الكتاب العملي لمادة التمريض الباطني والجراحة

LECTURE NOTES

For Nursing Students

Psychiatric Nursing

Alemayehu Galmessa

Alemaya University

In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,

the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

2004

Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.

Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter

Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.

Important Guidelines for Printing and Photocopying

Limited permission is granted free of charge to print or photocopy all pages of this

publication for educational, not-for-profit use by health care workers, students or

faculty. All copies must retain all author credits and copyright notices included in the

original document. Under no circumstances is it permissible to sell or distribute on a

commercial basis, or to claim authorship of, copies of material reproduced from this

publication.

©2004 by Alemayehu Galmessa

All rights reserved. Except as expressly provided above, no part of this publication may

be reproduced or transmitted in any form or by any means, electronic or mechanical,

including photocopying, recording, or by any information storage and retrieval system,

without written permission of the author or authors.

This material is intended for educational use only by practicing health care workers or

students and faculty in a health care field.

i

PREFACE

In low-income countries where morbidity and mortality due to

malnutrition and preventable infectious diseases are very common,

mental disorders, which are not regarded as life-threatening

problems, are considered to be insignificant and unworthy of

attention. Since Ethiopia is one of the poorest countries in the world,

providing high standard mental health services to the needy people is

not an easy task and the situation reflects the lack of attention

indicated above.

The training of psychiatric nurses who are well equipped in the

profession is the priority issue for the higher teaching institutions and

service giving organizations, in order to respond to the country mental

health need.

To fulfill this need, a need based training program, which is target

oriented and task based as well as community based training has

been established to tackle the major mental health problems of the

nation.

However, majority of Ethiopia’s higher learning institutions that are

training public health nurses in diploma programs experience a critical

shortage of teaching staff trained in psychiatric nursing and equipped

to teach health center teams and of teaching learning materials

appropriate to the needs of students and scope of their studies. Most

classroom lectures are based on western textbooks, which lack

relevance to the developing world context in many aspects The

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practice outlined and the general focus of the books are not

appropriate to developing countries and leave the students and

instructors in a difficult situation in relation to practice with in Ethiopia.

It is recognized that this type of dependence has many

disadvantages.

The Ethiopian Public Health Training Initiative, which is supported

and sponsored by the Carter Center, recognizes this problem. The

problem was discussed among the health center team training higher

institutions: Jimma University, Gondar College of Medical Sciences,

Addis Ababa University, Debub University (Dilla College of Teacher

Education and Health Science) and Alemaya University. Agreement

was reached among the colleges to develop lecture notes on different

subjects.

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ACKNOWLEDGMENTS

First and foremost I would like to express my gratitude to The Carter

Center for the initiative and its assistance in developing these lecture

notes.

I would like to convey my appreciation to Alemaya University,

particularly to the office of the Academic Vice President and Ato

Melake Damene, Dean of the Faculty of Health Sciences for the

continuous support and facilitation of the development of this

manuscript. I would like to extend my appreciation to the faculty staff

for their valuable support in the development of the draft. I would also

like to thank Professor Kate Ashcroft for English language edition,

Sister Tiruwork Tafessie and Ato Telake Azale for their meticulous

review of the final draft.

I would like to express my great gratitude to my wife W/ro Selamawit

Tekaligne for her support and tolerance during my absence from

home during weekends and journeys far from home to work while

developing this material.

I am highly indebted to my students whose inquisitive minds and

positive challenge which have motivated me to prepare this teaching

material.

Last but not least I would like to thank W/t Tigist Nega for her

cooperation in writing the first draft of this manual.

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TABLE OF CONTENTS

Preface ........................................................................................................i

Acknowledgements .....................................................................................iii

Table of Contents ........................................................................................iv

List of Tables ...............................................................................................vi

Introduction..................................................................................................viii

List of abbreviations.....................................................................................x

CHAPTER ONE: Introduction to Psychiatric Nursing .................................1

CHAPTER TWO: History and trends in psychiatric nursing .......................12

CHAPTER THREE: General technique in psychiatric Nursing...................18

CHAPTER FOUR: Counseling techniques in psychiatric nursing ..............29

UNIT TWO: Classifications of Mental illnesses and specific mental

illnesses...................................................................................35

UNIT THREE: Affective Disorders (Mood Disorders) .................................60

UNIT FOUR: Schizophrenia ........................................................................73

UNIT FIVE: Epilepsy (Seizure Disorders) ...................................................84

UNIT SIX: Organic Mental syndromes and Disorders

(Cognitive disorders) .................................................................92

UNIT SEVEN: Child and Adolescent Psychiatry ……………………………111

UNIT EIGHT: Alcohol and other substance abuse …………………………124

UNIT NINE: Defense Mechanisms …………………………………………...141

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UNIT TEN: Personality Disorder ……………………………………………...149

UNIT ELEVEN: Human Sexuality and sexual dysfunction…………………163

UNIT TWELVE: Psycho therapy …………………………………………….175

UNIT THIRTEEN: Psychopharmacology ……………………………………191

Annex I: Model patient assessment (History taking) in psychiatric ………215

Annex II: Answer Key for study questions for each unit …………………..222

Glossary ………………………………………………………………………..231

References ………………………………………………………………236

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LIST OF TABLES

Table 1: Comparative characteristics of a mentally healthy and a

mentally ill person..............................................................7

Table 2: Jo-Hari’s window of self......................................................19

Table 3: Differences between neurosis and psychosis ....................52

Table 4: Nursing diagnosis and nursing interventions for patients with

anxiety disorders ...............................................................56

Table 5: Nursing diagnoses and nursing interventions for depressed

and manic patients ...........................................................70

Table 6: Nursing diagnoses and nursing interventions for patients with

schizophrenic disorders.....................................................81

Table 7: Common nursing diagnoses and nursing interventions for

organic mental disorders ………………………………….108

Table 8: Nursing diagnoses and nursing intervention for withdrawal

symptoms due to multiple drug abuse ……………………138

Table 9: Examples of nursing diagnosis and nursing interventions for

personality disorder ………………………………………..159

Table 10: Nursing diagnosis and interventions for patients who exhibit

symptoms of sexual disorders ……………………………172

Table 11: Common phenothiazines antipsychotic drugs ………….193

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Table 12: Commonly used anti psychotic agents …………………..198

Table 13: Commonly used anti depressant agents ………………...201

Table 14: Nursing actions: antidepressants …………………………203

Table 15: Commonly used anti anxiety agents (anxiolytics) ………211

Table 16: Nursing actions in anti- anxiety drugs ……………………212

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INTRODUCTION

This lecture note on psychiatric nursing for nurses is designed to be

used as a study and reference material by nurses, other categories of

health students and teachers.

Each chapter in this manual contains the following components:

(a) Objectives at the beginning of each chapter to guide students

in their studies:

(b) Study questions related to each chapter

(c) A glossary for students to familiarize students with some new

terms

(d) A reference suitable for beginning students are listed at the

end of the manual.

These lecture notes are intended to fill the gap created by the

shortage and incompatibility of teaching and learning materials bring

the colleges close together in terms of teaching and learning

strategies to minimize variations. Hopefully this manual will alleviate

the shortage of material and help to prevent and improve morbidity,

disability and mortality caused as a result of accidents and disasters

in all human environments in Ethiopia.

The Author was motivated to develop this teaching material based

his ten years teaching and clinical experience in the field of

psychiatric nursing in Alemaya University, Nekemte School of

Nursing, Nekemte Hospital and Alemaya University student clinic. He

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is glad to contribute to this particular profession by producing this

teaching material which covers the university curriculum applicable in

all higher teaching institutions and other training centers under the

Ministry of Health as well as different regional states in Ethiopia.

Nothing is left out from the standard, but in addition, some important

content which will benefit students are added, for example,

counseling in mental illness.

This teaching material is organized to thirteen units and the first unit

is subdivided in to five chapters which are designed to assist the

reader by its systematic and simplified organization.

Student readers are requested to this end to attend classes and take

advantage of the support from their instructors so as their knowledge

and skill of the subject area and their profession in general.

They are also advised to read about recent issues and advances from

other references in order to keep up with new scientific knowledge on

the subject.

This manual is designed to be covered by two credit hours lectures

over a semester in the second year in the nursing course.

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LIST OF ABBREVIATIONS

ABO = Blood groups A,B and O

AWS = Alcohol Withdrawal Syndrome

CNS = Central nervous system

CPZ = Chlorpromazine

CT scan = Computerized tomography scan

CVS = Cardio Vascular system

DSM-III R = Diagnostic Statistical Manual of American psychiatrists

Associations III Revised

ECG = Electro cardiograph

ECT = Electro convulsive therapy

GABA = Gama amino butric acid

GIT = Gastrointestinal Tract

I&O = Input and Output

IM = Intramuscular injection

IQ = Intelligence quotient

IV = Intra venus injection

JOMAC = Judgment orientation memory affect and orientation

MOAI = Mono Amine Oxidase inhibitor

PGA =Psycho Galvanic Response

Kg = Kilogram

MOH = Ministry of Health

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Mg = Milligram

MOAI = Mono amine oxidase inhibitor

NPO = Nothing per os (mouth)

OPD = Out patient department

PAS = Para amino salsalic acid

PGA =Psycho galvanic response

RH = Rhesus factor

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UNIT ONE

CHAPTER ONE

INTRODUCTION TO PSYCHIATRIC NURSING

Learning objectives

After studying this chapter, the student should be able to:

1. Define psychiatric nursing
2. Define common psychiatric symptoms and key terms in

psychiatry

3. Describe normality
4. Describe mental illness
5. List the major criteria for the diagnosis of psychosis
6. Recognize the history and trends in psychiatric nursing
7. Describe general anxiety disorders and its sub classifications

(clinical manifestations, differential diagnosis, diagnosis,

treatment prognosis and complications)

8. List the sub-classifications of mental illness

Definition

Psychiatric nursing is the branch of nursing concerned with the

prevention and cure of mental disorders and their sequel. It employs

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theories of human behavior as its scientific frameworks and requires

the use of self as its art or expression in nursing practice. (Urdang:

1983, p1901).

Common psychiatric symptoms and key terms in

psychiatric nursing

1. Anxiety: A state of feeling uncertainty experienced in response to

an object or situation.

2. Stress: A state of extreme difficulty, pressure or strain with

negative effects on physical and emotional health and well-being.

3. Withdrawal: A state of habitual quiet and seeming un concerned

with other people a focus on one’s own thoughts.

4. Depression: A mood state characterized by a feeling of sadness,

dejection (self dislike), despair, discouragement, or hopelessness.

5. Suicide: The act of killing oneself (self distracting behavior)
6. Neurosis: A condition in which mal adaptive behaviors serves as

a protection against a source of unconscious anxiety.

7. Personality disorder: A non psychotic illness characterized by

maladaptive behavior that the person uses to fulfill his or her

needs and bring satisfaction to him or her self. As a result of the

inability to relate to the environment, the person’s actions conflicts

socially

8. Hysteria (conversion disorder): The loss or impairment of some

motor or sensory function for which there is no organic cause.

Formerly known as hysteria or hysterical neurosis.

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9. Mental retardation: A disorder characterized by sub average

intellectual functioning associated with or resulting in, the inability

or impairment of the ability to think abstractly, adapt to new

situations, learn new information, solve problem, or profit from

experience.

10. Dementia: A defuse brain dysfunction characterized by a gradual,

progressive, and chronic deterioration of intellectual function.

Judgment, orientation, memory, affect or emotional stability,

cognition, and attention all are affected.

11. Trauma: A severe physical injury to the body from an external

source; or a severe psychological shock.

12. Alcohol dependent: A person who can not break the habit of

drinking alcoholic drinks too much, especially one whose health is

damaged because of excessive alcohol intake.

13. Schizophrenia: A serious mental disorder characterized by

impaired communication with loss of contact with reality and

deterioration from a previous level of functioning in work, social

relationships, or self care.

14. Paranoid disorder: A psychotic state characterized by moderately,

or seriously, impaired reality testing, affect and sociability,

accompanied by persecutory, grandiose, erotic or jealous content

delusions.

15. Manic-depression: A mood disorder involving both mania and

depressive episode.

16. Illusion: A false interpretation or perception of a real

environmental stimulus that may involve any of the senses.

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17. Hallucinations: Sensory perceptions that occur in the absence of

an actual external stimulus. They may be auditory, visual,

olfactory, gustatory or tactile.

18. Delusion: False belief not true to fact ordinarily accepted by other

members of the person’s culture

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Normality

What is normality?

It is often said that we are all ‘a bit abnormal’ is this true or nonsense?

This question may be easier if the word ‘normal’ replaced by ‘healthy’

but the question remains whether it is normal to be a little unhealthy.

The difficulty which arises in answering these questions lies in the

fact that ‘normal’ is used in more than one sense. It is sometimes

employed for always or ‘most usual’ for example when considering

normal height, normal weight and so on. In this sense, with regard to

mental health, normality may be:

- A sense of well-being

- The use of sublimation as the main defense mechanism

- The ability to postpone present pleasures for future ones

- The presence of an intact sense of reality

- Good interpersonal relationship

- Optimal adjustment.

The activities of normal life in adults

Broadly speaking normal life, amongst other things involves the

following activities:

- Adaptation to the work situation

- Leisure time activity

- Management of social contacts

- Adjustment to the opposite sex.

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Mental health

It is difficult to define the idea of mental health without reference to

society. It could be said that a person is healthy if he/she manages to

deal with the demands made upon him/her by society in a way that is

compatible with his/her idea both of society and of him/her self.

He/she is ill to the degree that has failed in his/her adjustment to the

demands either of society or his definition of him/her self.

This definition is not entirely satisfactory. There are those who deviate

from the norms of society who are not mentally ill and the definition

also gives rise to the impression that psychiatrists and psychiatric

nurses are committed to maintain the status quo and preventing

social change.

Mental illness

The definition of mental illness remains elusive and is usually based

up on what constitutes socially accepted behavior norms. For

example behavior that is normal in one culture may be considered

abnormal in another culture.

Major criteria for the diagnosis of mental illness (Psychosis)

The criteria for psychosis include:

1. Bizarre behavior
2. Abnormal experience

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3. Loss of reality contact
4. Lack of insight

Table 1: Comparative characteristics of a mentally healthy and a

mentally ill person

MENTAL HEALTH MENTAL ILLNESS

1. Accepts self and others 1. - Feelings of inadequacy

- Poor self-concept

2. Ability to cope or tolerate

stress. Can return to normal

functioning if temporarily

disturbed

2. - Inability to cope

- Maladaptive behavior

3. Ability to form close and lasting

relationships

3. Inability to establish a

meaningful relationship

4. Uses sound judgment to make

decisions

4. Displays poor judgment
5. Accepts responsibility for

actions

5. Irresponsibility or inability to

accept responsibility for

actions

6. Optimistic 6. Pessimistic
7. Recognizes limitations (abilities

and deficiencies)

7. Does not recognize

limitations (abilities and

deficiencies)

8. Can function effectively and

independently

8. Exhibits dependency needs

because of feelings of

inadequacy

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9. Able to perceive imagined

circumstances from reality

9. Inability to perceive reality
10. Able to develop potential and

talents to fullest extent

10. Does not recognize

potential and talents due to

a poor self-concept

11. Able to solve problems 11. Avoids problems rather

than handling them or

attempting to solve them

12. Can delay immediate

gratification

12. Desires or demands

immediate gratification

13. Mental health reflects a

person’s approach to life by

communicating emotions,

giving and receiving. Working

alone as well as with other,

accepting authority, displaying

a sense of humor, and coping

successfully with emotional

conflict.

13. Mental illness reflects a

person’s inability to cope

with stress, resulting in

disruption, disorganization,

inappropriate reactions,

unacceptable behavior and

the inability to respond

according to his

expectations and the

demands of society.

(Shives: 1990)

People who are mentally healthy do not necessarily possess all the

characteristics of mental health listed. Under stress they may exhibit

some of the traits of mental illness but are able to respond to the

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stress with automatic, unconscious behavior that serves to satisfy

their basic needs in a socially acceptable way.

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REVIEW QUESTION

1. In the context of mental health list at least six points the enable us

to say someone is normal.

2. List some of the activities characteristics of normal life in adults

human beings

3. Which of the following is not characteristic of a mentally healthy

person?

1. Acceptance of self and others
2. Optimistic thinking
3. Inability to establish a meaningful relationship
4. Ability to delay immediate gratifications.
5. Identify the correct statements about criteria for the diagnosis of

major mental illness.

1. Bizarre behavior is one of the criteria for the diagnosis of

psychosis

1. Loss of reality contact is not a criteria for major mental illness
2. Loss of reality contact is an indication psychosis
3. Abnormal experience can be considered as criteria of

psychosis.

5. Is it true or false that mentally health people may exhibit some of

the traits of mental illness under stress but they are able to

suspend to the stress with automatic, unconscious behaviors that

serves to satisfy their basic needs in a socially acceptable why?

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1. True
2. False

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CHAPTER TWO

HISTORY AND TRENDS IN PSYCHIATRIC

NURSING

Learning objectives

After studying this chapter, the student should be able to:

1. Recognize general history and trends in psychiatric nursing
2. Describe history and trends psychiatric nursing in Ethiopia

Mental illness began in the primitive age as human existence began:

there is evidence that it existed at the time and attempts were made

to treat it. It was thought to be caused by evil sprits entering and take

over the body. People attempted to drive these evil sprits from the

body through the use of incantations and magic. Some primitive tribes

rejected their mentally ill and drove them from the community.

In the ancient civilization, Greeks, Romans and Arabs viewed mental

deviations as natural phenomena and treated the mentally ill

humanely. Care consisted of sedation with opium, music, good

physical hygiene, nutrition and activity. The Greek philosopher Plato

(429-348 BC) and the Greek physician Hypocrites (460-377 BC,

known as the father of medicine), were concerned about the

treatment of the mentally ill. Hypocrites described a variety of

personalities and attempted to classify people according to their

behavior

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In the middle ages (500 - 1450 AD) the Roman Empire fell (476 AD)

the humanitarian ideas concerning the mentally ill were forgotten.

People reverted to mysticism, witchcraft and magic. Sometimes,

patients were humanely cared for by members of religious orders.

However, the mentally ill were usually locked away in places where

flogging, starvation, torture and blood letting were common.

During the renaissance (14th- 17th Century), the belief that mental

illness was caused by evil spirit possessing the body continued to be

a menace to proper care mentally ill people were often put in prison

or society protected itself by locking the mentally ill in asylums where

non-professional people were paid to care for them.

Mental illness was considered irreversible. The mentally ill were

beaten for disobedience and confined to cages or closets. Generally,

mental patients were viewed as incompetent, defective, and

potentially dangerous. They had no rights and were left in social

isolation to communicate primarily with other mentally ill patients.

Their care-takers were untrained and often punitive. As a result, the

mentally ill tended to become more ill and less able to function.

Bethlehem Royal Hospital, the first mental hospital in England, was

opened during the 17th Century. In this hospital, the public was

allowed to wander through the hospital and see the patients, and

nurses lacked any interest in improving the care of mentally ill.

Franz Mesmer (1733-1815), an Austrian physician, was interested in

a therapeutic approach to behavior. He believed that the universe

was filled with magnetic forces. Mesmer professed that the mentally ill

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could be cured by having them hold rods filled with iron filings in

water. Although Mesmer’s techniques were later revealed as false,

his idea of suggestive power has carried over to some modern

psychiatric techniques.

The term mesmerized is from Mesmer; to be mesmerized is to be

placed in a hypnotic trance.

A French physician Philip Pineal (1745 - 1826), began the movement

toward more human treatment of the mentally ill when he removed

the chains from twelve male patients at Bicker Hospital near Paris in

1792. Pineal disavowed punitive treatment of mental patients. He

recognized the need for medical care and advocated freedom, useful

work, and kindness for patients.

The first hospital in America to admit mental patients was the

Pennsylvania Hospital located in Philadelphia.

The first American textbook on psychiatry was written, during this

period by Benjamin Rush (1745-1813) a physician who used a

humanistic approach in the treatment of mental illness. He is

considered by many to be the father of American psychiatry.

In 19th Century one of the best known reformers was Dorothea Lynde

Dix, who contributed much to the establishment of American hospitals

for the care of the mentally ill. She traveled throughout the country in

an effort to have legislation enacted for improved care for mental

patients. As a result of her efforts, many hospitals were built in United

States, Canada and in other countries.

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The first psychiatric training school in United States was established

in 1882 at McLean Hospital in Belmont, Massachusetts. Participation

in psychiatric nursing course becomes a requirement for a nursing

license in the USA in 1955.

In the 20th Century an Austrian neurologist, Sigmund Freud made a

significant contribution to the understanding and treatment of mental

illness. His belief in the power of unconscious memories and

repressed emotions led him to develop the theory and practice of

psychoanalysis. Because of his work, he is called the founder of

psychoanalysis. He studied the dreams, memories, and fantasies of

his patients in search for unconscious impulses and conflicts. He

identified three major divisions of the self or mind: the Id, superego,

and ego. He also presented a theory of psychosexual personality

development.

In Ethiopia the first mental hospital (Emanuel Hospital) was

established after the end of the Ethio-Italian war to protect the royal

family from mentally ill patients. The patients were collected and

taken to jails to the corner of the town that is now known as Emanuel

Hospital.

Slowly and gradually a more humanitarian type of care was

introduced by one psychiatrist. Dr. Fikire Workineh. The first

psychiatric nursing school was established in Emanuel Hospital in

1991 and twelve nurses graduated for the first time. Until this time

there was no formal psychiatric nursing training in Ethiopia. The

service started to be decentralized to other corners of the country,

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such as Jimma, Nekemte, Harar, Dire Dawa, Yirgalem, Bahirdar,

Mekele and Asmara.

By now some of hospitals in Ethiopia have psychiatric units even

though the quality is not yet of an appropriate level.

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REVIEW QUESTIONS

1. Is it true or false that during the middle ages mental illness was

considered curable and reversible during?

2. The first mental hospital in England was ______.
3. A French physician who begun the humanitarian type of treatment

and who removed chain from the mentally ill patients was ______.

4. The first American textbook of psychiatry was written

by__________ who was lived from _______to _______.

5. In 19th Century the well-known American psychiatric nurse

reformer who contributed for the establishment of mental hospitals

and made an effort to have legislation enacted for improved care

for the mentally ill patients was _______.

6. An Austrian neurologist in the 20th Century who made a significant

contribution for mental illness treatment was _____________.

7. The first and the only mental Hospital in Ethiopia is

_____________.

8. A prominent Ethiopian psychiatrist reformer is ______________.
9. Psychiatric nursing training was started in Ethiopia in _________.
10. How many nurses were trained for the first time from Emanuel

psychiatric nursing school?

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CHAPTER THREE

GENERAL NURSING TECHNIQUES USED

IN PSYCHIATRIC NURSING

Learning objectives

After studying this chapter, the student should be able to:

1. Recognize general nursing techniques
2. Define ‘self’
3. Define communication
4. Identify the different purposes of communication
5. Differentiate different models of communication
6. Describe reasons for ineffective communication
7. Identify some barriers to effective communication
8. Identify psychological barriers to effective listening
9. Describe psychiatric assessment techniques

Understanding ‘self’

Self is the sum of the attitudes that make up the personality.

According to the psychologist Erik Eriksson, certain developmental

tasks must be accomplished during each of stages of the life cycle

(infancy, childhood, adolescence, adulthood, old age). Each step is

necessary for self development.

An individual personality continues to develop throughout the life

cycle. In personality development environment, heredity, and

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nurturing play an important role. Joey Luft and Harry Ingham

developed the Jo-Hari window.

Table 2: Jo-Hari’s window of self

Known to self Not known to self

Known to others the public self

(1)

the blind self

(2)

Not known to others the private self

(3)

the unknown area

(4)

Source: Stoner (1996)

1. The public self: The first pane indicates knowledge about oneself

that the person knows and others know about him or her.

2. The blind self: The second pane indicates knowledge about one

self that the person does not know about him or her self and other

people know.

3. The private self: In pane three there are all manner of things that

a person knows about him or her self but does not choose to

share to others.

4. The unknown area: The last pane represents information about

oneself that neither the person nor anyone else knows.

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Self acceptance

Self-acceptance is a regard for oneself with a realistic concept of

one’s strengths and weaknesses. Behaviors of the self-accepting

person including the following:

- persevering

- minimizing weaknesses

- increasing strengths

- seeing reality

- trusting and accepting others

- continuing growth toward self-actualization

- recognizing and accepting one's own behavior

- reaching out to others

- learning from mistakes

The person who is self accepting accepts others more easily.

Therefore, it is important that the nurse works toward self acceptance.

The self-rejecting person is critical of others, more anxious, insecure

and depressed.

Communication

Communication is a mutual interaction or reciprocal action that can

occur between or among people. Shives1990.

Communication is the giving and receiving of information. The sender

prepares or creates a message when need occurs and sends the

message to a receiver or listener, through a proper channel: face to

face or through electronic or other media. The receiver may then

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return a message or feed back to the initiator (sender) of the

message.

Communication is a learned process influenced by attitudes, socio

cultural or ethnic background, past experience, knowledge of the

subject matter and the ability to relate to others.

Interpersonal perceptions also affect one’s ability to communication

because they influence the initiation of and response to

communication. Perception is affected by the sense of sight, sound,

touch, and smell and environmental factors such as time, place and

the presence of one or more people influence communication.

Therapeutic communication

Therapeutic communication is defined as a special form of

communication that has a health-related purpose and develops as a

continuous flow of interaction between nurse and patient, with input

from both contributing to it is nature and progression. Non-verbal

communication is sometimes considered a more accurate description

of true feelings because one has less control over non-verbal

reactions.

Non-verbal communication includes:

- Position or posture

- Gesture

- Touch

- Physical appearance

- Facial expressions

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- Vocal cues and

- Distance or spatial territory.

Models of communication (elements of communication) There

are four models of communication according to David and these are:

1. Source (a person who is responsible to create the message)
2. Message (the idea which is transmitted from the source to the

receiver)

3. Channel (it is a means by which a message can be transmitted

from a source to the receiver)

4. Receiver( a person who is receiving the message from the

source)

The main goal of therapeutic communication is to develop or maintain

a healthy personality. This is done by reliving stress and assisting the

patient in developing better coping mechanisms.

Reasons for ineffective communication

Communication is usually thought of as an exchange of words but it

also includes all methods used to relay message to another person,

for example, through gestures, body movements and tone of voice.

Communication that does not involve the spoken word is non verbal

communication.

Effective communication occurs when the receiver understands the

message as the sender intended. Unfortunately ineffective

communication often occurs due to some barriers.

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Some barriers to effective communication

1. Barriers caused by reception, need, attitude, environmental stimuli

etc.

2. Barriers caused by a lack of understanding language, knowledge

etc.

3. Barriers caused acceptance, prejudices, emotional conflict etc.
4. Psychological barriers to listening such as day dreaming,

detouring, debating, private planning.

Communication skills

The following suggestions are given to enable the student psychiatric

nurse to develop good communication skills for effective therapeutic

interactions.

1. Know yourself
2. Be honest with your feelings
3. Be sure in your ability to relate to people
4. Be sensitive to needs of others
5. Be consistent
6. Recognize symptoms of anxiety
7. Watch your non-verbal reactions
8. Use words carefully
9. Recognize differences
10. Recognize and evaluate your own actions and responses.

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Psychiatric assessment techniques

The student may experience difficulties in his/her first contact with

psychiatric patients. Some of these difficulties arise from the nature of

psychiatric symptoms and signs disorders of emotion of thinking or of

intelligence, which are less easy to elicit and describe than physical

signs and symptoms. The interviewer has to overcome his/her anxiety

and preconceptions about the mentally ill.

The range of information that is sought about the patient and his

illness is much wider than for other clinical disciplines and requires

tact, time and patience to elicit scheme of case taking. This

information may include:

1. The history-of the present illness

The social and personal history of the patient (supplementary

history to be obtained from relative if possible)

2. A physical examination
3. Psychiatric examination
4. Further investigations
5. Formulation of the case
6. History of present illness

Record briefly mode of referral/admission reason for referral and

patients complaints (in his own words) and their duration.

2. Social history

Record briefly accepts of the patient’s family history such as:

- Father

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- Mother

- Siblings

- Social position

- Home atmosphere and influence.

Record also the patient’s personal history, including details of their

experiences relating to:

- Date and place of birth

- Early development

- Neurotic symptoms in childhood

- School

- Adolescence

- Occupations

- Sexual history

- Marriage

- Children

- Habits

- Medical history

- Previous mental illness

- Antisocial behavior

- Current life situation.

Record any information available about personality before illness (pre

morbid personality):

- Social relations

- Activities and interests

- Mood

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- Character

- Standards, moral, religious, social, economic etc.

- Energy and initiative

- Reaction to stress

3. Physical examination

The physical examination should be comprehensive and should be

carried out within a day of admission. Special attention should be

given to the central nervous system. Positive and negative findings

should be recorded and a brief summary of abnormalities found

should be given.

4. Psychiatric examination (mental status examination) Record

the following aspects of the psychiatric patient’s state General

behavior, appearance, word behavior since admission attitude

towards hospital staff etc.

- Talk (form of talk), much or little, spontaneous, answers to

questions etc.

- Mood

- Form of thought; Does the patient experience blocking pressure

or poverty in thinking?

- Content of thought

- Delusions and misinterpretations

- Hallucinations

- Obsessional phenomena

- Orientation to time place and persons.

- Memory

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- Attention and concentration

- General information

- Apparent intelligence

- Insight and judgement

- Staff attitude.

5. Further investigations

Further investigations may be indicated ,including:

- Physical investigations as indicated

- Psychological testing

- Psychiatric social worker's report

6. Formulation of the case

Discuss a range of potential diagnosis, giving evidence for and

against the various possibilities. Make and record a provisional

diagnosis, an estimate of prognosis, a problem list, and plans for

further investigation and treatment.

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REVIEW QUESTIONS

1. Self is a sum of the attitudes that make up the personality
2. True b. False
3. Verbal communication is considered a more accurate description

of true feelings because one has more control over non verbal

reactions.

1. True b. False
2. A special form of communication that has a health-related

purpose and develops in a continuous flow of interaction between

nurse and patient, with input from both of them contributing to its

nature is termed as therapeutic communication.

1. True b. False
2. List the complete scheme of patient assessment/history taking/ in

psychiatric nursing.

5. Which of the following is not categorized under psychiatric

examination /mental status communication?

1. Delusion and misinterpretation
2. Attention and concentration
3. Blood test for biochemical analysis
4. Content of thought.

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CHAPTER FOUR

COUNSELING TECHNIQUES IN

PSYCHIATRIC NURSING

Learning objectives

After Studying this chapter, the student should be able to:

1. Define counseling in mental health
2. Describe purpose of counseling
3. Describe the importance of listening in counseling
4. List major techniques in counseling

Purpose of counseling

The purposes of counseling include developing the patient’s maturity

and self control. It requires a focus on the whole person, not just the

problem. This is because a mature person can solve problems and

the problem presented is usually not the real problem.

A four part process can teach people to solve their own problems.

This process involves:

1. Listening 2. Exploring
2. Understanding 4. Problem solving

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Listening

The goal of listening is to help the person to talk. This can be

facilitated by the following behavior on the part of the psychiatric

nurse:

1. Showing respect and care, this will make it easier for the person to

talk.

1. Demonstrating the body language of listening:
2. Face them
3. Look at them
4. Keep an open posture
5. Lean forward
6. Be relaxed but not too relaxed.
7. Listening for non-verbal messages. Notice:
8. Body movements
9. Gestures
10. Facial expression
11. Tone of voice.
12. Listen to everything, even things you don’t want to hear.
13. Listen to yourself
14. Saying yes or mmm or nodding your head at the right time

tells someone you are listening.

2. Repeating a few words a person has said lets them know you

heard them and encourages them to go on.

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3. Very brief questions can help clarify things that are not clear

or help the person continue talking.

Exploring the person and their problems

In order to learn all you can about the person and the problem you

will need to pay attention to the following:

1. The counselor must try to understand.
2. What has happened
3. How the person feels.

The psychiatric nurse does not have to agree with a person to

understand him or her. They should not make judgments at this point.

1. Try to make statements instead of asking questions
2. Start statements with “I” not “You”
3. Make statements that start with, “It seems to me,” or “I wonder

if”, or “I think that you are telling me….”

1. If you must ask a question make it an open question, not a closed

one for example, do not ask, “Why“, but rather, ask “What”.

1. Be concrete
2. If you don’t understand, say, “I don’t understand”
3. Do not give advice.

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Understanding the person’s point of view

The goal of understanding the person is to help them see the problem

clearly. In order to achieve this:

1. The counselor acts as a mirror
2. We show how it looks from our point of view
3. We show the good and the bad
4. Strengths
5. Resources
6. Ineffective response patterns
7. Inconsistencies
8. Other ways to label the problem
9. Hidden or double messages
10. Things he or she may be avoiding
11. Challenges to magical thinking.

This helps the person begin to change attitudes, beliefs, behaviors

and feelings.

1. Do not give advice.

Problem solving

The goal of problem solving is to encourage action that leads to

change. In order to achieve this psychiatric nurse should:

1. Help the person find a better way to solve his or her problem, but

remember:

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1. People are usually doing the best they know how
2. Perhaps the best way for you is not the best way for them.
3. List alternatives:
4. Do not judge them, just list them
5. Be creative
6. Evaluate the alternatives, list advantages and disadvantages.
7. Choose one solution
8. The person with the problem should make the decision if at all

possible.

2. Give your opinion if you want but remember to let the person

have control and take responsibility.

3. Be realistic
4. Encourage the patient to try it:
5. Be specific
6. Set time limits
7. Evaluate results.
8. If not successful explore the reasons why, list new alternatives and

try again.

1. Don’t give up

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REVIEW QUESTIONS

1. In counseling, the problem which is presented from a client is

always a true problem.

1. True B. False
2. In counseling the four processes to teach people and solve their

own problem are:- Listening, Explaining, understanding, and

problem solving.

1. True B. False
2. During counseling as a counselor one has to listen to things to be

listened and desired to be listened.

1. True B False
2. A counselor, while listening to the client has also to listen to

his/her self.

1. True B. False
2. During counseling, as a counselor it is desirable to make decision

on behalf of the client.

1. True B. False

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UNIT-TWO

GENERAL CLASSIFICATION OF MENTAL

ILLNESS AND SPECIFIC MENTAL

ILLNESSES

Learning objectives

After studying this unit, the student should be able to:

1. Describe general classifications of mental illness
2. Define generalized anxiety disorders
3. Discus classifications of generalized anxiety disorders
4. Identify different management criteria of Generalized Anxiety

disorders

5. Identify nursing management for schizophrenia.

Classification of mental illness

There are various types of classification of mental illness according to

their severity and different types of underlying causes. These have

been described by Lalitha, (1995) A decision tree which shows the

classification is outlined below.

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Decision Tree

1. Non psychosis Normal variation

Emotional disturbance (Neurosis)

Anxiety neurosis

Neurotic depression

Hysteria-dissociative hysteria

-conversion hysteria

Obsessive compulsive neurosis

Phobic neurosis

Traumatic neurosis

1. Psychosis Organic Acute Delirium

Chronic Dementia

Inorganic Affective Mania

Depression

Non affective

Schizophrenia Paranoid schi.ph

Schizoaffective Cata.schi. schi. ph

Paranoidillness Hebephrenic schi.ph

Reactive psychosis Simple schi. ph.

Residual. Schi.ph.

.

III. Addiction Alcohol

Drugs

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Substances abuse such as

♦ marijuana

♦ cannabis

♦ pot

♦ kaht

♦ LSD (lysergic acid diethylamide)

1. Mental sub normality (Mental retardation)
2. Personality disorder
3. Sexual disorders

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Different miner mental illnesses

Anxiety disorders

Anxiety disorder is characterized by at least six months’ duration of

anxiety in the absence of panic attacks, disorders, depression or

other psychiatric disorders.

According to DSM III- R classification there are three major categories

of symptoms.

1. Motor tension, such as muscle aches, inability to relax, fidgeting,

restlessness and being easily startled.

2. Autonomic hyperactivity, including cold and clammy hands, dry

mouth, dizziness, frequent urination, flushing, increased pulse

rate while resting, and upset stomach.

3. Vigilance and scanning, a state in which the person is

hyperactive, easily distracted, has difficulty concentrating,

experiences insomnia and is irritable or impatient.

The individual exhibits unrealistic or excessive anxiety and worry

about two or more life circumstances during a six month period and

may be mildly depressed. Symptoms rarely interfere with social or

occupational functioning.

Below are listed sub classifications of general anxiety disorders:

Sub types of anxiety disorders

1. Anxiety
2. Phobia

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3. Conversion disorder
4. Conversion reaction hysteria
5. Dessociative hysteria
6. Obsessive compulsive
7. Hypochondriasis
8. Neurotic depression.
9. Anxiety disorder

Anxiety is a common neurotic disorder with various combinations of

physical and psychological manifestations not attributable to any real

damage ‘free floating anxiety’ There are two types of anxiety:

1. Normal anxiety
2. Pathological anxiety can subdivided in to two sub categories:

- panic anxiety

- diffusive anxiety.

Panic (acute) anxiety is an episodic anxiety, which lasts for short

period of time.

Diffusive (chronic or generalized) anxiety is characterized by marked

apprehension, persisting or long lasting time.

Epidemiology

Anxiety disorder is a problem of about 5% adult population with

female to male ratio of 2:1 and it runs with in family.

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Etiology

Risk factors include:

1. Constitutional:

- genetic (it can be inherited genetically)

- developmental: if the developmental process is full of anxiety.

- provoking conditions e.g. war, famine, home disturbance etc.

2. Physiological:

- endocrine e.g. thyrotoxicosis

- head injury (traumatic neurosis)

3. Psychological:

- stress

- interpersonal conflict

- external:

􀂃 social

􀂃 occupational etc.

Clinical Features of Anxiety

- Palpitation

- Exhaustion

- Breathlessness

- Dizziness

- Chest pain

- Anxiousness

- Flashing of face

- Tachycardia

- Apprehensiveness

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- Head ache

- Faintness

- Insomnia

- Sweating

- Tachypnea

- Restlessness etc.

Differential diagnosis

1. Major mental disorders

- schizophrenia

- agitated depression.

2. Organic diseases such as:

- pheochromocytoma (Cancer of suprarenal gland)

- thyrotoxicosis

- angina pectoris

Method of Diagnosis

1. History
2. Clinical findings

Treatment

1. Psychotherapy
2. Sedatives (anxiolytics) diazepam or chlorodiazepoxide 5-10 mg

po/day at bedtime.

Prognosis:

Prognosis depends up on:

- Pre-morbid personality of the patient

- The frequency of occurrence of the anxiety inducing stimulus.

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Complications

- Alcoholism (alcohol dependence)

- Drug abuse (drug dependence)

2. Phobia

Phobia is described as an irrational fear’ of an object, activity or

situation that is out of proportion to the stimulus and results in

avoidance of the identified object, activity, or situation.

Epidemiology

Phobia occurs in 3-5% of population.

Etiology

The etiology of phobia is not clearly known

There are two types of phobias

1. Simple (specific phobia) mono-symptomatic phobia Simple phobia

refers to fear caused by the presence (anticipation) of a specific

object or situation, such as flying, heights, animal getting an

injection or seeing blood.

Examples of simple phobias include:

- Zoophobia - fear of animals

- Claustrophobia - fear of closed spaces

- Acrophobia - fear of heights

- Nyctophobia - fear of the night.

2. Complex phobia (social phobia)

A complex phobia is defined as a marked and persistent fear of one

or more social or performance situations.

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Examples of complex phobias include:

- Agoraphobia - fear of open place

- Social phobia - fear of public area

- Giminophobia - fear of marriage

- Gumnophobia - fear of being seen naked

- Minsnophobic - fear of going through child birth

- Sypridophobia - fear of having sexual relation etc.

Epidemiology

The epidemiology of complex phobia is not clearly, known, but it is

more common in females than males and it increases in late teens or

adulthood.

Etiology

According to psychoanalytic theory, phobias occur as a result of

conflicts arising from unresolved castration anxiety (displaced phobia)

which persists and tend to stay displaced to other objects during

adulthood.

Clinical features

Signs and symptoms of anxiety are manifested in presence of the

feared object or situation.

Differential diagnosis

Differential diagnoses include major mental illness (schizophrenia) or

prodroma of schizophrenia.

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Treatment

1. Behavioral therapy

- Desensitization - enabling the patient to adapt to a situation

piece by piece or part by part.

- Systematic – slow and gradual adaptation and understanding

of reality.

- Flooding - exposingthe individual to the feared object.

2. Antidepressant - phenotizine

- MAOI (monoamine oxidase inhibitors)

Prognosis

- Some patients undergo a spontaneous cure.

- The majorities are resistant to treatment and become chronic.

Complications

- Alcoholism

- Drug abuse

- Social and occupational disabilities.

3. Conversion disorder

A conversion disorder is a psychological condition in which an

anxiety-provoking impulse is converted unconsciously into functional

symptoms, for example, anesthesia, paralysis, or dyskinesia.

Although the disturbance is not under voluntary control, it meets the

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45

immediate needs of the patient and is associated with a secondary

gain (Shives: 1990).

Hysteria is a conversion disorder that represents a goal oriented

disease: the goal is attention seeking to avoid anxiety or to draw

attention (sympathy) by transferring a mental conflict in to a physical

symptom and in this way releasing tension or anxiety.

Epidemiology

- About 2% of the female population is affected

- It has wide age range distribution

- It runs with in family

- Married and single people are equally affected

- It is higher in populations with lower educational levels.

Etiology

According to psychodynamic theory, hysteria can be directed at:

- Fixation stage - during oedipal phase

- Anxiousness - the relief of unbearable somatic symptoms.

- Primary illness gain: obtaining relief from anxiety by using defense

mechanism to keep an internal need or conflict out of awareness.

- Secondary illness gain: obtaining benefit or support as a result of

being sick, rather than relief from anxiety.

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Clinically there are two forms of hysteria

1. Conversion reaction

Signs and symptoms of conversion reaction include:

1. Motor disturbance

- Paralysis

- Paraplegia, monoplegia

- Gait disturbance

- Tremor

1. Sensory:

- Aphonia

- Anesthesia

- Convulsions (hysterical fit)

- Blindness

- ‘La belle indifference’

2. Dissociative hysteria

Dissociation is the act of separating and detaching a strong

emotionally charged conflict from ones consciousness.

Signs and symptoms of dissociative hysteria include:

- Conscious disturbance

- Amnesia (psychogenic amnesia)

- Lack of Identity

- Fugue state (complete amnesia)

- Somnambulism (sleep walking)

- Multiple personality

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- Depersonalization

- Acute psychosis

- Gaunser's syndrome (clouded consciousness with approximate

answers).

Differential diagnosis

- Organic illness such as epilepsy

- Schizophrenia

- Depression

- Depersonalization

Treatment

- Psychoanalysis

- Hypnosis

- Breaking secondary illness gain

- Sedative and anxiolytic drugs (valium and chlorodiazepoxide are

recommended)

Prognosis

In patients with dependent and inadequate personality, the

relapse rate is very high.

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4. Obsessive compulsive disorder

Obsession

Obsession is defined by thought and feelings that the person

cannot get rid off voluntarily and instead reoccur against their will.

Compulsion is defined by the performance of a certain acts as a

result of irresistible thought and in order to reduce anxiety.

Epidemiology

- 0.05% of population encounters obsessive compulsive neurosis

- High in single (unmarried) people

- High in upper social class

- High in educated people

Etiology

- Constitutional function there is a heredity tendency

- Physical - brain injury and central nervous system (CNS)infection

- Psychological - conflicts between Id and superego conflict at anal

phase.

Signs and symptoms

- Commonly anxiety features

- Depression

- Obsessional ideas

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- Obsessional impulses

- Obsessional phobias

Treatment

- Psychotherapy (reassurance)

- Behavioral modification

- Antidepressant (amiltriptline) 25 - 50 mg/d

Prognosis

- 50% will be chronic

- A few develop schizophrenia

5. Hypochondria

Hypochondriasis is neurotic disorder in which the predominant

disturbance is unrealistic interpretation of physical signs as abnormal

leading to a preoccupation with illness and a belief that the patient

has a disease. Hypochondriac is a term used to describe persons

who presents unrealistic or exaggerated physical complaints.

Epidemiology

- Incidence rate is not clearly known

- Occurs most frequently in the 40 – 50 age range

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- More common in females

- More common in single people or people in unhappy marriages

- More common in people with a poor occupation.

Etiology

When a person looses his or her attention towards other objects then

he or she directs their attention to him or herself.

Signs and symptoms

- Ranges from simple preoccupation with illness to delusion

- Primarily mono-symptomatic (occurs with single disease

symptom)

- It may develop in to multi symptomatic (many disease symptoms)

- Most common areas of the body involved are abdomen, chest and

headache.

Diagnosis

- History

- Physical examination

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Treatment

- Treat any under lying illnesses

- Antidepressant (amiltriptline)

- Psychotherapy and supportive ideas

Prognosis

Hypochondria is refractive in some cases

Differentiation between neurosis and psychosis

Neurosis is differentiated from psychosis in the following table

(Shives: 1990):

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Table 3: Differences between neurosis and psychosis

NEUROTIC BEHAVIOUR PSYCHOTIC BEHAVIOUR

Reality oriented Out of contact with reality denies

reality

Demonstrates acceptable

behavior socially

Demonstrates bizarre

inappropriate, behavior (as

described in the chapters on

schizophrenic disorders and

manic- depressive psychosis)

Interacts with the real

environment

Creates a new world or

environment withdraws from

reality in an effort to seek

security in the newly created

world

Doesn’t exhibit maladaptive

behavior (e.g. hallucinations or

delusions)

Exhibits maladaptive behaviors

(e.g. delusions, hallucinations,

and autism)

Uses coping mechanism as

attempt to decrease anxiety

(primary gain)

Coping mechanisms are

ineffective, resulting in

disintegration of the personality

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Nursing intervention

People who exhibit signs of acute anxiety or a panic state may harm

themselves or others and need to be supervised closely until the

anxiety is decreased. The person may need to be placed in a

protective environment such as a general hospital, mental health

center or psychiatric hospital.

The person may be in severe distress or immobilized, or he may be

engaged in purposeless, disorganized, or aggressive activity.

Feelings of intense awe, dread, or terror may occur. The patient may

state he fear that he is ‘losing control.

After the patient is examined, a nursing care plan is initiated to

correspond to the physician’s or psychiatrist’s treatment plan for an

acute anxiety attack or panic state.

During the panic state the nursing interventions may include:

1. Staying with the patient at all times
2. Remaining calm: he patient will sense any anxiety exhibited by

the nurse.

3. Speaking in short, simple sentences
4. Displaying firmness to provide external controls of the patient
5. Keeping the patient in a quiet environment to minimize external

stimuli. The patient is unable to screen such stimuli and may

become over whelmed.

6. Providing protective care because the patient may harm him or

her self or others. The patient’s behavior also may elicit

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responses from other patients who are unable to tolerate his or

her anxiety state.

7. Attempting to channel the patient’s behavior by engaging him or

her in physical activates that provide an outlet for tension or

frustration.

8. Administering anti-anxiety medication to decrease anxiety.

Persons who exhibit symptoms of mild or moderate levels of

anxiety may be treated as outpatients. If the anxiety does not

interfere severely with the patient’s ability to function, he or she

generally is seen as an outpatient.

9. Nursing interventions for mild to-moderate anxiety levels include

assessment of the patient’s anxiety level, reducing anxiety,

providing protective care, encouraging verbalization of anxiety,

meeting basic human needs and setting realistic goals for patient

care.

The nurse provides supportive care by:

1. Recognizing the patient’s anxiety and helping him or her to identify

the anxiety and describe his or her feelings.

Reassuring the patient

2. Accepting the patient unconditionally and not passing judgment or

responding emotionally to the patient’s behavior.

3. Listening to the patient’s concern. Being available but respecting

the patient’s need for personal space.

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4. Protecting the patient’s defenses (e.g. ritualistic behavior). Any

attempt to stop such behavior increases anxiety because the

patient has no other defenses.

5. Encouraging verbalization of feeling and answering questions

directly.

6. Allowing the patient time to respond to nursing interventions.

Setting realistic goals for improvement. Allowing the patient to set

the pace.

7. Exploring alternative coping mechanisms to decrease present

anxiety to a manageable level. Assisting the patient in learning to

cope with anxiety.

8. Identifying the patient’s development stage and helping him or her

to work through unmet developmental tasks

10. Exploring one’s own feelings.
11. Administering treatments or medications to reduce anxiety or

other discomfort

Hospitalization of the patient with an anxiety disorder may be shortterm

and intensive. Outpatient follow-up care is usually recommended

to continue with supportive therapeutic care. Discharge planning will

include an evaluation of the patient’s present status,

recommendations for outpatient referral and instructions regarding

drug therapy if a maintenance dose is necessary. The patient should

be instructed about whom to contact if anxiety increases and panic or

a crisis occurs.

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The following are examples of nursing diagnoses and nursing

interventions for patients with anxiety disorders:

Table 4: Nursing diagnoses and nursing interventions for

patients with anxiety disorders.

Nursing Diagnoses Nursing Interventions

Anxiety Assess the patient’s level of anxiety. (Nursing

interventions for the panic state and mild to

moderate anxiety were covered in depth

earlier in this chapter.) Assess for suicidal

ideation.

Ineffective individual

coping. Obsessive

compulsive,

ritualistic behavior.

Remove patient from any situation that

stimulates or increases behavior. Observe for

signs of increasing anxiety and intervene

before the patient resorts to ritualistic behavior

if possible. Establish trust and one-to-one

relationship Anticipate needs. Seek out and

spend time with the patient. Discuss thoughts

and behavior with the patient. Explore conflicts

in relation to ritualistic behavior. Allow time for

rituals if already established. Set priorities and

time for other tasks to be done (i.e. eating,

chores and personal hygiene). Protect the

patient from ridicule. Encourage the patient to

explore and develop new interests outside of

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57

him or herself. Seek opportunities to

communicate your expectation of the patient’s

recovery. Encourage the patient to participate

in planning activities after allowing time for

ritualistic behavior to decrease. Support any

positive decisions made by the patient. Plan

divisional activities.

Alteration in though

process: Inability to

concentrate

Encourage patient to share feelings. Speak

concisely and clearly. Reassure the patient.

Be really available. Keep decision-making and

competitive situations to a minimum.

Ineffective individual

coping: Demanding,

manipulative

behavior such as

crying and talking

excessively because

of anxiety

Interpret behavior as a need for attention or

pleas for help. Be alert to what the patient is

trying to say and help the patient

communicate more clearly. Anticipate needs

Don’t give false, generalized reassurance

such as” everything will be fine” or “there’s

nothing to worry about.”

Sleep pattern

disturbance:

insomnia due to

anxiety

Recognize signs of increasing agitation.

Decrease environmental stimuli that could be

upsetting to the patient. Offer relaxing nursing

measures such as back-rubs and warm baths.

Teach relaxation exercises. Limit rest periods

during the day.

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Ineffective individual

coping: numerous

somatic complaints

due to anxiety

Avoid reinforcing physical complaints (i.e.

taking vital signs frequently increases

preoccupation with symptoms). Present reality

regarding physical condition. Encourage

participation in activities that provide

distraction an outlet for tension or anxiety and

that increase self-esteem. Identify activities

that the patient enjoys and encourage

participation to decrease the patient’s selfabsorbing

thoughts.

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REVIEW QUESTIONS

1. List at least five subtypes of generalized disorders.
2. Identify at least three approaches of behavioral therapy in phobic

disorder management.

3. identify two forms of hysteria
4. Describe primary illness gain and secondary illness gain
5. Identify the therapeutic measures for hypochondriacs.

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UNIT THREE

AFFECTIVE DISORDERS (MOOD

DISORDERS)

Learning objectives

Upon accomplishing this unit, the student should be able to:

1. Define affective disorder
2. Describe manic psychosis
3. Explain clinical features of mania
4. Describe depression
5. NSG management.

Affective disorder

Affective disorder is defined as a mental disorder exhibiting prominent

and persistent mood changes of elation or depression accompanied

by symptoms such as fatigue and insomnia. An abnormality of affect,

activity or thought process is present. The mood changes appear to

be disproportionate to any cause. Affective disorders are classified as

mania, depression and bipolar disorders.

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Manic psychosis

The word mania is derived from Greek word, it is synonymous with

‘madness’ it is used to describe a behavior disorder in which three

main symptoms predominate, euphoria, heightened psychomotor

activity and flight of ideas.

Clinical features of mania

1. Restlessness
2. Over -talking
3. Irritability
4. Inflated self esteem (grandeur delusion)
5. Decreased need for sleep
6. Expansiveness
7. The speech is very loud, rapid and difficult to understand, often it

is full of jokes, puns, plays on words, amusing irrelevance and

theatrical with singing and rhetorical mannerisms

8. If the mood is more irritable, then expansive the person may

become hostile and may go through three phases: contempt,

control, and triumph.

9. Flight of idea which is incoherent
10. Due to grandiose idea and inflated self esteem, the patient may

act as an advisor and consultant in areas the they do not have

special knowledge, such as how to fix and automobile and how to

run government, writing novel, composing music or painting

pictures.

11. Excessive energy

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12. Intense feeling of well-being
13. Heighten sense of reality
14. Breach in the barriers of individuality
15. Inhibition in the sense of reality.
16. Release of sexual and moral tension
17. Sense of ineffable revelation.

Differential diagnosis (DDX)

- Organic states (cerebral tumor and arteriosclerosis)

- Hypomania

- Alcohol intoxication

- Catatonic excitement

- Frontal lobe lesions.

Methods of diagnosis (DX)

History and physical examination

Treatment (RX)

1 Litium 600 mg po/day

2 Halloperidol (serinace) 5 mg - 100 mg/day

3 Chlorpromazine(CPZ)100 - 600 mg po/day in divided dose

4 Thiaridazine(melleril) 100 - 600 mg po/day in divided dose.

Prognosis

Prognosis is good with good treatment, living condition, and family

support.

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Depression

Depression is a sense of hopelessness, in which the world seems

totally unresponsive to one’s effort to meet one’s needs (Shives:1990)

According to Mendls "the central symptoms of depression are

sadness, pessimism, self dislike along with loss of energy, motivation

and concentration".

Classification of depression

1. Reactive Depression:

Reactive depression is commonest type of depression It may be

caused by a reaction to external events such as loss of a loved one or

a disaster. It is not usually responsive to physical therapies i.e. drug

and ECT. It is not genetically determined or it does not occur in cycles

or reoccur, and it is usually milder than the endogenous depression.

2. Endogenous depression (autonomous depression)

Endogenous depression is due to some unknown origin or internal

process, and it is not associated with external events. It usually

occurs in cycles (on and off), responds to drugs and ECT(shock

treatment) and it is suggested that hormonal and genetical

predisposition are contributing factors. The symptoms are generally

more serious than those of reactive depression.

3. Bipolar depression

- The patient experiences depression and manic episodes.

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- Mania looks like extreme elation and excitement, a mirror image

of depression

4. Uni-polar depression: has no manic episode.

Clinical features of depression

Regardless of age the classification of depressions are more alike

than different. Their clinical features include changes of mood,

thought behavior and appearances. In addition depressives are often

characterized by somatic symptoms as well as anxiety. The following

are clinical features of depression.

Mood: Sad, unhappy, blue and crying

Thought: Pessimism, ideas of guilt, self dislike loss of interest and

motivation, decrease in efficiency and concentration.

Behavior and appearance:

- Neglect of personal appearance

- Psychomotor retardation or agitation

Somatic:

- Loss of appetite or voracious appetite

- Loss of weight or over weight

- Constipation

- Poor sleep (insomnia or hypersomnia)

- Aches and pains

- Menstrual change in female patients

- Loss of libido

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Anxiety features: such as

- Palpitation

- Sweating

- Tremor

- Suicidal thoughts, threats and attempts or self destruction

behavior etc

- Psychomotor retardation

- Agitation

Not all these symptoms are likely to be observed in one person. Thus

one person may show psychomotor retardation (general slowing

down of movement, speech and thought disturbance) and another

person may show agitation.

The common signsare

- Sad face

- Stooped posture

- Crying at intervals

- Slow speech

- Dejected mood

- Diurnal mood variation

- Suicidal wishes

- Indecisiveness

- Hopelessness

- Inadequacy

- Conscious quiet

- Loss of interest

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- Loss of motivation

- Fatigability

- Disturbed sleep (early morning awaking)

- Loss of appetite

- Constipation

Treatment Amitriptyline (elavil) 75 - 200 mg/d in divided dose

1. Imipramin (tofranil)75 - 300 mg/d in divided dose
2. ECT (Electroconvulsive therapy)

Nursing interventions for depression and mania

Persons who are depressed may be difficult to communicate with or

approach. Isolation, withdrawal, ambivalence, hostility, guilt or

impaired thought processes are but a few symptoms that can

interfere with the development of a therapeutic relationship. The

manic patient’s hyperactivity, pressured speech, and manipulation

also interfere with attempts at communication.

The nurse must be aware of personal vulnerability to depressive

behavior: working with such persons may cause one to react to the

depressed atmosphere and in turn experience symptoms of

depression.

The following is a list of attitudes that the nurse should display toward

depressed and manic persons:

1. Acceptance
2. Honesty

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3. Empathy
4. Patience

Assessment focuses on mood, affect, behavior, and appearance.

Body language may replace communication skill because the person

is unable to convey feelings of anger, hostility and ambivalence.

Questions the nurse can ask the patient to assess the level of

depression, while observing facial expression, body posture, tone of

voice, and overall appearance, include the following:

1. Do you have difficult falling asleep at night?
2. Do you wake in the middle of the night?
3. If so, are you able to return to sleep?
4. Do you wake earlier than usual in the morning?
5. Are you alert or depressed when you get up in the morning?
6. Do you sleep excessively?
7. Have you been experiencing feelings of worthlessness, self

reproach, or guilt?

8. Do you have difficult concentrating or making decisions?
9. Can you watch an entire movie or television show?
10. Does your mood change or fluctuate during the day?
11. Has your sex drive lessened?
12. Are you frequently constipated?
13. Has your energy level decreased?
14. Have you lost interest in life?
15. Has there been a change in your appetite?
16. Do you feel alienated from those around you?

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17. Have you ever considered or attempted suicide? (If so, ask the

patient when and whether s/he has a plan at present.)

Simple activities are most effective for a person with a short attention

span or an inability to concentrate. Completion of such tasks

enhances the person’s self-concept because they feel more

worthwhile after the job is done. The nurse must also consider the

person’s energy level; the more energy the task requires, the less

energy s/he will have to engage in hostile, aggressive behavior.

Protective care may be necessary for the manic as well as for the

depressed person. Persons who exhibit manic behavior may injure

themselves owing to excessive motor activity, inability to concentrate,

distractibility and poor judgment. Their destructive tendencies may

include self-inflicted and accidental injury. They also may provoke

self-defensive actions unintentionally from others who fear injury.

Assisting with electro convulsive or electric shock therapy is another

nursing intervention while caring for depressed patients. Such

persons are given a complete physical examination before treatment.

The nurse’s role before treatment is to withhold breakfast and to

administer and anti cholinergic medication to decrease or dry up body

secretions to lessen chances of aspiration, to provide supportive care,

and to assist with the treatment and monitor the person’s responses

during a recovery period that usually lasts from a half hour to one

hour.

Patient education is another nursing intervention for depressed and

manic persons. Such persons should be informed about the

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importance of outpatient treatment as well as the continuation of

prescribed drugs. They may relapse if they discontinue the drugs.

They should be taught to recognize the onset of side effects, as well

as the recurrence of symptom, to avoid re-hospitalization. A person

diagnosed as having bipolar depression, mixed type, should be

helped to describe the changes in affect and behavior in the initial

phases of his illness.

Another aspect of nursing care is being supportive during

psychotherapy sessions. The person may have difficulty expressing

feelings of hostility, ambivalence, and guilt. Feelings of anxiety may

occur or increase as the person begins therapy sessions. Such

sessions may be directed at exploring feelings about self and the

patient’s relationship with the environment in an attempt to improve

his or here self-esteem and decrease feelings of helplessness,

hopelessness, and powerlessness. The nurse can be supportive

simply by making him or herself available to the patient and by

recognizing symptoms such as anxiety.

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Table 5: Nursing diagnoses and nursing interventions for

depressed and manic patients

NURSING DIAGNOSES NURSING INTERVENTIONS

Potential for injury:

Suicidal ideation

Suicide precautions

It is advisable to follow suicide rating scale for

protective care of the suicidal patient.

Social isolation Establish trust.

Assign the same staff members to work with the

person whenever possible. Accept the patient as he

or she is. When approaching the person, avoid

being overly cheerful, sympathetic or superficial.

Display empathy. Use therapeutic communication

skills such as silence and active listening.

Encourage ventilation of feelings.

Dysrhythmia of sleeprest

activity

Observe for signs of fatigue. Provide opportunities

for rest. Set limits regarding time to arise in morning

and the amount of time spent in bed during the day.

Decrease external stimuli before hour of retiring.

Offer warm milk and backrub at bedtime. Administer

prescribed medication for insomnia

Alterations in nutrition:

Less than body

requirements

Monitor Input and output.

Provide a high protein, high-calorie diet as needed.

Attempt to include the patient’s favorite foods.

Provide frequent, nutritional snacks in the form of

finger foods. Encourage adequate fluid intake. Offer

high calorie drinks. Weigh the patient weekly or as

ordered.

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Alternation in bowel

elimination: Constipation

Monitor Input and output. Encourage the intake of

fluids. Encourage exercise. Provide bulk and fiber in

diet. Administer laxatives as needed.

Alteration in selfconcept

Involve in activities directed toward raising selfesteem.

Display a sincere interest and offer praise

or recognition for accomplishments.

Activity intolerance

because of hyperactivity

and distractibility

Decrease or limit environmental stimuli. Provide

adequate room for hyperactivity. Provide private

room if necessary, to reduce external stimuli. Limit

social interactions initially to prevent intrusive

behavior. Select activities that provide an outlet for

excessive energy yet do not trigger loss of control.

Administer drugs as ordered to decrease

hyperactivity.

Manipulation Give simple explanations regarding hospital routine

and nursing care. Contact the patient frequently but

briefly to reassure him or her. Set limits and be

consistent. Avoid arguing with the patient.

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REVIEW QUESTIONS

1. Which of the following is not a clinical feature of mania?
2. Elation
3. Agitation
4. Dejected mood
5. Intense sense of well being
6. The prognosis of manic disorder depends on treatment, good

living condition and family support.

1. True b. False
2. In the case of bi-polar disorder, mania is considered as a mirror

image of depression

1. False b. True
2. Which one of the following is a true picture of depression?
3. Menstrual change in the female patients
4. Neglect of personal hygiene
5. Psychomotor retardation or agitation
6. All of the above
7. The endogenous depression is caused by a clear causal factor

and yet it doesn’t respond to drug therapy.

1. True b. False

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UNIT FOUR

SCHIZOPHRENIA

Learning objectives

After studying the material in this unit, the student should be able to:

1. Define schizophrenia
2. Describe different types of schizophrenia
3. Recognize DSM-IV-R diagnostic criteria of schizophrenia
4. Describe differential diagnosis of schizophrenia
5. Explain possible management of schizophrenia
6. List the nursing management of schizophrenia

Definition: The word schizophrenia is derived from a Greek word

meaning

Schizo - split } = meaning split mind

Phrenia - mind}

Generally schizophrenia is a serious psychiatric disorder

characterized by impaired communication with loss of contact with

reality and deterioration from a previous level of functioning in work,

social relations or self-care. Clinical types of schizophrenia include

disorganized, catatonic, paranoid, residual, and undifferentiated

schizophrenia (Shives: 1990)

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Types of Schizophrenia

1. Disorganized (hebephrenic type)

Features include incoherence, lack of systematized delusions, and

blunted, inappropriate or silly affect. The clinical picture usually

includes a history of poor functioning and poor adaptation even

before illness.

1. Catatonic type

A type of schizophrenia which is dominated by one of the following:

1. Catatonic stupor: Morbid lack of reactivity to environment

reduction in spontaneous movements and activity and/or mutism.

2. Catatonic negativism: Apparently motiveless resistance to all

instructions or attempts to be moved.

3. Catatonic rigidity: Maintenance of a rigid position against efforts

to be moved.

4. Catatonic excitement: Excited motor activity apparently

purposeless and not influenced by external stimuli.

5. Catatonic positioning: Assumption of inappropriate or bizarre

posture.

1. Paranoid type

Features of the paranoid type of schizophrenia include persecutory

and grandeur delusions, feeling and hallucinations.

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Associated features include anger, argumentative, violence,

fearfulness, delusion of reference and sometimes loss of gender

identity.

- Onset is relatively late

- Function remains more or less at constant level, and is not

marked by deterioration.

1. Undifferentiated type

Features include grossly disorganized behavior, hallucinations

incoherence or prominent delusion.

1. Residual type

Features include current schizophrenic symptoms and definite

experience of at least one schizophrenic episode in the past. There

may be some delusion and hallucination but the person is burned out.

There is no treatment for the residual symptoms. The patient often

functions poorly and experiences long term unemployment.

1. Simple type

The patient Experiences:

- Paranoid disorders

- Gradual insidious loss of drive, interest, ambition and initiative.

- Withdrawal

- Isolation

- Gradual decrease of performance

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Later the patient may show indifference to environment, slow

personality deterioration and drift aimlessly through life. Usually

hallucination and illusion are absent.

DSM III diagnostic criteria for schizophrenic disorders

The DSM III diagnostic criteria include the following:

A At least one of the following at some point of the illness

1. Bizarre delusions, such as the delusion of being controlled,

thought broadcasting, thought insertion and thought withdrawal,

somatic, grandiose, religious, and nihilistic or other delusions

without persecutory or jealous content.

2. Delusions with persecutory or jealous content, if accompanied by

hallucinations of any type.

3. Auditory hallucinations in which either a voice keeps up a running

commentator on the individual’s behavior or thoughts, or two or

more voices converse with each other.

4. Auditory hallucinations on several occasions with content of more

than one or more words having no apparent relation to depression

or elation.

5. Incoherence and marked loosing of association marked illogical

thinking or marked poverty of content of speech, if associated at

least with one of the following:

- Blunted, flat or in appropriate affect

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- Delusion or hallucination

- Catatonic or other grossly disorganized behavior.

1. Deterioration

Deterioration from a previous level of functioning in such area as

work, social relations and self care.

1. Duration:

Continuous signs of the illness for at least six continuous months

during the person’s life, with some signs of the illness at present. The

six month period must include one active phase during which

symptoms from criteria A (outlined above)are exhibited, with or

without pro-dromal or residual phase.

1. symptoms of depression or manic syndrome

The full depression or manic syndrome (major depression or manic

episode) if developed after any psychiatric symptoms in criteria A

(outlined) appear.

1. Onset of pro-dromal or active phase of the illness before age of 45

years.

1. Not due to any organic mental disorder or mental retardation.

Bawleres symptoms ‘The 4 A's’ Of schizophrenia

- Ambivalence

- Association loosening (incoherence)

- Affect disturbance

- Autism (turning towards self).

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Differential diagnosis

- Organic mental disorder

- Major affective disorder

- Schizophreniform disorder

- Paranoid disorder

- Mental retardation

- The developmental straggle of adolescent.

Prognosis:

Prognosis depends on onset, stress, pre morbid personality and

social and economic status.

Treatment (Rx)

1. Coma - Insulin coma is the ancient form of treatment. Nowadays

it is not treatment modality of schizophrenia.

2. ECT is also seldom used today
3. Contemporary treatment:

a, Supportive psychotherapy

b, Drug therapy: The hoice of drug depends upon availability,

cost and side effects

- Chlorpromazine(CPZ) 100 - 600 mg/day in divided dose

- Thioridazine (mellaril) 100 - 1000 mg/day

Nursing interventions

Nursing interventions focus on assisting the patient to meet the

following goals:

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1. Establish a trusting relationship;
2. Alleviate anxiety;
3. Maintain biological integrity; and
4. Establish clear, consistent, and open communication.

The nurse must establish a therapeutic relationship so that effective

communication with the patient can take place. The nurse must

remember that all behavior is meaningful to the patient, if not to

anyone else.

Reality should be presented when caring for the patient who is

disoriented. The nurse can do this by pointing out what would be

appropriate behavior, for instance, ‘I’d like you to put your shoes on

now’ Recognizing the presence of hallucinations and delusion, but not

reinforcing such behavior or thoughts is an appropriate response

when interacting with patients. The nurse should look for factors

causing hallucinations and attempt to intervene before they occur.

Safety measures may need to be incorporated to protect the patient

who displays poor judgment, disorientation, destructive behavior,

suicidal ideation, or agitation. Limit setting, acknowledging spatial

territory giving the patient room to breathe’ and providing protective

safety measures are examples of such nursing interventions. The

patient must be protected from her or himself because she or he may

injure her or himself accidentally, or may try to destroy her or himself

or attack other patients as a result of auditory hallucinations or

paranoid ideations.

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Efforts should be made to plan activates to increase the patient’s self

concept. Sincere compliments should be given as often as possible,

focusing on positive aspects of the person’s personality or

capabilities. Encourage participation in activates.

The nurse must observe for extra pyramidal side effects of

psychotropic drugs and monitor the patient’s willingness to take the

drugs. Patients may refuse to take medication, pretend to take

medication by palming it, or pretend to swallow the medication while

retaining the pill in the mouth (only to get rid of it at the first possible

moment).

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Table 6: Nursing diagnoses and interventions for patients with

schizophrenic disorders.

Nursing diagnoses Nursing Interventions

Sensory-perceptual alteration:

Disoriented to place and person,

disoriented in time.

Call the patient by name. Present reality

when talking to or working with the

patient. Keep a calendar in clear view to

orient the patient daily. Provide a

protective, safe environment.

Social isolation: Withdrawal Assign one member of the health care

team to establish a one-to-one

relationship.

Provide a structured list of activities

such as times to awaken, shower, and

eat.

Spend a specific amount of time daily

with the patient. Set limits regarding

amount of times spent alone in room.

Alteration in thought process:

Delusional

Present reality when talking to or

working with the patient. Ignore the

delusion but do not attempt to disprove

it or argue with the patient.

Set limits by instructing the patient not

to discuss the delusion with others.

Alteration in though process:

Hallucinations

Decrease environmental stimuli such

as loud music or television shows,

extremely bright colors, or flashing

lights. Present reality, for example: “The

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voices may be real to you but I don’t

hear anything.” Attempt to identify

precipitating factors by asking the

patient what happened before the onset

of the hallucination.

Ineffective individual coping:

Regression

Assess the patient’s present

developmental level. State expected

behavior to the patient. Set limits to

discourage regressive behavior.

Dysrhythmia of sleep-rest activity:

Agitation and unpredictable behavior

Recognize signs of increasing agitation.

Decrease environmental stimuli that

could be upsetting to the patient.

Sensory-perceptual alteration:

Suspiciousness

Be sincere and honest when talking

with the patient. Avoid making promises

that can not be fulfilled.

Face the patient while talking.

Avoid whispering or any other behavior

that may cause the patient to feel that

you are talking about him. Give detailed

explanations of tests, procedures, and

so forth to the patient. Allow the patient

to help to prepare food or have food

brought from home if he or she refuses

to eat (because s/he thinks food is

poisoned).

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REVIEW QUESTIONS

1. Schizophrenia is a mild psychiatric disorder characterized by

impairment of previous level of functioning in work, social relations

or self care

1. False b. True
2. Disorganized (hebephrenic schizophrenia) is characterized by

inappropriate or silly affect and lack of systematized delusion.

1. False b. True
2. Grandeur delusion and persecutory idea are mainly the

characteristics of paranoid schizophrenia among the rest of types

of schizophrenia.

1. True b. False
2. In residual type of schizophrenia the patient has definitive

experience of at least one schizophrenic episode in the present

among other symptoms experienced in the.

1. False b. True
2. List the Bawlers diagnostic criteria for schizophrenia

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UNIT FIVE

EPILEPSY

Learning objectives

After this unit, the student should be able to:

1. Define epilepsy
2. Describe different classifications of epilepsy
3. Identify different clinical features of epilepsy
4. Diagnose epilepsy
5. Identify differential diagnoses of epilepsy
6. Explain appropriate medical and nursing management of epilepsy
7. Give health teaching for clients and family members (care takers)

of epileptic patient.

Definition: Epilepsy is derived from the Greek word ‘epilepsia’ which

means to take hold of or to seize. It is paroxysmal neurological

disorder causing recurrent episodes of:

1. Loss of consciousness
2. Convulsive movements or motor activity
3. Sensory phenomena or
4. Behavioral abnormalities

(Brunner and Sundarth: 1998)

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The following are important characteristics of epilepsy:

Seizure A paroxysmal, uncontrolled, abnormal discharge of electrical

activity in the gray matter with in the brain causes events that

interfere with normal function, a symptom rather than a disease.

Prodromal phase: This Phase precedes some seizures and may last

minutes or hours: a vague change occurs in emotional reactivity or

affective responses (e.g. depression or anxiety)

Aura: A brief sensory experience occurs e.g. a feeling of weakness,

dizziness strange sensations in an arm or leg numbness, an odor that

occurs at the onset of some seizures

Epileptic cry: A cry, occurring in some seizures, caused by a thoracic

and abdominal spasm which expels air through the narrowed spastic

glottis.

Ictus, post ictal: Ictus is synonymous with seizures, post ictal refers to

the time immediately after a seizure during which the client usually

experiences some change in consciousness, behavior, or activity.

Etiology

The etiology of seizures varies remarkably in adults and includes:

- Brain tumor is the most common cause for organic seizure

(intracranial mass)

- Head injury

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Clinical manifestations

There are various types and classifications of seizures. They can be

classified into two major groups:

1. Generalized seizures:

- Tonic clonic seizures (grand mal)

- Absence (petit mall)

- Minor motor seizures (akinetic, myoclonic, atonic)

2. Partial seizures (focal epilepsy)

- Partial seizures with motor components

- Partial seizures with sensory components

- Partial seizures with complex symptoms

- Partial seizures that secondarily generalize

Diagnostic assessment

Assessment of a client experiencing seizures involves:

- History including, prenatal, birth, and developmental history,

family history, age of seizure onset, trauma, illness and complete

description of seizure including precipitating factors:

- Psychosocial assessment, including mental status examination

- Complete physical examination, including a detailed neurological

examination

- Skull radiographs

- EEG

- CT scan to detect tumor

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Medical management

Medical management includes:

- Eliminating factors that may cause or precipitate seizures.

- Improving the client’s physical and mental health

- Specific medical treatment, and

- Possible surgical treatment.

The main focus in intervention for epilepsy is preventing seizures from

occurring

Drug treatment

Drug treatment include:

1. Phenobarbital 30 - 100 mg po/daily (for grand mal epilepsy)
2. Phenytoin (dilantin) 100 mg po/day
3. Carbamazepine (tegretol)

Side effects of anti epileptic drugs include mental dullness, ataxia,

diplopia, hypertrophy of gums, emotional and mental changes

including depression, irritability, impotence, withdrawal seizures, if

drug is not discontinued slowly.

Nursing management

Nurses have a role in supporting and educating clients and their

significant others with epilepsy to provide information about the

following important points.

1. How anticonvulsants prevent seizures
2. The importance of taking prescribed medication regularly
3. Care during seizure

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Nursing care help the client identify factors that precipitate seizures

and ways of avoiding these factors. Such factors include:

- Increased stress

- Lack of sleep

- Emotional upset and

- Alcohol use

Certain dangerous activities should be avoided or performed with

special safeguards including:

- Swimming

- Horse back riding

- Tree climbing

- Activity involving fire hazards

- Driving motor vehicles

Nurses should advise adequate diet, fluid intake, sleep ,and moderate

recreation and exercise.

Emotional effects of epilepsy

Clients with epilepsy often have a poor self-image. They may

experience:

- Feelings of inferiority

- Self-consciousness

- Guilt

- Anger

- Depression and

- Other emotional problems

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Observation (assessment during the seizure attacks)

Nurses should make the following observations during seizures:

Duration of the seizure (tonic clonic 30 - 60 seconds)

- Were the seizure begun?

- Did eyes deviate?

- Were the respiration’s labored or frothy?

- Was client incontinent?

- Status epilepticus (persistent and uncontrollable seizure).

Family education

The client's family needs to know what to do for the client in the event

of a seizure. Nurses can advise the family about:

- Protecting the patient from self injury

- Loosening their clothing

- Protecting the patients head from impact and sharp objects

- Not to restrain the patient forcibly during seizure.

- Not to insert hard object or finger in the mouth

- Position the patient to their side when the seizure is over.

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REVIEW QUESTIONS

1. List at least four major characteristics typical of epilepsy
2. Seizure is a paroxysmal, uncontrolled discharge of electrical

activity in the brain’s gray matter that interferes with normal

function of the brain and also it is a symptom rather than a

disease

1. False b. True
2. Which one of the following activity is restricted or performed with

maximum safeguards in epileptic patients.

1. Horse back riding b. Swimming
2. Tree climbing d. All of the above
3. Which one of the following doesn’t trigger or precipitate the

occurrence of seizure in epileptic patients

1. Increased stress
2. Increased sleep
3. Emotional upset
4. Alcohol use
5. Which one of the following should be included in family education

about protection of the epileptic patient during the seizure attack?

1. Loosening of clothing’s of the patient
2. Protection of head from impact and sharp objects

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1. Positioning of the patient to the side
2. All of the above

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UNIT SIX

ORGANIC MENTAL SYNDROMES AND

DISORDERS (COGNITIVE FUNCTION

DISORDERS)

Learning objectives

After studying this unit the student should be able to:

1. Discuses organic mental syndrome
2. Discuses organic mental disorder
3. Define dementia
4. Describe diagnostic criteria for organic mental disorder
5. Describe different forms of treatment and care for different organic

mental disorders

6. Describe nursing intervention for organic mental syndromes and

disorders.

Definition

Organic mental syndromes and disorders are due to transient or

permanent brain dysfunction caused by a disturbance of physiologic

function of brain tissue. Organic mental disorder refers to a particular

organic mental syndrome in which the etiology is known or presumed.

Organic mental syndromes refers to a constellation of psychological

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or behavioral signs and symptoms without referral to etiology (Shives:

1990).

The following are lists of disorders and syndromes.

Organic mental disorders

Primary degenerative dementia of Alzhimers’ type

Multi-infarct dementia

Alcohol intoxication

Alcohol withdrawal

Alcohol withdrawal delirium

Alcohol hallucinosis

Alcohol aminestic disorder

Organic mental syndromes

Delirium and dementia

Aminestic syndrome and organic hallucinosis

Organic delusional syndrome

Organic mood syndrome

Organic anxiety syndrome

Organic personality syndrome

Intoxication and withdrawal

Organic mental syndrome not otherwise specified

Some syndromes and disorders are described in more detail below.

1. Delirium

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This disorder is characterized by a clouding of consciousness,

accompanied by

- Disorientation

- Memory impairment and

- A decreased ability to shift focus, or sustain attention to stimuli.

Irrelevant environmental stimuli may easily distract a person with

a diagnosis of delirium.

The person may misinterpret the environment or exhibit perceptual

disturbances such as illusions or hallucinations.

The patient may exhibit insomnia or daytime drowsiness often occurs

along with a disturbance of the sleep-wake cycle, resulting stupor,

semi coma, hyper-somnolence, vivid dreams, or nightmares.

Diagnosis of delirium is based on evidence of a specific organic factor

identified by a history, physical examination, or laboratory test. DSM -

III -R diagnostic criteria include:

1. Clouding of consciousness
2. At least two of the following
3. Perceptual disturbance
4. Incoherent speech at times
5. Disturbance of sleep-wake cycle with insomnia or daytime

drowsiness or

3. Disorientation and memory impairment
4. Clinical features develop with hours or days and fluctuate over the

course of a day

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1. Dementia

Dementia is a form of global or defused brain dysfunction that is

characterized by a gradual, progressive and chronic deterioration of

intellectual function. This deterioration affects judgment orientation,

memory and emotional stability. Cognition and attention are affected

either by a pattern of simple, gradual deterioration or by rapid

complicated deterioration.

Diagnostic criteria for dementia

1. Loss of intellectual abilities, resulting in interference of social or

occupational functioning

2. Memory impairment
3. At least one of the following
4. Impaired abstract thinking
5. Impaired judgment
6. Disturbed higher cortical function, such as aphasia

(loss of language comprehension or production) apraxia (loss of

ability to perform skilled motor act), agnosia (loss of the ability to

recognize objects) constructional difficulty (inability to copy threedimensional

figures, assemble blocks, or arrange sticks), or;

1. Depression
2. Unclouded state of consciousness
3. One of the following specific organic factors related to the

disturbance or, in the absence of evidence from the history,

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physical examination, or laboratory tests, an organic factor can be

presumed.

1. Alzheimer's disease (primary degenerative dementia)

Alzheimer’s disease is pre-senile brain disease; it is not a natural

course of aging, hardening of the arteries, an aftermath of a stroke,

brought on by alcoholism, trauma, or over medication, a depressed

state, communicable or curable.

It is considered to be a silent epidemic that begins with a slight and

easily dismissed flattening of personality, characterized by confusion,

restlessness, speech disturbances, withdrawal, decreased interest in

hobbies, inability to carry out purposeful movements, and

(sometimes)

Death can result from neglect, malnutrition, dehydration, incorrect

diagnosis, inappropriate treatment or suicide.

Nursing interventions focus on identification and symptomatic

management of the evident deterioration as well as other factors

noted during the assessment process.

A calm supportive approach is necessary when handling the patient's

emotional responses or defenses against the acknowledgment of

intellectual deficits.

1. Mental handicap

Mental handicap (amentia, oligophrenia) is a defect of intelligence

existing from birth or from an early age. The English Mental Health

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Act, 1995, prefers ‘mental sub normality’ and recognizes sub

normality and severe sub normality. The Scottish Act of 1960 retains

the older ‘mental deficiency’ and makes no subdivision. While low

intelligence is an essential feature for diagnosis, a low IQ is not the

sole criterion. Personality and associated physical defects have

significant effects on educability, and social competence has always

been the main diagnostic criterion.

Prevalence

Two to three per cent of the population has some degree of mental

handicap; it is generally identified between birth and 14 years, after

which the figure remains steady. Some 70% live in the community

and the remaining 30% may be institutionalized or isolated by the

family members at home.

For every case of severe sub normality (IQ less than 50), and there

are 15 mild cases of mild sub normality (IQ less than 75). Severe

cases have a prevalence of 3.7/1000. Sub normality is nine times

more common in high social class than lower social class. It is higher

in rural areas, and in males (1.3 to 1). There is high association

between family history and mental sub normality.

Etiology

There are two main types of sub normality: organic and sub cultural.

The latter group comprises those individuals of low intelligence who

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can be expected to occur at one end of the normal distribution curve.

Intelligence is normally distributed in the population, and most

intelligence tests are standardized with a mean IQ of 100 and a

standard deviation of 15. The subnormal population is usually defined

as having an IQ of more than two standard deviations below the

mean: i.e. an IQ under 70. The rate quoted above for illustrates the

effects of the probability distribution on sub normality. In the case of

severe defect IQ below 50 there are higher numbers than would be

expected by from a normal distribution(a ‘bulge in the tail’) and the

vast majority of this group have organic brain disease, compared with

only 25 per cent in those with IQ’s of 50 to 70.

Multiple handicaps: A substantial minority of mentally hand caped

people have associated psychosis or neurosis, and up to 40% show

difficult behavior in childhood. Accompanying handicaps include poor

physical development, sensory defects such as deafness and poor

vision, employment difficulties, but in people with an IQ above 50

education, upbringing, social class and temperament, together with

associated handicaps all play a part in the final achievement or

failure.

Diagnosis and assessment

Antenatal

Amniocentesis is a developing area of early diagnosis, together with

ultrasound, foetoscopy and foetal blood sampling. Tissue culture

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used to detect chromosomal abnormalities, enzyme defects and the

sex of the infant. Such tests may prove useful in older mothers with

high risk of Down’s syndrome, if an existing child has a genetic defect

and risk is high, or if the disorder suspected is sex linked. Alpha

fetoprotein estimation in amniotic fluid and blood are now used to

detect neural tube defects (spina bifida) and may also indicate fetal

death. The risk of error in such tests is 1 in 1000.

Infancy

The nurse should be aware of the risk of sub-normality when there

has been anoxia and when there is low birth weight, dysplasia,

cerebral palsy, convulsions or small cranial circumference. Probably

1% of live births show serious retardation, but at 7 years only 0.4 % of

children havean IQ below 50.This is the effect of selective mortality.

Investigations in suspected cases include chromosome studies,

amino-acid chromatography, specific blood and urine tests for inborn

error of metabolism and detection of specific antibodies in mother and

child. Developmental scales are available for diagnosis in infancy and

childhood.

Childhood

Many children with mental handicap may be identified by failure to

stand, walk or talk at the normal times.

School

Milder degrees of sub normality are commonly diagnosed in the early

school years thought educational difficulties.

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Classification of the causes mental handicap

Organic causes

1. Prior to conception
2. Chromosomal, e.g. Down’s syndrome
3. Genetic: single, e.g. inborn errors, or multifactor
4. Pre-natal and peri-natal
5. Maternal infections (rubella, toxoplasmosis, syphilis,

cytomegalic inclusion body disease)

1. Fetal infections (encephalopathy, maternal toxemia)
2. Maternal malnutrition-rate
3. Peri-natal damage (hypoxia, birth injury)
4. Kernicterus
5. Drugs or alcohol
6. Exposure to radiation.
7. Down’s syndrome (mongolism)

Down’s syndrome was described by John Langdon Down in 1866.

This syndrome is due to chromosomal abnormality. It takes various

forms, but 95% of cases are due to trisomy 21, an extra small

acrocentric chromosome in group G, giving 47 rather than 46

chromosomes, caused by non-disjunction during meiosis of the

oocyte. Thus, the ovum is involved and not the sperm. It is more

common in older mothers: compared with a 25 years old mother, a

mother of 40 has 20 times the risk and a mother aged 45 has 50

times the risk. Mongols born to young mothers usually show a

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different abnormality translocation, in which there are 46

chromosomes, one of which is large and atypical. Clinically,

mongolism is common, 1 in 700 live births, but up to 50 per cent of

the infants die during their first year. Mongols formerly had a short life

due to infection, but those who survive infancy now live longer. All

show varying degrees of sub normality. In infancy hypo-tonia and

hyper-flexibility are found. Down’s syndrome is characterized by

multiple abnormalities: microcephaly; flat face sloping eyes with

epicanthic fold, big tongue;short neck; broad, flat hands with simian

crease and short fingers; congenital heart lesions; infertility

Temperamentally such children. Temperamentally such children are

frequently jovial, and often musical. In early pregnancy Down’s

syndrome may now be identified by amniotic cell culture.

1. Metabolic abnormalities

Such abnormalities may be acquired, for example:

1. Hypoglycaemia
2. Hyperbilirubinaemia (kernicterus)
3. Hypothyroidism (cretinism)
4. Hypoproteinaemia
5. Hypercalcaemia
6. Lead poisoning

They may also be inborn, including:

1. Lipid metabolism
2. Carbohydrate metabolism
3. Amino acids metabolism

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Inborn errors of metabolism are interesting but very rare, acquired

abnormalities are four times as common.

Some of these abnormalities are described in more detail below.

Acquired metabolic abnormality

Kernicterus: This results from Rh or ABO incompatibility or in

prematurity. When level of un conjugated serum bilirubin exceeds 20

mg/100 ml, damage takes place in the basal ganglia and cerebellum.

The result is often hyper tonus, cyanosis, and convulsions with later

choreo-athetosis, deafness and sub normality. Antenatal detection

can enable an exchange transfusion to be given.

sm (Cretinism): This has various causes: enzyme deficiencies, absent

or mal developed thyroid, ingestion of drugs such as phenylbutazone,

PAS. Symptoms may include persistent jaundice, lethargy, protruding

tongue and umbilical hernia. Early thyroid treatment is essential to

prevent damage.

Inborn metabolic abnormality

Inborn metabolic abnormality includes all autosomal recessives.

Between 1 in 10 000 and 1 in 50 000 peopleare affected.It may be

caused by deficient enzyme blocking a metabolic reaction. Symptoms

arise from an accumulation of lipids, carbohydrate or amino acids

before the block, or deficiency beyond the block.

Lipid disorder includes Tay-Sach’s disease (ganglioside), Gaucher’s

disease (cerebroused) and Niemann-Pick disease (sphingomyelin).

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Such disorder are commoner in Jewish people, begin early, have a

rapid, fatal course.

Connective tissue disorders (mucopoly-saccharroidoses) include

Hurler’s syndrome (gargoylism).

Carbohydrate metabolism disorders include galactosaemia, in which

there is jaundice, cataracts, proteinuria and galactosurea. It is

treatable.

The best known amino acid metabolism disorder is phenylketonuria.

Infants are screened by Guthrie inhibition test on blood for raised

phenylalanine levels. The defect is caused by transforming

phenylalanine to tyrosine from a deficiency of the enzyme

phenylalanine hydroxylase. It occurs in 1 in 12000 births. There are

no physical abnormalities, but often have blue eyes, fair hair and

dermatitis there may be fits.

It may be treated through a phenylalanine free diet. Although this is

artificial and unpalatable, it must be adhered to in childhood as soon

as child will tolerate it. The diet can be stopped in adult life, but must

be resumed during pregnancy.

1. Neurological defects

Sturge-Weber syndrome is caused by a naevoid defect. It is

characterized by fits, hemiplegaia, naevi (port wine stains) especially

on face and neck, venous angioma of pia, and clacification of skull

may be apparent on X-ray. Hemispherectomy may help.

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Tuberous sclerosis eoukiua is characterized by sclerotic nodules in

the brain, epilepsy, tumors elsewhere, especially kidney and heart,

skin lesions, adenoma sebaceum, fibromatosis and phakomamta.

Laurence-Moon-Biedl Syndrome is characterized by mental defect,

pigment degeneration of the retina, obesity, hypogenitalism and

polydactyl.

1. Bony defects

Genetic micro-encephaly is probably caused by a single recessive

gene.

Hypertelorism: is characterized by great breadth between eyes, due

to abnormality of base of skull.

Oxycephally is characterized by telor skull or steeple-head. It is rarely

associated with defect:hypertelorism and oxycephaly need not be

associated with sub normality.

Treatment and care

Patients should be cared for at home where possible but of the

benefits of this must be weighed against the stresses on other

members of the family. Boredom and overcrowding may produce

disturbed behavior and drugs (e.g. anticonvulsants) may further

impair performance.

Education is essential and should emphasis practical social skills:

learning to wash, dress, eat, travel and work. Subnormal people with

an IQ of 50 or over can benefit from some form of schooling. Most

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mentally handicapped people in the community are capable of some

form of work and this may be in an occupation centered or sheltered

workshop if open employment cannot be found. Very severely

handicapped cases, with multiple handicaps or complicated by severe

behavior disorder (e.g. aggressiveness, uninhibited sexual behavior)

or psychotic illnesses mayrequire care in hospital possibly throughout

life. Prevention involves the pediatrician and obstetrician. Genetic

counseling is developing in importance.

Treatment and nursing interventions

Assessment of persons with organic mental disorders is important,

especially in the early diagnostic phase. The interview and the

assessment of judgment, orientation, memory, affect, and cognition

(JOMAC) are essential. Lancaster (1980) lists the following aspects

that also should be considered during the assessment process:

1. Intellectual ability, past and present
2. Changes in personality (i.e., depression, irritability, loss of

interest, and decrease or loss of interest in personal appearance)

3. Past and present health status
4. Any evidence of confabulation, negativistic behavior, preservation,

feigning deafness, projection, or rationalization for lack of

appropriate response.

5. Ability to provide self- care

Nursing interventions focus on identification and symptomatic

management of any evident deterioration, as well as other factors

noted during the assessment process. A calm, supportive approach is

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necessary when handling the patient’s emotional responses or

defenses against the acknowledgment of intellectual deficits. Smith

(Lego, 1984) lists the following observable behavioral defenses

frequently seen in persons with organic mental disorders:

1. Liability of affect or rapid fluctuations in emotional responses
2. Indifference or apathy
3. Lack of energy or anergia
4. Negativistic behavior
5. Impulsivity behavior or assult
6. Emotional incontinence or inability to control aggressive or sexual

impulses

7. Depression
8. Refusal to communicate

Short-term nursing goals include maintaining the patient’s contact

with reality, preventing injury, promoting adequate nutritional and fluid

intake, promoting adequate sleep and rest, encouraging expression

of feelings, and stimulating the memory through various activities.

Long-term goals focus on promotion of optimal level of independence,

decreasing socially inappropriate behavior, forming satisfactory social

relationships with limitations, and assisting the patient to live in as

nonrestrictive an environment as possible (Schultz, 1982). The

environment should be simple and well-structured, providing the

person with an opportunity to adapt to his or her impairments by

doing things in less complex ways than in the past. Meeting basic

needs becomes more demanding as physical deterioration occurs.

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Remaining learning potential should be maximized while the person is

made to feel comfortable both physically and emotionally. New

material or devices to provide self-care should be introduced simply

and gradually.

Delusional thought processes may increase as the intellectual

functioning deteriorates. Sudden deterioration may indicate a

superimposed treatable disease.

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Table 7: Common nursing diagnoses and nursing interventions

for organic mental disorders

NURSING DIAGNOSES NURSING INTERVENTIONS

Alteration in though process

related to disorientation

Assess level of disorientation. Use the

following reality therapy:

1. Orient to person, place, and time by using

clocks, calendars, or other visual aids.

2. Refer to date, time of day, and recent

activities during interactions with the patient.

3. Address the person by name
4. Correct errors in a matter-of-fact manner,

Establish a set daily routine.

Encourage the person to have familiar

personal belongings or possessions in his

room.

Assign the same nursing personnel to care the

patient whenever possible.

Self-care deficit because of

loss of independent

functions such as bathing

and dressing

Encourage independent functions by giving

verbal step by-step instructions.

Remain with the patient.

Allow ample time to perform a given task to

avoid frustration.

Assist the patient if sensor motor impairment

prevents him or her form functioning without

help.

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Alteration in though process

because of memory loss for

recent information

Provide the patient with clear, simple, step-bystep

directions while performing ADL routines.

Use supportive statements if fabricated stories

or untruths are given in defense of memory

loss (i.e. “It’s hard to find your glasses when

their location slips your mind.”).

Potential for injury owing to

sensory motor deficits such

as impaired vision and

unstable gait

Establish a safe environment by

1. Providing adequate lighting in the

patient’s room

2. Providing a night light
3. Placing the light switch close to the bed

for easy accessibility

4. Assessing the patient’s ability to

ambulate independently, providing

assistance as needed (i.e. walker, cane,

or assist with ambulation)

5. Providing adequate restraints such as a

poesy or vest if patient is disoriented as

well as physically unstable

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REVIEW QUESTIONS

1. Organic mental disorder refers to a particular organic mental

syndrome in which the etiology is unknown.

1. True b. False
2. List the diagnostic criteria of delirium according to DSM III R.
3. Which the following one is not the cause of death in Alzheimer’s

disease?

1. Neglect
2. Malnutrition
3. Suicide
4. None of the above
5. Two to three percent of the population has some degree of mental

handicap

1. True b. False
2. List at least five acquired metabolic abnormalities that can cause

mental handicap.

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UNIT SEVEN

CHILD AND ADOLESCENT PSYCHIATRY

Learning objectives

After studying the material in this unit, the student should be able to:

1. Define child and adolescent psychiatry
2. Describe the general characteristics of mental illness in children

and adolescents

3. List the causes of mental illness in children and adolescent age

group.

4. Identify classifications of child hood psychiatry
5. Identify specific syndromes of childhood psychiatric disorder
6. Identify different types of childhood and adolescent psychiatric

disorders.

Definition

Childhood and adolescent psychiatric disorders are types of mental

illness which occur in childhood and adolescent age group.

Etiology

1. Genetic factors

Genetic factors are important. Wide individual variations in mood,

level of activity, attention span are found in infants, and sex

differences in aggressive behavior may be evident at two years.

These temperamental differences may modify parental response to

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children’s aggression. The behavior of emotionally disturbed

children often accurately predicts adult personality. The child is

father of the man.

2. Separation from parents

For normal development, infants must form attachments and bonds

(selective attachments persisting over a long period). The se may

be disrupted, for example, by hospital admission. This is most

stressful for children between six months and four years, of age,

but children can be trained to accept separations gradually. Short

separations can lead to acute but brief distress. One long

separation rarely dose permanent emotional damage, but repeated

hospitalization in a child from an unhappy home often causes

psychiatric problems.

3. Other stresses

Other damaging stresses for children include moving house,

bereavement and a broken home. The latter is especially

associated with conduct disorders. The in the case of divorce, the

associated marital discord is more important than the parents’

separation. Children of one parent families have more psychiatric

problems than average; children of working mothers do not.

4. Delinquency

Delinquency is associated with particular geographical areas which

have poor or neglected housing, overcrowding, low family income

and high adult crime rate. Children in inner cities are twice as likely

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to have psychiatric disorder as those from elsewhere. These

children are also more likely to come from overcrowded, unhappy

homes with disturbed parents. Schools with high rates of teacher

and pupil turnover have more disturbed children. In western

country’s, immigrant children, especially West Indian, have high

rates for conduct disorders.

Classification

A World Health Organization Committee recommended that children

be assessed on four dimensions:

1. Clinical psychiatric syndrome
2. Intelligence
3. Organic factors and
4. Psychosocial factors

Clinically, children show the same range of anxiety disorders,

psychosomatic disorders and psychosis as those found in adults. The

vast majority can be divided into two groups:

1. Children with predominantly neurotic symptoms. These children

may suffer from anxiety, phobias, shyness, sleep and appetite

disorders and tics. Most grow up to be stable adults.

2. Children with predominantly conduct disorders; stealing,

aggression, lying, over-activity, truancy. These children have poor

prognosis in adult life with higher rates of crime, alcoholism

psychiatric admission and poor work record.

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Children with behavior disorders are usually disturbed at home or at

school; only in severe cases at both. About 7% of 10 to 11 year olds

have some kind of psychiatric disorder. Boys have twice as much as

girls and also exhibit conduct disorders more often.

A few disorders are specific to childhood and adolescence. These

include early childhood autism, the hyperkinetic syndrome and

anorexia nervosa. Specific developmental disorders include dyslexia,

stammering, enuresis, encoupresis and ‘clumsy children’. Some of

these are described in more detail below.

Specific syndromes of childhood psychiatric disorder

Nocturnal enuresis (bed wetting): This is more common in early

years. At 14 years of age and above, the problem drops to 1 in 35.

The problem is more common in males of below average intelligence

living in poor social conditions. It is associated with a strong family

history. 5% of cases are caused by urinary infections. Other cases

may be neurotic, for example, regression after birth of a younger

sibling. Yet other cases may be developmental. Treatment includes

conditioning by an incontinence pad connected to a bell. Imipramine

25 or 50 mg may be given at night to older children; prolonged

treatment is necessary.

Encopresis: This involves soiling; rater than enuresis. It is usually

characterized by retention with overflow. Children with this problem

are often of normal intelligence. The problem may be neurotic or

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developmental. Treatment tends be unrewarding, however, 50% of

children experience spontaneous recovery in two years, and almost

all recover before adult life.

Stuttering: There are two groups of children who may suffer from

stuttering. The first are dull, often from poor social backgrounds and

having suffered a birth injury. The second group tends to be of

average or above average intelligence, and come from, ambitious

families with anxious, obsess ional mothers. In both groups the

anxiety engendered by stuttering may lead to secondary neurotic

disorders. Speech therapy is helpful.

Early childhood autism: This is a form of childhood psychosis

beginning from birth or in the first three years. It should not be

confused with schizophrenia, which is rare and occurs later in

childhood. Autism is now generally agreed to be an organic condition,

although formerly it was attributed to upbringing or the parents’

personalities. The central defect is a difficulty in comprehension and

the use of language. It is rare, occurring in about 1 in 2000 school

children. Three boys are affected for every girl. The parents of autistic

children tend to be intelligent. The symptoms comprise lack of

speech: problem of comprehension, mutism or abnormal speech, with

echolalia and the avoidance of the personal pronoun, and a

monotonous mechanical voice. Autistic children have difficulty in

copying movements: flicking movements of hands, spinning and

jumping movements. They often exhibit a paradoxical response to

sounds. They are resistance to change of routine. They are generally

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socially aloof, live in a world of their own. They often have tantrums.

When testable, only 30% of autistic children have an IQ above 55. A

third of autistic children develop fits in adolescence or adult life.

Differential diagnoses include: deafness, partial blindness, elective

mutism, mental sub normality.

The prognosis is poor. 60% of autistic children remain unchanged,

only 15 per cent find open employment. The prognosis is slightly

improved in those children with a higher IQ.

School refusal (‘school phobia’): school phobia is relatively rare. Peak

age for its occurrence is 11 to 12 years. It is often precipitated by

change of school or illness in parents or grandparents. It is found

most often in boys and children of intelligence average. It is more

common in well behaved children doing well at school, who are often

anxious and shy. The problem is associated with increasing anxiety,

often with abdominal pain and vomiting, culminating in refusal to go to

school. It is quite distinct from truancy. The mothers of children

suffering from school refusal are often over-protective and subject to

depression. The problem is generally due to separation anxiety rather

than fear of school. The treatment may necessitate admission to a

residential school or temporary separation form parents.

Tics (habit spasms): Ticks are sudden, brief, often repeated

movements involving a group of muscles. They have no purpose but

are usually based on purposive movements such as: blinking, head

shaking and coughing. The most common tic is eye blinking; tics

decline in frequency from head to feet. They are found in 10% of

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children aged 6 to 7 years. They are twice as common in boys. There

is often a family history of tics. Children with tics are commonly of

average or above in intelligence and well behaved. They are often

associated with emotional disturbance; sometimes with speech

disorders, obsessions and hypochondria

The prognosis is good. Most tics are short-lived, the others

spontaneously generally improve in adolescence. The very rare Gilles

de la Tourette syndrome comprises multiple severe tics with

compulsive swearing, and has a poor prognosis.

Hyperkinetic syndrome: This syndrome is characterized by overactive

from an early age, sleeping little, wearing out clothes and shoes and

an inability to sit still. Children with this problem are dangerously

impulsive, distractible, with a short attention span. They exhibit day

dreaming and lack of perseverance. They are excitable and have

frequent temper tantrums. The syndrome is sometimes associated

with organic brain disease, epilepsy or a low IQ. But often it is not. It

is five times more common in boys and is not a rare condition,

children with the syndrome show an excess of minor neurological

abnormalities, for example, in coordination and clumsiness. Parents

generally have above average rates of personality disorder and

alcoholism. Children have similar risk in adult life. The prognosis is

poor, although some respond to large doses of ritalin (methyl

phenidate) or to imipramine.

Elective mutism: This is a neurotic disorder in which the child, usually

male, is persistently mute in selected circumstances, for instance, at

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school. Most are solitary and over-dependent on their parents.

Treatment includes a change of environment on admission.

Adolescent psychiatry

The adolescent years are a time of major change for the individual. A

growth spurt in early adolescence (13-14 years of age for boys and

10-12 years of age for girls) is followed soon after by sexual

maturation. The adolescent becomes physically different in a very

short time and is faced with a strenuous psychological adjustment to

these changes throughout adolescence, intellectual maturation

progresses. Although IQ does not continue to rise there, is an

increase in logical and abstract reasoning. Emotionally, the

adolescent generally strives for maturity and independence,

particularly from their parents, but finds it difficult to give up the

security and dependence of home and parents. Their ambivalent

feelings lead to frequent inconsistencies in behavior. This in between

state is accompanied by mild feelings of depression and emptiness in

50% of adolescents. Eriksson describes adolescence as a time of

identity crisis when the individual has to decide who she or he is what

she or he can do and what she or he will make of her or his life Social

pressures are plentiful. He or she must learn many new roles at this

time - changing from school to work, from child to parent. There is

much pressure to conform to the peer group, whose standards may

differ sharply form those of parents. It should be emphasized that

although minor conflicts are common, serious and persistent

difficulties between adolescents and their parents are rare.

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In a study of 14 year olds in the Isle of Wight, 20% demonstrated

evidence of psychiatric disorder, but half of these were not

handicapped by their symptoms either at school or at home. A survey

of urban teenagers showed that 6% of boys and 3% of girls had

severe disorders. In general, rates for psychiatric disorder are higher

than those for adults. Those who are disordered often communicate

poorly with their parents.

Types of adolescent disorder

As with children, adolescent disorders are may be classified as

behavioral (conduct) or emotional (neurotic) disturbance. Many

adolescents show both.

Neurotic disorder: As adolescence advances the symptoms are

similar to those seen in adults. Depression and anxiety are common,

the content of thought being the normal problems of the age group

but this are magnified; appearance, sexual problems, status with

friends are frequent preoccupations School refusal in adolescence

may be a sign of severe neurotic difficulty.

Conduct disorder: This disorder is more common in boys form

disturbed families. It is characterized by antisocial behavior in a wide

range of settings and poor relations with others; it should not be

confused with delinquency. The number of delinquents showing

psychiatric disorder is not much higher than average. Conduct

disorder is often associated with reading difficulties.

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Anorexia nervosa: This problem is a common and increasing disorder

of adolescent girls. It occurs in 1 in 150 girls in this age group. Only 1

in 20 of the patients are male. The disorder generally begins with the

wish to diet and feeling fat. It is characterized by progressive weight

loss associated with early amenorrhea. The patient quickly becomes

emaciated, but maintains s/he feels normal and looks normal and

claims to be eating adequately. The disorder often includes selfinduced

vomiting and excessive purging carried out in secret. There

may be intermittent over-eating (bulimia) especially after treatment.

Patients are very resistant to accepting treatment. the disorder is

potentially serious. In those whom the condition lasts for ten years the

later mortality may be 10%. Poor prognosis is associated with

disturbed body image.

The weight of patients with the disease typically falls to 30 to 35 kg.

The may be best regarded as a phobic avoidance of adolescent

weight gain and the physical and psychological changes of puberty.

The treatment target is to enable the patient to gain weight assisted

by good nursing, high doses of phenothiazines and psychotherapy.

Treatment requires extended and careful follow-up.

Other problems associated with adolescence. Suicide is rare but

rates rise in adolescence. Those who commit suicide are often taller

than average and above average intelligence. Attempted suicide is

very common it may be associated with parental death.

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Affective disorders are rare, but schizophrenia is more likely.

Schizophrenia often has an insidious onset and so cases may be

difficult to distinguish from the normal difficulties of a shy adolescent

with identity problems.

Brain damage resulting from road traffic accidents is a growing

problem.

Drug abuse is common in adolescence and alcoholism increasing.

Treatment methods

In emotional disorders of childhood, family relationships are often

relevant and most child psychiatric clinics employ a treatment team

including a doctor, a social worker, a psychologist, a nurse and a play

therapist. Individual or group therapy including the family members

and the child may be indicated, especially where there a family

history of suicide. Residential treatment in hospital or special

boarding school may be needed when the home is unsatisfactory or

where the behavior disorder cannot be contained by out-patient care

alone. Drug treatments are less often used than with adults but

tranquillizers and anti-depressants may be of value. ECT and

psychosurgery are seldom, if ever, needed.

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Treatment services

Many adolescents do not seek medical help with their symptoms.

Some psychiatrists specialize in this age group, but many patients

with conditions such as self- poisoning or anorexia are seen by adult

psychiatrists. Child psychiatrists often are involved with younger

adolescents, especially those with school difficulties. Interviewing and

treating adolescents poses problems for the doctor who is usually

seen by the patient as an agent if parental authority. The young

doctor has an advantage in dealing with teenagers. Severely

disturbed teenagers are best managed in a special adolescent unit

with appropriate facilities - social and educational -rather than an

adult hospital.

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REVIEW QUESTIONS

1. Children from one parent families have more psychiatric problems

than other children.

1. True b. False
2. Juvenile delinquency is not associated with particular

geographical areas, poor neglected housing, over crowding, low

family income and high adult crime rate

1. True b. False
2. List the four dimensions of children mental health classifications

according to world health organization

4. Boys have twice as many conduct disorders as girls.
5. False b. True
6. Anorexia nervosa is more common and increasing disorder of

adolescence.

1. True b. False
2. Suicide, brain damage due to accident, drugs and alcohol abuse

are common psychiatric problems in adolescent age group.

1. True b. False

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UNIT EIGHT

ALCOHOL AND OTHER SUBSTANCE

ABUSE

Learning objectives

After studying this unit, the student should be able to:

1. Define alcohol and alcohol related terms
2. Describe the characteristics of alcohol withdrawal syndrome

(AWS)

3. Describe different treatment modalities for substance abuse
4. Describe alcohol withdrawal delirium
5. Describe alcoholic amenestic syndrome (Wernicke Korsaff’s

syndrome)

6. Describe nursing intervention for organic mental syndromes and

disorders.

Definitions

Teetotaler: Person who do not drink alcohol at all

Social drinker: Person who drinks moderately but who may get drunk

from time to time

Excessive drinker: Person who may drink excessively and may show

either by the frequency with which they become intoxicated or by the

degree of the social, economic or medical consequence of their

continuous intake of alcohol. Not all excessive drinkers are alcoholics.

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Tolerance: The need for markedly increased amount of alcohol to

achieve the desired effect.

Withdrawal: The development of symptoms like morning shakes after

cessation or deduction in drinking when alcohol is withdrawn.

Abuse of substance (non therapeutic use of substance): Implies a

pathological pattern of use of substances such as drugs, an inability

to control this use and impairment in social or occupational

functioning, with the duration of the abuse of at least a month.

Alcohol

Alcohol (ethyl alcohol or ethanol) is perhaps the substance most

intensively used for non-medical purpose. It can be produced by the

growth of yeast in a sugar-containing medium (fermentation).

Alcohol acts on every cell of the body; however the CNS is its prime

target. Its effects occur more rapidly in the CNS than in any other

tissue of the body. It affects every level of organization with in the

CNS: from its chemistry to its molecular structure and the integrated

functions that govern thought process, emotions motor function and

behavior.

A single dose of alcohol results in non - specific general depression of

the CNS and subsequent behavioral changes. These changes are

dose dependent. They are related to the blood alcohol concentration

(BAC).However, some of the CNS changes may be longer lasting;

acute alcohol intake increases synaptic membrane fluidity. However,

chronic alcohol intake induces a long lasting resistance to its

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membrane fluidizing effect. Elimination of alcohol from the system, or

a marked decrease in BAC after long term use may cause the alcohol

withdrawal syndrome (AWS)

Characteristics of AWS

Characteristics of AWS include hyper-excitability (opposite of

depression) evidenced by tremors and agitation, convulsions, ataxia,

dizziness, diaphoresis, dilation of pupils and hallucination.

The depression of the CNS by alcohol is dependent on the amount

consumed. The effects on mood and behavior differ between

individuals and depend not only on the amount consumed but also to

a large extent, on the personality and the mental state of the

individual and their environment.

Small amounts of alcohol will produce sedation and relief of anxiety.

As the blood level increases, these symptoms become more

pronounced. When a large amount is consumed depression,

inadequate muscular coordination (ataxia), impaired psychomotor

performance, poor judgment and inhibited or irresponsible behavior

may be manifested. Excessive consumption will produce

unconsciousness and may be lethal in the presence of other

depressant drugs.

Alcohol is mainly absorbed directly in small intestine, but also in

stomach. In the presence of food the rate of absorption decreases.

Most of the absorbed ethanol is completely oxidized to CO2.Alcohol

affects the organs of the body as follows:

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CNS: Alcohol depresses brain function including behavior, cognition

judgment, respiration, sexuality and interferes with motor functions.

GIT (gastrointestinal tract): Alcohol erodes the stomach and causes

mucosa-gastritis, acute pancrititis, cirrhosis in the liver and alcoholic

hepatitis.

CVS: Alcohol may cause hypertension and alcoholic cardiomyopathy

(erosion of the wall of the heart).

Kidney: Alcohol causes diuresis.

Eye: Alcohol causes pupilary dilation, hyper reflexia.

Alcoholism

According to USA National Council on Alcoholism, the alcoholic is

powerless to stop the drinking that seriously alters his normal living

pattern. Alcoholics Anonymous describes alcoholism as a physical

condition associated with a mental obsession. It is considered to be

partly physical, partly psychological partly sociological and partly

caused by the effect of alcohol.

Chronic alcoholism is a disabling disorder which imposes on the

sufferer physical, social and psychological handicaps often of great

severity.

It has been repeatedly observed that the medical outpatients and

causality departments note an increase in problems on Monday

morning (Monday fever) as many of patients present with the

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symptoms of hangover (body pains, dizziness and so on) and request

to take sick leave.

Etiology

The precise causes of alcoholism are unclear; psychological and

coping factors play an important role of causation. Alcoholism runs in

families, various studies of alcoholic groups reveal that up to:

- 50% of alcoholics have alcoholic fathers

- 30% alcoholics have alcoholic brothers

- 6% alcoholics have alcoholic mothers

- 3% alcoholics have alcoholic sisters

Heavy drinkers tend to come from heavy drinking families and the

children of alcoholics have a higher risk of alcoholism than do

children of parents who are not alcoholics.

Females are more likely to become alcoholic if the mother is alcoholic

or they have a monozygotic twin who suffers from the disorder.

Certain races show clear cultural and racial links with alcoholism. The

Irish appear to be highly vulnerable, Jews and Moslems nearly

invulnerable. Alcoholism is common in men than in women (5:2) and

is mainly a disorder of middle age.

According to DSM III R, The essential features of alcohol abuse are:

1. Continuous or episodic use of alcohol for at least one month
2. Withdrawal from social, occupational, or recreational activities.

Social problems such as arguments or difficulties with family or

friends, violence, while intoxicated, missed work, being tired, legal

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problems resulting from alcohol intake such as being arrested for

intoxicated behavior and traffic accidents while intoxicated

3. Either psychological dependence or compelling desire to use

alcohol

4. Inability to cut down or stop drinking.
5. Frequent intoxication
6. Marked intolerance
7. Withdrawal symptoms

Alcohol dependence (alcoholism) is described in DSM III as having

the features of either tolerance or withdrawal.

The social complications due to alcoholism include a high rate of

marital separation and divorce, job troubles including absenteeism,

high frequency of accident and economic crimes. Usually the patient

has some alcohol –related impairment in at least one of the following

areas: Work or school; heath; family relationships; social functioning

such as seeing only drinking friends or legal problems such as arrest

for driving while intoxicated or alcohol related violence. Substances

are often taken to relieve or avoid withdrawal symptoms despite

knowledge of having impairment.

Alcohol-related disorders

Medical complications could result from acute effects of heavy

drinking, chronic effects of heavy drinking or withdrawal; nearly every

organ system can be affected directly or indirectly. Gastritis, gastric

ulcer, acute hemorrhagic pancrititis, liver cirrhosis, peripheral

neuropathy and aminestic syndromes are but a few of the major

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medical complications of alcoholism. Alcoholic paranoid psychosis

and korsakoff- syndrome (dementia) are generally not reversible.

Medical complications like cirrhosis, peptic ulcer disease, thiamine

deficiency and neurological diseases like cerebral degeneration can

occur.

Treatment

Alcoholism, when it is recognized, requires a treatment program

which has a total abstention as the main goal. Sedatives are to be

avoided and tranquilizers used only during the withdrawal phase.

Antidepressants should be used if depression is present. The suicidal

risk should always be considered. Suicide is 60 times more common

in alcoholics than in non alcoholics.

Detoxification

Out patient detoxification requires a co-operative patient and a cooperative

significant other person. The patient is given

chlorodiazepoxide hydrochloride 20 - 25 mg four times daily, with the

dose depending on the severity of the withdrawal symptoms.

Alcoholics who show signs of impending delirium, tremors, hyper

irritability, increased pulse rate and high blood pressure require

hospitalization for detoxification. Alcoholics who are seriously

depressed, suicidal, psychotic or who are uncooperative also require

a hospital setting for detoxification. Finally one must hospitalize those

alcoholics whose drinking can not be interrupted.

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Disulfiram (anti abuse) is useful in the treatment 250 mg/d starting 24

hours after the last drinking. This drug causes nausea; vomiting and

distress which is often severe if the patient resumes drinking alcohol.

Those patients who remain clinically depressed beyond the

detoxification period often benefit from antidepressant medications.

Initially the alcoholic is likely require drying out in a hospital for about

10 days. Since alcoholics have a tremendous craving to drink some

two or three weeks after drying out (stop drinking), hospitalization for

a period of six to eight weeks maytherefore be strongly advised.

Alcohol consuming individuals may present with alcohol dependence

and abuse, withdrawal effects or intoxication.

Alcohol withdrawal symptoms occur several hours after cessation of

or reduction in prolonged heavy alcohol consumption. At least two of

the following must be present autonomic hyper-activity, hand tremor,

insomnia, nausea or vomiting, transient illusions or hallucinations,

anxiety, seizures and agitation.

Alcohol withdrawal delirium

Delirium tremens is the most severe form of the alcohol withdrawal

syndrome. Among hospitalized patients about 5% develop delirium

tremor. A transient organic psychosis may occur. Delirium will occur

within one week of the cessation or reduction of heavy alcohol

ingestion.

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Additional features of withdrawal are:

1. Reduced wakefulness or insomnia
2. Perceptual disturbance (illusion, hallucination) mostly visual but

may be auditory or tactile.

3. Increased or decreased psychomotor activity tremor is almost

always present.

Treatment

Disalfiram-125-500 mg/day produces an unpleasant reaction when

the patient ingests small amount of alcohol. The reaction may be

headache, anxiety, weakness, dyspnea, hyperventilation and

confusion.

Appropriate medical treatment includes vitamin saturation, fluid

replacement, and antibiotics if infection develops.

Tranquilizers with a pharmacological cross tolerance to alcohol such

as chlorodizepoxide should be given in a dose of 25-50 mg every 2-4

hours. Diazepam may also be used. Phenothiazines should be

avoided because they may introduce the possibility of hepatitis

superimposed up on preexisting impaired hepatic functioning. They

also tend to reduce seizure threshold.

Alcoholic amnestic syndrome (Wernicke Korsakoff's syndrome)

The essential feature of alcohol amnestic syndrome is a short term

but not immediate memory disturbance due to the prolonged heavy

use of alcohol.

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Other complications of alcoholism such as cerebral signs, peripheral

neuropathy and cirrhosis may be present (the patient may or may not

confabulate but disoriented in special for the time). It rarely occurs

before the age of 35 years.

Etiology

The irreversible memory deficit known as Korsakoff’s psychosis often

follows an acute episode of Warnike's encephalopathy manifested by

ataxia, ophtalmoplegia, nystagmus and confusion.

Thiamine deficiency malnutrition is a predisposing factor.

Its prevalence is unknown

Treatment

The symptoms are usually irreversible; although various degrees of

recovery have been reported with a daily regimen of 50-100 mg

thiamin hydrochloride. Thiamine -100mg daily for 3 days may be

given to prevent Wernicke encephalopathy.

Substance related disorders

A variety of substances may cause substance related disorders

including alcohol, amphetamines and amphetamine-like substances

such as khat, cannabis cocaine, nicotine, hallucinogens, opoids, etc.

Khat, alcohol and cannabis (Hashish) are the commonly used

substances in Ethiopia.

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Epidemiology

The prevalence of khat consumption in Ethiopia is 50% and alcohol

consumption is 23.4%.

Khat

The chewing of the stimulant leaf khat is a habit that is widespread in

certain countries of east Africa and the Arabian peninsula It was

noticed, long ago, that the plant of khat growing in some regions of

East Africa including Ethiopia, has a certain influence of the psychic

and physical state of persons who uses it.. ‘Chat edulis’ or khat is

short evergreen plant or shrub from family celestraceae which grows

in higher altitude, with green glossy leaves, a small crown and

diminutive white flowers in a small branches.

Khat is cultivated in Ethiopia both for export and for local

consumption. Because of economic importance of khat in Ethiopian

its control may be difficult at present, since the export potential of this

agent is increasing. Between 1975 and 1982 an average of 2085

metric tones of khat were exported annually and the National Bank of

Ethiopia estimated that the khat export value in 1982 alone was $US

16 million. It is one of the top economic plants particularly in

Hararghe zone near by Alemaya University namely ’Awaday’.

It is evident from different studies that the medical and psychosocial

effects of khat chewing are harmful both to the individual and the

community. The habit of khat chewing seriously affects the psycho

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economic structure of the subject. It is important to be aware of the

increasing prevalence of khat chewing in order to assess the health

and socioeconomic problems of khat habituation and to take further,

appropriate medical and social measures.

As stated by some investigators, the prevalence rate of khat

consumption is 22.3% in Gondar College of medical sciences and it is

higher among the youngsters between the ages of 21

– 24 years, which is an economically productive age group. The

prevalence rate among the community in Jimma town is 54% and in

Agaro it is 62.9%.

Khat is used because of the effect it has on the person’s psychic and

physical condition. Khat has an extreme social effect (individual

sociability and ease within social gatherings). It provides a major

motivation for people to engage in social gatherings, and is used in all

major ceremonial occasions such as wedding, funerals and religious

holidays

Nowadays the medical and socioeconomic problems related to khat

have attracted the attention of many international agencies including

the United Nations. In 1975 the United Nations narcotic laboratory in

Geneva discovered the major active principle of fresh leaves, namely

cthionone. Khat has been the subject of phytochemical investigations

for over 100 years and so it is surprising that main active principle

was discovered only in the mid 1970's. This delay was because

earlier investigations on the plant were undertaken on dried leaves.

Interesting enough people, who are using khat without knowing its

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chemistry, consume the fresh leaf and stem of khat which contain the

active ingredient which has stimulating effect.

It is now established that the effect of khatleaves on the central

nervous system (CNS) are caused by cathionone, which exhibits

properties similar to those of amphetamine. Furthermore

phenylpentey amine merucathionone has been recently discovered in

khat leaves. This makes a minor contribution towards khat’s

psychoactive effect.

Khat is known for producing amphetamine-like effect. It is an

amphetamine-like substance with the following behavioral and

physical effects: alertness, euphoria, hyperactivity, irritability,

aggressiveness, agitation, paranoid trends and hallucinations. Other

physical effects include mydriasis, tremor, dry mouth,

tachycardia, arrhythmias, weight loss and convulsions. Patients can

also develop psychotic disorder, mood disorder, and sexual

dysfunction and sleep disorders.

The patient can also develop withdrawal symptoms upon cessation of

heavy use which manifest with dysphoria, fatigue, sleep disorder,

agitation and craving for the substance.

Treatment

For agitated patients, diazepam 5-10mg every 3hrs IM or P.O can be

given.

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Cannabis

Cannabis products include marijuana and hashish. Intoxicated

patients may exhibit:

Euphoria

Anxiety

Dry mouth

Tachycardia

Increased appetite

(Rarely) hallucinations

Treatment

Treatment includes providing reassurance in a quiet place and

diazepam may be given.

Nursing interventions

The attitude of nursing personnel can influence the quality of care

given to persons who abuse drug. Nurses may view patients who

overdose on drugs with disproval, intolerance, moralistic

condemnation, or anger, or they may not display any emotional

reaction. They should display an accepting, nonjudgmental attitude,

while coping with various behaviors such as manipulation,

noncompliance, aggression or hostility. Nursing personnel need to be

aware of the various signs and symptoms of drug abuse, if they are to

administer appropriate nursing care.

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Nursing interventions include providing medical relief for symptoms

such as nausea, vomiting, bruises, fluid and electrolyte imbalance

and withdrawal symptoms.

There are several nursing diagnoses and interventions in multiple

drug abusers, which include: potential for injury, sensory alterations,

anxiety, sleep pattern disturbance, alterations in nutrition, possible

fluid volume and electrolyte deficit, health maintenance alteration,

noncompliance, ineffective individual coping and potential for

violence.

Table 8: Nursing diagnoses and nursing interventions for

withdrawal symptoms due to multiple drug abuse.

Nursing diagnosis Nursing interventions

Sensory-perceptual

alteration: delirium.

Provide a safe environment.

Decrease environmental stimuli by placing the patient

in a partially lighted room. Avoid loud noise.

Asses level of sensorium.

Alteration in thought

process:

hallucinations.

Orient to person, time and place.

Avoid conveying to the patient the belief that the

hallucinations are real. Encourage the patient to make

the staff aware of the hallucinations. Be alert for signs

of increased fear, anxiety, or agitation.

Anxiety related to

withdrawal

Asses level of anxiety.

Decrease sensory stimulation.

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symptoms. Provide reassurance and comfort.

Potential for injury

owing to altered

sensorium.

Assess for the causative factor of altered sensorium.

Provide a safe environment by keeping the bed at

lowest level at night, utilizing side rails as necessary,

and restraining the patient if necessary (as a last

resort). Orient to surroundings by explaining the call

system, rationale for utilizing side rails, and so on.

Provide a night light to familiarize the patient with the

surroundings.

Alteration in

nutrition: Less than

body requirements

Provide diet as tolerated to supply adequate nutrition

for nourishment and tissue repair unless the patient is

NPO. Make sure that the dietary department serves

appetizing meals, including special dietary

preferences. Serve dietary supplements as needed to

maintain an adequate intake of vitamins, minerals,

and so forth. Maintain an intake and output (I&O) if

necessary.

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REVIEW QUESTIONS

1. In alcohol users, a need for markedly increased amount of alcohol

use to achieve the desired effect is termed as tolerance

1. True b. False
2. One of the following organ system is the main target of alcoholism

in alcohol user individuals

1. GIT (gastrointestinal tract)
2. Cardiovascular system
3. Kidney
4. Central nervous system (CNS)
5. Alcoholism is a problem which needs, physical, psychological and

sociological intervention, not only psychiatric intervention

1. True b. False
2. Detoxifying an alcoholic requires a co-operative patient and a cooperative

significant others.

1. False b. True

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UNIT NINE

DEFENSE MECHANISMS

Learning objectives

After studying this chapter, the student will be able to:

1. Define different defense mechanisms
2. Describe different uses of defense mechanisms.

Definition

Defense mechanism and mental mechanisms are terms used to

describe the unconscious attempt to obtain relief from emotional

conflict or anxiety. Coping mechanisms include both conscious and

unconscious ways of adjusting to environmental stress. Such

mechanisms are supposedly in action by age ten and are used as

follows:

1. To resolve a mental conflict
2. To reduce anxiety or fear
3. To protect one's self esteem
4. To protect one's sense of security.

Approximately 20 different mental mechanisms have been identified.

Some are considered to be healthy defense mechanisms, whereas

others are considered pathologic or characteristic of a mental

disorder. Some of these mechanisms are described below.

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1. Repression: This is an involuntary rejection of ideas. unconscious

thoughts, feelings and memories that are painful (automatic

forgetting): for example, the inability to remember the reason for

an argument or recall feelings of fear following an automobile

accident.

2. Suppression: This is the voluntary act of pushing unacceptable

feelings out of one’s consciousness. This mechanism is generally

used to protect one's self-esteem.

A deliberate intentional exclusion from the conscious mind is referred

to as voluntary forgetting “I had rather not talk about it right now “Let

us talk about my accident later” etc.

3. Rationalization: This is the most common ego defense

mechanism. It is used to justify ideas, actions or feelings by

providing good, acceptable reasons and explanations. It is used to

maintain self-respect, prevent guilt feelings, and obtain social

approval or acceptance: for example, a teenage girl who was not

asked to the junior prom might tell her friend someone really

wanted to date her but felt sorry for Sue and took her to the prom

instead.

4. Identification (the imitator): This is an unconscious adoption of

some of the characteristics of another person.

5. Sublimation: This is one of the defense mechanism that is not

pathogenic. It involves re-channeling of consciously intolerable or

occasionally unacceptable impulse or behaviors into activities that

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are personally or socially acceptable: for example, a college

student who has hostile feelings may re-channel them by joining

the debating team.

6. Displacement: This is a mechanism that serves to transfer feelings

such as frustration, hostility, or anxiety from one idea, person, or

object to another: for example, a person might disagree at his boss

but instead picks a fight with his wife or his children when he is

back at home.

7. Compensation: This is the act of ‘making up‘for a real or imagined

inability or deficiency with a specific behavior to maintain self

respect or self- esteem: for example, a short girl may become the

manager of the girl’s basketball team because she is not tall

enough to qualify for the team, or an unattractive man may select

expensive, stylish cloths to draw attention to himself or an

unattractive woman may dress like a fashion plate to attract

attention.

8. Introjection: This involves attributing to oneself the good qualities of

another: symbolically taking on the character trait of another

person by ‘ingesting’ his philosophy ideas, knowledge, or attitudes.

the term is often used loosely as synonymous with identification.

An example would be a psychiatric patient who claims to be

Mosses or Jesus Christ or other biblical or well known person, who

is observed dressing and acting like the personage they profess to

1. One patient who claimed to be Moses grew a beard and long

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hair, wore a blanket and sandals and read his bible daily. He

refused to participate in activities unless he was called Moses.

9. Projection: This is often termed as the ‘escaping goat’ defense

mechanism. The person rejects unwanted characteristics of her or

himself and assigns them to others. He/she may blame others for

faults, feelings, or shortcomings that are unacceptable to self.

Examples would be: a man who is late for work states, “my wife

forget to get the alarm last night so I overslept” or after spilling a

glass of milk while playing cards with a friend, a 10-year- old tells

his mother, “my brother made me spill the milk. He told me to hurry

up and play.”

10. Regression: This involves returning to past level of behavior to

reduce anxiety, allow one to feel more comfortable and permit

dependency: for example, a 5 year old boy who previously was

toilet trained and who becomes incontinent when his mother gives

birth for a new baby in order to get attention like a newly born

baby.

11. Conversion: This is the transferring of a mental conflict in to a

physical symptom to release tension or anxiety. Examples would

be an elderly woman who experiences sudden blindness after

witnessing a robbery or a middle-aged who man develops

paralysis of his lower extremities after he learns that his wife has

terminal cancer.

12. Reaction formation (overcompensation): This involves acting the

opposite way from what someone normally would in a given

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situation (it is also referred to as overcompensation). Examples

would be a young man who dislikes his mother-in-law who acts

very polite and courteous towards her, a woman who hates

children may talk very lovingly to a friend’s young son, or a man,

who has a strong desire to drink alcohol who condemns the use of

alcohol by others.

13. Undoing or restitution: This is the negation of a previous

consciously intolerable action or experience to reduce or alleviate

feelings of guilt. An example would be a young man sends flowers

to his fiancée after he embraced her friend at a cocktail party.

14. Denial: This is the unconscious refusal to face thoughts, feeling,

wishes, needs or reality factors that are intolerable: for example, a

student who is persistently late for a scheduled class because that

student is actually very fearful of the topic, so he/she expresses

the fear by being absent from the class, or a person who has just

been admitted to a mental hospital states “I am really not sick, I am

just in here to get a rest”

15. Substitution: This is defined as the replacement of consciously

unacceptable emotions, drives, attitudes, or needs by those that

are more acceptable or it is the act of finding another goal when

one is blocked: for example, a student nurse in a baccalaureate

program who decides she is unable to master the clinical

competencies and elects to become a laboratory technician is

using the mechanism of substitution

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16. Fantasy: This refers to imagined events or mental images (e.g.

day dreaming) to express unconscious ideas, conflict, gratify

unconscious wishes, or prepare for anticipated future events: for

example, in a popular television soap opera, a young woman

character who does not have a child fantasizes she has a child, as

she sits in a rocking chair, holding a baby doll, and singing

lullabies.

17. Symbolization: This refers to an object, idea or act that represents

another through some common aspect and carriers the emotional

feeling associated with the other. Symbolization allows emotional

self- expression: for example, the engagement ring symbolizes

love and a commitment to another person, wearing a white

wedding gown generally symbolizes the bride’s purity or chastity.

18. Isolation: This is the process of separating unacceptable feeling,

idea or impulse from one's thought (also referred to as emotional

isolation: for example, an oncologist is able to care for a terminally

ill cancer patient by separating or isolating his feelings or emotional

reaction to the patient’s inevitable death. He focuses on the

treatment, not the prognosis.

19. Dissociation: This is the act of separating and detaching a strong

emotionally charged conflict from one’s considering ness: for

example, a women who was raped was found wondering busy high

way in torn, disheveled clothing. When examined by the

emergency room physician, the woman was exhibiting symptoms

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of traumatic amnesia. She separated and detached her emotional

reaction to the rape from her consciousness.

20. Intellectualization: This refers to the act of transferring emotional

concern in to the intellectual sphere: for example, a young man

may use intellectualization as method of avoiding confrontation

with his fiancé if she changed her mind about wishing to marry

him.

In summary, defense mechanisms are categorized in various ways:

from healthy to unhealthy, sophisticated to primitive, most frequent to

least frequently used. Such lists of defense mechanisms have been

developed after extensive research of several psychological

sociological and psychiatric nursing texts and are based on the

degree of personality disintegration and reality distortion that can

occur when the mechanisms are used frequently.

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REVIEW QUESTIONS

1. State the purpose of defense mechanisms and list them.
2. Defense mechanisms are categorized in various ways, health to

unhealthy, sophisticated to primitive; most frequently used to least

frequently use. After extensive and several psychological,

sociological and psychiatric nursing research.

1. True b. False

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UNIT TEN

PERSONALITY DISORDER (CHARACTER

DISORDER)

Learning objectives

After studying this unit, the student should be able to:

1. Define personality and personality disorder
2. List terms of psychological quality and psychological process
3. List the characteristics of personality disorders
4. Identify the etiology of personality disorder
5. Classify personality disorder in cluster forms
6. Describe personality disorder in terms of clinical types
7. Describe the nursing interventions appropriate for personality

disorders.

Definition of personality

Personality is the total of a person’s internal and external patterns of

endowment and life experience. In general personality is the sum of

all somatic process plus psychological phenomena.

Psychological phenomena equate to psychological quality combined

with psychological process

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Psychological quality

Psychological quality includes the following features:

- Character

- Interest

- Habit

- Skills

- Attitudes

- Ability

- Knowledge

- Motives, etc.

Psychological process

Psychological processes include

- Sensation

- Attention

- Feelings

- Memory

- Thinking

- Will

- Cognition, etc.

Personality disorder

Personality disorder is described as a non-psychotic illness

characterized by maladaptive behavior, which the person utilizes to

fulfill his or her needs and bring satisfaction to self.

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Characteristics of personality disorder

1. The person denies the maladaptive behavior s/he exhibits; such

behavior has become a way of life for him.

2. The maladaptive behaviors are inflexible
3. Minor stress is poorly tolerated, resulting in increased inability to

cope with anxiety

4. Ego functioning is intact but may be defective therefore, it may not

control impulsive actions of the id

5. The person is in contact with reality although s/he has difficulty

dealing with it

6. Disturbance of mood, such as anxiety or depression may be

present

7. Psychiatric help rarely is sought because the person is unaware

or denies that his or her behavior is maladaptive.

Etiology of personality disorders

1. Biological predisposition may result from improper nutrition

neurological defects, and genetic predisposition

2. Child hood experiences can foster the development of

maladaptive behavior

3. Socially deviant persons may have defective egos through

which they are unable to control their impulsive behavior

4. A weak superego may result in the incomplete development of

or lack of a conscience. A person with immature superego will

feel no guilt or remorse for socially unacceptable behavior

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5. The drive for prestige, power and possession can result in

exploitative manipulative behavior

6. Urban societies such as inner cities are characterized by a low

degree of social interaction, thereby fostering the development

of deviant behavior.

Clusters of Personality Disorders

Cluster A

Paranoid personality disorder

The defining trait of paranoid personality disorder is suspiciousness.

Suspiciousness is some thing that we all feel in certain situations and

with certain people, often for good reasons. However, paranoid

personalities feel suspiciousness in almost all situations and with

almost all people, usually for very flimsy reasons. When a paranoid

person is confronted with evidence that their mistrust is unfounded,

they will simply begin to mistrust the person who brought them the

evidence ”So he is against me too”. This results in impairment in

cognitive function.

Schizoid personality disorder

Schizoid personality disorder is defined by a fundamental eccentricity,

a preference for social isolation. According to current thinking,

schizoids are deficient in the capacity to experience social warmth or

any deep feelings and unable to form attachments. Schizoid

personalities rarely marry, have few friends (if any), seem indifferent

to praise or criticism from others, and prefer to be alone. Because of

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their self- absorption, they may seem vague or absent-minded: ’out of

it‘, so to speak. However, such people do not show the unusual

thoughts, behaviors, or speech patterns that one sees in the

schizotypal personality. They may be quite successful in their work, if

it is an occupation that calls for little social contact. On the other hand

the disorder is more common among inhabitants of skid row.

Schizotypal personality disorder

The person with schizotypal personality disorder will seem odd in his

or her speech, behavior, thinking, and /or perception, but not odd

enough for a diagnosis of schizophrenia or the person may report

recurrent illusions, such as feeling as if his dead mother were in the

room: a situation nevertheless different from that of the schizophrenic,

who is likely to believe that his dead mother is actually in the room.

Schizotypal personality disorder may also show magical thinking,

claiming that they tell the future, read the thoughts of others, and so

1. They tend to be suspicious, aloof, and withdrawn. The disorder is

more common in the families of diagnosed schizophrenics than in the

population at large.

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Cluster B personality disorder

Antisocial

The defining characteristic of antisocial personality disorder is a

predatory attitude toward other people: a chronic indifference to and

violation of the rights of one’s fellow human being.

According to DSM-III-R’s lists of criteria for the diagnosis of antisocial

personality disorder can be summarized as five basic points:

1. A history of illegal or socially disapproved activity, beginning

before the age of fifteen and continuing into adulthood

2. Failure to show consistency and responsibility in work, sexual

relationships, parenthood or financial obligations

3. Irritability and aggressiveness, including not just street brawls but

often abuse of spouse and children

4. Reckless and impulsive behavior. Unlike most ’normal‘criminals,

antisocial personalities rarely engage in planning. Instead, they

tend to operate in an aimless, thrill-seeking fashion traveling from

town to town with no goal in mind, falling into bed with anyone

available, stealing a pack of cigarette or a car, depending on what

seems easiest and most gratifying at the moment

5. Disregard for the truth. People with antisocial personalities lie

frequently.

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Borderline personality disorder

Theorists state that the borderline personality disorders may be a

result of a faulty parent–child relationship, in which the child does not

experience a healthy separation from mother to interact with the

environment. Negative feelings are shared by parent and child, who

are bound together by all feelings of guilt. Trauma experienced at a

specific stage of development, usually 18 months may result in a

weakening the person’s ego and ability to handle reality and is

another possible cause. Additionally, the person who experiences an

unfulfilled need for intimacy is liable to develop the disorder.

According to the DSM-III-R, clinical symptoms may include:

1. Unstable interpersonal relationships
2. Impulsive, unpredictable behavior that may involve gambling,

shoplifting, and sex. Such a person tends to use and can tolerate

large amounts of drugs and alcohol

3. Inappropriate anger and inability to control anger.
4. Disturbance in self- concept, including gender identity
5. Unstable affect that shifts from normal moods to periods of

depression, dysphoria (unpleasant mood), or anxiety

6. Chronic feeling of boredom
7. Masochistic behavior (self inflicted pain) and thoughts of suicide
8. Frantic efforts to avoid real or imagined abandonment.

Histrionic personality disorder

The essential feature of histrionic personality disorder is selfdramatization:

the exaggerated display of emotion. Such emotional

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displays are often clearly manipulative, aimed at attracting attention

and sympathy. Interpersonal relationships are usually fragile. Initially,

upon meeting a new person, a person with this disorder will seem

warm and affectionate. Once the friendship is established they

become oppressively demanding, needing their friends to come right

over if they are having emotional crisis. In general they will take from

a relationship with out giving. The histrionic personality resembles a

caricature of the most sexist image of femininity: vain, shallow, self

dramatizing, immature, over-dependent and selfish. The disorder is

more common in women than in men.

Narcissistic personality disorder

The essential feature of narcissistic personality disorder is a

grandiose of self–importance, often combined with periodic feelings of

inferiority. In general people with narcissistic personality disorder

need constant admiration, expect favors from others without

reciprocating, and react to criticism with arrogance and contempt.

Cluster C

Avoidant personality disorder

Avoidant personality disorder is marked by social withdrawal.

However, this withdrawal is not out of inability to experience

interpersonal warmth or closeness but out of a fear or rejection.

Avoidant personalities, though they want to be loved and accepted,

accept that they will not be, and therefore tend to avoid relationships

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unless they are reassured again and again of the other’s uncritical

affection.

Not surprisingly, avoidant personalities generally have low selfesteem,

and while this problem may be a cause of their social

difficulties, it is also a result. They typically feel depressed and angry

at themselves for their social failure, and these feelings further erode

their self-esteem and create a vicious circle.

Obsessive compulsive personality disorder

Obsessive compulsive personality disorder is characterized by an

excessive preoccupation with trivial details at the cost of both

spontaneity and effectiveness. Obsessive compulsive personalities

are so taken up with the mechanics of efficiency: organizing, following

rules, making lists and schedules that they cease to be efficient, for

they never get anything important done. In addition, they are

generally stiff and formal in their dealings with others and are

incapable of taking genuine pleasure in anything. They have difficulty

of decision making. The disorder is more common in men than in

women.

Passive aggressive personality disorder

The essential characteristic of passive aggressive personality

disorder is an indirectly expressed resistance to demands made by

others. At home and in the workplace, passive aggressive

personalities find ways not to do what they are expected to do. Yet

they never openly state their refusal; rather they covertly sabotage

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the job by procrastinating dawdling, making errors or some other

means. Passive aggressive personalities tend to have troubled

marriages and checkered job records. Passive aggressive

maneuvering is not a cover for a laziness or job dissatisfaction but

rather for an underlying hostility towards other people. The diagnosis

should be given to only to those who show pervasive and longstanding

passive-aggressive behavior, both on job and at home.

Dependent Personal Disorder

The dependent person lacks self-confidence and is unable to function

in an independent role. In an attempt to avoid any chance of

becoming self sufficient, the person allows others to become

responsible for his or her life, letting them make all their major

decisions. He or she avoids making demands on others to avoid

jeopardizing any existing dependent relationships that meet his or her

needs. Social relationships and occupational functioning may be

impaired as a result of dependent needs. This disorder is seen in

more frequently in women. Intense discomfort is experienced by a

dependent person who is left alone for some time.

Nursing Intervention

The nursing care of a person who is diagnosed as having a

personality disorder is directed at the specific behavior,

characteristics, and symptoms that are common to the identified

disorder.

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Maladaptive behaviors such as acting-out, stubbornness,

procrastination, over-exaggeration, manipulation, and complete

dependency can elicit negative responses from nursing personnel. A

friendly, accepting environmental should be established in which the

patient is accepted but the maladaptive behavior is not. It is

imperative that the nurse examines her feelings about such behavior

so that she does not allow them to infect therapeutic nursing

interventions.

The individual needs to be given an opportunity to develop ego

controls such as the superego or conscience that is lacking or

underdeveloped. This can be achieved by consistent limit- setting that

is enforced 24 hours a day.

Table 9: Examples of nursing diagnosis and nursing

Interventions for personality disorder

Nursing Diagnoses Nursing Interventions

Ineffective individual

coping: hostility or acting

out

Recognize signs of increasing agitation. Attempt to

’talk down‘ the patient. Encourage verbalization of

feelings to find reason for anger. Maintain a safe

spatial distance to avoid physical contact. Evaluate

appropriateness of hostility. Respond positively to

reasonable demands and requests. Accept the

patient, but inform him or her when behavior is

unacceptable. Set limits and be consistent with

realist controls. Attempt to enrich behavior by

providing a safe environment for acting out hostility,

providing distraction, or assigning constructive

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tasks. Administer p,r,n, medication to decrease

anxiety. Use external controls (e.g. restraints) as a

last measure.

Noncompliance

manipulative behavior

Be aware of ‘power play’ or attempts to manipulate

members of the staff. Identify types of manipulative

behavior exhibited by the patient. Explore your own

feelings regarding such behavior. Confront the

patient if necessary, but without anger,

disappointment, or disgust. Assume a parental

surrogate role to reinforce authority when

necessary. Discuss expectations with patient. Set

limits and be consistent with care. Maintain

consistency and continuity of approach with staff.

Observe interactions with other patients to

discourage manipulative behavior. Intervene if

necessary.

Self- care deficit:

dependency on staff to

meet basic human

needs

Evaluate patient’s developmental level and ability to

carry out the activates for daily living (ADL)

Identify dependency needs, physically and psycho

locally. Identify present coping mechanisms and

support systems. Avoid assuming a parental role.

Be firm when interacting with the patient. Set shortterm

goals with the patient to increase

independence (i.e. daily responsibilities related to

self-care, decision making. etc).

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Impaired verbal

communication: inability

to develop positive

interpersonal

relationships

Develop trust or rapport. Establish a one- to-one

relationship. Encourage expression of self-concept,

including positive and negative feelings. Explore

feelings regarding inability to relate, positively to

others.

Sensory perceptual

alteration: inability to

trust others (suspicious)

Develop trust. Be honest with the patient. Be non

threatening when interacting with patient. Convey

concern and interest. Listen for expressions of

anxiety, fear, or mistrust. Face but keep a distance

from the patient when speaking, Avoid belong overly

friendly. Be specific and clear when presenting

information to the patient. Speak in a normal tone of

voice. Do not whisper when near the patient. Be

selective in the use of nonverbal gestures while

speaking with or near the patient. Respect the

patient’s need for privacy. Discuss confidentiality.

Include the patient in planning treatment to allow the

patient some control. Plan brief contacts with the

patient. Explain procedures to the patient tin detail

and discuss any changes in routine. Be honest;

never trick the patient into taking medication.

Ineffective individual

coping owing to

increased stress or

anxiety

Provide a calm, quiet atmosphere to decrease

excitatory environmental stimuli. Attempt to identify

the source or cause of increased stress or anxiety.

Encourage the patient to verbalize feelings. Identify

previous effective copping mechanisms. Medicate

with anti anxiety agents per physician’s order

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REVIEW QUESTIONS

1. A non psychotic illness characterized by maladaptive behavior,

which the person utilizes to fulfill his or her needs and bring

satisfaction to self is called personality disorder.

1. True b. False
2. A type of character disorder which is marked by social withdrawal

and a tendency to avoid relationships with others is termed as

obsessive compulsive personality disorder

1. True b. False
2. Avoidant personality disorder, obsessive-compulsive personality

disorder and passive aggressive personality disorders are sub

classifications of Cluster C personality disorders.

1. True b. False
2. Cluster B personality disorders include, antisocial, borderline and

histrionic personality disorders.

1. False b. True

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UNIT ELEVEN

HUMAN SEXUALITY AND SEXUAL

DYSFUNCTION

Learning objectives

After studying this unit, the student will be able to:

1. Define human sexuality
2. Discus the criteria for normal sexual behavior
3. Identify causal factors in sexual dysfunction
4. Define sexual déviation (sexual perversion) or paraphilias
5. Differentiate sexual deviation (sexual perversion) and paraphilias
6. Describe nursing interventions for human sexual deviations and

dysfunction.

Definition

Human sexual behavior should be considered in the context of the

whole personality. Normal sexual behavior takes a wide range of

forms and depends upon moral, social and logical norms in a given

culture or community. The aim of sexual behavior is pleasure and the

relief of sexual tension. Pathological behavior may be a presenting

symptom of an existing disorder or transient manifestation of an

emotional or personality disorder or of organic disease.

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Normal sexuality

Normal sexual behavior is generally described as a sexual act

between consenting adults, lacking any type of force and performed

in a private setting in the absence of unwilling observers. Abnormal

and unwanted sexual behavior therefore would be considered as any

act that does not meet the criteria set out in this definition.

According to Masters and Johnson’s (1970) observation that the

physiological process of sexual intercourse involves increasing levels

of vosocongestion and myotonia (tumescence) and the subsequent

release of the vascular activity and muscle tone as a result of orgasm

(detumescence). The process occurs in the four phases of

excitement, plateau, orgasm and resolution.

Excitement: This is brought on by physiological stimulation fantasy in

the presence of loved object: physical stimulation including stroking or

kissing or both. It may last several minutes to several hours.

Plateau: This is a continuous stimulation and characterized by an

increase in intensity. It lasts from 30 seconds to several minutes

depending up on the sexual stimuli and drive.

Orgasm: This involves subjective sense of ejaculatory inevitability

which triggers the man’s orgasm. It lasts from 3 - 45 seconds. The

ejaculation consists of about one teaspoonful (2.5ml) of fluid and

contains about 120 - 250 million sperm cells.

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Resolution: Resolution through orgasm is characterized by a

subjective sense of well being. If orgasm occurs resolution is rapid. If

it doesn’t occur, resolution may take 2 - 6 hours.

Sexual response of the female

Whether explicitly stated or not, discussion of ‘normal’ female sexual

response sometimes seems to imply that a women should reach

orgasm during intercourse, preferably without manual stimulation. Yet

millions of women do not fit this description and some may feel

deficient. One of the most common complaints women bring to sex

therapists is a socially defined dysfunction: they reach orgasm only

through manual or oral stimulation of the clitoris, or only through

manual or oral stimulation of the clitoris, or only when the intercourse

is combined with such direct stimulation. In fact, this is normal.

Causal factors in human sexual dysfunction

Most causes of sexual dysfunction seem traceable to psychological

rather than physical causes. The following psychosocial factors are

commonly found:

Faulty learning: Masters and Johnson consider faulty learning to be

the primary cause of orgasmic dysfunction in females. In vaginismus,

a some what different conditioning pattern may have occurred,

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leading the female to associate vaginal penetration with pain, either

physical, psychological or both. On the other hand, in males a first

sex experience with a prostitute, or some other situation in which

harried ejaculation was necessary, may result in premature

ejaculation. Once this pattern is established the individual may be

unable to break the conditioned response.

Feelings of fear, anxiety and inadequacy: Males who suffer from

impotence are often anxious, frustrated and humiliated by their

inability to produce or maintain an erection. Premature ejaculation

can also lead to feelings of inadequacy and guilt.

Interpersonal problems (conflict with others)

Changing male-female relationships: Many men consider themselves

as supposedly ‘dominant’ partners who take the initiative in sexual

relations. This may not always be appropriate in modern

relationships.

Homosexuality and other factors

Drug affecting sexual dysfunction

Drugs can lead to the following sexual dysfunctions:

1. I) Impaired ejaculation

- Guanathidine

- Bethamedine

- Thioridazine.

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1. II) Decreased libido and impotency

- a. Oral contraceptive

- b. Sedatives

- c. Major tranquilizers

- d .Lithium

- e. Methyldopa

- f. Clamidine

Sexual disorders can be symptomatic of biological problems, intrapsychological

conflicts, interpersonal differences or a combination of

these. The sexual function can be adversely affected by stress of any

fixed emotional disorders and by a lack of sexual knowledge.

Classifications of Sexual dysfunctions:

Erectile dysfunction or impotence: This is characterized by an inability

to achieve or maintain an erection sufficient for successful sexual

intercourse. In primary impotence the man is not able to have

erection at all in his sexual life. In secondary impotence, the man has

successfully achieved vaginal penetration at some time in his sexual

life but is later unable to do so. But In selective impotence, the man is

unable to do so in certain circumstances but not in others.

Premature ejaculation: This occurs when the man recurrently

achieves orgasm and ejaculation before he wishes to do so. It is more

common today among college educated men than among men with

less education and it is thought to be related to their concern for

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partner satisfaction. About 40% of men treated for sexual disorders

have premature ejaculation as the chief complaint.

There are three types of premature ejaculation known as

1. Habitual premature ejaculation
2. Acute onset premature ejaculation
3. Insidious onset premature ejaculation

Frigidity (inhibited sexual excitement) in female: This is characterized

by the inability of the female to express sexual satisfaction. Its chef

physical manifestation is a failure to produce the characteristic

lubrication of the vulva and vaginal tissue during sexual stimulation, a

condition that may make coitus uncomfortable.

Inhibited Female orgasm (anorgasmia): This is characterized by a

recurrent and persistent inhibition of the female orgasm as

manifested by a delay in or absence of orgasm following a normal

sexual excitement phase during sexual activity, It refers to the inability

of the women to achieve orgasm by masturbation or coitus.

Dyspareunia: This is a recurrent and persistent pain during coitus in

either the man or the women. It often coincides with vaginismus. It is

due to physical factors like trauma, inflammation, endometritis. It can

also result from psychological cause.

Vaginismus: This is an involuntary constriction of the outer one third

of the vagina that prevents penetration, insertion and coitus. It is less

prevalent than anorgasmia. It often affects highly educated women

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and those in higher socioeconomic groups. Sexual trauma as rape

may result in vaginismus.

Sexual deviation (sexual perversion) or paraphilias

This is characterized by a sexual behavior which is not customarily

accepted.

1. Homosexuality: This involves the attraction for sexual relation with

persons of the same sex. Homosexuality between women is

termed as lesbianism. In most cultures it is not considered a

perversion.

2. Exhibitionism: This is sexual gratification by genital exposure in

public. It is found in men who have directed towards children of

either sex. It is a form of homosexuality and tends to occur in

impotent males.

3. Pedophilia: This is a sexual deviation in which there is unusual

sexual interest directed towards children of either sex. It tends to

occur in impotent males.

4. Voyeurism: It is sexual gratification from observing others

engaged in sexual activity.

5. Fetishism: This is a male sexual deviation in which the deviant is

unable to love a person sexually because of immature sexual

development. This involves sexual contact with inanimate article

or fetish, such as clothes.

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6. Transvestitism: This involves sexual arousal and satisfaction by

wearing the clothes appropriate to the opposite sex.

7. 7. Sadism: This involves a sexual gratification from inflicting of pain

on one's sexual partner.

8. Transsexualism: This involves a persistent sense of discomfort

about one’s anatomic sex and wish to live as a member of the

opposite sex.

9. Masochism: This involves the enjoyment of pain, humiliation and

punishment by the sexual partner.

10. Zoophilia (bestiality): This involves obtaining sexual gratification

through contact with animals.

11. Rape: Violence and the lack of consent by the sexual partner are

the elements in rape that makes it both criminal and deviant.

12. Incest: This involves sexual union of close relatives. This is a

taboo that is one of the strongest in our culture.

13. Nymphomania: This is excessive sexual derive or desire in

females.

14. Satyriasis: This is excessive sexual drive or desire in males.
15. Telephone scatologia: Sexual gratification is achieved by

telephoning someone and making lewd remarks or remaining

silent on the line.

16. Frotteurism: Sexual excitement is achieved by touching and

rubbing against a non consenting person.

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Nursing intervention in sexual disorders

The nurse must examine their feelings about her/his own sexuality

before she /he is able to care for the patients who sexually act out or

present symptoms of sexual disorders. Nurses are not immune to the

development of identity disorders, an unresolved Oedipal or Electra

complex, or psychosexual dysfunction. Feelings of disgust, contempt,

anger or fear need to be identified and explored so that they do not

interfere with the development of a therapeutic relationship. This is

one of the reasons patients do better with a team approach rather

than with individual therapy. The quality of nursing care will depend

on the nurse’s ability to be nonjudgmental and to understand the

behavior of a patient who is sexually acting out.

Nursing intervention for patients who exhibits symptoms of sexual

disorders also includes planning care to meet the basic human

needs, providing a protective care for the patient, exploring methods

to re-channel sexually unacceptable behavior and participation in a

variety of therapies, including behavior therapy, and psychotherapy.

The nurse must also assume the role of patient advocate to ensure

the promotion of sexual health when the opportunity occurs.

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Table 10: Nursing diagnoses and interventions for patients who

exhibit symptoms of sexual disorders

Nursing diagnoses Nursing interventions

Alteration in pattern of

sexuality: impulsive

sexual actions

resulting In physical

contact.

Explain to the patient that touching makes you feel

uncomfortable. Ask the patient to explain his feelings t

the time he acted impulsively - Explore the meaning of

specific behavior. Be firm but nonjudgmental when

setting limits. Be consistent. Intervene in any overt acts

towards other patients. Explain to the patient that he

must respect the rights of others. Avoid placing the

patient in activities requiring physical contact. Provide

protective isolation for other patients if necessary since

his overt behavior may provoke hostility.

Alteration in pattern of

sexuality: verbal

comments with

sexual overtones

Respond by recognizing the patient’s feelings (i.e., “it

must be difficult to be away from your fiancée”).

Allow the patient to ventilate the reason for his

comment without encouraging his behavior.

Explore alternative ways to channel the patient’s

advances to result in a more positive outcome.

Alteration in pattern of

sexuality:

masturbatory

behavior

Request that the patient limit his activity to private area

to avoid offending others. Intervene in any attempt by

the patient to involve others in his activity. Explore the

meaning behind the patients behavior. Discuss

alternative behavior with the patient.

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Sexual dysfunction

owing to increased

anxiety.

Encourage verbalization of feelings. Explore reasons

for increased anxiety. Assess the patient’s knowledge

of cause of sexual dysfunction. Inform the patient of

various resources available (e.g., sex education

courses, clinics, counseling therapy, and reference

books). Administer any prescribed anti-anxiety agents.

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REVIEW QUESTIONS

1. List at least four types of drugs which can affect libido and cause

impotency.

2. List at least five types of human sexual dysfunctions.
3. Sadism is a sexual gratification from inflicting of pain on one’s

sexual partner.

1. False b. True
2. Homosexuality between men is called lesbianism
3. True b. False
4. List the four consecutive process of human normal sexual

responses according to Masters and Johnson’s observations.

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UNIT TWELVE

PSYCHOTHERAPY

Learning objectives

After studying this unit, the student should be able to :

1. Define psychotherapy
2. Identify Freud and psychoanalysis method
3. Identify indications for psychotherapy
4. Differentiate different types of psychotherapy
5. Identify different methods of psychotherapy
6. List the advantages of psychotherapy

Definition

Psychotherapy may be broadly defined as any treatment designed to

influence behavior by verbal or non-verbal means. It includes

techniques as varied as confession, reassurance, hypnosis,

psychoanalysis and brain-washing.

There is ample evidence from outside medicine that what one person

says to another may greatly influence behavior and doctors have

always realized the therapeutic, as well as the diagnostic value of

intelligent history-taking. Historically, much treatment relied on

suggestion, reassurance and the doctor’s prestige, administered

directly or through placebo therapy. Such psychotherapy is informed,

unplanned, and usually lacks any theoretical foundation. Formal

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psychotherapy proceeds in a planned way and is based on a theory

explaining the psychogenesis of the patient’s complaints and the

relationship between doctor and patient. The doctor-patient

relationship remains immeasurable important in all specialties.

Freud and psychoanalysis

All modern psychotherapy owes much to Sigmund Freud (1856-

1939), the originator of the theory and technique psychoanalysis. His

work has been criticized as unscientific, but his ideas permeate

twenty first century thought and have perhaps been more influential

outside medicine than within.

The theory of psychoanalysis includes:

1. The role of unconscious factor in normal and neurotic behaviors;

known long before Freud and easily proven in experimental

hypnosis. Freud developed the idea of an active or dynamic

unconscious

2. Psychological determinism: The view that seemingly chance or

absurd dreams, slips of the tongue and neurotic symptoms have a

meaning, usually unconscious and symbolic.

3. Infantile sexuality: Freud’s libido theory stated that energy

attached to the sexual instincts become linked to different objects

at different developmental stages. The oral phase lasts from birth

to 18 months, and from 18 months to 3 years the phallic stage.

Seven years until puberty, there is a latency period. During the

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phallic stage boys develop the Oedipus complex in which the

father is seen as a rival for month’s affection

4. Topographical model: Freud’s structural model of the mind

comprising the id (instinctual, childish, unconscious forces), the

ego (the conscious, rational, adult part of the mind) and the

superego (which contains a harsh conscience derived from

parental ideas)

5. Psychogenesis: The view that symptoms have psychological

origins, particularly through conflict and anxiety and in childhood

experiences

6. Mechanisms of defense: Mental mechanisms that are often typical

of the individual or a particular neurosis and are used to deal with

anxiety.

Defense mechanisms include:

Projection: attributing ones own intentions (usually unconscious) to

others, for example in paranoid personalities.

Reaction-formation: behaving consciously in a way opposite to

unconscious wishes, for example, the over-polite person concealing

hostility.

Rationalization: attempting to provide logical reasons for emotional

and illogical attitudes.

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Displacement: an undesirable idea is not allowed to reach

consciousness but is transferred to a more acceptable object or

person, for example, an outburst of anger is directed at the cat

instead of the parent.

Identification: modeling behavior on that of another, e.g. the boy

identifying with his father. In developing the technique of

psychoanalysis.

Freud’s methods

1. Free association. The patient is encouraged to say whatever

enters his or her head at any time during the daily hour of

treatment (the ‘basic rule’).

2. Interpretation. The analyst remains largely silent; refusing to ask

or answer questions, but may offer interpretations of the patient’s

dreams, fantasies and behavior.

3. Analysis of the transference. Transference phenomena are the

feelings, positive and negative, developed by the patient for the

doctor (the doctor may have counter-transference feelings).They

have no realistic foundation in the present and are related to the

patient’s feelings for significant figures, usually parental, in the

past, for example, the patient may treat the male psychotherapist

at though s/he were his or her parent. Psychoanalysis, and indeed

any kind of intensive understanding of the patient’s problems, is

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insufficient and emotional understanding, as relived in

transference, is essential for improvement.

4. Working through. Insight gained in the above way must be put into

practical use in real life as part of successful treatment.

As a practical procedure, psychoanalysis occupies some five daily

hours each week over several years and is carried out by a

psychoanalyst, usually medically qualified, who himself has

undertaken a lengthy training analysis. There are few analysis carried

out in the National Health Service and clearly they can treat only a

handful of patient.

Freud has had many disciples, some of whom, notably Adler and

Jung, broke with the master and formed their own schools. C.G. Jung

(1875-1961) did not agree with Freud’s views on infantile sexuality,

coined the terms ‘introversion’ and ‘extraversion’, and took a mystical

view of a collective unconscious. Alfred Adler (1870-1937) paid more

attention to the individual’s willpower and to social factors. There

have been many influential neo-Freudians. In the U.S. Erich Fromm,

H.S. Sultana and K. Horney, and in Great Britain Anna Freud,

Melanie Klein and R.Fairbairn have all added to psychoanalytic

theory. Despite the multiplicity of theories and schools, studies of

psychotherapists show that their actual practice differs surprisingly

little. Current practice tends to more active participation by the

therapist, concentration on interpersonal events in the present rather

than the past, and on analysis of transference and the patient’s

typical defense mechanisms rather than to a search for traumatic

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events in the patient’s childhood. Successful therapists have qualities

of accurate empathy, non-possessive warmth, and genuineness.

Indications for psychotherapy

Psychotherapy may be useful in psychoneurosis and some

personality and psychosomatic disorders. For intensive

psychotherapy the patients selected are usually young intelligent,

highly-motivated, with an ability to verbalize freely and capacity for

insight. Brief and supportive psychotherapy is used in all the milder

psychiatric disorders.

Types of psychotherapy

Psychiatrists and many others practice psychotherapy of varying

degrees of intensity, ranging from brief and infrequent interviews to

weekly sessions of one hour continuing over months and years.

1. Brief therapy. A variety of techniques are exploited, usually in

combination: ventilation, in which the patient confides, confesses, and

is given the opportunity to ventilate his past and present difficulties;

clarification, where problems are discussed and their nature and

relations made clear; abreactions, verbalizing emotionally charged

material, with the release of anxiety, anger or grief; and

desensitization, in which repetitive ventilation of feelings, as in

mourning, has a therapeutic effect.

2. Intensive psychotherapy. Such treatment is usually practiced by

those with specialist training and includes psychoanalysis. In contrast

to brief therapy the interviews are longer and more frequent. The

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therapist assumes a more neutral attitude, there is more detailed

examination of the patient’s past and present problems, and some

analysis of the transference is used in the treatment.

3. Group therapy. This involves treating psychoneurotic patients in

small groups, usually of 6 to 8 people. It is more economical than

individual psychotherapy and has advantages for patients with

marked social and interpersonal difficulties. Defense mechanisms

and transference reactions are seen, akin to those that occur in

individual therapy, and are made use of by the therapist. Sessions

are generally held weekly, last one to one and a half hours, and

continue for one to two years. Group theory has developed to explain

the type of leadership, the life of a group, interaction. This theory uses

social psychology and sociology as well as psychoanalysis as

sources.

Group therapy has flourished in the social climate of the United

States with a bewildering variety of techniques, much subject to

fashion. Psychodrama was an early technique, in which patients are

encouraged to act out their problems and family conflicts by roleplaying

and improvisation. ‘T’ (training) groups (Lewin) were

developed as an educational group experience, emphasizing the

present and self-disclosure. Encounter groups were developed to

heighten awareness in normal people rather than patients. They also

emphasize group confession. Transactional analysis (Berne) has had

wide success. There are many fringe groups with untrained leaders or

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run as self- help groups. They may attract potential patients, including

the psychotic and have a detrimental effect on them.

4. Conjoint family therapy. This is a form of psychotherapy in which

one or two therapists see several members of a family together. It can

be regarded as a special form of group therapy. As well as using

analytic ideas it has made use of sociological concepts of role and of

general systems theory in explaining what happens in normal and

pathological family relationships, e.g. scapegoat, when one member

of the family is consistently blamed for all the family’s problems for

unproven efficacy.

5. Administrative therapy. Because interpersonal relationships are

so important in the genesis and treatment of psychiatric disorders,

considerable attention is given nowadays to staff-patient relations in

psychiatric hospitals and wards. The concept of the hospital as a

therapeutic community, developed by Maxwell Jones, involves

organizing the hospital in a democratic way, with patients having a

say in the conduct of their affairs and staff relinquishing authoritarian

habits. There must be free communications between doctors, nurses,

other staff and patients and all should feel able and have the

opportunity to express their feelings to one another. To this end staff

and patients meet regularly, and ward meetings become and

extension of group psychotherapy. When such principles were

neglected, patients become apathetic and experience a loss of

individuality, a condition which has been called institutional neurosis.

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Effectiveness of psychotherapy

Despite its use over 80 years there are no entirely satisfactory trials of

psychotherapy because of the technical difficulties of such research;

those studies that have been completed are equivocal about the

efficacy of psychotherapy. A well-known research project by Sloane

(1975) compared three groups of patients, assigning them to 14

weekly analytic psychotherapy sessions, to a similar period of

behavior therapy, or to a waiting list. All patients improved including

those on the waiting list who had an initial assessment, telephone

contact and emergency services as needed. The two groups having

active treatment improved more than the ‘control’ group. There was

little change in those results one and two years later.

Behavior therapy

Behavior therapy is the most active area of growth in psychotherapy.

It has been developed largely by psychologists from their studies on

experimental learning in humans and animals. It attempts to change

symptom directly rather than seek for underlying causes, and

assumes that neurotic symptoms stem from faulty learning. Many of

its ideas are commonsensical and have long been used by parents

and teachers. It involves the following concepts:

Learning: The term is used to describe any relatively permanent

change in behavior resulting from past experience; it need not be

intentional, nor need the learner be aware that he or she is learning.

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Classical conditioning: This as first described by Pavlov (1849- 1936).

An unconditioned response (a dog salivating) to an unconditioned

stimulus (sight or smell of food) is modified by pairing a conditioned

stimulus (a bell ringing) with the unconditioned stimulus. After a

number of trials the conditioned stimulus (bell) alone will produce the

conditioned response (salivation). After a while extinction or the

response will occur. The response can be generalized to other

sounds or discrimination may be taught (e.g. high pitched bells).

Operant conditioning: This is also known as instrumental learning. It

involves changing the frequency with which a certain behavior occurs

in a particular situation. The typical experiment involves a pigeon in a

Skinner box. When a lever is pecked, at first by accident, food enters

the box. The pigeon learns to press the lever more frequently for the

reward. The behavior is reinforced by the reward. This can be done

continuously, intermittently or at second hand. As well as reward

training, animals can be trained to escape from or avoid painful

stimuli. Operant learning can be complex, developed by successive

approximation (shaping) and building up sequences (chaining).

Avoidance responses are very lasting (e.g. agoraphobia).

Mowre’s 2 - factor theory explains this by:

1. Development of a conditioned response pairing fear and the place

or situation to be avoided.

2. Reinforcement of the avoidance. Fear occurs on approach to the

place or situation and the subject reacts by avoidance.

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Observational learning; This is found in human beings when they

model actions of others, for example in sports and new social

situations. It can teach others to do things and to avoid things.

Types of behavior therapy

Systematic desensitization: This technique was developed by a South

African psychiatrist, Wolpe (1969) from animal experiments on the

principle of reciprocal inhibition of neurotic responses. If a response

incompatible with anxiety can be made to occur at the same time as

an anxiety provoking stimulus, then the anxiety will be reduced. The

patient’s detailed history is used to construct a hierarchy of response

from the least to the most anxiety provoking. He is taught relaxation

exercises or is relaxed by drugs and asked to imagine himself in the

anxiety provoking situations: progressive desensitization occurs.

Token economy: Severely socially handicapped patients in long stay

wards may be re-motivated by the use of tokens. The basic essentials

of nursing care are provided, but extra food, attention, privileges are

bought with tokens. The tokens are used by the staff as an operant

conditioning device. The desired behavior, when it appears, is

immediately rewarded and shaped by tokens.

Aversion treatment: Pleasant but undesirable behavior (alcoholism,

deviant sexual fantasies) can be reduced by aversive conditioning,

pairing the pleasant stimulus with an unpleasant response (alcohol

and apomorphine, fantasy and electric shock). Thought stopping

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techniques are used to abolish obsessional ruminations. The patient

signals when such thoughts begin and the therapist shouts ‘stop’ or

gives a shock to the patient. Later the patient may control the

symptom by saying ‘stop’ to him or herself or flicking a rubber band

on the wrist to produce a painful stimulus.

Flooding and response prevention: Research on systematic

desensitization suggests that exposure to the feared object is the sole

essential ingredient. Flooding involves direct prolonged contact with

the feared object with the therapist’s support, encouragement and

modeling. In the treatment of obsessional rituals response, prevention

a similar and effective treatment is used. Both require skilled

therapists (often specially trained nurses) and may be very time

consuming.

Social skills training: Argyle’s work on social interaction led him to

compare social skills to complex motor skills, capable of being broken

down into separate parts and of being analyzed in terms of cues,

responses and feedback. Individuals with social difficulties can be

taught social skills, often in groups. They can be instructed in how to

move and what to say. They may model their performance from a live

person or a TV film, rehearse the skill and be socially reinforced by

the watching a videotape of their performance.

Other behavioral techniques: An animal model of neurosis is

provided by Pavlov’s dogs conditioned to a painful stimulus they

cannot avoid. Subsequently when put in an operant conditioning

experiment where they can evade punishment, they do not so.

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Seligman has called this learned helplessness and compared it to the

behavior of people with neurotic depression. Treatment by assertive

marital therapy involves teaching the couple to mutually reinforce

each other. Weekly contracts are made, in which each lists positive

actions he or she would like the other to do. This ‘giving to get’

approach is also used in treating sexual dysfunction.

Biofeedback: The development of small, light and sensitive electronic

apparatus makes it possible for the patient to be given immediate,

portable feedback on physiological activities not normally available to

his conscious mind: for example, pulse, EEG, alpha activity, psycho

galvanic response (PGR), blood pressure and muscle activity. Much

clinical experimentation is exploring the possibility that patients may

thus be able to control responses normally not within their awareness.

Relaxation can certainly be facilitated and there have been results

indicative of success in treating tension headaches, migraine

(temporal artery flow) and hypertension.

Recreational therapy

This is used in mental health and psychiatric nursing (Lalitha: 1995).

Recreation is a form of activity therapy used in most psychiatric

settings. Recreation or play activities provide patients with the

opportunity for fun and for feeling good. It adds balance to their daily

schedule and helps in treating the whole patient. Therapeutic

recreations can occur as:

- Informal playing

- Card games

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- Trips outside the hospital

- Structured soft ball

- Basket ball or volley ball games

- Attending sport events and so on.

Occupational therapy

Occupation is variously defined as ‘any activity which engages a

persons resources of time and energy and is composed of skills and

values (Lalitha: 1995). Occupational therapy is a potent and uniquely

valuable approach to health care that enables people to take control

of their own lives and over come their own disabilities. The essence

of occupational therapy lies in the use of activities of every description

as the treatment medium, with a minimum aim of improving the

quality of life and a maximum aim of complete rehabilitation.

Points to be kept in mind include the importance of:

- Selecting an activity that interests the client

- Starting at the point the client is at and progress slowly

- Providing ample in enforcement for even shall achievements.

Advantages:

- It helps to build a more healthy and integrated ego

- It helps to express and deal with needs and feelings

- It assists in a gratification of frustrated basic needs.

- It may strengthen ego defenses

- It may reverse psychopathology

- It facilitates personality integration

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- It offers opportunities to explore and see valuate self concepts

and object concepts

- It develops a more realistic view of the self in relation to action

and others.

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REVIEW QUESTIONS

1. List theories of psychoanalysis in psychotherapy
2. List the different types of psychotherapy
3. List the different types of behavior therapy
4. List the different types of recreational therapy used in most

psychiatric settings

5. List the advantage of occupational theory

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UNIT THIRTEEN

PSYCHOPHARMACOLOGY

Learning objectives

After studying this unit, the student should be able to:

1. Define psychopharmacologies
2. Identify different antipsychotic drugs
3. Identify commonly used antipsychotic drugs
4. Identify commonly used antidepressants
5. Identify commonly used anxiolytic drugs

6 Identify commonly used antiepileptic drugs

7. Identify different reasons for choice of drugs
8. Discuss nursing actions in drug administration.

Definition

Psychopharmacology is the scientific study of medicines and drugs

acting upon psychic aspects of human being and animals.

Antipsychotic (Psychoactive drugs)

Antipsychotic drugs are used mainly for treatment of severe mental

illnesses such as schizophrenia and other psychotic disorders. They

include:

- Antipsychotic

- Antianxiety (anxiolytics)

- Antidepressants.

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Antipsychotic (neuraleptics)

Antipsychotic drugs are derived from several chemical groups and

are broadly categorized as phenothiazines and non phenothiazines.

Despite chemical differences, their pharmacologic actions and

antipsychotic effectiveness are similar.

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Table 11: Common phenothiazines antipsychotic drugs

Generic

name

Trade name Routs of

administration and

dosages for adults

Major side

effects

Remarks

Chlorpromazine Thorazine 200-600mg/ day

IM, PO

High sedation

-Moderate to low

hypotension

Tablets,

capsules and

suspensions

are available

Fluphenazine

decanoate and

enanthate

Prolixin

decanoate;

Prolixin

enanthate

12.5 mg initially

followed by 25 mg

every 2 weeks rarely

exceeds 100mg 2-6

weeks

IM

Low to moderate

sedation

High extra

pyramidal

reaction

Low sedation

Fluphenazine

hydrochloride

Prolixin Permitil 2.5-10 mg initially,

gradually reduce to

maintenance dose of

Low to moderate

sedation

High extra

2 mg of the oral

hydrochloride

salt is

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1-5 mg

PO/IM

pyramidal

reactions

Low hypotension

equivalent to

100 mg of

chlorpromazine

Thioridazin Mellaril 150-300 mg daily in

divided dose gradually

increased if necessary

to a maximum daily

dose of 800 mg

PO

High sedation

Low extra

pyramidal

reactions

Moderate

hypotension

100 mg is

equivalent to

100 mg of

chlorpromazine

Trifluoperazine Stelazine 2-4 mg daily in divided

dose for out patient

PO

Moderate

sedation

High extra

pyramidal

reactions

Low hypotension

5 mg is

equivalent to

100 mg of

chlorpromazine

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Commonly used non-phenothiazines

Haloperidol (haldol): This is a butyrophenone compound and the only

drug of this group available for use in psychiatric disorders.

Haloperidol is a frequently used antipsychotic agent that is chemically

different but pharmacologically similar to phenothiazines. It is potent

and long acting drug, readily absorbed following oral or intramuscular

administration, metabolized in liver and excreted in urine and bile.

Haloperidol may cause adverse effects similar to those of other

antipsychotic drugs. Usually it produces a relatively low incidence of

hypotension and sedation and a high incidence of extra pyramidal

effects.

A 2-mg dose is therapeutically equivalent to 100 mg of

chlorpromazine.

Routes and dosage ranges: 1-15 mg/ daily initially in divided doses,

gradually increased to 100 mg /day if necessary: usual maintenance

dose, 2-8 mg daily is a recommended dose for adult.

Actions of neuroleptics: The antipsychotic drugs act primarily by

occupying dopamine receptors in brain tissue, thereby decreasing the

effects of dopamine, a catecholamine neurotransmitter. Excessive

dopamine activity is believed to be an important factor in the

development of schizophrenia. This concept is supported by

observations of the effects of drugs that increase dopamine levels in

the brain (e.g. amphetamines, levodopa), which can cause psychotic

or schizophrenic symptoms.

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The drugs act with in hours to decrease manifestations of hyper

arousal (e.g., anxiety, agitation, hyperactivity, insomnia, aggressive/

combative behavior, hallucination, and delusion). Several weeks or

months may be required for elimination of thought disorder and

increased socialization.

Choice of drug: The choice of particular anti-psychotic drug is largely

empirical because no clear cut guidelines exist. Some general factors

to consider include the client’s age and physical condition; severity

and duration of illness; frequency and severity of adverse effects

produced by each drug; response to antipsychotic drugs in the past;

subjective response to the drug (such as the adverse reaction a

person is willing to tolerate); supervision available; and the

experience of the personnel with a particular drug. The following are

among some specific factors.

1. Antipsychotic drugs are apparently equally effective regardless of

the client’s symptoms. Drugs producing greater sedation are often

prescribed for agitated, over active persons and drugs producing

less sedation are prescribed for those who are apathetic and

withdrawn.

2. Some clients who do not respond well to one type of antipsychotic

drug may respond to another. Unfortunately, there is no way of

predicting which drug is likely to be most effective for particular

client.

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3. There is no logical basis for giving more than one antipsychotic

agent at a time. There is no therapeutic advantage, and risk of

series adverse reactions is increased.

4. If lack of therapeutic response requires that another antipsychotic

drug be substituted for the one a client is currently receiving, this

substitution must be done gradually. Abrupt substitution may

cause re appearance of symptoms. This can be avoided by

gradually decreasing doses of the old drug while substituting

equivalent dose of the new one.

5. Nonphenothiazine antipsychotics are probably best used for

clients with chronic schizophrenia whose symptoms have not

been controlled by the phenothiazines and for clients with hyper

sensitivity reactions to the phenothiazines.

6. Unless the choice of a drug is dictated by the client’s previous

favorable response to a particular drug, the preferred drug should

be available in both parenteral and oral forms for flexibility of

administration.

7. Clients who are unable or unwilling to take daily doses of a

maintenance antipsychotic may be given periodic injections of a

long- acting form of fluphenazine.

8. Any person who has had an allergic or hypersensitivity reaction to

antipsychotic drug should generally not be given that particular

drug again or any drug in the same chemical group.

Duration of therapy: Antipsychotic drugs are usually given for months

or years. There are no clear guidelines on duration of drug therapy.

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Table 12: Commonly used anti psychotic agents

Nursing actions Rationale / explanation

1. Administer

accurately

Peak sedation occurs about 2 hours after

administration and aids sleep. Hypotension, dry mouth

and adverse reactions are less bothersome with this

schedule. etc.

2. Observe for

therapeutic effect

The sedative effects of antipsychotic drugs are

exerted with in 48 to 72 hours. Sedation that occurs

with treatment of acute psychotic episodes is a

therapeutic effect. Sedation that occurs with treatment

of non acute psychosis disorders, or excessive

sedation at any time, is an adverse reaction etc.

3.Observe for

adverse effects

Excessive sedation is most likely to occur during the

first few days of treatment of an acute psychosis

episode, when large doses are usually given.

Psychotics also seem sedated because the drug lets

them catch up on psychosis-induced sleep

deprivation. Sedation is more likely to occur in elderly

or debilitated persons. Tolerance to the drugs’

sedative effects develops, and sedation tends to

decrease with continued drug therapy.

4. Observe for drug

interaction

Additive ant cholinergic effects, especially with

Thioridazine. Potential for sedative and ant cholinergic

effects. Additive CNS depression, sedation,

orthostatic hypotension, urinary retention, and

glaucoma, may occur unless dosages are decreased.

Apparently these two drug groups inhibit the

metabolism of each other, thus prolonging the actions

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of both groups if they are given concomitantly.

5. Teach clients Anti acids may decrease absorption of these drugs

from intestines.

To avoid low blood pressure, dizziness, and faintness,

which may occur in standing

To avoid falls or other injuries

Dryness of mouth which can predispose to mouth

infection, dental cavities, and ill fitting dentures.

-Sensitivity to sunlight is an adverse reaction of these

drugs.

-Fever (hyperthermia) and heat prostration may occur

with high environmental temperatures.

Antidepressants

Types of antidepressants: Antidepressant drugs are derived from

several chemical groups mainly as tricyclic antidepressants and

monoamine oxidase inhibitors. Several newer agents differ chemically

from the tricyclics but are similar in pharmacologic actions and

antidepressant effectiveness.

Tricyclic antidepressants: Tricyclis antidepressants (TCA) are a group

of eight chemically and pharmacologically similar drugs. These

compounds contain a triple-ring nucleus from which their name is

derived. The drugs are structurally similar to phenothiazine anti

psychotic agent and have similar anti adrenergic and anti cholinergic

properties. They produce relatively high incidence of sedation,

orthostatic hypotension, cardiac arrhythmias, and other adverse

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effects in addition to dry mouth and ant cholinergic effects. TCAs are

well absorbed after oral administration. Once absorbed, these drugs

are widely distributed through body tissues and metabolized by the

liver to active and inactive metabolites. Amitriptyline (elavil) and

Imipramin (Tofranil) are commonly used TCAs. And there are

miscellaneous antidepressants.

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Table 13: Commonly used anti depressant agents

Tricyclic

antidepressant

Generic

name

Trade name Root and dosage range for adults

Amitriptline Elavil, Endep Po 75-100 mg/daily in divided dose gradually

increased to Po150-300 mg/ daily if necessary

Imipramin Tofranil Po 75-mg /daily in three divided doses gradually

increased to a maximum of 300 mg daily if

necessary

Miscellaneous

Anti Depressants

Eg. Bupropin Wellbutrin PO 100 mg/ day

Mono amine

oxidase inhibitor

Eg.Isocarbao

xide

Marplan Po. 30 mg in divided dose

Ant manic agents Lithium

carbonate

Eskalith For bipolar disorder (manic depressive disorder)Po

900-1200mg daily in divided dose, gradually

increased in 300 mg increments if necessary.

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Mechanisms of action

The mechanisms by which most antidepressant drugs exert

therapeutic effects are directly related to the hypothesized cause of

depression, that is the drugs increase the amount of neurotransmitter

(noreepinephrin, serotonin) available to stimulate receptors on

postsynaptic nerve fibers and/or decrease sensitivity (and possibly

numbers) of the receptors.

After neurotransmitters are released from presynaptic nerve endings,

they are normally inactivated by reuptake in to the presynaptic nerve

fiber that released them or metabolism by the enzyme MAO. The

tricycles (TCAs) prevent reuptake of one or more neurotransmitters.

The MAO inhibitors prevent the metabolism of neurotransmitter

molecules. Apparently all of the currently available drugs decrease

the sensitivity of receptors, especially postsynaptic beta-adrenergic

receptors, with chronic use.

Drug Selection

The choice of an antidepressant depends upon the following major

factors: the type of depression present; its severity; a drug’s

effectiveness and adverse effects.

Guidelines for choosing a drug include the following:

1. A tricycles (TCA) has been the primary drug of choice for most

depressed clients; even though there is relatively little base for

choosing.

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2. MOA inhibitors are considered second line drugs for treatment of

depression because of the potential interactions with other drugs

and certain foods.

3. Lithium is the primary drug of choice in clients with bipolar

disorder. When used therapeutically, lithium is effective in

controlling mania in about 80% of clients. When used

prophylactically, the drug decreases the frequency and intensity

of manic cycles.

Table 14. Nursing actions: antidepressants

Nursing actions Rationale/ explanation

1. Administer accurately Give lithium with or just after meals

to decrease gastric irritation

2. Observe for therapeutic

effects

Therapeutic effects usually do not occur for 2-

3 weeks after drug therapy is started

3. Observe for adverse effects Most adverse effects result from anti

cholinergic or anti adrenergic activity

4. observe for drug interactions Adverse anti cholinergic effects (e.g. Dry

mouth blurred vision, urinary retention,

constipation. etc.)

5. Teach clients Inform about potentially serious adverse

effects , low salt intake(with lithium therapy),

regular measurement of blood lithium etc.

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Anticonvulsants

Anticonvulsant drugs are used to treat seizure disorders.

Types of anticonvulsants: Anticonvulsant drugs belong to several

different chemical groups, including long-acting barbiturates,

benzodiazepines, hydanotions and succinimides. The drugs can

control seizure activity, but they do not cure the underlying disorder.

Long-term administration is usually required. Therapeutic and

adverse effects depend primarily on serum drug levels.

Most anticonvulsant drugs can be taken orally and are absorbed

through the intestinal mucosa. After absorption, the drugs pass

through the liver and undergo transformation by liver enzymes, during

which some of the drug is inactivated. All anticonvulsant drugs are

metabolized in the liver.

Mechanisms of actions of anticonvulsants

Anticonvulsant drugs have similar antiseizure properties. The precise

mechanism and site of action are unclear. However, it is thought

these drugs act in two ways to control seizure activity.

First, they may act directly on abnormal neurons to decrease their

excitability and responsiveness to stimuli. Consequently, the seizure

threshold is raised and seizure activity is decreased.

Second, and more commonly, they prevent the spread of impulses to

the normal neurons that surround the abnormal ones. This helps to

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prevent or minimize seizures by confining excessive electrical activity

to a small portion of the brain.

The drugs ability to reduce the responsiveness of normal neurons to

stimuli may be related to alterations in the activity of sodium,

potassium, calcium, and magnesium ions at the cell membrane. Such

ionic activity is necessary for normal condition of nerve impulses, and

changes engendered by the anticonvulsant drugs result in stabilized,

less responsive cell membranes.

Indications for use

The major clinical indication for anticonvulsant drugs is in prevention

or treatment of seizure activity, especially the chronic recurring

seizures of epilepsy. Indications for particular drugs depend on the

types of seizures involved.

Contraindications

Anticonvulsants are contraindicated or must be used with caution in

clients with central nervous system depression. Hydration,

succinamides, and carbamazepine are contraindicated with hepatic or

renal damage and bone marrow depression (e.g. leukopenia,

agranulocytosis).

Individual anticonvulsant drugs (commonly used anticonvulsant)

Barbiturates: Phenobarbital is a long acting barbiturate and is one of

the safest, most effective, and most widely used anticonvulsant

drugs. It is most effective in generalized tonic clinic epilepsy (major

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motor or grand mal), temporal lobe and other partial seizures, and

febrile convulsions in children.

Drug dependence and barbiturate intoxication are unlikely to occur

with the usual doses of phenobarbital used in epilepsy treatment.

Since phenobarbital has a long half-life, it takes about 2 to 3 weeks to

reach therapeutic serum levels and about 3 to 4 weeks to reach a

steady state concentration.

Hydantoins: Phenytoin (dialantion) is the prototype of a group of

anticonvulsant drugs called the hydantoins. It is the most widely used

and effective drug for generalized tonic-clonic and some partial

seizures such as psychomotor seizures. Phenytoin is usually the

initial drug of choice, especially in adults. It is often given with

phenobarbital or prim done where a single agent does not control

seizures. The drug may also be used in some cardiac arrhyththmias,

especially those resulting from digitalis toxicity, but such usage is

declining with the availability of newer ant arrhythmic drugs.

The adult dose is as follows:

PO = 3.5.7 mg/kg/day

IM = 8.6 mg/kg/day in multiple sites

IV = Same as PO dose; maximum 50mg/minute.

Benzodiazepines:

1. a) Clonazepam (klonopin) is a benzodiazepine used as

anticonvulsant. It may be used alone or with other anticonvulsant

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drugs in myoclonic or akintic seizures. Tolerance to anticonvulsant

effects develops with long term use. Clonazepam also produces

physical and psychological dependence as well as withdrawal

symptoms. Because of its long half-life, withdrawal symptoms may

appear several days after administration is stopped. Abrupt

withdrawal may precipitate seizure activity or status epilepticus.

Adults dose is PO 1.5mg/day, increased by 0.5 mg/day every 3-7

days if necessary to a maximum dose of 20mg/day.

1. b) Diazepam (valium) is a benzodiazepine widely used as antianxiety

or sedative agent. In seizure disorders, it is used to terminate acute

convulsive seizures. It is the drug of choice for treating the life

threatening seizures of status epilepticus.

The dose in adults for acute convulsive seizures, status epilepticus is

IV 5-10mg at no more than 2mg/min. Repeat every 5-10 minute if

needed to a maximum dose, 30 mg. If necessary, repeat regimen in

2-4 hours to a maximum close, 100mg/24 hours.

Other Anticonvulsant drugs:

Carbamazepine (tegretol) is related chemically to the tricyclic

antidepressants and pharmacologically to the hydantoin

anticonvulsants. It is used mainly for psychomotor, generalized tonic–

clonic, and mixed seizures.

Since carbamazepine may cause life threatening blood dyscrasias

(e.g. a plastic anemia agranulocytosis, thrombocytopenia,

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leucopenia), its use should be reserved for clients whose seizures

can not controlled with other drugs. Carbamazepin is contra indicated

in clients with previous bone marrow depression or hypersensitivity to

carbamazepin or tricyclic antidepressants or clients who are receiving

monoamine oxidase (MAO) inhibitors. MAO inhibitors should be

discontinued at least 14 days before carbamazepine is started. It is

also used to treat facial pain associated with trigeminal neuralgia (tic

douloureux).

The adult dose for epileptics is PO 200mg twice /day initially,

increased gradually to 600-1200 mg if needed, in 3 or 4 divided

doses. For trigeminal neuralgia the does is PO 200mg/day initially,

increased gradually to 1200 mg if necessary.

Anti-anxiety drugs

Ant-anxiety agents are central nervous system (CNS) depressants

with sedative-hypnotic properties. They are commonly prescribed

drugs.

1. Benzodiazepines: These are by far the most commonly used drugs

for treatment of situational anxiety and other anxiety disorders.

Chlordiazepoxide (librium) is the prototype of the group, although

diazepam (valium) and others are more frequently prescribed. This

drug may cause physical and psychological dependence, so that it is

recommended to be prescribed more selectively and for short periods

of time.

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These drugs are highly lipid-soluble, widely distributed in body

tissues, and extensively bound to plasma proteins. They are well

absorbed with oral administration. Chlordiazepoxide, diazepam, and

lorazepam (ativan) are available for parenteral use. When given

intramuscularly, chlordiazepoxide, and diazepam are usually painful,

erratically absorbed, and produce lower serum levels. lorazepam is

well absorbed with intramuscular use. Diazepam is often given

intravenously.

Pharmacologically, all the benzodiazepines have similar

characteristics and produce the same effects.

Mechanisms of action

The benzodiazepines are thought to decrease anxiety by binding with

benzodiazepines receptors in the brain and there by increasing the

effects of gamma-aminobutric acid (GABA). GABA is an inhibitory

neurotransmitter.

An increase in GABA activity results in decreased ability of excitatory

neurotransmitters to stimulate nerve impasses.

Indications for use

Major clinical uses of the benzodiazepines are as anti-anxiety,

hypnotic, and anticonvulsant agents. They are also used for

preoperative sedation, sedation before or during invasive diagnostic

tests such as endoscopy, and angiography, and prevention of

agitation and delirium tremens in acute alcohol with drawl. Diazepam

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(valium) has been extensively studied and has more approved use

than others.

Contraindications for use

Contraindications include severe respiratory disorders, severe liver or

kidney disease, hyper sensitivity reactions, and a history of drug

abuse.

Non benzodiazepine antianxiety agents

Busprone (buspar): This differs chemically and pharmacologically

from other antianxiety drugs. Its mechanism of action is unclear, but it

apparently interacts with serotonin and dopamine receptors in the

brain. Compared to other anti-anxiety drugs, buspirone causes less

sedation and does not apparently increase the CNS depression of

alcohol and other drugs. It is only indicated in short-term treatment of

anxiety.

Buspirone is rapidly absorbed following oral administration. It is

metabolized by the liver to inactive metabolites, which are then

excreted in the urine and feces. Its elimination half-life is 2 to 3 hours.

Meprobamets (equanil, miltown): This is an anti-anxiety agent that is

chemically different from the benzodiazepines and hydroxyzing. It is

also used as a muscle relaxant, but its effectiveness for that purpose

is questionable. Drug tolerance, abuse, dependence and withdrawal

symptoms occur with long term use.

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Table 15: Commonly used anti anxiety agents (anxiolytics)

Generic

Name

Brand

Name

Clinical indications Route and dosage rage

for adults

Chlordiazepo

xide

Librium Anxiety PO 0.25-0.5 mg 3 times

daily, maximum dose 4

mg daily in divided dose

Diazepam Valum Anxiety, seizure

disorders acute

alcohol withdrawal

muscle spasm,

preoperative sedation

hypnotics

PO 2-10mg 2-4 times

daily sustained release

PO 15-30mg once daily

IM, IV 5-10mg repeated

in 3-4 hours if necessary.

Halazepam Paxipam - Anxiety PO 20-40mg 3-4 times

daily

Lorazepam Ativan - Anxiety

- Preoperative

sedation

PO 2-6 mg/day in 2-3

divided doses. IM 0.05

mg/kg to a maximum of

4mg. IV. 2mg diluted with

2ml of sterile water,

dextrose sodium chloride,

or 5% dextrose injection,

injected over 1minute or

longer

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Table 16: Nursing actions in anti-anxiety drugs

Nursing actions Rationale/explanation

1. Administer accurately To avoid excessive sedation and

adverse effects

2. Observe for therapeutic effects As with most other drugs,

therapeutic effects depend on the

reason for use. Observations of

individual recipients of antianxiety

drugs can be more

accurate if the same nurse

assesses the person before and

after the drug is given.

3. Observe for adverse effects such

as:-

- Over sedation

- Hypotension

- Pain and in duration at injection site

- Paradoxical excitement, anger

aggression and hallucinations

- Skin rashes and others.

Most adverse reactions are

caused by CNS depression.

Drowsiness is the most adverse

effect. They are more likely to

occur with large doses or if the

recipient is elderly, debilitated or

has liver disease that slows drug

metabolism.

4. Observe for drug interactions such

as alcohol: barbiturates, sedative

hypnotics, narcotics, analgesics,

phenothiazines and other

antipsychotic.

These drugs cause addictive

CNS depression, sedation and

respiratory depression others

such as cemeteries interferes with

the hepatic metabolism of

diazepam and other

benzodiazepines.

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5. Teach clients To avoid falls and injuries or

adverse effects. These drugs may

interfere with both mental and

physical functioning.

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REVIEW QUESTION

1. List at least three commonly used phenothiazines.
2. What is the commonly used nonphenotiazine antipsychotic drug

which is chemically different but pharmacologically similar to

phenothiazines?

3. What are the nursing actions (responsibilities) in antipsychotic

drug administration?

4. List at least two tricyclic antidepressants which are commonly

used.

5. List at least two commonly used benzodiazepins (anxiolytics).

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ANNEX I

Model of Patient Assessment (History Taking) in

Psychiatric Nursing

1. Personal identification of patient

Name: Ato. X

Age: 27 years

Sex: Male

Marital status: Married

Occupation: Carpenter.

Address: Finkile

II Chief Complaints: The client claimed that he is ok. However, the

family members brought him chained and escorted to the hospital

labeling him as a mad.

III History of present illness: A 25 years old male patient was

brought to the hospital, escorted by 2 brothers and his wife. On

interview he claimed that he is OK. But as per the informant (his wife)

stated that he was relatively OK before 3 months ago but then started

to become sleepless, inappropriate, insulting and started to refuse

social harmonies both at home and at work place. More recently, he

became jocular insulting, easily irritable, laughing at nothing and

energetic so that no one is willing to approach him except herself.

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IV Social and personal History

Family history:

His father is quite healthy except he is sleepless and occasionally he

has moody characteristics. He is 65 years old; a farmer by occupation

and a sociable person in his interaction with the environment.

His mother died at the age of 30 when the patient was a two year old

child. He does not know the reason for her death. She was housewife

by occupation. These facts were confirmed from his brothers.

Siblings: He has two brothers and one sister; he is the last child in

the family. All of his siblings are married and in a poor occupational

and professional standard. There was poor social interaction between

and among the family members because of the hatred of the step

mother had to them and vice versa. Two of the siblings are

complaining of health problems which he clearly does not know

about.

There was history of mental illness in the family. His grandfather died

due to mental problem. Also his uncle attended a mental hospital on a

monthly regular base.

Personal History

He was born in 1967 but does not exactly remember the exact date,

but the elder brother informed that he was born at home by the

assistance of traditional birth attendant. The patient and his family do

not know his birth weight and of any complications during pregnancy,

except at that time there was starvation on that community.

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In his early development, the appeared to be no gross problem

except he was fat among other siblings. He walked and talked and

commanded his sphincters at appropriate developmental time. The

patient and his family report:

No night terrors, sleepwalking, bedwetting, thumb sucking, nail biting,

stammering and stuttering and no mannerism.

He did not have any major illness in his childhood.

He had good school performance during his education. He started

primary school at age of 6 and learnt up to 8th grade. His performance

was good (he stood 1-3) up to the 8th grade. He has special ability in

mathematics. He has hobby of driving gears and was interest in

manual works and social interaction with his age mates.

At age of 16 he started to roam out of home and developed special

interest towards the opposite sex, especially adolescent girls and

rejected the home values. He had high sociogram among his

classmates and peer groups outside classroom. He had a friendly

approach outside the home in general.

He started work at the age of 20 after the interruption of his study. He

is carpenter and he earns good money but he is extravagant, so that

he can not control his money and so he is poor in his economic

status.

He is sexually active and seductive and he had multiple sexual

partners prior his marriage and even after he is married. He is a father

of one daughter who is 1 1/2 years old.

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He has a habit of chewing khat, smoking cigarettes, and drinking

alcohol.

He has no history of medical and surgical illness in the past.

He has no history of previous mental illness.

Pre-morbid personality

- Prior to his illness he has harmonious relation with family and

workmates

He has a special inclination in group work with youngsters

􀂃 He had hobby of listening music, reading fiction books, watching

television and cinemas.

􀂃 Mood wise he was cheerful, not wary and not fluctuating

􀂃 His tended to be irritable and over-sensitive.

􀂃 He was extravagant (not economical) he has inflated self steam.

􀂃 He is Muslim by religion.

􀂃 He was energetic and he was clear cut decision maker.

􀂃 He was tolerant to stress, not easily frustrated by things but

sometimes he was fearful person.

Physical examination.

􀂃 On arrival at hospital psychiatric OPD he appeared aggressive,

destructive, chained and energetic.

􀂃 He was not appropriately gloomed, although his hair was trimmed

􀂃 He demonstrated no CNS abnormality except agitation and

aggression

􀂃 He exhibited to have no physical disability or organic illness.

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Psychiatric examination (mental status examination)

His behavior appeared generally inappropriate on physical

examination. He was aggressive to family members and hospital staff.

He is sleepless, hyperactive and avoidant of food (he claimed a

shortage of time to eat food).

He talked loudly and spontaneously. The rate of speech was fast and

non coherent: from his talk he appeared to think of himself as an

advisor and expert as well as a leader: he claimed that he is the

leader of the country.

He was irritable but occasionally claimed that he felt happiness. In

general he exhibited inappropriate mood on physical examination. It

was noted:

- He has no suicidal thoughts ideas or wishes

- He is hopeful, energetic and courageous.

- He is able to think abstractly (explains poems) consistently and

without interruption of flow

- Has no thought block, or poverty of ideas

- Thought contents are full of delusions (grandeur delusion): his

main worry is, in his absence, this world will perish.

- He claims that he sees objects such as prophets and angels and

he prefers to be a friend of them, has no tactile, and auditory

hallucination.

- He has as no ideas of reference or persecution

- He exhibits ideas of self inflation (grandeur delusion)

- He has the obsessional idea of leading and controlling the world

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- He is oriented to place, person and time

- He has no memory impairment of either recent, remote or

immediate matters (he recalls the name of persons, remote

events and serials of numbers and address immediately and

after 5 minutes)

- He is not attentive, he is easily distracted and distracts others and

he answered to test of questions on days and months in reverse

order; he subtracted serial 7's quickly

- He answered general information tests quickly.

- The intelligence test was not done

- He has poor insight and judgment e.g. he suspects food,

treatment, and he has a plan of leading the world

- He has a negative attitude towards hospital staff because they

caused him pain with an injection needle.

Further investigation

Further investigation, a hematology test and psychological testing

from psychologist, are needed.

Formulation of the case

Differential Diagnosis:

- Organic states (cerebral tumor and arteriosclerosis)

- Hypomania

- Alcoholic intoxication

- Catatonic excitement

- Frontal lobe lesions.

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Impression: Mania

Treatment

1. Lithium; it can only be given in hospital where it is possible to

monitor sodium (Na) level.

2. Halloperidol (serinace)
3. CPZ Chlorpromazine.

Prognosis

- Good, with good living condition, treatment and family support.

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ANNEX II

Answer Key to Study Questions

Unit One

Chapter One

1. a) Sense of well being
2. b) The use of sublimation as the main defense mechanism
3. c) The ability to postponed present pleasures for future
4. d) The presence of an intact sense of reality
5. e) Good interpersonal relationship
6. f) Optimum adjustment
7. a) Adoption to the work situation
8. b) Leisure – time activity
9. c) Management of social contacts
10. d) Adjustment to the opposite sex
11. C
12. B
13. A

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Unit One

Chapter Two

1. (False)
2. Bethlehem Royal hospital
3. Philip Pineal
4. 5Benjamin Rush(1745-1813)
5. Dorothe Lynde Dix
6. Sigmond Freud
7. Amanuel Hospital
8. Dr. Fikire Workineh
9. 1991 Gc
10. 12 Nurses

Unit One

Chapter Three

1. A
2. B
3. A
4. a) History of present illness
5. b) Social and personal history (Supplementary history to be

obtained from relative if possible)

1. c) Physical examination
2. d) Psychiatric examination
3. e) Future investigation
4. f) For mutation of the case
5. C

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224

Unit One

Chapter Four

1. False
2. True
3. False
4. True
5. False

Unit Two

1. a) Anxiety disorder b) Phobia
2. c) Hysteria d) Obsessive compulsive disorder
3. e) Hypochondria
4. a) Desensitization
5. b) Systematic
6. c) Flooding
7. a) Conversion reaction hysteria
8. b) Dissociative hysteria
9. a) Primary illness gain is obtaining relief from anxiety by using

defense mechanism to keep an internal need or conflict out of

awareness.

1. b) Secondary illness a gain is any benefit or support that obtained

as a result of being sick, other than relief from anxiety.

5. a) Treating the underlying illness
6. b) Administration of antidepressant
7. c) Psychotherapy and supportive idea

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Unit Three

1. C
2. A
3. B
4. D
5. B

Unit Four

1. A
2. B
3. A
4. B
5. a) Ambivalence
6. b) Association loosing (incoherence)
7. c) Affect disturbance
8. d) Autism (turning towards self)

Unit Five

1. a) Loss of consciousness
2. b) Convulsive movement
3. c) Sensory phenomena
4. d) Behavioral administrates
5. B
6. D
7. B
8. D

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Unit Six

1. B
2. a) Clouding of consciousness
3. b) At least two of the following

1) Perceptual disturbance

2) Incoherent speech at a times

3) Disturbance of sleep-wake cycle with insomnia or day time

drowsiness

4. D
5. A
6. a) Hypoglycemia
7. b) Hyperbilirubinaemia (kernicterus)
8. c) Hypothyroidism (cretinism)
9. d) Hypoproteinaemia
10. e) Hypocalcaemia
11. f) Lead poisoning

Unit Seven

1. A
2. B
3. a) Clinical psychiatric syndrome
4. b) Intelligence
5. c) Organic factors
6. d) Psychosocial factors
7. B
8. A
9. B

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Unit-Eight

1. A
2. D
3. A
4. B

UNIT NINE

1. a) To resolve a mental conflict
2. b) To reduce anxiety or fear
3. c) To protect one’s self esteem
4. d) To protect one’s sense of security
5. A

UNIT TEN

1. A
2. B
3. A
4. B

UNIT ELEVEN

1. a) Oral contraceptive
2. b) Sedatives
3. c) Major tranquilizers
4. d) Methyldopa and others

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2. a) Erectile dysfunction or importance
3. b) Premature ejaculation
4. c) Frigidity (inhabited sexual excitement) in female
5. d) Inhabited female organism (anorganismia)
6. e) Dyspareunea and others
7. B
8. B
9. a) Excitement
10. b) Plateau
11. c) Organism
12. d) Resolution

UNIT TWELVE

1. a) The role of unconscious factors in normal and neurotic

behavior

1. b) Psychological determinism
2. c) Infantile sexuality
3. d) Topographical model
4. e) Psychogenesis
5. f) Mechanisms of defance
6. a) Brief therapy
7. b) Intensive psychotherapy
8. c) Group therapy
9. d) Conjoint family therapy
10. e) Administrative therapy

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3. a) Systematic desensitization
4. b) Token economy
5. c) Aversion treatment
6. d) Flooding and response prevention
7. e) Social sills training
8. a) Informal ping pong
9. b) Card games
10. c) Trip outside the hospital
11. d) Structured soft ball
12. e) Basket ball of volley bal games
13. f) Attending sport events and so on
14. a) Helps to build a more healthy and integrated ego
15. b) It helps to express and deal with needs and feelings
16. c) Assist in a gratification of frustrated basic needs]
17. d) Strengthens ego defenses
18. e) Reverse psychotherapy

UNIT THIRTEEN

1. a) Chlorpromizine
2. b) Thiorizadine
3. c) Fluphenazine
4. Halloperodol (halidol)
5. a) Accurate adminstration
6. b) Observation for therapeutic effect

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1. c) Observation for adverse effect
2. d) Observation for drug interactions
3. e) Teaching client
4. a) Amitriptlin
5. b) Imipramin
6. a) Chlordiazepoxide (librieum)
7. b) Diazepam (valium)

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GLOSSARY

Akinesia: Absence or poverty of movements

Alcoholism: A disorder marked by a pathological pattern of alcohol

use that causes serious impairment in social or

occupational functioning (alcohol abuse).

Amnesia: Pathogenic impairment of memory

Anesthesia: Loss of feeling or sensation, especially the loss of pain

sensation induced to permit the performance of surgery or

other painful procedures.

Anoxia: Absence of oxygen supply to tissues despite adequate

perfusion of the tissue by blood (hypoxia)

Aphonia: Loss of voice, inability to produce vocal sounds.

Apraxia: Loss of ability to carry out familiar purposeful movements in

the absence of major or sensory impairment, especially

inability to use objects correctly.

Atonic: Lack of normal tone of the muscle or strength.

Autism: The condition of being dominated by subjective, selfcentered

trends of thought or behavior which are not

subject to correction by external information.

Cataract: An opacity of the crystalline lens of the eye or its capsule

Cerebral Palsy: Persistent qualitative motor disorder, appearing

before age three.

Psychiatric Nursing

232

Delusion: A false personal belief based on incorrect inference about

external reality and firmly maintained in spite of

incontrovertible and obvious proof or evidence to the

contrary.

Dementia: Defuse brain dysfunction characterized by a gradual,

progressive and chronic deterioration of intellectual

function.

Depersonalization: Alteration in the perception of self so that the

usual sense of one’s own reality is temporarily lost or

changed. It may be a manifestation of a neurosis or

another mental illness or can occur in mild form in normal

persons.

Downs syndrome: Mongoloid features, short phalanges, widened

space between the first and second toes and fingers, and

moderate to severe mental retardation: associated with a

chromosomal abnormality usually trisomy of chromosome

21.

ECT : Electroconvulsive therapy.

Ego: Segment of the personality dominated by the reality principle

comprising integrative and executive aspects functioning.

The ego is able to adapt the forces and pressures of the

superego and the requirements of external reality by

conscious perception, thought and learning.

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Fixation stage: The cessation of psycho sexual development before

maturity.

Fugue state: A dissociative reaction in which amnesia is

accompanied by physical flight from customary

surroundings.

Hyperbillirubinemia: Excess of bilirubin in the blood classified

conjugated or unconjugated, according to the predominant

form of bilirubin present.

Hypoglycemia: Deficiency of glucose concentration in the blood

which may lead to nervolegness, hypothermia, headache,

confusion, and sometimes convulsions and common.

Hypothyroidism: Deficiency of thyroid activity.

ID: That paart of the personality that is an unconscious reservoir of

primitive drives and instincts dominated by the pleasure principle.

illusion: A mental impression derived from misinterpretation of an

actual experience.

Judgment: Orientation, memory, affect or emotional stability,

cognition, and attention.

Kernicterus: A condition with severe neural symptoms, associated

with high levels of bilirubin in the blood.

Labelle indifference: An inappropriate lack of concern, indifference.

Mania: It is an abnormally elated mental state, typically ccarecterized

by feelings of euphoria, lack of inhibitions, racing thoughts,

Psychiatric Nursing

234

diminished need for sleep, talkativeness, risk taking, and

irritability. In extreme cases , mania can induce hallucination

and other psychotic symptoms.(www.word reference.com/

definition/mania-12k-18dec2004)

Myoclonics: Shock-like contractions of a muscle or a group of

muscles.

Neurosis: A descriptive term used to differentiate non psychotic

clinical symptoms.

Paranoia: A rare condition characterized by a delusional system that

develops gradually, becomes fixed, and is based on the

misinterpretation of actual event.

Personality disorder: A non psychotic illness characterized by

maladaptive behavior that the person uses to fulfill his her

need and bring satisfaction to self. As a result of the

inability to relate to the environment, the person acts out

conflicts socially.

Petitimal epilepsy - is one type of epilepsy seem in children, in which

there is sudden momentary unconsciousness with only

minor myoclonic jerks

Phetoscope: A specially designed stethoscope for listening to the

fetal heart beat.

Primary illness gain: obtaining relief from anxiety by using defense

mechanism to keep an internal need or conflict out of

awareness.

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235

Psychosis: A severe mental disorder in which a person experiences

an impairment of the ability to remember, think,

communicate, respond emotionally, interpret reality, and

behave appropriately.

Schizophrenia: A serious psychiatric disorder characterized by

impaired communication with loss of contact with reality

and deterioration from a previous level of functioning in

work, social relations, or self care.

Secondary illness gain: Any benefit or support that a person obtains

as a result of being sick, other than relief from anxiety.

Somnambulism: Sleep walking; rising out of bed and walking about

during an apparent state of sleep.

Spinabifida: A developmental anomaly marked by defective closure

of the boney encasement of the spinal cord through which

the meanings may or may not protrude.

Status epilepticus: Rapid succession of epileptic spasms with out

interlining periods of consciousness.

Super ego: the aspect of the personality that acts as a monitor and

evaluator of ego functioning comparing it with an ideal

standard, In psychoanalysis.

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236

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237

8. Harold I. Kaplan, Comprehensive Textbook of Psychiatry, 6th

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9. Harold I. Kaplan, Pocket Handbook of clinical psychiatry, 2nd

edition

10. Ingram I.M (1968), Notes on psychiatry, 5th edition, London.
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12. Lalitha. K. (1995), Mental Health and Psychiatric Nursing, First

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13. Mayer Gross, Slater and Ross, Clinical Psychiatry, 3rd edition
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15. Suzane. C. Smeltzer and Brenda. G. Bare (1998) Brunner and

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17. Williams and Wilkins (1996), NMS psychiatry; National Medical

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