client often provides a
of hospital rules and regulations that affect nonverbal means for the client to express and
patient's personal liberties like bedtime, meal resolve his feelings),
time, weekend permission, control of radio or
TV,social activities, late night privileges, etc. Occupational Therapy
Occupational therapy is the application of goal-
Disadvantages of Therapeutic Community oriented, purposeful activity in the assessment
Role blurring between staff and patient. and treatment of individuals with psychological,
Group responsibility can easily become physical or developmental disabilities.
nobody's responsibility.
Individual needs and concerns may not be Goal
met. The main goal is to enable the patient to achieve a
Patient may find the transition to community healthy balance of occupations through the
difficult development of skills that will allow him to
function at a level satisfactory to himself and
Role of the Nurse others.
Providing and maintaining a safe and conflict
free environment through role modeling and Settings
group leadership. Occupational therapy is provided to children,
Sharing of responsibilities with patients. adolescents, adults and elderly patients. These
Encouraging patient to participate in decision- programs are offered in psychiatric hospitals,
making functions. nursing homes, rehabilitation centers, special
Assisting patients to assume leadership roles. schools, community group homes, community
Giving feedback. mental health centers, day care centers, halfway
Carrying out supervisory functions. homes and deaddiction centers.
Advantages Therapeutic activities: These activities are used to
Helps to develop social skills and provide an attain a specific care plan or goal.
outlet for self-expression. For example, basket making, carpentry, etc.
Strengthens ego defenses.
Develops a more realistic view of the self in Suggested Occupational Activities for
relation to others. Psychiatric Disorders
Anxiety disorder Simple concrete tasks with no
Points to be Kept in Mind more than 3 or 4 steps that can be learnt quickly.
The client should be involved as much as For example, kitchen tasks, washing, sweeping,
possible in selecting the activity. mopping, mowing lawn and weeding gardens.
Select an activity that interests or has the
Depressive disorder Simple concrete tasks which
potential to interest him.
are achievable; it is important for the client to
The activity should utilize the client's
experience success. Provide positive reinforce-
strengths and abilities.
ment after each achievement.
The activity should be of short duration to
For example, crafts, mowing lawn, weeding
foster a feeling of accomplishment.
gardens.
Ifpossible, the selectedactivity should provide
some new experience for the client. Manic disorder Non-competitive activities that
allow the use of energy and expression of feelings.
Process of Intervention Activities should be limited and changed
It consists of six stages: frequently. Client needs to work in an area away
1. Initial evaluation of what patient can do and from distractions.
cannot do in a variety of situations over a For example, raking grass, sweeping, etc.
period of time. Schizophrenia (paranoid) Non-competitive, solitary
2. Development of immediate and long-term
meaningful tasks that require some degree of
goals by the patient and therapist together.
concentration so that less time is available to focus
Goals should be concrete and measurable so
on delusions.
that it is easy to see when they have been
For example, puzzles, scrabble.
attained.
3. Development of therapy plan with planned Schizophrenia (catatonic) Simple concrete tasks in
intervention. which client is actively involved. Client needs
4. Implementation of the plan and monitoring continuous supervision, and at first works best
the progress. The plan is followed until the on a one-to-one basis.
first evaluation. If satisfactory it is continued, For example, metal work, molding clay, etc.
or altered if not.
5. Review meetings with patient and all the staff Antisocial personality Activitiesthat enhance self-
involved in treatment. esteem and are expressive and creative, but not
6. Setting further goals when immediate goals too complicated. Client needs supervision to
have been achieved; modifying the treatment make sure each task is completed.
program as relevant. Dementia Group activities to increase feeling of
belonging and self-worth. Provide those activities
Types of Activities which promote familiar individual hobbies.
Diversional activities: These activities are used to Activities need to be structured, requiring little
divert one's thoughts from life stresses or to fill time for completion and not much concentration.
time. Explain and demonstrate each task, then have
For example, organized games. client repeat the demonstration.
Substance abuse Group activities in which client Sensory forms: These can be either visual, e.g.
uses his talents. For example, involving client in looking at motion pictures, play, etc., or auditory
planning social activities, encouraging inter- such as listening to a concert.
action with others, etc.
Intellectual forms: These include reading, debating
Childhood and adolescent disorders and so on.
Children: Playing, story telling, painting, poetry,
music, etc.
Suggested RecreationalActivities for
Adolescents: Creative activities such as leather Psychiatric Disorders
work, drawing, painting.
Anxiety disorders Aerobic activitieslike walking,
Mental retardation Repetitive work assignments jogging, etc.
are ideal;provide positivereinforcementafter each
achievement. Depressive disorder Non-competitive sports,
For example, cover making, candle making, which provide outlet for anger, like jogging,
packaging goods, etc. walking, running, etc.
Manic disorder One-to-one basis individual
Recreational Therapy
games like badminton, ball.
Recreation is a form of activity therapy used in
most psychiatric settings. It is a planned thera- Schizophrenia (paranoid) Concentrative activities
peutic activity that enables people with like chess, puzzles.
limitations to engage in recreational experiences.
Schizophrenia (catatonic) Socialactivities to give
Aims client contact with reality, like dancing, athletics.
To encourage social interaction. Dementia Concrete, repetitious crafts and pro-
To decrease withdrawal tendencies. jects that breed familiarization and comfort.
To provide outlet for feelings.
Childhood and adolescent disorders It is better to
To promote socially acceptable behavior.
work with the child on a one-to-one basis and
To develop skills, talents and abilities.
To increase physical confidence and a feeling give him a feeling of importance. Some activities
of self worth. include playing, story telling, and painting.
Adolescents fare better in groups; provide
Points to be Kept in Mind gross motor activities like sports and games to
use up excess energy.
Provide a non-threatening and non-deman-
ding environment. Mental retardation Activitiesshould be according
Provide activities that are relaxing and to the client's level of functioning such as walking,
without rigid guidelines and time-frames. dancing, swimming, ball playing, etc.
Provide activities that are enjoyable and self-
satisfying.
Educational Therapy
Types of RecreationalActivities Educational therapy is used when the client has
Motor forms: These can be further divided into problems which result from a great deal of mis-
fundamental and accessory; among the funda- conception. The educational therapist provides
mental forms are such games as hockey and reading and learning experiences that can do a
football, while the accessory forms are exempli- great deal to eliminate his misconceptions and
fied by play activity and dancing. anxiety.
Biblio Therapy Free play vs Controlled play therapy In free play

It is described as the prescription of reading the child is given freedom in deciding with what
materials that will help to develop emotional toys he wants to play.
maturity and sustain mental health. In controlled play therapy, the child is
Some emotionally disturbed individuals are introduced into a scene where the situation or
able to relate therapeutically to the experiences of setting is already established.
others when they read about them, rather than Structured vs Unstructured play therapy Structured
experiencing them directly. It also provides a play therapy involves organizing the situation in
medium for discussion with others. such a way so as to obtain more information.
In unstructured play therapy no situation is
Play Therapy set and no plans are followed.
Playis a natural mode ofgrowth and development
Directive vs Non-directive play therapy In directive
in children. Through play a child learns to express
play therapy, the therapist totally sets the
his emotions and it serves as a tool in the
directions, whereas in non-directive play therapy,
development of the child. the child receives no directions.
Play therapy is generally conducted in a
Curative Functions playroom. The playroom should be suitably
It releases tension and pent-up emotions. stocked with adequate play material, depending
It allows compensation for loss and failures. upon the problems of the child.
It improves emotional growth through his
relationship with other children. Music Therapy
It provides an opportunity to the child to act Music therapy is the functional application of
out his fantasies and conflicts, to get rid of music towards the attainment of specific
aggression and to learn positive qualities from therapeutic goals.
other children.
Advantages
Diagnostic Functions
Facilitates emotional expressions .
Play therapy gives the therapist a chance to Improves cognitive skills like learning,
explore family relationships of the child and listening and attention span.
discover what difficulties are contributing to Social interaction is stimulated.
the child's problems.
Play therapy allows to study hidden aspects Dance Therapy
of the child's personality. It is a psychotherapeutic use of movement, which
It is possible to obtain a good idea of the furthers the emotional and physical integration
intelligence level of the child. of the individual.
Through play inter-sibling relationships can
be adequately studied Advantages
Helps to develop body awareness.
Types of Play Therapy
Facilitates expression of feelings.
Individual vs Group play therapy In individual Improves interaction and communication.
therapy the child is allowed to play by himself Fosters integration of physical, emotional and
and the therapist's attention is focused on this social experiences that result in a sense of
one child alone. increased self-confidence and contentment.
In group play therapy other children are Exercise through body movement maintains
involved. good circulation and muscle tone.
Art Therapy Neuroleptic malignant syndrome
The goal of art therapy is to help the patient Anti psychotic drugs (Oct 2004)
express his thoughts, emotions, and feelings Atypical anti psychotics (Apr 2006)
through his drawings. Mood stabilizing drugs (Nov 2001, Nov 2003)
Lithium (Nov 1999, Apr 2004, Oct 2004, Oct
2005)
Importance of Art Therapy
Antidepressants (Apr 2006)
It is used as a diagnostic and therapeutic tool. Benzodiazepines
It provides socially acceptable outlet for Drugs used in treatment of anxiety (Apr 2006)
fantasy and wish fulfillment. Electroconvulsive therapy (Feb 2000, Apr
It helps the patient to gain relief from anxiety 2006, Oct 2006)
by graphically representing conflict and Pre ECT preparation (Apr 2006)
aggressive and traumatic material without Post ECT care (Nov 2002, Nov 2003)
guilt. Complications of ECT (Oct 2002, Oct 2005)
Role of a nurse in ECT management (Nov
Implications of Activity Therapies for 1999,Apr 2004)
Nursing Practice Psychological therapies (Nov 1999,Apr 2006)
The nurse has an important role in enhancing Psychoanalytical therapy (Nov 2003)
the therapeutic effects of activity therapies. Some Dream analysis (Nov 2003, Oct 2004)
points to be kept in mind are: Behavior therapy (Feb 2000, Nov 2003)
Close coordination between the nursing staff Systematic desensitization
and the activity therapy department is Aversion therapy (Oct 2000)
essential. Token economy (Nov 2001)
By engaging in these activities, the nurse not Hypnosis (Nov 2002, Nov 2003)
only has an opportunity to support the Abreaction therapy (Oct 2000)
therapeutic efforts of the recreational therapist Narco-analysis (Oct 2005)
but also has an invaluable opportunity to Supportive psychotherapy
observe the client in different settings. Individual psychotherapy (Oct 2005)
Through her observations of the client's Family therapy (Apr 2002, Oct 2002, Oct 2005,
behavior during these activities, the nurse will Oct 2006)
gain valuable information that she can Group therapy (Feb 2001, Apr 2002, Apr 2006)
subsequently utilize to therapeutic advantage Psychodrama (Nov 2002)
in the working phase of the nurse-client Recreation therapy (Apr 2002, Apr 2006)
relationship. Play therapy (Nov 2002, Nov 2003, Apr 2004,
Oct 2005)
REVIEWQUESTIONS What are the characteristics of a therapeutic
Classification of psychotropic drugs (Feb environment? How will you create such an
2001) environment in a psychiatric unit? (Feb 2000)
Classification of antipsychotic drugs Milieu therapy (Oct 2005)
Role of a nurse in administration of Therapeutic community (Nov 1999,Nov 2002,
psychotropic drugs (Nov 1999) Nov 2003, Oct 2004, Apr 2006)
EPS (Oct 2000, Nov 2001, Nov 2003) Activity therapy (Oct 2000)
Drug induced parkinsonism Social skill training (Nov 2003)
Akathesia (Apr 2004) Occupational therapy (Nov 1999, Feb 2001,
Dystonia (Oct 2006) Nov 2002, Nov 2003, Oct 2006)
Crisis Intervention
0 GRIEF Stage I-Denial: This is a stage of shock and
Stages of Grief disbelief. The response may be one of "No, it can't
Resolution of Grief be true!" Denial is a protective mechanism that
Maladaptive Grief Responses
Treatment
allows the individual to cope within an imme-
Nursing Intervention diate time-frame while organizing more effective
0 CRISIS defense strategies.
Definition
Crisis Proneness Stage II-Anger: "Why me?" and "It is not fair!"
Types of Crisis are comments often expressed during the anger
Phases of Crisis
Signs and Symptoms of Crisis stage. Anger may be directed at self or displaced
Resolution of Crisis on loved ones, caregivers, and even God. There
Crisis Intervention may be a preoccupation with an idealized image
0 ROLEOFA NURSEINCRISISINTERVENTION
of the lost entity.
0 MODALITIESOFCRISISINTERVENTION
0 STRESS StageIII-Bargaining: "IfGod will help me through
Body Coping Mechanism with Stress
Sources of Stress this, I promise I will go to church every Sunday
Symptoms of Stress and volunteer my time to help others". During
Stress Management Strategies this stage, which is generally not visible or evident
Role of a Nurse in Stress Management
to others, a bargain is made with God in an
attempt to reverse or postpone the loss.
GRIEF
Grief is a subjective state of emotional, physical Stage IV--Depression: During this stage the full
and social response to the loss of a valued entity. impact of the loss is experienced. This is a time of
The loss may be real, in which case it can be sub- quiet desperation and disengagement from all
stantiated by others (e.g. death of a loved one),or associations with the lost entity.
perceived by the individual alone, in which case StageV-Acceptance: The finalstage brings a feeling
it cannot be perceived or shared by others(e.g.loss of peace regarding the loss that has occurred.
of feeling of femininity following mastectomy). Focus is on the reality of the loss and its meaning
for the individuals affected by it.
Stages of Grief
Kubler-Ross (1969) having done extensive All individuals do not experience each of these
research with terminally illpatients identified five stages in response to a loss, nor do they
stages of feelings and behavior that individuals necessarily experience them in this order. Some
experience in response to a real, perceived or individuals grieving behavior may fluctuate, and
anticipated loss: even overlap between stages.
Resolution of Grief of the grieving process. The emotional pain

Resolution of the process of mourning is thought associated with loss is not experienced, but there
to have occurred when an individual can look may be evidence of anxiety disorders or sleeping
back on the relationship with the lost entity and disorders. The individual may remain in denial
accept both the pleasure and the disappointments for many years until the grief response is triggered
(both the positive and negative aspects) of the by a reminder of the loss or even by another
association. Pre-occupation with the lost entity is unrelated loss.
replaced with energy and desire to pursue new
situations and relationships. Distorted Response
The length of the grief process may be The individual who experiences a distorted
prolonged by a number of factors: response is fixed in the anger stage of grieving.
If the relationship with the lost entity had been The normal behaviors associated with grieving,
marked by ambivalence, reaction to the loss may such as helplessness, hopelessness, sadness,
be burdened with guilt, which lengthens the grief anger and guilt are exaggerated out of proportion
reaction. to the situation. The individual turns the anger
In anticipatory grief where a loss is anti- inward on the self and is unable to function in
cipated, individuals often begin the work of normal activities of daily living. Pathological
grieving before the actual loss occurs.Most people depression is a distorted grief response.
experience the grieving behavior once the actual
loss occurs, but having this time to prepare for Treatment
the loss can facilitate the process of mourning, Normal grief does not require any treatment while
actually decreasing the length and intensity of complicated grief requires medication depending
the response. on the prevailing behavior responses.
The number of recent losses experienced by
an individual also affectsthe length of the grieving Nursing Intervention
process and whether he is able to complete one
Provide an open accepting environment.
grieving process before another loss occurs.
Encourage ventilation of feelings and listen
actively.
Maladaptive Grief Responses
Provide various diversional activities.
Maladaptive grief responses to loss occur when Provide teaching about common symptoms
an individual is not able to satisfactorily progress of grief.
through the stages of grieving to achieve reso- Reinforce goal-directed activities.
lution. Several types to grief responses have been Bring together similar aggrieved persons, to
identified as pathological [Lindemann (1944), encourage communication, share experiences
Parkes (1972)]. of the loss and to offer companionship, social
These are prolonged, delayed/ inhibited, and and emotional support.
distorted responses.
CRISIS
Prolonged Response
Crisis can be viewed as an integral component of
It is characterized by an intense preoccupation everyday life situations. A crisis may influence
with memories of the lost entity for many years people's lives in different ways. As a consequence
after the loss has occurred. of a crisis experience, the individual may go down
to a lower or less healthy level of functioning
Delayed or Inhibited Response than what was before the crisis, or he may resume
The individual becomes fixed in the denial stage the same level of functioning by repressing the
Crisis Intervention 203
crisisand the related emotions.On the other hand, relation to crisis prone characteristics as well as
he may function at a healthier level than prior to personality traits.
the crisis, because the challenge of a crisis can
bring out new strengths, skills and coping Types of Crisis
mechanisms. MaturationalCrisis
Intervention at a crisisis extremely important
A maturational crisis is a stage in a person's life
to prevent mental illness, because long-standing
where adjustment and adaptation to new
problems make the person totally incapable of
responsibilities and life patterns are necessary.
handling the situation. If proper guidance is
The transition points where individuals move
provided at the correct time, the victim will come
into successive stage often generate disequili-
out ofitbetter equipped to handle future problems
brium. Individuals are required to make cognitive
in life.
and behavioral changes and to integrate those
physical changes that accompany development.
Definition
The extent to which individuals experience
Crisis is a state of disequilibrium resulting from success in the mastery of these tasks depends on
the interaction of an event with the individual's previous successes, availability of support
or family's coping mechanisms, which are systems,influenceofrolemodels and acceptability
inadequate to meet the demands of the situation, of new role by others.
combined with the individual's or family's The transitional periods or events that are
perception of the meaning of the event (Taylor most commonly identified as having increased
1982). crisis potential are adolescence, marriage,
parenthood, midlife and retirement.
Crisis Proneness
Hendricks (1985) suggests that certain Situational Crisis
individuals are more prone to crisis than others. A situational crisis is one that is precipitated by
The following are characteristics often found in an unanticipated stressful event that creates
individuals who are regarded as being more disequilibrium by threatening one's sense of
susceptible to crisis: biological, social or psychological integrity.
Dissatisfaction with employment or lack of Examples of events that can precipitate
employment. situational crises are premature birth, status and
History of unresolved crisis. role changes, death of a loved one, physical or
History of substance abuse. mental illness, divorce, change in geographic
Poor self-esteem,unworthiness. location and poor performance in school.
Superficial relationship with others.
Difficultyin coping with everyday situations. Social Crisis
Under utilization of resources and support
Social crisis is accidental, uncommon, and
systems.
unanticipated and results in multiple losses and
Aloofness and lack of caring.
radical environmental changes. Social crises
It is important to note that individual perso- include natural disasters like floods, earthquakes,
nality traits must also be considered in con- violence, nuclear accidents, mass killings,
junction with these characteristics. Crisis is contamination of large areas by toxic wastes,
defined by the individual; what is a crisis for one wars, etc.Thistype of crisisis unlike maturational
is merely an occurrence for another. This factor is and situational crisis because it does not occur in
a critical component that must be evaluated in the lives of all people.
Because of the severity of the effects of social Signs and Symptoms of Crisis
crisis coping strategies may not be effective. The major feeling in a crisis situation is
Individuals confronted with social crisis usually anxiety. The individual experiences a heavy
do not have previous experience from which to burden of free-floating anxiety.
draw expertise. Support systems may be The anxiety may be manifested through
unavailable because they may also be involved depression, anger and guilt. The victim will
in similar situations. Mental health professionals attempt to get rid of the anxiety using various
are called upon to act quickly and provide services coping mechanisms, healthy or unhealthy.
to large numbers of people and in some cases, the The individual may become incapable of even
whole community. taking care of his daily needs and may neglect
his responsibilities.
Phases of Crisis The individual may become irrational and
Caplan (1964)has described four phases of crisis blame others for what has happened to him .
as described below:
Resolution of Crisis
Phase I Healthy resolution of a crisis depends upon the

following three factors:
Perceived threat acts as a precipitant that gene-
1. Realistic appraisal of the precipitating event,
rates increased anxiety. Normal coping strategies
i.e.recognition of the relationship between the
are activated, and if unsuccessful, the individual
event and feelings of anxiety is necessary for
moves into Phase II. effectiveproblem-solving to occur.
2. Availability of support systems.
Phase II 3. Availability of coping measures over a life-
The ineffectiveness of the Phase I coping time: A person develops a repertoire of
mechanisms leads to further disorganization. The successful coping strategies that enable him
individual experiences a sense of vulnerability. to identify and resolve stressful situations.
The individual may attempt to cope with the
There are three ways by which the individual
situation in a random fashion. If the anxiety
may resolve the crisis:
continues and there is no reduction, the
individual enters Phase III. Pseudo-resolution
In this, the individual uses repression and pushes
Phase/II
out of consciousness the incident and the intense
Redefinition of the crisis is attempted and the emotions associated with it, so there will not be
individual is most amenable to assistance in this any change in the level of functioning of the
phase. New problem solving measures may also individual. But in future, if and when a crisis
affect a solution. Return to pre-crisis level of occurs, the repressed feelings may surface and
functioning may occur. If problem solving is influence the feelings aroused by the new crisis.
unsuccessful, further disorganization occurs and In such a situation, the particular crisis may be
the individual is said to have entered Phase IV. more difficult to resolve because the feelings
associated with the earlier crisis are neither
Phase IV expressed nor handled at that time.
Severe to panic levels of anxiety with profound
cognitive, emotional and physiological changes Unsuccessful Resolution
may occur. Referralto further treatment resources In this, the victim uses pathological adaptation
is necessary. at any phase of crisis, resulting in a lower level of
functioning. The victim, rather than accepting the Assessment should also be done to identify
loss and reorganizing his life, keeps ruminating the strengths and limitations of the victim.
over the loss. An example is prolonged grief
Defining the event
reaction, which results in depression.
The victim at times may not be able to identify
Successful Resolution the precipitating event because of possible
denial, or due to reluctance to talk about it.
In this, the victim may go through the various
It may be necessary for the therapist to review
phases of crisis, but reaches Phase III where
the details of the incidents in the past 2 to 4
various coping measures are utilized to resolve
weeks in order to identify the event that
the crisissituation. The individual develops better precipitated the crisis.Such a review will help
skills and problem solving ability, which can be the victimbecoming aware of the precipitating
and will be used in various crisis situations in event.
future.
Develop a plan of action
Crisis Intervention The victim and the people closely associated
Crisis intervention is a technique used to help an with him should have active involvement in
individual or family to understand and cope with developing the plan of action.
the intense feelings that are typical of a crisis. The therapist must be aware that the victim
may not be in a condition to mentally
Nurses function as part of the interdisciplinary
comprehend complicated information due to
team in the use of crisis intervention as a
the overwhelming anxiety experienced by
therapeutic modality. ).."ursesmay employ crisis
him. The instructions given by the therapist
techniques in their work with high-risk groups
must be simple and clear, and too much
such as clientswith chronic diseases, new parents
information should not be given at a time. The
and bereaved persons.
instructions may have to be written down, as
Nurses may also use crisis intervention in
the victim may not be able to retain all the
dealing with intra-group staH issues and client
information.
management issues.
B. Steps to assist the victim in managing the intense
Aims of Crisis Intervention Technique feelings
To provide a correct cognitive perception of Helping the individual to be aware of thefeelings
the situation. The victim needs help in identifying his own
To assist the individual in managing the feelings, which is the first step in handling
intense and overwhelming feelingsassociated them.
with the crisis. The therapist should use appropriate com-
munication technique so that the victim will
Intervention feelcomfortableto express his feelingswithout
A Steps to provide a correct cognitioe perception the fear of being judged or criticized.
The therapist should also be efficient in
Assessment of the situaiu
observing verbal and non-verbal behavior of
This may be achieved !Jy direct questioning
the victim, so that he will be able to make a
with the purpose oi identification of the
careful assessment of his feelings.
problem and the pee'? ~einvolved.
It is necessary to icieni-'::.-the support systems Help the individual to attain mastery over thefeelings
available and to kr.c- - fue depth in which the The individual should be given adequate
individual's feelir:::;::-
are affected. support and guidance through therapeutic
process in order to handle feelings associated Patient's previous strengths and coping
with crisis but special care should be taken mechanisms
not to give any false reassurance. During this phase the nurse begins to establish
He should not in any way be encouraged to a positive working relationship with the patient.
blame others, as this will only let him escape
from taking any responsibility.
Nursing Diagnoses
Care must be taken to ensure that the
individual does not develop too much The primary nursing diagnoses in crisis
dependency on the therapist, which is intervention are:
unhealthy. Ineffective individual coping
After the victim and the support groups Ineffectivefamily coping
prepare the plan of action under the guidance Altered family process
of the therapist, it should be discussed with Post trauma response
the victim and the concerned others, so that Ineffective individual coping refers to the
they will have a clear understanding of the inability to ask for help, problem solving
methods of implementation of the plan. or meet role expectations
To improve coping with the situation Ineffective family coping occurs when the
necessary environmental manipulation must family's support systems are not
be done in physical or interpersonal areas.
successful and family's economic or social
It is advisable to have another appointment
well being is threatened
for the victim to visit the therapist within a
week, in order to assess how the plan is Altered family processes result when
working out, and if needed, to revise and family members are unable to adapt to the
modify the plan. traumatic experience constructively
Post-traumatic response is a sustained
ROLE OF A NURSE IN CRISIS painful response to an overwhelming
INTERVENTION traumatic event.
Nurses respond to crisis situations on a daily
basis. Crisiscan occurin any unit for e.g.in general Planning
hospitals, home settings, community health In planning the previously collected data is
centers, schools, offices, and in private practice. analyzed and specificinterventions are proposed.
Indeed, nurses may be called upon to function as During this phase the nurse will undertake the
crisis helpers in any situation.
following activities:
Knowledge of crisis intervention techniques
Dynamics underlying the present crisis are
is thus an important clinical skill of all nurses,
formulated
regardless of the setting or practice specialty.
Alternative solutions to the problem are
Nursing Assessment explored
The first step of crisis intervention is assessment. Steps for achieving the solutions are identified
During this phase the nurse collects data Environmental support needed to help the
regarding the following factors: patient is decided upon, coping mechanisms
Precipitating event or stressor that need to be developed and those which
Patient's perception of the event or stressor need to be strengthened are identified
Nature and strength of the patient's support
systems, coping resources
Implementation
Level of psychological stress patient is
suffering from and the degree of impairment The following interventions are carried out to
he is experiencing resolve crisis:
Environmental Manipulation 2. Clarification: Encouraging the patient to

Environmental manipulation includes interven- express more clearly the relationship between
tions that directly change the patient's physical certain events.
or interpersonal situation. These interventions 3. Manipulation: Using the patient's emotions,
may remove stress or provide situational support. wishes or values to benefit the patient in the
For example a patient having difficulty in his job therapeutic process.
may take a week of sick leave so that he can be 4. Reinforcement of behavior: Giving the patient
removed temporarily from that stress. positive reinforcement to adaptive behavior.
5. Support of defenses: Encouraging the use of
General Support healthy, adaptive defenses and discouraging
The nurse uses warmth, acceptance,empathy and those that are unhealthy or maladaptive.
reassurance to provide general support to the 6. Increasing self-esteem: Helping the patient to
patient. regain feelings of self worth.
7. Exploration of solutions: Examining alternative
Generic Approach ways of solving the immediate problem.
The generic approach is designed to reach high
Evaluation
risk individuals and large groups as quickly as
possible. It applies a specific method to all The nurse and patient review the changes that
individuals faced with a similar type of crisis (e.g. have occurred. The nurse should give credit for
in social disasters). Debriefing is a method of successful changes to patients so that they realize
generic approach. In debriefing method, disaster their effectivenessand understand that what they
victims are helped to recall events and clarify learnt from crisis may help in coping with future
traumatic experiences. It attempts to place the crisis. If the goals have not been met, the patient
traumatic event in perspective, allows the and nurse can return to the first step- assessment
individual to relive the event in a factual way, and continue through the phases again.
encourages group support, and provides infor-
mation on normal reaction to critical events. The MODALITIES OF CRISIS INTERVENTION
goal of debriefing is to prevent the maladaptive
Community-based crisis intervention modalities
responses that may result if the trauma is
have recently been developed. They are based on
suppressed.
the philosophy that the health care team must be
active and go out to the patients rather than wait
Individual Approach
for the patients to come to them. Nurses working
The individual approach is a type of crisis inter- in these modalities intervene in a variety of
. vention similar to the diagnosis and treatment of community settings, ranging from patients
a specific problem in a specific patient. It is homes to street corners.
particularly useful in combined situational and
maturational crises and also beneficial when
Mobile Crisis Programs
symptoms include homicidal and suicidal risk.
The nurse must use the intervention that is most Mobile crisisteams provide front-line interdiscip-
likely to help the patient develop an adaptive linary crisis intervention to individuals, families
response to the crisis. and communities. The nurse, who is a member of
a mobile crisis team, should be able to provide
Techniques of Crisis Intervention on-site assessment, crisismanagement, treatment,
1. Catharsis: The release of feelings that takes referral and educational services to patients,
place as the patient talks about emotionally families and the community at large. Nurses are
charged areas. thus able to ensure mental health care for even
the most under-served populations efficientlyand evaluation, empathic support, and information
cost effectively. and help with the large system and social
networking system.
Telephone Contacts
Crisis intervention is sometimes practiced by Crisis Intervention Centers
telephone rather than through face-to-face Crisis intervention centers provide emergency
contacts.Thenurse should have effectivelistening psychiatric care and counseling to victims,
skills to provide crisis intervention to victims. experiencing extreme stress or conflict, often
involving suicide attempts or drug or alcohol
Group Work abuse. These centers, which are usually self-
People who have common traits on stressors will contained units within a hospital or community
form a group. The group provides an opportunity health care center, provide services 24 hours a
for members to express common concerns and day. The servicesmay be delivered directly on the
experiences, foster hope and build mutual premises, or counselingmay be provided over the
support. The nurse's role in the group is active, telephone. The primary objective of crisis
focal and focused on the present. The nurse and intervention centers is to help the person cope
the group help the patient solve the problem and with immediate problem and to offer guidance
reinforce new problem solving behavior. and support for long-term therapy.
Disaster Response Health Education

As part of the community, nurses are called on Nurses are involved in identifying people who
when an adventitious or social crisis strikes are at high risk for developing crisis and in
the community. Floods, earthquakes, airplane teaching coping strategies to avoid the
crashes, fires, nuclear accidents etc. precipitate development of crisis. The public also needs
large number ofcrises.Thenurse has an important education so that they can identify those needing
role in dealing with psychosocial problems of crisis services, be aware of available services,
disaster victims. The nurse participates in crisis change their attitude so that people will feel free
operations and acts as a case-finder for persons to seekservices,and obtaininformationabout how
suffering from psychosocial stress. It is important others deal with potential crisis producing
that nurses in the immediate post disaster period problems.
go to places where victims are likely to gather,
such as hospitals, shelters, morgues. During this
STRESS
period nurses use the generic approach of crisis
intervention so that as many people as possible The term stress means pressure and in human
can receive help in a short duration of time. life it represents an uneasy experience. It is an
unpleasant psychological and physiological state
Victim Outreach Programs caused due to some internal and or external
demands that go beyond our capacity.
Victim outreach programs use crisis intervention
techniques to identify the needs of victims and
Body Coping Mechanism with Stress
then to connect them with appropriate referrals
and other resources. Each person has his own normal (homeostatic)
Nurses often work in victim outreach pro- level of arousal at which he functions best. If
grams, where victims are often seen immediately something unusual in the environment occurs,
after the crisis. These victims need thorough this level of arousal is affected.
General Adaptation Syndrome (GAS) Hans thus decreasing blood supply to organs which
Selye, 1945) do not assume an immediate active role.
Homeostatic mechanisms are aimed at RBC production is increased leading to an
counteracting the everyday stress of living. If increase in the ability of the blood to clot. This
they are successful, the internal environment helps control bleeding.
maintains normal physiological limits of Liver converts glycogen into glucose and
temperature, chemistry and pressure. If stress releases it into the bloodstream; this provides
is extreme or long lasting, the normal the energy needed to fight the stressor.
mechanisms may not be sufficient.In this case, The rate ofbreathing increases and respiratory
the stress triggers a wide-ranging set ofbodily passages widen to accommodate more air; this
changes called General Adaptation Syndrome: enables body to acquire more oxygen.
When stress appears, it stimulates the Production of saliva and digestive enzymes
hypothalamus to initiate the GASthrough two reduces. This reaction takes place as digestive
pathways: activity is not essential for counteracting
1. The first pathway is stimulation of the stress.
sympathetic division of the autonomic
nervous system and adrenal medulla. This Alarm Reaction
produces an immediate set of responses Stressor
called the alarm reaction. j, Stimulates
2. The second pathway, called the resistance Hypothalamus
reaction involves the anterior pituitary j, Stimulates
gland and adrenal cortex; the resistance Sympathetic nervous system
reaction is slower to start, but its effects j, Stimulates
last longer. Adrenal medulla
Alarm Reaction j, Releases
The alarm reaction or fight-or-flight response is Catecholamines
the body's initial reaction to a stressor. It is a set (epinephrine and norepinephrine)
of reactions initiated when the hypothalamus j, Produces
stimulates the sympathetic division of the Alarm reaction (fight-or-flight response)
autonomic nervous system, and the adrenal
medulla. Resistance Reaction
The alarm reaction is meant to counteract a The resistance reaction is the second stage in
danger by mobilizing the body's resources for the stress response. It is initiated by regulating
immediate physical activity. hormones secretedby the hyphothalamus, and
The stress responses which characterize the is a long-term reaction. These regulating hor-
alarm reaction include the following: mones are Corticotrophin ReleasingHormone
Heart rate and strength of cardiac muscle (CRH),Growth Hormone ReleasingHormone
contraction increases; this circulates blood (GHRH)and Thyrotropin ReleasingHormone
quickly to areas where it is needed to fight the (TRH)
stress. CRH stimulates the anterior pituitary to
Blood vessels supplying skin and viscera, increase its secretion of Adreno Corticotropic
except heart and lungs, constrict; at the same Hormone (ACTH). ACTH stimulates the
time blood vessels supplying skeletal muscles adrenal cortex to secrete more of its hormones.
and brain dilate; these responses route more The action of these hormones helps to control
blood to organs active in the stress responses, bleeding, maintain blood pressure, etc.
Resistance Reaction
Stressor
.!- Stimulates
Hypothalamus
.!- Releases
CRH
GHRH
TRH
.!- Stimulates
!
Anterior pituitary
Releases
r
ACTH HGH
l
TSH
1 Stimulates .!- Stimulates l Stimulates
Adrenal cortex Liver Thyroid gland
l Releases .!- 1
Adrenal hormones Supplies energy Supplies energy
(glucocorticoids and through glyconeogenesis through increased
mineralocorticoids and increased breakdown breakdown of
of fats carbohydrates
GHRH stimulates the anterior pituitary to heart, blood vessels and adrenal cortex, which
secrete Human Growth Hormone (HGH). may suddenly failunder the strain. In this respect,
TRH causes the anterior pituitary to secrete ability to handle stressors is to a large extent
Thyroid-Stimulating Hormone (TSH). The determined by the general health.
combined actions of (HGH) and TSH help to
supply additional energy to the body. Source of Stress
The resistance reaction allows the body to 1. Environmental stressors
continue fighting a stressor for a long time. Noise, pollution, traffic and crowding and
Thus it helps us to meet emotional crisis,
weather.
perform strenuous tasks, fight infection, or
2. Physiological stressors
resist the threat ofbleeding to death.
Illness, injuries, hormonal fluctuations,
Generally, the resistance reaction is successful
inadequate sleep or nutrition.
in helping us cope with a stressful situation,
3. Socialstressors
and our bodies then return to normal.
Financial problems, work demands, social
Occasionally it fails to fight the stressor,
events, losing a loved one etc.
especially if it is too severe or long-lasting. In
this case, the General Adaptation Syndrome
4. Thoughts
Negative self talk, catastrophizing and
(GAS)moves into the stage of exhaustion.
perfectionism.
5. Change of any kind can induce stress
Exhaustion Stage Fear of the new, the unknown
At this stage, the cells start to die, and the organs Feelings of personal insecurity
weaken. A long-term resistance reaction puts Feelings of vulnerability
heavy demand on the body, particularly on the Fear of rejection
Need for approval Rapid breathing or pounding of the heart

Fear of conflict Indigestion
Fear of taking a risk Ulcers
Fear of inability to cope with changed Difficulty in sleeping
circumstances Fatigue
6. Individual personalities that can induce stress Headaches, back or neck problems
Low self-esteem Increased smoking or drinking alcohol
Feelings of over-responsibility Backaches
Fear of loss of control Being more prone to accidents
Fear of failure, error, mistakes
Chronic striving to be perfect CognitiveSymptoms
Chronic guilt
Forgetfulness
Chronic anger, hostility or depression
7. Interpersonal issues that can induce stress Unwanted or repetitive thoughts
A lack of adequate support within the Difficulty in concentration
relationship Fear of failure
A lack of healthy communication within Self criticism
the relationship
A sense of competitiveness between the Emotional Symptoms
people involved Irritability
Threats of rejection or disapproval Depression
between people Anger
Struggle for power and control in the Fear or anxiety
relationship Feeling overwhelmed
Poor intimacy or sexuality within the Mood swings
relationship
Over dependency of one person on another Stress Management Strategies
8. System (family, job, school, club, organization
issues that can induce stress) 1. Take a Deep Breath
Lack of leadership When you feel 'uptight' try taking a minute to
Un co-operative atmosphere slow down and breathe deeply. Breathe in
Competitive atmosphere through your nose and out through your mouth.
Autocratic leadership Try to inhale enough so that your lower abdomen
Lack of team work rises and falls. Count as you exhale - slowly.
Confused communication
2. Practice Specific Relaxation Techniques
Symptoms of Stress Relaxationtechniques are extremely valuable tools
Symptoms of stress appear in many forms. Some in stress management. Most of the techniques like
symptoms only impact the person who is directly meditation, self hypnosis, and deep muscle
experiencing stress, while other symptoms may relaxation work in a similar fashion. In this state
have an impact on our relationship with others. both the body and the mind are at rest and the
outside world is screened out for a time period.
Physical Symptoms Thepractice of one of these techniques on a regular
Muscle tension basis can provide a wonderfully calming and
Colds or other illnesses relaxing feeling that seems to have a lasting effect
High blood pressure for many people.
3. Manage Time 8. Get Physical
One of the greatest sources of stress is poor time When you feel nervous, angry or upset, release
management. Give priority to the most important the pressure through exercise or physical activity.
ones and do those first.Ifa particularly unpleasant Running, walking or swimming are good options
task faces you, tackle it early in the day and get for some people, while others prefer dance or
over with it; the rest of your day will include much martial arts.Working in the garden, washing your
less anxiety. car, or playing with children can relieve that
Most importantly, do not overwork yourself, "uptight" feeling, relax you and often will
schedule time for both work and recreation. actually energize you. Remember, your body and
mind work together. Most experts recommend
4. Connect with Others
doing 20 minutes of aerobic activity daily will
A good way to combat sadness, boredom and reduce stress.
loneliness is to see out activities involving others.
9. Take Care of Your Body
5. Talk it Out
Healthy eating and adequate sleep fuels your
When you feel something, try to express it. Share
mind as well as your body. Avoid consuming too
your feelings. "Bottled Up" emotions increase
much caffeineand sugar. Take time to eat breakfast
frustration and stress. Talking with someone else
in the morning, it really will help keep going
can help clear your mind of confusion so that you
can focus on problem solving. Also consider through the day. Well-nourished bodies are better
writing down thoughts and feelings. Putting prepared to cope with stress. If you are irritable
problems on paper can assist you in clarifying and tense from lack of sleep or not eating right,
the situation and allow you a new perspective. you will be less able to" go the distance in dealing
with stressful situations". Increase the amount of
6. Take a "Minute" Vacation fruits and vegetables in daily diet. Take time for
Imagining a quiet country scene can take you out personal interests and hobbies. Listen to one's
of the turmoil of a stressful situation. When you body.
have the opportunity, take a moment to closeyour
eyes and imagine a place where you feel relaxed 10. Laugh
and comfortable. Notice all the details of your Maintain your sense of humor, including the
chosen place, including pleasant sounds, smells ability to laugh at yourself.
and temperature or change your mental
"channel" by reading a good book or playing 11. Know Your Limits
relaxing music to create a sense of peace and
There are many circumstances in lifebeyond your
tranquility.
control, consider the fact that we live in an
imperfect world. Know your limits. If a problem
7. Monitor Your Physical Comfort
is beyond your control and cannot be changed at
Wear comfortable clothing. If it's too hot, go the moment, don't fight the situation. Learn to
somewhere where it's not. If your chair is
accept what is, for now, until such time when
uncomfortable, change it. If your computer
you can change things.
screen causes eye-strain or backaches, change
that, too. Don't wait until your discomfort turns
12.Think Positively
into a real problem. Taking five minutes to arrange
back support can save you several days of back Refocusthe negative to be positive. Make an effort
pain. to stop negative thoughts.
13.Clarify Your Values and Develop a Sense Rigid and self-punishing moral standards
of Life Meaning High and unrealistic expectations
Clarify your values and deciding what you really Too much dependence on others for love and
want out ofyour life,can help you feelbetter about affection and approval
yourself and have that sense of satisfaction and Inability to master change or learn new ways
centeredness that helps you deal with the stresses of dealing with frustration
of life. A sense of spirituality can help with this. Easily prone to extreme emotional responses
of fear, anxiety and depression
14.Compromise Type A personality persons
Consider co-operation or compromise rather than In addition, the presence of stressful lifeevents
confrontation. A little give and take on both sides such as births, deaths, marriages, divorces,
may reduce the strain and help you feel more retirement, economic success or failure etc can
comfortable. predispose the person to stress-related illnesses.
15.Have a Good Cry Assessment of the Family

A good cry during periods of stress can be a Assess the family's perception of the problem, and
healthy way to bring relief to your anxiety, and it whether it is supportive of the client's efforts at
might prevent a headache or other physical coping.
consequences of "bottling" things up.
Assessment of the Environment
16.Avoid Self Medication
Occupations with a high degree of stress; adverse
Alcohol and other drugs do not remove the environmental influences like too much of
conditions that cause stress. Although they may lighting, temperature etc.
seem to offer temporary relief, these substances
only mask or disguise problems. In the long run, Interventions
alcohol use increases rather than decreases stress,
Interventions are directed towards relief of acute
by changing the way you think and solve
or chronic stress. A nurse can help the person to
problems and by impairing your judgment and
examine the situation, identify possible solutions
other cognitive capacities. Medications should be
and accept his feelings without guilt or fear.
taken only on the advice of a doctor.
People suffering from acute stress-related
illnesses often need to change their lifestyles and
17. Look for the "Pieces of Gold" Around You
ways of relating to others. The initial work of the
Pieces of gold are positive or enjoyable moments nurse involves helping the client to recognize that
or interactions. These may seem like small events change is essential, and develop clear personal
but as these "pieces of gold" accumulate they can objective in relation to the change.
often provide a big lift to energy and spirits and Some clients may show resistance to a neces-
help you begin to see things in new, more balanced sary change. In such cases, nursing measures
way. include:
Increasing the client's awareness as an actual
Role of a Nurse in Stress Management or potential health problem exists.
Assessment Helping him realize that the health problem
can increase if personal changes do not occur.
Assessment of the Person
Identifying all possible resources (his family,
Assess for the following characteristics in the friends etc.).To support the client through the
individual. Such individuals are at high risk of process of change, and co-operation with the
developing stress - related disorders: treatment.
When the client becomes aware of the nature In all this, the nurse must always bear in mind
of the health problem and is told of the change that they are only facilitators of the change
needed, he often experiences a feeling of process, and the clients have the rights and
anxiety, depression and anger. The client is responsibilities in relation to change.
encouraged to talk about the losses that have
resulted from the behavior change. REVIEW QUESTIONS
Recognizing this grieving process provides Stages of grief (Feb 2001)
the nurse with clear direction as to how she Definition and types of crisis (Apr 2006)
can help the client. Phases of crisis
Family members also need accurate
Crisis intervention (Feb 2000,Nov 2002,Nov
information about the nature of the disorder,
2003, Oct 2004)
and how they can help the client in coping
Role of a nurse in crisis intervention (Nov
with stress. The client and families also need
to be informed about various alternatives such 2001)
as meditation, yoga, relaxation training etc. Bereavement (Oct 2005)
These techniques have a valuable role to play What is normal grief reaction (Apr 2004)
in helping individuals cope with stressful life Grief process (Nov 2003)
events. Maturational Crisis (Nov 2003)
Legal Aspects of Mental
Health Nursing
D THE INDIAN LUNACYACT (1912) CHAPTER II
D THE INDIANMENTALHEALTHACT (1987)
It contains mainly the procedure to be followed to
D LEGAL ISSUESIN PSYCHIATRY
D LEGALASPECTSIN PSYCHIATRICNURSING admit a psychiatric patient into a mental hospital.
Role of the Nurse in Admission Procedure
Role of the Nurse in Parole CHAPTER Ill
Role of the Nurse in Discharge Procedure .
Basic Rights of Psychiatric Patients and It describes the procedure to be followed for
Nurse's Responsibilities administering care, treatment and discharge.
Nursing Malpractice In Chapter III the term 'Parole' refers to the
Informed Consent 'permission given to patients to perform certain
Substituted Consent l d f 1 f 'D
confidentiality ntua s or atten certam arru y unctions. urmg
Record Keeping parole, the patient can leave the hospital any time
D LEGALRESPONSIBILITIESOFA MENTALLYILL and can be brought back forcefully if he does not
PERSON return within a maximum period of 90 days.
A psychiatric nurse is in the ward 24hours of the The remaining Chapters (IVto VIII)deal with
d ay, an d th e fima 1 responsiibilit
i i y o
f th e war d establishment of asylums, . expenses of lunatics
. and the rules to be imposed by the state
management is on the nurse. She should therefore di f .
1ega1 aspects of care an d
b e we 11-verse d in government regar mg care o 1unatics.
treatment of the mentally ill. This knowledge THE INDIAN MENTAL HEALTH ACT (1987)
helps her to guide the patients and relatives in
matters related to rights of the patient and other The Indian Mental Health Act is derived from
aspec t s of men t a1h ea1th care. Mental Health
. Act of England and Wales
. (1959
. amended in 1982).The Mental Health Billbecame
There are two Acts concer.ned with the care the Act 14of1987 on 22nd Ma 1987.
and treatment of the mentally ill: Y
The Indian Lunacy Act of 1912 Reasons for Enactment
The Indian Mental Health Act of 1987.
1. The attitude of the society towards the
THE INDIAN LUNACY ACT (1912) mentally ill has changed considerably and it
. . . . is now realized that no stigma should be
It is denved from English Lunacy Act, 1890and it attached to such illness, as it is curable
contains eight Chapters. practically when diagnosed at an early stage.
Thus the mentally ill individuals should be
CHAPTER I treated like any other sick persons and the
It contains some preliminary information and environment around them made as normal as
definitions. possible.
2. The experience of working of the Indian Reception order: An order made under the
Lunacy Act, 1912 has revealed that it has provisions of this Act for the admission and
become outmoded with the rapid advance- detention of a mentally ill person in a
ment of medical science and the under- psychiatric hospital/nursing home.
standing of nature of malady. It has therefore
become necessary to make fresh legislation in CHAPTER II
accordance with the new approach. It deals with establishment of central and state
authorities for regulation and coordination of
Objectives of the Indian Mental Health Act mental health services.
To regulate admission into psychiatric hos-
pitals and psychiatric nursing homes. CHAPTER Ill
To protect society from the presence of It provides guidelines for establishment and
mentally ill persons. maintenance of psychiatric hospitals/nursing
To protect citizens from being detained in homes.
psychiatric hospitals I nursing homes without
sufficient cause. CHAPTER IV
To regulate maintenance charges of It deals with the procedures for admission and
psychiatric hospitals/nursing homes. detention in psychiatric hospitals/nursing
To provide facilities for establishing guar- homes.
dianship of mentally ill persons who are
incapable of managing their own affairs. 1. Admission on Voluntary Basis
To establish central and state authorities for
Any person who considers himself to be mentally
mental health services.
ill and wishes to be admitted to a psychiatric
To regulate the powers of the government for
hospital may apply to the medical officer-in-
establishing, licensing and controlling psy-
charge; if he is a minor, the guardian can make
chiatric hospitals/nursing homes.
this application on his behalf.
To provide legal aid to mentally ill persons at
The medical officer should make inquiry
state expense in certain cases.
within 24 hours and should admit the patient if
The Act contains 10 Chapters. he opines that treatment is required. Thevoluntary
patient thus admitted is now bound to abide by
CHAPTER I the rules made by the institution.
It contains preliminary information. Some defini-
2. Admission under Special Circumstances
tions included in this are:
Psychiatric hospital/nursing home: A hospital/ Any mentally ill patient who is unwilling for
nursing home established or maintained by admission on a voluntary basis may be admitted
the government or any other person for the and kept as an inpatient in a psychiatric hospital/
care of mentally ill persons. nursing home. For such purpose an application
Mentally ill person: A person who is in need of should be made out on his/her behalfby a relative
treatment by reason of any mental disorder or a friend of the mentally illperson, provided the
other than mental retardation. medical officerdeems fit.
Psychiatrist: A medical practitioner possessing
3. Admission under Reception Order
a post-graduate degree or diploma in
psychiatry recognized by the MCI (Medical On application: Only a relative not other than
Council of India). husband, wife, guardian or a friend can make out
Legal Aspects of Mental Health Nursing 21 7
an application for the admission of a mentally ill 6. Admission of Mentally Ill Prisoners
patient. Such an application should be made out A mentally ill prisoner may be admitted into a
to the magistrate in writing supported by two mental hospital on the order of the presiding
medical certificates, one of them issued by a officer or a court.
gazetted medical officer. However no person
being a minor or one who has not seen the 7. Miscellaneous Admission
mentally ill patient in the last 14 days can make
A mentally ill patient can be admitted either on
such an application. The patient may now be
humanitarian grounds (e.g. wanderers) or for
admitted after the magistrate obtains consent from
observation purpose. Social workers can obtain
the medical officer in-charge of the mental
an order from the magistrate pending report from
hospital.
medical officer.
The medical officer in-charge can extend
inpatient treatment to more than 6 months by
making such an application to the magistrate. CHAPTERV
It deals mainly with the procedure to be followed
On production before the magistrate: Mentally ill
for the discharge of mentally ill persons from a
patients exhibiting violent behavior, creating
mental hospital under different circumstances.
obscene scenes and dangerous to the society can
be detained by the police officer and produced
1. Discharge of a Patient Admitted on Voluntary
in court within 24 hours of such detention,
Basis
supported by two medical certificates,subsequent
to which the magistrate issues a reception order. Medical officerin-charge of psychiatric hospital/
nursing home on recommendation from two
4. Admission in Emergencies medical practitioners preferably a psychiatrist,
can issue directions for discharge of the patient.
The medical officer in-charge may order the
admission of a mentally ill patient if he thinks he
2. Discharge of a Patient Admitted under Special
is dangerous to himself or others. However the
Circumstances
patient should be produced before the magistrate
within 24hours (maximum time limit is 72hours, A relative or a friend may make an application to
which is exclusive of the examination period), or the medical officer for care and custody of the
the magistrate himself may visit the psychiatric patient. The relatives are required to furnish a
hospital/ nursing home and pass reception order bond with or without sureties, along with an
on examination. undertaking that the mentally ill person shall be
prevented from causing injury to self or others.
5. Temporary Treatment Order
It is an order issued by the magistrate in cases 3. Discharge of a Patient Admitted on
where the risk is perceived to the patient's life or Reception Order
to that of others. If the medical officer in-charge An applicant who feels that the patient has
feels it necessary to bring legal authorities into recovered from illness may make an application
the picture he can do so by applying to the for discharge to the magistrate. A certificate
magistrate. Alternatively the relatives can get the should accompany such an application from
magistrate to issue an order for treatment. In such medical officer in-charge of the psychiatric
case a single medical certificate is required which hospital/nursing home. If the magistrate deems
is valid for 6 months. fit he may issue an order for discharge.
4. Discharge of a Patient Admitted by Police 2. No mentally ill person under treatment shall
In cases where the police detain the mentally ill be used for the purpose of research unless
individual in hospital, he may be discharged after such research is of direct benefit to him.
the familymembers agree in writing to take proper a consent has been obtained in writing
care, and the medical officer-in-chargeopines that from the person (in voluntary admission)
he is fit to be discharged. or from the guardian/relative (if admis-
sion was involuntary).
5. Discharge of a Mentally Ill Prisoner 3. No letter or communication sent by or to a
mentally ill person shall be intercepted,
The hospital authorities have to report every 6
detained or destroyed.
months about the person's state of mind to the
authority, which had ordered detention. As soon
CHAPTER IX
as they find that the person is fit to stand the trial,
they have to inform about the same to the authority It deals with procedures to be followed for the
concerned. The person is then handed over to the establishment and maintenance of psychiatric
prison officer for further legal action. hospitals/nursing homes, and the penalties,
which can be relatively severe and explicit, for
Leave of Absence contravening them.
On application by a relative or others to the
CHAPTERX
medical officer-in-charge and a bond duly signed
stating that the patient will be taken proper care It deals with clarification pertaining to certain
of and prevented from injuring selfor others, leave procedures to be followed by the medical officer-
of absence may be granted (for a period of in-charge of the psychiatric hospital/nursing
maximum 60 days). home.
CHAPTER VI LEGAL ISSUES IN PSYCHIATRY

It deals with judicial enquiry regarding mentally 1. Laws Relating to Psychiatry in India
ill persons possessing property, their custody and 1. The Care and Treatment Legislation
management of property. A guardian may be (Mental Health Legislations)
appointed by court of law on behalf of an alleged 2. Criminal Responsibilities Formulation
mentally ill person incapable of looking after self (Criminal Laws)
and property. 3. Civil Status Provisions (Civil Laws)
CHAPTER VII 2. Mental Health Related Legislations

It deals with ways and means to meet the cost of Mental Health Act 1987
maintenance of mentally ill persons detained in Persons with Disabilities Act 1996
psychiatric hospital/nursing home. Rehabilitation Council of India Act 1992
Juvenile Justice Act 1986
CHAPTER VIII Consumer Protection Act 1986
It is the latest addition to the Act, which provides
for the protection of human rights of mentally ill 3. Civil Laws Relating to Mental Ill Persons
person. These rights include: Indian Evidence Act 1925Sec. 118
1. No mentally ill person shall be subjected Law of Contract Sec. 6, 11 and 12
during treatment to any indignity (physical Right to Vote and Stand for Election- Act
or mental) or cruelty. 326, 102 of the Constitution of India
Legal Aspects of Mental Health Nursing 219
Law of Torts On 16th September 1985, the above mentioned

Testamentary Capacity- Indian Succes- Acts were repealed and NDPSA Act 61of1985
sion Act 1925 Sec. 59 was enforced.
Marriage and Mental Health Legislation
Indian Divorce Act 1869 Contents
Parsi Marriage+ Divorce Act 1936 The act includes Narcotic drugs (opium,
Dissolution of Muslim Marriage Act poppy, straw, cannabis, cocaine, coca and all
1939 related synthesized drugs) and psychotropic
The Special Marriage Act 1954 substances (76drugs and their derivatives e.g.
The Hindu Marriage Act 1955, 1976 major tranquilizers, minor tranquilizers,
The Family Court Act 1984 pentazocine, barbiturates etc.).
In this act if a person produces, possesses,
4. Civil Laws Relating to Psychiatry transports, imports, sells, purchases or uses
Provisions as to Accused Persons of any narcotic drugs or psychotropic substances
Unsound Mind Secs. 328-339Cr. Pc. 1973 (except 'Ganja') he shall be punishable with
Criminal Responsibility Sec. 84 IPC-1860 Rigorous imprisonment for not less than
Attempt to Commit Suicide Sec.309IPC 10 years, which may be extended up to 20
Right to Private Defence Against an Insane years and a fine of not less than 1 lakh
Person Sec.98 IPC rupees, which may extend to two lakh
Unnatural Offences Sec. 377 IPC (Sexual rupees.
Perversions) For repeat offencea rigorous imprisonment
Affrays (Sec.159In Mania) of not less than 15 years which may be
Misconduct in Public under Intoxication extended upto 30 years and a fine of not
(e.g. Alcohol Defence Sec.510IPC) less than 1.5 lakh rupees, which may be
NDPS Act 1985 (Amended 1988) extended up to 3 lakh rupees.
For handling 'Ganja', a rigorous imprison-
5. Suicide and Indian Law ment which may extend to 10 years and a
Suicide is the only criminal act for which fine upto 1 lakh rupees.
a person is punished if he fails in the On carrying' small quantities' e.g. Heroin
attempt to do so - 250 mg, Opium - 5 gm, Cocaine - 125
"No person shall be deprived of his life" mg, Charas - 5 gm, as were later specified
Act 21 constitution of India in this act, the punishment may extend to
Sec.309/IPC- attempt to commit suicide- 1 year or a fine or both. For Ganja, (below
punishable 500gms), imprisonment is up to 6 months.
1994 - S.C. Judgment - Sec. 309 was Under a specified court order, there is a
declared void provision for detoxification of the patient.
Sec.306 - abetment of suicide an offence Under a later enactment, thepreventionof
No specific laws for assisted suicide and illicittraffic in Narcotic Drugs and Psycho-
euthanasia tropic Substances Act (NDPSA) 1988(Act
46) has been passed. Now there is a
6. The Narcotic Drug and Psychotropic provision for preventive detention, seizure
Substances Act (Act 61of1985) of property, death penalty if a person is
In India the opium Act of 1857was revised first bound to be trafficking more than or equal
in 1878. In 1950, the opium Act of 1878 was to 1 kg of pure heroin despite conviction
revised as the Opium and Revenue Laws Act 1950. and warning on the first attempt.
LEGAL ASPECTS IN PSYCHIATRICNURSING If the patient is receiving any medications,

In no other type ofnursing are the legal and ethical insist on regularity and give necessary
considerations of practice so crucial as in instructions to the family members about
psychiatric nursing. Thus, knowledge of the law dosage, side-effects,etc.
regarding psychiatry in the area where the nurse
is practicing helps her to protect herself from Role of the Nurse in Discharge Procedure
liability and the patient from unnecessary Nurse must ensure that the patient leaves the
detention and mistreatment. unit with all belongings and personal effects,
has the appropriate medications with him,
Role of the Nurse in Admission Procedure and appointment for follow-up has been
A most important feature of the admission made and understood.
procedure involves settling the patient in the All necessary instructions especially regar-
ward. It begins with introducing him to the ding his medication regimen, side-effects etc.
other staff members and patients. must be clearly given to the patient and his
Before assigning him a bed consider his family members.
biological and emotional needs. If he seems to Any paper work, signing of documents
be nurturing suicidal ideation or is floridly should be completed. The hospital file along
psychotic, he should be located in a place with all charts and notes should be sent to the
where he can be closely observed. medical records section.
He should be shown various facilities like The nurse should ascertain his travel plan and
eating, recreation, bathroom facilities, etc. offer assistance if necessary.
Acquaint him with some of the ward rules, The nurse must bear in mind that the patient
e.g. meal time, ward activities, visiting hours, may have mixed feelings about leaving the
how to make appointments to see staff hospital and going back to his home
members, timings of any group meetings, etc. environment. She should help him cope with
The patient and his relatives are likely to have any distress about separating from his new-
all sorts of anxieties about various procedures found friends and staff members.
and investigations. The nurse needs to be
sensitive to these feelings, and give enough
Basic Rights of Psychiatric Patients and
time and attention and allow them to express
their feelings about the patient's condition,
treatment and outcome. All information Psychiatric patients are often the least capable of
should be provided as appropriate. protecting theirownrights. Itis therefore one ofthe
responsibilities of the nurse to guide the patients
Role of the Nurse in Parole and relatives in matters related to their rights and
Parole is the permission given to patients to protect the patient from any mistreatment.
perform certain rituals or attend certain family
functions. Some of the Rights of Psychiatric Patients
Relatives are clearly instructed about the The right to wear their own clothes.
purpose for which the patient is being sent The right to have individual storage space for
home and when he should be brought back. their private use.
Instruct the relatives as to how they should The right to keep and use their own personal
converse or behave with the mentally ill possessions.
person according to the instructions given by The right to spend a sum of their money for
the doctor. their own expenses.
The right to have reasonable access to all physician. During such interactions the patient
communication media like telephone, letter is allowed to fully consider and comprehend the
writing and mailing. information about the proposed treatment. Such
The right to see visitors every day. consent is termed as informed consent. It includes
The right to treatment in the least restricted the mode of administering the treatment,
setting. prognosis, side- effects and the risks.
The right to hold civil service status. However, in the case of psychiatric patients
The right to refuse electroconvulsive therapy. the ability to give informed consent as regards a
The right to manage and dispose of property procedure is highly debatable due to the nature
and execute wills. of the problem. Though most of the patients
Nurse's implications for protecting patient's rights perceive and act in their own best interests, some
To protect patient's rights, the nurse should may not be capable of giving a valid consent. Due
be aware of these rights in the first place. to such variations, the patients have to be screened
She should ensure that ward procedures and for the following:
policies should not violate patient's rights. whether the patient is competent to give
Discussing these rights with the mental health informed consent
team and including these rights in the nursing whether information provided to the patient
care plan is all part of her responsibility in is assimilated on a regular basis and under-
protecting the patient's rights. stood
whether enough opportunity and freedom
Nursing Malpractice are vested with thepatienttoreject/ revoke the
When a prudent nurse expected to meet the consent during a specific course of treatment.
normal standards of care, causes a breach by
deviating from the norms, it is termed as nursing Substituted Consent
malpractice. Such breach of act can invoke legal When it is deemed that a patient is incapable of
proceedings against the nurse for not discharging giving informed consent, health serviceproviders
her duty diligently and in good faith. should obtain substituted consent for the
If the malpractice suit has to stand and be procedure I treatment. It refers to an authorization
decreed in favor of the aggrieved patient, he will given by another individual, being a guardian
have to prove various facets which contributed to appointed by the court or the kith and kin on
the breach. However it is to be noted that the behalf of the patient.
burden of proof lies with the patient who in this
case is the plaintiff. The various facets include:
the nurse had a duty to discharge due Confidentiality
standards of care to the patient During the nurse-patient relationship a lot of
the nurse's performance was well below the information is gathered through direct and
expected standards, thus causing a breach indirect sources, which is both verbal and written.
substandard care provided should be Keeping in view the ethics of the nursing practice,
construed to have adversely affected the such information gathered is kept confidential
patient and family and best used for providing enhanced care rather
the actual proof of adverse effects/injury than for other purposes such as gossip or personal
caused. gain.
Any breach of confidentiality could jeopardize
Informed Consent the best interests of the patient, be it social or
In the course of normal treatment a series of economical, keeping in view the social stigma
interactions result between a patient and a attached to mental illness.
Record Keeping managing his property. In such a case a manager
Nursing notes and progress records constitute is appointed by the court of law to take care of his
legal documents and hence should be maintained property, which may include sale or disposal of
carefully. They should be non-judgemental and the property to settle his debts I expenses.
the statements made should be objectivein nature.
Marriage
LEGAL RESPONSIBILITIES OF A As per the Hindu Marriage Act (1955),marriage
MENTALLY ILL PERSON between any two individuals one of whom was
In legal parlance responsibility refers to liability I of unsound mind at the time of marriage is
accountability for his/her acts of negligence. If considered null and void in the eyes of the law.
such acts are contrary to the law of the land, Unsoundness of mind for a continuous period
suitable punishment is awarded. A person of can be sighted as a ground for obtaining divorce.
unsound mind committing an act contrary to law, The other party can file for divorce when lunacy
incapable of knowing its nature shall not be held continues for a period of more than 2 years after
for the offence. marriage. However if divorce is filed after a 3-
However a point to be noted is that 'irresistible year period, divorce is granted with a pre-
impulse test' is used in unison with the condition that the other party has to pay
M'Naghten rule. It refers to a situation where a maintenance charges for the mentally ill person.
person may know the difference between right
and wrong but finds himself impulsively driven Testamentary Capacity
to commit the crime. As per the Indian Succession Act, testamentary
M'Naghten rule states that the individual at capacity of the mental ability of a person is a pre-
the time of the crime did not know the nature and condition for making a valid will. The testator
quality of the act and if he did know what he was must be a major, free from coercion, understan-
doing,he did not comprehend it to be wrong. These ding and displaying soundness of mind. At times
rules are also referred to as the 'nature and quality doctors and nurses are called upon to witness
rule' and 'right from wrong' test. the will of an ailing person. Under such
'Durham test' or 'product rule' states that an circumstances the doctor tests the testator for
accused person is not criminally responsible if orientation, concentration and memory. A person
his/her unlawful act is the product of mental
affected by delusional disorder can also make a
disease or mental defect.
valid will if those delusions are not related to the
As per the American Law Institute' s (ALI)test,
disposal of the property.
a person lacking adequate capacity to realize the
criminality of his act or conformity of his conduct
Right to Vote
to the provisions of law is not responsible for
performing such an act. A person of unsound mind cannot contest for
elections or exercise the privilege of voting.
Civil Responsibilities of a Mentally In conclusion, nursing practice must confirm
Ill Person to pre-set legal standards and continuously re-
orient itself to the ever evolving legal standards.
Management of Properly It is only the motivated and capable nurse who
The court may on an application from any can incorporate legal knowledge while dis-
relative direct an inquiry to ascertain whether a pensing patient care, and it is to her that many
person is of unsound mind and incapable of patients will turn for information and care.
REVIEW QUESTIONS Admission procedures for a mentally
Indian Mental Health Act (Nov 2003,Oct 2004, ill patient (Apr 2003, Nov 2003, Apr 2006)
Apr 2006) Discharge procedure for a mentally ill patient
(Oct 2005)
Indian Lunacy Act (Nov 2002, Apr 2006)
Legal aspects in psychiatric nursing (Nov 2000)
Parole or leave of absence (Oct 2005)
Protection of the rights of the mentally ill
Types of admission in mental hospital (Nov 2003)
(Feb 2000) Rights of mentally ill patient (Nov 2002)
Community Mental
Health Nursing
D COMMUNITYMENTALHEALTHIN INDIA institution to the community, and heralding the
D COMMUNITYMENTALHEALTHCENTERS- era of deinstitutionalization.
CERTAINFEATURES
D COMMUNITYFACILITIESFORPSYCHIATRIC COMMUNITY MENTAL HEALTH IN INDIA
PATIENTS
Psychiatric Hospitals The overall goal of community mental health as
Partial Hospitalization outlined by Mrs. Indira Gandhi in May 1981while
Quarterway Homes
addressing the World Health Assembly is as
Halfway Homes
Self-help Groups follows:
Suicide Prevention Centers "In India, we would liketo go to homes instead
Other Facilities of large numbers gravitating towards centralized
D COMMUNITYMENTALHEALTH-PSYCHIATRIC
hospitals. Services must begin where people are
NURSING
Community Mental Health Psychiatric and where problems arise."
Nurse Attributes Active thinking in this area marked the decade
Assessment of 1970s, and concern for organizing mental
Intervention health services was expressed in national and
Some Tips to be kept in Mind When
Working in the Community regional forums. Notable among these are the
D LEVELSOF PREVENTIONAND ROLEOFA NURSE Indian Psychiatric Society's seminars/work-
Primary Prevention shops at Madurai (1971),Trivandrum (1975)and
Secondary Prevention Nagpur (1976).
Tertiary Prevention
D PSYCHIATRICREHABILITATION One of the most important elements in the
Principles of Rehabilitation supply of health care in India has been the
Psychiatric Rehabilitation Approaches Primary Health Center (Provisionof mental health
RehabilitationTeam care is one of the components of Primary Health
Steps in Psychiatric Rehabilitation
Role of a Nurse in Psychiatric Rehabilitation Care). This provides a unique opportunity to
Vocational Rehabilitation provide mental health care through the
D NATIONALMENTALHEALTHPROGRAM multidisciplinary approach and collaborative
Objectives services. Failure in this regard is due to complex
Approaches
Components
problems such as limited resources, lack of trained
manpower and inadequate long-term planning.
The methods of treating mental illness have The next important phase of development of
changed dramatically in the past century. mental health services was the setting up of
Community mental health as a treatment General Hospital Psychiatric Units (GHPUs).The
philosophy, was mandated by the Community GHPU provided a big push for the greater
Mental Health Centers Act of 1963,thus bringing acceptance of psychiatric services by the public
about the shift of mental health care from the without fear of social stigma.
Community Mental Health Nursing 225
The next phase of development of mental transition to the community and out-patient
health services was the community care treatment and follow-up.
approach. Two centers that took up community
mental health work in 1975were Bangalore and Case Management
Chandigarh. Thus the approach to development Case managers are clinicians who can provide
of serviceshas been a rapid transition from mental continuity of care; they ensure continuing treat-
hospitals to GHPUs and to community care. ment by initiating contact during hospitalization
According to mental health experts, a and continuing support through after-care.
community mental health program should:
provide mental health care in the community Community Participation
as opposed to institutional care Community should participate in decisions about
focus services on a total community or their mental health care needs and programs.
population rather than on an individual
patient Evaluation and Research
focus on preventive and promotive services Evaluation is the process of obtaining information
as distinguished from therapeutic ones about a community mental health program and
provide continuity and comprehensiveness of its effect on people and situations.
services rather than fragmentary and Research may focus specifically on key issues
symptom-based care and address a particular disorder or a treatment
provide indirect services such as consultation method.
and mental health education rather than direct
services alone Possible Community Mental Health
include selection and training of primary care Practice Sites
workers from the local community in order to Community mental health centers
provide basic mental health care Youth centers
Private practice office
COMMUNITY MENTAL HEALTH CENTERS- Crisis centers
CERTAIN FEATURES Shelters
Commitment Clients' homes
School and day care centers
Commitment suggests that the centers should
Nursing homes
identify all the mental health needs of the
Day hospital facilities
population. This requires that the mental health
Emergency department of community hos-
services be located close to people's residences or
pitals
workplaces to make it easy for them to identify
Churches, temples, mosques
illness and obtain treatment.
COMMUNITY FACILITIES FOR PSYCHIATRIC
Services
PATIENTS
Integrated and balanced services in response to
In the community, seven provisions are required
expressed local needs must be provided.
to replace long-term care in hospital:
Suitable well-supported carers
Long-term Care
Suitable accommodation
Continuity of care enables a single clinician to Suitable occupation
follow a patient through emergency services, Arrangements to ensure the patient's colla-
hospitalization and partial hospitalization as a boration with treatment
Regular reassessment, including assessment Examples of such homes are 13th and 14th
of physical health psychiatric wards of NIMHANS at Bangalore.
Effective collaboration amongst carers D. Halfway home: A halfway home is a
Continuity of care and rapid response to crises transitory residential center for mentally ill
Some facilities available include: patients who no longer need the full services of a
A Psychiatric hospitals: Hospitals have become hospital, but are not yet ready for a completely
part of a continuum of mental health services independent living. It attempts to maintain a
available to patients and their families, and climate of health rather than of illness, and to
offer a variety of treatments for psychiatric develop and strengthen individual capacities. At
disorders. the same time it enables the recognition of
problems that require medical attention, and
B. Partial hospitalization: Partial hospita-
permits the discovery of conditions in the
lization is an innovative alternative to
community which are acting adversely on the
hospitalization. It is ideally suited to most of
individual. Thus, halfway homes have a major
the psychiatric syndromes, particularly
role in the rehabilitation of the mentally ill
chronic psychotic disorders, neurotic
individual.
conditions, personality disorders, drug and
alcohol dependence and mental retardation. Objectives
Day care centers, day hospitals and day To ensure a smooth transition from the
treatment programs come under partial hospital to the family.
hospitalization. To integrate the individual into the
Partial hospitalisation has the advantages of mainstream of life.
lesser separation from families,more involvement
Activities
in the treatment program and a lessening of
Community mental health nurses play a vital role
patient's preoccupation with the illness, which
in monitoring the progress of discharged patients
may be intensified by full hospitalization.
in halfway homes, especially with regard to their
Main day care centres in India medication regimen and coordination of care.
Sanjivini, New Delhi Some of the interventions carried out in halfway
SCARF (Schizophrenia Research Founda- homes include:
tion), Chennai, has started a day care center Assessment: Clinical assessment including
called "BAVISHYA"in 1985 assessing for residual psychiatric symptoms
Association of the Friends of Mentally Ill, which may affect his ability to function; social
Mumbai assessment including assessing family
Institute of Mental Health, Ahmedabad support, attitude of family members and
Psychiatric Center, Kolkata economic status of the family; psychological
NIMHANS, Bangalore assessment including assessing self-esteem,
Krupamayie Institute of Mental Health, Miraj confidence, patient's level of motivation;
Anugraha Day Care Center, Chennai vocational assessment including assessing
The Richmond Fellowship Society,Bangalore physical strength, hand coordination,
C. Quarterway homes: This is a place usually attention, concentration etc.
located within the hospital campus itself, but Reduction of impairments: This includes
not having the regular services of a hospital. reduction or elimination of the symptoms and
There may not be routine nursing staff or cognitive impairments that interfere with
routine rounds, and most of the activities of social and vocational performance. These
the place are taken care of by the patients impairments are eliminated for the greater part
themselves. by various psychotropic agents.
Remediation of disabilities through skill life crisis, and have improved the emotional
training: Skill training is used to remediate health and well being of many people. Usually
disabilities in social, family and vocational organized with a particular task in mind, such
functioning. Patients generally require groups do not attempt to explore individual
training in self-careskills,interpersonal skills, psychodynamics in great depth or to change
vocational and employment pursuits, personality functioning significantly.
recreational and leisure skills. A distinguishing characteristic of self-help
Remediating disabilities through supportive groups is their homogeneity. The members
interventions: These strategies aim at helping have the same disorders and share their
the individuals compensate for handicaps by
experiences good or bad, successful or
learning skills in living and working
unsuccessful, with one another. The members
environments, adjusting the individual and
work together using their strengths to gain
family expectations to a level of functioning
that is realistically attainable. control over their lives. By so doing, they
educate each other, provide mutual support,
Outcomes and alleviate the sense of alienation usually
Expected outcomes could be: Successfulreturn of felt by people drawn to this kind of group. In
the patients to their homes, prevention of relapses, other words, self-help groups are based on
economic self-sufficiencymade possible through the premise that people who have experienced a
vocational counseling and self-employment particular problem areable to help others who have
programs.
the same problem.
Nurses need to be familiar with the various
One of their most important functions is to
halfway homes available in the community;
demonstrate to individuals that they are not
collaboration with such facilities is absolutely
alone in having a particular problem. Sharing
essential for successfulrehabilitation. Some of the
halfway homes available in India include: each others' experiences not only helps the
Medico-Pastoral Association, Bangalore members by providing mutual support, but
Atmashakti Vidyalaya, Bangalore also by generating alternate ways to view and
Richmond Fellowship, Bangalore resolve problems. Thus they help in
Puraskara Aftercare Home, Bangalore overcoming maladaptive patterns ofbehavior
Cadabam's Home for the Mentally Disabled, or states of feeling that traditional mental
Bangalore health professionals have not generally dealt
Family Fellowship Society for Psychosocial with successfully.
Rehabilitation, Bangalore Self-help groups emphasize cohesion, which
Raju Rehabilitation Foundation, Bangalore is exceptionally strong in these groups.
YWCA Halfway Home for Mentally Ill, Because the group members have similar
Chennai problems and symptoms, they develop a
Dr. Boaz's Rehabilitation Center, Chennai strong emotional bond. But each group may
Dr. Dhairyan's Psychotherapy and Reha- have its unique characteristics, to which the
bilitation Center, Chennai members can attribute magical qualities of
Sowkya Halfway Home at Madurai healing.
Delhi Psychosocial Rehabilitation Society Strategies: The strategies used by group
Paripurnata Halfway Home, West Bengal leaders include promotion of dialogue, self-
Society for Mental Health, Kerala disclosure and encouragement among
E. Self-help groups members. Concepts used in support groups
Self-helpgroups are composed of people who include psychoeducation, self-disclosure,and
are trying to cope with a specific problem or mutual support.
Processes:The processes involved in self-help G. Other
groups are social affiliation; learning self- Community group homes
control; and modeling methods to cope with Large homes for long-term care
stress and acting to change the social Hostels
environment. Home care programs
The end result is that these groups prevent District rehabilitation centers
physical, emotional and social problems and
breakdowns; improve an individual's or a COMMUNITY MENTAL HEALTH-
family's quality of life; and provide the PSYCHIATRIC NURSING
education necessary to develop the member's
Community mental health-psychiatric nursing is
potential further. Examplesof self-helpgroups
the application of specialized knowledge to
are AlcoholicsAnonymous (AA),Association
for Mentally Disabled (AMEND). populations and communities to promote and
The self-help group movement in India is in maintain mental health, and to rehabilitate
its ascendancy. One of the recent populations at risk that continue to have residual
developments is the start of AMEND in effects of mental illness.
Bangalore. People with mental illness suffer Psychiatric nursing in the community setting
from social stigma and discrimination. More differs markedly from its hospital counterpart.
so their family members are struck with The community setting requires that the
disbelief, loneliness and sorrow. Families of psychiatric nurse possess knowledge about a
such people have got together to form an broad array of community resources and be
organization in Bangalore called AMEND - flexible in approaching problems related to
Association for Mentally Disabled, under the individual psychiatric symptoms, family and
leadership ofDr.Nirmala Srinivasan.AMEND support systems and basic living needs such as
has been advocating and practicing family housing and financial support.
based care. At AMEND, families share
experiences, talk about side effects of
Community Mental Health-Psychiatric
medication and discuss how they can
Nurse Attributes
communicate problems to psychiatrists.
AMEND also conducts workshops to train Awareness of self, personal and cultural
consumers in living skills so that they can values
look after themselves, tell them what is wrong Non-judgmental attitude
with one self, why they need to take their Flexibility
medication, and what can happen if they stop Problem solving skills
and so on. Many of AMEND's consumers Ability to cross service systems (e.g. to work
have been rehabilitated and are holding jobs with schools, other health care providers,
as part of their occupational therapy. employers, etc.)
F. Suicide prevention centres: There are many Knowledge of community resources
suicide prevention centers in India in the Willingness to work with the family or
voluntary sectors doing good work and significant others identified by the client as
helping those in need. Some of them are: support people
Helping Hands and MPA in Bangalore Understanding of the social, cultural and
Sneha in Chennai political issues that affect mental health and
Sahara in Mumbai illness
Sanjivini and Sumaitri in New Delhi Knowledge of political activism
Goals of Community Mental Health Nursing The expected outcome of the assessment is a
To provide prevention activities to popu- detailed outline of the person's present func-
lations for the purpose of promoting mental tioning, highest level of functioning, and the
health. needed services.
To provide interventions as early as possible.
Toprovide corrective learning experiences for Intervention
client-groups who have deficits and disabi- Community psychiatric nurses must approach
lities in the basic competencies needed to cope interventions with flexibilityand resourcefulness
in society, and to help individuals develop a to meet the broad range of needs of the patients
sense of self-worth and independence. with continued mental deficits. Interventions
To anticipate when populations become at risk cannot be directed only towards discrete
for particular emotional problems and to psychiatric symptoms, but must also facilitate
identify and change social and psychological client's access to various community resources
factors that diversely affect people's providing for basic needs such as housing,
interaction with their environments. nutrition, etc.
To develop innovative approaches to primary Since people suffering from mental illness
prevention activities. often remain in or return to the community
To assist in providing mental health following treatment, nurses must be able to assess
education to populations about mental health the presence of continued mental health problems
and illness and to teach people how to assess and plan and implement interventions within the
their mental health. confines of the resources available in the
community.
Community Mental Health Nursing Process Carr et al (1984)have identified the following
roles for nurses working in community mental
Assessment
health services:
The key aspects of assessment include:
Impairments directly due to the psychiatric Consultative role:This means giving advice to other
disorder such as persistent hallucinations, professionals in the community about the type
negative symptoms, socialwithdrawal, under- and level of nursing care required for a given
activity and slowness. client group.
Secondary social disadvantages such as Clinician role:Providing direct nursing care to the
unemployment, poverty and homelessness, as patients in the community.
well as the stigma attached to psychiatric
illness. Therapeutic role: Employing psychotherapeutic
and behavioral methods for management of
Personal reactions to illness and social
patients.
disadvantage such as low self-esteem and
hopelessness, poor motivation and capacity Assessor/researcher role: The nurse may assess the
for self-management and performance of care given to the client/ client group, and may
social roles. also assess the outcome of ongoing care programs.
Unpredictable behavior, risk of harm to self
Educator: Creating awareness in the community
and others, and liability to relapse.
about mental health and mental illness with
Financial position of the client.
special focus on vulnerable groups.
Availability of community resources.
Social circumstances to which the patient is Trainer/Manpower facilitators: Training of parapro-
likely to return to. fessionals, community leaders, school- teachers
and other care-g1vmg professionals in the who are suspicious and claim that others are
community. trying to harm them
who have become unusually cheerful, crack
Manager/Administrator: Management of resources,
jokes and say that they are very wealthy and
planning and coordination.
superior to others when it is not really so
Domiciliary care:Servicesare provided to the client who have become very sad lately and cry
by visiting their homes. Services like adminis- without reason
tration of medications, assessment of the level of who talk about suicide or have made an
functioning and improvement of patients, attempt at suicide
monitoring of side-effects of drugs, counseling of who get possessed by god or spirit or who are
patients and family members are offered at the said to be the victims of black magic or evil
client's home setting. power
Liaison role: Nurses working in the community who are dull, mentally not grown up like
help the clients and the family members by others of their age and slow since birth
bridging the gap between the client and the When you visithomes, enquire about members
hospital, client and the employers and also by suffering from mental illness. Ask the above-
networking in the community for resource mentioned questions tactfully without offending
development. them and obtain information about the existence
Preventive roles:These preventive roles are under of a patient in them in that family, neighborhood
primary, secondary and tertiary levels. or among their relatives.
When you go to a school,enquire from teachers
Other areasof community health psychiatric nursing
and students about children who suffer from fits,
are:
behavioral and learning problems.
Social skills training
Anxiety management and relaxation 2. Refer the patient immediately in the following
Assertive training conditions:
Bereavement counseling the patient is severely ill, violent or unmana-
Group meetings geable at home
Community outreach work services history of recent head injury
Child care services repeated convulsions (continuous or more
Adult care and elderly care services than 3 times a day)
disturbed behavior after delivery
Some Tips to be Kept in Mind When the client has attempted suicide or is
Working in the Community threatening to commit suicide
1. Identification of Patients in the Community: disturbed behavior in people with known
Talk to important people like, village panchayat diabetes or hypertension
members, local leaders, teachers, educated youth, people who show abnormal behavior after
members of service agencies like, angawadi, taking alcohol or any other intoxicating
mahila mandals, etc. and request them to tell you substances
about individuals: 3. Follow-up care with special emphasis on medi-
who talk nonsense and act in a manner cation regimen, improvement made, and side-
considered strange or abnormal effects, patient's occupationalfunction
who have become very quiet and do not talk
or mix with other people 4. Be prepared to answer certain common questions
who claim to hear voices or see things that asked regarding mental illness
others cannot hear or see Is mental illness hereditary?
Is mental illness contagious? managed early and correctly, the patient may
Do ghosts, black magic, curse cause mental become socially and occupationally normal
illness? within few weeks.
Is mental illness treatable?
Can marriage cure mental illness?
Can patients take up responsibilities after
recovery? A mentally ill person can get worse if he gets
Can marriage cure mental illness? married when he is ill, as marriage can become
an additional stress. A patient who has recovered
Is mental illness hereditary? can get married and live a normal life like any
The role of genetic factors is well established only other person.
in some psychiatric illnesses (e.g.Schizophrenia, A nurse can play an important role in
Mania and Depression). It is also not true that if a community by making the public aware of some
family member is suffering from Schizophrenia, important principles related to mental illness:
the other members will always develop the same Mental illnesses, like physical illness, can be
illness. The chances are more but the factors such easily treated with medications and psycholo-
as personality and environmental factors play an gical methods.
equally important role. The treatment of mental illness is not just
Is mental illness contagious? confined to drugs; it also includes many other
Mental illnesses do not spread through contact psychological therapies like behavior modifi-
of any form. Individual genetic vulnerability or cation therapy, counseling, activity therapy,
predisposition and precipitating factors play an family therapy, group therapy etc.
important role in disease occurrence. Continuity of treatment is more important for
curing mental illnesses. Treatment should
Do ghosts, black magic, curse cause mental never be tampered without the advice of a
illness? psychiatrist.
Many people consider that mental illness is not In majority of mental illnesses e.g. Mania,
an illness, but possession by ghost or depression and other neurotic disorders like
supernatural power. The causation of most of the dissociative disorder, patients completely
mental illnesses is well known and specific recover without a residual effect, if the
methods are available to treat mental illnesses. treatment is taken on a regular basis.
Is mental illness treatable? Early detection and prompt treatment for
80% of the mental illnesses are fully curable and mental illnesses gives better improvement in
preventable. Excluding Schizophrenia, all other psychiatric patients, they can lead socially
mental illnesses can be easily controlled and productive lives.
prevented through proper medications and
5. Remember
psychological therapies.
do not give false assurances or make false
Can patients take up responsibilities after promises; just tell them you will do your best
recovery? to help them
Like other physical illnesses mental illnesses are do not make any decisions for the family
curable with drugs and other physical and do not criticize or blame
psychological methods. see that they develop confidence in their
Depression and mania are self-limiting abilities
illnesses, lasting from 6 to 9 months. Anxiety do not make them dependent on you
neurosis, hysteria etc. are fully curable and avoid half-hearted attempts; hard work yields
preventable disorders. If schizophrenia is good results
Levels of Prevention
I Health Maintenance
MENTAL HEAL TH
I
Ability to cope with activities of Specific protection of
~ PRIMARY
daily living in an adaptive manner PREVENTION I':,. vulnerable populations
Early diagnosis and
MENTAL ILLNESS
v SECONDARY
PREVENTION
prompt treatment
Inability to adapt
~.
I TERTIARY
PREVENTION
hi Rehabilitation
I
(This paradigm was developed by Bloom, 1979)
LEVELS OF PREVENTION AND Ensuring timely and efficient obstetrical

ROLE OF A NURSE assistance to guard against the ill effects
In the 1960s, psychiatrist Gerald Caplan of anoxia and injury to the newborn at
described levels of prevention specific to birth.
psychiatry. He described primary prevention as an Dietary corrections to those infants
effort directed towards reducing the incidence of suffering from metabolic disorders.
mental disorders in a community. Secondary Correction of endocrine disorders.
prevention refers to decreasing the duration of Liberalization of laws regarding termina-
tion of pregnancy, when it is unwanted.
disorder while tertiary prevention refersto reducing
Training programs for physically, and
the level of impairment.
mentally handicapped children like blind,
Primary Prevention deaf, mute and mentally subnormal etc.
Counseling the parents of physically and
Primary prevention seeks to prevent the mentally handicapped children, with
occurrence of mental disorders by strengthening particular referenceto the nature of defects.
individual, family and group coping abilities. The parents need to accept the child and
emotionally support the child and be
Role of a Nurse in Primary Prevention satisfied with limited goals in the field of
Community mental health nurses are in a key achievement.
position to identify individual, family and group Fostering bonding behaviors. Explaining
needs, conflicts and stressors. Thus they play a importance of warm, accepting, intimate
major role in identifying high-risk groups and relationship and avoiding the prolonged
preventing the occurrence of mental illness in separation of mother and child are
them. Some interventions include : essential.
1.Individual centered intervention 2. Interventions oriented to the child in the
Antenatal care to the mother and edu- school
cating her regarding the adverse effectsof Teaching growth and development to
irradiation, certain drugs and prematurity. parents and teachers.
Identifying the problems of scholastic a wage earner in the family, desertion by the
performance and emotional disturbances spouse etc. crisis intervention can be given at
among school children and giving timely Mental hygiene clinics
intervention. School teachers can be Psychiatric first-aid centers
taught to recognize the beginning symp- Walk-in clinics
toms of problems and referring to 6. Mental health education
appropriate agencies. Conduct mass health education programs
3. Family centered interventions to ensure through film shows, flash cards and
harmonious relationship appropriate audio-visual aids regarding
Consulting with parents about appro-
prevention of mental illnesses and pro-
priate disciplinary measures.
motion ofmental health in the community.
Promoting open health communication in
Educate health workers regarding preven-
families.
tion of mental illness so that they can
Rendering crisis counseling to the parents
function effectively in all the areas of
of physically and mentally handicapped
children. prevention.
Ensuring harmonious relationship among 7. Society-centeredpreventive measures
members of the family and teaching Community development
healthy adaptive techniques at the time of Culturally deprived families need biolo-
stress producing events. gical and psychosocial supplies. They
4. Interventions oriented to keep families intact need better hygienic living conditions,
Extending mental health education proper food, education, health facilities,
services at Child Guidance Clinics about and recreational facilities. Otherwise,
child rearing practices; at parent-teacher psychopathy, alcoholism, drug addiction,
associations regarding the triad crime and mental illness, will result in
relationship between teacher, child and such situations.
parent; and at various extramural health Collection and evaluation of epidemiolo-
agencies regarding integration of mental gical, biostatistical data.
health into general health practice.
Strengthening social support for the Secondary Prevention
frustrated aged and helping them to retain Secondary prevention targets people who show
their usefulness. early symptoms of mental health disruption but
Promoting educational servicesin the field
regain premorbid level of functioning through
of mental health and mental hygiene.
aggressive treatment.
Developing parent-teacher associations.
Rendering home-maker services - when
Role of a Nurse in Secondary Prevention
there is absence of the mother from home
due to illness or other reasons for Early diagnosis and case finding: This can be
prolonged periods, the public health achieved by educating the public, community
nurse can arrange for the service. leaders, industrialists, Mahila mandals,
Providing marital counseling for those Balwadis etc. in how to recognize early
having marital problems. symptoms of mental illness. Case finding
5. Interventions for families in crisis through screening and periodic examination
In developmental crisis situations such as the of population at risk, monitoring of clients etc.
child passing through adolescence, birth of a Thus in clinics,schools, home health care and
new baby, retirement or menopause, death of the work place, community mental health
nurses detect early signs of increased levels of discharged patients in halfway homes, houses
anxiety, decreased ability to cope with stress etc., especially with regard to their medication
and failure to perceive self, the environment regimen, coordination of care etc.
and/ or reality accurately, and provide direct
services as appropriate. Role of a Nurse in Tertiary Prevention
Early reference :The public should be educated Family members should be involved actively
to refer these cases to proper hospitals as soon in the treatment program so that effective
as they recognize early symptoms of mental follow-up can be ensured.
illness. Occupational and recreational activities
Screening programs : Simple questionnaires should be organized in the hospital so that
should be developed to identify the symptoms idling is prevented.
of mental illness, and administration of the Community based programs can be launched
same in the community for early identification through meeting with the family members
of cases. These questionnaires can be when the need for discharge from the hospital
simplified in local languages, and used widely should be emphasized. These programs can
in the colleges, schools, industries etc. be implemented through day hospitals, night
Early and effective treatment for patient, and hospitals, after care clinics, half-way homes,
if necessary, to family members as relevant; ex-patient hostels,foster care homes etc.Follow
providing counseling services to caregivers up care can be handed over to community
of mentally ill patients. health nurses.
Training of health personnel : Orientation There should be constant communication
courses should be provided to health workers between the community health nurses and the
to detect cases in the course of their routine mental health institution regarding the follow
work. up of the discharged patient. The ultimate aim
Consultation services : Nurses working in of the hospital and community based
general hospitals may come across various programs is to re-socialize and re-motivate the
conditions such as puerperial psychosis, patient for a functional role in the community,
anxiety states, peptic ulcer, ulcerative colitis, consistent with his resources.
bronchial asthma etc. These basic care There are a wide range of services that need to
providers need guidance and consultation to be provided to patients as part of the tertiary
deal with these conditions in an effective prevention program. Nurses need to be fami-
manner. liar with the agencies in the community that
Crisis intervention : If crisis is not tackled in provide these services. Collaborative relation-
time it may lead to suicide or mental disorders. ships between mental health care providers
Sometimes anticipating the crisis situation and community agencies are absolutely
and guiding the individual in time can help essential if rehabilitation is to succeed.
them to cope with the crisissituation in a better An important intervention in the maintenance
way. of patients in their own homes in the
community is the Training in Community
Tertiary Prevention Living (TCL)program, designed by 'Stein and
Tertiary prevention targets those with mental Test'. In this model when a person is referred
illness and helps to reduce the severity, discomfort for a hospital admission the staff goes to the
and disability associated with their illness. In community with him rather than his going to
these terms community mental health nurses play the hospital to be with the staff.This real world
a vital role in monitoring the progress of experience with the patient enables the nurse
to assess accurately the skills that the person The following disorders are indicated com-
needs to learn and to mutually agree on monly for rehabilitation:
realistic goals. Chronic schizophrenia
Another aspect of community lifethat is more Chronic organic mental disorders
difficult to assess accurately and deal with Mental retardation
effectively, is the stigma attached to mental Alcohol and drug dependence
illness. Many patients and their families try
to avoid stigma by keeping the nature of the Principles of Rehabilitation
person's illness a secret. The need for secrecy Increasing independence would be the first
places additional stress on the family system step in rehabilitation process.
because there is always the fear that the truth
Primary focus is on improvement of capabili-
will be revealed. Nurses in the community are
ties and competence of clientswith psychiatric
in a key position to monitor community
problems.
attitudes and help in fostering a realistic
Maximum use must be made of residual
attitude towards the mentally ill.
capacities.
For some patients, the emotional climate of
Patient's active participation is very essential.
the family to which they return can have a
Skill development, therapeutic environment
significant effect on their adjustment, and
are fundamental interventions for a successful
eventually recovery from the debilitating
rehabilitation process.
effects of chronic mental illness. Families
sometimes view mental illness as a weakness
Psychiatric Rehabilitation Approaches
of character that can be overcome by exertion
of moral effort. This type of familial attitude a. Psychoeducation: Includes diagnosing the
may result in guilt on the part of the patient problem, telling the person what to expect
who believes that he has disappointed his regarding illness and discussing treatment
significant others. Guilt leads to increased alternatives.
anxiety and decreased self-esteem. These are b. Working with families: Encouraging family
the conditions that interfere with a high level members to get involved in treatment and
offunctioning. Thereforenurses working with rehabilitation programs.
families need to foster healthy attitudes c. Group therapy: Positive aspects of group
towards the mentally ill member. therapy include an opportunity for ongoing
contact with others, validation of their
PSYCHIATRICREHABILITATION perceptions, sharing their views about
Rehabilitation is the process of enabling the problems and problem solving abilities.
individual to return to his highest possible level d. Social skills training: It involves teaching
of functioning. It is an important component of specificliving skillsthat the patient is expected
the community mental health program, and is to have in order to survive in the community.
undertaken at the level of tertiary prevention.
Rehabilitation Team
Definition Professionals contributing to psychiatric reha-
Rehabilitation is " an attempt to provide the best bilitation include, psychiatrist, clinical psycho-
possible community role which will enable the logist, psychiatric social worker, psychiatric
patient to achieve the maximum range of activity, nurse, occupational therapist, recreational
interest and of which he is capable". therapist, counselor and other mental health
-Maxwell Jones [1952] paraprofessionals.
Steps in Psychiatric Rehabilitation interpersonal skills,self-esteem,activities of daily
Psychiatric rehabilitation begins with a com- living and drug compliance.
prehensive medical psychiatric diagnosis and
functional assessment. These are key elements in Assessment of Family
identifying impairments and disabilities. The Components of family assessment:
steps of rehabilitation include: Family structure including developmental
a. Reduction of impairments: Rehabilitation inter- stages, roles, responsibilities, norms and
ventions with psychiatric patients require
values.
reduction or elimination of the symptoms and
cognitive impairments that interfere with Family attitudes towards the mentally ill
social and vocational performance. These member.
impairments are reduced and eliminated for Emotional climate of the family.
the greaterpart by various psychotropicagents. Social support available to the family.
b. Remediation of disabilities through skill training: Past family experiences with mental health
Skill training is used to remediate disabilities services.
in social, family and vocational functioning. The family's understanding of the patient's
Patients generally require training in self-care problems and the plan of care.
skills, interpersonal skills, vocational and
employment pursuits, recreational and leisure Assessment of Community
skills.
It includes assessment of community agenciesthat
c. Remediating disabilities through supportive
provide services to people who have mental
interventions: When restoration of social and
illnesses, assessment of attitudes of the people
vocational functioning through skills training
is limited by continuing deficits,rehabilitation towards the mentally ill, etc.
strategies aim at helping the individuals
compensate for handicap by learning skills in Planning and Implementation
living and working environments, adjusting Planning and implementation in rehabilitative
the individual and family expectations to a psychiatric nursing focuses on fostering indepen-
level of functioning that is realistically dence by maximizing personal strengths. The
attainable. nurse and the patient must work together to find
d. Remediation ofhandicaps: In addition to clinical ways for the patient to overcome any remaining
rehabilitation interventions, the disabled per- impaired areas of functioning.
sons canbe helped to overcome their handicaps
throughsocialrehabilitationinterventions,e.g. IndividualInterventions
community support programs. Hospital rehabilitation (Inpatient rehabilitation):
This involves therapeutic community, recrea-
Role of a Nurse in Psychiatric Rehabilitation tional therapy, social skills training and training
Rehabilitative psychiatric nursing must be in basic living skills.
studied in the contextofboth the patient and social
system. This requires the nurse to focus on three Community rehabilitation:Providing care in com-
elements, the individual, family and community. munity settings (Homes, residential care settings
foster homes etc).
Assessment
Assessment of the Individual Family Interventions
The nurse should assess the individual in the Health education to family members regar-
areas of symptoms present, motivation, strengths, ding the disease process, available resources,
communication skills and problem solving Indian Red Cross Society (IRCS)which runs
techniques. VIC for the handicapped has offered voca-
Motivating the family members to provide tional training for the chronic mentally ill.
proper care to the patient. Indian Council for Child Welfare, an NGO
Group therapy and support to familymembers caring for underprivileged children.
through self-help groups; nurses are in a
favorable position to help families cope with Phases in Vocational Rehabilitation
stress and adapt to changes in the family
structure. Vocational assessment
Vocational counseling
Community Interventions Vocational training
Job exploration
There are several ways that nurses can intervene
Job placement
in the community tertiary prevention programs. Follow-up
Among these are health education to the public,
training to school teachers, village leaders and
Vocational Assessment
paraprofessionals in the rehabilitation of mentally
ill people. It is done in four areas viz., clinical, social, psy-
chological and vocational.
Evaluation Clinical assessment includes assessing for
Evaluation of psychiatric rehabilitation services residual psychiatric symptoms which may
usually takes place at the level of impact on the affect his ability to function.
patient, family and the effectiveness of the Social assessment includes assessing family
community service system. support, attitude of family members and
economic status of the family.
Vocational Rehabilitation Psychological assessment includes assessing
self-esteem, confidence, patient's level of
Vocational rehabilitation is a part of conti-
motivation .
nuous and coordinated process of rehabilitation
Vocational assessment includes assessing
which involves the provision of those vocational
services (e.g. vocational guidance, vocational physical strength, hand coordination, atten-
tion, concentration, etc.
training and selective placement) designed to
enable a disabled person secure and retain
Vocational Counseling
suitable employment.
This includes informing patients and family
Main Vocational Rehabilitation Centers in India members regarding the type of training available.
Mithra SpecialSchooland VocationalTraining Family consent should be taken for rehabilitation
Center for the Mentally Retarded, Chennai. training.
Banyan, Chennai.
Vocational Rehabilitation Center, Chennai. Vocational Training
Shristi Center for Psychiatric Rehabilitation, It includes:
Madurai. Course content
VIC (Vocational Training Center) for the Duration of training
physically handicapped run by the Ministry Incentives
of Labor, Government of India, has opened Assessment of the progress
up its facility for the mentally ill for the first Imparting skills
time in Chennai. Supervision
Job Exploration NATIONAL MENTAL HEALTH PROGRAM

Finding out various jobs available in the The National Mental Health Program was
community. launched in 1982 in India and aims to provide
mental health care to the total population within
Job Placement the available resources.
This includes selecting suitable job, placement of
Objectives
the client in the job, checking the facilities
available and evaluating work performance. Basic mental health care to all the needy
especially the poor from rural, slum and tribal
Follow-up areas.
Application of mental health knowledge in
It includes evaluation of the four dimensions viz.,
general health care and in socialdevelopment.
clinical, social, psychological and vocational.
Promotion of community participation in
mental health service development and
Vocational Program
increase of efforts towards self-help in the
Open competitive job placement: Though it is community.
difficult to place the mentally restored in open Prevention and treatment of mental and
competitive job placements, it is also possible to neurological disorders and their associated
provide this opportunity for selected groups of disabilities.
patients with the clinical diagnoses of reactive Use of mental health technology to improve
psychosis, bipolar affective disorders, and acute general health services.
psychotic episodes. They can be equipped to Application of mental health principles in
function successfully by regular follow-up total national development to improve quality
programs. oflife.
Sheltered employment: This is provided for those
disabled persons, who, because of the nature and Approaches
severity of the disability, cannot cope with Integration of mental health care serviceswith
ordinary employment. This is suitable for those the existing general health services.
with the problems of mental retardation, chronic Utilization of the existing infrastructure of
mental illness (e.g. schizophrenia, repeated health services and also deliver the minimum
attacks of affective disorder in spite of regular mental health care services.
medication). Provision of appropriate task-oriented
training to the existing health staff.
Self-employment: Persons who cannot cope with
Linkage of mental health services with the
the demands of vocational adjustment in open
existing community development program.
competitive job situations, but who have the
capacity to do some work with the help of any
family members, may be considered for self- Components
employment schemes which are usually spon- I. Treatment
sored by differentwelfare schemesofnationalized
Multiple levels were planned.
banks and social welfare departments. A Village and sub-center level multipurpose
Home-bound work programs: For those disabled workers (MPW)and health supervisors (HS),
needing total care, work can be given at home, under the supervision of medical officer(MO)
which shall be collected by the center and paid to be trained for:
according to the performance. a. management of psychiatric emergencies
b. administration and supervision of main- II. Rehabilitation
tenance treatment for chronic psychiatric
disorders The components of this sub-program include
c. diagnosis and management of grandma! treatment of epileptics and psychotics at the
epilepsy, especially in children community levels and development of
d. liaison with local school teachers and rehabilitation centers at both the district level and
parents regarding mental retardation and higher referral centers.
behavioral problems in children
e. counseling in problems related to alcohol II I. Prevention
and drug abuse The prevention component is to be community-
B. MO of Primary Health Centre (PHC) aided by based, with initial focus on prevention and
HS, to be trained for: control of alcohol-related problems. Later on,
a. supervision of MPW's performance problems like addictions, juvenile delinquency
b. elementary diagnosis and acute adjustment problems like suicidal
c. treatment of functional psychosis attempts are to be addressed.
d. treatment of uncomplicated cases of
psychiatric disorders associated with REVIEW QUESTIONS
physical diseases
e. management of uncomplicated psycho- Community facilities available for mentally
social problems ill patients (Nov 1999,Nov 2000, Nov 2001)
f. epidemiological surveillance of mental Mental health services (Apr 2002,Nov 2002)
morbidity Halfway homes (Feb 2000,Nov 2002)
C. District hospital: It was recognized that there Self-help groups
should be at least one psychiatrist attached to Role of a nurse in community mental health
every district hospital as an integral part of (Feb 2000)
the district health services. The district
hospital should have 30-50psychiatric beds. Levels of prevention (Nov 2001,Nov 2003)
The psychiatrist in a district hospital was Role of a nurse in prevention of psychiatric
envisaged to devote only a part of his time to disorders (Feb 2001,Nov 2003,Oct 2005,Apr
clinical care and a greater part in training and 2006)
supervision of non-specialist health workers. Primary prevention (Nov 2003)
D. Mental hospitals and teaching psychiatric Tertiary prevention (Oct 2004)
units: Major activities of these higher centers
Role of nurse in psychiatric rehabilitation (Oct
of psychiatric care include:
2005)
a. help in care of 'difficult' cases
b. teaching Vocational rehabilitation
c. specialized facilities like, occupational National mental health program
therapy units, psychotherapy, counseling Enumerate the therapeutic activities of a nurse
and behavioral therapy in community mental health care (Oct 2004)
Psychiatric Emergencies
0 COMMONPSYCHIATRICEMERGENCIES Suicide is a type of deliberate self-harm and is
Suicidal Threat defined as an intentional human act of killing
Violent or Aggressive Behavior or oneself.
Excitement
Panic Attacks
Catatonic Stupor Etiology
Hysterical Attacks
Transient Situational Disturbances Psychiatric Disorders
0 ORGANICPSYCHIATRICEMERGENCIES Major depression
DeliriumTremens
Epileptic Furor
Schizophrenia
Acute Drug Induced Extrapyramidal Drug or alcohol abuse
Syndrome Dementia
Drug Toxicity Delirium
Personality disorder
Psychiatric emergency is a condition wherein the
patient has disturbances of thought, affect and Physical Disorders
psychomotor activity leading to a threat to his Patients with incurable or painful physical
existence (suicide), or threat to the people in the disorders like, cancer and AIDS.
environment (homicide). This condition needs
immediate intervention to safeguard the life of Psychosocial Factors
the patient, bring down the anxiety of the family Failure in examination
members and enhance emotional security to Dowry difficulties
others in the environment. Marital difficulties
Loss of loved object
COMMON PSYCHIATRIC EMERGENCIES Isolation and alienation from social groups
Suicidal threat Financial and occupational difficulties
Violent or aggressive behavior or excitement
Panic attacks Risk Factors for Suicide
Catatonic stupor Age
Hysterical attacks males above 40 years of age
Transient situational disturbances females above 55 years of age
Sex
SUICIDAL THREAT men have greater risk of completed suicide.
In psychiatry a suicidal attempt is considered to suicide is 3 times more common in men
be one of the commonest emergencies. than in women.
Psychiatric Emergencies 2 41
women have higher rate of attempted of the havoc alcohol has created in his life can
suicide cause the individual to wish to die.
Being unmarried, divorced, widowed or Personality disorder: Individuals with histrio-
separated nic and borderline traits may occasionally
Having a definite suicidal plan attempt suicide.
History of previous suicidal attempts Organic conditions: Conditions such as
Recent losses delirium and dementia due to changes of
mood like anxiety and depression may also
Suicidal Tendency in Psychiatric Wards induce suicidal tendency.
Certain psychiatric disorders where the patient
may develop suicidal tendencies include: Management
Major depression: This is one of the commonest 1. Beaware of certain signs which may indicate
conditions associated with a high risk of that the individual may commit suicide, such
suicide. Suicide in a major depressive episode as:
is due to pervasive and persistent sadness; suicidal threat
pessimistic cognitions concerning the past, writing farewell letters
present and future; delusions of guilt, help- giving away treasured articles
lessness, hopelessness and worthlessness; making a will
and derogatory voices urging him to take his closing bank accounts
life.The risk of suicide is more when the acute appearing peaceful and happy after a
phase has passed and the characteristic period of depression
psychomotor retardation has improved. This refusing to eat or drink, maintain personal
is so because the patient has more energy to hygiene.
carry out his suicidal plans now, though he 2. Monitoring the patient's safety needs:
might have been harboring them forquite some
take all suicidal threats or attempts
time.
seriously and notify psychiatrist
Schizophrenia: The major risk factors among
search for toxic agents such as drugs/
schizophrenics include the presence of
alcohol
associated depression, young age and high
do not leave the drug tray within reach of
levels of premorbid functioning (especially
the patient, make sure that the daily
during college education). People in this risk
medication is swallowed
group are more likelyto realizethe devastating
significance of their illness more than other remove sharp instruments such as razor
groups of schizophrenic patients do, and see blades, knives, glass bottles from his
suicide as a reasonable alternative. environment.
Mania: Manic patients may occasionally remove straps and clothing such as belts,
commit suicide. This is usually the result of neckties
grandiose ideation: the patient may believe do not allow the patient to bolt his door on
that he is a great person, or wish to prove his the inside, make sure that somebody
supernatural powers. With this intent in mind, accompanies him to the bathroom
he may carry out some dangerous activity that patient should be kept in constant
can cost him his life. observation and should never be left alone
Drug or alcoholabuse: Suicideamong alcoholics have good vigilance especially during
can be due to depression in the withdrawal morning hours
phase. Also, the loss of friends and family, spend time with him, talk to him, and allow
self-respect, status, and a general realization him to ventilate his feelings
encourage him to talk about his suicidal of organic pathology. In particular check for
plans I methods history of convulsions, fever, recent intake of
if suicidal tendencies are very severe, alcohol, fluctuations of consciousness.
sedation should be given as prescribed Carry out complete physical examination.
3. Encourage verbal communication of suicidal Send blood specimens for hemoglobin, total
ideas as well as his/her fear and depressive cell count, etc.
thoughts. A 'no suicidal' pact may be signed, Look for evidence of dehydration and malnut-
which is a written agreement between the rition. If there is severe dehydration, glucose
client and the nurse, that client will not act on saline drip may be started.
suicidal impulses, but will approach the nurse Have less furniture in the room and remove
to talk about them. sharp instruments, ropes, glass items, ties,
4. Enhance self-esteemof the patient by focusing strings, match boxes, etc. from patient's
on his strengths rather than weaknesses. His vicinity.
positive qualities should be emphasized with Keep environmental stimuli, such as lighting
realistic praise and appreciation. This fosters and noise levels to a minimum; assign a single
a sense of self-worth and enables him to take room; limit interaction with others.
control of his life situation. Remove hazardous objects and substances;
caution the patient when there is possibility
VIOLENT OR AGGRESSIVE BEHAVIOR OR of an accident.
EXCITEMENT Stay with the patient as hyperactivity
This is a severe form of aggressiveness. During increases to reduce anxiety level and foster a
this stage, patient will be irrational, uncooperative, feeling of security.
delusional and assaultive. Redirectviolent behavior with physical outlets
such as exercise, outdoor activities.
Etiology Encourage the patient to 'talk out' his
Organic psychiatric disorders like, delirium, aggressive feelings, rather than acting them
dementia, Wemicke-Korsakoff' s psychosis. out.
Other psychiatric disorders like, schizophre- If the patient is not calmed by talking down
nia, mania, agitated depression, withdrawal and refuses medication, restraints may
from alcohol and drugs, epilepsy, acute stress become necessary.
reaction, panic disorder and personality Following application of restraints, observe
disorders. patient every 15 minutes to ensure that
nutritional and elimination needs are met.
Management Also observe for any numbness, tingling or
An excited patient is usually brought tied up cyanosis in the extremities. It is important to
with a rope or in chains. The first step should choose the least restrictive alternative as far
be to remove the chains. A large proportion of as possible for these patients.
aggression and violence is due to the patient Guidelines for self-protection when handling
feeling humiliated at being tied up in this an aggressive patient:
manner. never see a potentially violent person
Talk to the patient and see ifhe responds. Firm alone.
and kind approach by the nurse is essential. keep a comfortable distance away from the
Usually sedation is given. Common drugs patient (arm length).
used are: diazepam 10-20mg, IV;haloperidol be prepared to move, a violent patient can
10-20mg; chlorpromazine 50-100mg IM. strike out suddenly.
Once the patient is sedated, take careful maintain a clear exit route for both the staff
history from relatives; rule out the possibility and patient.
Psychiatric Emergencies 243
be sure that the patient has no weapons in Other care is same as that for an unconscious
his possession before approaching him. patient
if patient is having a weapon ask him to
keep it on a table or floor rather than HYSTERICAL ATTACKS
fighting with him to take it away. A hysteric may mimic abnormality of any
keep something like a pillow, mattress or function, which is under voluntary control. The
blanket wrapped around arm between you common modes of presentation may be .
and the weapon. Hysterical fits
distract the patient momentarily to remove Hysterical ataxia
the weapon (throwing water in the Hysterical paraplegia
patient's face, yelling etc). All presentations are marked by a dramatic
giveprescribed antipsychotic medications. quality and sadness of mood.
PANIC ATTACKS Management

Episodes of acute anxiety and panic can occur as Hysterical fit must be distinguished from
a part of psychotic or neurotic illness. genuine fits (Seep. 122for differencesbetween
The patient will experience palpitations, hysterical and epileptic seizures).
sweating, tremors, feelings of choking, chest pain, As hysterical symptoms can cause panic
among relatives, explain to the relatives the
nausea, abdominal distress, fear of dying,
psychological nature of symptoms. Reassure
paresthesias, chills or hot flushes.
that no harm would come to the patient.
Help the patient realize the meaning of
Management
symptoms, and help him find alternative ways
Give reassurance first of coping with stress.
Search for causes Suggestion therapy with IV pentothal may be
Diazepam 10 mg or lorazepam 2 mg may be helpful in some cases.
administered
TRANSIENT SITUATIONAL DISTURBANCES
CATATONIC STUPOR These are characterized by disturbed feelings and
Stupor is a clinical syndrome of akinesis and behavior occurring due to overwhelming external
mutismbutwithrelativepreservationofconscious stimuli.
awareness. Stupor is often associated with cata-
Management
tonic signs and symptoms (catatonic withdrawal
or catatonic stupor). The various catatonic signs Reassurance
Mild sedation if necessary
include mutism, negativism, stupor, ambiten-
Allowing the patient to ventilate his/her
dency, echolalia,echopraxia, automatic obedience,
feelings
posturing, mannerisms, stereotypies, etc.
Counseling by an understanding professional
Management
Ensure patent airway ORGANIC PSYCHIATRIC EMERGENCIES
Administer IV fluids Delirium tremens
Collect history and perform physical Epileptic furor
examination Acute drug-induced extrapyramidal
Draw blood for investigations before starting syndrome
any treatment Drug toxicity
DELIRIUM TREMENS Management

Delirium tremens is an acute condition resulting The drug should be stopped immediately.
from withdrawal of alcohol (Refer p. 131 for Treatment is symptomatic and includes cooling
details). the patient, maintaining fluid and electrolyte
balance and treating intercurrent infections.
Diazepam can be used for muscle stiffness.
Management
Dantrolene, a drug used to treat malignant
Keep the patient in a quiet and safe hyperthermia, bromocriptine, amantadine and L-
environment. dopa have been used.
Sedation is usually given with diazepam
10mg or lorazepam 4 mg IV,followed by oral DRUG TOXICITY
administration. Drug over-dosage may be accidental or suicidal.
Maintain fluid and electrolyte balance. In either case all attempts must be made to find
Reassure patient and family. out the drug consumed. A detailed history should
(see chapter 11 p. 132 for further details on be collectedand symptomatic treatment instituted.
management) A common case of drug poisoning is lithium
toxicity. The symptoms include drowsiness,
EPILEPTIC FUROR vomiting, abdominal pain, confusion, blurred
Following epileptic attack patient may behave in vision, acute circulatory failure, stupor and coma,
a strange manner and become excited and violent. generalized convulsions, oliguria and death.
Management Management
Sedation: Inj. Diazepam 10 mg IV [or] Inj. Administer 02
Luminal 10 mg. IV followed by oral anti- Start IV line
convulsants. Assess for cardiac arrhythmias
Haloperidol 10 mg IV helps to reduce Refer for hemodialysis
psychotic behavior. Administer anticonvulsants
(see chapter 14 p. 177 for further details on
ACUTE DRUG-INDUCED EXTRAPYRAMIDAL lithium toxicity).
SYNDROME
Antipsychotics can cause a variety of movement- REVIEW QUESTIONS
related side-effects, collectively known as Extra List the common psychiatric emergencies
Pyramidal Syndrome (EPS). Neuroleptic Nursing management for a suicidal patient
malignant syndrome is rare but most serious of (Nov 1999)
these symptoms and occurs in a small minority Nursing management for a violent patient
of patients taking neuroleptics, especially high- Suicidal risk (Nov 2003)
potency compounds (refer chapter 14p. 174 for a Suicide prevention (Oct 2004,Oct 2005)
,., detailed description). Management of aggressive patient (Apr 2004)
Psychosocial Issues
Among Special
Population
0 ADOLESCENTMENTALHEALTHNURSING Co-morbidity or co-occurrence of psychiatric
0 GERIATRICMENTALHEALTHNURSING
0 PSYCHIATRICDISORDERSRELATEDTO WOMEN
disorders e.g. adolescents with substance
0 PSYCHOSOCIALISSUESAMONG HIVIAIDS abuse disorders, are more likely to have
PATIENTS comorbid disruptive behavior disorders.
Comorbidity in adolescents is associated with
ADOLESCENT MENTAL HEALTH NURSING impaired role functioning, likelihood of
According to the World Health Organization suicidal behavior, academic problems and
(WHO), individuals between 10 -19 years of age increased conflict with parents.
come under the adolescent age group.
Adolescence is a period of physical growth and Common Reasons for Mental Health
intellectual attainment at its peak, coupled with Problems among Adolescents
setting of personality traits, decisions regarding Emotional difficulties in adolescents often
future profession, and extreme emotional arise from faulty or inconsistent child-rearing
instability. This is also a period of identity crisis- practices.
physical, sexual and spiritual. Environmental factors such as poverty, lack
of adequate support systems, major
Mental Health Problems among Adolescents cumulative life stresses, and maternal
Rates of depression, Bipolar Affective , employment influence coping abilitiesamong
Disorders (BPAD), attempted suicide, children and adolescents.
completed suicide, conduct disorders and Constitutional factors or those characteristics
schizophrenia increase during adolescence. within the adolescent affect the level of
Antisocial activities increase in frequency. individual vulnerability.
Agoraphobia and socialphobia become more
common during adolescence. Nursing Interventions
The incidence of acting out behavior, and Nursing care of adolescents begins with a
juvenile violent crime in adolescents continues thorough assessment of their health status.
to rise. Violent crimes include homicide, Data collectionby the nurse isbased on current
forcible rape, robbery or aggravated assault. and previous functioning in all aspects of an
Adolescents are especially at an increased risk adolescent's life. The data collection should
of sexual abuse. In tum rape and sexual abuse include the following information
are associated with a greatly increased risk of General appearance
depression and suicide. Growth and development
Substance abuse usually starts during General health status
adolescent age. Mental health status
Cultural and socio-economic background In Karnataka out of a population of 5.5 crores, 8%
Communication patterns (family, peers, are elderly citizens. The 1st of October every year
society) is observed as World Elders' Day globally. (The
Sexualbehaviors and use of drugs, alcohol Indian Express Olst Oct. 2002)
and other addictive substances WHO report of 2004 states that 236 elderly
Available human and material sources people per 10,000 suffer from mental illness
(friends, school and community mainly due to stress, heart disease, stroke and
involvement). cancer. Dementia, a crippling disorder of old age,
Nurses need to understand normal adolescent currently affects 1 in 20 people over 65 years of
development and also the difference between age in our country. It is projected that by the year
constructive and age-appropriate exploration 2025, 4 million Indians will become victims of
and engagement in activities that are dementia (The Hindu, 16th Feb. 2003,p.6).
potentially dangerous to physical and Elderly individuals usually face a higher risk
emotional wellbeing. of developing mental as well as physical
Nurses who work in schools and community morbidity. Their vulnerability to mental problems
settings can engage in screening and early is due to ageing of the brain, physical problems,
nursing intervention with high risk teenagers socio-economic factors, cerebral pathology,
to promote adaptive responses and prevent emotional attitude and family structure. The
the development of future problems. biochemical and morphological changes in the
Encouraging the adolescent to identify and aging brain of normal individuals are similar to
discuss his /her feelings is extremely those suffering from dementia. In most cases,
important in this regard. mental illnesses coexist alongside physical
Nursing interventions useful in working with problems in elderly individuals. Chronic physical
adolescents include health education, family, disorders and sensory impairments (vision and
group and individual therapy and medication hearing defects) are known to be especially
management. Emphasis should be laid on associated with mental problems of the elderly.
lifestyle and compliance issues, such as
benefits of exercise, stress management and PROBLEMS OF THE ELDERLY
safer sex practices. Special attention should
be given to talking with adolescents and Physical
working with their parents. Ageing is a natural progressive decline in body
Building a therapeutic relationship with an systems. Physical changes include wrinkling of
adolescent demands confidence and a strong skin, flabbiness of muscles, atrophy of viscera,
sense of one's own identity or sense of comfort decreased vision and hearing, and a loss in
with one's memories of the teenage years. The efficiency of cardiovascular system. Old people
nurse needs to offer unconditional acceptance suffer from immobility, instability, incontinence
and positive attitude and gentle encourage- and intellectual impairment. These are called as
ment for what the adolescent can become. the Giants of Geriatrics. These disabilities do not
,., kill, but they greatly diminish the value of living.
GERIATRIC MENTAL HEALTH NURSING
Older adults are the most rapidly growing Psychiatric
segment of the population. In India, life Delirium, dementia, depression, agitation
expectancy at birth has increased by about 20 Crying spells, irritability, wandering,
years in the past 5 decades. The average life span assaultiveness
today is 66years. Today there are about 77million Expressions of feeling of worthlessness,
aged people in India (i.e. above 60 years of age). hopelessness, helplessness
Psychosocial Issues Among Special Population 247
Diminished memory, orientation and Nursing Management
judgment The nurse who works with mentally ill elders
Apathy, withdrawal, suicidal impulses or is challenged to integrate psychiatric nursing
attempts, loneliness skills with knowledge of physiological dis-
Paranoid delusions, demanding behavior, orders, the normal ageing process and socio-
anxiety disorders cultural influences on the elderly and their
Alcohol abuse, impaired concentration, short families
attention span The goal of nursing intervention is to promote
Stress incontinence maximum independence of the older adults,
based on capacity and functional abilities
Personality Changes The role of geropsychiatric nurse includes
These may occur due to psychoses with cerebral providing primary mental health nursing care,
arteriosclerosis, senile dementia. Personality including intervening with caregivers,
breakdown in old may lead to criminal behavior providing case management and consulting
or suicidal tendencies. with other care providers. Advanced practice
nurses provide individual and group
Psychosocial psychotherapy
The theme of this age period is loss, and dealing The nurse should be proficient at assessing
with death is one of the tasks of the elderly. Since patient's cognitive, affective, functional,
death is the only certainty in life,without adequate physical and behavioral status, as well as
emotional support to sustain and bear the losses their family dynamics
(loss of work role, spouse, friends, sensory and Geropsychiatric nurses should be knowle-
motor abilities and intellectual processes), the dgeable about the effects of psychotropic
elderly individual is vulnerable to depression and medication on elderly people. Nurses often
despair. work closely with the physician to monitor
Social problems include harassment, ill- complex medication regimens and assist the
treatment, exploitation,desertion, separation from patients and caregivers with medication
dear ones, living alone and none to help, etc. management
The key concepts of geropsychiatric nursing
Some therapies in the management of assessment include
geriatric disorders include: Mental health status examination (it
includes mini-mental status examination,
Somatic Therapies
mental status examination, depression,
Electro convulsive therapy anxiety and psychosis)
Psychopharmacology Frequently observed problem behavior
Functional abilities
Psychological Therapies General health and
Psychotherapy Social support system
Lifereview therapy Nursing interventions with geropsychiatric
Reality orientation therapy patients include creation of a therapeutic
Validation therapy milieu, involvement in somatic therapies, and
Cognitive training interpersonal interventions. The basic
Relaxation therapy characteristics of a therapeutic milieu are:
Counseling cognitive stimulation, promotion of a sense of
Patient and family education calm and quietness, consistentphysical layout,
structured routine, focus on strengths and Management
abilities, minimizing of disruptive behavior, The syndrome has been widely treated with
providing safety progesterone, oral contraceptives, bromo-
Care givers should be involved in planning, criptine, diuretics and antidepressant drugs
implementation and evaluation of nursing Psychological support and encouragement
interventions. Cognitive behavior therapy
PSYCHIATRIC DISORDERS RELATED TO II. PSYCHIATRIC DISORDERS ASSOCIATED

WOMEN WITH CHILD BIRTH
In most societies, psychiatric disorders are more There is an increased risk of mental illness
common in women. The common reasons for this associated with childbirth, mostly in the
include: genetic differences, societal pressures on postpartum period but problems may also be
women, differencesin rearing pattern and cultural present before or during pregnancy.
expectations. A Mental illness in pregnancy
The mental disorders more commonly B. Puerperal mental disorders
reported in females include major depression,
A. Mental illness in pregnancy
neurotic depression, anxiety states, phobic
neurosis, hypochondriasis, dissociative dis- The incidence of mental illness in the first
orders, adjustment problems, attempted suicide, trimester ofpregnancy is thought to be high, when
anorexia nervosa and senile dementia. compared to second and third trimesters of
There are many psychiatric disorders peculiar pregnancy.
The predisposing factors for mental illnesses
to females which include :
during pregnancy are;neurotic traits in premorbid
Premenstrual syndrome
personality, marital tension, history of previous
Psychiatric disorders associated with child
abortion.
birth The majority of episodes of mental illness
J'vfenopausalsyndrome during pregnancy are neuroses. The commonest
condition is depressive neurosis with anxiety,
I. PREMENSTRUAL SYNDROME phobic anxiety and obsessive compulsive
Menstruation is a normal physiological process disorders. In most cases these conditions resolve
in females. The various psychological sympton:i-s by the second trimester of pregnancy.
attributed to premenstrual syndrome are:sadness, The major mental illnesses in pregnancy
anxiety, anger, irritability, labile mood, decreased include bipolar affective disorder, severe
concentration, indecision, suspiciousness, sensi- depression and schizophrenia. The risk of women
tivity, suicidal or homicidal ideations, insomnia, developing a new episode of one of these
hypersomnia, anorexia, craving for certain foods, conditions in pregnancy is lower than at other
fatigue, lethargy, agitation, libido changes, times in her life.
decreased motivation, impulsivity and social
withdrawal. Management
This premenstrual syndrome starts about 5 to The nurse should provide support, counse-
10 days before onset of menses and lasts till the ling, reassurance and information which is
end of menses. It not only affects social but also communicated in a caring, intelligible way.
occupational functioning, leading to various If the psychiatrist feels that there is a
degrees of maladjustments. substantial risk of relapse if the women's
medications are withdrawn, then this risk has A majority of women recover spontaneously. The
to be weighed against that of the drugs having depressive episodes are manifested as poor
a teratogenic effect on the fetus. concentration, feeling of guilt, loss of energy, lack
of interest in usual activities, social withdrawal,
B. Puerperal Mental Disorders inability to cope, tiredness, irritability, anxiety,
As many as 16%of mothers develop mental illness ruminative worry about the baby, guilt about their
in the puerperium. The risk of becoming mentally perceived poor mothering skills, sleep distur-
ill during the puerperium is greater than at other bances, depressive ideation and anomie (which
times in the women's reproductive life. is a painful feeling of inability to experience love
Many factors are associated with puerperal or pleasure).
mental illness such as lack of confiding
relationship and support, marital tension, socio- Management
economic problems and a previous psychiatric Counseling
history.
Cognitive therapy
Common puerperal mental disorders are :
Antidepressants like amitriptyline and
A Postnatal blues
tetracyclic drugs
B. Postnatal depression
Good supervision and support
C. Puerperal psychosis
c. Puerperal Psychosis
a. Postnatal blues (transitory mood
disorders) Puerperal psychosis affectsapproximately 1-2per
1000births. Unmarried status, primigravida, past
Postnatal blues are transient, a self limiting
history of schizophrenia may predispose to
condition with no known serious after effects.
puerperal psychoses.
Most women recover from the blues within a day
or two. It occurs at any time between the third The onset is very sudden, commonly occurring
and tenth postnatal day. It is considered a normal within the first postnatal week. The main features
reaction to childbirth and affects about 70% to are;
80% of all postnatal mothers. These are more Insomnia and early morning waking
common in primigravida and in those who Lability of mood, sudden tearfulness or
complain of premenstrual tension. inappropriate laughter
The women experience unfamiliar episodes Abnormal behavior such as restlessness,
of crying, irritability, depression, emotional excitement or sudden withdrawal
liability, feeling separate and distant from the Suspiciousness and fear
baby, insomnia and poor concentration. Unexpected rejection of the baby or a
The support given to mothers in the postnatal conviction that baby is deformed or dead
period may help them to cope with their feelings Suicidal or infanticide threats
and have a significant contribution to their emo- Excessive guilt, depression or anxiety
tional wellbeing and adaptation to motherhood.
Management
b. Postnatal depression Puerperal psychosis is a psychiatric emer-
Postnatal depression is the most frequent neurotic gency. Admission to hospital is always
disorder during postnatal period. It occurs in 10% required, due to the potential danger to the
to 15% of women. Onset is usually within the baby and difficulty in dealing with the
first postpartum month, often on returning home mother's behavior at home
and usually between day 3 and day 14. Electroconvulsive therapy
Antipsychotics -may cause over sedation in Psychosocial Issues Related to a Positive

baby Result
Supportive psychotherapy 1. Emotional: Shock, numbness, disbelief,
confusion, uncertainty about present and
Ill. MENOPAUSAL SYNDROME future, denial, guilt, frequent changes of
mood, sadness and concern about the future.
Menopause, the cessation of ovulation, generally
2. Behavioral: Crying, anger expressed
occurs between 45 and 53 years of age. The
verbally and physically, withdrawal,
hypoestrogenism that follows can lead to hot
checking the body for signs of infection/
flashes; sleep disturbances, vaginal atrophy and
deterioration.
dryness, and cognitive and affective disturbances
3. Fear: Fear of pain, of death, of disability,
like worrying, depression, anxiety, irritability,
loss of functioning, of loss of privacy I
difficulty in concentration and decreased self
confidentiality, of desertion.
confidence. 4. Loss: Of future and ambitions, of physical
attractiveness and potency, of sexual
Management relationship, of status in community, of
Hormonal replacement therapy independence, of control over life, of
Reassurance confidence.
Psychological support 5. Guilt: Guilt about the behavior that resulted
Early identification of emotional problems in HIV infection, about infecting others,
and prompt treatment about disrupting the life of others.
Counseling 6. Grief: Grief over the loss of health.
Psychotherapy 7. Isolation: Due to social stigma.
8. Resentment: At changes in living patterns.
PSYCHOSOCIAL ISSUES AMONG HIV I AIDS 9. Depression: Depression due to absence of
a cure, loss of personal control.
PATIENTS
10. Anxiety: Anxiety about prognosis, social,
HIV I AIDS is one of the most devastating global occupational, domestic and sexual hostility
epidemics of the twentieth century. The Human and rejection.
Immunodeficiency Virus (HIV)and the resulting 11. Anger: Anger about the helplessness of the
Acquired Immune Deficiency Syndrome (AIDS) situation, unfair fate, others who are
include a variety of serious and debilitating infection-free, health care workers, others
disorders such as opportunistic infections who discriminate.
resulting from a compromised immune system 12. Suicidal thoughts and acts
and significant co-occurring psychiatric illnesses. 13. Loss of self esteem :Due to rejection,loss of
In India the number of people with the virus is confidence, loss of identity, physical impact
5.134 millions, according to the National AIDS of HIV infection.
Control Organization (NACO) estimate of 2005, 14. Obsession: Due to pre-occupation with
with nearly 90 percent of cases in the 15- 49 year health
age group (The Indian Express, 17th Aug. 2005,p- In some instances, a symptom complex
8). Karnataka and Tamil Nadu have the highest similar to post-traumatic stress disorder
prevalence of HIV I AIDS cases. A 2004 survey is common in the first few weeks after
estimated that 50,000people in Karnataka were notification of HIV positivity.
affectedby the disease (The Indian Express 0151Dec. The person may become extremely
anxious and hypervigilant about
2005, p-1).
physical symptoms, exhibiting marked Helping establish the diagnosis and

dependence on health care providers. treatment of other psychiatric illnesses
Other responses are, transient or chronic commonly seen in patients with HIV
sexual dysfunction and social with- Implementing psychosocial interventions
drawal due to fear of infecting others or like psychotherapy, cognitive behavioral
of social rejection. therapy, counseling etc.
Significant others of patients with HIV
Helping patients, their families and others
disease face a great many stresses
in their lives with interpersonal problems
associated with the patient's illness.
related to HIVI AIDS
They may experience grief response,
financial concerns and lack of social Assisting AIDS patients during the final
support (due to stigma attached to phase of their illness.
illness).
Many psychiatric syndromes are Steps in Pre-test Counseling
associated with HIV I AIDS. These are- Assess the individual's motivation for testing
depression, anxiety, paranoia, mania, Assess what information the person already
irritability, psychosis and substance has about HIV I AIDS
abuse. They complicate immune system Provide basic information regarding HIV in
function, adversely affect the patient's very simple terms
ability to fully participate in treatment, Clarify I correct misconceptions, if necessary
and negatively impact the quality of life. Describe the process of antibody testing
On the whole, the diseases tax coping
Give information about the accuracy of tests
responses to the limit and beyond.
Explain window period
Nursing Management Explain what the test result means, i.e. in
Psychiatric nurses are in a unique position to terms of being HIV positive, negative or
help diagnosis, treat and support patients indeterminate
affectedby HIVI AIDS. Discuss the issue of confidentiality
A thorough psychiatric history and complete Facilitate informed decision and consent for
neuropsychiatry evaluation are indicated the test
when HIV positive patients present with Review client's assessment of own risk
psychiatric symptoms. Provide risk reduction information
Planning health care for person with HIV/ Assess the client's social network and coping
AIDSmust involve the multidisciplinary team. strategies.
Interventions include case management,
medications, risk reduction, support groups, Steps in Post-test Counseling
crisisintervention, encouragement of produc-
Build rapport
tive activity,enhancement of self-esteem,grief
Revealtest result (never divulge the test result
counseling, support during terminal stages,
and support of significant others. over the telephone)
The psychiatric interventions for patients After disclosing that the test is positive, keep
with HIVI AIDSare; quite for a while - let the patient react and
Helping patients change risky behavior, ventilate his feelings; give him time to absorb
thus promoting prevention of HIV infection the test result.
Helping patients during the difficult Explore the patients understanding of the
process of HIV testing (pre and post-test medical meaning of test
counseling) Empathize to understand the way he feels
Talk about the things he can do safely Necessity to stop donating blood, donating
Provide information regarding precautions to organs, sharing needles, etc.
avoid transmission Safety practices in HIV drug use, blood
Assess his commitment to reducing risk. If donation, tests, etc.
change is resisted, emphasize harm reduction Regular medical monitoring
Assess patients lifestyle - tell him how a few Safety tips to patients who work in jobs
changes with regard to diet, substance abuse where they may infect others
etc., will have to be made Need to discuss HIV infection with their
Develop a health plan sexual partner.
Find out how he usually copes with stress; The level of support required to assist patients
assess social support network available and others who deal with AIDS demands skilled
Explore and assist patient to face the interventions and an integrated team effort among
consequences of having to declare HIV status mental health professionals including psychiatric
to significant others e.g. spouse/sexual nurses.
partners, family, health-care providers etc.
Work with the families regarding their own REVIEW QUESTIONS
anxieties about their own health or the future
Mental health problems among adolescents
of the infected person. Provide counseling
services to family members if so desired by the List the psychiatric problems among elderly
patient people
Some important instructions which must be List the psychiatric disorders associated with
communicated to a HIV+ patient includes : child birth
Safe-sex information, correct use of Describe psychosocial issues among HIV I
condoms all the time AIDS patients
Appendix/
Glossary
Abreaction: A treatment procedure whereby repressed painful experiences are voluntarily recalled to
awareness. This ventilation gives a therapeutic effect.
Abstract thinking: Ability to appreciate nuances of meaning; multidimensional thinking with ability
to use metaphors and hypotheses appropriately.
Addiction: Strong dependence, both physical and emotional, on alcohol or some other material.
Affect: A short-lived emotional response to an idea or an event.
Agitation: Presence of anxiety with severe motor restlessness.
Ambivalence: The co-existence of two opposing drives, desires, feelings or emotions towards the same
person, object or goal; a conflict to do or not to do.
Amnesia: Pathological impairment of memory.
Anterograde amnesia: Amnesia of events occurring after the episode which precipitated the disorder.
Retrogradeamnesia: Amnesia of events occurring prior to the episode which precipitated the disorder.
Anhedonia: Inability to experience pleasure in any activity.
Apathy: Lack of emotional feeling.
Apraxia: Inability to carry out normal activities despite intact motor function.
Autistic thinking: Preoccupations totally removing a person from reality.
Automatic obedience: The patient obeys every command though he has first been told not to do so.
Automatism: Undirected behavior that is not consciously controlled, as seen in complex partial
seizures.
Blunted affect: A reduction in emotional experience.
Cataplexy: Temporary loss of muscle tone and weakness precipitated by a variety of emotional states.
Catharsis: The expression of ideas, thoughts and suppressed material accompanied by an appropriate
emotional response that produces a state of relief in the patient.
Circumstantiality: A pattern of communication that is demonstrated by the speaker's inclusion of
many irrelevant and unnecessary details in his speech before he is able to come to the point.
Clang association: Client uses two words with a similar sound, i.e. his choice of words is determined
by their sound and not by their meaning, which often reduces the intelligibility of speech. It may lead
to punning (humorous use of words to suggest different meanings) and rhyming, and is often seen in
manic patients.
Compulsion: Pathological need to act on an impulse that, if resisted, produces anxiety; repetitive
behavior in response to an obsession or performed according to certain rules, with no true end in itself
other than to prevent something from occurring in the future (the patient fears something bad will
occur in future if he does not indulge in such behaviors).
Concrete thinking: Thought processes are focused on specifics rather than generalizations. These
individuals are unable to comprehend abstract meanings.
Confabulation: The unconscious filling of memory gaps by imagined or untrue experiences due to
memory impairment. It is most often associated with organic pathology.
Deja vu: A subjective feeling that an experience, which is occurring for the first time, has been
experienced before.
Depersonalization: A person's subjective sense of being unreal, strange or unfamiliar.
Derealization: A subjective sense that the environment is strange or unreal; a feeling of changed
reality.
Delusion: A false, unshakeable belief, which is not amenable to reasoning and is not in keeping with
the patient's sociocultural and educational background.
Primary (Autochthonous) delusion is one that appears suddenly and with full conviction, but without
any previous events leading up to it. Such delusions are suggestive of schizophrenia.
Secondary delusions can be understood as derived from some preceding morbid experience.
Delusional mood: Occasionally, when a person first develops a delusion, the first experience is a
change of mood, often a feeling of anxiety with the foreboding that some sinister event is about to
take place, and the delusion follows. In German this change of mood is called Wahnstimmung, a
term usually translated as delusional mood.
Delusional perception: In some occasions when a person first develops a delusion, the first change
may be attaching a new significance to a familiar percept without any reason. For example, a new
arrangement of objects on a colleague's desk may be interpreted as a sign that the patient has been
chosen to do God's work. This is called delusional perception.
Delusion ofgrandeur: An individual's exaggerated conception of his importance, power or identity,
a belief that he is somebody special, or is born with a special mission in life, or is related to the most
important people of his time.
Delusion of persecution: A belief that he is being attacked, harrassed, spied, cheated or conspired
against.
Delusion of reference: It is the delusion that events, objects, behavior of others have got a particular
or unusual significance for oneself, usually of a negative nature. For instance the person may
falsely believe that others are talking about him (such as, the belief that people on television or
radio are talking about the person).
Delusion of control: This refers to the belief that the patient's will, thoughts or feelings are being
controlled by external forces.
Delusion of infidelity (Delusion ofjealousy): This is the delusion that one's lover is unfaithful to him/
her.
Delusion ofguilt: Belief that one is a sinner and is responsible for the ruin of his family or society.
Somatic delusion: Belief involving functioning of the body. For example, belief that the brain is
rotting or melting.
Nihilistic delusion:The delusional belief that others, oneself or the world do not exist.Most commonly
seen in major depressive episode.
Erotomania:A delusional belief that the other person is deeply in love with him/her. The supposed
lover is usually inaccessible and of much higher social status (also known as Clerambault-
Kandinsky Complex).
Moad-incongruent delusion: Delusion with content that has no association to mood or is mood
neutral (for example a depressed patient has delusions of thought control or thought broadcasting).
Mood- congruentdelusion:Delusion with mood appropriate content (forexample, a depressed patient
believes that he is responsible for the destruction of the world).
Systematized delusion:False belief or beliefs united by a single event or theme.
Bizarre delusion: An absurd, totally implausible, strange false belief in a person's mind.
Echolalia: Pathological repetition by imitation of the speech of another.
Echopraxia: Pathological repetition by imitation of the behavior of another.
Egocentric: Self-centered; preoccupied with one's own needs and lacking interest in others.
Ego-dystonic: Distressing to the individual.
Flat affect: Absence or near absence of any sign of affective expression; voice monotonous, face
immobile.
Flight of ideas: The client's thoughts and conversation move quickly from one topic to another, so that
one train of thought is not completed before another appears. These rapidly changing topics are
understandable because the links between them are normal, a point that differentiates them from
loosening of associations. Flight of ideas is characteristic of mania.
Folie a' deux: A psychotic reaction in which two closely related persons, usually in the same family,
mutually share the same delusions.
Formal thought disorder: Disturbance in the form of thought rather than the content of thought;
thinking characterized by loosened associations, neologisms, and illogical constructions; thought
process is disordered, and the person is defined as psychotic.
Functional: Having a psychological rather than an organic pathology.
Geriatric psychiatry: A speciality of psychiatry which deals with mental health problems of the
elderly.
Hallucinations: A false sensory perception in the absence of an actual external stimulus. Hallucinations
may be described in terms of their sensory modality as visual, auditory, olfactory,gustatory, tactile.
Auditory hallucinations:These are by far the commonest, and may be experienced as noise, music or
voices. Voices may seem to address the patient directly (second-personhallucinations) or talk to one
another referring to the patient as 'he' or 'she' (third-person hallucinations). Third-person
hallucinations may be experienced as voices commenting on the patient's intentions or actions.
Such commentary voices are strongly suggestive of schizophrenia.
Visual hallucination:False perception involving sight consisting ofboth formed images (for example
people) and unformed images (forexample, flashes of light);most common in medically determined
disorders.
Olfactory hallucination: False perception of smell; most common in medical disorders.
Gustatory hallucination: False perception of taste, such as unpleasant taste, caused by an uncinate
seizure; most common in medical disorders.
Tactile (Haptic) hallucination: False perception of touch or surface sensation, as from an amputated
limb (phantom limb); crawling sensation on or under the skin (formication).
Somatic hallucination: False sensation of things occurring in or to the body, most often visceral in
origin (also known as cenesthetic hallucination).
Mood-congruent hallucination : Hallucination in which the content is consistent with either a
depressed or a manic mood (for example depressed hears voices saying that the patient is a bad
person; a manic hears voices saying that the patient is of inflated worth, power and knowledge).
Mood-incongruent hallucination: Hallucination in which the content is not consistent with either
depressed or manic mood (for example in depression, hallucinations not evolving such themes as
guilt, deserved punishment, or inadequacy; in mania, hallucinations not involving such themes
as self-inflated worth or power.
Command hallucination: False perception of orders that a person may feel obliged to obey or unable
to resist.
Hypnagogic hallucinations: These hallucinations occur when falling asleep, generally considered as
non-pathological.
Hypnopompic hallucinations: Hallucinations occur when the subject is awakening, often occurring in
healthy individuals.
Hypochondriasis: Exaggerated concern with one's physical health, not based on organic pathology.
Illusion: The misinterpretation of a real, external sensory experience.
Insight: Insight means the capacity to appreciate that one's disturbance of thought and feeling are
subjective and invalid. Loss of insight has traditionally been considered to occur in psychosis, while
its retention characterizes neurosis.
Intellectual insight: Understanding of the objective reality of a set of circumstances without the
ability to apply the understanding in any useful way to master the situation.
True insight: Understanding of the objective reality of a situation, coupled with the motivation and
the emotional impetus to master the situation.
Intelligence Quotient (IQ): Intelligence of a person measured through psychological testing. Normal
IQ is 90-110;an IQ of below 70 denotes mental retardation.
Illogical thinking: Thinking containing erroneous conclusions and internal contradictions.
Jam ais vu: Failure to recognize events that have been encountered before.
Judgment: Judgment is the mental act of comparing and evaluating alternatives for the purpose of
deciding on a course of action. Judgment is said to be disturbed when the individual deviates from
what is generally held as valid, and holds obstinately to its content although it interferes with his
adaptation.
Labile affect: Rapidly shifting emotions, unrelated to external stimuli.
Loosening of associations: A pattern of spontaneous speech in which things said lack a meaningful
relationship, or there is idiosyncratic shifting from one frame of reference to another; it is usually the
general lack of clarity in the client's conversation that makes the most striking impression.
Loosening of association takes several forms:
Knight's move or derailment refers to a transition from one topic to another, either between sentences
or in mid-sentence, with no logical relationship between the two topics. When this abnormality is
extreme it disrupts not only the connections between sentences and phrases, but also the finer
grammatical structure of speech. It is then called word salad. One effect of loosened associations on
the client's conversation is sometimes called talking past the point (also known by the German term
vorbeireden). In this condition the patient seems always about to get near to the matter in hand, but
never quite reaches it. Incoherence is a marked degree of loosening of association in which the
patient shifts ideas from one to another without logical connection and the patient's talk cannot be
understood at all.
Libido: A term used in psychoanalytic theory for sexual drive.
Malingering: Deliberate simulation or exaggeration of an illness or disability that in fact is non-
existent or minor.
Manipulation: A behavior pattern characterized by exploitation of interpersonal contact; indiscriminate
use of interpersonal relationship to meet one's own end without any consideration for the other
person in the relationship.
Mannerism: Ingrained, habitual involuntary movement.
Munchausen Syndrome: A disorder in which sufferers habitually attempt to hospitalize themselves
with self-inflicted pathology.
Narcissism: Obsessive and exclusive interest in one's own self.
Narcoanalysis: A procedure by which a chemical is injected in to a person (e.g. slow IV injection of
pentathol), while encouraging him to ventilate the unconscious desires and motives which he cannot
recollect during conscious state. It's a therapeutic and a diagnostic procedure commonly used in
neurotic disorders.
Negativism: Motiveless resistance to all attempts to be moved or to all instructions.
Neologism: A word newly coined or an everyday word used in a special way, not readily understood
by others.
Obsession: Pathological persistence of an irresistible thought or feeling that cannot be eliminated from
consciousness by logical effort; associated with anxiety.
Oedipus complex: Attachment of the child to the parent of the opposite sex, accompanied by envious
feelings towards the parent of the same sex.
Overvalued idea: Unreasonable, sustained false belief maintained less firmly than a delusion.
Paranoid: An adjective applied to individuals who are over-suspicious.
Para suicide (Deliberate self-harm): Any act deliberately undertaken by a person which mimics the act
of suicide, but which does not result in a fatal outcome.
Passivity phenomenon: The delusional belief that an external agency is controlling the self.
Phobia: Persistent, irrational, exaggerated and invariably pathological dread of a specific stimulus or
situation; results in a compelling desire to avoid the feared stimulus.
Pressure of speech: Rapid production of speech output, with a subjective feeling of racing thoughts.
Perseveration: Persistent repetition of words or themes beyond the point of relevance.
Poverty of speech: Decreased speech production.
Pseudodementia: Similar clinically to dementia, but has a non-organic cause and is reversible.
Psychometry (Psychological testing): The science of testing and measuring mental and psychological
ability, efficiency, potentials and functioning.
Psychopathology: The study of significant causes and processes in the development of mental disorders.
Rapport: Establishing a meaningful conversation.
Rorschach test: A psychological test to disclose conscious and unconscious personality traits and
emotional conflicts by eliciting patients' associations to a standard set of inkblots.
Somatic delusion: The belief that one's body is changing and responding in some unusual way.
Stereotypes: Persistent mechanical repetition of speech or motor activity.
Stupor: A state in which the individual does not react to his surroundings and appears to be unaware
of them. Commonly seen in catatonic and depressive disorders.
Tangentiality: A form of thinking/ speech in which the client tends to wander away from the intended
point, and never returning to the original idea.
Thematic apperception test (TAT): A psychological test used as a diagnostic tool consisting of 30
cards, to assess personality and psychopathology.
Thought block: A sudden interruption in the thought process before the thought is completed. After a
pause, the subject cannot recall what he had meant to say. This may be associated with thought
withdrawal. Thought block is strongly suggestive of schizophrenia.
Thought broadcast: The delusional belief that one's thoughts are being broadcast or projected into the
environment.
Thought insertion: The delusional belief that thoughts are being put into one's mind. These thoughts
are recognized as being foreign.
Thought withdrawal: The delusional belief that one's thoughts are taken away by some external
agent, often associated with thought block.
Transference: A process in which feelings, attitudes and wishes originally linked with significant
figures in one's early life are projected onto the therapist.
Verbigeration: Senseless repetition of some words or phrases over and over again.
Wechsler Intelligence Scale: A test for assessing intellectual functioning.
Word approximation (Paraphasias): Commonly used words used in a new or unconventional way.
Often the meaning is evident though the usage may be peculiar (for example, describing 'stomach' as
'food vessel').
Appendix/I
260
Mental Mechanisms
Every individual has devices for protecting himself against psychological dangers and distress. These
protective devices are known as ego defences or defence mechanisms or mental mechanisms. Both
well-adjusted and maladjusted individuals make use of these mechanisms in their daily behavior.
While well-adjusted individuals use them sparingly and in socially desirable ways, maladjusted
individuals including psychotics and neurotics, use them frequently and inappropriately.
Some of the commonly used mental mechanisms are:
Repression: It is a process of unconscious forgetfulness of unpleasant and conflict producing emotions.
Rationalization: It is a defence mechanism in which an individual justifies his failures and socially
unacceptable behavior by giving socially approved reasons.
For example, a student who fails in the examination may complain that the hostel atmosphere is
not favorable and has resulted in his failure to get through.
Intellectualization: Focusing of attention on technical or logical aspects of a threatening situation.
For example, a wife describes the details of the nurse's unsuccessful attempts to prevent the death
of her husband.
Compensation: Attempting to overcome feelings of inferiority or make up for a deficiency.
For example, a student who fails in his studies may compensate by becoming the college champion
in athletics.
Substitution: A mechanism in which original goals are substituted by others.
For example, a student who has not been accepted for admission in a medical college may satisfy
herself by becoming a nurse.
Sublimation: Unconscious gradual channelization of unacceptable impulses into personally satisfying
and socially valuable behavioral pattern.
For example, a hostile young man who enjoys fighting becomes a football player.
Suppression: Suppression is an intentional pushing away from awareness of certain unwelcome
ideas, memories or feelings.
For example, a student consciously decides not to think about her weekend so that she can study
effectively.
Reaction formation: Unconscious transformation of unacceptable impulses into exactly opposite
attitudes, impulses, feelings or behaviors, i.e. unacceptable real feelings are repressed and acceptable
opposite feelings are expressed.
For example, a young man with homosexual feelings, which he finds to be threatening, engages in
excessive heterosexual activities.
Appendix II-Mental Mechanisms 261
Displacement: Unconscious shifting of emotions usually aroused by perceived threat from an

unconscious impulse, to a less threatening external object which is then felt to be the source of threat.
For example, a person who is angry with his boss, but cannot show it for fear of losing the job may
fight with his wife and children on return from the office.
Denial: Refusal to accept or believe in the existence of something that is very unpleasant.
For example, an addict takes alcohol everyday and he cannot think of a day without it. However he
says "I am not an addict, if I decide I can give up."
Isolation: Separation of the idea of an unconscious impulse from its appropriate affect, thus allowing
only the idea and not the associated affect to enter awareness, as in the ability to express traumatic
experiences without the associated disturbing emotions, with passage of time.
For example, a soldier humorously describes how he was seriously wounded in the war.
Projection: Unconscious attribution of one's own attitudes and urges to other persons, because of
intolerance or painful affect aroused by those attitudes and urges. A person who blames another for
his own mistakes is using the projection mechanism.
For example, a surgeon whose patient does not respond as well as he anticipated may tend to
blame the theater nurse who helped the doctor at the time of operation.
Regression: Coping with present conflict or stress by returning to earlier, more secure stage of life.
For example, tears, temper tantrums in adults are very effective in overcoming stress.
Conversion: A mental mechanism in which an emotional conflict is expressed as a physical symptom
for which there is no demonstratable organic basis.
For example, a student very anxious about his exams may develop a headache.
Undoing: Unconsciously motivated acts, which magically or symbolically counteract unacceptable
thoughts, impulses or acts.
For example, a mother who has just lost her temper and beaten her children develops compulsive
handwashing and child checking behaviors.
262 Index
A Child psychiatric nursing 150 Communication skills in

Childhood psychiatric disorders depressed patients 101
Abuse 129 150 Community facilities for
Activity therapy 196 behavioral and emotional psychiatric patients 225
aims 196 disorders 162 halfway home 226
art therapy 200 conduct disorders 164 partial hospitalization 226
biblio therapy 199 hyperkinetic disorder 162 psychiatric hospitals 226
dance therapy 199 juvenile delinquency 166 quarterway homes 226
educational therapy 198 phobic anxiety disorder 167 self-help groups 227
implications 200 separation anxiety disorder suicide prevention centres 228
music therapy 199 166 Community mental health centers
occupational therapy 196 sibling rivalry disorder 167 225
play therapy 199 Community mental health in
social anxiety disorder 167
recreational therapy 198 India 224
childhood autism 158
Acute intoxication 131, 140 Conceptual models 48
classification 151
Adaptive behavior 141, 151 behavioral 49
disorders of psychological
Adolescent mental health nursing communication 51
development 157
common reasons for mental holistic 54
developmental disorders of
interpersonal 50
health problems 245 motor function 158 nursing 52
mental health problems 245 developmental disorders of psychoanalytical 48
nursing interventions 245 scholastic skills 158 Conversion disorders 122
Agencies concerned with alcohol- disorders of speech and Crisis 202
related problems 134 language 157 crisis intervention 205
Aggressive patient 91 encopresis 169 modalities 207
Agoraphobia 111 enureses 168 role of a nurse 206
Alcohol deterrent therapy 133 feeding disorder 169 phases 204
Alcoholics 141 mental retardation 151 resolution 204
Alcohol-induced psychiatric care and rehabilitation 154 signs and symptoms 204
disorders 132 classification 152 types 203
Antidepressants 175 epidemiology 151
Antipsychotic drugs 173 nursing management 156 D
Anxious behaviour 112 prevention 153
Anxious personality disorder 145 mutism 167 Delirium 107
Asperger's syndrome 162 Delirium tremens 131
stereotyped movement
Delusional behaviour 83
Atypical autism 162 disorders 170
Dementia 104
stuttering 170
Depressed patients 101
B tic disorders 168
Depression 250
Common psychiatric emergencies Dissociative identity disorder 121
Behavior theory 122 240 Dissociative motor disorders 121
Benzodiazepines 180 catatonic stupor 243 Dissociative stupor 121
Brain damage 8 hysterical attacks 243 Disulfiram 133
panic attacks 243
c suicidal threat 240 E
transient situational
Carbamazepine 178 disturbances 243 Eating disorders
Child and adolescent psychiatry violent or aggressive behavior anorexia nervosa 125
assessment format 64 242 bulimia nervosa 127
### A Guide to Mental Health and Psychiatric Nursing
266 263
Encopresis 169 L course and prognosis 97
Epileptic seizures and dissociative depressive episode 95
convulsions 122 Legal aspects in psychiatric etiology 88
nursing manic episode
F basic rights of psychiatric classification of mania 89
patients 220 nursing management for
Fetishism 147 confidentiality 221 hypomania 94
Frotteurism 148 informed consent 221 nursing management for
nursing malpractice 221 mania 90
G record keeping 222 symptoms of hypomania 90
role of the nurse in admission treatment 90
Ganser's syndrome 121
procedure 220 Multidisciplinary team 10
Gender identity disorder of
role of the nurse in discharge
childhood 147
procedure 220
Geriatric history collection format N
role of the nurse in parole 220
65
substituted consent 221 Narcissistic personality disorder
Geriatric mental health nursing
Legal issues in psychiatry 218 145
246
Legal responsibilities of a mentally National mental health program
Grief 201, 250
ill person 222 238
maladaptive grief responses
Levels of prevention and role of a Neurosis 110
202
nurse 232 Neurotic disorder
nursing intervention 202
Lithium toxicity 177 classification 110
resolution 202
stages 201 dissociative disorders 120
treatment 202 M generalized anxiety disorder
Grief reaction 100 113
Manic violent behaviour 92
obsessive-compulsive disorder
Manipulative behaviour 93
H Mental disorders 116
burden of 5 panic disorder 114
Hallucinatory behaviour 84
classification 11 phobic anxiety disorder 111
History collection in alcohol
DSMIV 12 reaction to stress and
dependence 64
ICDlO 11 adjustment disorder 120
Histrionic personality disorder 145
Homosexuality 147 Indian 12 somatoform disorders 123
Hostels 135 problems of 5 Normal and abnormal behavior 4
Hyperactive behaviour 91 Mental health 1 Nursing theories
Hypnosis 189 characteristics 2 Orem's 53
Hypomanic patients 96 components 1 Peplau's 53
criteria for 2 Roger's 54
indicators of 2 Roy's 54
I Nutritional status in depressive
Mental health facts 6
Indian Lunacy Act (1912) 215 Mental health issues 7 patients 102
Indian Mental Health Act (1987) Mental health team 10 Nutritional status of manic patient
215 Mental illness 2, 6, 9, 231 92
Indian Mental Health Act, characteristics 3
objectives 216 common signs and symptoms 4 0
Insomnia 127 etiology of 7
Intersexuality 147 features 3 Obsession 250
Intoxication 137 misconceptions 9 Obsessive compulsive behaviour
Mentally ill person 222 119
K Milieu therapy 193 Organic mental disorders 104
Mood disorders delirium 107
Korsakoff's syndrome 132 classification 88 clinical features 108
264 Index ###
267
etiology 107 incidence 144 psychiatric rehabilitation
nursing intervention 108 nursing intervention 146 approaches 235
dementia 104 treatment 146 rehabilitation team 235
clinical features 105 Phobia 111 role of a nurse 236
etiology 104 Problems of the elderly 246 vocational rehabilitation 237
nursing interventions 105 Process recording 74 Psychoactive substance use
stages 104 disorders 129
Psychiatric disorders 7, 130
mental disorders due to brain alcohol dependence syndrome
Psychiatric disorders related to
damage 109 women 248 130
organic amnestic syndrome medical and social
menopausal syndrome 250
109 complications 131
premenstrual syndrome 248
personality and behavioral psychiatric disorders 131
psychiatric disorders associated
disorders due to brain barbiturate use disorder 138
with child birth 248
disease 109 cannabis use disorder 136
Psychiatric nurses 251
Organic psychiatric emergencies cocaine use disorder 137
Psychiatric nursing 14,57, 228
243 etiological factors 129
current issues and trends in care
acute drug-induced inhalants or volatile solvent use
17
extrapyramidal disorder 138
development of psychiatry 14
syndrome 244 LSD use disorder 137
functions of a psychiatric nurse
delirium tremens 244 nursing management 139
24
drug toxicity 244 opioid use disorders 136
general principles 22
epileptic furor 244 prevention 138
legal aspects 18
Over dependence behaviour 101 rehabilitation 139
methods of assessment 60
history taking 60 Psychological therapies 185
p
mental status examination abreaction therapy 189
Panic anxiety 115 61 behavior therapy 186
Personality physical investigations for cognitive therapy 188
psychosocial factors 29 psychiatric patients 63 family and marital therapy 192
development 31 psychological assessment 63 group therapy 190
environmental factors 29 new trends in role of a hypnosis 188
role of heredity 29 psychiatric nurse 18 individual psychotherapy 190
theories of personality nursing process 57 psychoanalytic therapy 185
development 34 biopsychosocial assessment psychodrama 191
behavior theory 45 58 relaxation therapies 189
cognitive development nursing assessment 58 supportive psychotherapy 190
theory 40 nursing diagnosis 59 Psychophysiological/
humanistic approach 42 planning 59 psychosomatic disorders
interpersonal theory 36 prerequisites for a mental common examples 124
psychoanalytic theory 34 health nurse 20 nursing management 125
theory of moral Psychosis 110
qualities of a psychiatric nurse
development 41 24 Psychosocial issues among HIV I
theory of psychosocial standards 21 AIDS patients 250
development 38 Psychotic disorder and neurotic
standards of mental health
trait and type theories 43 disorder 110
nursing 18
Personality disorder Psychotropic drugs 172
therapeutic roles of a psychiatric
classification 144 mental health nurse 26
clinical features of abnormal Psychiatric nursing skills 20
R
personalities 144 Psychiatric rehabilitation Rett's syndrome 162
etiology 145 principles of rehabilitation 235 Ritalin 182
### A Guide to Mental Health and Psychiatric Nursing
268 265
s antabuse drugs 181
antidepressants 175
Therapeutic communication
techniques 72
Schizophrenia 77 antiparkinsonian agents 180 Therapeutic community 195
clinical features 79 antipsychotics 172 Therapeutic nurse-patient
clinical types 80 anxiolytics and hypnosedatives relationship 66
course and prognosis 82 179 characteristics 68
epidemiology 77 drugs used in child psychiatry components 67
etiology 77 181 goals 66
nursing management 82 electroconvulsive therapy 182 phases 68
prognostic factors 81 lithium and other mood introductory or orientation
Schneider's first-rank stabilizing drugs 176 phase 69
symptoms 78 methylphenidate 182 pre-interaction phase 68
treatment 82 psychosurgery 185 termination phase 71
Schizotypal disorder 145 Somatic and neurotic depression working phase 70
Self-care for depressed patients 98 types 66
102 Stimulus - response theories Trance and possession disorders
Sexual disorders classical conditioning 45 121
classification 147 cognitive theories 47 Transvestism 148
nursing intervention 148 reinforcement theories 45
sexual dysfunctions 148
Sexual masochism 148
Stress
body coping mechanism 208
v
Simple phobia 111 management strategies 211 Violent behaviour 85
Sleep disorders 127 role of a nurse in stress Voyeurism 148
disorder of sleep-wake management 213
schedule 128
dyssomnias 127
source 210 w
symptoms 211
hypersomnia 128 Suicidal behavior 100,132 Wernicke's syndrome 132
parasomnias 128 Withdrawal syndrome 131
stage IV sleep disorders 128 Withdrawn behaviour 84, 87
Sleeping pattern 102 T
Social isolation behaviour 113
Social phobia 111
Tertiary prevention 234 z
Therapeutic and socialrelationship
Somatic (physical) therapies 171 67 Zoophilia 148

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SECOND EDITION

1. Mental Health and Mental Illness 1

Predisposing Factors Brain Damage

CLASSIFICATION OF MENTAL DISORDERS F13 Mental and behavioral disorders due

8. Maintain Realistic Nurse-Patient FUNCTIONSOF A PSYCHIATRICNURSE

Principles and Concepts of Mental Health Nursing 27

skills and advances that occur during childhood. 8. Mass Media

Early Childhood (2-6 years) Late Childhood (6-11 years)

Late Adulthood (Old age- 60 years and above) Psychoanalytic Theory

one's inability to satisfy needs or achieve Sullivan's Stages of Personality Development

Theory of Psychosocial Development 2. Early Childhood (2- 3 years) -Autonomy vs

SI.No. Stage Psuchosocial Crisis Virtue

1 Infancy (Birth to 1 year) Basic Trust vs Mistrust Hope

prominent way. Therefore they are called reserved; stable-emotional; self-sufficient,

is going to be rewarded, and so he remains outgrowth of different theoretical perspectives

MEDICAL MODEL psychosurgery, are important components of the

HISTORICAL OVERVIEW OF NURSING NURSING PROCESS

Interventions for psychological dimension IV. History of present illness

Therapeutic relationship Social relations/zip

COMPONENTS OF THERAPEUTIC It is the ability to put oneself in another

Genuineness Pre-interaction Phase

Person Verbatim Non-verbal Inference

his self and are being experienced by others understood by others).

Other Features Delusions of grandiosity: Individuals with

Increase in speech production. Ambitendency: A conflict to do or not to do,

Good prognostic factors Poor prognostic factors

1. Abrupt or acute onset 1. Insidious onset

Electroconvulsive Therapy (ECT)

Table 7.1: Nursing interventions for delusional behaviour

from a number of sources. Schizophrenic patients evidenced by inappropriate responses, disor-

Table 7.3: Nursing interventions for withdrawn behaviour

(a) Convey an accepting attitude by This increases feelings of self-worth and

Nursing Diagnosis IV Nursing Diagnosis V

Table 7.4: Nursing interventions for violent behaviour

Table 7.5: Nursing interventions for impaired verbal communication

(a) Attempt to decode incomprehensible These techniques reveal how the

Nursing Diagnosis VI Nursing Diagnosis VII

Table 7.7: Nursing interventions to improve family coping skills

Evaluation Regression is another process predominant

Nursing Diagnosis II Nursing Diagnosis Ill

Table 7.8: Nursing interventions for hyperactive behaviour

Table 7.10: Nursing interventions to improve nutritional status of manic patient

Table 7.11: Nursing interventions for manipulative behaviour

Table 7.12: Nursing interventions to improve self-esteem among manic patient

Nursing Diagnosis VI own actions.

Evaluation The patient's resources and effect on other

NURSING DIAGNOSIS Ill Objective: Patient will demonstrate adequate

Objective: Patient will not harm self or others. EVALUATION

Table 7.17: Nursing interventions to improve cognitive function in hypomanic patients

depression in males is 8 to 12%and in females it Depressed mood: Sadness of mood or loss of

Psychomotor activity: Psychomotor retardation Electroconvulsive therapy (ECT)

Unmarried, widowed or divorced self, evidenced by expression of worthlessness,

Table 7.20: Nursing interventions for grief reaction

Table 7.21: Nursing interventions for over dependence behaviour

Table 7.22: Nursing interventions to improve self-esteem in depressed patients

Table 7.23: Nursing interventions to improve communication skills in depressed patients

(a) Plan daytime activities according to To improve sleep during night.

Table 7.25: Nursing interventions to improve nutritional status in depressive patients

Table 7.26: Nursing interventions to improve self-care for depressed patients

Evaluation Thought block (Apr 2004)

Nutrition and Body Weight established in healthy years must be maintained

Moods and Emotions Interpersonal Relationship