MENTAL HEALTH

Definition
 According to the World Health Organization (WHO), mental health is a state of emotional well-being which
enables one to function comfortably within society and to be satisfied with one’s own achievements.
 This is a state of balance between an individual and the surrounding world, a state of harmony between
oneself and others, a co-existence between the realities of the self and that of other people and the
environment.
Criteria for Mental Health
• Adequate contact with reality
• Control of thoughts and imagination
• Efficiency in work and play
• Social acceptance
• Positive self-concept
• A healthy emotional life

Characteristics of a mentally healthy person

1. He has ability to make adjustments.
2. He has a sense of personal worth, feels worthwhile and important.
3. He solves his problems largely by his own effort and makes his own decisions.
4. He has a sense of personal security and feels secure in a group, shows understanding of other people’s
problems and motives.
5. He has a sense of responsibility.
6. He can give and accept love.
7. He lives in a world of reality rather than fantasy.
8. He shows emotional maturity in his behaviour, and develops a capacity to tolerate frustration and
disappointments in his daily activities.
9. He has a variety of interests and generally lives a well-balanced life of work, rest and recreation.

Psychiatry
 This is an art as well as medical science concerned with mental process of an individual, the interaction
between the doctor, the patients and their relatives and workmates, in the process of identifying the
problem and carrying out appropriate action.
 Psychiatry generalized approach stresses the unity of the body and mind.

What do you understand by the term ‘mental illness’?

This is maladjustment in living. It produces disharmony in the person’s ability to meet human needs comfortably or
effectively and function within a culture. An individual loses his ability to respond according to the expectations he has
for himself and the demands the society has for him.

Characteristics of mental illness

 Changes in ones thinking, memory, perception, feeling and judgement resulting in changes in talk and behaviour
which appears to be deviant from previous personality or from the norms of the community.
 These changes in behaviour causes distress and suffering to the individual or others or both.
 Changes and the consequent distress cause disturbance in day-to-day activities, work and relationship with
important others. (social and vocational dysfunction)

Psychology: Science of behavior.

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Historical Trends in Psychiatric Nursing
Psychiatric nursing, and the understanding of mental illness, with which it associates, has developed in several epochs
through the centuries. You will now look at each of those epochs in more detail.
Demonological Period
The earliest records of a person believed to have suffered from mental illness relate to king Nebuchadnezzar, who ate
grass believing that he was an ox. Another example is Ajax, who impaled himself on a sword believing that he was
tormented by demons.
During that time people believed that the cause of mental illness was demons. The treatment was quite harsh, degrading
and dehumanizing and involved beating, chaining, locking the individual up in a dark room and throwing the individual
into rivers and ponds.
Those patients who escaped this harsh treatment survived on stealing food or eating wild fruits. Wild animals ate up those
who inadvertently wandered into the forest.
Political Period
This period is associated with King Edward II of England.
During that time, a law was passed in the parliament to protect the property of the mentally sick. In the year 1403, the
Sisters of the Order of Saint Mary managed to start a facility to care for the mentally sick at Bedlam. The facility was able
to accommodate six patients only. Thereafter, other hospitals followed the example.
The cause of mental illness, however, was still thought to be demons. The treatment, therefore, remained more or less as
in the demonological period. Facilities were often dark, humid and infested with lice. They were also overcrowded,
leading to mass deaths during outbreaks of disease such as the plague.
In the early 18th century, the first qualified nurse was appointed to look after the mentally ill by Edward Tyson. However,
although qualified, the nurses appointed to look after the mentally sick were equally harsh to patients.
Men and women were housed together and members of the public used to visit these facilities as a form of entertainment.
It was at
St. Luke’s hospital in London where this form of entertainment was eventually banned. In order to enforce the policy,
members of the public were only allowed to see the mentally ill in the presence of an attendant after being issued with a
ticket.

Humanitarian Period
During this period, reforms of the patient care system for the mentally ill began in France, followed by Britain and later
America.
Reform in France started in 1793 at Bicetre Hospital in Paris.
Dr. Philippe Pinel unchained a group of patients who had been in chains for 30 years. He advocated kindness for mentally
sick persons, and as a result there was a marked improvement in mentally sick patients.
William Tuke started reforms in Britain in 1796. He advocated humane treatment of the mentally sick. In addition, he
introduced what we today call ‘occupational therapy’. Men were involved in gardening while women were involved in
sewing. Both men and women assisted attendants in their daily work activities. It is worth noting that so far, members of
staff were not specifically trained to deal with mental health issues. In 1808, a bill was passed to regulate the treatment of
mental health patients.
In America, Dorothea Lynda Dix introduced reforms after visiting Britain and seeing how mentally sick persons were
improving after getting reformed type of management. In 1841, she managed to have a bill passed in parliament to
regulate the treatment of the mentally sick in America.
In 1853, Dr. W.A.F Browne started giving informal mental health lectures to nurses so as to give quality care.
By 1882, formal training on mental health had begun in America at McLean Hospital, Boston.
In 1884, formal training in mental health was started in Germany and thereafter other countries followed that example.
The Scientific Period
The scientific period is associated with the 19th Century. During that period science was devoted to developing modern
treatments that were based on scientific findings. Many forms of treatments were discovered and later abandoned like
hydrotherapy, insulin therapy and leucotomy.
The current forms of treatments include physical treatment like chemotherapy and
electroconvulsive therapy.
There are also various psychological treatments, which include:
Individual/group psychotherapy
Behavior therapy
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Occupational therapy
Rehabilitation
Cognitive therapy
Counseling
Some of these treatments will be covered in more detail in section two of this unit
The scientific period witnessed the integration of mental health services with other health services. Trained manpower
was developed to care for the mentally sick.
Men and women were either managed separately or in the same wards, depending on the policy of the particular hospital.

Children were managed in special wards.

Where resources were available, different mental health conditions were managed in different units

Development of Psychiatry and Mental Health Services in Kenya

The current Mathari hospital was started in July 1910 as a lunatic asylum(place for housing the insane). Before then, the
facility served as a smallpox isolation centre. The asylum was renamed Mathari Mental Hospital in 1924. The care was
mainly custodial, taking place in dark, gloomy and often damp conditions.

Europeans, Africans, and Asians were managed separately and the quality of mental health care provided depended on the
individual’s racial background.
Mathari was the only mental hospital until the 1962 Decentralization of Mental Health Services Act. Other facilities began
to spring up, including a 22 bed psychiatric unit in Nakuru in 1962, Machakos in 1963, Nyeri and Muranga in 1964 and
Port Reitz and Kakamega in 1965.
Currently all provincial hospitals have operational psychiatric units. However, only some district hospitals have
operational psychiatric units. Outpatient psychiatric clinics have been established in most of the district hospitals.

Mathari hospital is being redeveloped, and the future plan is to intensify community based psychiatric services all over the
country. It is worth noting that community psychiatric services were established in Nairobi in 1983.

Training of Mental Health Workers

The training of enrolled psychiatric nurses was started in 1961 and later changed to a post enrolled psychiatric nursing
course. In 1963, the first two registered psychiatric nurses were trained overseas.
In 1979, a post basic diploma in psychiatric nursing was started in Kenya. Between 1972 and 1982 most psychiatrists
received overseas training at the Institute of Psychiatry in England.
In 1982, the University of Nairobi started training psychiatrists.

Factors that Influence Attitudes towards Mental Health and Mental Illness
Having outlined the classification of mental illness, you will now turn your attention to the factors that influence attitudes
towards mental health and mental illness. In this section, you are going to look at just a few examples.
Culture
The way people think, behave or feel is shaped by their culture. Culture also determines the features of insanity, for
example, who is labeled as insane and under what circumstances.
What is considered insane in one culture may be considered perfectly normal in another. Culture also gives guidelines on
the nature of treatment and the identity of the helper.
Education
The level of education also influences attitudes towards mental health and mental illness.
An educated person has a better understanding of health and mental illness, thus making their attitude more positive.
Health Beliefs
These will determine whether the individual’s attitude is positive or negative. It will depend on how the patient explains
the illness to themselves, that is, whether they believe in germ theory, evil spirits or an imbalance of some kind.
Religion
A patient’s reaction to mental illness will often depend on whether or not the patient believes in God or a particular

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religion, for example, some religions believe that ill health is caused by evil spirits. Usually, religion encourages the
followers to be empathetic to sick people.

STIGMA AND MENTAL DISORDERS

Mental illness can cause severe disability and suffering to patients, their relatives and society. Living with a mentally ill
person leads to restrictions of social and leisure activities not only for the mentally ill, but for the whole family.
Mentally ill people and their relatives are usually rejected and stigmatized by the society.
Stigma: the feelings of disapproval that people have about particular illnesses or way of behaving.
Stigma related to mental illness is in three forms:
The patient may be stigmatized by health care providers, relatives and society.
The relatives also experience stigma from society given that some communities associate mental illness with a curse or
taboo.
Popular attitudes towards the mentally ill are deep seated and can be seen in the stigmatizing language that is often used to
describe people who are mentally ill-“nuts” or “pyscho”. Some people still refer to psychiatric hospitals as “nuthouses”.

MYTHS ON MENTAL ILLNESS

1. People with mental illness cannot work

 Fact: people with mental illness work, even if they have these symptoms. Work is a vital part of
rehabilitation; it increases self-esteem, reconnects the ill person to the community and provides a
meaningful way to fill time.
2. People with mental illness are violent
 Fact: mental disorders and violence are closely linked in the public mind. The stereotype of the
violent mental patient causes public fear and avoidance of the mentally ill. People with mental
illness in general are no more dangerous than healthy individuals from the same population.
 Things to keep in mind about the stereotype (thoughts and beliefs that do not reflect reality) of
violence:
 Treatment dramatically reduces the risk of violence.
 The risk of violence is not necessarily due to illness,but a combination of disorders.
 The violence associated with mental illness is most often directed at a family member.
 People with mental illness do not pose a risk to children.
 The risk of violence in persons with mental illnesses appears to be very similar to that in the
healthy population, when substance abuse is factored out.
 The contribution of those with mental illness to the overall incidence is relatively small.
 The risk of sexual offences associated with mental illness is low.
3. All people with mental illness are mentally retarded
 Fact: mental illness and mentally retardation are entirely different conditions. Most mental
illnesses occur in people of all levels of intelligence and often in talented and creative people.
4. Jail is an appropriate place for people with mental illness
 Fact: jail and prison do not have psychiatry services. Mentally ill prisoners receive little or no
treatment. Moreover, they are subjected to “double punishment.” If they are housed with the
general prison population, their abnormal behavior leads to beating and abuse by other prisoners.
If they are segregated for their protection, they lose all social contact and the isolation often
worsens their symptoms.
5. People never recover from a psychotic illness
 Fact: this misconception leads to hopelessness and despair. It may cause some families to neglect
or abandon ill relatives. This disorder takes many different courses with varying outcomes. Some
people have episodes of illness lasting weeks or months with full remission of their symptom
between each episode; others have a fluctuating course in which symptoms are continuous, but
rise and fall in intensity; others have very little variation in the symptoms of their illness over
time. At the end some people with psychosis recover completely from the illness-all their
psychotic symptoms disappear and they return to their previous level of functioning. Others
continue to have symptoms, but are able to lead satisfying and productive lives, while others do
not recover.
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 6. Mental illness is contagious
 Fact: fear of contagion results in people avoiding those who have a mental disorder. Fear of
contagion also leads to stigmatization of family members,mental health professionals and places
of treatment.
7. Mental illness is caused by evil spirits or witchcraft
 Fact: there is a multitude of misconceptions about the cause of mental illness,but mental disorder
is not caused by a curse or an “evil eye,” God’s punishment for family sins or lack of faith in God
or reading too many books. It’s not a form of demonic possession.
8. People with mental illness are not able to make decisions about their own treatment
 Fact: most people with mental illness are able and eager to participate in decision-making about
their treatment. During the onset of the illness or during periods of relapse, people may have
some difficulty with decision-making.

REDUCING STIGMA AND DISCRIMINATION

 Increase use of treatment strategies that control symptoms, while avoiding the side effects.
 Initiate community educational activities aimed at changing attitudes toward people with mental
illness.
 Include ant stigma education in the training of teachers and health care providers.
 Improve pyschoeducation of patients and families about ways of living wither disease.
 Involve patient and families in identifying the discriminatory practices.
 Put emphasis on development of medications that improve the quality of life and minimize
stigmatizing side effects.

Principles and Qualities of Psychiatric Nursing

Respect for the Patient
This is achieved by accepting the patient as they are.
The therapist should take time to listen to the patient and provide privacy for all conversations.
Minimise situations and experiences that might humiliate the patient and be honest in providing information on medicines,
privileges, length of management and stays in hospital if indicated.
Availability
The nurse must be constantly available to assist the patient to attain their basic needs and alleviate suffering.
Spontaneity
You should avoid being overly formal. Instead, you should be comfortable with yourself, be flexible and aware of the
therapeutic goals.
Acceptance
Even if the patient behaves in a way that does not please the nurse, they should be accepted as they are, but taking care not
to reinforce their behaviour.
Sensitivity
You should do your best to show genuine interest and concern.
You should be persistent and patient even if no observable improvement is made.
Accountability
Since mentally ill patients are vulnerable due to their distorted thinking and behaviour, accountability is required more in
a psychiatric setting than any other type of health care (Peplau, cited by Wilson and Kneisl, 1988). You are also
accountable to yourself as well as professional colleagues and peers.
Empathy
This is the process of putting yourself in another’s shoes and remaining emotionally detached. The nurse should strive to
understand the patient’s perspective, and work toward mutually developed goals.
The most important function of empathy is that it enables you to give the patient the feeling of being understood and cared
about.

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Self-understanding
This involves recognition and acceptance of your own behaviour and how it affects your relationship with other people.
This will inevitably help you, as a therapist, to understand other peoples’ behaviour, needs and problems.
Permissiveness and Firmness
Although you have been told to accept the patient as they are, this does not mean that you are in a position to allow them
to do whatever they like. The therapist is expected to set limits and to be firm in implementing them.
Skill in Observation
It is important for a psychiatric nurse to be alert and observant at all times of the patient’s behaviour, attitudes and how
they react to staff, relatives and fellow patients.

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 PSYCHOPATHOLOGY
AETIOLOGICAL FACTORS OF MENTAL ILLNESS
Many factors are responsible for the causation of mental illness. These factors may predispose an individual to mental
illness, precipitate or perpetuate the mental illness.

Predisposing factors
These factors determine an individual’s susceptibility to mental illness. They are:
 Genetic make-up.
 Physical damage to the CNS.
 Adverse psychosocial influence.

Precipitating factors
These are events that that occur shortly before the onset of a disorder and appear to have induced it. They are:
 Physical stress.
 Psychological stress.

Perpetuating factors
These factors are responsible for aggravating or prolonging the diseases already existing in an individual.
Etiological factors of mental illness can be:
 Biological factors.
 Physiological changes.
 Psychological factors.
 Social factors.

A. Biological factors

1. Heredity
 What one inherits is not the illness or its symptoms, but a predisposition to the illness, which is determined by the
genes that we inherit directly.

2. Brain damage
Any damage to the structure and functioning of the brain can give rise to mental illness. Damage to the structure of the
brain may be due to one of the following causes:
 Infection: neurosyphyllis, encephalitis, HIV infection.
 Injury: resulting in loss of brain tissue due to brain injury.
 Intoxication: damage to brain tissue due to toxins such as alcohol,barbiturates.
 Vascular: poor blood supply, bleeding.
 Alteration in brain function: changes in blood chemistry that interfere with brain functioning such as disturbance
in blood glucose levels,hypoxia,anoxia,fluid and electrolyte imbalance.
 Brain tumors.
 Vitamin deficiency and malnutrition,in particular deficiency of vitamin B complex.
 Degenerative diseases: dementia.
 Endocrine disturbances: hypothyroidism,thyrotoxicosis.
 Physical defects and physical illness:results in loss of mental capacities.

3. Biochemical factors

 Disturbance in neurotransmitters in the brain is found to play an important role in the etiology of certain
psychiatric disorders.
 Neurotransmitters play an essential function in the role of human emotion and behaviour. They are chemicals that
convey information across the synaptic cleft to neighboring target cells.
 Major categories of neurotransmitters include: cholinergics, amino acids, monoamines and neuropeptides.
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Neurotransmitters functions and implications for mental illness

Neurotransmitter Function Implications for mental illness

1. Cholinergics Sleep arousal,pain perception, Decreased levels- Alzheimer’s
acetylcholine movement, memory. disease.
Increased levels-Depression
2. Monoamines
norepinephrine Mood cognition, perception, ↓ levels- depression
locomotion, cardiovascular ↑ levels- Mania, anxiety states,
functioning, sleep and arousal. schizophrenia.
dopamine Movement and coordination, ↓ levels- Parkinson’s disease and
emotions, voluntary judgement, depression.
release of prolactin. ↑levels – mania and
Sleep, arousal, libido, appetite, schizophrenia.
serotonin mood, aggression, pain ↓ levels- depression
perception, coordination and ↑ levels- anxiety states.
judgement.
Control of gastric secretions,
Histamine smooth muscle control, cardiac ↓ levels- depression
stimulation, stimulation of
sensory nerve endings and
alertness.
3. Amino acids
Gamma amino butyric acid Slowdown of body activity. ↓ levels – Anxiety disorders,
(GABA) schizophrenia and various forms
of epilepsy.
Glycine Recurrent inhibition of motor ↑ levels – glycine
neurons. encephalopathy
↓ levels- are correlated with
spastic motor movements.
Glutamate and Aspartate Relay sensory information & in ↑ levels – Huntington’s disease,
the regulation of various motor temporal lobe epilepsy, spinal
and spinal reflexes. cerebral degeneration.

Hormone functions and implications for mental illness

Hormone Functions Implications for mental illness

Antidiuretic hormone Conservation of body water & Altered pain response,modified
maintenance of blood pressure. sleep pattern.
Oxytocin Contraction of the uterus for May play a role in stress
labour,release of breast milk. response by stimulation of
ACTH.
Growth hormone Growth in children,protein Anorexia nervosa
synthesis in adults.
Thyroid stimulating hormone Stimulation of thyroid hormone ↑ levels – cause insomnia,
secretion, needed for metabolism anxiety,emotional labiality.
of food and regulation of ↓ levels – depression & fatigue
temperature
Adrenocorticotropic hormone Stimulation of cortisol secretion; ↑ levels – mood disorders,
which plays a role in response to psychosis.
stress. ↓ levels – Depression, apathy,
fatigue, Alzheimer’s disease.
Prolactin Stimulation of milk production ↑ levels – depression, anxiety,

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 decreased libido, irritability.
↓ levels – Negative symptoms in
schizophrenia.
Gonadotropic hormone Stimulation of estrogen secretion, ↑ levels – increased sexual
progesterone & testosterone. behavior and aggressiveness.
↓ levels – depression & anorexia
nervosa.
Melanocyte stimulating Stimulation of secretion of ↑ levels - depression
hormone. melatonin.

B. Physiological changes
 It has been observed that mental disorders are more likely to occur at certain critical periods of life namely:
puberty, menstruation, pregnancy, delivery, and puerperium.
 These periods are marked not only by physiological (endocrine) changes, but also by psychological issues that
diminish the adaptive capacity of the individual.
 Thus an individual becomes more susceptible to mental illness during this period.

C. Psychological factors
 It is observed that some specific personality types are more prone to develop certain psychological disorders. E.g.
unsocial and reserved.
 Strained interpersonal relationships at home,place of work,school or college,bereavement,loss of prestige,loss of
job.
 Childhood insecurities due to parents with pathological personalities, faulty attitude of parents (over strictness,
over leniency), abnormal parent child relationship (over protection,rejection,unhealthy comparisons), deprivation
of child’s essential psychological and social needs.
 Social and recreational deprivations resulting in boredom,isolation and alienation.
 Marriage problems like forced bachelorhood, disharmony due to physical, emotional, social, educational or
financial incompatibility, childlessness, too many children.
 Sexual difficulties arising out of improper sex education, unhealthy attitudes towards sexual functions, pre- and
extra-marital sex relations, worries about sexual perversions.
 Stress,frustration and seasonal variations are sometimes noted in the occurrence of mental diseases.

Social factors
 Poverty, unemployment, injustice, insecurity, immigration, urbanization.
 Gambling, alcoholism, prostitution, broken homes, divorce, very big family, religion, traditions, political
upheavals and other social crises.

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FEATURES OF MENTAL ILLNESS
PSYCHOPATHOLOGY
This is the study of abnormal states of the mind. This is the objective description of abnormal states of the mind. It is
concerned with the conscious experience and observable behaviours and defines the essential qualities of morbid mental
experiences. These descriptive states include:

A. DISTURBANCES OF CONSCIOUSNESS
Consciousness is the state of awareness of the self and the environment. The disturbances are more often associated with
brain pathology for example brain tumors, infections of the CNS, epilepsy, narcolepsy and physical trauma. Levels of
consciousness may range from a slight alteration noticeable as confusion to deep unarousable coma. Altered state of
consciousness include:
Clouding of consciousness
A person is slightly less wakeful or less aware than normal. They are not aware of time or their surroundings and find it
difficult to pay attention and appear confused.
Stupor
This is the lack of critical mental function and a level of consciousness wherein an affected person is almost entirely
unresponsive and only responds to intense stimuli such as pain.
Delirium
There is disturbance in attention (reduced ability to direct, focus, sustain and shift attention) and awareness. The
disturbance develops over a short period of time usually hours to days. An additional disturbance in cognition (memory
deficit, disorientation, language or perception). The patient may be anxious, confused or disoriented. There is evidence
from the history and physical examination the disturbance is caused by a medical condition, substance intoxication or
withdrawal or medication side effect.
Coma: deep unconsciousness.
Depersonalization:
A state in which one's thoughts and feelings seem unreal or not to belong to oneself. The persistent feeling of observing
oneself from outside one’s body or having a sense that one’s surroundings aren't real.
Derialisation: A feeling that one's surroundings are not real, especially as a symptom of mental disturbance.

B. DISTURBANCES OF ATTENTION
Attention refers to ability to direct one’s activity. It is the ability to concentrate. Examples of disturbances include:
Distractibility: this is the inability to concentrate; attention is easily diverted to other activities that are irrelevant.
Trance: a state in which you behave as if you were asleep but are still able to hear and understand what is said to you. a
half-conscious state, seemingly between sleeping and waking, in which ability to function voluntarily may be suspended.
E.g. First she goes/falls into a deep trance, and then the spirit voices start to speak through her.
He sat staring out of the window as if in a trance.
Selective inattention: The ignoring or otherwise screening out of stimuli that are threatening, anxiety-producing, or felt to
be unimportant. E.g. Focusing on watching television while speaking with someone.
Hypervigilance: This is a state of increased alertness. If you're in a state of hypervigilance, you're extremely sensitive to
your surroundings. It can make you feel like you're alert to any hidden dangers, whether from other people or the
environment. Often, though, these dangers are not real.

C. DISTURBANCES IN EMOTIONS
Emotion is the feeling or response to sensory input from the external environment or mental images.
Mood: this is sustained and pervasive inward subjective feeling.
Affect: the outward expression of emotion.
Variations in mood include:
Depression: a pathological feeling of sadness.
Dysphoric mood: an unpleasant mood.
Euthymic mood: normal mood. Neither elated nor depressed.
Irritable mood: easily offended leading to anger.
Elevated mood: cheerful, happy mood.
Euphoria: intense elation of mood.
Anhedonia: loss of interest or the inability to enjoy previously pleasurable activities.

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Apathy: an absence of interest in or concern about emotional, social, spiritual, philosophical, or physical life and the
world.v

D. DISTURBANCES OF MOTOR BEHAVIOUR

Motor behavior are externally observable behaviours that depict aspects of psyche, for example impulses, motivations,
drive, instincts and wishes.examples include:
Echopraxia: imitation of one’s person movement by another.
Catatonia: Catatonia is a group of symptoms that usually involve a lack of movement and communication, and also can
include agitation, confusion, and restlessness.
Types of catatonia:
Catatonic excitement: a period of increase in psychomotor activity, ranging from restlessness, agitation, excitement,
aggressiveness, violent behavior (furore). There is also increase in speech production, pressure of speech, loosening of
association, and incoherence.
The excitement has no apparent relationship with the external environment; inner stimuli e.g. thoughts and impulses
influence the excited behavior. So the excitement is not goal directed.
Catatonic stupor: this is characterized by lack of movement and communication. The characteristic signs include:
mutism, rigidity, negativism, posturing,stupor, echolalia, echopraxia,waxy
flexibility,ambitendency,mammerism,stereotyping and automatic obedience.
Delusions and hallucinations are usually present but not prominent.
Catalepsy: A position maintained for a long time.voluntary assumption of an inappropriate and often bizarre posture for
long periods of time.
Negativism: an apparently motiveless resistance to all commands and attempts to be moved or doing just the opposite.
Echolalia: repetition or mimicking of phrases or words heard.
Waxy flexibility: parts of body can be placed in positions that will be maintained for long periods of time even if very
uncomfortable, flexible like wax.
Mannerism: A habitual or characteristic manner, mode or way of doing something;distinctive quality or style as in
behaviour or speech. E.g. he has annoying mannerism of tappinghis fingers while he talks.
Ambitendency: the tendency to act in opposite ways based on conflicting behavioural motivation. It is a pattern of
incomplete motor responses in anticipation of a voluntary response. E.g. on asking to take out tongue, tongue is slightly
protruded but taken back again.
Mutism: complete absence of speech. Without underlying organic pathology.
Akathisia: a feeling of muscle shaking, restlessness and inability to sit still with the need to keep on moving.
Compulsion: An uncontrollable urge to perform an act repeatedly.
Stereotyping: over-generalized belief about a particular category of people. It is an expectation that people might have
about every person of a particular group.
Automatic obedience: commands are followed automatically, irrespective of their behavior.

THOUGHT DISTURBANCES
Thought can be described as goal directed flow of ideas, symbols and associations leading to reality oriented conclusion.
Thinking is said to be normal when a logical sequence occurs.

Disorders in the form of thoughts (disorders in the flow and structure of thoughts)

Autistic thinking: preoccupation with the inner private world. It is a type of mental activity in which focus is directed
inward and the thinking is subjective (as opposed to objective). Autistic thinking is comprised of inner thoughts and
individual reality. Daydreaming and fantasies are common elements of autistic thinking.
Neologisms: new word created by the patient or a normal word used to mean a different thing.
Word salad: A confused or unintelligible mixture of seemingly random words and phrases, specifically (in psychiatry) as
a form of speech. Several words put together with no clear meaning.
Incoherence: thinking that does not flow logically.
Echolalia: psychopathological repetition of words or phrases said by another person.
Derailment: sudden or gradual deviation in the flow of thoughts without blocking.
Flight of ideas: occurs when a person rapidly shifts between conversation topics, making his or her speech challenging or
even impossible to follow. The pace of the person’s /speech may pick up, and they speak rapidly, with a tendency toward

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changing the subject frequently. The new subject may be related to the preceding subject, but it might not. The connection
might be very weak.
Thought block: Sudden interruption During thought blocking, a person stops speaking suddenly and without
explanation in the middle of a sentence.
Disorders of the content of thought
Delusions
False unshakeable belief not consistent with the person’s intelligence or cultural belief.
Types of delusions
 Erotomanic: The person believes someone is in love with them and might try to contact that person. Often it’s
someone important or famous. This can lead to stalking behavior.
 Grandiose: People experiencing grandiose delusions see themselves as great, highly accomplished, more important
than others, or even magical. Also known as a delusion of grandeur, this is a person’s belief that they have special
abilities, possessions, or powers, despite a lack of evidence.
 Jealous: A person with this type believes their spouse or sexual partner is unfaithful.
 Persecutory: Someone who has this believes they (or someone close to them) are being mistreated, or that someone is
spying on them or planning to harm them. They might make repeated complaints to legal authorities.
 Somatic: They believe they have a physical defect or medical problem.
Guilt and unworthiness: When an individual believes that they are bad or evil and have ruined their family, despite no
evidence to support this. This is commonly seen in those with depressive illness.
Negation/Nihilistic: The delusion of nonexistence: a fixed belief that the mind, body, or the world at large—or parts
thereof—no longer exists.
Grandiose/Religion: This delusional ideation frequently includes beliefs that the individual is the embodiment of a
notable religious figure, such as a messiah or prophet, and that he or she possesses special powers.
Hypochondriac delusions: belief in one’s illness contrary to all medical evidence.
Disorders of control of thought
These are delusions of control of one’s thoughts by outside forces
Thought withdrawal: a situation in which other people or agents remove one’s thoughts from the mind.
Thought insertion: A situation where other people or forces are putting thoughts into one’s mind against their wish.
Thought broadcasting: A situation in which one’s thought is made known to others without being talked out by the one
thinking.
Obsession
Pathological persistent of an irresistible
Speech disturbances
Communication through the use of words and language.
Pressure of speech: the patient talks a lot and rapidly and it may be difficult to follow the speech.
Poverty of speech: very little speech
Dysarthria: difficulty in articulation
Aphasia: disturbances in speech output.

Perception
The way something is understood or interpreted in the presence of a stimuli.
Hallucinations
This is a false sensory perception without stimuli. Involves any of the five senses.
Auditory hallucinations: the patient hears a sound or a voice without any stimulus.
Visual hallucinations: sight of images without stimulus
Tactile hallucinations: false perception of touch without stimulus
Olfactory hallucinations: false perception of smell without stimulus
Gustatory hallucinations: false perception of taste without stimulus
COGNITIVE FUNCTIONS
This describes assessment of higher mental functions
Sensorium/consciousness
Disturbance of consciousness usually denotes organic brain conditions. Determine the level of consciousness
and any fluctuations if present. This may range from mild clouding of consciousness to stupor or coma.
Orientation
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This is to check if the patient knows the time, place and person. Does the patient know time of the day, of the
week, month and year? The responses expected are determined by the social and cultural background of the
patients. For place, ask about familiar places. For person, ask about his name, age, name of children, parents
and siblings. These should be counter checked with family members.
Attention and concentration
Is the attention easily aroused and sustained; Naming three objects to the patient or giving a telephone number
which the patient is told to repeat after the interviewer can assess whether they are attentive. By this time the
interview process one can gauge a patient’s attention span by how they answer the questions and their
participation in the whole process.
Can the patient concentrate; is he easily distractible; On the other hand, concentration can be determined using
simple calculations like subtracting 7 from 100 (serial seven)upto 65 or 3 from 20 (serial three) or by means of
simple problems.

Memory
Memory is assessed in three categories: immediate (recall), recent and remote.
Immediate memory, which pertains to retention and recall involves events occurring in the last few seconds to
minutes, can be assessed by giving the patient telephone numbers with 5 to 6 digits and asking them to repeat.
Recent memory is hours to 2-3 days, thus involves asking patients what they ate for breakfast or where they
were in the last few days.
Remote memory involves past years’ events. Important family or historic dates in the patient’s socio-cultural
context may be used. e.g date and place of marriage, name and birthdays of children
Intelligence
This is the ability to think logically and deal effectively with the environment.
Ask questions about general information, keeping in mind the pateint’s educational and social background, his
experiences and interests.
Judgment
Does the patient understand the harmful consequences of his behavior to himself, the family and community?
Would the patient make wise decisions, for example, in case of fire, drowning or any life threatening situation?
Judgement is rated as good/intact/normal/poor/abnormal/impaired
Insight
This is the degree of awareness and understanding that the patient has regarding his illness
Ask the patient’s attitude towards his present state; whether there is an illness or not; if yes, which kind of
illness (physical, psychiatric or both); is any treatment needed; is there hope for recovery; what is the cause of
the illness.

PSYCHIATRIC INTERVIEW, ASSESSMENT AND CLASSIFICATION

THE PYSCHIATRIC INTERVIEW
 This interview is the most important tool in psychiatry. It is used to understand the patient’s problem, elicit signs
and symptoms, make appropriate diagnosis, initiate treatment and predict outcome.
 Offers patients an opportunity to express themselves and others in a non-critical and non-judgmental atmosphere.
Psychiatry vs medical interview
 Presence of disturbances in thinking, behavior and emotions can interfere with meaningful communication.
 Collateral information from significant others can be important.
 Important to obtain detailed information of personal history and premorbid personality.
 Need for more astute observation of patient’s behavior.
 Difficulty in establishing rapport maybe encountered more often.
 Patient may lack insight into their illness and may have poor judgement.
 Usually more important to elicit information regarding stressors and social situations.

REASONS WHY A PATIENT CONSULTS A MENTAL HEALTH WORKER

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  Due to disturbing experiences
 Pressure from the family, relatives, friends or the employer.
 Others may be forced through the courts.

THE SETTING OF THE PSYCHIATRIC INTERVIEW

 Should provide privacy and assure confidentiality.
 The patient should receive full attention of the medial practitioner.
 The sitting positions determine how the interview proceeds and what is said during the interview.
 The patient to sit at right angles to the clinician with the distance between the patient and the clinician permitting
easy communication without shouting and at the same time avoiding the discomfort of close physical proximity.

GENERAL PRINCIPLES IN PSYCHIATRIC INTERVIEWS

Active observation and awareness behavior
This begins from the moment the patient walks into the consultation room.
The gait, the physical appearance and greetings, as well as the general attitude to the interview are all important. Focus on
verbal and non-verbal communication.
Assessment and evaluation is a two-way process
While the medical worker is assessing the patient, the patient is also evaluating the medical worker on sensitivity and
genuine desire to help. The patient may not reveal a great deal about himself unless he senses that the clinician is
interested and concerned about him.
If for instance the clinician looks at his watch, it may give the impression that he finds the patient boring.
Acceptance of the behavior of the patient
All behavior including what appears at first sight as odd has a meaning to the patient.
Such behavior may invite ridicule and laughter. The clinician should accept such odd behavior.
Accepting does not however mean approving it.
Avoid arguments with the patient
Avoid getting drawn into an argument with the patient. It may the patient’s way of relating to others or seeking help. The
clinician should try to find the underlying relationship problems.
Do not assume you understand the patient
At all times the clinician should make sure he understands what the patient says or feels.
Very often what the patient expresses may be about problems close to our own, e.g ordinary feelings like depression. One
has to find the depth of the depression, whether he cries, has feelings of hopelessness and suicidal thoughts and the
presence or absence of associated symptoms, such as change in appetite and weight, and disturbance of sleep.
One method of clarifying one’s thoughts of what the patient says and feel, is for the clinician to summarize a number of
times during the interview by repeating what the patient has said and the feelings the patient has expressed. The patient
can correct the clinician if he has been misunderstood.
Stress on feelings
The feeling of the patient may be difficult for the new clinician to understand. First the beginner may feel awkward and at
a loss of what to do with an outpouring of feelings for example crying by the patient.
The patient should be offered the opportunity to unburden these feelings, which may have a cathartic effect.
The second dilemma encountered by novices is when a patient talk about suicidal feelings. For example, they may end up
suggesting it to the patients.
The important point is when and how to ask such questions.
When the patient is telling the clinician his feelings of hopelessness, posing such a question such as “don’t you think of
suicide?” is not appropriate.
It would be appropriate to ask, “When you feel so low, do you feel sometimes feel that life is not worth living?” and to
proceed from there.
The clinician should focus on feelings and emotionally charged areas should be explored. At times the patient may show
resistance and these should be kept in mind for further discussion later in the interview.
Sensitive topics should be handled carefully and tactfully. Introduce them gradually.
Focus on interpersonal relationships
Apart from the usual information about family history, the important areas are the interpersonal sense of love, acceptance,
security and discipline. These facts reveal factors responsible in shaping the personality of the patient.

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Avoid being moralistic or judgmental
Some patients may come to the interview, expecting the worst with a great deal of anxiety or guilt.
That is one of the main reasons why people avoid sharing their problems and feelings.
Show empathy
This is sensing the client’s inner world of private personal meaning as if it were your own, but without losing the “as if”
quality.
Try to tolerate the silence
The novice may find it difficult when the patient does not respond to the posed question right away. The period of silence
may be as a result of the patient trying to sort out his thoughts, or the patient may not wish to respond to that particular
question, probably due to illness itself or feeling aroused.

THE STAGES OF A PSYCHIATRIC INTERVIEW

The initial phase
 This phase begins from the first contact with the patient. The clinician should greet the patient and introduce
himself. Both of them should sit comfortably. Questions should be open ended and simple. Those that begin with
“why” are usually difficult to answer, and createresistance, thus should be avoided. Avoid technical terms. The
initial phase mainly covers the patient’s illness.
The middle phase
 This part of the interview focusses on the background of the patient, hisupbringing, familylife, educational and
vocational life and interpersonal relationships, both past and present. The clinician tries to find out the influences
of these factors on personality and current problems of the patient.

Closing phase
It is important to give the patient some minutes before closing the interview to ask questions or express the points that
were not covered during the interview.
Questions such as “before we finish for the day, is there any question you wanted to ask?” or “are there any points which
you feel that you wanted to discuss now?”
This may open new areas for interview. The patient may raise points already discussed showing the areas of his particular
concern. Discuss the patients areas of concern and the feelings associated with it.

THE PSYCHIATRIC ASSESSMENT/HISTORY

This is obtained from the parent as well as from the family, relatives or friends. This is because in some cases the patient
may not be responsive or may be confused and in others the history given by the patient may be inaccurate.
An alcoholic, for example, tends to conceal his drinking or a schizophrenic patient may not reveal his abnormal
experiences, such as delusions or hallucinations.
An accurate history and MSE are the cornerstones of diagnoses and treatment in psychiatry.

WHEN DO YOU WRITE THE PSYCHIATRIC HISTORY

It is best to write the entire history and MSE at the end of the session. However, note down important points like dates,
presence of psychopathological symptoms as it may be difficult to recall this later.

WHEN DO YOU INTERVIEW THE FAMILY

In severely disturbed patients, it is important to involve the family during the initial interview. So much information may
be obtained from the family, which may not be readily available from the patient.

COMPONENTS OF THE PSYCHIATRIC HISTORY

Personal /Identifying Data
Here you ask for information pertaining to age,
sex, marital status, occupation, residence
and nationality.
The referral system
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Note the source of referral, whether by a health worker, brought by family members or self-accord indicating the main
reasons for referral.
Chief complaint
The presenting complains and reasons for patient seeking help should be noted. Both the patient’s and informant’s version
should be recorded. If the patient has no complain due to absence of insight this fact should also be recorded.
It is important to use patient’s own words and note the duration of each presenting complaint. Note the following:
Onset of the present illness/symptom.
Duration of the present illness/illness.
Predisposing factors.
Precipitating factors.
Perpetuating or relieving factors.
History of Presenting Illness
When the patient was last well or asymptomatic should be clearly noted. This provides useful information about the onset
as well as duration of illness. The symptoms of illness, from the earliest time at which change was noticed (onset) until the
present time, should be narrated chronologically.
The chief complains should be expanded.

Remember:
In an outpatient clinic, this information is better taken first, since the patient or the informant would like to
talk about it straight away.
Past Medical and Psychiatric History
Any history of any past psychiatric illness should be obtained. Any past history of having received any psychotropic
medication, alcohol and drug abuse or dependence and psychiatric hospitalization should be enquired.
A past history of any serious medical or neurological illness, surgical procedure, accident or hospitalization should be
obtained.
The nature of treatment received, allergies should be established.
A past history of relevant aetiological causes such as a head injury, convulsions, unconsciousness, diabetes,heart disease,
syphilis and HIV should be explored.

Family History
The family history usually includes the family of origin that is the patient’s parents, siblings, grandparents, uncles etc.
The family of procreation that is the patient’s spouse, children and grandchildren is recorded.
Family history is usually recorded under the following headings:
1. Family structure: it should be noted whether the family is nuclear or extended. The age and cause of death if any
of family members should be asked.
2. Family history of similar or other psychiatric illnesses, major medical illnesses, alcohol or drug dependence and
suicide or suicide attempts should be recorded.
3. Current social situation: home circumstances, per capita income. Socio-economic status, leader of the family as
well as current attitudes of family members towards the patient illness should be noted.
Personal History
The past period of the life of the patient should be reviewed. The aim is to obtain a comprehensive picture of the patient
and to find out factors in his past which may explain his psychological make-up, personality and present problems. Maybe
divided into the following periods:
Pregnancy, birth and early development upto around 6 years
The interviewer should ask the following questions:
Was the pregnancy unwanted, or out of wedlock and what were the consequences on the relationship of mother and child
and other members of the family?
Was there any problem during pregnancy and delivery?
Was it an extended or nuclear family? In the case of an extended family, who in the family was closely attending to the
patient’s needs? The interpersonal relationship of the individuals in the family unit, its cohesiveness, and the social
economic situation of the family should be investigated.

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Have there been significant incidents in the family like separation, divorce, illness and death of significant people? Was
there any problem with separation and socialization? How was the performance at school? Were there any neurotic traits
like nail biting and thumb sucking?

Six years to puberty

This section focusses on the individual sense of identity, participation in structured activities, whether they liked school,
their school performance, type of discipline and attitude towards authority (both at home and in school), peer group
activities and its influence on the patient as well as coping mechanisms.
Adolescence to 19 years
This is a period of heightened sexual awareness. Social achievements and relationships both at home and in school with
other students and teachers should be explored. What are the patient’s professional interests and future goals, involvement
in any extra-curricular activities? Daily activities and social contacts are explored for the patient who did not go to school.
Occupational history
The age and which work the patient first engaged in, any income generating activity or employment, the nature of work,
social and occupational relationships, job satisfaction, growth and improvement or deterioration in the job are considered.
Repeated absenteeism from work or deterioration of work activity, for example, may indicate alcoholism, depression or
schizophrenia.
Marital and sexual history
Areas to be enquired about include:
Masturbation (fantasy or activity), adolescent sexual activity, premarital and extramarital sexual relationships, sexual
practices normal and abnormal, any gender identity disorders.
The duration of marriage and relationship, time known the partner before marriage, marriage arranged by parents with or
without consent or by self-choice with or without parental consent, number of marriages, divorces or separations, sexual
satisfaction, mode and frequency of sexual intercourse.
Premorbid personality
The following sub headings are often used for the description:
Interpersonal relationship: with family members, friends, work, colleagues, introverted/extroverted, ease of
making and maintaining social relationships.
Use of leisure time: hobbies, interests, intellectual activities, energetic or sedentary.
Predominant mood: optimistic/pessimistic, stable / prone to anxiety, cheerful/despondent; reaction to stressful
life events.
Attitude to self and others: self confidence levels, self-criticism, self-conscious, self-centered/thoughtful of
others, achievements and failures.
Attitude to work and responsibility: decision making, acceptance of responsibility, flexibility, perseverance;
foresight.
Habits: food fads, alcohol, tobacco, drugs, sleep
Get information from informants.

Mental Status Assessment/ Examination

This is used to determine whether a patient is experiencing abnormalities in thinking and reasoning ability,feelings or
behaviour.
Check facial expressions to provide information about mood, orientation to time, place, person, concentration and
perceptual disorder, where you should check for the following senses:
Olfactory
Auditory
Tactile
Visual
Gustatory

The following outline is generally accepted in reporting MSE findings:

General appearance and behavior

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General appearance:
The important points to be noted are:
Physique and body build, approximate height, weight and appearance. Looks comfortable/uncomfortable.
Physical health, grooming, hygiene, self-care, dressing is it adequate, appropriate, any peculiarities.
Attitude towards examiner
Cooperation/guarded/evasive/hostile/haughty. Attentive, appears interested/disinterested/apathetic.
Comprehension: intact/impaired
Gait and posture
Normal or abnormal (way of sitting,standing, walking, lying)
Motor activity
Increased/decreased. Excitement/stupor, abnormal involuntary movements such as tremors, akathisia.
Restlessness/at ease.
Catatonic signs (mannerisms, stereotypies, posturing, waxy flexibility, negativism, stupor, echopraxia)
Social withdrawal.
Compulsive acts, rituals or habits such as nail biting.
Social manner and non-verbal behavior
Increased, decreased, or inappropriate behaviour.
Eye contact (gaze aversion, staring vacantly, staring at the examiner, hesistant eye contact or normal eye
contact)
Hallucinatory behavior
Smiling or crying without reason, muttering or talking to self (non-social speech)
Odd gesturing in response to auditory or visual hallucinations.
Speech
Speech can be examined under the following headings:
Rate and quantity of speech
Whether speech is absent or present (mutism)
If present, whether it is spontaneous, whether productivity is increased or decreased.
Rate is rapid or slow, pressure of speech or poverty of speech.

Volume and tone of speech

Increased/decreased. Low/high/normal pitch.

Flow and rhythm of speech

Smooth/hesitant/blocking/sudden
Stuttering/stammering/cluttering any accent
Circumstantiality/tangentiality/flight of ideas
Mood
Refer to expression of emotion, which is subjective. Note the variability or range, intensity and appropriateness.
Mood could be described as dysphoric, euthymic, expansive, irritable, labile, elevated, euphoric, ecstatic,
depressive or anhedonic.
Affect is said to be appropriate or inappropriate, blunted, restricted, flat or labile.
In some cases the patient may have difficulty expressing feelings or emotions referred to as alexithymia.
Thoughts
Two components of thoughts are assessed: the thought process and the thought content.
Thought process includes the flow of ideas and quality of associations; the process of thinking should include
rate and flow of ideas. Thoughts can be racing or totally slowed down. There may becircumstantiality, blocking
or perseveration as occurs in schizophrenia. Thought broadcasting and insertion are pathogenic features of
schizophrenia.
Associations defined as the relationships between ideas can be exhibited by loosening, flight of ideas,
neologisms, word salad or echolalia.
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Thought content includes distortions, delusions, ideas of reference, depersonalization, derealization,
preoccupations, obsessions, phobias,somaticconcerns, suicidal or homicidal ideation. In suicidal and homicidal
ideation the interviewer needs to assess the thoughts, plans, feelings and potential for actions and deterrents to
action.

Perception
Perception is the process of being aware of sensory experience and being able to recognize it by comparing it
with previous experiences
Enquiries about perceptual disturbances require careful approach and should evaluate the presence or absence of
illusions, hallucinations, depersonalization or derealization. Hallucinations should focus on all the five sense
organs (sight,hearing,taste.touch and smell) involved, with their contact, frequency and circumstances of their
occurrence are recorded.

COGNITIVE FUNCTIONS
This describes assessment of higher mental functions
Sensorium/consciousness
Disturbance of consciousness usually denotes organic brain conditions. Determine the level of consciousness
and any fluctuations if present. This may range from mild clouding of consciousness to stupor or coma.
Orientation
This is to check if the patient knows the time, place and person. Does the patient know time of the day, of the
week, month and year? The responses expected are determined by the social and cultural background of the
patients. For place, ask about familiar places. For person, ask about his name, age, name of children, parents
and siblings. These should be counter checked with family members.
Attention and concentration
Is the attention easily aroused and sustained; Naming three objects to the patient or giving a telephone number
which the patient is told to repeat after the interviewer can assess whether they are attentive. By this time the
interview process one can gauge a patient’s attention span by how they answer the questions and their
participation in the whole process.
Can the patient concentrate; is he easily distractible; On the other hand, concentration can be determined using
simple calculations like subtracting 7 from 100 (serial seven)upto 65 or 3 from 20 (serial three) or by means of
simple problems.
Memory
Memory is assessed in three categories: immediate (recall), recent and remote.
Immediate memory, which pertains to retention and recall involves events occurring in the last few seconds to
minutes, can be assessed by giving the patient telephone numbers with 5 to 6 digits and asking them to repeat.
Recent memory is hours to 2-3 days, thus involves asking patients what they ate for breakfast or where they
were in the last few days.
Remote memory involves past years’ events. Important family or historic dates in the patient’s socio-cultural
context may be used. e.g date and place of marriage, name and birthdays of children
Intelligence
This is the ability to think logically and deal effectively with the environment.
Ask questions about general information, keeping in mind the pateint’s educational and social background, his
experiences and interests.
Judgment
Does the patient understand the harmful consequences of his behavior to himself, the family and community?
Would the patient make wise decisions, for example, in case of fire, drowning or any life threatening situation?
Insight
This is the degree of awareness and understanding that the patient has regarding his illness

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Ask the patient’s attitude towards his present state; whether there is an illness or not; if yes, which kind of
illness (physical, psychiatric or both); is any treatment needed; is there hope for recovery; what is the cause of
the illness.

PSYCHIATRIC CLASSIFICATION
There are two main sets of classification used in psychiatry:
The international classification of diseases version 10 (ICD-10) chapter 5 by the WHO.
The diagnostic and statistical manual for mental disorders,5th edition (DSM-V TR)
We will adopt DSM-IV TR classification. Its multiaxial approach is described in detail below.
MULTIAXIAL ASSESSMENT
A multiaxial system involves an assessment on several axes, each of which refers to a different domain of
information that may help a clinician plan treatment and predict outcome.
There are 5 axes included in the DSM-V multiaxial classification:
Axis 1: clinical disorders
Other conditions that may be a focus of clinical attention
Axis II: personality disorders.
Mental retardation
Axis III: general medical conditions.
Axis IV: psychosocial and environmental problems.
Axis V: global assessment of functioning.

AXIS 1: CLINICAL DISORDERS

Other conditions that maybe a focus of clinical attention.
Axis 1 is for reporting all the various disorders or conditions in the classification except for personality
disorders and mental retardation(axis II). Also reported on axis I are other conditions that maybe a focus of
clinical attention.
Examples:
Disorders usually first diagnosed in infancy,childhood or adolescence(excluding mental retardation)
Delirium,dementia,amnesia(cognitive disorders)
Mental disorders due to a general medical condition.
Substance related disorders.
Schizophrenia and other psychotic disorders.
Mood disorders.(affective disorders;major depression and bipolar)
Anxiety disorders.
Somatoform disorders.
Factitious disorders.
Dissociative disorders.
Sexual and gender identity disorders.
Eating disorders.
Sleep disorders.
Impulse control disorders.
Adjustment disorders.
Other conditions that may be a focus of clinical attention.
When an individual has more than one Axis I disorder,all of these should be reported.if more than Axis
Idisorder is present, the principle diagnosis or the reason for visit should be indicated by listing it first.
When an individual has both Axis I and an Axis II disorder, the principal diagnosis or the reason for the visit
will be assumed to be on Axis I unless the Axis II diagnosis is followed by the qualifying phrase “(principal
diagnosis)” or “reason for visit.”
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If no Axis I disorder is deferred,pending the gathering of additional information, this should also be stated.
AXIS II: PERSONALITY DISORDERS
Mental retardation
This is for reporting personality disorders and mental retardation. It may also be used for noting prominent
maladaptive personality features and defence mechanisms.
When an individual has both Axis I and Axis II diagnosis and the Axis II is the principal diagnosis or the main
reason for visit, this should be indicated by adding the qualifying phrase “(principal diagnosis)” or “(reason for
visit)” after the Axis II diagnosis.
Examples
Paranoid,
Schizoid
Schizotypal ”
Antisocial
Borderline
Histrionic
Narcissitic
Avoidant
Dependent
Obsessive compulsive
Personality
Specified
Mental retardation
AXIS III: GENERAL MEDICAL CONDITIONS
This is for reporting current general medical conditions that are potentially relevant to the understanding or
management of the individuals\’s mental disorder.
The purpose of distinguishing GMC is to encourage thoroughness in evaluation and to enhance communication
among health care providers.
GMC can be related to mental disorders in various ways.
In some cases it may be related directly to the aetiological development or worsening of the mental symptoms
and that the mechanism for this effect is physiological.
When a mental disorder is judged to be a direct physiological consequence of the GMC, a mental disorder due
to a GMC should be diagnosed on Axis I and the GMC should be recorded on both Axes I and III.
In those instances in which the aetiological relationship between the GMC and the mental symptoms is
insufficiently clear to warrant Axis I diagnosis of mental disorder due to a GMC, the appropriate mental
disorder (e.g major depressive disorder) should be listed and coded on Axis I; the GMC should only be coded
on Axis III.
There are other situations in which the GMC are recorded on Axis III because of their importance to the overall
understanding or treatment of the individual with mental disorder:
An Axis I disorder maybe a psychological reaction to an Axis III.
Some GMC may not be directly related to a mental disorder but nonetheless have important prognostic or
treatment implications.
The choice of pharmacotherapy is influenced by the GMC.
When an individual has more than one clinically relevant Axis III diagnosis,all should be reported.
AXIS IV: PSYCHOSOCIAL AND ENVIRONMENTAL PROBLEMS
This is for reporting psychosocial and environmental problems that may affect the diagnosis,treatment and
prognosis of mental disorders (Axes I and II).
When an individual has multiple psychosocial or environmental problems, the health worker may note as many
as are judged to be relevant. Only those that have been present during the year preceeding the current evaluation
should be noted.

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You may also note those occurring prior to the previous year if these clearly contribute to the mental disorderor
have become a focus for treatment.
In practice, most psychosocial and environmental problems will be indicated on Axis IV. However,when it is
the primary focus of clinical attention, it should also be recorded on Axis I.
They are grouped in the following categories:
Problems with primary support group:
Death of a family member; health problems in the family; disruption of family by separation; divorce, or
enstrangement; removal from the home,remarriage of parent; sexual or physical abuse; parental
overprotection;neglect of child; inadequate discipline; discord with siblings; birth of a sibling.
Problems related to the social environment:
Death or loss of a friend; inadequate social support; living alone; difficulty with acculturation; discrimination;
adjustment to life cycle transition (such as retirement)
Educational problems:
Illiteracy; academic problems; discord with teachers or classmates; inadequate school environment.
Occupational problems:
Unemployment; threat of job loss; stressful work schedule; difficult work conditions; job dissatisfaction; job
change; discord with boss or co-workers.
Housing problems:
Homelessness; inadequate housing; unsafe neighbourhood; discord with neighbours or landlord.
Economic problems:
Extreme poverty; inadequate finances; insufficient welfare support.
Problems with access to health care services:
Inadequate heal the care services; transportation to health care facilities unavailable, inadequate health
insurance.
Problems related to interaction with the legal system, crime and arrest:
Incarceration;litigation;victim of crime.
Other psychosocial and environmental problems:
Exposure to disaster,war and other hostilities: discord with non-family care givers such as counselor,social
worker or physician; unavailability of social service agencies.
AXIS V: GLOBAL ASSESSMENT OF FUNCTIONING
This is for reporting the clinicians judgement of the individual’s overall level of functioning.
This information is useful in planning treatment and measuring its impact and in predicting outcome.
The reporting of overall functioning on Axis V can be done in using GAF scale.
It is useful in tracking the clinical progress of individual in global terms, using a single measure.
The GAF scale is rated with respect to psychological,social and occupational functioning.
The instructions specify, “do not include impairement in functioning due to physical or environmental
limitations”
The GAF scale is divided into10 ranges of functioning.
Making a GAF rating involves picking a single value that best reflects the individual’s overall level of
functioning.
The description of each 10-point range in the GAF scale has two components:
The first part covers the symptom severity, and the second part covers functioning.
In order to ensure that no elements of the GAF scale are overlooked when a rating is being made, the following
method may be applied:
STEP 1: start at the top level, evaluate each range each range by asking “is either the individual’s
symptom severity or level of functioningworse than what is indicated in the range of description?”
STEP 2: keep moving down the scale until the range that best matches the individual’s symptom severity
or the leveling is reached, whichever is worse.

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STEP 3: look at the next lower range as a double – check against having stopped prematurely. This range
should be too severe on both symptom severity and level of functioning. If it is appropriate range has been
reached (continue with step 4)if not, go back to step 2 and continue moving down the scale.
STEP 4: to determine the specific GAF rating within the selected 10-point range, consider whether the
individual is functioning at the higher or lower end of the 10-point range. For example, consider an individual
who hears voices that do not influence his behaviour.
GAF scale
This gives a score that ranges from a possible maximum of 100 to a possible 0 as indicate below.
CODE
100-91 superior functioning day in a wide range of activities,life’s problems never seem to get out of hand, is
sought out by others because of his many positive qualities. No symptoms.
90-81 abscent or minimal symptoms (e.g mild anxiety before an exam), good functioning in all areas, interested
and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday
problems or concerns (e.g an occasional argument with family members)
80-71: If symptoms are present that are transient and expected reactions to psychosocial stressors
(e.g difficulty concentrating after family argument); no more than slight impairement in social, occupational or
school functioning (e.g. temporarily falling behind in schoolwork)
70-61 some mild symptoms (e.g. depressed mood and mild insomnia) or some difficulty in social, occupational
or school functioning (e.g. occasionally truancy, or theft within the household),but generally functioning pretty
well, has some meaningful interpersonal relationships.
60-51 moderate symptoms (e.g. flat affect and circumstantial speech,occasional panic attacks) or moderate
difficulty in social occupational or school functioning (e.g a few friends, conflicts with peers or co-workers).
50-41 serious symptoms (e.g. suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious
impairment in social, occupational, or school functioning (e.g. no friends, unable to keep a job).
40-31 some impairment in reality testing or communication (e.g. speech is illogical at times, obscure or
irrelevant) or major impairment in several areas, such as work or school, family relations, judgement, thinking
or mood (e.g. depressed, avoid friends, neglects family, and is unable to work; child frequently beats up
younger children,is defiant at home,and is failing at school).
30-21 behaviour is considerably influenced by delusions or hallucinations or serious impairement in
communication or judgement (e.g. sometimes incoherent,acts grossly inappropriately,suicidal preoccupation) or
inability to function in almost all areas (e.g stays in bed all day; no job,home or friends).
20-11 some danger of hurting self or others (e.g suicide attempts without clear expectations of death; frequently
violent; manic excitement) or occasionally fails to maintain minimal personal hygiene (e.g smears faeces) or
gross impairement in communication (e.glargerly incoherent or mute)
10-1 persistent danger of severely hurting self or others (e.g recurrent violence) or persistent inability to
maintain minimal personal hygiene or serious suicidal act with clear expectation of death.
0 inadequate information
ICD – 10 CLASSIFICATION
F00-F09
Organic including symptomatic mental disorders such delirium, dementia, organic amnestic syndrome,
F10-F19
Mental and behavioural disorders due to psychoactive substance use such as acute intoxication,dependence,
withdrawal state, psychotic disorders due psychoactive substance use.
F20-F29
Schizophrenia, schizotypal and delusional disorders
F30-F39
Mood disorders such as manic episode, depressive episode, bipolar affective disorder
F40-F49
Neurotic, stress related and somatoform disorders (there is no category with code F49) such as anxiety
disorders, phobias. OCD, dissociative disorders, adjustment disorders.
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F50-F59
Behavioural syndromes associated with psychological disturbances and physical factors such as eating
disorders, sleep disorders, sexual dysfunctions, mental and behavioural disorders associated with pueperium.
F60-F69
Disorders of adult personality and behavior such as gender identity disorders, disorders of sexual preference and
orientation.
F70-F79
Mental retardation
F80-F89
Disorders of psychological development such as speech and language disorders, developmental disorders
F90-F98
Behavioural and emotional disorders with onset usually occurring in childhood and adolescence such as conduct
disorders
F99
Unspecified mental disorders

SECTION 3: TREATMENT USED IN THE MANAGEMENT OF MENTALLY ILL PERSONS

A.Drugs(psychotropics)
There are various types of drugs and other physical treatments used to treat patients suffering from mental health illness.
These can be grouped together under the following categories:
 Antipsychotic Medication
 Antidepressant
 Anxiolytics and hypnosedatives.
 Antiepileptic drugs
 Antiparkinsonian Drugs
You will now look at each of these categories in turn.

A. Antipsychotic Medication
Antipsychotic drugs are also called major tranquillizers or neuroleptics used in the treatment of psychoses like
schizophrenia, bipolar disorders (manic phase) and alcohol withdrawal disorder.
Antipsychotic Drugs
Generic Name Trade Name Daily Doses (range)
Low Potency Drugs
Chlorpromazine Largactil 300-1000mgs
Sulpride Domatil,Sulparex 200-2400mg
Thioridazine Melleril 50-800mg
High Potency Drugs
Haloperidol Haldol,Serenace 1-20mg
Thiothixene Navane 6-60mgs
Zoxapine Loxitane 60-250mgs
Molindone Lidone 50-400mgs
Flupenthixol Depixol 6-18mg
Fluphenazine Moditen 2.5-20mg
Trifluoperazine Stelazine 5-30mg
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Zuclopenthixol Clopixol 20-150mg
Pimozide Orap 2-10mg
Depot Injections
Fluphenazinedecanoate Modecate 12.5-100mg(IM 2 Weekly)
Zuclopenthixol Acetate ClopixolAcuphase 50-150mg every 2-3 days
Haloperidol decanoate Haldol decanoate 50-300mg (IM 4 weekly)

Mechanisms of Action
The drugs are thought to work by blocking dopamine receptors causing a decrease in psychotic symptoms. The drug is
metabolised in the liver and excreted by the kidneys. For one to get the desired effects, one must maintain the patient on
the lowest dose possible and initial therapy should be on divided doses so that the patient can be monitored.

For acutely psychotic patients:

 Give intramuscular haloperidol, for example, 5mg every 30 to 60 minutes over a two to six hour period. Peak
level is attained 20 to 40 minutes after injection.
 Monitor blood pressure before each dose and withhold if the systolic blood pressure is 90mm Hg or below.
 Sleep state should be monitored to ensure six to seven hours of sleep.
 Dystonia occurring 1 hour to 48 hours after starting treatment should be treated with an antiparkinsonism drug.
 To decrease the danger to the patient themselves and others, the patient needs to be monitored for possible
adverse reactions to the medication.

Drugs should be given using the following time frame:

 Six months for first psychotic episode.
 One year period for second psychotic episode.
 Indefinite period for third and later psychotic episodes.
 The drug should be discontinued through tapering the dosage to avoid dyskinesia.
 Gertrude and MacFarland (1986) have identified the following expected responses
to the treatment:
 Initially the patient is drowsy and co-operative within hours to a week.
 The patient becomes more sociable and less withdrawn for the next two months.
 The thought disorder generally disappears in six weeks or more.
 Improvement is generally noted in hallucinations, acute delusions, sleeping habits, appetite, tension,
combativeness, hostility, negativism and personal grooming.

Remember:
Use of more than one phenothiazine is not recommended.
Geriatric patients should be given lower dosages to avoid hypertension due to prolonged half-life in people
aged over 55 years.

INDICATIONS

 Organic psychiatric disorders: Delirium,dementia,delirium tremens,drug induced psychosis,

 Functional disorders: schizophrenia,schizoaffective disorders,paranoid disorders.
 Mood disorders: mania, major depression with psychotic symptoms.
 Childhood disorders: attention deficit hyperactivity disorder,autism, enuresis,conduct disorder.
 Medical disorders: Huntington’s chorea,nausea and vomiting,tic disorder,eclampsia,severe pain in
malignancy,tetanus.

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Side Effects
1. Extrapyramidal symptoms

These are serious neurologic symptoms and major side effects of antipsychotics. Typical antipsychotics cause a greater
incidence of EPS than do atypical antipsychotics.

Neuroleptic induced parkinsonism: symptoms include rigidity, tremors, bradykinesia, stooped posture,drooling,
akinesia, ataxia. This disorder can be treated with anticholinergic drugs.

Acute dystonia: results from a slow sustained muscular spasm that lead to involuntary movement. Can involve the neck,
jaw, tongue and the entire body (opisthotonus). There is also involvement of eyes leading to upward lateral movement of
the eyes known as oculogyric crisis. Can be prevented anticholinergics, antihistamines, benzodiazepines.

Akathisia: this is a subjective feeling of muscular discomfort that can cause patients to be agitated, restless and feel
generally dysphoric. Can be treated with propranolol, benzodiazepines and clonidine.

Tardive dyskinesia: it is a delayed adverse effect of antipsychotics. It consists of abnormal, irregular choreoathetoid
movements of the muscles of the head, limbs and trunk. It is characterized by chewing, sucking, grimacing and perioral
movements.

Neuroleptic malignant syndrome: this is a rare but serious disorder occurring in a small minority of patients taking
neuroleptics, especially high potency compounds. The onset is usually in the first 10 days of treatment.

2. Autonomic side effects: Dry mouth,constipation,cyclopedia,mydriasis,urinary retention, orthostatic hypotension,

impotence and impaired ejaculation.

3. Seizures.

4. Sedation.

Other effects: Agranulocytosis,sialorrhoea(increased salivation),weightgain,jaundice, dermatological effects.

NURSE RESPONSIBILITY FOR A PATIENT RECEIVING ANTIPSYCHOTICS

 Instruct the patient to take sips of water frequently to relieve dryness of mouth.
 A high fiber diet,increased food intake and laxatives if needed,help to reduce constipation.
 Advise patient to get up from the bed or chair very slowly. Patient should sit on the edge of the bed for one full
minute dangling his feet before standing up. Check Bp before and after medication is given.
 Differentiate between akathisia and agitation and inform the physician. A change of drug may be necessary if side
effects are severe. Administer antiparkinsonian as prescribed.
 Observe regularly patient regularly for abnormal movements.
 Take all seizure precautions.
 Patient should be warned about driving or operating machinery when first treated with antipsychotics. Give
medications at bedtime to eliminate sedation.
 Teach the importance of drug compliance, side effects of the drugs and reporting if too severe, regular follow ups.
Give reassurances and reduce unfounded fears and anxiety.

B. Antidepressants
These drugs are used to treat depressive disorders.
Mechanisms of Action
They act by increasing epinephrine and serotonin. Both of them are metabolized in the liver and excreted in the urine.

Table showing some examples of antidepressant drugs.

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Major Groups Generic Name Trade Name Daily Dosage (range)
Tricyclic antidepressants Amitriptyline Elavil (laroxyl) 75-300mg
Imipramine Tofranil 100-300mg
Tetra cyclic anti-depressants Maprotiline Ludiomil 75-300mg
Monoamine Oxidase Inhibitors Isocarboxacid Marplan 10-60mg
Phenelzine Nardil 45-90mg
Selective Serotonin Reuptake Inhibitors Fluoxetine Prozac 20mg
Citalopram Cipramil 20-60mg
Paroxetine Seroxat 10-50mg

For the drugs to be effective:

 Dosage may be divided, but the total dose can be given at bed time due to the sedative effects.
 Minimum dose should be given then increased gradually.
 5 to 21 days must be allowed before any mood change is observed.
 Four to six weeks must be allowed to pass for therapeutic effects to be observed.
 Medication needs to be continued for 6 months after patient is free from depression.

Side Effects
According to Gertrude and McFarland (1986), some of the side effects that might be experienced include mild
anticholinergic effects from tricyclic and monoamine oxidase inhibitors, dry mouth, constipation, blurred vision,
tachycardia nausea, edema, hypotension and urinary retention. Adjusting the dosage to a lower level will usually resolve
the problem.
Side effects that are specific to tricyclics are:
 Allergic reactions manifested as skin rash and jaundice.
 Tachycardia.
 Tremors.
 Long term treatment may depress bone marrow, predispose to sore throat and aching, and fever.
 Under such circumstances, stopping the use of the drug is the intervention of choice.
 Meanwhile, specific side effects of monoamine oxidase
inhibitors include:
 Liver damage that is rare but fatal.
 Precipitation of manic episodes.
 Hypertension crisis characterized by severe headache palpitation, neck stiffness, nausea, vomiting, increased Bp,
chest pain and collapse. It occurs 30 minutes to 24 hours after eating food containing tyramine. These foods
include cheese, wine, beer, sour cream, liver, chocolate, bananas, avocadoes, soy sauce, and beans.
 The main form of treatment when side effects occur is to discontinue the drug and then give regitine to lower the
blood pressure.

Contraindications
The use of antidepressants is contraindicated when the patient suffers from glaucoma, agitated states, urinary retention,
cardiac disorders and seizure disorders.
Having looked at major tranquillizers and antidepressants, now you will look at minor tranquillizers.

Remember:
Anti-depressants should be discontinued prior to surgery.

C. Anxiolytics or Anti-anxiety Drugs / Hypnotics

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  These drugs, when given to a patient having generalized anxiety disorder, are able to provide relief.
 These are also called minor tranquilizers. Most belong to the BZ group of drugs.
 They are mainly recommended for acute anxiety states, which may present with palpitations, sweating, trembling,
shortness of breath, chest pain, nausea, dizziness, a feeling of unreality, fear of losing control or dying, chills or
numbness.

Classification of BZ

Barbiturates: examples; phenobarbital, pentobarbital, secobarbital and thiopentone.

Non – barbiturate non – benzodiazepine antianxiety agents: for example; Meprobamate glutethimide, ethanol,
diphenhydramine and methaqualon.
Benzodiazepines: presently BZ are the drugs of first choice in the treatment of insomnia.
Very short acting: for example, triazolam, midazolam.
Short – acting: example, chlordiazepoxide (Librium), Diazepam (valium,calmpose), clonazepam (lonazepam),
Flurazepam (Nindral), Nitrazepam (Dormin)

Effects
The main effects include sedation, muscle relaxation and elevation of seizure threshold.

Side Effects

Side effects include dizziness, headache, nervousness, insomnia, light headedness, dry mouth, nausea, vomiting,
abdominal and gastric distress and diarrhea.
When high doses of medication are used for more than four months, the patient is likely to develop drug dependence or
withdrawal syndrome.

Contraindications
Benzodiazepines should not be used together with other central nervous system depressants. They should be given with
caution to patients who are elderly, depressed or suicidal and those with a history of substance abuse.
It is worth noting that these drugs need to be combined with psychotherapy to ensure complete cure of the problem.
This implies that anxiolytics by themselves are not a cure for psychological problems. The most commonly used drug is
diazepam.
This is usually administered as a dose of 2-10mg bid/qid orally or 2-20mg IM or IVThis can be repeated one hour after
the initial dose.

Nurses responsibility in the administration of BZ

 Administer with food to minimize gastric irritation.
 Advise the patient to take medication as exactly as directed. Abrupt withdrawal may cause insomnia, irritability
and sometimes even seizures.
 Explain about adverse effects and advise him to avoid activities that require alertness.
 Caution the patient to avoid alcohol or any other CNS depressants along

D. Antiparkinsonian Drugs
These are drugs given to counteract the side effects of major tranquillizers. They are used as treatment for medication
induced movement disorders,particularly neuroleptic – induced Parkinsonism, acute dystonia and medication induced
tremors.

Anticholinergics
 Trihexyphenidyl(Artane, trihexane, Trihexy, Pacitane)
 Benztropine(Cogentin) whose initial dose is 0.1-1mg daily, the maintenance dose is 0.5-6mg daily divided into
two or four times.
 Biperaden

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Dopaminergic agents
 Bromocriptine
 Carbidopa / levodopa.

Artane

Indications
 Drug – induced Parkinsonism.
 Adjunct in the management of Parkinsonism.
MOA
Increases the release of dopamine. Usually given 1-2 mg per day orally initially, maximum dose upto 15mg/day in divided
doses.

Side Effects
Dizziness, nervousness, drowsiness, weakness, headache, confusion, blurred vision, mydriasis, tachycardia, orthostatic
hypotension, dry mouth, nausea, constipation, vomiting, urinary retention and decreased sweating.

Nurse’s responsibility
Assess parkinsonian and extrapyramidal symptoms. Medications should be tapered gradually.
Caution patient to make position changes slowly to minimize orthostatic hypotension.
Instruct the patient about frequent rinsing of the mouth and good oral hygiene.
Caution patient that this medication decreases perspiration and overheating may occur during hot weather.

ANTABUSE DRUGS
Disulfiram is an important drug in this class and is used to ensure abstinence in the treatment of alcohol dependence. Its
main effect is to produce a rapid and violently unpleasant reaction in a person who ingests even a small amount of alcohol
while taking Disulfiram.

MOOD STABILIZERS
Lithium which is available in the following preparations:
Lithium carbonate: 300mg tablets; 400mg tablets.
Lithium citrate: 300mg/5ml liquid.
The usual range of dose per day in acute mania is 900-2100 mg given in 2-3 divided doses.

Carbamazepine(Tegretol, Mazetol, Zeptol and Zen Retard). The average daily dose is 600-1800 mg orally in divided
doses.
Sodium Valproate (Encoratechrono, Valparin, Epilex, Epival). The usual dose is 15mg/kg/day with a maximum of
60mg/kg/day orally.

B. Psychological Treatments

Having completed your look at the physical treatment methods, you will now look at some of the psychological treatments
used to treat patients suffering from mental health illness.

I. Psychotherapy
This is a form of treatment involving communication between the patient and the therapist, with the aim of modifying and
alleviating illness. Employs verbal communication as the means of treatment aimed at relieving the patient’s symptoms
and helping him to understand and modify his conduct so as to lead a well-adjusted life.

Types of psychotherapy
Dimension Types
Depending on the number of patients taking part Individual psychotherapy
Group psychotherapy
Depending on the duration of treatment Long term psychotherapy
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 Short term psychotherapy
Depending on the amount of responsibility given to the Supportive
patient Deep
Depending on the nature of the group Family
Marital
Group
Therapy with children & adolescents

Individual psychotherapy
This is a method of bringing about change in a person by exploring his or her feelings, attitudes, thinking and behaviour.
Therapy is conducted on a one-to-one basis, i.e. the therapist treats one patient at a time. Patients generally seek this kind
of therapy based on their desire. Such therapy helps to:
 Understand themselves and their behaviour.
 Make personal changes.
 Improve interpersonal relationships.
 Get relief from emotional pain or unhappiness.

Indications
 Stress – related disorders
 Alcohol and drug dependence
 Sexual disorders
 Marital disharmony

Therapy process
The patient is encouraged to discover for himself the reasons for his behaviour.
The therapist listens to the patient and offers explanation and advise when necessary.
By this he helps the patient to come to a greater understanding of self and to find a way of dealing with his problems.

Approaches
There are four main approaches to individual therapy which includes:

1. Psychodynamic therapy
Based on the assumption that when a patient has insight into early relationships and experiences as the source of his or her
problems they can be resolved.

2. Humanistic therapy
Centers on the patients view of the world and his or her problems.
The goal is to help patients realize their full potential through the therapist’s genuineness, unconditional positive regard,
which fosters the patient’s sense of self-worth and empathetic understanding of the patient’s point of view. This therapy is
non-directive but focusses on helping the patient to explore and clarify his or her own feelings and choices.

3. Behaviour Therapy
This is defined as a therapeutic technique, which attempts to change the patient’s behaviour directly rather than correct the
basic cause of the undesirable behaviour.
The two main methods that are used are:
Changing the behaviour from inside using covert and cognitive therapies. Here, the priority is to help the patient modify
their view of the world and themselves, by helping them change the things they say about themselves.
Changing the behaviour from outside. This is achieved through positive reinforcement of acceptable behaviour and
negative reinforcement for unacceptable behaviour.
4. Cognitive therapy
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Based on the idea that behavior is secondary to thinking. It focuses on how patients think about themselves and their
world,make changes in their current ways of thinking and behaviour.
Focusses on identifying and correcting distorted thinking patterns that can lead to emotional distress and problem
behaviours.
This therapy is based on the belief that patients are the architects of their own misfortune and have control over their own
thoughts and actions.

Techniques of cognitive therapy

There are 4 main groups of cognitive techniques. They are the following:

a. Techniques for stopping intrusive cognitions

These methods aim at stopping intruding thoughts through distraction.
Attention is directed to another mental act like doing mental arithmetic or copying a figure.

b. Techniques to counterbalance faulty cognitions

This involves counterbalancing intruding cognitions and the emotions provoked by them, with another thought.
As an example, when an anxious patient with chest pain becomes apprehensive thinking he has a “heart problem”, he
may-be trained to think that it is only a muscular pain and does not relate to the heart.
c. Techniques for altering cognitions
These are aimed at changing the nature of cognitions. The patient is helped to identify “maladaptive cognitions” and their
“logical errors”. Some errors are not mutually exclusive and which occur in depression are given below:
Faulty inference: this is making faulty interpretations of a situation or an event where there is no factual evidence to
make such conclusions. For example, if a friend fails to respond to a letter sent by the patient, he considers it as a sign of
the friend’s hostility or dislike to the latter.
Overgeneralization: this is making a general conclusion based on a single incident. An example is generalizing all
students of a particular class as substandard, based on the poor marks scored by one student.
Magnification or minimization: these are distorted evaluations. For example a minor error is magnified or an important
achievement is minimized in an unrealistically distorted manner.
Unrealistic assumptions
An example is the assumption one can be happy only if one is a top scorer all the time.
d. Techniques to resolve problems directly
These involve several steps and consists of:
Defining the problem more clearly.
Dividing it small sub problem which can be better managed.
Finding out alternative methods of solving each sub-problem.
Considering the merits and demerits of each method.
Selecting one method which is most advantageous at that instance.

II. Supportive psychotherapy

In this the therapist helps the patient to relieve emotional distress and symptoms without probing into the past and
changing the personality. He uses various techniques such as:

Ventilation: It is a free expression of feelings or emotions. Patient is encouraged to talk freely whatever comes to his
mind.
Environmental modification:/manipulation: Improving the well-being of mental patients by changing their living
condition.
Persuasion: Here the therapist attempts to modify the patient’s behavior by reasoning.
Re-education: Education to the patient regarding his problems, ways of coping, etc.
Reassurance: Reassurance is used to dispel apprehension and to restore confidence and promote hope. However care
should be taken against offering false reassurance and providing it prematurely even before the patient has fully opened
up.

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Explanation: The explanation of the nature of symptoms and their causes is done by the therapist during the therapy. The
choice of treatment and the likely outcome are explained to the patient.
Guidance: Guidance involves offering direct advice on handling particularly difficult situation in the real life of the
patient. He may be advised on how and when he should seek help in the future. Suggestion involves advising in an
indirect manner.

Phases of therapy

Initial phase: Focused on assessment and relationship formation. Assessment encompasses full physical and psychiatric
evaluation including level of motivation, the patients strengths and weaknesses. The therapist should be able to empathize
with the patient inorder to understand him better.

The working phase: Involves intense therapeutic activity and there is further exploration of the patient’s problems and
life situations. The various therapeutic techniques are applied and attempts are made to give the patient an insight into his
problems.

The terminal phase: Is intended to strengthen the patient’s improvement and to prepare him to end his treatment.

III. Psychoanalytic therapy

Assignment: read on psychoanalytic theory by Sigmund Freud
The main indication is the presence of long standing mental conflicts, which maybe unconscious but produce symptoms.
In psychoanalysis the focus is on the cause of the problem, which is buried somewhere in the unconscious. The therapist
tries to take the patient in the past in an effort to determine where the problem began. The aim of the therapy is to bring all
the repressed material to conscious awareness so that the patient can work towards a healthy resolution of his problems,
which are causing the symptoms.
Therapy process
The psychoanalyst typically is positioned at the head of the patient and slightly behind, so that the patient cannot see the
therapist. This decreases any kind of non-verbal communication between the two people. The patient is typically on the
couch, relaxed, and ready to focus on the therapist’s instruction, which facilitates free association. The patient is an active
participant, freely revealing all thoughts exactly as they occur and describing all dreams. The psychoanalyst is a shadow
person. He reveals nothing personal, nor does he give any directions to the patient.
His verbal responses are for the most part brief and non-committal, so as not to interfere with the associative flow.

Some of the techniques used in psychoanalysis are:

Free association
The patient is allowed to speak whatever comes to his mind, in response to a word that is given by the therapist. For
example, the therapist might say “mother” or “blue” and the patient would give a response, also typically one word, to
each of the word the therapist says.
The therapist then looks for a theme or pattern to the patient’s responses. So if the patient responds “evil” to the word
“mother” or “dead” to the word “blue” the therapist might pick up one potential theme, but if the patient responds “kind”
and “true” to the words “mother” and “blue” respectively, the therapist might hear a completely different theme. The
theme may give the therapist an idea of the cause of the patient’s emotional disturbance.

Dream analysis
Freud believed that behaviour is rooted in the unconscious and that dreams are a manifestation of the troubles people
repress, the better way to get an idea of the problem is to monitor and interpret dreams.
The patient is asked to keep a dream lag. Analysis of the patient’s dreams helps to gain additional insight into his problem
and the resistances. Thus dreams symbolically communicate areas of intrapsychic conflicts through the use of
interpretation.

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The process is complicated by the occurrence of transference reactions. This refers to the patient’s development of strong
positive or negative feelings towards the analyst, and they represent the patient’s past response to a significant other,
usually a parent. The patient’s reciprocal response to the patient is called countertransference. Such reactions must be
handled appropriately before the progress can be made.
By termination of therapy, the patient is able to conduct his life according to an accurate assessment of external reality and
is also able to relate to others uninhibited by neurotic conflicts.
Psychoanalytical therapy is a long term proposition. The patient is seen frequently, usually 5 times a week. It is therefore
time consuming and expensive.
Hypnosis
This is an artificially induced state in which the person is relaxed and usually suggestible. The relaxation is guided by a
therapist.
Hypnosis is also a means for entering an altered state of consciousness and in this state using visualization and suggestion
to bring about desired changes in behavior and thinking.
Can be induced in many ways such as by using a fixed point for attention, rhythmic monotonous instructions etc.
In hypnotherapy relaxation is guided by the therapist who has been trained in techniques of trance formation and who then
asks certain questions of the patient or uses guided imagery to help picture the situation in an effort to find the cause of the
problem.
At the end of the session, the therapist leaves some helpful hints for the patients.
These are called posthypnotic suggestions and typically include positive affirming statements for the patient to think about
as well as instructions to help the patient accomplish self-hypnosis.

Catharsis
This is the act of purging or purification or elimination of a complex by bringing it to consciousness and affording to
expression.
In psychoanalysis the therapist helps the person see the root of the problem and then, by talking or some other means,
allows the patient to learn to evacuate this problem from the psyche. This can take place in conjunction with other form of
psychoanalysis.
These therapies are undertaken on a one-to-one basis between the patient and the therapist. The nurse can be helpful in the
treatment process by allowing the patient to talk about experiences in therapy and by carefully documenting the responses
of the patient.
=
Abreaction therapy
This is a process by which repressed material, particularly a painful experience or conflict is brought back to
consciousness. The person not only recalls but also relieves the material, which is accompanied by the appropriate
emotional response.
It is most useful in acute neurotic conditions caused by extreme stress (PTSD, hysteria etc)

Method
This can be brought about by strong encouragement to relieve the stressful events. The procedure is begun with neutral
topics at first, and gradually approaches areas of conflict.

IV. Family and marital therapy

This is that branch of psychiatry which sees an individual’s psychiatric symptoms as inseparably related to the family in
which he lives. Therefore the focus of the treatment is not the individual but the family.

Indications
Whenever there is relational problems within a family or marital unit.

Components of therapy
 Assessment of family structure, roles, boundaries, resources, communication patterns and problem solving skills.
 Teaching communication skills.
 Teaching problem solving skills.
 Writing a behavioural marital contract.
 Homework assignments.

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Types of family therapy
Individual family therapy
Each family member has a single therapist. The whole family may meet occasionally with one or two of the therapists to
see how the members are relating to one another and work out specific issues that have been defined by individual
members.

Conjoint family therapy

The nuclear family is seen, and the issues and problems raised by the family are the ones addressed by the therapist.
The way in which the family interacts is observed and becomes the focus of therapy.
The therapist helps the family deal more effectively with problems as they arise and are defined.

Couples therapy
Couples are often seen by the therapist together.
The couple may be experiencing difficulties in their marriage, and in therapy they are helped to work together to seek a
resolution for their problems.
Family patterns, interaction and communication styles, and each partner’s goals, hopes and expectations are examined in
therapy.
This examination enables the couple to find a common ground for resolving conflicts by recognizing and respecting each
other’s similarities and differences.

Multiple family group therapy

4 or 5 families meet weekly to confront and deal with problems or issues they have in common.
Ability or inability to function well in the home and community, fear of talking to or relating to others, abuse, anger,
neglect, the development of social skills, and responsibility for oneself are some of the issues on which these groups
focus.
The multiple family group becomes the support for all the families.
The network also encourages each person to reach out and form new relationships outside the group.

V. GROUP THERAPY
This is a treatment in which carefully selected people who are emotionally ill meet in a group guided by a trained
therapist, and help one another effect personality change.

Selection
 Homogeneous groups
 Adolescents and patients with personality disorders.
 Families and couples where the system needs change.
Contraindications
 Antisocial patients
 Actively suicidal or severely depressed patients.
 Patients who are delusional and who may incorporate the group into their delusional system.

Group size
Optimal size is 8-10 members. Sessions conducted once a week; each session may last for 45 minutes to one hour.

Approaches to group therapy

 The therapist role is primarily that of a facilitator; he should provide a safe, comfortable atmosphere for self-
disclosure.
 Focus on the ‘here’ and ‘now’.

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  Use any transference situations to develop insight into their problems.
 Protect members from verbal abuse or from scapegoating.
 Whenever appropriate, provide positive reinforcement, this gives ego support and encourage future growth.
 Handle circumstantial patients, hallucinating and delusional patients in a manner that protects the self-esteem of
the individual and also sets limit on the behaviour so as to protect other group members.
 Develop ability to recognize when a group member is fragile; he should be approached in a gentle, supportive and
non-threatening manner.
 Use silence effectively to encourage introspection and facilitate insight.
 Laughter and a moderate amount of joking can act as a safety valve and at times contribute to group cohesiveness.
 Role playing may help a member develop insight into the ways in which he relates to others.

Therapeutic factors involved in group therapy

Sharing experience: This helps the patients to realize that they are not isolated and that others have similar experiences
and problems.
Hearing from other patients that they have shared experiences is often more convincing and helpful than reassurance from
the therapist.

Support to and from group members: receiving help from other group members can be supportive to the person helped.
The sharing action of being mutually supportive is an aspect of the group cohesiveness that can provide a sense of
belonging for patients who feel isolated in their everyday lives.

Socialization
It is acquisition of social skills e.g. maintaining eye contact within a group through comments that members provide about
one another’s deficiencies in social skills. This process can be helped by trying out new ways of interacting within the
safety of the group.
Imitation
It is learning from observing and adopting the behaviours of other group members. If the group is run well, patients
imitate the adaptive behaviours of other group members.

Interpersonal learning
It refers to learning about difficulties in relationships by examining the interaction of individuals with the other members
of the group.

Some techniques useful in group therapy

 Reflecting or rewarding comments of group members.
 Asking for group reaction to one member’s statement.
 Asking for individual reaction to one member’s statement.
 Pointing out any shared feelings within the group.
 Summarizing various points at the end of the session.

VI. BEHAVIOUR THERAPY

It is a form of treatment for problems in which a trained person deliberately establishes a professional relationship with
the patient, with the objective of removing or modifying existing symptoms and promoting positive personality, growth
and development.
Involves identifying maladaptive behaviours and seeking to correct these by applying the principles of learning derived
from the following theories:

Assignment read on the following

Classical conditioning model by Ivan Pavlov (1936)
Operant conditioning model by BF Skinner (1953)

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Major assumptions of behaviour therapy
Based on the above mentioned theories, the following are the assumptions of BT:

All behaviour is learned (adaptive and maladaptive)

Human beings are passive organisms that can be conditioned or shaped to do anything if correct responses are rewarded or
reinforced.
Maladaptive behaviour can be unlearned and replaced by adaptive behaviour if the person receives exposure to specific
stimuli and reinforcement for the desired adaptive behaviour.
Behavioural assessment is focused more on the current behaviour rather than historical antecedents.

BT is a short duration therapy, therapists are easy to train and it is cost effective.
The total duration of therapy is usually 6-8 weeks.
Initial sessions are given daily but the later sessions are spaced out.
Unlike psychoanalysis where the therapist is a shadow person, in behaviour therapy both the patient and the therapist are
equal participants.
There is no attempt to unearth an underlying conflict and the patient is not encouraged to explore his past.

Behaviour techniques

1. Systematic desensitization: it was developed by Joseph Wolpe, based on the behavioral principle of counter
conditioning. In this patients attain a state of complete relaxation and are then exposed to the stimulus that elicits the
anxiety response. The negative reaction of anxiety is inhibited by the relaxed state, a process called reciprocal inhibition.
It consists of 3 main steps:
 Relaxation training.
 Hierarchy construction.
 Desensitization of the stimulus.

Relaxation training: there are many methods which can be used to induce relaxation. Some of them are:
Jacobson’s progressive muscle relaxation
Hypnosis
Meditation or yoga
Mental imagery

Hierarchy construction: Here the patient is asked to list all the conditions which provoke anxiety. Then he is asked to
list them in descending disorder of anxiety provocation.

Desensitization of the stimulus: This can either be done in reality or through imagination. At first, the lowest item in
hierarchy is confronted. The patient is advised to signal whenever anxiety is produced. With each signal he is asked to
relax. After a few trials, patient is able to control his anxiety gradually.

Indications: phobias,obsessions,compulsions, certain sexual disorders.

2. Flooding: The patient is directly exposed to the phobic stimulus,but escape is made impossible.
By prolonged contact with the phobic stimulus, the therapist’s guidance and encouragement and his modeling behaviour
reduce anxiety.
Indication: phobias

3. Aversion therapy: Pairing of the pleasant stimuli with an unpleasant response, so that even in absence of the
unpleasant response the pleasant stimulus becomes unpleasant by association.
Punishment is presented immediately after a specific behavioural response and the response is eventually inhibited.
Unpleasant response is produced by electric stimulus, drugs, social disapproval or even fantasy.

Indications: Alcohol abuse,paraphilias,homosexuality, transvetism.

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4. Operant conditioning procedures for increasing adaptive behaviour
Positive reinforcement: when a behavioural response is followed by a generally rewarding event such as food, praise or
gifts, it tends to be strengthened and occurs more frequently than before the reward. This technique is used to increase
desired behaviour.
Token economy: this program involves giving token rewards for appropriate or desired targets. For example, in inpatient
hospital wards, patients receive a reward for performing a desires behavior, such as tokens which they may use to
purchase luxury items or certain privileges.

5.Operant conditioning procedures to teach new behaviour

Modeling: This is a method of teaching by demonstration, where in the therapist shows how a specific behaviour is to
performed. In modeling the patient observes other patients indulging intarget behaviours and getting rewards for those
behaviours. This will make the patient repeat the same behaviour and earn rewards in the same manner.
Shaping: In shaping the components of a particular skill, the behaviour is reinforced step by step. The therapist starts
shaping by reinforcing the existing behaviour. Once it is established he reinforces the responses which are closest to the
desired behaviour, and ignores the other responses.
For example, to establish eye to eye contact, the therapist sits opposite the patient and reinforces him even if he moves his
upper body towards him. Once this is established, he reinforces the person’s head movement in his direction and this
procedure continues till eye to eye contact is established.
Chaining: this is used when a person fails to perform a complex task. The complex task is broken into a number of small
steps and each step is taught to the patient. In forward chaining one starts with the first step, then to the third and so on.
In backward chaining, one starts with the last step and goes on to the next step in a backward fashion.

6. Operant conditioning procedures for decreasing maladaptive behaviour

Extinction/Ignoring: Means removal of attention rewards permanently, following a problem behaviour. This includes
actions like not looking at the patient, not talking to the patient or having no physical contact with the patient, etc.
following the problem behaviour. This is commonly used when the patient exhibits odd behaviour.
Punishment: punishment is presented contingent upon the undesirable response. The punishment procedure should be
administered immediately and consistently following the undesirable behaviour with clear explanation.
Timeout: this method includes removing the patient from the reward or the reward from the patient for a particular period
of time following problem behaviour. This is often used in the treatment of childhood disorders.
Restitution (over-correction): this means restoring the disturbed situation to a state that is much better than what it was
before the occurrence of the problem behaviour. For example, if a patient passes urine in the ward he would be required to
not only clean the dirty area but also mop the entire area of the floor in the ward.
Response cost: this procedure is used with individuals who are on token programs for teaching adaptive behaviour. When
undesirable behaviour occurs, a fixed number of tokens or points are deducted from what the individual has already
earned.

7. Assertiveness and social skill training:

This is a BT technique in which the patient is given training to bring about change in emotional and other behavioural
pattern by being assertive. Patient is encouraged not to be afraid of showing appropriate response, negative or positive, to
an idea or suggestion. Provided by the therapist, first by role play and then by practice in a real life situation. Attention is
focused on more effective interpersonal skills. Helps to improve social manners like encouraging eye contact, speaking
appropriately, observing simple etiquette, and relating to people.

VII. PLAY THERAPY

Play is a natural mode of growth and development in children. Through play a child learns to express his expressions and
it serves as a tool in the development of the child.

Curative factors
It releases tension and pent-up emotions.
It allows compensation for loss and failures.
It improves emotional growth through his relationship with other children.

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 It provides an opportunity to the child to act out his fantasies and conflicts, to get rid of aggression and to learn positive
qualities from other children.

Diagnostic functions
Play therapy gives the therapist a chance to explore family relationships of the child and discover what difficulties are
contributing to the child’s problems.
Play therapy allows studying hidden aspects of the child’s personality.
It is possible to obtain a good idea of the intelligence level of the child.
Through play inter-sibling relationships can be adequately studied.

Types of play therapy

Individual vs. group play therapy: In individual therapy the child is allowed to play by himself and the therapist
attention is focused on this one child alone. In group play therapy other children are involved.

Free play vs. controlled play therapy: In free paly the child is given freedom deciding with what toys he wants to play
with. In controlled play therapy, the child is introduced into a scene where the situation or setting is already established.

Structured vs. unstructured play therapy: SPT involves organizing the situation in such a way so as to obtain more
information. In USPT no situation is set and no plans are followed.

Directive vs. non-directive play therapy: In DPT, the therapist totally sets directions,whereas in NDPT, the child
receives no directions.

Play therapy is generally conducted in a play room. The playroom should be suitably stocked with adequate play material,
depending upon the problems of the child.

VIII. PSYCHODRAMA
This is a specialized type of group therapy that employs a dramatic approach in which the patient becomes actors in life
situation scenarios. The goal is to resolve interpersonal conflicts in a less threatening atmosphere than the real life
situation would present.
The patient is brought directly into the situation as an active participant. The director co-ordinates the process so that the
group and the protagonist receive maximal benefit. Other group members act as auxiliary egos and play the roles of
significant others with whom relationships are being explored.
The primary advantage of psychodrama is its direct access to re-enacting painful situations so that the painful emotions
associated with them can be reworked, with the potential for spontaneously learning new responses in a safe therapeutic
environment.

IX. MUSIC THERAPY

This is the functional application of music towards the attainment of specific therapeutic goals.

Advantages
 Facilitates emotional expressions.
 Improves cognitive skills like learning listening and attention span.
 Social interaction is stimulated.

X. DANCE THERAPY
This is psychotherapeutic use of movement, which furthers the emotional and physical integration of the individual.

Advantages
 Helps to develop body awareness.
 Facilitates expression of feelings.
 Improves interaction and communication.

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  Fosters integration of physical, emotional and social experiences that result in a sense of increased self-confidence
and contentment.
 Exercise through body movement maintains good circulation and muscle tone.

XI. RECRETIONAL THERAPY

This is a form of activity therapy used in most psychiatric settings. It is a planned therapeutic activity that enables people
with limitations to engage in recreational experiences.

Aims
 To encourage social interaction.
 To decrease withdrawal tendencies.
 To provide outlet for feelings.
 To promote socially acceptable behaviour.
 To develop skills, talents and abilities.
 To increase physical confidence and a feeling of self-worth.

Points to be kept in mind

 Provide a non-threatening and non-demanding environment.
 Provide activities that are relaxing and without rigid guidelines and time-frames.
 Provides activities that are enjoyable and self-satisfying.

Types of recreational activities

Motor forms: These can further be divided into fundamental and accessory; among the fundamental forms are such
games as hockey and football, while accessory forms are exemplified by play activity and dancing.

Sensory forms: These can either be visual, for example looking at motion pictures, play etc or auditory such as listening
to a concert.

Intellectual forms: These include reading, debating and so on.

XII. RELAXATION THERAPIES

Relaxation produces physiological effects opposite those of anxiety: this includes:
Slowed heartrate, increased peripheral blood flow and neuromuscular stability.
There are many methods which can be used to induce relaxation.

a. Progressive muscular relaxation

It is a method of deep-muscle relaxation which is based on the premise that the body responds to anxiety provoking
thoughts and events with muscle tension.

Indications
Muscular tension Muscle spasms
Anxiety Neck and back pain
Insomnia High blood pressure
Depression Mild phobia
Fatigue Stuttering
Irritable bowel

Technique
In this procedure the patient relaxes major muscle groups of the feet and working towards the head and vice versa.
Muscle relaxation can be done in sitting or lying down position.
Each muscle group is tensed for 5 – 7 seconds and then relaxed for 20 to 30 seconds, during which time the individual
concentrates on the difference in sensations between the two conditions.
Soft slow background music may facilitate relaxation.

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 b. Mental imagery
It is a relaxation method in which patients are instructed to imagine themselves in a place associated with pleasant relaxed
memories.
Such images allow patients to enter a relaxed state or experience a feeling of calmness and tranquility.
The frame of reference is very personal, based on what each individual considers being a relaxing environment.
Some might select a scene at the sea shore; some might choose a mountain atmosphere.
Using guided imagery can promote a sense of wellbeing in patients and help them change their perceptions about their
disease, treatment and healing ability.
Significant especially during a painful or stressful event.

c. Yoga
This is based on the principle of body-mind unity whereby a chronically restless or agitated mind will result in poor health
and decreased mental clarity.
Yoga uses a combination of physical postures, breathing techniques and meditation to promote relaxation and enhance the
flow of vital energy.
The yoga system advocates identification of the soul with its final aim being union with the supreme being. This is
brought about by the following 8 steps:

1. Self-control obtained by such devices as chastity, non-stealing, non-violence, truthfulness and avoidance of greed.
2. Religious observance through chanting hymns, austerity, purity and contentment.
3. Assumption of certain positions.
4. Regulation of breath, with controlled rhythmic exhalation, inhalation and temporary suspension of breathing.
5. Restraint of the senses.
6. Steadying of the mind, through fixation on some part of the body, such as the nose or navel.
7. Meditation on the true object of knowledge, the supreme spirit, to the exclusion of other things in life.
8. Profound contemplation with such complete absorption and detachment that there is insensitivity to heat and cold,
pain and pleasure.

d. Meditation
This is a kind of self-discipline that helps one achieve inner peace and harmony by focusing uncritically on one thing at a
time.
Medical meditation and Yoga balances and regenerates spiritual and physical energies, thus forging a healing alliance in
which the spirit nurtures body and mind.
Mindful meditation refers to focusing on physical sensations, such as movement or breath, and on the thoughts in order to
increase awareness and enhance living in the movement to the fullest extent possible.
It promotes deep states of psychological and physical relaxation.
Beneficial for patients with depression and anxiety.

e. Physical exercise
Regular exercise is the most effective method of relieving stress by providing a natural outlet for tension produced by the
body in its state of arousal for “fight or flight”
Aerobic exercises strengthen cardiovascular system and increases body’s ability to use oxygen more efficiently.
Aerobic exercises includes: brisk walking, jogging; running; cycling; swimming and dancing. To achieve the benefit of
exercises they must be performed regularly for at least 30 minutes per day.
Effective in reducing general anxiety and depression.

f. Deep breathing exercises

Tension is released when the lungs are allowed to breath in as much oxygen as possible.

Indications
Anxiety
Depression

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 Irritability
Muscular tension
Fatigue

Technique
Sit or lie down comfortably, inhale slowly through the nose and exhale through the mouth.
While inhaling place one hand below the ribs.
Allow that hand to expand outward when inhaled, let that hand fall back to its original position when exhaled.
Exhalation should take twice as long as inhalation.

XIII. OCCUPATIONAL THERAPY

This is the application of goal oriented, purposeful activity in the assessment and treatment of individuals with
psychological, physical or developmental disabilities.

Goal
To enable the patient to achieve a healthy balance of occupations through the development of skills that will allow him to
function satisfactory to himself and others.

Advantages
 Helps to develop social skills and provide an outlet for self-expression.
 Strengthens ego defenses.
 Develops a more realistic view of the self in relation to others.

Points to be kept in mind

 The patient should be involved as much as possible in selecting the activity.
 Select an activity that interests or has the potential to interest him.
 The activity should utilize the patient’s strengths and abilities.
 The activity should be of short duration to foster a feeling of accomplishment.
 If possible the selected activity should provide some new experience to the patient.

Types of activities
Diversional activities: These activities are used to divert one’s thoughts from life stresses or to fill time. E.g. organized
games.
Therapeutic activities: these activities are used to obtain a specific care plan or goal. E.g. basket making, carpentry.

C. PHYSICAL THERAPIES
These are treatment approaches that use physiologic or physical interventions to effect behavioural change. The most
common is ECT.

ELECTROCONVULSIVE THERAPY
This is the artificial induction of a grandma seizure through the application of electrical current to the brain. The stimulus
is applied through electrodes that are placed either bilaterally in the fronto-temporal region, or unilaterally on the non-
dominant side (right side of the head in a right handed individual).

Parameters of Electrical current applied

 Voltage – 70 – 120 volts.
 Duration – 0.7 – 1.5 seconds

Types of seizure produced

 Grandmal seizure-tonic phase lasting for 10-15 seconds.
 Clonic phase lasting for 30-60 seconds.

Types of ECT

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Direct ECT: in this, ECT is given in the absence of anaesthesia and muscular relaxation.
Modified ECT: here the ECT is modified by drug induced muscular relaxation and general anesthesia.

Frequency and total number of ECT

Frequency: 3 times per week or as indicated.
Total number: 6 to 10; upto 25 times may be preferred as indicated.

Application of electrodes
Bilateral ECT: Each electrode is placed 2.5-4 cm above the midpoint, on a line joining the tragus of the ear and the
lateral canthus of the eye.

Unilateral ECT: Electrodes are placed only on one side of the head, usually non-dominant side (right side of the head in
a right handed individual).
This is safer, with much fewer side effects particularly those of memory impairment.

Indications
Major depression: with suicidal risk, stupor,poor intake of food and fluids, melancholia with psychotic features,
unsatisfactory response to drugs or where drugs are contraindicated or have serious side effects.

Severe catatonia: with stupor,poor intake of food and fluids, unsatisfactory response to drug therapy, or when drugs are
contraindicated or have serious side effects.

Severe psychosis (schizophrenia or mania): with risk of suicide, homicide or danger of physical assault, depressive
features, unsatisfactory response to drug therapy or when drugs are contraindicated or have serious side effects.

Organic mental disorders: organic mood disorders, organic psychosis.

Contraindications
Absolute
 Raised ICP

Relative
 Cerebral aneurysm
 Cerebral hemorrhage
 Brain tumor
 Acute myocardial infarction
 Congestive heart failure
 Pneumonia or aortic aneurysm.
 Retinal detachment.

Side effects of ECT

 Memory impairment
 Drowsiness, confusion and restlessness
 Poor concentration/ anxiety
 Headache, weakness/fatigue,backache, muscle aches.
 Dryness of mouth, palpitations, nausea, vomiting.
 Unsteady gait.
 Tongue bite and incontinence.

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Role of the nurse

Pre-treatment evaluation
 Detailed medical and psychiatric history including history of allergies.
 Assessment of patients and families’ knowledge of indications, side-effects, therapeutic effects and risks
associated with ECT.
 Any informed consent should be taken. Allay any unfounded fears and anxieties regarding the procedure.
 Assess baseline vital signs.
 Patient should be on empty stomach for 6-8 hours prior to ECT.
 Withhold night doses of drugs, which increases seizure threshold like diazepam, barbiturates and anticonvulsants.
 Withhold oral medications in the morning.
 Head shampooing in the morning since oil causes impedance of passage of electricity to brain.
 Any jewellery, prosthesis, dentures, contact lens, metallic objects and tight clothing should be removed from the
patient’s body.
 Empty bladder and bowel just before ECT.
 Administration of 0.6 mg atropine IM or SC 30 minutes before ECT, or IV just before ECT.

Intra-procedure care
 Place the patient comfortably on the ECT table in supine position.
 Stay with the patient to allay anxiety and fear.
 Assist in administering the anesthetic agent.
 Since muscle relaxant paralyzes all muscles including respiratory muscles, patent airway should be ensured and
ventilator support should be started.
 Mouth gag should be inserted to prevent possible tongue bite.
 The place(s) of electrode placement should be cleaned with normal saline or 25% bicarbonate solution, or a
conducting gel applied.
 Monitor voltage, intensity and duration of electric stimulus given.
 Monitor seizure activity using cuff method.
 100% oxygen should be provided.
 During seizure monitor vital signs, ECG, oxygen saturation, EEG, etc.
 Record findings and medicines given in the patient’s chart.

Post-procedure care
 Monitor vital signs.
 Continue oxygenation till spontaneous respiration starts.
 Assess for post-ictal confusion and restlessness.
 Take safety precautions to prevent injury (side-lying position and suctioning to prevent aspiration of secretions,
use of side rails to prevent falls).
 If there is severe post-ictal confusion and restlessness, IV diazepam may be administered.
 Reorient the patient after recovery and stay with him until fully oriented.
 Document any findings as relevant in the patient’s record.

ADMISSION AND DISCHARGE PROCEDURES OF MENTALLY SICK PATIENTS

Mental Health Act (Cap 248) and Legal Application
The Mental Health Act is an act of parliament to amend and consolidate the law relating to the care of persons who are
suffering from mental disorders, or mental sub-normality with mental disorder, for the custody of these persons,
management of their properties, management and control of a mental hospital and for custodial purposes.
The act provides for the procedures to be followed for reception into a mental hospital. It also stipulates that no person
shall be received or detained for treatment in a mental hospital, unless they have been received and detained under this act
or under criminal
procedure code.

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Kenyan Board of Mental Health
The act also provides for the establishment of a board, that is, the Kenya board of mental health for
the purposes of administering this act.
The members of the Kenya board of mental health include:
 Chairman, who can be the cabinet secretary or the principle secretary of Medical Services and is appointed by the
president
 Psychiatrist (medical practitioner) appointed by the cabinet secretary.
 One clinical officer with training and experience in mental health care appointed by the CS.
 One psychiatric nurse with experience in mental health care, appointed by the CS.
 The commissioner of social services or their nominee appointed by the CS.
 Director of education or their nominee appointed by the CS.
 A representative from each county in Kenya, being resident in the counties, appointed by
the minister.
 The board may co-opt any person whose skills, knowledge or experience may be useful.
It may also establish a committee for better function and regulate its own procedure.

The functions of the Board are under the control and direction of the minister for health.
They include:
 To coordinate mental health activities in Kenya.
 To advise the government on the state of mental health and mental health care facilities in Kenya.
 To inspect mental health care hospitals to ensure that they meet the prescribed standards.
 To approve the establishment of mental health care hospitals.
 To assist when necessary in the administration of mental health hospitals.
 To receive and investigate any matters referred to it by a patient or relative of a patient concerning the treatment
of the patient at a mental health hospital and, where necessary, to take or recommend to the minister any remedial
action.
 To advise the government on the care of the persons suffering from mental sub-normality without mental
disorder.
 To initiate and organize community or family based programs for the care of persons suffering from mental
disorder, and to perform such other functions as may be placed upon it by this act or under the law.

Sections of the Mental Health Act

Part V - Voluntary Patients (Section 10)
Any person who has attained the apparent age of sixteen years, decrees to voluntarily submit them-self to treatment for
mental disorder, and who makes to the ‘person in charge’ a written application in duplicate in the form prescribed, may be
perceived as a voluntary patient into a mental hospital.
The person fills in a form MOH 613, in duplicate provided for in the first schedule to these regulations before
admitting them to the institution as an in-patient. This indicates that the admission is at their own request.
Any person who has not attained the apparent age of sixteen years and whose parent or guardian desires to submit them
for treatment for mental disorder, may if the guardian or parent makes to the ‘person in charge’ of a mental institution, a
written application in duplicate in the prescribed forms, be perceived as a voluntary patient. In such cases forms MOH 637
in duplicate should be filled and signed by the guardian or the parent.

Part VI - Involuntary Patients (Section 14 M.H.A)

Involuntary patients are those who are incapable of expressing themselves as willing or unwilling to receive treatment.
They require the forms MOH 614 to be filled in duplicate by the husband, wife or relative of the patient, indicating the
reasons why they are applying for admission.
Any person applying on behalf of another person should state the reasons why a relative could not make the application
and specify their connection with the patient.
The patient is admitted for a period of not more than six months. The ‘person in charge’ can prolong this period by six
more months provided the total period does not exceed twelve months. An MOH 615 form should be filled by the doctor
indicating why he thinks that the patient can benefit from the treatment. They should write down their own name,
qualifications, date and then sign the forms.
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Both the MOH 614 and MOH 615 forms must reach the hospital within 14 days of the date they were signed, otherwise
they become invalid.

Part VII - Emergency Admissions (Section 1b M.H.A)

A police officer, chief or assistant chief can arrest any person who is found to be dangerous to themselves or others, and
take them to a mental hospital for treatment within 24 hours or a reasonable time. The patient should be reviewed after 72
hours and can be discharged if found to be of sound mind. If found to be of unsound mind, the patient may be admitted for
treatment as an involuntary patient. For the purposes of admission, the form MOH 638 must be filled in by the police
officer or an administrative officer.

Part VIII - Admission and Discharge of Members of the Armed Forces

(Section 17 M.H.A)
Any member of the armed forces may be admitted into a mental hospital for observation, if a medical officer of the armed
forces, by letter addressed to the ‘person in charge’, and certifies that:
The member of the armed forces has been examined within a period of 48 hours before issuing the letter
For reasons recorded in the letter, the member of the armed forces is a proper person to be admitted to a mental hospital
for observation and treatment
A member of the armed forces may be admitted under section 17 for an initial period of 28 days from the date of
admission, that period may be extended if, at or before the end of 28 days, two medical practitioners, one of whom shall
be a psychiatrist, recommend the extension after re-examining the patient.
The said patient can be discharged if two medical practitioners, one of whom is a psychiatrist, by a letter addressed to the
‘person in charge’, certifying that they have examined the member of the armed forces within a period of 72 hours before
issuing the letter.
Where any member of the armed forces suffers from mental illness whilst away from his armed forces unit and is under
any circumstance, admitted into a mental hospital, the ‘person in charge’ shall inform the nearest armed forces unit
directly, or through an administrative officer or gazetted police officer.
If a member of the armed forces is admitted to a mental hospital they cease to be a member of the armed forces, the
‘person in charge’ shall be informed of that fact and the patient shall be declared an involuntary patient under part VI
(section 14) with effect from the date the information is received.

Part IX - Admission of a Patient from Foreign Countries (Section 18 M.H.A)

According to this section of the act:
No person suffering from mental disorder shall be admitted into a mental hospital in Kenya from any state outside Kenya
except under Part IX of M.H.A.
This part will not apply to individuals ordinarily resident in Kenya.
(Section 19 M.H.A) Where it is necessary to admit a person suffering from mental disorder from any foreign country into
any mental hospital in Kenya for observation, the government or other relevant authority in that country shall apply in
writing to the mental health board to approve the admission, no mental hospital shall receive a person suffering mental
disorders from a foreign country without the board’s written approval.
The application for the board’s approval under subsection (I) shall indicate that the person whom it relates to has been
legally detained in the foreign country for a period not exceeding two months under the law in that country, relating to the
detention and treatment of persons suffering from mental disorder, and their admission into mental hospital in Kenya has
been found necessary.
No person shall be admitted under this section unless they are accompanied by a warrant or other documents together with
the board’s approval under subsection (2) shall be sufficient authority for their conveyance to admission and treatment in
the mental hospital to which the board’s approval relates.

According to this section of the act:

On the admission of a person into a mental hospital under this section, not being a person transferred to the mental
hospital under section 23, the ‘person in charge’ shall within 72 hours or such longer period as the board may approve (i)
Examine the person or cause the person to be examined to determine the extent of the mental disorder and the nature of
treatment and

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(ii) Within that period forward to the Board a report on the findings, together with the warrant or other document from the
foreign country concerned accompanying the patient/person.
A person shall not be detained in a mental hospital under this section for a period longer than two months from the date of
admission to the mental hospital unless the board, on application in the prescribed forms by the ‘person in charge’,
approves.
Part X – Discharge and Transfer of Patients (Section 21 and 22 of M.H.A)
The ‘person in charge’ of a mental hospital may, by order in writing, and upon the recommendation of the medical
practitioner in charge of any person’s treatment in the mental hospital, recommend discharge and that person shall
thereupon be discharged as having recovered from mental disorder, provided that:
An order shall not be made under this section for a person who is detained under criminal procedure Cap 75.
This section shall not prejudice the board’s powers under section 15 of M.H.A.

Section 15 provides that:

Where any person has been received into a mental hospital under part V and part VI (voluntary and involuntary mode of
admission), the board may at any time order that the person shall be discharged or otherwise dealt with under this act.

Section 22: Order for delivery of patient into care of relative or friend.
If any relative or friend of a person admitted into any mental hospital under this act desires to take the person into their
custody and care, they may apply to the ‘person in charge’ who may, subject to subsection (2), order that the person be
delivered into the custody and care of the relative or friend upon such terms and conditions to be complied with by the
relative or friend.
In the exercise of their powers subsection (1) the person in charge shall consult with the medical practitioner in charge of
the person’s treatment in the mental hospital and the board on the relevant district mental health council, which is
performing the board’s functions under section 7, subsection (1).

Part XIV – Offences under MHA

Section 47:
It is an offence for a person other than medical practitioner to sign certificates.
Section 48:
Any medical practitioner who knowingly, willfully or recklessly certifies anything in a certificate made under this act,
which they know to be untrue, shall be guilty of an offence.
Section 49:
It is an offence for any person to assist the escape of any person suffering from mental disorder being conveyed to or
from, or while under care and treatment in a mental hospital. It is also an offence to harbor any person suffering from
mental disorder that they know have escaped from a mental hospital.
Section 50:
It is an offence for any person in charge of or any person employed at a mental hospital to unlawfully permit a patient to
leave such a hospital.
Section 51:
Any person in charge of, or any person employed at a mental hospital that strikes, ill-treats, abuses or willfully neglects
any patient in the mental hospital, shall be guilty of an offence.
Section 52:
Any person who without the consent of a ‘person in charge’ gives, sells or barters any articles or commodities of any kind,
to any patient in a mental hospital, whether inside or outside the grounds of the mental hospital, shall be guilty of an
offence.
Section 53:
General Penalty: Any person who is guilty of an offence under this act, or who contravenes any of the provisions of this
act or any regulations made under this act, shall where no other penalty is provided, be liable on conviction to a fine not
exceeding Ksh 10,000. or to imprisonment not exceeding twelve months or both.

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 PSYCHIATRIC DISORDERS
SCHIZOPHRENIA
This is a psychotic condition characterized by a disturbance in thinking, emotions, verbal behaviour, perception, affect
and relationships to the external world in the presence of clear consciousness, which usually leads to social withdrawal.

A CLINICAL OVERVIEW OF SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS

Schizophrenia

Clinical features
A disturbance that lasts for atleast 6 months and includes atleast 1 month of 2 or more active phase symptoms.

The symptoms include:

Delusions,hallucinations,disorganised speech, grossly disorganised or catatonic behaviour,negative symptoms.

Subtypes
Paranoid,
Disorganised,
Catatonic,
Undifferentiated,
Residual.
Schizophreniform disorder is characterised by:
A symptomatic presentation that is equivalent to schizophrenia except aduration of 1 to 6 months.

Schizoaffective disorder is a disturbance in which a mood episode and the active phase symptoms of schizophrenia occur
together were precede or are followed by atleast 2 weeks of delusions or hallucinations without prominent mood
symptoms.

Delusional disorder atleast 1 month of non-bizarre delusions without other active-phase symptoms of schizophrenia.

Brief pyschotic disoder: A psychotic disturbance that lasts more than 1 day and remits by 1 month.

Shared psychotic disorder: A disturbance that develops in an individual who is influenced by someone else who has an
established delusion with similar content.

Psychotic disorder due to a general medical condition: psychotic symptoms are judged to be a direct physiological
consequence of a GMC.

Substance induced psychotic disorder: psychotic symptoms are judged to be a direct physiological consequence of
adrug of abuse, a medication or toxin exposure.

There are several risk factors associated with the conditions. Schizophrenia is often witnessed in individuals with family
members who have schizophrenia or in children who are:
 Highly individualistic in their thought processes.
 Overtly independent and obedient.
 Shy, withdrawn and loners.
 Unmanageable, prone to destructive, aggressive behaviour.
 Truant from school.
 Sensitive to separation.

CAUSES
NEUROTRANSMITTERS
 There is a hyperactivity of dopaminergic systems.
 Drugs that increase dopamine (e.g. Amphetamine and cocaine) aggravate or trigger schizo.
 Epinephrine activity is increased in schizo, leading to increased sensitization.
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  There is decrease in Gamma Amino butyric Acid (GABA) activity resulting in hyperactivity of dopaminergic
neurons.

CLINICAL SIGNS AND SYMPTOMS

EUGEN BLEULER’S SYMPTOMS OF SCHIZOPHRENIA
Ambivalence
Autistic thinking: social withdrawal
Affect disturbances e.g inappropriate, blunt or flat
Association disturbances: mainly thought disturbances

Schneider's First-Rank Symptoms of Schizophrenia (SFRS)

Kurt Schneider proposed the firstrank symptoms of schizophrenia in 1959.The presence of even one of these symptoms is
considered to be strongly suggestive of schizophrenia. They include:
• Hearing one's thoughts spoken aloud (audible thoughts or thought echo).
• Hallucinatory voices in the form of statement and reply (the patient hears voices discussing
him in the third person).
• Hallucinatory voices in the form of a running commentary (voices commenting on one's action).
• Thought withdrawal (thoughts cease and subject experiences them as removed by an external force).
• Thought insertion (subject experiences thoughts imposed by some external force on his passive mind).
• Thought broadcasting (subject experiences that his thoughts are escaping the confines of his self and are being
experienced by others around).
• Delusional perception (normal perception has a private and illogical meaning).
• Somatic passivity (bodily sensations especially sensory symptoms are experienced as imposed on body by some external
force).
• Made volition or acts (one's own acts are experienced as being under the control of some external force, the subject
being like a robot).
• Made impulses (the subject experiences impulses as being imposed by some external force).
• Made feelings or affect(the subject experiences feelings as being imposed by some external force).

Clinical Features
Thought and Speech Disorders
• Autistic thinking (preoccupations totally removing a person from reality).
• Loosening of associations (a pattern of spontaneous speech in which the things said in juxtaposition lack a meaningful
relationship with each other).
• Thought blocking (a sudden interruption in the thought process).
• Neologism (aword newly coined, or an everyday word used in a special way, not readily
understood by others).
• Poverty of speech (decreased speech production).
• Poverty ofideation (speechamount is adequate
but content conveys little information).
• Echolalia (repetition or echo by patient of the
words or phrases of examiner).
• Perseveration (persistent repetition of words
or themes beyond the point ofrelevance).
• Verbigeration (senseless repetition of some
words or phrases over and over again).
• Delusions of various kinds i.e., delusions of
persecution (being persecuted against); delusions of grandeur (beliefthat one is especially
very powerful, rich, born with a special
mission in life); delusions of reference (being
referred to by others); delusions of control
(beingcontrolled by an external force);somatic
delusions.
Disordersof Perception
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• Auditory hallucinations (described under
SFRS).
• Visual hallucinations may sometimes occur
along with auditory hallucinations; tactile,
gustatory and olfactory types are far less
common.
Disorders of Affect
These include apathy, emotional blunting, emotional shallowness, anhedonia and inappropriate emotional response. The
incapacity of the
patient to establish emotional contact leads to lack
ofrapport with the examiner.
Disordersof MotorBehavior
There can be either an increase or a decrease in
psychomotor activity. Mannerisms, grimacing,
stereotypes, decreased self-care and poor
grooming are common features.
Other Features
• Decreased functioning in work, social relations and self-care,as compared to earlier life.
• Loss of ego boundaries.
• Loss of insight.
• Poorjudgment.
• Suicide can occur due to the presence of associated depression, command hallucinations,
impulsive behavior, or return of insight that
causes the patient to comprehend the devastating nature of the illness and take his life.
• There is usually no disturbance of consciousness, orientation, attention, memory and
intelligence.
• There is no underlying organic cause

Major diagnostic criteria for schizo

A. One month or more of at-least two of the following symptoms
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms (decrease expression of emotions, poverty of speech, loss of interests and drive, tremendous inertia)

B.Social and occupational dysfunction

One or more areas affected (work, relationships, self-care)

C. Duration
Continuous symptoms and signs for greater or equal to 6 months. These 6 months must include:
At least one month of symptoms meeting criteria 1.
Various combinations of prodromal and residual symptoms exclude:
Schizoaffective and mood disorder.
Substance use or a medical condition

SUBTYPES OF SCHIZOPHRENIA
Paranoid Schizophrenia
A type of schizophrenia in which the following criteria are met:
Preoccupation with one or more delusions or frequent auditory hallucinations.
None of the following is dominant: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
This is a disorder characterized by delusions of persecution or grandeur.

Disorganized(Hebephrenic) Schizophrenia
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A type of schizo in which the following criteria are met:
A. All of the following are prominent:
Disorganized speech.
Disorganized behavior.
Flat or inappropriate affect.
B. the criteria are not met for catatonic type.
Catatonic Schizophrenia
A type of schizo in which the clinical picture is dominated by at least two of the following:
Motoric immobility AEB catalepsy including waxy flexibility or stupor.
Excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
Extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against
attempts to be moved) or mutism peculiarities of voluntary movement AEB posturing (voluntary assumption of
inappropriate or bizarre postures), stereotyped movements, prominent mannerisms or prominent grimacing echolalia or
echopraxia.
This is a disorder characterized by a stuporous state in which the person is mute, negative or
complains in response to a request. The individual may be immobile, display waxy flexibility and may retain urine and
faeces.
It may alternatively be characterized by a highly excited state in which the person is abusive, aggressive, and hyperactive
or agitated
(catatonic excitement).

Undifferentiated Schizophrenia
A type in which symptoms that meet criteria A are present, but the criteria are not met for the paranoid, disorganized or
catatonic type.
This disorder is also known as simple types.

Residual type
This is the type in which the following criteria are met:
Absence of prominent delusions, hallucinations, disorganized speech and grossly disorganized or catatonic
behaviour.
There is continuing evidence of the disturbance as indicated by the presence of negative symptoms or two or
more symptoms listed in criteria A for schizophrenia, present in an attenuated form (e.g. odd beliefs, unusual
perceptual experiences)

EUGEN BLEULER’S SYMPTOMS OF SCHIZOPHRENIA

Ambivalence
Autism: social withdrawal
Affect disturbances
Association disturbances: thoughts

INVESTIGATIONS
Perform P/E and laboratory tests to rule out other medical conditions including malaria, typhoid, HIV/AIDS and
substance use.
Treatment
Pharmacological: Give antipsychotics
Physical therapies: ECT
Psychological therapies: group therapy, behaviour therapy, social skills training, cognitive therapy, family therapy.

Nursing management
 Schizophrenic patients in an acute episode of the illness are seldom able to make a significant contribution to their
history.
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  Data may be obtained from family members, other people familiar with the patient and also from old records.
 A nursing assessment includes information regarding any previous incidence of mental illness or psychotic
episodes.
 Observe behaviour pattern, posturing, psychomotor disturbance, hygiene.
 Identify the type of disturbance the patient is experiencing.
 Ask the patient about feelings while thought alterations are evident.
 Note the affect and the emotional tone of the patient and whether they are appropriate in relation to the thought or
present situation.
 Assess for theme and content of delusional thinking. If the delusion is persecution oriented, assess the nature of
the threat and risk for violence.
 Assess speech patterns associated with the delusions.
 Assess for ability to perform self-care activity, i.e. sleep pattern and interaction with other patients.
 Determine any suicidal intent or recent attempts that may have been made.

Nursing diagnosis
Disturbed thought process, related to inability to trust, panic anxiety evidenced by delusional thinking, extreme
suspiciousness of others.

Goal/outcome: the patient will:

Eliminate pattern of delusional thinking.
Demonstrate trust in others.
Demonstrate decreased anxiety levels.
Demonstrate improved reality orientation.

Ineffective health maintenance related to inability to trust, extreme suspiciousness evidenced by poor diet intake,
inadequate food and fluid intake, difficulty in falling asleep.

Goal/outcome: the patient will:

Maintain adequate nutrition, hydration and elimination.
Maintain adequate sleep and rest.
Take medication as administered.

Self-care deficit related to withdrawal, regression, panic anxiety, cognitive impairment, inability to trust evidenced by
difficulty in carrying out tasks associated with hygiene, dressing, grooming, eating, sleeping and toileting.

Goal/outcome: the patient will:

Demonstrate increased interest in self-care.
Complete daily activities with minimum assistance.
Demonstrate adequate personal hygiene.

Potential for violence, self-directed or at others related to command hallucinations evidenced by physical violence,
destruction of objects in the environment or self-destructive behaviour.
Goal/outcome: the patient will:
Not injure others or destroy property or self.
Verbalize feelings of anger or frustration.
Express decreased feeling of agitation fear or anxiety.

Risk for self-inflicted or life-threatening injury related to command hallucinations evidenced by suicidal ideas, plans or
attempts.

Goal/outcome: the patient will not harm him/herself.

Disturbed sensory perception (auditory/visual) related to panic anxiety or biochemical factors evidenced by inappropriate
responses, disordered thought sequencing, poor concentration, disorientation, withdrawn behavior.
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Goal/outcome: the patient will:
Demonstrate decreased hallucinations.
Interact with others.
Verbalize plans to deal with hallucinations, if they recur.

Social isolation related to inability to trust, panic anxiety, delusional thinking evidenced by withdrawal, sad, dull affect
preoccupation with own thoughts, expression of feelings of rejection of aloneness imposed by others.

Goal/objective: patient will voluntarily spend time with other patients and staff members in group activities in the unit.

Impaired verbal communication related to panic anxiety, disordered, unrealistic thinking evidenced by loosening of
associations, echolalia, verbalizations that reflect concrete thinking and poor eye contact.

Goal/outcome: patient will be able to communicate appropriately and comprehensibly by the time of discharge.

Ineffective family coping related to highly ambivalent family relationships, impaired family communication evidenced by
neglectful care of the patient, extreme denial or prolonged over-concern regarding his illness.

Goal/outcome: family will identify more adaptive coping strategies for dealing with patient’s illness and treatment
regimen.

Course and prognosis

Complete remission is possible after an acute attack and the remission of symptoms, maintenance therapy should be
continued for at least one year.
Negative symptoms: the presence of these indicates a poorer prognosis.
Sex: Females tend to be better socially adjusted.
Marital status: prognosis is better in those who are married.
Acute or gradual onset: prognosis is better in acute onset with a clear triggering factor as opposed to gradual onset.
Premorbid personality: premorbid social withdrawal and other schizoid traits predict a poor outcome. Those with social
contacts outside the home have a better prognosis.
Comorbid disorders: these include depression, substance use and the presence of structural brain changes. The last two are
associated with a poor prognosis.

For an individual to be diagnosed as having schizophrenia, symptoms must persist for six months with one
month of acute symptoms.

Affective Disorders (mood disorders)

These are characterized by disturbance of mood, accompanied by full or partial manic or depressive syndrome, which is
not due to any other physical or mental disorder.

Classification of mood disorders

Mood(affective disorders)
 Manic episode
 Bipolar affective disorder
 Depressive episode
 Recurrent depressive disorder
 Persistent mood disorder
 Other mood disorders
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  Unspecified mood disorder.

Manic episode
Mania refers to a syndrome in which the central features are over-activity, mood change which maybe towards elation or
irritability and self-important ideas.

Classification of mania
 Manic episode
 Hypomania
 Mania without psychotic symptoms.
 Mania with psychotic symptoms
 Other manic episodes
 Manic episode unspecified.

Causes
Related to excessive levels of norepinephrine and dopamine and a deficiency in serotonin.

Clinical features
An acute mania is characterized by the following features which should last for at least one week

Elevated, expansive or irritable mood

This has four stages depending on the severity of manic episodes:
Euphoria (stage 1): increased sense of psychological well-being and happiness not in keeping with ongoing events.
Elation (stage II):moderate elevation of mood with increased psychomotor activity.
Exaltation (stage III): Intense elevation of mood with delusions of grandeur.
Ecstasy (stage IV): Severe elevation of mood, intense sense of rupture or blissfulness seen in delirious or stuporous mania.
Expansive mood is increasing and unselective enthusiasm for interacting with people and surrounding environment.

Psychomotor activity
There is increased activity ranging from over activeness and restlessness to manic excitement. The person involves in
ceaseless activity.

Speech and thought

Flight of ideas: thoughts racing in mind, rapid shifts from one topic to another.
Pressure of speech: speech is forceful, strong and difficult to interrupt. Uses playful language with punning, rhyming,
joking and teasing and speaks loudly.
Delusions of grandeur.
Delusions of persecution.
Distractibility.

Other features
 Increased sociability.
 Impulsive behavior.
 Disinhibition.
 Hypersexual and promiscuous behavior.
 Poor judgment.
 High risk activities (buying sprees, reckless driving, foolish business investments, distributing money or articles
to unknown persons)
 Dressed up in gaudy and flamboyant clothes although in severe mania there may be poor self-care.
 Decreased need for sleep (< 3 hours)
 Decreased food intake due to over activity.
 Decreased attention and concentration.
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  Absent insight.

Symptoms of hypomania
 This is a lesser degree of mania.
 There is persistent mild elevation of mood and increased sense of psychological well-being and happiness not in
keeping with ongoing events.

Management

Pharmacotherapy
Lithium: 900-2100 mg/day.
Carbamazepine 600-1800 mg/day
Sodium valproate 600-2600 mg/day
Other drugs: clonazepam, calcium channel blockers.

Electroconvulsive therapy
For acute manic excitement if not adequately responding to antipsychotics and lithium.

Psychosocial treatment
Family and marital therapy is used to decrease interfamilial and interpersonal difficulties and to reduce or modify
stressors. The main purpose is to ensure continuity of treatment and adequate drug compliance.

Nursing management for mania

Nursing assessment
Assess the severity of the disorder, forming an opinion about the causes, assessing the patient’s resources and judging the
patient’s behaviour on other people.
Relevant data should be collected from the patient as well as from his relatives, because the patient may not always
recognize the extent of his abnormal behaviour.
During assessment the nurse should include mood and affect, thinking and perceptual ability, sleep disturbances, changes
in energy level and character of speech patterns.
Mood and affect should be assessed for congruency.
Note the patterns of verbal speech.
The tone of voice, pace at which thoughts are processed and communicated and the rate at which are spoken are all
relevant.
Assess for sleeping and eating patterns, energy levels and weight changes.

Objective signs of mania Subjective signs of mania

Disturbance of speech Feelings of joy
Rapid speech Rapid mood swings
Loud, pressured speech Sleep disturbances
Easily distracted Delusions
Over activity hallucinations
Mood lability
Weight changes

Nursing diagnosis
High risk for injury related to extreme hyperactivity and impulsive behaviour, evidenced by lack of control over
purposeless and potentially injurious movements.
G/O: patient will not injure self.

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High risk for violence; self-directed or directed at others related to manic excitement, delusional thinking and
hallucinations.
G/O: patient will not harm self or others.

Altered nutrition, less than body requirements related to refusal to feed or inability to sit still long enough to eat,
evidenced by weight loss, amenorrhea.
G/O: patient will not exhibit signs and symptoms of malnutrition.

Impaired social interaction related to egocentric and narcissistic behaviour, evidenced by inability to develop satisfying
relationships and manipulation for others for own desires.
G/O: patient will interact with others in an appropriate manner.

Self-esteem disturbance related to unmet dependency needs, lack of positive feedback, unrealistic self-expectations.
G/O: patient will have realistic expectations about self.

Altered family processes related to euphoric mood and grandiose ideas, manipulative behaviour, refusal to accept
responsibility for own actions.
G/O: the family members will demonstrate coping ability in dealing with the patient.

DEPRESSIVE EPISODE
Definition: characterized by one or more depressive episodes.

Classification
Depressive episode
Mild depressive episode
Moderate depressive episode
Severe D.E without psychotic symptoms
Other depressive episodes- atypical depression.
Depressive episode,unspecified.
Recurrent depressive disorder.

Causes
This is due to negative cognitions which include:
Negative expectation of the environment, self and the future. These cognitive distortions arise out of defect in cognitive
development and cause an individual to feel inadequate, worthless and rejected by others.
Stressful life events for example death, marriage, financial loss before the onset of a disease.
This result in the levels of norepinephrine and serotonin are decreased and deregulation of acetylcholine and GABA.

Clinical features
Characterized by the following features, which should last for at least two weeks in-order to make a diagnosis?

Depressed mood
Sadness of mood or loss of interest and loss of pleasure in almost all activities (pervasive sadness), present throughout the
day (persistent sadness)

Depressive cognitions
Hopelessness (a feeling of no hope in future due to pessimism)
Helplessness (the patient feels that no help is possible)
Worthlessness (a feeling of inadequacy and inferiority)
Unreasonable guilt and self-blame over trivial matters in the past.

Suicidal thoughts

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Ideas of hopelessness are often accompanied by the thought that life is no longer worth living and that death has come as a
welcome release. These gloomy preoccupations may progress to thoughts of plans for suicide.

Psychomotor activity
Psychomotor retardation is frequent. The retarded patient thinks and acts slowly. Slowing of thoughts is reflected in the
patient’s speech; questions are often answers after a long delay and in monotonous voice.
In older patients, agitation is common with marked anxiety, restlessness and feelings of uneasiness.

Somatic (melancholic features) symptoms of depression

Significant decrease in appetite or weight.
Early morning awakening at 2 or more hours before the usual time of waking up.
Diurnal variation, with depression being worse in the morning.
Pervasive lack of interest and lack of reactivity to pleasurable stimuli.
Psychomotor agitation or retardation.
Other symptoms
Difficulty in thinking and concentration.
Subjective poor memory.
Menstrual or sexual disturbances.
Vague physical symptoms such as fatigue, discomfort, constipation, thoughts of death, decreased libido, dependency,
spontaneous crying and passiveness.

Management
Psychopharmacology: antidepressants
ECT: for severe depression with suicidal risk.
Psychological treatment
Psychotherapy based on psychoanalytic interventions emphasizes helping patients gain insight into the cause of the
depression.
Cognitive therapy: aims at correcting the depressive negative cognitions like hopelessness, worthlessness, helplessness
and pessimistic ideas and replacing them with new cognitive and behavioural responses.
Supportive psychotherapy
Group therapy: negative feelings such as anxiety, anger, guilt, despair are recognized and emotional growth is improved
through expression of their feelings.
Family therapy
Behavioral therapy

Nursing management of major depression episode

Nursing assessment
Should focus on judging the severity of the disorder including the risk of suicide, identifying the possible causes, the
social resources available to the patient, and the effect of the disorder on other people.
Although there is a risk of suicide in every depressed patient, the risk is much more in the presence of the following
factors:
Presence of marked helplessness.
Male sex
More than 40 years of age
Unmarried, widowed or divorced.
Written or verbal communication of suicidal intent or plan.
Early stages of depression.
Recovery from depression (at the peak of depression the patient is usually either too depressed or too retarded to commit
suicide)
Period of three months from recovery. The nurse should routinely enquire about the patient’s work, finances, family life,
social activities, general living conditions and physical health.
It is also important to consider whether a patient could endanger other people, particularly if there are depressive
delusions and the patient may act on them.

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Observe for mood, affect, thinking, perceptual ability, somatic complains, sleep disturbances and changes in energy
levels.
Determine the amount of assistance required for personal hygiene and elimination needs.
Assess for any suicidal ideation and whether a plan has been devised.
Assess for objective signs and subjective symptoms.

Objective signs Subjective symptoms

Alterations of activity Anhedonia
Poor personal hygiene Worthlessness, hopelessness, helplessness.
Apathy Suicidal ideas.
Altered social interactions Impairement of cognition
Delusions
Hallucinations

Nursing diagnosis
High risk of self-directed violence related to depressed mood, feelings of worthlessness and anger directed inward towards
self.
G/O: patient will not harm self.

Dysfunctional grieving related to real or perceived loss, bereavement evidenced by denial of loss, inappropriate
expression of anger, inability to carry out activities of daily living.
G/O: patient will be able to verbalize normal behaviors associated with grieving.

Powerlessness related to dysfunctional grieving process, life style of helplessness evidenced by feelings of lack of control
over life situations, over-dependence on others to fulfill needs.
G/O: the patient will be able to take control of life situations.

Self-esteem disturbance related to learned helplessness, impaired cognition, negative view of self, evidenced by
expression of worthlessness, sensitivity to criticism, negative and pessimistic outlook.
G/O: patient will be able to verbalize positive aspects about self and attempt new activities without fear of failure.

Altered communication process related to depressive cognitions, evidenced by being unable to interact with others,
withdrawn, expressing fear of failure or rejection.
G/O: patient will communicate or interact with staff or other patients in the unit.

Altered sleep and rest related to depressed mood and depressive cognitions evidenced by difficulty in falling asleep, early
morning awakening, verbal complaints of not feeling well rested.
G/O: patient will sleep adequately during the night.

Altered nutrition, less than body requirements related to depressed mood, lack of appetite or lack of interest in food,
evidenced by weight loss, poor muscle tone, pale conjunctiva, poor skin turgor.
G/O: patient’s nutritional status will improve.

Self-care deficit related to depressed mood, feelings of worthlessness, evidenced by poor personal hygiene and grooming.
G/O: patient will maintain adequate personal hygiene.

BIPOLAR MOOD DISORDER (BIPOLAR AFFECTIVE DISODER,MANIC DEPRESSIVE DISORDER)

This is characterized by recurrent episodes of mania and depression in the same patient at different times. Typically, the
patient experiences extreme highs (mania and hypomania) alternating with extreme lows (depression); interspersed
between the highs and lows are periods of normal mood.
Onset usually occurs between ages 20 and 30 years.
Causes
Exact cause is unknown but is thought that genetic, biochemical and psychological factors may play a role.
Maybe triggered by stressful events, antidepressant use.
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Sleep deprivation and hypothyroidism.

Signs and symptoms

Manic phase Depressive phase
Expansive, grandiose, or hyperirritable mood. Low self esteem
Increased psychomotor activity such as agitation, Overwhelming inertia
pacing or hand wringing. Feelings of hopelessness, apathy or self-reproach.
Excessive social extroversion Difficulty concentrating or thinking clearly
Rapid speech with frequent topic changes (without obvious disorientation or intellectual
Decreased need for sleep and food impairement)
Impulsivity Psychomotor retardation
Impaired judgement Anhedonia
Suicidal ideation

Symptoms
There are several types of bipolar and related disorders. They may include mania or hypomania and depression.
Symptoms can cause unpredictable changes in mood and behavior, resulting in significant distress and difficulty in life.
 Bipolar I disorder. You've had at least one manic episode that may be preceded or followed by hypomanic or
major depressive episodes. In some cases, mania may trigger a break from reality (psychosis).
 Bipolar II disorder. You've had at least one major depressive episode and at least one hypomanic episode, but
you've never had a manic episode.
 Cyclothymic disorder. You've had at least two years — or one year in children and teenagers — of many periods
of hypomania symptoms and periods of depressive symptoms (though less severe than major depression).
 Other types. These include, for example, bipolar and related disorders induced by certain drugs or alcohol or due
to a medical condition, such as Cushing's disease, multiple sclerosis or stroke.

Treatment
 Lithium
 Valporoic acid
 Carbamazepine
 Antidepressants
 Antipsychotics.
Course and prognosis of mood disorders
An average manic episode lasts for 3-4 months, while a depressive disorder lasts for 4-9 months.

ORGANIC BRAIN DISORDERS

These are mental disorders as a result of medical conditions which induce brain dysfunction and lead to the appearance of
characteristic psychological symptoms.
Causes of brain dysfunction
Infections (cerebral) Malaria (falciparum); typhoid fever; syphilis; trypanasomiasis; bacterial
meningitis; viral meningitis; toxoplasmosis; HIV/AIDS.
Infections (systemic) Septicemia; typhoid fever; bronchopneumonia;
Hypoxia Carbon monoxide poisoning
Metabolic Electrolyte imbalance; vitamin B deficiency; porphyria; liver and renal
diseases; spontaneous hypoglycemia
Endocrine Thyrotoxicosis; myxoedema’ cushing’s syndrome; diabetic ketoacidosis.
Cerebral tumor Primary; metastaic
Head injury
Vascular disease Sub-arachnoid hemorrhage; multi-infact dementia
Degenerative disease Alzheimer’s disease

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Substance use Alcohol; barbiturates; cannabis; hallucinogens.

DEMENTIA IN ALZHEIMER’S DISEASE (CHRONIC ORGANIC BRAIN SYNDROME)

Refers to the chronic progressive brain dysfunction that leads to impaired memory, personality changes and intellectual
deterioration but without impairment of consciousness.

Alzheimer’s disease: this is a chronic neurodegenerative disease that usually starts slowly and gets worse overtime.
There are two types: presenile dementia that occurs before the age of 65 years and senile dementia that occurs after the
age of 65 years

Stages of dementia
Stage I: early stage (2-4 years)
Forgetfulness.
Declining interest in environment.
Hesitancy in initiating actions.
Poor performance at work.

Stage II: middle stage (2 to 12 years)

Progressive memory loss
Hesitates in response to questions
Has difficulty in following simple instructions.
Irritable,anxious.
Neglects personal hygiene.
Social isolation.

Stage III: final stage (upto a year)

Marked loss of weight because of inadequate food intake.
Unable to communicate.
Does not recognize family.
Incontinence of urine and feces.
Loses the ability to stand and walk.
Death is usually caused by aspiration pneumonia.

Clinical features (for Alzheimer’s type)

Personality changes: Lack of interest in day to day activities, easy mental fatigability, self-centered, withdrawn ,decreased
self-care.
Memory impairment: recent memory is prominently affected.
Cognitive impairment: disorientation, poor judgment, difficulty in abstraction, decreased attention span.
Affective impairement: labile mood,irritableness,depression.
Behavioural impairement: stereotyped behaviour alteration in sexual drives and activities, neurotic/psychotic behaviour.
Neurological impairement: aphasia,apraxia, agnosia,seizures,headache.
Catastrophic reaction: agitation,attempt to compensate for defects by using strategies to avoid demonstrating failures in
intellectual performances,such as changing the subject,cracking jokes or otherwise diverting the interviewer.
Sundowner syndrome: it is characterized by drowsiness,confusion,ataxia,accidental falls may occur at night when external
stimuli such as light and interpersonal orienting cues are diminished.

MANAGEMENT
The main aim of treatment is to maintain the patient in the community.
Pharmacological methods:
Antipsychotic medications such as risperidone and haloperidol maybe used to decrease verbal and physical aggressiveness
to alleviate hallucinations and delusions.
Benzodiazepines for insomnia and anxiety.

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Antidepressants for depression.
Anticonvulsants to control seizures.

Nursing management
Nursing assessment
Assessment data includes the following:
 Disorientation
 Mood changes
 Fear
 Suspiciousness
 Self-care deficit
 Social behavior
 Level of mobility, wandering behavior.
 Judgement ability
 Sleep disturbance
 Speech or language impairement
 Hallucinations, illusions or delusions
 Bowel and bladder incontinence
 Apathy
 Any decline in nutritional status
 Recognition of family members
 Identify primary care giver, support system and the knowledge base of family members.

Nursing interventions
Daily routine
Maintaining a daily routine includes drawing a fixed timetable for the patient for waking up in the morning, toilet,
exercise and meals. This gives the patient a sense of security. Patient often deteriorate after dark, a phenomenon known as
sundowning. Additional care must be taken during the evening and at night.
Orient the patient to reality in order to decrease confusion. Provide newspapers which stimulate interest in current events.
Orientation of place, person and time should be given before approaching the patient.
Nutrition and body weight
Provide a balanced diet. Allow plenty of time for meals. Tell the patient which meal it is and what is there to be eaten,
food served should neither be too cold nor too hot.
Personal hygiene
This includes brushing of teeth, bathing, keeping the skin clean and dry, particularly in areas prone to perspiration, such as
the armpits and the groin.
Nail care for those unable to. They may have a problem with the lock on the bathroom door, if this happens it is advisable
to remove the lock.
Toilet habits and incontinence
Toilet habits should be established as soon as possible and maintained as a rigid routine. This includes conditioned
behavior such as going for bowel movement immediately after a cup of tea. The patient should be taken to urinate at fixed
interval.
Accidents
Great care should be taken to avoid accidents caused by tripping over furniture; falling down the stairs or slipping in the
bathroom. Let the patients wear fitting shoes. They should be gently persuaded to stop driving as this can pose a hazard to
them and others. Do not allow the patient to take medication alone.
Mood and emotions

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Some patients have abrupt change in their moods and emotions. These changes can be unpredictable. Mood changes are
best controlled by keeping a calm environment with fixed daily routine. The patient should not be questioned repeatedly
or given too many choices, such what they want to eat or what they want to wear. Mood changes are also responsive to
distraction, particularly if topics related to the past are discussed or favorite music played which puts them in a nostalgic
mood.
Wandering
These patients often lose their geographic orientation and can even get lost in familiar surroundings. They may be found
wandering aimlessly either in the neighborhood or far away. It is advisable to have some identification bracelet or card
always in their possession. The doors of the house should be securely locked so that the patients cannot leave unnoticed.
The patient should always be accompanied while going for walks or for simple chores outside the house.
Disturbed sleep
Sleep disturbances are extremely distressing to the family. If the patient is restless at night or wanders and talks at night,
the entire family is disturbed. Sleep patterns must be maintained. Napping during the day should be avoided.
Interpersonal relationship
Verbal communication should be clear and unhurried. Questions that require yes or no answers are best. Give necessary
information repeatedly. Try to make sure that each day has something of interest for the patient-it might be going for a
walk, listening to music, talk about the day’s activities. Try to involve old friends for a chat about the past.

DELIRIUM
This is an acute organic mental disorder characterized by impairment of consciousness, disorientation and disturbances in
perception and restlessness. There are additional features such as restlessness, illusions and psychotic features in the form
of auditory or visual hallucinations and delusions.
Clinical features
The main symptom and sign is the clouding of consciousness (GCS less or equal to 8)
Eye opening Best verbal response Best motor response
5. Normal 5. Oriented 5. Obeys verbal commands
4. Spontaneous 4. Confused but talking in 4. Localizing to pain.
sentences.
3. To speech 3. Uttering inappropriate sounds 3. Flexion to pain
2. To pain 2. Incomprehensible sounds (no 2. Extension to pain.
words)
1. None 1. None 1. None

Impairment of attention: difficulty in shifting,focusing and sustaining attention.

Perceptual disturbances: illusions and hallucinations most often visual.
Disturbance of cognition: impairement of abstract thinking and comprehension,impairement of immediate and recent
memory,increased reaction time.
Psychomotor disturbance: hypo or hyperactivity.aimless groping or picking at the bed cloths (flocculation), enhanced
startle reaction.
Disturbance in the sleep-wake cycle: insomnia or in severe cases total sleep loss or reversal in the sleep wake
cycle,daytime drowsiness,nocturnal worsening of symptoms,disturbing dreams or nightmares, which may continue as
hallucinations after awakening.
Emotional disturbances: depression,anxiety,fear,irritability,euphoria,apathy.
Course and prognosis
The onset is usually abrupt. The duration of an episode is usually brief, lasting for about a week.
Management
Pharmacotherapy: identification of cause and its immediate correction,for example,50mg of 50% dextrose IV for
hypoglycemia, oxygen for hypoxia,100mg of vitamin B one IV for thiamine deficiency, IV fluids for fluid and electrolyte
imbalance.
Benzodiazepines for
Antipsychotics for
Nursing intervention
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Providing safe environment
Restrict environmental stimuli, keep unit calm and well illuminated.
There should be always somebody at the patient bedside reassuring and supporting.
As the patient is responding to a terrifying unrealistic world of hallucinatory hallucinations and delusions, special
precautions are needed to protect him from himself and to protect others.
Alleviating patient’s fear and anxiety:
Remove any object in the room that seems to be a source of misinterpreted perception.
As much as possible have the same person all the time by the patient’s bedside.
Keep the room well lighted especially at night.
Meeting the physical needs of the patients
Appropriate care should be provided after physical assessment.
Use appropriate nursing measures to reduce fever if present.
Maintain intake and output chart.
Mouth and skin should be taken care of.
Monitor vital signs.
Observe patient for any extreme drowsiness and sleep as this maybe an indication that the patient is slipping into a coma.
Facilitate orientation
Repeatedly explain to the patient where he is and what date, day and time it is.
Introduce people with name even if the patient misidentifies the people.
Have a calendar in the room and tell him what day it is.

ORGANIC AMNESTIC SYNDROME

There is impairment or loss of recent memory with preservation of immediate recall,remote memory and other cognitive
functions due to an underlying organic course.
There is no disturbance of consciousness.
The most common cause for this condition is thiamine deficiency as a result of chronic alcoholism. It is also called as
“Wernicke’s-Korsakoff syndrome.”
Wernicke’s encephalopathy is an acute phase of delirium preceding amnestic syndrome,while Korsakoff syndrome is a
chronic phase of amnestic syndrome.
Clinical features
Recent memory impairement.
Anterograde and retrograde amnesia.
Management
Treatment for underlying cause.

NEUROSES
This is a less severe form of psychiatry disorder where patients show either excessive or prolonged emotional reaction to
any given stress.
These disorders are not caused by organic disease of the brain and however severe ,do not involve hallucinations and
delusions.
Maybe classified as:
Generalized anxiety disorder (GAD)
Panic disorder.
Phobic disorders.
Obsessive compulsive disorder (OCD)
Post-traumatic stress disorder.(PTSD)
Secondary to general medical condition.

Definition
Anxiety is a state of tension and apprehension with hyperactivity of the autonomic nervous system as a natural response to
perceived threat.

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The frequency and intensity of anxiety responses are out of proportion when compared to situations that trigger them.
Anxiety may interfere with daily life.
These disorders have three components:
Cognitive components: subjective feeling of apprehension, a sense of impending danger and a feeling of inability to cope.
Physiological response: increased heart rate, Bp, muscle tension,rapid breathing,dry mouth,diarrhea and frequent
urination.
Behavioural responses: avoidance of certain situations and impaired task performance.
GENERALIZED ANXIETY DISORDER (GAD)
This is a disorder in which there is persistent and excessive feelings of anxiety not attached to any particular specific
situations, but rather caused by a general tendency to worry excessively.
Anxiety may last for months with the signs almost present continuously .there is a sense of impending disaster,though not
specific.
Typical worries include excessive worries about work or social performance,exaggerated concerns about finances and the
possibility of becoming ill or having an accident.

Common symptoms of GAD

Psychological: fearful anticipation,irritability,sensitivity to noise,restlessness,poor concentration,worrying thoughts and
apprehension.
Physical symptoms
Gastrointestinal: dry mouth, difficulty in swallowing, epigastric discomfort, frequent or loose motions.
Respiratory: constriction in the chest,difficulty inhaling, over-breathing.
Genitourinary: frequency or urgent micturition,failure of erection,menstrual discomfort, amenorrhea.
Neuromuscular system: tremor,prickling sensations,tinnitus,dizziness,headache,aching muscles.
Sleep disturbances: insomnia,night terrors.
Other symptoms: depression,obsessions,depersonalization,derealization.
Management
pharmacotherapy
Antianxiety drugs
Antidepressants
SSRIs
Beta blockers.
Behavioural therapy: teach the patient how to become aware of them and then consciously control various body
functions(vital signs). Relaxation techniques e.g.Yoga, meditation.
Cognitive therapy: by teaching the patient how to restructure her thoughts and view her worries more realistically. A
patient may be taught to record worries and lists evidence that justifies or contradicts each one. Patient learns that
worrying about worry maintain anxiety; avoidance and procrastination are ineffective problem solving techniques.

PANIC DISORDER
This is characterized by anxiety, which is intermittent and unrelated to particular circumstances. It is a discrete period of
intense fear or discomfort,in which four or more of the following symptoms developed abruptly and reached a peak within
10 minutes.
Palpitations,pounding heart or accelerated heart rate.
Sweating.
Trembling or shaking.
Sensations of shortness of breath or smothering.
Feeling of choking.
Chest pain or discomfort.
Nauseaor abdominal distress.
Feeling dizzy,unsteady,lightheaded or faint.
Derealization (feeling of unreality) or depersonalization (being detached from oneself)
Fear of losing control or going crazy.
Fear of dying.
Paresthesias(numbness or tingling sensation)
Chills or hot flushes.

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Management
Pharmacotherapy: benzodiazepines;antidepressants,beta blockers to control severe palpitations that have not responded to
anxiolytics.
Behavioural therapy
Relaxation techniques to help patient cope with panic attack by easing physical symptoms and directing attention
elsewhere.
Deep breath relaxation,which involves tightening and relaxation of the skeletal muscles in a sequential fashion.
Positive verbalization or guided imagery,in which the patient elicits peaceful mental images or some other purposeful
thought or action,promoting feelings of relaxation,renewed hope,and a sense of being in control of a stressful situation.
Listening to calming music.
Cognitive therapy
Teaches the patient to replace negative thoughts with more realistic, positive ways of viewing the attacks.
Helps the patient to identify possible triggers for the panic attacks, such as a particular situation or thought or evena slight
change in heartbeat.
Helps the patient to identify and evaluate the thoughts that precede anxiety and then restructures them to gain a more
realistic perception.

PHOBIC ANXIETY DISORDER

A phobia is an unreasonable fear of a specific object,activity or situation. This fear is disproportionate to the
circumstances that precipitate it.it cannot be delt with by reasoning or controlled by will power. The individual avoids the
feared object or situation.
TYPES OF PHOBIA
Simple,social,agoraphobia and specific phobias.
Simple (specific) phobia
It is an irrational fear of a specific object or stimulus.common in childhood.
Examples of some specific phobias
Acrophobia: fear of heights.
Hematophobia: fear of the sight blood.
Claustrophobia: fear of closed spaces.
Gamaphobia: fear of marriage.
Insectophobia: fear of insects.
AIDS phobia: fear of AIDS
Zoophobia: fear of animals
Microphobia: fear of germs
Brontophobia:fear of thunder
Algophobia:fear of pain

Social phobia
It is an irrational fear of performing activities in the presence of other people or interacting with others. The patient is
afraid of his own actions being viewed by others. Critically,resulting in embarrassment or humiliation.
S&S of S.phobia
Hyperventilation
Sweating,cold clammy hands.
Blushing.
Palpitations
GIT symptoms
Trembling hands and voice
Urinary urgency
Muscle tension
Anticipatory anxiety

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Fear of embarrassment or ridicule.
Many people who have social phobia are under achievers because of test anxiety,poor job performance,or poor
communication skills. They may have few or no friends, a decreased support system and poor interpersonal relationships.

Agoraphobia
This is characterized by an irrational fear of being in places away from familiar setting of home, in crowds or in situations
that the patient cannot leave easily.
As the agoraphobia increases in severity, there is gradual restriction in normal day to day activities
S&S
Overriding fear of open or public spaces.
Deep concern that help might not be available in such places.
Avoidance of public places and confinement to home.
Course and prognosis
More common in women. Onset is sudden without any cause. The course is usually chronic. Sometimes phobias are
spontaneous remitting.
Management
Pharmacotherapy: BZ and antidepressants.
Behavioral therapy
Desensitization therapy to gradually reintroduce the feared situation while coaching the patient on relaxation techniques.
Role playing in guided imagery to allow the patient to rehearse ways to relax while confronting a feared object or
situation.

Obsessive compulsive disorder

Either obsessions(thoughts of being infected by germs) or compulsions(behavioral-washing and cleaning rituals)
Obsessions defined as:
Repetitive and persistent thoughts,impulses,or images that are experienced at some time during the disturbance, as
intrusive and inappropriate that intrude an individual’s consciousness and that causes marked anxiety or distress. They
are often abhorrent (distasteful) to the person, but very difficult to dismiss or control.
The thoughts,impulses or images are not simply excessive worries about real life problems.
The person attempts to ignore or suppress such thoughts,impulses or images or to neutralize them with some other thought
or action.
The person recognizes that the obsessional thoughts,impulses or images are a product of his or her own mind.
Compulsions(focus on contamination) defined as:
Repetitive, persistent and uncontrollable behavioral urges to perform certain behaviours (e.g. hand-washing, ordering,
checking things repeatedly,cleaning,counting) or mental acts(e.g. praying,counting,repeating words silently) resisted only
with great difficulty. That the person feels driven to perform in response to an obsession or according to rules that must be
applied rigidly and in a specific order. Failure to perform the compulsive acts leads to tremendous intensity of anxiety.
The behaviours or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation;
however these behaviours or mental acts either are not connected in a realistic way with what they are designed to
neutralize or prevent or are clearly excessive.
OCD may lead to avoidance of certain objects or situations (e.g. dirt and not leaving the house to avoid unlocking doors);
life disruption;frustration;irritation to an individual,family,friends,workmates,depression and anxiety.
Management
Pharmacotherapy: antidepressants,anxiolytics.
Behavioral therapy:
Exposure and response prevention e.g. compulsive hand washers are encouraged to touch contaminated objects and then
refrain from washing in order to break the negative reinforcement chain.
Thought stoppage:
This is a technique to help an individual to learn to stop thinking unwanted thoughts. Ask the patient to bring to mind the
unwanted thought concentrating only on one thought per procedure.
As soon as the thought forms,give the command “Stop.” follow this with calm and deliberate diversion of thought to
something pleasant.
Repeat the procedure to bring the unwanted thought under control.

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Relaxation technique: it includes deep breathing exercises,progressive muscle relaxation,meditation,imagery and music.

POST TRAUMATIC DISORDER

This is a long-lasting anxiety response following a traumatic or catastrophic event.
Typically traumatic events include violent assault; being kidnapped; held a prisoner at war; victim of manmade or natural
disasters, being diagnosed with life-threatening illness,torture,terrorist attack and witnessing or learning about unexpected
death of another person.
Usually PTSD develops within 3-6 months of the traumatic event. Major symptoms include:
Severe symptoms of anxiety, arousal and distress that was not present before the trauma on exposure to trauma cues.
Relieving the traumatic event recurrently in “flashbacks” dreams, images and fantasy.
Nightmares and disturbed sleep.
Becoming numb to the world and avoiding stimuli that remind one of the traumas.
Being easily startled.
Amnesia about important aspects of the traumatic event.
Concentration and memory difficulties.
Depressed or irritable mood.
Social withdrawal.
Experiencing extreme guilt about surviving the catastrophe when others did not.

MANAGEMENT
The general approach is to provide emotional support; to encourage recall of the traumatic events.BZ may be needed to
reduce anxiety.
Establish trusting relationship.
Encourage patient to express her grief,complete the mourning process.
Encourage move from physical to verbal expressions of anger.

PERSONALITY DISORDERS
Personality is the relatively stable and predictable emotional and behavioural traits that characterize persons in their day to
day living. They assist an individual to respond to wide range of situations.
When these traits are inflexible and maladaptive and causing distress and impairement in the functional abilities of an
individual they constitute a personality disorder. These represent significant deviations from the way average individuals
in a given culture perceive think, feel and relate to one another.
Individuals with PD are often unaware of their conditions and are likely to reject treatment.
There symptoms are alloplastic (capable of adopting and altering external environment) and egosyntonic (acceptable to
the ego). As a result, they are not anxious and routinely ignore complaints from other members of the society.
CLASSIFICATION
CLUSTER A (odd and eccentric): paranoid.Schizoid,schizotypal personality disorders.
CLUSTER B (dramatic,emotional and erratic): antisocial,histrionic,narcissistic personality disorders.
CLUSTER C (anxious and fearful): avoidant,dependent and OCD

TYPES OF PERSONALITY DISORDERS

CLUSTER A PD
Paranoid personality disorder
This is characterized by persistent and long standing suspicion, sensitivity and mistrust of people.
They avoid responsibility for their actions,blame others,are hostile,angry and irritable and often interpret the actions of
other people as being deliberately demeaning and threatening.
They tend to be pathologically jealous and argumentative.
They are usually un-emotional and fail to maintain friendly relationships.
In some cases they may show stubbornness and feeling of self-importance.

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Schizoid personality disorder
This is characterized by patient display a lifelong pattern of detachment and social withdrawal.
They are emotionally cold, self-sufficient,detached and have limited ability to express warmth or anger towards others.
They prefer solitary activities (e.g. reading) and are preoccupied with a variety of fantasies.
They generally lead a lonely life.
Their sexual life may exist only in fantasy and they often remain unmarried.
They prefer lonely non-competitive solitary jobs that other people find difficult to tolerate and tend to work at night to
avoid contact with others.
They lack close friends or confidants other than first degree relatives.
Schizotypal personality disorder
The patients are eccentric,suspicious and show poor interpersonal relationships.
They are strikingly odd even to lay people and have a tendency to experience extrasensory perception e.g. telepathy
including magical thinking and superstitions. On examination:
Inappropriate affect,odd thinking and speech (vague,circumstantial,metaphorical, overelaborate or stereotyped)odd
beliefs or magical thinking that influences behaviour and is inconsistent with subcultural norms(e.g. superstitiousness,
belief in clairvoyance, telepathy or 6th sense),social withdrawal,odd,eccentric or peculiar behaviour,lack of close
relationships,social isolation,not fitting easily with others.

CLUSTER B PERSONALITY DISORDER

Antisocial (dissocial)personality disorder (sociopath, psychopath)
This is characterized by chronic antisocial behavior that violates other rights or social norms which predisposes the
affected person to criminal behaviour. The person is unable to maintain consistent, responsible functioning at work,
school or as a parent. S&S are:
Failure to sustain relationships
Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are
grounds for arrest.
Deceitfulness, as indicated by repeated lying, using of aliases, or conning others for personal profit or pleasure.
Disregard for the feelings of others
Impulsivity or failure to plan ahead.
Irritability and aggressiveness,as indicated by repeated physical fights or assaults.
Consistent irresponsibility,as indicated by repeated failure to sustain consistent work behavior or honor financial
obligations.
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated or stolen from another.

Histrionic personality behavior

This type is characterized by excessive display of emotions, dramatization and extroversion.
The individual has attention seeking behavior and over concerned with physical attractiveness.
Their relationships are superficial and don’t last long. They tend to be dependent on others, demanding and have endless
need for reassurance.
They have a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present
in a variety of contexts as indicated by the following:
Is uncomfortable in situations in which he os she is not the center of attention.
Interaction with others is often characterized by inappropriate sexually seductive or provocative behaviour.
Displays rapidly shifting and shallow expression of emotions.
Consistently uses physical appearance to draw attention to self.
Has a style of speech that is excessively impressionistic and lacking in detail.
Shows self-dramatization,theatricality, and other exaggerated expression of emotions.
Is suggestible i.e. easily influenced by others or circumstances.
Considers relationships to be more intimate than they actually are.

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Narcissistic personality disorder
Narcissism is a pattern of grandiosity, need for admiration and lack of empathy. Narcissistic individuals have a heightened
sense of self- importance and entitlement. They believe they are unique in some way and behave accordingly. They are
envious of others, arrogant and expect favors. Affected persons have fragile self-esteem and are prone to develop
depression.
They have the following:
Has a grandiose sense of self-importance (e.g. exaggerates achievements and talents, expects to be recognized as superior
without commensurate achievements)
Is preoccupied with fantasies of unlimited success, power, brilliance, beauty or ideal love.
Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or
high status people (or institutions)
Requires excessive admiration.
Has a sense of entitlement i.e. unreasonable expectations of especially favorable treatment or automatic compliance with
his or her expectations.
Is interpersonally exploitative i.e. takes advantage of others to achieve his or her own ends.
Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
Is often envious of others or believes that others are envious of him or her.
Shows arrogant,haughty behaviours or attitudes.

CLUSTER C PERSONALITY DISORDER

Avoidant (anxious) personality disorders
Patients are persistently anxious and show great sensitivity to criticism or rejection by others which may lead to social
withdrawal. They show great desire for companionship and are generally shy.
They display a pattern of social inhibition,feelings of inadequacy and hypersensitivity to negative evaluation.
This situation begins by early adulthood and present in a variety of contexts:
Avoids occupational activities that involve significant interpersonal contact,because of fears of criticism,disapproval or
rejection.
Is unwilling to get involved with people unless certain of being liked.
Show restraint with intimate relationships because of fear of being shamed or ridiculed.
Is preoccupied with being criticized or rejected in social situations.
Is inhibited in new interpersonal situations because of feelings of inadequacy.
Views self as socially inept, personally unappealing, or inferior to others.
Is usually reluctant to take personal risks or to engage in any new activities because they may prove to be embarrassing.

Dependent personality disorder

This disorder is characterized by pervasive patterns of dependent and submissive behavior related to an excessive need to
be taken care of. The patients are indecisive, lack initiative and avoid responsibility. They fear being alone and usually
seek others on whom they can depend. They are often pessimistic, passive and cannot express aggressive feelings. They
cling to others for fear of abandonment and often persevere maltreatments for long periods,
They are at increased risk of depression especially associated with the loss of the person they are dependent on. Very
common in females. Characterized by the following symptoms:
Has difficulty making everyday decisions without excessive amount of advice and reassurance from others.
Need others to assume responsibility for most major areas of his or her life.
Has difficulty expressing disagreement with others because of fear of loss of support or approval.
Has difficulty initiating projects or doing things on his or her own because of lack self confidence in judgement or
abilities rather that a lack of motivation or energy.
Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are
unpleasant.
Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
Urgently seeks another relationship as a source of care and support when a close relationship ends.
Is unrealistically preoccupied with fears of being left to take care of himself or herself.

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SEXUAL DISORDERS
This is persistent impairement of the normal patterns of sexual interest or response. In other words, these are disorders
characterized by individuals’ failure to respond normally in key areas of sexual functioning, making it difficult to enjoy
sexual intercourse.

Classification
 Gender identity disorders
 Psychological and behavioral disorders associated with sexual development and maturation.
 Disorders of sexual preference.
 Sexual dysfunctions.
Gender identity disorders
In these disorders, the sense of one’s masculinity or femininity is disturbed. They include:
Transsexualism
In this there is persistent and significant sense of discomfort regarding one anatomic sex, and a feeling that it is
inappropriate to one’s perceived gender. The person will be preoccupied with the wish to get rid of the one’s genitals and
secondary sex characteristics and to adopt the sex characteristics of the other sex.
Management
Counseling to help the individual reconcile with the anatomic sex.
Sex change to the desired gender (sex reassignment surgery) in some selected cases.
Gender identity disorder of childhood
This is a disorder similar to transsexualism, with a very early age of onset.
Dual role transvetism
It is characterized by wearing clothes of the opposite sex in order to enjoy the temporary experience of membership of the
opposite sex but without any desire for permanent sex change.
Intersexuality
The patient has gross anatomical or physiological features of the other sex. For example pseudo hermaphroditism,
turnerssyndrome, congenital adrenal hyperplasia.
Psychological and behavioural disorders associated with sexual development and maturation
Homosexuality
In this,sexual relationships are maintained between persons of the same sex. Female homosexuals are called as “lesbians”
and male homosexuals are called as “gay.”
Management
Behaviour therapy: aversion therapy, covertsensitization, systematic desensitization.
Supportive psychotherapy
Psychoanalytic therapy.

Disorders of sexual preference or paraphilias

In paraphilias sexual arousal occurs persistently and significantly in response to objects, which are not part of normal
sexual arousal. These disorders include:
Fetishism: sexual arousal occurs with non-living object which is usually intimately associated with the human body. The
fetish objects may include bras,underpants,shoes,gloves, vests etc.
Transvetism: sexual arousal occurs by wearing clothes of the opposite sex.
Sexual sadism: the person is sexually aroused by physical and psychological humiliation, suffering or injury of the sexual
partner.
Sexual masochism: here the person is sexually aroused by physical or psychological humiliation or injury inflicted on
self by others.
Exhibitionism: in this the person is sexually aroused by the exposure of one’s genitalia to unsuspecting stranger.
Voyeurism: this is persistent or recurrent tendency to observe unsuspecting persons naked (usually of the other sex) and
engaged in the sexual activity.
Frotteurism: this is a persistent or recurrent involvement in the act of touching and rubbing against an unsuspecting,non-
consenting person.
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Pedophilia: it is characterized by persistent or recurrent involvement of an adult in sexual activity with prepubertal
children.
Zoophilia (bestiality): involving in sexual activity with animals.

Management
Behavioral therapy: aversion therapy
Psychoanalysis
Drug therapy: antipsychotics have been used for severe aggression associated with paraphilias.

Sexual dysfunctions
This is a significant disturbance in the sexual response cycle, which is not due to an underlying organic cause.
The common dysfunctions are:
Frigidity: absence of desire for sexual activity.
Impotence: the disorder is characterized by an inability to have or sustain penile erection till the completion of
satisfactory sexual activity.
Premature ejaculation: ejaculation before completion of satisfactory sexual activity for both partners.
Non-organic vaginismus: an involuntary spasm of the lower 1/3rd of the vagina, interfering with coitus.
Non-organic dyspareunia: pain in the genital area of either male or female during coitus.
Treatment
Psychoanalysis
Hypnosis
Group psychotherapy
Behaviour therapy

Nursing intervention in a patient with sexual disorder

Assess patient’s sexual history and previous level of satisfaction in sexual relationships; also assess patient’s perception of
the problem.
Note cultural, social, ethnic, racial and religious factors that may contribute to conflicts regarding variant sexual practices.
Assess for medication which might be affecting libido.
Provide information regarding sexuality and sexual functioning,correct any misconceptions if necessary. Teach the patient
that sexuality is a normal human response and that it involves complex inter-relationships among one’s self-concept,body
image,family and cultural influences.
Both the patient and his/her partner may need additional assistance if problems in sexual relationship are severe or remain
unresolved.
Refer for additional counseling or sex therapy if required.
Assist the therapist as necessary in plan of behaviour modification to help decrease variant behaviour.
In all cases,an accepting and non-judgemental attitude on the part of the nurse is highly essential for successful resolution
of these problems as these are highly sensitive issues and maybe causing significant distress to the patient.

SUBSTANCE USE DISORDERS

DEFINITIONS
Drug: this refers to any chemical agent that once taken in the body is capable of causing physiological and psychological
changes. The term “drug” is interchangeably used with “substance.”
Psychoactive substance: this is a chemical compound that produces emotional, cognitive or behavioral changes which
maybe pleasurable or desirable to the user, with adverse medical consequences and is socially unsanctioned because of its
undesirable effects on the user and others.
Use: relative to a licit substance, use refers to a situation where a person takes psychoactive substance with no subsequent
harm to health, social and occupational function.
Abuse: is a pathological pattern of use where one experiences loss of control and begins to suffer health, social and
occupational effects.
Criteria for substance abuse
A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or
more of the following, occurring within a 12 month period:

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Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g. repeated
absences or poor work performance related to substance use; substance related absences, suspensions, or expulsions from
school; neglect of children or household.)
Recurrent substance use in situations in which it is physically hazardous (e.g.driving or operating a machine when
impaired by substance use)
Recurrent substance related legal problems (e.g. arrests for substance related disorderly conduct)
Continued substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the
effects of the substance (e.g. arguments with spouse about consequences of intoxication, physical fights)
Tolerance
The need for more of the drug in order to achieve a similar effect realized before at a lower dose.
Dependence
Refers to the compulsion to take the drug on a continuous basis in order to feel its effect and to further avoid the
discomfort of its absence. Dependence can be both be physical and psychological.
Criteria for dependence
A maladaptive pattern of substance use,leading to clinically significant impairement or distress,as manifested by the
following occurring at any time in the same 12-month period:
Tolerance as defined by need for markedly increased amounts of the substance to achieve intoxication or desired effect or
markedly diminished effect with continued use of the same amount of the substance.
Withdrawal as manifested by the following:
The characteristic withdrawal syndrome for the substance(refer to criteria A and B)
The same (or a closely related)substance is taken to relieve or avoid withdrawal symptoms.
The substance is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control substance use.
A great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long
distances),use the substance (e.g. chain smoking), or recover from its effects.
Important social,occupational,or recreational activities are given up or reduced because of substance use.
The substance use is continued despite knowledge of having persistent or recurrent physical or psychological problem that
is likely to have been caused or exacerbated by the substance(e.g continued drinking despite recognition that an ulcer was
made worse by alcohol consumption)
Substance intoxication
Clinically significant maladaptive behavioural or psychological changes that are due to the effect of the substance on the
central nervous system (e.g. belligerence (aggressive), mood labiality, cognitive impairment, impaired judgment, impaired
social or occupational functioning) and develop during or shortly after use of the substance.
Substance withdrawal
The development of a substance specific syndrome due to the cessation or (or reduction in) substance use that has been
heavy and prolonged.
The substance specific syndrome causes clinically significant distress or impairement in social occupational or other
important areas of functioning.
Commonly abused substances
Alcohol,cocaine,opioids.
Amphetamines,hallucinogens
Cannabis, nicotine, sedatives
Etiological factors in alcohol and substance abuse
Involves an interaction of three main factors: the agent;host and environment
AGENT(ALCOHOL AND OTHER SUBSTANCES)
These substances have a euphoric and calming effect. This is why they are repeatedly used,eventually leading to
development of tolerance,withdrawal from prolonged use of a substance,manifests in a syndrome which is characterized
by physical and psychological discomfort. One therefore avoids this uncomfortable state by taking the substance on a
continuous basis.
HOST(INDIVIDUAL)
Individuals who are prone to alcohol and substance abuse have some inherent predisposing factors. These include:
Genetic factors: dependence on alcohol has adegree of genetic predisposition. An individual is likely to be alcoholic if the
parents or siblings are.

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Family drug use: children often accept and copy the behaviour of their elders when they grow up and this may include
alcohol and substance abuse.
Peer pressure: in order to belong to certain social groupings and conforming to the norms of the group,pressure within
the group may result in an individual member acquiring habits that are maladaptive such as these.
Mental state
This refers to the emotional attitude regarding the use of a substance and can be negative,positive or neutral. A negative
attitude subsequent to influence of religion,social,political or family beliefs will lead to rejection of the substance. A
positive attitude will be one that encourages use of the substance.
Environmental factors
In environments where supply and availability of the substance is widespread, susceptible individuals may begin to use
the substance. Other factors that enhance substance use and abuse are poverty, unemployment, dysfunctional
families,migration and rapid urbanization.
ALCOHOL
This is the most widely abused substance in the world over. It is also the drug that gives the most serious health and social
effects in the societies
Effects
Physiological effects
1) Alcohol intoxication:
This is seen after recent ingestion of alcohol. There is a clinically significant maladaptive behavioural or psychological
change (e.g. inappropriate sexual or aggressive behaviour,mood labiality,impaired judgement, impaired social or
occupational functioning)
One or more of the following signs develop during or shortly after alcohol use:
Slurred speech, Inco-ordination,unsteady gait,nystagmus,impairement in attention or memory,stupor or coma.
Other body effects include: cutaneous vasodilatation,increased salivation and gastric salivation,increased output of adrenal
steroids and suppression of the antidiuretic hormone leading to diuresis.
Chronic effects
Following chronic use, alcohol is capable of causing damage to all body systems. The amount of damage will depend on
amounts taken,duration of drinking.
Digestive system: predisposes to multiple oral problems, esophagitis,cancer of the oesophagus,gastric ulcers,liver
cirrhosis and pancreatitis.
CVS: predisposes to high blood pressure and alcoholic cardiomyopathy.
Reproductive system: leads to loss of libido,erectile dysfunction and consequent infertility. For pregnant mothers who
consume large amounts the baby may suffer from general growth retardation,low intelligence and congenital
abnormalities.

Psychological effects
These result from direct toxic effect,withdrawal or nutritionaldeficiencies. Immediate effects are pathological intoxication
and alcoholic blackout.withdrawal gives rise to two forms of withdrawal states (with or without delirium)

Withdrawal state (withdrawal syndrome)

This happens when there is stoppage or reduction in alcohol use that has been heavy and prolonged. Two or more of the
following developing within several hours to a few days after stopping or reducing the amount:
Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100)
Increased hand tremor
Insomnia
Nausea or vomiting
Transient visual,tactile,or auditory hallucinations or illusions.
Psychomotor agitation.
Anxiety
Grand mal seizures.
Withdrawal state with delirium
It is a more serious condition and usually manifests 3 to 4 days after the total cessation or reduction in usual amounts of
alcohol taken.

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The commonest form of withdrawal is delirium tremens. DT is self-limiting and short lived, but could be fatal.
Initially the clinical picture resembles that of withdrawal state without delirium, but as the condition progresses the person
becomes delirious and confused.
Clinical features include prodromal symptoms of insomnia,anxiety,fear,restlessness,tremors and convulsions. As the
condition progresses there is clouding of consciousness,disorientation and profound confusion.
The condition tends to get worse at night.

Long-term effects
Nutritional deficiencies lead to Wernicke’s encephalopathy,korsakoff’s psychosis and alcoholic dementia
Social effects
Alcohol use and abuse leads to dysfunctional social and occupational functions at individual, family, community and
national level.
At individual level: there is common problem of personality deterioration. Such people lack a sense of responsibility. In
economic terms,there is general reduction in income. Student suffers poor academic performance.
At family level: domestic violence is common occurrence and usually results in dysfunctional families,separation and
divorce. Children from such families develop serious emotional disorders,usually leading to poor academic performance.
At the community level: associated with high crime rates and indiscipline.
At the national level: the burden of caring for the substance dependent individual is enormous. Such persons contribute
to loss of many hours through absenteeism, repeated treatments for depression and physical ailments.

Diagnosis for alcohol use problems

CAGE is a common simple and effective screening tool. The following questions are asked:
Have you ever tried to cut down your drinking? (C)
Do you get annoyed when people talk about your drinking? (A)
Do you ever feel guilty about your drinking? (G)
Do you ever take an early morning drinking? (E)

Other screening tools include:

Alcohol use disorders identification tests (AUDIT)
Short Michigan alcohol screening test (S-MART)
Laboratory investigations or markers:
Blood alcohol concentration (BAC)
Breathe alcohol levels

CANNABIS SATIVA(BHANG)
This is a green flowering plant that is widely grown in the tropical regions in Africa.
Other common names include: marijuana,hashish,njaga,ganja,kikoola,kipapi and dagga.

Commonly forms of use

Dry leaves are usually smoked alone or mixed with ordinary tobacco. The fresh leaves are boiled in water and taken with
tea. The same leaves can also be chewed or eaten fresh.
Features of its intoxication
A. Recent use of cannabis.
B. clinically significant maladaptive behavioural or psychological changes (e.g. impaired motor
coordination,euphoria,anxiety,sensation of slowed time,impaired judgement,social withdrawal) that developed during, or
shortly after, cannabis use.
C. Two or more of the following signs developing within two hours of cannabis use:
Conjunctiva injection, increased appetite, dry mouth, tachycardia.
Health effects
Mild sedation and stimulation.
Feeling of relaxation and well-being.
Sharpened sensory awareness.
A slowed sense of time.

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Increased appetite.
Delusions and hallucinations.
Increased heart rate and red eyes.
Chronic and heavy use can lead to lung diseases including cancers,immune suppression, a motivation syndrome and
interference with male reproductive functions.

CATHA EDULIS (KHAT)

This is a crop that is indigenous to Eastern Africa and Yemen. It is also known as Miraa,mairungi and khat. Once
taken,khat produces euphoria,suppresses appetite and hunger,and makes one alert.
Thus it is used for relaxation,to facilitate communication at social events and to suppress sleep and fatigue in work
situations.
Common forms of use
The leaves are chewed fresh, sometimes together with chewing gum or soft drinks. Other users combine khat with alcohol
and other substances of abuse.

Health effects
Khat produces dependence,tolerance and withdrawal symptoms.
Oral-dental complications,gastritis and constipation.
In men spermatorrhoea and erectile dysfunction.
Some individuals experience psychosis with prominent paranoia and hallucinations.
However khat a crop of significant economic value in many countries. It therefore remains a legal substance.
The clinical features of khat are similar to those of amphetamines, thus intoxication and withdrawal can be summarized
using information on amphetamines.
AMPHETAMINE INTOXICATION
A. recent use of amphetamine or a related substance (e.g. methylphenidate)
B. clinically significant maladaptive behavioural or psychological changes (e.g. euphoria or affective blunting;changes in
sociability; hyper vigilance;interpersonal sensitivity;anxiety;tension or anger,stereotyped behaviours,impaired judgement;
or impaired socialor occupational functioning) that developed during,or shortly after useof amphetamine or a related
substance.
Two or more of the following,developing during,or shortly after use of amphetamine or a related substance:
Tachycardia or bradycardia
Pupillary dilatation.
Elevated or lowered pressure
Perspiration or chills.
Nausea or vomiting.
Evidence of weight loss.
Psychomotor agitation or retardation.
Muscular weakness, respiratory depression,chestpain,or cardiac arrhythmias.
Confusion, seizures,dyskesias,dystonias,coma.
Amphetamine withdrawal
Dysphoric mood and two or more of the following physiological changes,developing within a few hours to several days
after cessation:
Fatigue,vivid unpleasant dreams,insomnia or hyper insomnia, increased appetite,psychomotor retardation or agitation

HEROIN(OPIATES)
Opium is a coagulated juice from the unripe capsule of a flowering plant called papaver somniferum.
Other common names for heroin include boy,white lady, brown sugar,junk and muggo. Morphine and codeine are key
medicinal products of the plant. From morphine,heroine can be illegally produced by a simple chemical process.
Common forms of use
Consumption is mainly through smoking of the drug mixed with either tobacco or marijuana,sniffed or snorted from foil
that is heated from underneath. Can be injected into the veins.

Opioid intoxication
A. recent use of an opioid.

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B. clinically significant maladaptive behavioral or psychological changes (e.g. initial euphoria followed by apathy,
dysphoria, psychomotor agitation or retardation, impaired judgement, or impaired social or occupational functioning) that
developed during or shortly after opioid use.
Pupillary constriction (or pupillary dilatation due to anoxia from severe overdose) and one or more of the following sign,
developing during, or shortly after, opioid use:
Drowsiness or coma.
Slurred speech.
Impairment of attention or memory.
Health effects
Development of dependence is high with the use of heroin
The user experiences an intense pleasurable feeling (‘rush or euphoria’)
There is a degree of analgesia and drowsiness
The eyes are red and the pupil constricted.
Others may experience nausea, cough suppression or depressed respiration.
In the long term, there is damage to the nasal septum, respiratory infections and constipation.

Opioid withdrawal
Three or more of the following developing within several minutes to several days after criteria A:
Dysphoric mood, nausea and vomiting, muscle aches, lacrimation or rhinorrhea, pupillary dilatation, piloercetion,or
sweating,diarrhea,yawning,fever,insomnia.

COCAINE
This is a white powder that is extracted from the leaves of the coca bush (erythroxylon coca)
Common street names include: snow,lady,bazooka,crude,flun and snow dust.
Coca is mainly grown in South America.

Common form of use

Use is mainly by snorting or smoking. It can be smoked either directly or mixed with tobacco and also injected SC or IV.
HEALTH EFFECTS
After taking cocaine the user experiences a feeling of physical and mental wellbeing.
There is increased alertness and energy.
Hunger is suppressed and there is significant reduction of fatigue with resultant malnutrition.
The pupils dilate with an increase in heart rate, body temperature and blood pressure.
With larger doses,hallucinations, talkativeness and hyper-excitability may ensue.
High doses can also lead to convulsions or stroke from cerebral hemorrhage.

Cocaine intoxication
A.Recent use of cocaine
B. clinically significant maladaptive behavioural or psychological changes (e.g. euphoria or affective blunting,changes in
sociability; hyper vigilance; interpersonal sensitivity; anxiety, tension,or anger,stereotyped behaviours,impaired
judgement or impaired social or occupational functioning) that developed during,or shortly after use of cocaine.
Two or more of the following,developing during,or shortly after,cocaine use:

Tachycardia or bradycardia.
Pupillary dilation.
Elevated or lowered blood pressure.
Perspirations or chills.
Nausea or vomiting.
Evidence of weight loss.
Psychomotor agitation or retardation.
Muscular weakness,respiratory depression,chestpain,or cardiac arrhythmias
Confusion,seizures, dyskinesia,dystonias or coma.

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Cocaine withdrawal
A.dysphoric mood and two or more of the following physiological changes, developing within a few hours to several days
after………
Fatigue, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, psychomotor retardation or agitation.

SOLVENTS
Also called inhalants, this group represents the many chemicals that are inhaled to get high. They include varnish, petrol,
glue, aerosols, nail polish remover and cleaning detergents.
Since many are domestic or industrial chemicals,they are easily obtained.
Abuse is by sniffing from a piece of cloth that is socked with the chemical. Others directly inhale the chemical from a
container or plastic bag.
Inhalant intoxication
A.recent use
B. clinically significant maladaptive behavioural or psychological changes (e.g. belligerence, assaultiveness, apathy,
impaired judgement, impaired social or occupational functioning) that developed during or shortly after use of or exposure
to volatile inhalants.
Two or more of the following signs developing during or shortly after inhalant use or exposure:
Dizziness, nystagmus, Inco-ordination, slurred speech, unsteady gait, lethargy, depressed reflexes, psychomotor
retardation, tremor, generalized muscle weakness, blurred vision or diplopia, stupor or coma, euphoria.

NICOTINE WITHDRAWAL
A. Daily use of nicotine for at least several weeks.
B. abrupt cessation of nicotine use, or reduction in the amount of nicotine used, followed within 24 hours by four or more
of the following signs:
Dysphoric or depressed mood, insomnia, irritability, frustration, or anger, anxiety,difficulty
concentrating,restlessness,decreased heartrate,increased appetite or weight gain

PRINCIPLES OF MANAGEMENT
Substance use or dependence is a treatable disease.
Management of substance related disorder aims at assisting individuals to attain reasonable state of function and involves
taking the patient through a multi-disciplinary programme.
The management process involves detoxification, rehabilitation, relapse prevention, after-care, social and vocational
rehabilitation.
Detoxification
This is the first stage in treatment and is the process of helping the individual to stop using the substance without
experiencing painful effects.
Detoxification, which usually lasts 3-7dayscan be medical or psychological and the setting maybe in or outpatient.
In medical detoxification, medication similar to what was being used by the client is given:
Alcohol-chlordiazepoxide:
Cannabis-Haloperidol
Cocaine-Ritalin
Heroine-Methadone
If the substitute medication is not available, symptomatic relief of the presenting symptoms in combination with
psychological support is recommended.
Psychological treatments target behavioural, social and psychological triggers that continued substance use. They are used
to motivate the client to stop using substances and to improve interpersonal functioning.
During such treatments, clients are taught life skills and how to deal with family problems and pressure from friends who
use substances. They are also taught relapse prevention techniques by increasing involvement in substance free
social,vocational and family activities. Clients are encouraged to make lifestyle changes and address problems resulting
from years of dependence.
Rehabilitation
This focusses on full recovery, which involves preparing the client for social re-intergration.it further involves helping the
client in skill development and job training. Where possible, employment opportunities are also extended to the client.

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Relapse prevention
This is a process of not starting substance use again through counseling. The process of relapse follows a predictable
pattern. Signs of impending relapse can be identified by the therapist and the patient. There are warning signs in behavior
and thinking that patients can be taught to monitor. They need to learn the indicators of stress and anxiety such as
insomnia, nervousness or headaches, and to view these as signals of possible relapse. Once the relapse indicators are
identified, a plan to intervene needs to be quickly enacted. Learning from previous relapse is critical. The relapse starts
with triggers. Triggers are people, places, objects, feelings and times which cause people cravings.
After care
The aftercare programme ensures the client follows up treatment and also serves to review the client’s status. This is
achieved through effective participation in self-help or support groups.

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