COMMUNITY PSYCHIATRY NURSING

MASALLA GILBERT

Description

This course introduces the learner to concepts in mental health/community health

nursing and the variety of commonly occurring psychiatric conditions throughout the
lifespan. Patient assessment with a mental health/psychiatric disorder using the nursing
process is taught along with relevant management modalities, requisite interpersonal skills
and attitudes necessary for the learner to act as a therapeutic agent. The module will enable
the student to develop competence in using the DSM IV-TR multi-axial diagnosis approach;
and in evaluating factors in the individual, family or community that hinder or promote
achievement of optimal mental health. Mental health promotion activities will also be
implemented. Psychiatric nursing interventions will be covered.

Aim
To equip learners with knowledge and skills for the identification and management of
mental health/ psychiatric disorders and the necessary mental health promotion strategies to
prevent or mitigate their impact.
Learning outcomes
On successful completion of this module the learners will:
1. Implement activities for promoting the mental health of individuals, family and
community across the lifespan.
2. Utilise the nursing process and DSM IV-TR multi-axial diagnosis in managing clients
with psychiatric/mental health problems in a variety of settings.
3. Prescribe a variety of treatment/management modalities to appropriately manage
individuals, families and communities with mental health/psychiatric needs.
4. Demonstrate requisite interpersonal skills, attitudes, self-awareness and therapeutic
use of self in engaging with clients across the lifespan.
5. Collaborate with the multidisciplinary team and multi-sectoral agencies in providing
care to individuals, family and community with mental health needs.

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Content
UNIT 1: Characteristics of mental health versus mental ill-health
UNIT 2: Assessment of a patient with psychiatric/mental health problems: History, Physical
Assessment (including laboratory findings), Mental status assessment, The DSM IV-TR
Multiaxial diagnosis
UNIT 3: Pathophysiological causations of psychiatric disorders : HIV and ARVs, Diabetes,
Hypertension, Hepatic disorders, Renal disorders, Endocrine disorders, TB and Anti-
tuberculosis medications, Febrile disorders, Malnutrition
UNIT 4: Patients with Anxiety Disorders: Types, Diagnostic criteria, Impacts on individual,
family and community, Stress and its impact, Nursing Management (including
psychopharmacology), Care in the community
UNIT 5: Patients with mood disorders : Depressive disorders, Diagnostic criteria, Impacts on
individual, family and community, Nursing Management (including psychopharmacology),
Care in the community, Bipolar disorders, Diagnostic criteria, Impacts on individual, family
and community, Nursing Management (including psychopharmacology), Care in the
community
UNIT 6: Patients with Psychotic disorders: Types of psychotic conditions, Diagnostic
criteria, Schizophrenia and its subtypes, Impacts on individual, family and community,
Management (including psychopharmacology), Care in the community
UNIT 7: Substance use disorders: Classification, Diagnostic criteria, Alcoholism, Cannabis
and other substances, Impacts on individual, family and community Management (including
psychopharmacology), Care in the community
UNIT 8: Psychiatric disorders common in children and adolescents :Elimination disorders
and their management, Learning disorders and their management, Eating disorders and their
management, Intellectual disability types and management, Attention-deficit hyperactivity
disorders and their management, Conduct disorders and their Management
UNIT 9: Personality Disorders: Types and diagnostic criteria, Impacts on individual, family
and community, Nursing management
UNIT 10: Therapeutic nursing Interventions: Counselling, Group therapy, community-based
therapy Management of aggression/violence

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Competencies
The learner will be able to:
 Gather information for arriving at a mental health/psychiatric diagnosis using the
DSM IV-TR and the nursing process
 Apply knowledge gained in assessing the mental health status of individuals across
the
lifespan for prevention, care and management across the lifespan
 Identify characteristics of mental health versus ill-health
 Design mental health promotion programmes/activities for individuals throughout the
lifespan
 Manage identified mental health/psychiatric disorders utilizing psycho pharmacologic
agents and other treatment modalities
 Conduct mental health promotion activities for individuals, families and communities
 Apply interpersonal nursing skills and attitudes when providing care to patients of all
ages
 Facilitate the creation of therapeutic environments for the care, management and
support
of persons with mental health/psychiatric nursing needs
 Develop appropriate care plans for meeting the individualized needs of
patients/families
under his/her care.
 Follow up on effectiveness of care rendered for patients both in hospital and in the
community.
 Conduct health education on specific conditions identified for individuals across the
lifespan.

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 UNIT ONE: INTRODUCTION TO MENTAL HEALTH NURSING
A. Definitions of concepts:
 Psychiatry is a branch of medicine that deals with the recognition, treatment and
prevention of mental abnormalities and disorders. It deals with illnesses that
predominantly affect the person’s mental life and behavior, that is, his feelings, his
thinking, behavior and social relationship.
 Psychiatric Nursing: is the branch of nursing concerned with the prevention and cure
of mental disorders and their sequel. It employs theories of human behavior as its
scientific frameworks and requires the use of self as its art or expression in nursing
practice.
 Community Psychiatry: Community psychiatry means providing community mental
health services to persons and their families with mental illness within the community
using community resources. The community settings may be any religious place, the
persons own house or any other place in community. Here psychiatry focuses on
detection, prevention, early treatment, and rehabilitation of emotional and behavioral
disorders as they develop in a community.
 Mental Health
It is difficult to define the idea of mental health without reference to society. It could
be said that a person is healthy if he/she manages to deal with the demands made upon
him/her by society in a way that is compatible with his/her idea both of society and of
him/herself. He/she is ill to the degree that has failed in his/her adjustment to the demands
either of society or his definition of him/herself. This definition is not entirely satisfactory.
There are those who deviate from the norms of society who are not mentally ill and the
definition gives rise to the impression that psychiatrists and psychiatric nurses are committed
to maintain the status and preventing social change.
We can therefore say that mental health is the balanced development of the individual’s
personality and emotional attitudes, which enable him to live harmoniously with his fellow -
men. Mental can also be defined as the capacity for an individual to form harmonious
relations with others, and to participate in, or contribute constructively to changes in his
social and physical environment.
 Mental illness
The definition of mental illness remains elusive and is usually based up on what
constitutes socially accepted behavior norms. For example, behavior that is normal in one

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culture may be considered abnormal in another culture. Major criteria for the diagnosis of
mental illness include:
 Bizarre behavior
 Abnormal experience
 Loss of reality contact
 Lack of insight
Therefore, mental illness is a psychological or behavioral manifestation of impairment
in brain function characterized by inaccurate perception of reality, disordered thinking, social
dysfunction and the inability to cope in the society.
B. CHARACTERISTICS OF MENTAL HEALTH VERSUS MENTAL
ILLHEALTH
a. Comparative characteristics of a mentally healthy and a mentally ill person

No Mental Health Mental Illness

1 Accepts self and others Feelings of inadequacy and Poor self-
concept
2 Ability to cope or tolerate stress. Can return Inability to cope and Maladaptive behavior
to normal functioning if temporarily
disturbed
3 Ability to form close and lasting Inability to establish a meaningful
relationships relationship
4 Uses sound judgment to make decisions Displays poor judgment
5 Accepts responsibility for actions Irresponsibility or inability to accept
responsibility for actions
6 Optimistic Pessimistic
7 Recognizes limitations (abilities and Does not recognize limitations (abilities and
deficiencies) deficiencies)
8 Can function effectively and Independently Exhibits dependency needs because of
feelings of inadequacy
9 Able to perceive imagined circumstances Inability to perceive reality
from reality
10 Able to develop potential and talents to Does not recognize potential and talents due
fullest extent to a poor self-concept
11 Able to solve problems Avoids problems rather than handling
them or attempting to solve them
12 Can delay immediate gratification Desires or demands immediate gratification
13 Mental health reflects a person’s approach Mental illness reflects a person’s inability to
to life by communicating emotions, giving cope with stress, resulting in disruption,
and receiving. Working alone as well as disorganization, inappropriate reactions,
with other, accepting authority, displaying a unacceptable behavior and the inability to
sense of humor, and coping successfully respond according to his expectations and
with emotional conflict. the demands of society.

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 People who are mentally healthy do not necessarily possess all the characteristics of
mental health listed above. Under stress, they may exhibit some of the traits of mental illness
but are able to respond to the stress with automatic, unconscious behavior that serves to
satisfy their basic needs in a socially acceptable way.
b. ETIOLOGIC FACTORS OF MENTAL ILLNESS
There is no known single causative agent for mental illnesses. Mental illnesses
are caused by one or more of the following factors:
1. Genetic factors such as abnormalities in chromosomes may cause mental illness.
Children from mentally ill parents are more likely to develop mental illnesses than
children of healthy parents.
2. Organic factors like cerebrovascular diseases, nervous system diseases, endocrine
diseases and chronic illnesses such as epilepsy are associated with mental illnesses.
3. Social and environmental crises like poverty, tension, emotional stress, occupational
and financial difficulties, unhappy marriage, broken homes, abuse and neglect,
population mobility, frustration, changes in life due to environmental factors like
earthquakes, flood and epidemics are associated with mental illness.
Environmental factors other than the psychosocial ones capable of
producing abnormal human behavior include toxic substances such as carbon
disulfide and monoxide, mercury, manganese, tin, lead compounds, etc.
4. Psychological factors like early childhood experiences of abuse and other
psychological trauma during childhood play an important role in the development of
mental illness in adult life.
5. Behavioral factors like indulging in drugs, alcohol and substances like khat are
associated with mental illness.
6. Other factors associated with mental illness include nutritional deficiency; infections
before and after delivery and birth trauma; road, occupational and other accidents; and
radiation accidents. The nervous system is most sensitive to radiation during the
period of neural development.
c. Clinical features of mental illnesses or common psychiatry signs and symptoms
Mental illnesses have diverse signs and symptoms, which are grouped or clustered
together to become a specific diagnosis. These groups of symptoms and signs should be
persistent and intense to indicate mental illness. Examples of some clinical disorders are
discussed below.

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 I. Disorders of perception: Perception is being aware of what is happening within the
internal and external environment. The most distinctive phenomena in mental
illnesses are disorders of perception. They are:
 Illusion: Misinterpretation of real external sensory stimuli or wrong interpretation of
external environment. E.g. the client may interpret the rustle of leaves around outside
his/her window as noise of people coming to attack him/her. A person looks at a
cracked wall and sees branched tree.
 Hallucination: False sensory perception not associated with real external stimuli.
This may affect any of the five senses E.g. A person sees spiders and snakes on the
ceiling of his or her room where there are none.
 Auditory hallucination: Here the client hears voices sometime unidentifiable and
lacking in clarity. Often they could be voices of people of people known to him
altering single ward or complete phrases. They may be accusation, give command,
altered suggestion, threaten punishment or just give reassurance.
 Visual hallucination: here the client sees vision usually of clearly define people
or object. The accompanying emotion may vary from joy to terror.
 Olfactory and gustatory: these affect the senses of smell and taste respectively
and are often found together in one client. The smell is rarely a pleasant one and is
commonly described as horrible linked to bodily excretions, disease or decay. In
the gustatory the client complains that his food have a particular smell linked to
poison
 Tactile hallucination: these false perceptions may be felt at any part of the body
surface and at time bizarre sensation may be felt in internal organs. These
commonly affect the sexual region e.g the female client complains of feeling in
her genital track which indicates that sexual approaches has been made on her
during her sleep.
II. Disorder of thinking
Delusion: Patients may have fixed false beliefs that cannot be corrected by reassuring
and are not ordinarily accepted by other members of the particular person’s culture.
E.g. A person believes that an external force controls him, a spaceman sends him
message by radio. The patients may also have exaggerated self-importance.
Type of delusions
 Persecutory delusion: these are belief held by the client that certain
happening indicate the existence of some types of plot against him

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  Delusion of guilt: Beliefs without evidence that he/she has committed such
wickedness in his/her pass life. He may think of having committing the
unpardonable sin without saying precisely what is involved.
 Nihilistic delusion or delusion of nothingness: This may be an idea held by
the client that the whole world has been destroyed or he may be convinced that
a similar faith has befallen one of his relatives. He may state that certain part
of his body or brain or heart had ceased to function.
 Delusion of grandeur: feeling big. These are firmly held ideas of great,
power, wealth and influence. The client may belief that he is a king; a person
believes he is the Prime Minister of the country when he or she is not.
 Delusion of infidelity: a false belief that one lover or spouse is unfaithful
III. Disorders of emotion: This involves a sustained abnormal feeling tone experienced
by patient. Such patients may have low mood, anger, anxiety or excessive happiness
without any reason. Normal emotion varies from cheerfulness to mild sadness. E.g. A
person laughs at a sad event like death of a loved one. A depressed person might feel
that life isn’t worth living.
 Depression: this is a state of severe sadness which persists and interferes with the
person daily routine and adjustment to life. It is often accompanied by feelings of
anger, guilt, hopelessness and helplessness. Suicide is quite obvious in the
presence of such feelings.
 Elation: this is an elevation of mood above the normal range. The client is
abnormally cheerful and optimistic. He over estimates his own capacities without
any realistic view of his/her situation.
 Euphoria: simply an increase sense of person wellbeing, confident and
enthusiasm.
 Apathy or inadequate affect: this is emotional dullness with detachment and
insensitivity to stimuli in the environment. The flatness of mood which is more
severe and long lasting. The client shows no emotional respond to any life
experience and his emotional flatness may be reflected in his facial expression,
that is, he neither smiles nor frowns nor does he shows any other facial expression
of emotion no matter what happens around him/her.
 Labiality or inappropriate affect: this is a rapid and wide fluctuation of feelings.
He may act happy when he should be sad and sad when he should be happy.

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  Hostility: is a feeling of persistence anger arising from insignificant stimulus. The
client may try to hide his rage but his mood is demonstrated through the look in
his eyes, tone of voice or clenched fist.
IV. Disorders of motor activity: These are abnormalities of social behavior, facial
expressions and posturing. E.g. standing on one leg for a long time.
 Mannerism: repeated movement of a habitual kind, eg gestures of the hand or
certain way of raising the eyebrows
 Catatonia: abnormal posture of the body which normally results from diseases of
the CNS or bone or joints or nerves. It is characterized by immobility or rigidity or
inflexibility.
 Compulsion: insistent repetitive and unwanted urge to perform an act that is
contrary to one’s usual wishes, eg the client feels the need to repeat a certain kind
of behavior such as hand washing for the fear of impending illness, or getting out
of the bed to check on the front door.
 Echolalia and Ecopraxia: Echolalia is the senseless involuntary repetition of a
word or sentence just spoken by another person while Ecopraxia is the senseless
imitation of an action or emotion made by another person.
V. Disorders of memory: This is the inability to retain and recall information (distortion
of recall). E.g. A person suddenly and unexpectedly leaves home and is unable to
return. A person may find it difficult to remember what he or she had for breakfast
after few hours.
 Amnesia: loss of memory which could be of several types. In the old there is
gradual but inability to recall pass event and knowledge (senile dementia). Here
recent memory is lost earlier than pass memory. It may be unable to recall the
previous day event yet he can discuss vividly the event during his childhood.
 Disorientation: the inability to correctly identify self in relation to time, place or
person.
 Confusion: a mental state of perplexity resulting from disorientation. E.g a client
is brought to the hospital and he/she does not know the person who brought her
nor her where about.
VI. Disorders of consciousness: This is the impaired awareness of self and the
environment. The level of consciousness can vary between the extremes of alertness
and coma.

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VII. Disorders of attention and concentration: This is the inability to focus on the
matter at hand and failure to maintain that focus.
VIII. Insight: This is defined as awareness of one’s mental condition. Patients who do not
have insight do not know that they are sick and thus fail to seek medical attention.
People who are mentally healthy may exhibit some of the traits of mental illness when
they are under stress and show adaptive behavior that serves to satisfy their basic
needs in a socially acceptable way
d. Some key terms associated with psychiatric nursing
- Anxiety: A state of feeling uncertainty experienced in response to an object or
situation.
- Stress: A state of extreme difficulty, pressure or strain with negative effects on
physical and emotional health and well-being.
- Withdrawal: A state of habitual quiet and seeming unconcerned with other
people a focus on one’s own thoughts.
- Suicide: The act of killing oneself (self-distracting behavior)
- Neurosis: A condition in which mal adaptive behaviors serves as a protection
against a source of unconscious anxiety.
- Personality disorder: A non-psychotic illness characterized by maladaptive
behavior that the person uses to fulfill his or her needs and bring satisfaction to
him or herself. As a result of the inability to relate to the environment, the
person’s actions conflicts socially.
- Hysteria (conversion disorder): The loss or impairment of some motor or
sensory function for which there is no organic cause. It was formerly known as
hysteria or hysterical neurosis.
- Mental retardation: A disorder characterized by sub average intellectual
functioning associated with or resulting in, the inability or impairment of the
ability to think abstractly, adapt to new situations, learn new information, solve
problem, or profit from experience.
- Dementia: A defused brain dysfunction characterized by a gradual, progressive,
and chronic deterioration of intellectual function. Judgment, orientation, memory,
affect or emotional stability, cognition, and attention all are affected.
- Trauma: A severe physical injury to the body from an external source; or a severe
psychological shock.

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 - Alcohol dependent: A person who cannot break the habit of drinking alcoholic
drinks too much, especially one whose health is damaged because of excessive
alcohol intake.
- Schizophrenia: A serious mental disorder characterized by impaired
communication with loss of contact with reality and deterioration from a previous
level of functioning in work, social relationships, or self-care.
- Paranoid disorder: A psychotic state characterized by moderately, or serious
impaired reality testing, affect and sociability, accompanied by persecutory,
grandiose, erotic or jealous content delusions.
- Manic-depression: A mood disorder involving both mania and depressive
episode.
- Anhedonia: Inability to experience pleasure especially one that was once
enjoyable
- Alogia: Poverty of thought
- Avolition: Lack of motivation
e. Diagnosis of psychiatric disorders
Psychiatry deals with causes and treatment of mental illness and the care to be given to such
patients, who are considered abnormal in their behavior. In general, the symptoms are too
vast and complex to reach a correct diagnosis of the illness, which it needs to comprise
different approaches and models. Within the scope of this course, the best approach to the
diagnosis of mental illness is to use the skills of:
 Detailed history taking
 Mental status examination.
f. Some Treatment modalities in mental illnesses
 Psychotherapy: This is defined as any treatment done to influence behavior by
verbal or non-verbal communication which includes reassurance and
brainwashing.
 Management therapy: This includes occupational, educational, art, music and
recreational activities. All these can improve mental illness.
 Drug treatment: Different types of drugs such as antidepressants, antianxiety
agents, antipsychotics and anticonvulsants are used to treat mental illnesses. Since
drugs are given for a long period of time, patients need to be followed for drug
side effects and compliance.

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  Physical treatment
- Electro-convulsive therapy: This is done by applying electric shock waves
to the temporal area and behind the ears. This may improve the mental
condition. However it is done only in hospitals.
- Surgery: Surgery on the brain may also be done to treat cases that are the
most serious. The surgery is done in hospitals. Now it is rarely done and most
of the modalities of treatment are replaced by drug treatment.
In cases of psychiatric emergencies, the attitude the caregivers towards the patient
should be calm, quiet and confident. Patient should never be lied to about what he has or
where his being taken to. If patients are violent, there should be a place for physical restraint
to avoid risk of injury to him/her and others.
g. Prevention of Mental illnesses
Three levels of prevention have been described: Primary, secondary and tertiary
preventions.
1. Primary prevention
This is prevention or the control of preventable causes: There are limitations to the
knowledge of the causes of mental illnesses. However, there are certain known risk factors
associated with mental illness. Hence, prevention of mental illness involves control of those
risk factors including:
 Prevention and control of environmental hazards and other causative factors such as:
 Prevention of poisoning and drug intoxications E.g. Lead, arsenic
 Prevention of nutritional deficiency E.g.: Iodine, vitamin B deficiency.
 Brain injuries E.g.: Trauma as a result of road traffic accidents.
 Control of early childhood and neonatal infections. E.g.: Meningitis
 Legal and social enforcement against drug abuse
 Control of environmental pollution: E.g.: Pollution by mercury
 Prevention/control of pregnancy related risk factors like:
 Infections and Rh incompatibility
 Counseling for known genetic risk factors
 Early referral of mothers with abnormal labor
 There are certain relationships between human development and mental illness -
prenatal period, first 5 years of life, school age and adolescence are the most
important developmental periods. Therefore, greater effort should be made to

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 establish harmonious family relations to prevent the occurrence of mental illness in
the later life of the child.
 Health education about
 Environmental hazards
 Antenatal care
 Misconceptions about mentally ill patients.
 Persons subject to stress such as prospective parents, migrants, adolescents and the
population in disaster stricken areas have to be supported to improve their
interpersonal relationships.
2. Secondary prevention
This is early diagnosis and treatment of a patient with mental illness
 Referral of a mentally ill patient to a health institution for diagnosis and treatment in
the early stage so that the progress of illness will be halted or its duration shortened.
3. Tertiary prevention
This aims to reduce chronic disabilities from mental illnesses by
 Provision of social support
 Creation of sheltered workshops and supervised residential care outside a health
institution.

C. HISTORY AND TRENDS OF PSYCHIATRIC NURSING

Mental illness began in the primitive age as human existence began and there is evidence that
it existed at that time and attempts were made to treat it. It was thought to be caused by evil
spirits entering and take over the body. People attempted to drive these evil spirits from the
body through the use of incantations and magic. Some primitive tribes rejected their mentally
ill and drove them from the community.
- In the ancient civilization, Greeks, Romans and Arabs viewed mental deviations as
natural phenomena and treated the mentally ill humanely. Care consisted of sedation
with opium, music, good physical hygiene, nutrition and activity.
- The Greek philosopher Plato (429-348 BC) and the Greek physician Hypocrites (460-
377 BC, known as the father of medicine), were concerned about the treatment of the
mentally ill. Hypocrites described a variety of personalities and attempted to classify
people according to their behavior.

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 - During the renaissance (14th- 17th Century), the belief that mental illness was caused
by evil spirit possessing the body continued to be a problem to proper care of
mentally ill people. Mentally ill were often put in prison or society protected itself by
locking the mentally ill in asylums where non-professional people were paid to care
for them. Mental illness was considered irreversible. The mentally ill were beaten for
disobedience and confined to cages or closets. Generally, mental patients were viewed
as incompetent, defective, and potentially dangerous. They had no rights and were left
in social isolation to communicate primarily with other mentally ill patients. Their
care-takers were untrained and often punitive. As a result, the mentally ill tend to
become more ill and less able to function.
- Bethlehem Royal Hospital, the first mental hospital in England, was opened during
the 17th Century. In this hospital, the public was allowed to wonder through the
hospital and see their patients, and nurses lacked any interest in improving the care of
mentally ill.
- The first hospital in America to admit mental patients was the Pennsylvania Hospital
located in Philadelphia.
- The first American textbook on psychiatry was written, during this period by
Benjamin Rush (1745-1813), a physician who used a humanistic approach in the
treatment of mental illness. He is considered by many today to be the father of
American psychiatry.
- The first psychiatric training school in United States was established in 1882 at
McLean Hospital in Belmont, Massachusetts. Participation in psychiatric nursing
course becomes a requirement for a nursing license in the USA in 1955.
- In the 20th Century an Austrian neurologist, Sigmund Freud made a significant
contribution to the understanding and treatment of mental illness. His belief in the
power of unconscious memories and repressed emotions led him to develop the theory
and practice of psychoanalysis. Because of his work, he is called the founder of
psychoanalysis. He studied the dreams, memories, and fantasies of his patients in
search for unconscious impulses and conflicts. He identified three major divisions of
the self or mind: the Id, superego, and ego. He also presented a theory of
psychosexual personality development.

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Some Misconceptions towards mental illness
 Patients in mental hospitals are often considered as people who spend their time doing
useless things and showing bizarre behavior.
 People who have had a mental illness are viewed with suspicion and as dangerous
persons.
 Mental illness is something to be ashamed of.
 Mental illness is caused by evil spirits (black magic).
 Mental illness is something that cannot be cured and is contagious.
 Mental hospitals are places where only dangerous, mentally ill people are treated.
 Marriage can cure mental illness.

D. COMMUNITY PSYCHIATRY
Community psychiatry means providing community mental health services to the
persons and families with mental illness within the community using community resources.
The community settings may be any religious place, that is the persons own house or any
other place in community. This psychiatry focuses on the detection, prevention, early
treatment, and rehabilitation of emotional and behavioral disorders as they develop in a
community. Community psychiatry goes “beyond the hospital-based care and treatment” to
manage people with mental disorder.

History of Community Psychiatry (in USA)

In the U.S. from the late 18th Century to the present, approaches to the treatment of
the mentally ill evolved from asylums to custodial care to community based services.
Era of moral treatment: The era of so called moral treatment of the mentally ill lasted from
the American Revolution until mid-19th century, bolstered by such people as Benjamin Rush.
The Asylum was considered to be the cornerstone for the moral treatment of patients, freeing
sufferers from shackles and barbaric physical treatments. The influence of Phileppe Pinel, in
France and William Tuke, in Great Britain began the era of moral treatment in Europe. The
formation of Association of Medical Superintendents in 1844 heralded the transition from the
era of moral treatment to the custodial era of psychiatric care.
Custodial era: The rise of the public hospital system in America continued throughout the
later half of 19th Century. At the same time there were early examples of alternatives to the

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large mental asylums, such as Farm of St. Anne described by John Galt in 1855. In 1877 the
Illinois
State Hospital Developed a cottage plans and in 1885 a community boarding home for mental
patients was started in Massachusetts. In early 20th Century (1908-1910) Clifford Beers
along with William Jones and Adolph Meyer furthered the mental hygiene movement and led
in 1909 to the National Committee for Mental Hygiene in New York.
De-instutionalization: Federal legislation was important to the movement towards
deinstitutionalization. The U.S. Public Health Service has formed the Division of Mental
Hygiene in 1930s.The National Mental Health Act 9 of 1946 changed this division to the
National Institute for Mental Health (NIMH). The NIMH was pivotal in funding essential
health research for the developing the mental health field.
Therapeutic community: Between World War II and the present era of community
psychiatry, social science researchers have been working on many relevant issues. Maxwell
Jones advocated a new concept of therapeutic community. Though essentially it was a British
experiment, it was widely accepted in the U.S. Before the advent of the concept of
therapeutic community, the dominant forms of psychiatric care were isolation and quarantine.
The essential features of the therapeutic community concept were patient's participation in
decision making, collective responsibility for ward events, a multi-disciplinary staff and a
belief in the rehabilitative potential of the environment. The movement was essentially
psychodynamic and antiauthoritarian.

Community Mental Health Services Act:

In 1963, the Community Mental Health Services Act was passed by U.S. Congress. It called
for the construction of Mental Health Centres in different geographic catchment areas. These
centres provide inpatient care, outpatient care, partial hospitalization, emergency care,
consultation, education services; follow up care and transitional housing.
The current community psychiatric era: From 1963, when the legislation was passed to the
present, the number of Community Health Centres has grown to about 800 serving 54% of
U.S. Population. Thus all indications for the immediate future point to a continuation, and
perhaps intensification, of the pace in the evolution of community residential care for the
mentally ill. With the development in community psychiatry movement, naturally, different
types of community residences have come up. These are:
 Group home
 Personal Care Home.

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  Foster home
 Natural Family Placement.
 Satellite Housing and
 Independent Living.
The objectives of the community mental health program are:
 To ensure availability and accessibility of minimum mental health care for all
 To encourage application of mental health knowledge in general health care and
 To promote community participation in the mental health services development and to
stimulate efforts towards self-help in community.
Principles of Community Psychiatry: “Community psychiatry comprises the principles and
practices needed to provide mental health services for a local population by
 Establishing population-based needs for treatment and care;
 Providing a service system linking a wide range of resources of adequate capacity,
operating in accessible locations and
 Delivering evidence based treatments to people with mental disorders
These ‘principles’ of community psychiatry, proposed by Caplan have also proved
useful and valid to varying degree in defining the subject. These principles include:
 Responsibility to a population, usually a catchment area defined geographically
 Treatment close to the patient’s home
 Multi-disciplinary team approach
 Continuity of care
 Client participation
 Comprehensive services
Features of Community Psychiatry:
The purpose of community mental health model is to provide all mental health and
well-being needs of the community within the community, using community resources and
the primary health-care system. It goes “beyond the hospital-based care and treatment” and
includes:
 Programs for mental health promotion, prevention, and treatment of mental disorders.
 Inclusion of psychosocial support available in the community (religious groups, self-
help groups, faith healers, local bodies, etc.)
 Rehabilitation plans for persons with significant disability due to intellectual disability
and recovering substance abusers and chronically mentally ill patients

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  Prevention of harm from alcohol and substance use
 Developing linkages with primary health-care system and tertiary care hospitals.
 Plans for stigma removal
 Protection of the human rights of mentally ill persons.
 To enhance the status of mental health within public health.
For effective implementations of these services, there is a need of paradigm shift from
exclusion to inclusion. The community services should give preference to the
biopsychosocial approach rather than the biomedical model, thus taking psychiatric care from
the hospital bed to a family setting, from hospital to community, from short-term to long-term
care, that is, rehabilitation, from individual work to teamwork, thus finally bridging the
(WHO, 2006) span from treatment to service.
For the purpose to assess the effectiveness of a program, regular monitoring and
review of community mental health services should be inbuilt component of the services
from the time of inception. Although each service can design its own monitoring mechanism,
the following impact indicators can be used to assess the impact of the services in meeting the
mental health needs of the community
 Knowledge and awareness about the mental health delivery services in the community
 Acceptability of services
 Reduction in the treatment gap
 Reduction of stigma
 Patient satisfaction with treatment and continuity of treatment
 Reduction of violence in the community and schools due to mental health issues.
Various Hurdles in Providing Community Mental Health Services:
In spite of having community outreach services in various cities and states, still
people do not prefer to visit these centers. Here could be various reasons for not seeking help
from these centers. It could be:
 Inadequate participation of community
 Lack of integration of mental health into general health care
 Lack of ideal model of mental health delivery
 Weak link between mental health and social development
 Non availability of services in certain areas
 No regular monitoring and evaluation.

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Community Mental Health Models:
1. Integration of mental health into primary health care:
There are various reasons for integrating mental health into primary health care:
 Mental disorders create a substantial personal burden for affected individuals and
their families and cause significant economic and social hardships that affect society
as a whole. Hence, mental and physical health problems are interwoven and can be
taken at same time
 Many people suffer from both physical and mental disorders. Integrating primary care
services ensure that people are treated in a holistic manner, meeting the mental health
needs of people with physical disorders, as well as the physical health needs of people
with mental disorders
 When mental health is integrated into primary care, people can access mental health
services closer to their homes, thus keeping their families together and maintaining
their daily activities
 Primary care for mental health also facilitates community outreach services and
mental health promotion through IEC, as well as long-term monitoring and
management of affected individuals
 Mental health services delivered in primary care setting minimize stigma and
discrimination. It also removes the risk of human rights violations that can occur in
psychiatric hospitals.
 Primary care for mental health issues is affordable and cost effective. Primary care
services for mental health are less expensive than psychiatric hospitals. In addition,
patients and families avoid indirect costs of travelling to city-based hospital,
registration, etc.
 The treatment outcome is likely to be better in patients treated at primary care setting,
particularly when linked to a network of services at secondary level and in the
community.
2. Satellite clinics (or community outreach clinics):
 Need of community outreach clinics
 Team composition
 Location, timing, and frequency
 Scope of services
 Community de-addiction camps

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  Home-based detoxification
 Para institutional care (half-way homes and daycare centers)
 School mental health

UNIT TWO: ASSESSMENT OF PATIENTS WITH PSYCHIATRIC

DISORDERS/MENTAL HEALTH PROBLEMS
A. PSYCHIATRIC ASSESSMENT TECHNIQUES
The student may experience difficulties in his/her first contact with psychiatric
patients. Some of these difficulties arise from the nature of psychiatric symptoms and signs
disorders of emotion of thinking or of intelligence, which are less easy to elicit and describe
than physical signs and symptoms. The interviewer has to overcome his/her anxiety and
preconceptions about the mentally ill. The range of information that is sought about the
patient and his illness is much wider than for other clinical disciplines and requires tact, time
and patience to elicit scheme of case taking. This information may include: The history-of the
present illness, a physical examination, Psychiatric examination, further investigations,
Formulation of the case.
Specific to the psychiatric evaluation is the mental status examination. A well trained
health worker should take a detailed psychiatric history and gather data with confidentiality,
carry out the mental status examination, develop a differential diagnosis and devise a
treatment plan.
1. History of present illness; Record briefly mode of referral/admission reason for
referral
and patients complaints (in his own words) and their duration.
2. Social history; Record briefly aspects of the patient’s family history such as: Father,
Mother, Siblings, Social position, Home atmosphere and influence. Record also the
patient’s personal history, including details of their experiences relating to: -Date and
place of birth - Early development - Neurotic symptoms in childhood - School -
Adolescence - Occupations - Sexual history - Marriage - Children - Habits – Medical
history -Previous mental illness - Antisocial behavior - Current life situation.
Record any information available about personality before illness (pre morbid
personality): -Social relations - Activities and interests- Mood - Character - Standards,
moral, religious, social, economic etc. - Energy and initiative - Reaction to stress.
3. Physical examination; the physical examination should be comprehensive and
should be

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 carried out within a day of admission. Special attention should be given to the central
nervous system. Positive and negative findings should be recorded and a brief
summary of abnormalities found should be given.
4. Psychiatric examination (mental status examination);
Record the following aspects of the psychiatric patient’s state
 General behavior and appearance – development, nourishment, grooming
 Behavior since admission - agitation, level of activity, gait
 Attitude towards hospital staff – hostile, co-operative, guarded
 Talk (form of talk), much or little, spontaneous, answers to questions etc. –
Speech-rate, volume, tone and mode, relevance, coherence
 Mood - Form of thought; Does the patient experience blocking, pressure or
poverty in thinking?
 Content of thought - Delusions and misinterpretations – Hallucinations -
Obsessional phenomena
 Cognition - measures ability of the brain to function: Orientation to time place and
persons. – Memory.
5. Further investigations; further investigations may be indicated, including: - Physical
investigations as indicated - Psychological testing - Psychiatric social worker's report.
6. Formulation of the case; Discuss a range of potential diagnosis, giving evidence for
and against the various possibilities. Make and record a provisional diagnosis, an
estimate of prognosis, a problem list, and plans for further investigation and
treatment.
B. DSM IV-TR: Multi-axial Diagnostic Approach
Diagnosis is a conclusion that the expert made about the clients problems and
complaints and it is used to plan care for the client. It reveals two meanings:
 To distinguish: process of sorting out various categories of illness and weighing
information for and against such categories to identify patients’ disorder.
 To know thoroughly: process of obtaining comprehensive characterization of
individual’s condition (multi-axial model).
Taxonomy is the practice and science of classification and it is used to organize and
categorize the data into appropriate, care guiding diagnosis.
Medical Diagnosis is a medical term that summarizes the symptoms and clinical
manifestations of illness. Medical psychiatric diagnosis is made by the psychiatrist

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 or clinical psychologist. For instance, schizophrenia and major depression are medical
diagnosis.
In psychiatric, classification has two components:
 Taxonomy: establishing diagnostic groupings.
 Diagnosis: applying those groupings to individual cases.
Taxonomy for writing the diagnosis
 Taxonomy for diagnosis is useful for mental health practitioners (MHP) to make
accurate diagnosis in their clinical practice.
 It provides a listing of standardized labels representing health problems and responses
to illness and helps build a scientific foundation for the mental health profession.
Classification of Mental Disorders
The first multi-axial thinking was Hippocratic approach before the DSMs were
developed. He intensified six conditions:
 Phrenitis acute mental disorders with fever.
 Mania acute mental disorders without fever.
 Melancholia (all winds of chronic mental disorders)
 Epilepsy.
 Scythian disease= transvestitism.
Essen and Wohlfahrt proposed the first formal multi-axial system in 1947 and there
are more than 15 multi-axial diagnostic systems.

C. The DSM-IV-TR = Diagnostic and statistical manual of mental Disorders. Text

revision-Fourth edition
This taxonomy is universally used by psychiatrists and some therapists in the
diagnosis of psychiatric illnesses. The DSM-IV-TR classifies mental disorders into
categories. It describes each disorder and provides diagnostic criteria to distinguish one from
another. It was first published in 1952 by American Psychiatric Association (DSM-I) and
revised 1965 (DSM-II), 1980 (DSM-III), and 1994 published (DSM IV) and revised in 2000
(DSM-IV-TR).
The DSM-IV-TR used multi-axial system as follows:
 Axis I: Clinical disorders and other conditions that could be a focus of clinical
disorders.
 Axis II: Personality disorders & mental retardation.
 Axis III: General medical conditions.

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  Axis IV: Psychosocial and environmental problems.
 Axis V: Global assessment of functioning (GAF) within the last six months.

Common Disorders in the mental health field

 Childhood and adolescence  Psychotic disorders
disorders  Schizophrenic disorders.
 Mental handicap (disability,  Paranoid disorders.
retardation)  Affective disorders or mood
 Anxiety disorders. disorders.
 Conduct disorder.  Anxiety disorders/neurotic
 Sleep walking terror. disorders
 Infantile autism.  Anxiety state
 Physical disorders (stuttering,  Phobias or Panic attack/disorder
enuresis).  Obsessive-compulsive disorder
 Adjustment disorders.  Post-traumatic stress disorder.
 Pervasive developmental disorder.
Nursing Diagnosis related to care plan, example: schizophrenia
 Non-compliance related to refusal to take prescribed psychotropic medication.
 Disturbed sleep pattern related to the presence auditory hallucination.
 Ineffective coping related to fear
 Disturbed thought process related to the presence of persecutory delusion.
 Disturbed sensory perception related to the presence of visual hallucination.
 Self-care deficit related to poor personal hygiene.
 Impaired verbal communication related to thought disturbance.

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 UNIT THREE: ANXIETY DISORDERS

Anxiety disorder is characterized by at least six months duration of anxiety in the

absence of panic attacks, disorders, depression or other psychiatric disorders. According to
DSM III- R classification, there are three major categories of symptoms.
- Motor tension, such as muscle aches, inability to relax, fidgeting, restlessness and
being easily startled.
- Autonomic hyperactivity, including cold and clammy hands, dry mouth, dizziness,
frequent urination, flushing, increased pulse rate while resting, and upset stomach.
- Vigilance and scanning, a state in which the person is hyperactive, easily distracted,
has difficulty concentrating, experiences insomnia and is irritable or impatient.
The individual exhibits unrealistic or excessive anxiety and worry about two or more
life circumstances during a six-month period and may be mildly depressed. Symptoms rarely
interfere with social or occupational functioning. Below are listed sub classifications of
general anxiety disorders: Sub types of anxiety disorders
 Anxiety  Neurotic depression
 Phobia  Post-Traumatic Stress Disorder
 Conversion disorder (PTSD)
 Obsessive compulsive disorder (OCD)  Substance-Induced Anxiety Disorder
 Hypochondriasis

A. ANXIETY
Anxiety is a feeling of apprehension, uneasiness, uncertainty, or dread resulting from
a real or perceived threat. Anxiety is a common neurotic disorder with various combinations
of physical and psychological manifestations not attributable to any real damage “free
floating anxiety”. There are two types of anxiety: Normal anxiety and Pathological anxiety,
which can be subdivided in to two sub categories: - panic anxiety - diffusive anxiety. Panic
(acute) anxiety is an episodic anxiety, which lasts for short period of time. Diffusive (chronic
or generalized) anxiety is characterized by marked apprehension, persisting or long lasting
time
Forms of Anxiety
 Mild: Individual perceives reality in sharp focus. Symptoms presented is slight
discomfort and uses mild tension relieving behaviors.

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  Moderate: Individual Sees, hears and grasps less information. Symptoms includes
tension, heart pounding, increased pulse and respiratory rate
 Severe: Individual Perceptual field reduced, he focuses on one detail. Symptoms
includes dazed, headache, nausea, dizziness and insomnia
 Panic: Individual is unable to process reality and may lose touch. Symptoms includes
running, screaming, shouting, hallucinations and erratic behavior
Risk factors for anxiety include:
i. Constitutional: - genetic (it can be inherited genetically) – Increased chances if a first-
degree relative has an anxiety disorder
ii. Developmental: If the developmental process is full of anxiety, provoking conditions
e.g. war, famine, home disturbance etc.
iii. Physiological: - endocrine e.g. thyrotoxicosis - head injury (traumatic neurosis).
iv. Psychological: - stress - interpersonal conflict. Traumatic Experiences like death of
loved ones, illness diagnoses, divorce, military/combat experiences, abuse, natural
disasters, prison, terrorism
Clinical Features of Anxiety
 Palpitation  Flushing of the  Faintness
 Exhaustion face  Insomnia
 Breathlessness  Tachycardia  Sweating
 Dizziness  Apprehensiveness  Tachypnea
 Chest pain  Headache  Restlessness etc.
Method of Diagnosis
 History taking
 Clinical findings
Treatment
 Psychotherapy
 Sedatives (anxiolytics) diazepam or chlorodiazepoxide 5-10 mg po/day at bedtime.
Complications
 Alcoholism (alcohol dependence)
 Drug abuse (drug dependence)

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 B. PHOBIA
Phobia is described as persistent, irrational fear of a specific object, activity or
situation that is out of proportion to the stimulus. Leads to a desire to avoid object or activity
despite awareness that it is not dangerous. There are two types of phobias;
a) Simple (or specific phobia) mono-symptomatic phobia: Simple phobia refers to fear
caused by the presence (anticipation) of a specific object or situation, such as flying,
heights, animal, getting an injection or seeing blood.
Examples of simple phobias include:
 Zoophobia - fear of animals  Hematophobia – fear of blood
 Claustrophobia- fear of closed  Acrophobia - fear of heights
spaces  Nyctophobia - fear of the night
b) Complex phobia (social phobia): A complex phobia is defined as a marked and
persistent fear of one or more social or performance situations.
Examples of complex phobias include:
 Agoraphobia - fear of open place
 Social phobia - fear of public area
 Giminophobia - fear of marriage
 Gumnophobia- fear of being seen naked
 Minsnophobia - fear of going through child birth
 Sypridophobia - fear of having sexual relation etc.
Etiology:
According to psychoanalytic theory, phobias occur as a result of conflicts arising from
unresolved castration anxiety (displaced phobia) which persists and tend to stay displaced to
other objects during adulthood.
Clinical features:
- Feeling of panic, terror and dread when exposed to source of fear
- Avoiding exposure to fear as much as possible
- Inability to function normally as a result
- Physical reactions: rapid heartbeat and difficulty breathing
Treatment
1. Behavioral therapy
- Desensitization - enabling the patient to adapt to a situation piece by piece or part
by part.

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 - Systematic – slow and gradual adaptation and understanding of reality.
- Flooding – exposing the individual to the feared object.
2. Antidepressant
- MAOI (monoamine oxidase inhibitors) e.g. Phenotizine

C. CONVERSION DISORDER
A conversion disorder is a psychological condition in which an anxiety-provoking
impulse is converted unconsciously into functional symptoms, for example, anesthesia,
paralysis, or dyskinesia. Although the disturbance is not under voluntary control, it meets the
immediate needs of the patient and is associated with a secondary gain. Hysteria is a conversion
disorder that represents a goal oriented disease: the goal is attention seeking to avoid anxiety or
to draw attention (sympathy) by transferring a mental conflict in to a physical symptom and in
this way releasing tension or anxiety. Clinically there are two forms of hysteria
 Conversion reaction: Signs and symptoms of conversion reaction include;
 Motor disturbance: Paralysis, Paraplegia, Monoplegia, Gait disturbance, and Tremor
 Sensory: Aphonia, Anesthesia, Convulsions (hysterical fit), and Blindness.
 Dissociative hysteria: Dissociation is the act of separating and detaching a strong
emotionally charged conflict from ones consciousness. Signs and symptoms of
dissociative hysteria include:
Conscious disturbance, Amnesia (psychogenic amnesia), Lack of Identity, Fugue state
(complete amnesia), Somnambulism (sleep walking), and Multiple personality.
Treatment
 Psychoanalysis
 Hypnosis
 Breaking secondary illness gain
 Sedative and anxiolytic drugs (valium and chlorodiazepoxide are recommended).

D. OBSESSIVE COMPULSIVE DISORDER (OCD)

- Obsession is defined by thought and feelings that the person cannot get rid of
voluntarily and instead reoccur against their will.
- Compulsion is defined by the performance of a certain acts as a result of irresistible
and in order to reduce anxiety.

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Etiology
 Constitutional function: there is a heredity tendency
 Physical: brain injury and central nervous system (CNS) infection.
 Psychological: conflicts between Id and superego.
Signs and symptoms
 Obsession symptoms
- Fear being contaminated or touched
- Doubts about locking the door or turning off the stove
- Intense stress when things are not orderly
- Avoidance of situations that trigger obsessions (e.g. shaking hands)
 Compulsion symptoms
- Hand-washing until skin is raw
- Checking doors repeatedly to ensure they are locked
- Counting in certain patterns
- Silently repeating a word or phrase
Treatment
 Psychotherapy (reassurance)
 Behavioral modification
 Antidepressant (amitriptyline) 25 - 50 mg/day

E. HYPOCHONDRIASIS
Hypochondriasis is neurotic disorder in which the predominant disturbance is unrealistic
interpretation of physical signs as abnormal leading to a preoccupation with illness and a belief
that the patient has a disease. Hypochondriac is a term used to describe persons who presents
unrealistic or exaggerated physical complaints.
Etiology:
When a person loses his or her attention towards other objects then he or she directs their
attention to him or herself.
Signs and symptoms
 Ranges from simple preoccupation with illness to delusion
 Primarily mono-symptomatic (occurs with single disease symptom)
 It may develop in to multi symptomatic (many disease symptoms)
 Most common areas of the body involved are abdomen, chest and head.

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Treatment
 Treat any underlying illnesses
 Antidepressant (amitriptyline)
 Psychotherapy and supportive ideas.

NURSING INTERVENTION OF AXIETY DISORDER

 People who exhibit signs of acute anxiety or a panic state may harm themselves or
others and need to be supervised closely until the anxiety is decreased.
 The person may need to be placed in a protective environment such as a general
hospital, mental health center or psychiatric hospital.
 The person may be in severe distress or immobilized, or he may be engaged in
purposeless, disorganized, or aggressive activity. Feelings of intense awe, dread, or
terror may occur. The patient may state he fear that he is losing control. After the patient
is examined, a nursing care plan is initiated to correspond to the physician’s or
psychiatrist’s treatment plan for an acute anxiety attack or panic state.
 During the panic state the nursing interventions may include:
 Staying with the patient at all times
 Remaining calm: the patient will sense any anxiety exhibited by the nurse.
 Speaking in short, simple sentences
 Displaying firmness to provide external controls of the patient
 Keeping the patient in a quiet environment to minimize external stimuli. The
patient is unable to screen such stimuli and may become over whelmed.
 Providing protective care because the patient may harm him or herself or others.
The patient’s behavior also may elicit responses from other patients who are
unable to tolerate his or her anxiety state. Attempting to channel the patient’s
behavior by engaging him or her in physical activates that provide an outlet for
tension or frustration. Administering anti-anxiety medication to decrease
anxiety. Persons who exhibit symptoms of mild or moderate levels of anxiety
may be treated as outpatients. If the anxiety does not interfere severely with the
patient’s ability to function, he or she generally is seen as an outpatient.
 Nursing interventions for mild to-moderate anxiety levels include assessment of the
patient’s anxiety level, reducing anxiety, providing protective care, encouraging

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 verbalization of anxiety, meeting basic human needs and setting realistic goals for
patient care.
The nurse provides supportive care by:
 Recognizing the patient’s anxiety and helping him or her to identify the anxiety and
describe his or her feelings. Reassuring the patient
 Accepting the patient unconditionally and not passing judgment or responding
emotionally to the patient’s behavior.
 Listening to the patient’s concern. Being available but respecting the patient’s need for
personal space.
 Protecting the patient’s defenses (e.g. ritualistic behavior). Any attempt to stop such
behavior increases anxiety because the patient has no other defenses.
 Encouraging verbalization of feeling and answering questions directly.
 Allowing the patient time to respond to nursing interventions. Setting realistic goals for
improvement. Allowing the patient to set the pace
 Exploring alternative coping mechanisms to decrease present anxiety to a manageable
level. Assisting the patient in learning to cope with anxiety
 Identifying the patient’s development stage and helping him or her to work through
unmet developmental tasks. Exploring one’s own feelings.
 Administering treatments or medications to reduce anxiety or other discomfort.
Hospitalization of the patient with an anxiety disorder may be short-term and intensive.
Outpatient follow-up care is usually recommended to continue with supportive therapeutic care.
Discharge planning will include an evaluation of the patient’s present status, recommendations
for outpatient referral and instructions regarding drug therapy if a maintenance dose is
necessary. The patient should be instructed about whom to contact if anxiety increases and
panic or a crisis occurs.
Psychotherapies include:
1. Cognitive-Behavior Therapy (CBT): CBT recognizes that our thoughts affect the way
we feel. The goal is to restructure the negative thinking that contributes to anxiety:
 Identify negative thoughts
 Challenge negative thoughts
 Replace negative thoughts with realistic thoughts and accurate appraisals
2. Exposure Therapy: Systematic desensitization: gradually challenging fears to
overcome them. Step-by-step process starting with mildly threatening situations

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  E.g. Step1: Looks at photos of planes
 Step 2: Pack for the plane flight
 Step 3: Take the plane flight
Anti-Anxiety Agents
Benzodiazepines
 Depresses the centra! nervous system and produces a tranquilizer effect
 Reduces anxiety and promotes relaxation and sleep
Common side effects: Muscle weakness, memory loss, slurred speech, constipation, dry mouth
Examples: Alprazolam (Xanax), Clonazepam (Rivotril), Lorazepam (Ativan)

MOOD DISORDERS or BIPOLAR DISORDER

Mood disorder is characterized by feeling of depression or euphoria sometimes with
psychotic features. Specific ‘mood episodes’ should be identified which help as building blocks
for diagnosing ‘mood disorders’.
- Highs and lows in mood
- Euphoria [feelings of excitement, high energy, grandiose thoughts]
- Inconsistencies and "breaks" in personality. Four types of mood episodes are identified;
 Major depressive episodes
 Mixed episode
 Manic episode
 Hypo manic episode
A. Major depressive episode (MDE): This is characterized by a feeling of anhedonia,
withdrawal from family and friends, loss of libido, weight loss, anorexia, disturbed sleep
(like insomnia or hypersomnia) of at least fifteen days duration. On examination - such
patients may have psychomotor retardation, agitation, sad mood, soft, low monotonous
speech, suicidal ideas, feeling of hopelessness, worthlessness, guilt, delusions,
hallucination, poverty of thought, poor concentration and memory.
B. Manic episode: This is a distinct period of elevated or irritable mood that lasts for at
least 1 week. Such patients have disinhibited behavior, hyper sexuality, and excessive
energy. On examination, such patients have psychomotor agitation, hyper excitability
and euphoric mood, pressured and loud speech, elevated self-esteem, flight of ideas,
delusions (e.g. of grandiosity), poor concentration and very poor judgment.

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 C. Mixed episodes: Such patients meet the criteria for two as the above disorders, which
last over a week. They have pressured speech, irritability and the need for little sleep
while feeling worthless and suicidal
D. Hypo manic episode: This is similar but less severe than manic episode. Such episodes
last for at least 4 days. There is no need for hospitalization, no psychotic features
(delusions) and no severe social or occupational impairment. Mood disorder is divided
into:
 Depressive disorders
 Bipolar disorders
The diagnoses of major depressive disorder or bipolar disorder depend on these episodes.
Type of bipolar disorder
Bipolar I: Patient has at least one manic or mixed episode with or without major depressive
episode or hypo manic episode.
Bipolar II: Patient has at least one major depressive episode and hypomanic episode in the
absence of any manic or mixed episode.
Etiology of bipolar disorder
 Biological
 Neuro chemical
 Increased level of norepinephrine, serotonin, and dopamine in mania.
 Decreased level in depression.
 Hormonal
 Hypothalamus-pituitary-adrenal axis involved E.g. Increased cortisol level in
depression
 Decreased immune functions in mania and depression
 Genetic: the disorders tend to run in families
 Psychosocial
 High stress
 Psychoanalytic
 Loss of a loved one
 Major life changes
 Drug or alcohol abuse
 Cognitive
 Negative self-view

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  Negative interpretation of experience
 Negative view of future
Pathophysiology of Bipolar Disorder
- Episodes of mania and depression
- Classified as a mood disorder
- Decreased ligand-binding to serotonin transporter which takes up serotonin from
synaptic deft
- Decreased serotonin, norepinephrine, and dopamine
- Damage to areas of brain that regulate emotions
Diagnosis
- Easily confused with other disorders (i.e. unipolar depression or schizophrenia)
- No single test can be used to identify bipolar disorder
- Involves a combination of physical/mental assessment, clinical questionnaires, blood
and urine tests to rule out presence of drugs

UNIT FOUR: AFFECTIVE DISORDER

Affective disorder is defined as a mental disorder exhibiting prominent and persistent
mood changes of elation or depression accompanied by symptoms such as fatigue and
insomnia. An abnormality of affect, activity or thought process is present. The mood changes
appear to be disproportionate to any cause. Affective disorders are classified as mania,
depression and bipolar disorders.
A. Manic psychosis
The word mania is derived from a Greek word; it is synonymous with “madness” it is used to
describe a behavior disorder in which three main symptoms predominate, euphoria, heightened
psychomotor activity and flight of ideas.
Clinical features of mania
 Restlessness, Over –talking, Irritability
 Inflated self-esteem (grandeur delusion)
 Decreased need for sleep
 Expansiveness, Excessive energy, Sexual promiscuity
 The speech is very loud, rapid and difficult to understand, often it is full of jokes, puns,
plays on words, amusing irrelevance and theatrical with singing and rhetorical
mannerisms.

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  If the mood is more irritable, then expansive the person may become hostile and may go
through three phases: contempt, control, and triumph.
 Flight of idea which is incoherent
 Due to grandiose idea and inflated self-esteem, the patient may act as an advisor and
consultant in areas they do not have special knowledge, such as how to fix and
automobile and how to run government, writing novel, composing music or painting
pictures.
Methods of diagnosis (DX): History taking and physical examination
Treatment (RX):
- Litium 600 mg po/day,
- Halloperidol 5 mg - 100 mg/day,
- Chlorpromazine (CPZ) 100 - 600 mg po/day in divided dose reduce symptoms of mania
- Thiaridazine (melleril) 100 - 600 mg po/day in divided dose.
- Lamotrigine for maintenance therapy
- Antianxiety medications for psychomotor agitation
- Atypical antipsychotic medications (i.e, olanzapine or risperidone) for sedative and
mood stabilizing
B. Depression
Depression is a sense of hopelessness, in which the world seems totally unresponsive to
one’s effort to meet one’s needs. The central symptoms of depression are sadness, pessimism,
self-dislike along with loss of energy, motivation and concentration".
Clinical features of depression: Regardless of age, the classifications of depressions are more
alike than different. Their clinical features include;
- Changes of mood, thought, behavior and appearances. In addition, depressives are often
characterized by somatic symptoms as well as anxiety. The following are clinical
features of depression.
 Mood: Sad, unhappy, blue and crying
 Thought: Pessimism, ideas of guilt, self-dislike loss of interest and motivation, decrease
in efficiency and concentration.
 Behavior and appearance: - Neglect of personal appearance - Psychomotor retardation
or agitation.
 Somatic: - Loss of appetite or voracious appetite - Loss of weight or over weight -
Constipation - Poor sleep (insomnia or hypersomnia) - Aches and pains – Menstrual

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 change in female patients - Loss of libido.
 Anxiety features: such as - Palpitation - Sweating - Tremor - Suicidal thoughts, threats
and attempts or self-destruction behavior etc - Psychomotor retardation – Agitation
 Lack of sexual interest & concentration
Treatment; Amitriptyline (elavil) 75 - 200 mg/d in divided dose, Imipramin (tofranil) 75 - 300
mg/d in divided dose, ECT (Electroconvulsive therapy)
Nursing interventions for depression and mania
- Persons who are depressed may be difficult to communicate with or approach. Isolation,
withdrawal, ambivalence, hostility, guilt or impaired thought processes are but a few
symptoms that can interfere with the development of a therapeutic relationship.
- The manic patient’s hyperactivity, pressured speech, and manipulation also interfere
with attempts at communication. The nurse must be aware of personal vulnerability to
depressive behavior: working with such persons may cause one to react to the depressed
atmosphere and in turn experience symptoms of depression. The following is a list of
attitudes that the nurse should display toward depressed and manic persons: Acceptance,
Honesty, Empathy, Patience
- Remove hazardous objects from environment
- Provide a private room if possible
- Provide high-calorie finger foods and fluids
- Reduce environmental stimuli
- Do not argue with the client but set limits on inappropriate behaviors

UNIT FIVE: PSYCHOTIC DISORDERS

SCHIZOPHRENIA
Schizophrenia literally means “Fragmented Mind”. Schizophrenia is one of the most
complex, chronic and challenging of psychiatric disorders that affects how a person thinks,
feels, behaves. It represents a heterogeneous syndrome of disorganized thoughts, delusions,
hallucinations, and impaired psychosocial functioning.
Epidemiology
The prevalence of schizophrenia ranges from 0.6% to 1.9%, with an average of
approximately 1% Schizophrenia most commonly has its onset in late adolescence or early
adulthood and rarely occurs before adolescence or after the age of 40 years. The peak ages of
onset are 20–38 years for males and 26–32 years for females. Slightly more men are diagnosed
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with schizophrenia than women (on the order of 4:1) and women tend to be diagnosed later in
life than men.
Etiology
While many factors have been associated with developing schizophrenia; including
genetics, early environment, neurobiology, and psychological and social processes; the exact
cause of the disease is unknown.
Clinical Manifestations
 Confabulation: filling a gap in memory with fantasy
 Flight of ideas: rapidly jumping from one topic to the next
 Looseness of association: ideas are presented without logical connection
 Neologisms: newly made up words that only have meaning for the client
 Thought blocking: client cannot continue the train of thought
 Word salad: unintelligible mixture of random words and phrases
Types of Schizophrenia
Disorganized (hebephrenic type):
Features include incoherence, lack of systematized delusions, and blunted, inappropriate
or silly affect. The clinical picture usually includes a history of poor functioning and poor
adaptation even before illness. Behaviour is disorganized and without purpose. Thoughts are
disorganized, difficult to understand by others. Pranks, giggling, health complaints, grimacing
and mannerisms are common. Delusions and hallucinations are fleeting. Usually develops
between 15-25
Catatonic type:
A type of schizophrenia which is dominated by one of the following: Catatonic stupor:
Morbid lack of reactivity to environment reduction in spontaneous movements and activity
and/or mutism.
 Catatonic negativism: Apparently motiveless resistance to all instructions or attempts
to be moved.
 Catatonic rigidity: Maintenance of a rigid position against efforts to be moved.
 Catatonic excitement: Excited motor activity apparently purposeless and not
influenced by external stimuli.
 Catatonic positioning: Assumption of inappropriate or bizarre posture.
Paranoid type:
Features of the paranoid type of schizophrenia include persecutory and grandeur delusions,

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feeling and hallucinations. Associated features include anger, argumentative, violence,
fearfulness, delusion of reference and sometimes loss of gender identity.
Undifferentiated type:
Features include grossly disorganized behavior, hallucinations incoherence or prominent
delusion. Some characteristics of paranoid, hebephrenic or catatonic schizophrenia are present
but do not obviously fit one of these types.
Residual type:
Features include current schizophrenic symptoms and definite experience of at least one
schizophrenic episode in the past. There may be some delusion and hallucination but the
person is burned out. There is no treatment for the residual symptoms. The patient often
functions poorly and experiences long term unemployment
Diagnosis of Schizophrenia
Medical history: A thorough medical history is the first step in the diagnosis of schizophrenia.
This may be done to find other problems that could be causing
 symptoms and to check for any related complications.
 Blood tests & imaging: A Complete Blood Count (CBC) test is helpful to monitor
general health and rule out other conditions that may have been responsible for the
symptoms. A blood test can provide accurate information about the involvement of
recreational drugs. In some cases, certain imaging techniques such as Magnetic
Resonance Imaging (MRI) or Computed Tomography (CT) scan may aid in the
diagnosis.
DSM III diagnostic criteria for schizophrenic disorders
The DSM III diagnostic criteria include the following: At least one of the following at some
point of the illness
 Bizarre delusions, such as the delusion of being controlled, thought broadcasting,
thought insertion and thought withdrawal, somatic, grandiose, religious, and nihilistic
or other delusions without persecutory or jealous content.
 Delusions with persecutory or jealous content, if accompanied by hallucinations of
any type.
 Auditory hallucinations in which either a voice keeps up a running commentator on
the individual’s behavior or thoughts, or two or more voices converse with each other.
 Auditory hallucinations on several occasions with content of more than one or more
words having no apparent relation to depression or elation.

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  Incoherence and marked loosing of association marked illogical thinking or marked
poverty of content of speech.
 Bawleres symptoms: The 4 A's of schizophrenia;
 Ambivalence
 Association loosening (incoherence)
 Affect disturbance
 Autism (turning towards self).

According to DSM-V, in order to be diagnosed with schizophrenia the individual must

have experienced at least 2 of the following:
- Hallucination
- Delusions
- Disorganized speech
- Catatonic behavior
- Negative symptoms (At least 1symptom must include hallucinations, delusions
or disorganized speech)
Duration: At least 6 months of continuous disturbance. At least 1month of active symptoms
with social or occupational dysfunction
Psychiatric evaluation: A doctor or mental health professional checks mental status
by observing appearance, demeanor and asking about thoughts, moods and awareness.
A person may be diagnosed if they have at least 2 of the following symptoms usually
over a month; Delusions
 Hallucinations
 Disorganized behaviour
 Disorganized speech and thought processes
 Catatonic behaviour, presenting as strong daze or hyperactivity
 Negative symptoms, impaired normal function

Complication

i. Depression: Depression afflicts approximately half of schizophrenic patients. Sadly, it

is not always recognized or treated. It can significantly add to the suffering of the
person. Additionally, comorbid depression increases the risk of suicide in
schizophrenic.
ii. Anxiety: Many individuals with schizophrenia also have an anxiety disorder, such as

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 social anxiety disorder, PTSD, generalized anxiety disorder, OCD or panic disorder. In
fact, research suggests between 30% and 85% of people with schizophrenia have had
an anxiety disorder at some point in time.
iii. Suicide: Suicide is one of the primary causes of death for individuals with
schizophrenia. There are several factors which contribute to suicide risk in
schizophrenia which include psychotic symptoms, such as voices telling the person to
kill himself, substance abuse, recent diagnosis of schizophrenia and comorbid
depression.
Substance abuse & smoking: Substance abuse is a form of self-medication for many
people with psychiatric disorders. Unfortunately, when patients use substances such as
alcohol or street drugs it can make their symptoms worse. They are also less likely to
continue taking their medications when they abuse substances.
iv. Violence: While the media often depicts schizophrenic patients as violent, they are not
necessarily more prone to violence than the general population. That being said, some
factors can increase the risk of violent behavior in individuals with schizophrenia, such
as delusions or command hallucinations, a history or violent acts or using alcohol or
drugs.
v. Self-injury: Self-injury, especially bizarre types of self-mutilation, is not uncommon
with schizophrenia. Hallucinations and delusions can cause them to harm themselves
in ways which can be very serious, such as attempting to remove a finger or other body
part.
Prognosis
There is no known cure for Schizophrenia. Fortunately, there are effective treatments
that can reduce symptoms, decrease the likelihood that new episodes of psychosis will occur,
shorten the duration of psychotic episodes, and in general, offer the majority of people the
possibility of living more productive and satisfying lives. With proper medications and
supportive counseling, the ability of schizophrenic persons to live and function relatively well
in society is excellent.
Treatment (Rx)
 ECT is also seldom used today,
 Contemporary treatment: Supportive psychotherapy
 Drug therapy: The choice of drug depends upon availability, cost and side effects -
Chlorpromazine(CPZ) 100 - 600 mg/day in divided dose - Thioridazine (mellaril) 100 -

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 1000 mg/day
Hospitalization: During crisis periods or times of severe symptoms, hospitalization may be
necessary to ensure safety, proper nutrition, adequate sleep and basic hygiene.
Psychosocial interventions
 Individual therapy: Psychotherapy may help to normalize thought patterns. Also,
learning to cope with stress and identify early warning signs of relapse can help
people to manage their illness.
 Social skills training: This focuses on improving communication, social interactions
and improving the ability to participate in daily activities.
 Family therapy: This provides support and education to patient families.
 Vocational rehabilitation and supported employment: This focuses on helping
people with schizophrenia prepare for, find and keep jobs.

Electroconvulsive therapy: For adults with schizophrenia who do not respond to drug
therapy, electroconvulsive therapy (ECT) may be considered. ECT may be helpful for
someone who also has depression. The indications for ECT in schizophrenia are: Catatonic
stupor & uncontrolled catatonic excitement. Acute exacerbations not controlled with drugs.
Risk of suicide, homicide or danger of physical assault

Cognitive behavioral therapy: CBT aims to help to identify the thinking patterns that are
causing to have unwanted feelings & behavior and learn to replace this thinking with more
realistic and useful thoughts. Most people require between 8 and 20 sessions of CBT over the
space of 6 to 12 months. CBT sessions usually last for about an hour.
Nursing interventions
Nursing interventions focus on assisting the patient to meet the following goals:
 Establish a trusting relationship
 Alleviate anxiety
 Maintain biological integrity
 Establish clear, consistent, and open communication.
The nurse must establish a therapeutic relationship so that effective communication
with the patient can take place. The nurse must remember that all behavior is meaningful to
the patient, if not to anyone else. Reality should be presented when caring for the patient who
is disoriented. The nurse can do this by pointing out what would be appropriate behavior, for
instance, I’d like you to put your shoes on now‟ recognizing the presence of hallucinations

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 and delusion, but not reinforcing such behavior or thoughts is an appropriate response when
interacting with patients. The nurse should look for factors causing hallucinations and attempt
to intervene before they occur. Safety measures may need to be incorporated to protect the
patient who displays poor judgment, disorientation, destructive behavior, suicidal ideation, or
agitation. Limit setting, acknowledging spatial territory giving the patient room to breathe‟
and providing protective safety measures are examples of such nursing interventions. The
patient must be protected from her or himself because she or he may injure her or himself
accidentally, or may try to destroy her or himself or attack other patients as a result of
auditory hallucinations or paranoid ideations.
Efforts should be made to plan activates to increase the patient’s self-concept. Sincere
compliments should be given as often as possible, focusing on positive aspects of the
person’s personality or capabilities. Encourage participation in activates. The nurse must
observe for extra pyramidal side effects of psychotropic drugs and monitor the patient’s
willingness to take the drugs. Patients may refuse to take medication, pretend to take
medication by palming it, or pretend to swallow the medication while retaining the pill in the
mouth (only to get rid of it at the first possible moment).

UNIT SIX: DEFENSE MECHANISMS

Definition; Defense mechanism and mental mechanisms are terms used to describe the
unconscious attempt to obtain relief from emotional conflict or anxiety. Coping mechanisms
include both conscious and unconscious ways of adjusting to environmental stress. Such
mechanisms are supposedly in action by age ten and are used as follows:
 To resolve a mental conflict  To protect one's self esteem
 To reduce anxiety or fear  To protect one's sense of security.
Some of these mechanisms are described below:

1. Repression: This is an involuntary rejection of ideas. Unconscious thoughts, feelings

and memories that are painful (automatic forgetting): for example, the inability to
remember the reason for an argument or recall feelings of fear following an automobile
accident.
2. Suppression: This is the voluntary act of pushing unacceptable feelings out of one’s
consciousness. This mechanism is generally used to protect one's self-esteem.
3. Rationalization: This is the most common ego defense mechanism. It is used to justify
ideas, actions or feelings by providing good, acceptable reasons and explanations. It is

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 used to maintain self-respect, prevent guilt feelings, and obtain social approval or
acceptance.
4. Identification (the imitator): This is an unconscious adoption of some of the
characteristics of another person.
5. Displacement: This is a mechanism that serves to transfer feelings such as frustration,
hostility, or anxiety from one idea, person, or object to another: for example, a person
might disagree at his boss but instead picks a fight with his wife or his children when he
is back at home.
6. Introjection: This involves attributing to oneself the good qualities of another:
symbolically taking on the character trait of another person by „ingesting‟ his
philosophy ideas, knowledge, or attitudes. The term is often used loosely as
synonymous with identification. An example would be a psychiatric patient who claims
to be Moses or Jesus Christ or other biblical or well-known person, who is observed
dressing and acting like the personage they profess to be.
7. Projection: This is often termed as the „escaping goat‟ defense mechanism. The person
rejects unwanted characteristics of her or himself and assigns them to others. He/she
may blame others for faults, feelings, or shortcomings that are unacceptable to self.
Examples would be: a man who is late for work states, “my wife forget to get the alarm
last night so I overslept” or after spilling a glass of milk while playing cards with a
friend, a 10-year- old tells his mother, “my brother made me spill the milk. He told me
to hurry up and play.”
8. Regression: This involves returning to past level of behavior to reduce anxiety, allow
one to feel more comfortable and permit dependency: for example, a 5 year old boy who
previously was toilet trained and who becomes incontinent when his mother gives birth
for a new baby in order to get attention like a newly born baby.
9. Denial: This is the unconscious refusal to face thoughts, feeling, wishes, needs or reality
factors that are intolerable: for example, a student who is persistently late for a
scheduled class because that student is actually very fearful of the topic, so he/she
expresses the fear by being absent from the class, or a person who has just been
admitted to a mental hospital states “I am really not sick, I am just in here to get a rest”
10. Substitution: This is defined as the replacement of consciously unacceptable emotions,
drives, attitudes, or needs by those that are more acceptable or it is the act of finding
another goal when one is blocked: for example, a student nurse in a baccalaureate

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 program who decides she is unable to master the clinical competencies and elects to
become a laboratory technician is using the mechanism of substitution.

UNIT SEVEN: PERSONALITY DISORDERS

Personality disorder is described as a non-psychotic illness characterized by
maladaptive behavior, which the person utilizes to fulfill his or her needs and bring
satisfaction to self.
Characteristics of personality disorder
i. The person denies the maladaptive behavior s/he exhibits; such behavior has become
a way of life for him.
ii. The maladaptive behaviors are inflexible
iii. Minor stress is poorly tolerated, resulting in increased inability to cope with anxiety
iv. Ego functioning is intact but may be defective therefore, it may not control impulsive
actions of the id
v. The person is in contact with reality although s/he has difficulty dealing with it
vi. Disturbance of mood, such as anxiety or depression may be present
Psychiatric help rarely is sought because the person is unaware or denies that his or her
behavior is maladaptive.
Etiology of personality disorders
i. Biological predisposition may result from improper nutrition neurological defects, and
genetic predisposition Variations in brain chemistry and structure
ii. Abusive family life during childhood: Child hood experiences can foster the
development of maladaptive behavior
iii. Socially deviant persons may have defective egos through which they are unable to
control their impulsive behavior
iv. A weak superego may result in the incomplete development of or lack of a
conscience. A person with immature superego will feel no guilt or remorse for
socially unacceptable behavior
DIAGNOSIS
Physical Exam
- Observations of behavior, mood, & affect
- May include screening test for alcohol or drugs

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 - In-depth questions regarding health will be asked
Psychiatric Evaluation
- Discussions regarding thoughts, feelings, and behavior
- Information from family members may be obtained
Diagnostic Criteria in DSM-5
- The Health Care Provider may match symptoms to criteria in DSM-5
Clinical Manifestations
- Lack of inhibition
- Impaired judgment
- Distorted view of reality
- Distorted view of self
- Acting out [yelling, swearing)
- Insomnia, agitation, poor attention span
Types of personality disorders
1. Paranoid personality disorder
The defining trait of paranoid personality disorder is suspiciousness. Suspiciousness is
something that we all feel in certain situations and with certain people, often for good reasons.
However, paranoid personalities feel suspiciousness in almost all situations and with almost all
people, usually for very flimsy reasons. When a paranoid person is confronted with evidence
that their mistrust is unfounded, they will simply begin to mistrust the person who brought
them the evidence “So he is against me too”. This results in impairment in cognitive function.
2. Schizoid personality disorder
Schizoid personality disorder is defined by a fundamental eccentricity, a preference for social
isolation. According to current thinking, schizoids are deficient in the capacity to experience
social warmth or any deep feelings and unable to form attachments. Schizoid personalities
rarely marry, have few friends (if any), seem indifferent to praise or criticism from others, and
prefer to be alone. Because of their self- absorption, they may seem vague or absent- minded:
‟out of it„, so to speak. However, such people do not show the unusual thoughts, behaviors, or
speech patterns that one sees in the schizotypal personality.
3. Antisocial personality disorder
The defining characteristic of antisocial personality disorder is a predatory attitude toward
other people: a chronic indifference to and violation of the rights of one’s fellow human
being. According to DSM-III-R lists of criteria for the diagnosis of antisocial personality

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 disorder can be summarized as five basic points:

i. A history of illegal or socially disapproved activity, beginning before the age of

fifteen and continuing into adulthood
ii. Failure to show consistency and responsibility in work, sexual relationships,
parenthood or financial obligations
iii. Irritability and aggressiveness, including not just street brawls but often abuse of
spouse and children
iv. Reckless and impulsive behavior. Unlike most ‟normal criminals, antisocial
personalities rarely engage in planning. Instead, they tend to operate in an aimless,
thrill-seeking fashion traveling from town to town with no goal in mind, falling into
bed with anyone available, stealing a pack of cigarette or a car, depending on what
seems easiest and most gratifying at the moment
v. Disregard for the truth. People with antisocial personalities lie frequently.
4. Borderline personality disorder
Theorists state that the borderline personality disorders may be a result of a faulty parent–
child relationship, in which the child does not experience a healthy separation from mother to
interact with the environment. Negative feelings are shared by parent and child, who are
bound together by all feelings of guilt. Trauma experienced at a specific stage of
development, usually 18 months may result in a weakening the person’s ego and ability to
handle reality and is another possible cause. Additionally, the person who experiences an
unfulfilled need for intimacy is liable to develop the disorder.
According to the DSM-III-R, clinical symptoms may include:
i. Unstable interpersonal relationships
ii. Impulsive, unpredictable behavior that may involve gambling, shoplifting, and sex.
Such a person tends to use and can tolerate large amounts of drugs and alcohol
iii. Inappropriate anger and inability to control anger.
iv. Disturbance in self- concept, including gender identity
v. Unstable affect that shifts from normal moods to periods of depression, dysphoria
(unpleasant mood), or anxiety
vi. Chronic feeling of boredom
vii. Masochistic behavior (self-inflicted pain) and thoughts of suicide
viii. Frantic efforts to avoid real or imagined abandonment.

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 5. Narcissistic personality disorder
The essential feature of narcissistic personality disorder is a grandiose of self–importance, often
combined with periodic feelings of inferiority. In general people with narcissistic personality
disorder need constant admiration, expect favors from others without reciprocating, and react to
criticism with arrogance and contempt.
6. Obsessive compulsive personality disorder
Obsessive compulsive personality disorder is characterized by an excessive preoccupation with
trivial details at the cost of both spontaneity and effectiveness. Obsessive compulsive
personalities are so taken up with the mechanics of efficiency: organizing, following rules,
making lists and schedules that they cease to be efficient, for they never get anything important
done. In addition, they are generally stiff and formal in their dealings with others and are
incapable of taking genuine pleasure in anything. They have difficulty of decision making. The
disorder is more common in men than in women.
Nursing Intervention
The nursing care of a person who is diagnosed as having a personality disorder is
directed at the specific behavior, characteristics, and symptoms that are common to the
identified disorder. Maladaptive behaviors such as acting-out, stubbornness, procrastination,
over-exaggeration, manipulation, and complete dependency can elicit negative responses from
nursing personnel.
- A friendly, accepting environmental should be established in which the patient is
accepted but the maladaptive behavior is not. It is imperative that the nurse examines her
feelings about such behavior so that she does not allow them to infect therapeutic
nursing interventions. The individual needs to be given an opportunity to develop ego
controls such as the superego or conscience that is lacking or underdeveloped. This can
be achieved by consistent limit- setting that is enforced 24 hours a day.
- Assess for suicide risk
- Avoid direct eye contact
- Establish trust
- Acknowledge client's feelings but do not share his or her interpretation of event
- Do not whisper in patient’s presence
- Limit physical contact
- Antipsychotic medications (ex/ risperidone]
- Anti-anxiety medications [ex/ Xanax)

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 - Mood stabilizers (ex/ lithium)

UNIT EIGHT: CHILDHOOD AND ADOLESCENT PSYCHIATRY

Definition: Childhood and adolescent psychiatric disorders are types of mental illness which
occur in childhood and adolescent age group.
Etiology
 Genetic factors:
Genetic factors are important. Wide individual variations in mood, level of activity, attention
span are found in infants, and sex differences in aggressive behavior may be evident at two
years. These temperamental differences may modify parental response to children’s
aggression. The behavior of emotionally disturbed children often accurately predicts adult
personality.
 Separation from parents:
For normal development, infants must form attachments and bonds (selective attachments
persisting over a long period). The se may be disrupted, for example, by hospital admission.
This is most stressful for children between six months and four years, of age, but children can
be trained to accept separations gradually. Short separations can lead to acute but brief
distress. One long separation rarely dose permanent emotional damage, but repeated
hospitalization in a child from an unhappy home often causes psychiatric problems.
 Other stresses:
Other damaging stresses for children include moving house, bereavement and a broken home.
The latter is especially associated with conduct disorders. The in the case of divorce, the
associated marital discord is more important than the parents‟ separation. Children of one
parent families have more psychiatric problems than average; children of working mothers do
not.
 Delinquency:
Delinquency is associated with particular geographical areas which have poor or neglected
housing, overcrowding, low family income and high adult crime rate. Children in inner cities
are twice as likely to have psychiatric disorder as those from elsewhere. These children are
also more likely to come from overcrowded, unhappy homes with disturbed parents. Schools
with high rates of teacher and pupil turnover have more disturbed children.
Classification
A World Health Organization Committee recommended that children be assessed on four

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dimensions:
 Clinical psychiatric syndrome  Organic factors and
 Intelligence  Psychosocial factors
Clinically, children show the same range of anxiety disorders, psychosomatic disorders
and psychosis as those found in adults. The vast majority can be divided into two groups:
a. Children with predominantly neurotic symptoms:
These children may suffer from anxiety, phobias, shyness, sleep and appetite disorders and
tics (A child with tics experiences what appear to be uncontrollable movements or vocal
sounds. For example, a child with motor tics may engage in repetitive and rapid shoulder
shrugging, eye blinking, lip biting, or facial grimacing. A child with vocal tics may
repetitively clear his throat, hum, sniff, snort, or squeal.). Most grow up to be stable adults.
b. Children with predominantly conduct disorders:
Like stealing, aggression, lying, over- activity, truancy. These children have poor prognosis in
adult life with higher rates of crime, alcoholism psychiatric admission and poor work record.
Children with behavior disorders are usually disturbed at home or at school; only in severe
cases at both. About 7% of 10 to 11 year olds have some kind of psychiatric disorder. Boys
have twice as much as girls and also exhibit conduct disorders more often. A few disorders are
specific to childhood and adolescence. These include early childhood autism, the hyperkinetic
syndrome and anorexia nervosa. Specific developmental disorders include dyslexia,
stammering, enuresis, encopresis and clumsy children. Some of these are described in more
detail below.
Specific syndromes of childhood psychiatric disorder
Nocturnal enuresis (bed-wetting): This is more common in early years. At 14 years of age
and above, the problem drops to 1 in 35. The problem is more common in males of below
average intelligence living in poor social conditions. It is associated with a strong family
history. 5% of cases are caused by urinary infections. Other cases may be neurotic, for
example, regression after birth of a younger sibling. Yet other cases may be developmental.
Treatment includes conditioning by an incontinence pad connected to a bell. Imipramine 25 or
50 mg may be given at night to older children; prolonged treatment is necessary.
Encopresis: This involves soiling; rather than enuresis. It is usually characterized by retention
with overflow. Children with this problem are often of normal intelligence. The problem may
be neurotic or developmental. Treatment tends be unrewarding, however, 50% of children
experience spontaneous recovery in two years, and almost all recover before adult life.

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Stuttering: There are two groups of children who may suffer from stuttering. The first are
dull, often from poor social backgrounds and having suffered a birth injury. The second group
tends to be of average or above average intelligence, and come from, ambitious families with
anxious, obsessional mothers. In both groups the anxiety engendered by stuttering may lead to
secondary neurotic disorders. Speech therapy is helpful.
Early childhood autism: This is a form of childhood psychosis beginning from birth or in the
first three years. It should not be confused with schizophrenia, which is rare and occurs later in
childhood. Autism is now generally agreed to be an organic condition, although formerly it
was attributed to upbringing or the parents‟ personalities. The central defect is a difficulty in
comprehension and the use of language. It is rare, occurring in about 1 in 2000 school
children. Three boys are affected for every girl. The parents of autistic children tend to be
intelligent. The symptoms comprise lack of speech: problem of comprehension, mutism or
abnormal speech, with echolalia (repetition of words) and the avoidance of the personal
pronoun, and a monotonous mechanical voice. Autistic children have difficulty in copying
movements: flicking movements of hands, spinning and jumping movements. They often
exhibit a paradoxical response to sounds. They are resistance to change of routine. They are
generally socially aloof, live in a world of their own. They often have tantrums. When testable,
only 30% of autistic children have an IQ above 55. A third of autistic children develop fits in
adolescence or adult life.
Differential diagnoses include deafness, partial blindness, elective mutism, mental sub
normality. The prognosis is poor. 60% of autistic children remain unchanged, only 15 per cent
find open employment. The prognosis is slightly improved in those children with a higher IQ.
School refusal (school phobia): school phobia is relatively rare. Peak age for its occurrence is
11 to 12 years. It is often precipitated by change of school or illness in parents or grandparents.
It is found most often in boys and children of intelligence average. It is more common in well
behaved children doing well at school, who are often anxious and shy. The problem is
associated with increasing anxiety, often with abdominal pain and vomiting, culminating in
refusal to go to school. It is quite distinct from truancy. The mothers of children suffering from
school refusal are often over-protective and subject to depression. The problem is generally
due to separation anxiety rather than fear of school. The treatment may necessitate admission
to a residential school or temporary separation form parents.
Tics (habit spasms): Tics are sudden, brief, often repeated movements involving a group of
muscles. They have no purpose but are usually based on purposive movements such as

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blinking, head shaking and coughing. The most common tic is eye blinking; tics decline in
frequency from head to feet. They are found in 10% of children aged 6 to 7 years. They are
twice as common in boys. There is often a family history of tics.
Hyperkinetic syndrome: This syndrome is characterized by overactive from an early age,
sleeping little, wearing out clothes and shoes and an inability to sit still. Children with this
problem are dangerously impulsive, distractible, with a short attention span. They exhibit day
dreaming and lack of perseverance. They are excitable and have frequent temper tantrums.
The syndrome is sometimes associated with organic brain disease, epilepsy or a low IQ. But
often it is not. It is five times more common in boys and is not a rare condition.
Elective mutism: This is a neurotic disorder in which the child, usually male, is persistently
mute in selected circumstances, for instance, at school. Most are solitary and over-dependent
on their parents. Treatment includes a change of environment on admission.

ADOLESCENT PSYCHIATRY
The adolescent years are a time of major change for the individual. A growth spurt in
early adolescence (13-14 years of age for boys and 10-12 years of age for girls) is followed
soon after by sexual maturation. The adolescent becomes physically different in a very short
time and is faced with a strenuous psychological adjustment to these changes throughout
adolescence, intellectual maturation progresses. Although IQ does not continue to rise there, is
an increase in logical and abstract reasoning? Emotionally, the adolescent generally strives for
maturity and independence, particularly from their parents, but finds it difficult to give up the
security and dependence of home and parents. Their ambivalent feelings lead to frequent
inconsistencies in behavior. This in between state is accompanied by mild feelings of
depression and emptiness in 50% of adolescents. Eriksson describes adolescence as a time of
identity crisis when the individual has to decide who she or he is what she or he can do and
what she or he will make of her or his life Social pressures are plentiful. He or she must learn
many new roles at this time - changing from school to work, from child to parent. There is
much pressure to conform to the peer group, whose standards may differ sharply from those of
parents. It should be emphasized that although minor conflicts are common, serious and
persistent difficulties between adolescents and their parents are rare.

Types of adolescent disorder

As with children, adolescent disorders are or may be classified as behavioral (conduct) or
emotional (neurotic) disturbance. Many adolescents show both.

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Neurotic disorder: As adolescence advances the symptoms are similar to those seen in adults.
Depression and anxiety are common, the content of thought being the normal

problems of the age group but this are magnified; appearance, sexual problems, status
with friends are frequent preoccupations School refusal in adolescence may be a sign
of severe neurotic difficulty.
 Conduct disorder: This disorder is more common in boys form disturbed families. It
is characterized by antisocial behavior in a wide range of settings and poor relations
with others; it should not be confused with delinquency. The number of delinquents
showing psychiatric disorder is not much higher than average. Conduct disorder is
often associated with reading difficulties.
 Eating Disorders: An eating disorder is a psychiatric illness involving the disturbance
of eating behaviors and an over-assessment of weight and body shape. Eating disorders
are commonly associated with other psychiatric conditions such as depression,
schizophrenia, generalized anxiety disorder, OCD and personality disorders
 ANOREXIA NERVOSA: Mental illness characterized by self-inflicted weight
loss due to an irrational fear of being overweight. The disorder generally begins
with the wish to diet and feeling fat. It is often characterized by progressive weight
loss associated with early amenorrhea. The disorder often includes self-induced
vomiting and excessive purging carried out in secret.
Etiology: Greater lifetime prevalence in women than men. Prevalence in females = l% - 2%.
Prevalence in teenage girls = 03%- 0.7%. Prevalence in males = 03%. Majority of cases are
girls and young women. Onset is generally in late adolescence (median: 18 years of age). To
diagnose use of BMI to determine low body weight.
Clinical manifestations: Extreme weight loss, Amenorrhea, Restricting calories, Lethargy,
Over-exercising Hypotension, Low self-esteem, Insomnia, Cold intolerance, inappropriate
laxative use, Hypothermia, Dehydration, self-induces vomiting after eating
Complications: Electrolyte imbalances, Anemia, Hypoglycemia, Osteoporosis, Enlarged
salivary glands, delayed gastric emptying, Abnormal liver function
Interventions
- Non-pharm therapy is 1st line therapy in anorexia nervosa treatment
- Psychotherapy: standard treatment (includes Cognitive Behavioral Therapy (CBT),
behavioral management family therapy, nutritional counselling), coping improvement
 BULIMIA NERVOSA: mental illness characterized by binge eating followed by

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 purging (self-induced vomiting) or excessive use of laxatives/diuretics th is greater
lifetime prevalence in women than men, l% - 2% of females, 0.5% of males.
Majority of cases are girls and young women.
Diagnostics: Recurrent episodes of binge eating characterized by: Eating a larger amount of
food than the majority of people would eat (under similar circumstances) within a two-hour
period. During a binge-eating episode, there is a sense of lack of control about eating
Complications: Enlarged salivary glands, Loss of dental enamel Electrolyte imbalances,
Dysrhythmias, Esophageal tears, Stomach rupture
Interventions
- Psychotherapy: standard treatment Includes: Cognitive Behavioral Therapy (CBT),
Behavioral and coping management, Family therapy, Nutritional counselling
- Nutritional Rehabilitation: establish regular eating patterns. Aim for 3 meals and 2
snacks per day
 BINGE-EATING DISORDER: mental illness characterized by recurrent episodes
of eating large quantities of food during a defined time period. Greater in women
than in men lifetime prevalence. Majority of cases are obese middle-aged adults.
Individuals often present with depression, anxiety and other mental illnesses
Symptoms: Usually overweight or obese, Feeling disgust, depression or guilt after a binge
episode
Episodes: Recurrent (2 or more times a week), Eating more rapidly than usual, Eating until
uncomfortably full, Eating when not physically hungry, Eating alone or in secret, Feeling a
loss of control
Complications: Type 2 diabetes, Hypertension, Hyperlipidemia, Coronary heart disease,
Heart failure, Gallbladder disease, Depression, Social isolation
Interventions
- Monitor weight regularly
- Monitor intake during meals
- Referral to dietitian, nutritional support team, counselling and support, groups for
people with eating disorders
Other problems associated with adolescence: Suicide is rare but rates rise in adolescence.
Those who commit suicide are often taller than average and above average intelligence.
Attempted suicide is very common, it may be associated with parental death. Drug abuse is
common in adolescence and alcoholism increasing.

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Treatment methods
In emotional disorders of childhood, family relationships are often relevant and most child
psychiatric clinics employ a treatment team including a doctor, a social worker, a psychologist,
a nurse and a play therapist. Individual or group therapy including the family members and the
child may be indicated, especially where there a family history of suicide. Residential
treatment in hospital or special boarding school may be needed when the home is
unsatisfactory or where the behavior disorder cannot be contained by out-patient care alone.
Drug treatments are less often used than with adults but tranquillizers and anti-depressants
may be of value. ECT and psychosurgery are seldom, if ever, needed.

UNIT NINE: ALCOHOL AND OTHER SUBSTANCE ABUSE

Definitions

 Teetotaler: Person who do not drink alcohol at all.

 Social drinker: Person who drinks moderately but who may get drunk from time to
time.
 Excessive drinker: Person who may drink excessively and may show either by the
frequency with which they become intoxicated or by the degree of the social, economic
or medical consequence of their continuous intake of alcohol. Not all excessive
drinkers are alcoholics.
 Tolerance: The need for markedly increased amount of alcohol to achieve the desired
effect.
 Withdrawal: The development of symptoms like morning shakes after cessation or
deduction in drinking when alcohol is withdrawn. Negative psychological and physical
reactions that occur when use of substance abruptly ceases
 Abuse of substance (nontherapeutic use of substance): Implies a pathological
pattern of use of substances such as drugs, an inability to control this use and
impairment in social or occupational functioning, with the duration of the abuse of at
least a month. Use of a drug or substance in a way that is inconsistent with
medical/social norms
 Detoxification: Process of safely withdrawing from a substance
Alcohol: Alcohol (ethyl alcohol or ethanol) is perhaps the substance most intensively used for
non-medical purpose. It can be produced by the growth of yeast in a sugar-containing medium
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(fermentation). Alcohol acts on every cell of the body; however the CNS is its prime target. Its
effects occur more rapidly in the CNS than in any other tissue of the body. It affects every level
of organization with in the CNS: from its chemistry to its molecular structure and the integrated
functions that govern thought process, emotions motor function and behavior. A single dose of
alcohol results in non - specific general depression of the CNS and subsequent behavioral
changes. These changes are dose dependent. They are related to the blood alcohol concentration
(BAC). However, some of the CNS changes may be longer lasting; acute alcohol intake
increases synaptic membrane fluidity. However, chronic alcohol intake induces a long lasting
resistance to its membrane fluidizing effect. Elimination of alcohol from the system, or a
marked decrease in BAC after long term use may cause the alcohol withdrawal syndrome
(AWS) Characteristics of AWS
Characteristics of AWS include hyper-excitability (opposite of depression) evidenced by
tremors and agitation, convulsions, ataxia, dizziness, diaphoresis, dilation of pupils and
hallucination. The depression of the CNS by alcohol is dependent on the amount consumed.
The effects on mood and behavior differ between individuals and depend not only on the
amount consumed but also to a large extent, on the personality and the mental state of the
individual and their environment. Small amounts of alcohol will produce sedation and relief of
anxiety. As the blood level increases, these symptoms become more pronounced. When a large
amount is consumed depression, inadequate muscular coordination (ataxia), impaired
psychomotor performance, poor judgment and inhibited or irresponsible behavior may be
manifested. Excessive consumption will produce unconsciousness and may be lethal in the
presence of other depressant drugs.

Alcohol is mainly absorbed directly in small intestine, but also in stomach. In the presence of
food the rate of absorption decreases. Most of the absorbed ethanol is completely oxidized to
CO2. Alcohol affects the organs of the body as follows:
 CNS: Alcohol depresses brain function including behavior, cognition judgment,
respiration, sexuality and interferes with motor functions.
 GIT (gastrointestinal tract): Alcohol erodes the stomach and causes mucosa-gastritis,
acute pancreatitis, cirrhosis in the liver and alcoholic hepatitis.
 CVS: Alcohol may cause hypertension and alcoholic cardiomyopathy (erosion of the
wall of the heart).
 Kidney: Alcohol causes diuresis.
 Eye: Alcohol causes pupillary dilation, hyper reflexes.

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ALCOHOLISM
A physical condition associated with a mental obsession. It is considered to be partly physical,
partly psychological partly sociological and partly caused by the effect of alcohol. Chronic
alcoholism is a disabling disorder that imposes on the sufferer physical, social and
psychological handicaps often of great severity.
Etiology
The precise causes of alcoholism are unclear; psychological and coping factors play an
important role of causation. Alcoholism runs in families, various studies of alcoholic groups
reveal that up to:
 50% of alcoholics have alcoholic fathers
 30% alcoholics have alcoholic brothers
 6% alcoholics have alcoholic mothers
 3% alcoholics have alcoholic sisters
Heavy drinkers tend to come from heavy drinking families and the children of alcoholics have
a higher risk of alcoholism than do children of parents who are not alcoholics. Females are
more likely to become alcoholic if the mother is alcoholic or they have a monozygotic twin
who suffers from the disorder.
The essential features of alcohol abuse are:
 Continuous or episodic use of alcohol for at least one month
 Withdrawal from social, occupational, or recreational activities
 Either psychological dependence or compelling desire to use alcohol
 Inability to cut down or stop drinking.
 Frequent intoxication
 Marked intolerance
 Withdrawal symptoms
Alcohol-related disorders
Medical complications could result from acute effects of heavy drinking, chronic
effects of heavy drinking or withdrawal; nearly every organ system can be affected directly or
indirectly. Gastritis, gastric ulcer, acute hemorrhagic pancreatitis, liver cirrhosis, peripheral
neuropathy and amnestic syndromes are but a few of the major medical complications of
alcoholism. Alcoholic paranoid psychosis and korsakoff- syndrome (dementia) are generally

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not reversible. Medical complications like cirrhosis, peptic ulcer disease, thiamine deficiency
and neurological diseases like cerebral degeneration can occur.
Treatment Alcoholism
When it is recognized, requires a treatment program which has a total abstention as the main
goal. Sedatives are to be avoided and tranquilizers used only during the withdrawal phase.
Antidepressants should be used if depression is present. The suicidal risk should always be
considered. Suicide is 60 times more common in alcoholics than in non-alcoholics.
Detoxification: Outpatient detoxification requires a co-operative patient and a cooperative
significant other person. The patient is given chlorodiazepoxide hydrochloride 20 - 25 mg four
times daily, with the dose depending on the severity of the withdrawal symptoms.
Alcoholics who show signs of impending delirium, tremors, hyper irritability, increased pulse
rate and high blood pressure require hospitalization for detoxification. Alcoholics who are
seriously depressed, suicidal, psychotic or who are uncooperative also require a hospital
setting for detoxification. Finally one must hospitalize those alcoholics whose drinking cannot
be interrupted.
Disulfiram (anti abuse) is useful in the treatment 250 mg/d starting 24 hours after the last
drinking. This drug causes nausea; vomiting and distress which are often severe if the patient
resumes drinking alcohol. Those patients who remain clinically depressed beyond the
detoxification period often benefit from antidepressant medications.
Initially the alcoholic is likely required drying out in a hospital for about 10 days. Since
alcoholics have a tremendous craving to drink some two or three weeks after drying out (stop
drinking), hospitalization for a period of six to eight weeks may therefore be strongly advised.
Alcohol consuming individuals may present with alcohol dependence and abuse, withdrawal
effects or intoxication. Alcohol withdrawal symptoms occur several hours after cessation of or
reduction in prolonged heavy alcohol consumption. At least two of the following must be
present autonomic hyper-activity, hand tremor, insomnia, nausea or vomiting, transient
illusions or hallucinations, anxiety, seizures and agitation.

Alcohol withdrawal delirium (Delirium tremens) is the most severe form of the alcohol
withdrawal syndrome. Among hospitalized patients about 5% develop delirium tremor. A
transient organic psychosis may occur. Delirium will occur within one week of the cessation
or reduction of heavy alcohol ingestion.
Alcoholic amnestic syndrome (Wernicke Korsakoff's syndrome): The essential feature of
alcohol amnestic syndrome is a short term but not immediate memory disturbance due to the

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prolonged heavy use of alcohol.
SUBSTANCE ABUSE
Substance related disorders
A variety of substances may cause substance related disorders including alcohol,
amphetamines and amphetamine-like substances such as, cannabis, cocaine, nicotine,
hallucinogens, opioids, etc.
Cannabis: Cannabis products include marijuana and hashish. Intoxicated patients may exhibit
Euphoria, Anxiety, Dry mouth, Tachycardia, Increased appetite, Hallucinations
Etiology: High stress, inconsistency in parenting & lack of nurturing, Peer pressure, Having
parents that abuse, alcohol
Treatment
- Treatment includes providing reassurance in a quiet place and diazepam may be given.
- Providing health teaching regarding relapse, recovery, and effects of substance abuse
- Confronting family issues such as codependence
- Promoting adaptive coping skills
- Lorazepam & chlordiazepoxide are used for alcohol withdrawal
- Disulfiram maintains abstinence from alcohol
- Methadone maintains abstinence from heroin
- Levomethadyl acetate maintains abstinence from opiates
- Naltrexone reduces alcohol cravings
- Clonidlne suppresses opiate withdrawal symptoms
- Acamprosate suppresses alcohol cravings
- Thiamine or vitamins B1prevents or treats Wernlcke-Korsakoff syndrome in alcoholism
Nursing interventions
The attitude of nursing personnel can influence the quality of care given to persons who abuse
drug. Nurses may view patients who overdose on drugs with disproval, intolerance, moralistic
condemnation, or anger, or they may not display any emotional reaction. They should display
an accepting, nonjudgmental attitude, while coping with various behaviors such as
manipulation, noncompliance, aggression or hostility. Nursing personnel need to be aware of
the various signs and symptoms of drug abuse, if they are to administer appropriate nursing
care. Nursing interventions include providing medical relief for symptoms such as nausea,
vomiting, bruises, fluid and electrolyte imbalance and withdrawal symptoms.

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PERVERSION
This is deviation from what is said to be normal or acceptable behavior, particularly in
relation to sexual behavior.
Sexual Deviation:
A deviation is a disorder since it is a source of concerned discomfort with unpleasant
consequences to the individual indulging into it. It is also pathological when the act is
harmful to the individual or to the society. There are many type of sexual deviation and
person with this deviant behaviors may or may not seek psychiatry therapy. They are divided
into two major group;
A. Minor deviation : more common ones are;
a. Masturbation: This is the physical stimulation of the external sex organ to gain
satisfaction, and this may even results to orgasm.
b. Oral and anal practices
- Fellatio: the penis stimulation into the mouth.
- Cunnilingus: clitoris and labia stimulation with the tongue
c. Promiscuity: it is the indiscriminate sex affair with the same or opposite sex partner.
Lesbians; are two female sex partners.
d. Homosexuality: It is divided into two main group;
- Homosexual panic; an acute episode of anxiety related to fear or delusional concept
that the individual is to be attacked sexually by another person of the same sex (man)
or where the individual is thought to be homosexual by others. The condition maybe
due to a loss or separation of a member of the same sex to whom the subject is
emotionally attached. It may also be due to fatigue in sexual performance, severe
illness, fear of impotence, or failure in sexual performance.
- Homosexual proper: sexual relationship with person of the same sex (man). The
courses have been attributed to constitutional, endocrine, developmental or social
factor.
e. Sexual activity with animals: When it happens, it may require psychiatric help.
f. Voyeurism: this is a condition where either sex may obtain sexual gratification through
looking at the sexual organ of the opposite sex. The condition is usually refer red to us
peeping tom and is common in men and they usually also obtain satisfaction. Though it
may be common in women they do not obtain any satisfaction
g. Exhibitionism: it is the display of sexual organs to the gaze of strangers or members of
the opposite sex. The condition is more of a nuisance than a romance. Interesting enough

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 these exhibitionists never made any advances than just display of their sexual organ. It
occurs more often with people who are insecure or inadequate personality and is
generally believed that they display is aimed at frightening or shocking their victim.
h. Transvestism: this is the psychological term which refer to the practice of wearing the
clothing of the opposite sex, often for personal sexual gratification or to fulfil the desire to
express ones gender identity. Some men wear their wife underpants, and paint their toes
and some may go out with women clothing or get into women toilets. Women usually
dress in men clothing but they do not hide their woman.
i. Frotteurism: this is the recurrent preoccupation with intense sexual urge or fantasy
involving touching or rubbing a non-consenting individual. Sexual excitement is derived
from that act from of touching or rubbing. The individual usually choose to commit the
act in crowded places. He stays in the crowd and identify the person then follow her and
allow the crowd to push him against her buttock or touching her breast or even her
genital. They often escape detection due to the victim initial sock and deny that such an
act has been committed in a public place.
j. Pseudocysis: false pregnancy especially in young women and those approaching
menopause. This disorder gives a good illustration of the powerful action of
psychological factor on female behavior or endocrine function. Characteristics involved
cessation of menstruation, nausea and vomiting, enlargement and pigmentation of the
breast. They may be imaginary labor pain. In history, there is often a wish for pregnancy
sometime link with the desire to please the husband or to retain his attention or attraction
or affection. At time, the wish of pregnancy is to prove is to prove youthfulness or health.
It rarely occurs in unmarried women as it an attempt to force marriage. Diagnosis is
repeated negative pregnancy test, presence of abdominal tumor with disappearance of
abdominal tumor from an anesthesia.
k. Impotence including premature ejaculation: this is total partial inability of the male to
perform an even enjoy sexual intercourse. The condition is usually psychogenic but it is
also found rarely in so many neurological diseases and also a side reaction on certain
medication or drugs.
Courses: As a result of inhibition derived from a sheltered background family or
repressive religion upbringing or fear of women or fear of humiliation from one sexual
partner or fear of disease. Anxiety regarding sexual inadequacy. Impotence is a frequent
symptom of depression and may result in divorce and patient may attempt suicide.

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 B. Major deviation
a. Incest: is sexual relationship between a male and female who are blood related. This
may be between father and daughter mother and son and even close cousin. As a real
act, incest is believed to be rare but the impulse towards it in psychiatric client is very
frequent.
b. Rape: sexual activity true force and without the consent of the other party
c. Sadism: a condition were pain is inflicted in order to achieve sexual gratification. The
sexual act (intercourse) may be rough or you dip your finger or even bite the sexual
organ.
d. Pedophilia: this is the love of children by adult for sexual purposes. A client who is
impotent may be capable of some sexual excitement with young boys or girls and is a
serious sexual deviation which may have some permanent emotional or
developmental or both of them

PSYCHOTHERAPY
Definition: Psychotherapy may be broadly defined as any treatment designed to influence
behavior by verbal or non-verbal means. It includes techniques as varied as confession,
reassurance, hypnosis, psychoanalysis and brain-washing.
Freud and psychoanalysis
All modern psychotherapy owes much to Sigmund Freud (1856-1939), the originator
of the theory and technique psychoanalysis. His work has been criticized as unscientific, but
his ideas permeate twenty first century thought and have perhaps been more influential
outside medicine than within.
Freud’s methods
 Free association: The patient is encouraged to say whatever enters his or her head at
any time during the daily hour of treatment (the basic rule).
 Interpretation: The analyst remains largely silent; refusing to ask or answer
questions, but may offer interpretations of the patient’s dreams, fantasies and
behavior.
 Analysis of the transference: Transference phenomena are feelings; both positive
and negative developed by the patient for the doctor (the doctor may have counter-
transference feelings). They have no realistic foundation in the present and are related
to the patient’s feelings for significant figures, usually parental, in the past, for
example, the patient may treat the male psychotherapist at though s/he were his or her

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 parent. Psychoanalysis, and indeed any kind of intensive understanding of the
patient’s problems, is insufficient and emotional understanding, as relived in
transference, is essential for improvement.
 Working through: Insight gained in the above way must be put into practical use in
real life as part of successful treatment.
As a practical procedure, psychoanalysis occupies some five daily hours each week over
several years and is carried out by a psychoanalyst, usually medically qualified, who himself
has undertaken a lengthy training analysis.
Types of psychotherapies
Brief therapy: Varieties of techniques are exploited, usually in combination:
ventilation in which the patient confides, confesses, and is given the opportunity to
ventilate his past and present difficulties. Clarification, where problems are
discussed and their nature and relations made clear; abreactions, verbalizing
emotionally charged material, with the release of anxiety, anger or grief; and
desensitization, in which repetitive ventilation of feelings, as in mourning, has a
therapeutic effect.
 Group therapy: This involves treating psychoneurotic patients in small groups,
usually of 6 to 8 people. It is more economical than individual psychotherapy and
has advantages for patients with marked social and interpersonal difficulties.
Sessions are generally held weekly, last one to one and a half hour, and continue for
one to two years.
 Conjoint family therapy: This is a form of psychotherapy in which one or two
therapists see several members of a family together. It can be regarded as a special
form of group therapy. As well as using analytic ideas it has made use of
sociological concepts of role and of general systems theory in explaining what
happens in normal and pathological family relationships, e.g. scapegoat, when one
member of the family is consistently blamed for all the family’s problems for
unproven efficacy.
 Behavior therapy is the most active area of growth in psychotherapy. It has been
developed largely by psychologists from their studies on experimental learning in
humans and animals. It attempts to change symptom directly rather than seek for
underlying causes, and assumes that neurotic symptoms stem from faulty learning.
 Recreation therapy is a form of activity therapy used in most psychiatric settings.
Recreation or play activities provide patients with the opportunity for fun and for

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 feeling good. It adds balance to their daily schedule and helps in treating the whole
patient. Therapeutic recreations can occur as: - Informal playing - Card games- Trips
outside the hospital - Basketball, football or volley ball games - Attending sport
events and so on.

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