Mental health nursing book R shrivani.pdf

Expanded my collection knowledge skill at all to help and require education and skill

1. SECOND EDITION
RSreevani
Foreword
KReddemma
JAYPEE

2. A Guide to
MENTAL HEALTH
AND
PSYCHIATRIC NURSING
R Sreevani
MSc (Psychiatric Nursing)
Associate Professor, Sri Devaraj Urs College of Nursing
Tamaka, Kolar
Karnataka
Contributing Editor
Prasanthi N
Research Scholar in Nursing
NTMHANS
Bengaluru
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
New Delhi

3. Contents
1. Mental Health and Mental Illness 1
2. Principles and Concepts of Mental Health Nursing 14
3. Personality Development and Theories 29
4. Conceptual Models 48
5. Nursing Process in Psychiatric Nursing 57
6. The Therapeutic Nurse-Patient Relationship 66
7. The Individual with Functional Psychiatric Disorder 77
8. Organic Mental Disorders 104
9. The Individual with Neurotic Disorder 110
10. Behavioral Syndromes Resulting from Physiological Disturbances 124
11. Disorders due to Psychoactive Substance Use 129
12. Disorders of Adult Personality and Behavior 144
13. Childhood Psychiatric Disorders 150
14. Therapeutic Modalities in Psychiatry 171
15/Crisis Intervention 201
16. Legal Aspects of Mental Health Nursing 215
17. Community Mental Health Nursing 224
18./Psychiatric Emergencies 240
19. Psychosocial Issues Among Special Population 245
AppendixI-Glossary 253
Appendix II-Mental Mechanisms 260
Further Reading 263
Index 265
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2

4. MentalHealthand
MentalIllness
DMENTALHEALTH
Definitions
ComponentsofMentalHealth
CriteriaforMentalHealth
IndicatorsofMentalHealth-Jahoda(1958)
CharacteristicsofaMentallyHealthy
Person
DMENTALILLNESS
Definition
CharacteristicsofMentalIllness
FeaturesofMentalIllness
CommonSignsandSymptomsofMental
Illness
DCONCEPTSOFNORMALANDABNORMAL
BEHAVIOR
DPROBLEMSOFMENTALDISORDERS
DBURDENOFMENTALDISORDERS
DMENTALHEALTHFACTS
DMENTALHEALTHISSUES
DMINIMUMACTIONSREQUIRED
DMAGNITUDEOFTHEPROBLEMININDIA
DETIOLOGYOFMENTALILLNESS
DMISCONCEPTIONSABOUTMENTALILLNESS
GeneralAttitudeTowardsTheMentallyIll
DMENTALHEALTHTEAM
DCLASSIFICATIONOFMENTALDISORDERS
ICD10
DSMIV
IndianClassification
MENTALHEALTH
Itisastateofbalancebetweentheindividualand
thesurroundingworld,astateofharmonybet­
weenoneselfandothers,aco-existencebetween
therealitiesoftheselfandthatofotherpeople
andtheenvironment.
Definitions
KarlMenninger(1947)definesmentalhealthas
"Anadjustmentofhumanbeingstotheworld
andtoeachotherwithamaximumof
effectivenessandhappiness."
TheAmericanPsychiatricAssociation(APA
1980)definesmentalhealthas:"Simultaneous
successatworking,lovingandcreatingwiththe
capacityformatureandflexibleresolutionof
conflictsbetweeninstincts,conscience,important
otherpeopleandreality".
Thusmentalhealthwouldincludenotonly
theabsenceofdiagnosticlabelssuchasschizo­
phreniaandobsessivecompulsivedisorder,but
alsotheabilitytocopewiththestressorsofdaily
living,freedomfromanxietiesandgenerallya
positiveoutlooktowardslife'svicissitudesand
tocopewiththose.
ComponentsofMentalHealth
Thecomponentsofmentalhealthinclude:
•Theabilitytoacceptself:Amentallyhealthy
individualfeelscomfortableabouthimself.He
feelsreasonablysecureandadequately
acceptshisshortcomings.Inotherwords,he
hasself-respect.
•Thecapacitytofeelrighttowardsothers:An
individualwhoenjoysgoodmentalhealthis
abletobesincerelyinterestedinother's
welfare.Hehasfriendshipsthataresatisfying
andlasting.Heisabletofeelapartofagroup
withoutbeingsubmergedbyit.Hetakes
responsibilityforhisneighborsandhisfellow
members.
•Theabilitytofulfilllife'stasks:Thethird
importantcomponentofmentalhealthisthat

5. 2AGuidetoMentalHealthandPsychiatricNursing
itbestowsonanindividualtheabilitytomeet
thedemandsoflife.Amentallyhealthyperson
isabletothinkforhimself,setreasonablegoals
andtakehisowndecision.Hedoessomething
abouttheproblemsastheyarise.Heshoulders
hisdailyresponsibilities,andisnotbowled
overbyhisownemotionsof'ear,anger,love
orguilt.
CriteriaforMentalHealth
•Adequatecontactwithreality
•Controlofthoughtsandimagination
•Efficiencyinworkandplay
•Socialacceptance
•Positiveself-concept
•Ahealthyemotionallife
IndicatorsofMentalHealth
Jahoda(1958)hasidentifiedsixindicatorsof
mentalhealthwhichinclude:
1.Apositiveattitudetowardsself
Thisincludesanobjectiveviewofself,
includingknowledgeandacceptanceof
strengthsandlimitations.Theindividualfeels
astrongsenseofpersonalidentityandsecurity
withintheenvironment.
2.Growth,developmentandtheabilityforself
actualization
Thisindicatorcorrelateswithwhetherthe
individualsuccessfullyachievesthetasks
associatedwitheachlevelofdevelopment.
3.Integration
Integrationincludestheabilitytoadaptively
respondtotheenvironmentandthedevelop­
mentofaphilosophyoflife,bothofwhich
helptheindividualmaintainanxietyata
manageablelevelinresponsetostressful
situations.
4.Autonomy
Referstotheindividual'sabilitytoperform,
inanindependentself-directedmanner;the
individualmakeschoicesandaccepts
responsibilityfortheoutcomes.
5.Perceptionofreality
Thisincludesperceptionoftheenvironment
withoutdistortion,aswellasthecapacityfor
empathyandsocialsensitivity-arespectand
concernforthewantsandneedsofothers.
6.Environmentalmastery
Thisindicatorsuggeststhattheindividual
hasachievedasatisfactoryrolewithinthe
group,societyorenvironment.Heisableto
loveandaccepttheloveofothers.
CharacteristicsofaMentallyHealthyPerson
•Hehasanabilitytomakeadjustments.
•Hehasasenseofpersonalworth,feels
worthwhileandimportant.
•Hesolveshisproblemslargelybyhisown
effortandmakeshisowndecisions.
•Hehasasenseofpersonalsecurityandfeels
secureinagroup,showsunderstandingof
otherpeople'sproblemsandmotives.
•Hehasasenseofresponsibility.
•Hecangiveandacceptlove.
•Helivesinaworldofrealityratherthan
fantasy.
•Heshowsemotionalmaturityinhisbehavior,
anddevelopsacapacitytotoleratefrustration
anddisappointmentsinhisdailylife.
•Hehasdevelopedaphilosophyoflifethat
givesmeaningandpurposetohisdaily
activities.
•Hehasavarietyofinterestsandgenerally
livesawell-balancedlifeofwork,restand
recreation.
MENTALILLNESS
Mentalillnessismaladjustmentinliving.It
producesadisharmonyintheperson'sabilityto
meethumanneedscomfortablyoreffectivelyand
functionwithinaculture.
Amentallyillpersonloseshisabilityto
respondaccordingtotheexpectationshehas
forhimselfandthedemandsthatsocietyhasfor
him.
Ingeneralanindividualmaybeconsidered
tobementallyillif:

6. MentalHealthandMentalIllness3
•theperson'sbehavioriscausingdistressand
sufferingtoselfandIorothers
•theperson'sbehavioriscausingdisturbance
inhisday-to-dayactivities,jobandinter­
personalrelationships.
Definition
Mentalandbehavioraldisordersareunderstood
asclinicallysignificantconditionscharacterized
byalterationsinthinking,mood(emotions)or
behaviorassociatedwithpersonaldistressand/
orimpairedfunctioning.(WHO,2001)
CharacteristicsofMentalIllness
•Changesinone'sthinking,memory,percep­
tion,feelingandjudgmentresultingin
changesintalkandbehaviorwhichappear
tobedeviantfrompreviouspersonalityorfrom
thenormsofcommunity
•Thesechangesinbehaviorcausedistressand
sufferingtotheindividualorothersorboth
•Changesandtheconsequentdistresscause
disturbanceinday-to-dayactivities,workand
relationshipwithimportantothers(socialand
vocationaldysfunction).
FeaturesofMentalIllness
Thefeaturesofmentalillnessareclassifiedunder
fourheadings
1.Disturbancesinbodilyfunctions
2.Disturbancesinmentalfunctions
3.Changesinindividualandsocialactivities
4.Somaticcomplaints
1.DisturbancesinBodilyFunctions
•Sleep:Disturbedsleepthroughoutthenight,
ornosleepatall,ordifficultyinfallingasleep,
orwakingupinthemiddleofnightand
failingtofallasleepagain.Inaddition,the
individualmayexperiencelethargyandlack
offreshnessinthemorning.
•Appetiteandfoodintake:Increasedappetiteor
decreasedappetite,weightlossorweightgain,
nausea,vomiting.
•Bowelandbladdermovement:Diarrheaorconsti­
pation,increasedmicturition,bed-wetting.
•Sexualdesireandactivity:Decreasedinterestin
sex,prematureejaculation,impotenceorlack
ofsexualsatisfaction.Insomeconditions
therecanbeexcessivesexualdesireorlackof
socialinhibitions.
2.DisturbancesinMentalFunctions
•Behavior:Thepatientmayexhibitoveractivity,
restlessness,irritability,maybeabusiveto
othersfortrivialornoreasonsatall,orthe
patientmaybecomedull,withdrawnandnot
respondtoexternalorinternalcues.Attimes
thepatientmaybehaveinabizarrewaywhich
thefamilymembersmayfindirritating.Some­
timesthepatient'sbehaviorcanbedangerous
toselforothers.
•Speech:Patienttalksexcessivelyandunneces­
sarilyortalksverylittleorstaysmute.The
talkbecomesirrelevantandun-understand­
able(incoherent).
•Thought:Patientexpressespeculiarandwrong
beliefswhichothersdonotshare.
•Emotions:Patientmayexhibitexcessiveemo­
tionslikeexcessivehappiness,anger,fearor
sadness.Sometimesemotionscanbe
inappropriatetosituations.Hemaylaughto
selforweepwithoutanyreason.
•Perception:Thepatientmayperceivewithout
anystimulus.Therecanbemisinterpretation
ofperception.Forexampleamentallyill
personcanseethingsorhearsoundsorfeel
objectswhichdonotexistorwhichothersdo
notsee.Thisisknownashallucinations.A
patientwhoishallucinatingisseentalkingto
self,laughingorweepingtoself,wandering
inthestreetsandbehavinginamannerwhich
othersmayfindabnormal.
•Attentionandconcentration:Patientmayhave
decreasedattentionandconcentration;he
maygetdistractedeasily,orhaveselective
inattention.
•Memory:Patientmaylosehismemoryandstart
forgettingimportantmatters.

7. 4AGuidetoMentalHealthandPsychiatricNursing
•Intelligenceandjudgment:Insomemental
illnesses,intelligenceandtheabilitytotake
decisionsdeteriorate.Patientlosesreasoning
skillsandabilities,maynotbeabletoperform
simplearithmetic,orcommitsmistakesin
routinework.
•Levelofconsciousness:Insomementalillnesses
duetopossiblebraindamagetheremaybe
changesinthelevelofconsciousness.Patient
failstoidentifyhisrelatives.Hecanbe
disorientedtotimeandplace.Hemayremain
confusedorbecomeunconscious.
3.ChangesinIndividualandSocialActivities
Patientsmayneglecttheirbodilyneedsand
personalhygiene.Thepatientmayalsolosesocial
sense.Theybehaveinaninappropriatemanner
insocialsituationsandembarrassothers.They
behavestrangelywiththeirfamilymembers,
friends,colleaguesandothers.Theymayinsult,
abuse/assaultthem.
4.SomaticComplaints
Patientmaycomplainofachesandpainsin
differentpartsofthebody,fatigue,weakness,
involuntarymovements,etc.
CommonSignsandSymptomsofMental
Illness
DisturbancesinMotorBehavior
Motorretardation,stupor,stereotypes,negati­
vism,ambitendence,waxyflexibility,echopraxia,
restlessness,agitationandexcitement.
Disordersofthought,languageandcommunication
Pressureofspeech,povertyofspeech,dysarthria,
flightofideas,circumstantiality,looseningof
association,tangentiality,incoherence,persevera­
tion,neologism,clangassociation,thoughtblock,
thoughtinsertion,thoughtbroadcasting,echo­
lalia,delusions,obsessionsandphobias.
Disordersofperception
Illusions,hallucinations,depersonalization,
derealization.
Disordersofemotion
Bluntaffect,labileaffect,elatedmood,euphoria,
ecstasy,dysphoricmood,depression,anhedonia.
Disturbancesofconsciousness
Cloudingofconsciousness,deliriumandcoma.
Disturbancesinattention
Distractibility,selectiveinattention.
Disturbancesinorientation
Disorientationoftime,placeorperson.
Disturbancesofmemory
Amnesia,confabulation.
Impairedjudgment
Disturbancesinbiologicalfunction
Persistentdeviationsintemperature,pulseand
respiration,nausea,vomiting,headache,lossof
appetite,increasedappetite,lossofweight,pain,
fatigue,weightgain,insomnia,hypersomniaand
sexualdysfunction.
CONCEPTSOFNORMALAND
ABNORMALBEHAVIOR
Psychiatryasevidentfromtheaboveisconcerned
withabnormalbehaviorinitsbroadestsense,but
definingtheconceptsofnormalandabnormal
behaviorassuchhasbeenfoundtobedifficult.
Theseconceptsaremuchundertheinfluenceof
socioculturalfactors.
Severalmodelshavebeenputforwardinorder
toexplaintheconceptofnormalandabnormal
behavior.Someofthemare:
MedicalModel
Medicalmodelconsidersorganicpathologyas
thedefinitecauseformentaldisorder.According
tothismodelabnormalpeoplearetheoneswho
havedisturbancesinthought,perceptionand
psychomotoractivities.Thenormalaretheones
whoarefreefromthesedisturbances.
StatisticalModel
Itinvolvestheanalysisofresponsesonatestora
questionnaireorobservationsofsomeparticular

8. MentalHealthandMentalIllness5
behavioralvariables.Thedegreeofdeviationfrom
thestandardnormsarrivedatstatistically,
characterizesthedegreeofabnormality.
Statisticallynormalmentalhealthfallswithin
twostandarddeviations(SDs)ofthenormal
distributioncurve.
SocioculturalModel
Thebeliefs,norms,taboosandvaluesofasociety
havetobeacceptedandadoptedbyindividuals.
Breakinganyofthesewouldbeconsideredas
abnormal.Normalcyisdefinedincontextwith
socialnormsprescribedbytheculture.Thus
culturalbackgroundhastobetakenintoaccount
whendistinguishingbetweennormaland
abnormalbehavior.
BehaviorModel
Behaviorthatisadaptive,isnormal,maladaptive
isabnormal.Abnormalbehaviorisasetoffaulty
behaviorsacquiredthroughlearning.
PROBLEMS OFMENTALDISORDERS
•Self-carelimitationsorimpairedfunctioning
relatedtomentalillness
•Significantdeficitsinbiological,emotional
andcognitivefunctioning
•Disability,life-processchanges
•Emotionalproblemssuchasanxiety,anger,
sadness,lonelinessandgrief
•Physicalsymptomsthatoccuralongwith
alteredpsychologicalfunctioning
•Alterationinthinking,perceiving,communi­
catinganddecisionmaking
•Difficultiesinrelatingtoothers
•Patient'sbehaviormaybedangeroustoself
orothers
•Adverseeffectsonthewell-beingofthe
individual,familyandcommunity
•Financial,marital,family,academicand
occupationalproblems.
BURDENOFMENTALDISORDERS
Mentaldisordersarecommon,affectingmore
than25percentofallpeopleatsometimeduring
theirlives.Theyarealsouniversal,affecting
peopleinallcountriesandsocieties,individuals
ofallages,womenandmen,therichandthepoor,
fromurbanandruralenvironments.Theyhave
aneconomicimpactonsocietiesandonthe
qualityoflifeofindividualsandfamilies.
•Mentaldisordersatanypointoftimeare
presentinabout10percentoftheadult
population.Around20percentofallpatients
seenbyprimaryhealthcareprofessionalshave
oneormorementaldisorders.
•Duringthelasttwodecadesmany
epidemiologicalstudieshavebeenconducted
inIndia,whichshowthatmentaldisorders
prevailin18to207per1000,withmedian
65.4per1000atanygiventime.About2.3%of
thepopulationsuffersfromseriously
incapacitatingmentaldisordersorepilepsy.
Alargenumberofadultpatients(10.4%to
53.0%)comingtothegeneraloutpatient
departmentarediagnosedasmentallyill.
•Itisestimatedthatin2000,mentaldisorders
accountedfor12%ofthetotalDisability
AdjustedLifeYears(DALYs)lostduetoall
diseasesandinjuries.Commondisorders,
whichusuallycauseseveredisability,include
depressivedisorder,substanceusedisorders,
schizophrenia,epilepsy,Alzheimer'sdisease,
mentalretardationanddisordersofchildhood
andadolescence.
•Morethan450millionpeopletodaysuffer
frommentalandbehavioraldisorders.Within
thenext20yearsdepressionwillhavethe
dubiousdistinctionofbecomingthesecond
biggestcauseforglobalburdenofdisease.
•Worldwide70millionpeoplesufferfrom
alcoholdependence,50millionfromepilepsy,
24millionfromschizophreniaandanother
20millionpeopleattemptsuicideeveryyear.
•GlobalBurdenofDisease(GBD)2000
estimatesshowthatmentalandneurological
conditionsaccountfor30.8%ofallYearsLived
withDisability(YLD).Depressioncausesthe
largestamountofdisability,accountingfor
almost12%ofalldisabilities.Sixneuro­
psychiatricconditionsfiguredinthetop

9. 6AGuidetoMentalHealthandPsychiatricNursing
twentycausesofdisabilityworldwidewhich
include:
•Unipolardepressivedisorders
•Alcoholusedisorders
•Schizophrenia
•Bipolaraffectivedisorders
•Alzheimer'sandotherdementias
•Migraine
•Mentalillnessescausemassivedisruptionin
thelivesofindividuals,familiesandcommu­
nities.Individualssufferthedistressingsymp­
tomsofdisorders.Theyalsosufferbecause
theyareunabletoparticipateinworkand
leisureactivitiesoftenasaresultofdiscrimi­
nation.Theyworryaboutnotbeingableto
shouldertheirresponsibilitiestowardstheir
familyandfriendsandarefearfulofbeinga
burdentoothers.Mentalillnessesarecommon
toallcountriesandcauseimmensesuffering.
Peoplewiththesedisordersareoftensubjected
tosocialisolation,poorqualityoflifeand
increasedmortality.Thesedisordersarethus
thecauseofstaggeringeconomicandsocial
costs.
•Itisestimatedthatoneinfourfamilieshasat
leastonemembercurrentlysufferingfroma
mentalillness.Thesefamiliesarerequirednot
onlytoprovidephysicalandemotionalsup­
port,butalsotobearthenegativeimpactof
stigmaanddiscriminationpresentinallparts
oftheworld.
•Familiesinwhichonememberissuffering
fromamentaldisordermakeanumberof
adjustmentsandcompromisesthatprevent
othermembersofthefamilyfromachieving
theirfullpotentialinwork,socialrelation­
shipsandleisure.Thesearethehuman
aspectsoftheburdenofmentaldisordersthat
aredifficulttoassessandquantify.
•Theimpactofmentaldisordersincommu­
nitiesislargeandmanifold.Thereisthecost
ofprovidingcare,thelossofproductivityand
certainlegalproblemsassociatedwithsome
mentaldisorders.
MENTALHEALTHFACTS
•Oneinfourpatientsvisitingahealthservice
hasatleastonemental,neurologicalor
behavioraldisorderbutmostofthesedisorders
areneitherdiagnosednortreated.
•Barrierstoeffectivetreatmentofmentalillness
includelackofrecognitionoftheseriousness
ofmentalillnessandlackofunderstanding
aboutthebenefitsofservices.Policymakers,
insurancecompanies,healthandlaborpoli­
ciesandthepublicatlarge-alldiscriminate
betweenphysicalandmentalhealthprob­
lems.
•Mostmiddleandlow-incomecountriesdevote
lessthan1%oftheirhealthexpenditureto
mentalhealth.Consequently,mentalhealth
policies,legislation,communitycarefacilities,
andtreatmentforpeoplewithmentalillness
arenotgiventheprioritytheydeserve.
•Morethan40%ofcountrieshavenomental
healthpolicyandover30%havenomental
healthprogram.Over90%ofcountrieshave
nomentalhealthpolicythatincludeschildren
andadolescents.Inadditionhealthplans
frequentlydonotcovermentaland
behavioraldisordersatthesamelevelasother
illnesses,creatingsignificanteconomic
difficultiesforpatientsandtheirfamilies.
Therefore,thesufferingcontinuesanddifficul­
tiesgrow.
•Thereisawidegapbetweenavailabilityand
implementationofeffectiveinterventions,e.g.
inIndia,treatmentratesforschizophreniaand
epilepsyarereportedtobe20%ofallcasesin
needoftreatment,comparedto80%forthe
samedisordersinthewest.
•Thereisanurgentneedtosensitizegovern­
mentsontheimportanceofmentalhealthand
clearlydefinethegoalsandobjectivesof
community-basedhealthprograms.Mental
healthservicesshouldbeintegratedintothe
overallprimaryhealthcaresystem.Innovative
community-basedhealthprogramswhichare
culturallyandgenderappropriateandreach
outtoallsegmentsofthepopulationneedto

10. MentalHealthandMentalIllness7
bedeveloped.Well-organizedcommunity­
basedcareisurgentlyrequiredbesides
increasingthenumberofpsychiatricbedsin
thegeneralhospitals;governmentsmusttake
theresponsibilityforensuringthatmental
healthpoliciesaredevelopedandimplemen­
ted.Strategieslikeincludingtheintegration
ofmentalhealthtreatmentandservicesinto
thegeneralhealthsystem,particularlyinto
primaryhealthcare,mustbepursued.
MENTALHEALTHISSUES
Thereareanumberofnewissuesthathavecome
upinthecountrywithimplicationsformental
health.Themostnotablearealcoholpolicies,
violenceinsociety,thegrowingpopulationof
elderlypersons,urbanization,mentalhealthof
women,disastercare,migrantsandrefugees,street
children,andstressattheworkplace.Thesenew
problemsposeseriouschallengestoexisting
mentalhealthservicesandinfrastructure.
TheNationalRuralHealthMission(NRHM)
hasoverlookedvariousgroundrealitiesrelated
tomentalhealth.Thereisashortageofmanpower,
andtrainingprogramsarenotabletomeetthe
demandsinprovidingtrainingtoallmedical
privatepractitionersandmedicalofficers.
Appropriatementalhealthcanbeprovidedatthe
subcentreandvillagelevelbyminimumtraining
ofthehealthworkersthatwillhelpinproviding
comprehensivehealthcareatthemostperipheral
level.ItisnecessarytointegrateNationalMental
HealthProgramandDistrictMentalHealth
ProgramandincludementalhealthinNational
RuralHealthMissiontoachievehealthforall.
MINIMUMACTIONSREQUIRED
•Formulatingpoliciesdesignedtoimprovethe
mentalhealthofpopulations
•Assuringuniversalaccesstoappropriateand
cost-effectiveservices(includingmental
healthpromotionandpreventionservices)
•Ensuringadequatecareandprotectionof
humanrightsforinstitutionalizedpatients
withmostseverementaldisorders
•Assessingandmonitoringmentalhealthin
communities
•Promotinghealthylifestylesandreducingrisk
factorsformentaldisorders
•Supportingstablefamilylife,socialcohesion
andhumandevelopment
•Continuingresearchinrelatedareas
•Introducingmentalhealthcareactivitiesin
workplaceandschools
•Useofmassmediatopromotementalhealth,
fosterpositiveattitude,andhelpprevent
disorders.
(Source:SyedAminTabish,JK-practitioner
2005,12(1):34-38).
MAGNITUDE OFTHEPROBLEM ININDIA
Thecommonpsychiatricillnessesencountered
inaclinicofaGeneralHospitalare-Neurotic
disorders(e.g.anxietyneurosis,obsessive­
compulsivedisorderandreactivedepression),
psychosomaticdisorders(e.g.hypertension,
diabetesmellitus,pepticulcer,tensionheadaches,
etc.),functionalpsychosis(e.g.schizophrenia,
maniaanddepression)andorganicpsychosis.
Inachildguidanceclinic,thecommonmental
illnessesincludementalretardation,conduct
disorder,hyperkineticsyndrome,enuresis,etc.
Inageriatricclinicthecommondisordersare
depression,dementia,delusionaldisorders,etc.
Inapsychosexualclinicthecommonproblems
includeDhatsyndrome,prematureejaculation,
erectileimpotenceandsoon.
Theprevalenceofpsychiatricdisordersis58.2
perthousandwhichmeansthatthereareabout
5.7crorepeoplesufferingfromsomesortof
psychiatricdisturbance.Outofthis4lakhpeople
haveorganicpsychoses,26lakhpeoplehave
schizophreniaand1.2crorepeoplehaveaffective
psychosis;thusthereareabout1.5crorepeople
sufferingfromseverementaldisorders,besides
12,000patientsingovernmentmentalhospitals
inthecountry(Reddyetal,1996).
ETIOLOGYOFMENTALILLNESS
Manyfactorsareresponsibleforthecausationof
mentalillness.Thesefactorsmaypredisposean

11. 8AGuidetoMentalHealthandPsychiatricNursing
individualtomentalillness,precipitateor
perpetuatethementalillness.
PredisposingFactors
Thesefactorsdetermineanindividual'ssuscep­
tibilitytomentalillness.Theyinteractwith
precipitatingfactorsresultinginmentalillness.
Theseare:
•Geneticmakeup
•Physicaldamagetothecentralnervoussystem
•Adversepsychosocialinfluence
PrecipitatingFactors
Theseareeventsthatoccurshortlybeforethe
onsetofadisorderandappeartohaveinducedit.
Theseare:
•Physicalstress
•Psychosocialstress
PerpetuatingFactors
Thesefactorsareresponsibleforaggravatingor
prolongingthediseasesalreadyexistinginan
individual.Psychosocialstressisanexample.
Thusetiologicalfactorsofmentalillnesscan
be:
•Biologicalfactors
•Physiologicalchanges
•Psychologicalfactors
•Socialfactors
BiologicalFactors
Heredity
Whatoneinheritsisnottheillnessoritssymp­
toms,butapredispositiontotheillness,whichis
determinedbygenesthatweinheritdirectly.
Studieshaveshownthatthree-fourthsofmental
defectivesandone-thirdofpsychoticindividuals
owetheirconditionmainlytounfavorable
heredity.
BiochemicalFactors
Biochemicalabnormalitiesinthebrainare
consideredtobethecauseofsomepsychological
disorders.Disturbanceinneurotransmittersinthe
brainisfoundtoplayanimportantroleinthe
etiologyofcertainpsychiatricdisorders.
BrainDamage
Anydamagetothestructureandfunctioningof
thebraincangiverisetomentalillness.Damage
tothestructureofthebrainmaybeduetooneof
thefollowingcauses:
•Infection:E.g.Neurosyphilis,encephalitis,HIV
infection,etc.
•Injury:Lossofbraintissueduetoheadinjury
•Intoxication:Damagetobraintissuedueto
toxinssuchasalcohol,barbiturates,lead,etc.
•Vascular:Poorbloodsupply,bleeding(intra­
cranialhemorrhage,subarachnoidhemor­
rhage,subduralhemorrhage)
•Alterationinbrainfunction:Changesinblood
chemistrythatinterferewithbrainfunctioning
suchasdisturbanceinbloodglucoselevels,
hypoxia,anoxia,andfluidandelectrolyte
imbalance
•Tumors:Braintumors
•Vitamindeficiencyandmalnutrition,in
particulardeficiencyofvitaminBcomplex
•Degenerativediseases:Dementia
•Endocrinedisturbances:Hypothyroidism,
thyrotoxicosisetc.
•Physicaldefectsandphysicalillness:Acute
physicalillnessaswellaschronicillnesses
withalltheirhandicappingconditionsmay
resultinlossofmentalcapacities
PhysiologicalChanges
Ithasbeenobservedthatmentaldisordersare
morelikelytooccuratcertaincriticalperiodsof
lifenamely-puberty,menstruation,pregnancy,
delivery,puerperiumandclimacteric.These
periodsaremarkednotonlybyphysiological
(endocrine)changes,butalsobypsychological
issuesthatdiminishtheadaptivecapacityofthe
individual.Thustheindividualbecomesmore
susceptibletomentalillnessduringthisperiod.
PsychologicalFactors
•Itisobservedthatsomespecificpersonality
typesaremorepronetodevelopcertain

12. MentalHealthandMentalIllness9
psychologicaldisorders.Forexamplethose
whoareunsocialandreserved(schizoid)are
vulnerabletoschizophreniawhentheyface
adversesituationsandpsychosocialstresses.
•Psychologicalfactorslikestrainedinter­
personalrelationshipsathome,placeofwork,
schoolorcollege,bereavement,lossof
prestige,lossofjob,etc.
•Childhoodinsecuritiesduetoparentswith
pathologicalpersonalities,faultyattitudeof
parents(over-strictness,overleniency),abnor­
malparent-childrelationship(over­
protection,rejection,unhealthycomparisons),
deprivationofchild'sessentialpsychological
andsocialneeds,etc.
•Socialandrecreationaldeprivationsresulting
inboredom,isolationandalienation.
•Marriageproblemslikeforcedbachelorhood,
disharmonyduetophysical,emotional,social,
educationalorfinancialincompatibility,
childlessness,toomanychildren,etc.
•Sexualdifficultiesarisingoutofimpropersex
education,unhealthyattitudestowardssexual
functions,guiltfeelingsaboutmasturbation,
preandextra-maritalsexrelations,worries
aboutsexualperversions.
•Stress,frustrationandseasonalvariationsare
sometimesnotedintheoccurrenceofmental
diseases.
SocialFactors
•Poverty,unemployment,injustice,insecurity,
migration,urbanization
•Gambling,alcoholism,prostitution,broken
homes,divorce,verybigfamily,religion,
traditions,politicalupheavalsandother
socialcrises
MISCONCEPTIONS ABOUTMENTALILLNESS
Beliefsaboutmentalillnesshavebeencharacte­
rizedbysuperstition,ignoranceandfear.
Althoughtimeandadvancesinscientific
understandingofmentalillnesshavedispelled
manyfalseideas,thereremainanumberof
popularmisconceptions.Someofthemare:
•Mentalillnessiscausedbysupernaturalpower
andistheresultofacurseorpossessionbyevil
spirit:Manypeopledonotconsidermental
illnessasanillness,butpossessionbyspirits
orcursethathasbefallenonthepatientor
familybecauseofpastsinsormisdeedsin
previouslife.
•Mentallyillpeopleshowbizarrebehavior:
Patientsinmentalhospitalsandclinicsare
oftenpicturisedasaweirdlot,whospend
theirtimeexhibitinguselessbizarrebehavior
liketwistingofhands,etc.
•Mentallyillpeoplearedangerous:Peoplewho
haveorhadamentalillnessareviewedwith
suspicionandasdangerouspersons.
•MentalillnessissomethingtobeashamedofThis
ideaarousesanunsympathetic,cruelattitude
towardsamentallyillperson.Thisisthe
reasonwhymanypeoplehidementalillness
inthefamily.
•Mentalillnessisnotcurable:Peopleobjecttohave
normalrelationshipwithmentallyillpeople,
ortogivethememploymentevenafterbeing
cured,oreventoacceptthemasneighbors.
•Mentalillnessiscontagious:Thefearthatitis
contagiousisthemainfalsenotionwhich
leadspeopletoviewsuspiciously,orobjectto
maritalrelationswithapersonbelongingto
thehouseholdofthementallyill.
•Mentalillnessishereditary:Itisnotarulethat
childrenofmentallyillpatientsshouldbecome
mentallyill.
•Marriagecancurementalillness:Amentallyill
personcangetworseifhegetsmarriedwhen
heisill,asmarriagecanbecomeanadditional
stress.Apatientwhohasrecoveredcanget
marriedandliveanormallifelikeanyother
person.
•Mentalhospitalsareplaceswhereonlydangerous
mentallyillindividualsaretreatedandrestraint
isamajorformoftreatment:Peoplehesitateto
taketheirrelativestomentalhospitalsfor
treatmentbecauseoffear.Further,asex­
patientofamentalhospital,he,aswellashis
familymembersareoftenisolated.Therefore,
peopleseekhelpfrommentalhospitalsonly
asalastresort.

13. 10AGuidetoMentalHealthandPsychiatricNursing
GeneralAttitudetowardtheMentallyIll
•Ingeneralthecommunityrespondstothe
mentallyillthroughdenial,isolationand
rejection.Thereisalsoalackofunderstanding
ofmentalillnessasanyotherillness,anda
lackoftendencytorejectboththepatientsand
thosewhotreatthem.
•Mentallyillareviewedaspeoplewithno
capacityforunderstanding.
•Peoplefeelmentalillnesscannotbecured,and
evenifthepatientgetsbetter,completephysical
restisconsideredessential.
•Thementallyillarebyandlargeperceivedas
aggressive,violentanddangerous.
Anindividual'svaluesandpersonalbeliefs
affecthisattitudeaboutmentalillness,the
mentallyillandtreatmentofmentalillness.There
stillexistsastigmasurroundingindividualswho
needorusepsychiatricmentalhealthservices.
Theneedcontinuesforpubliceducationto
modifyoraltermisconceptionsaboutmental
illnessandpeoplewithmentaldisorders.
MENTALHEALTHTEAMOR
MULTIDISCIPLINARY TEAM
Multidisciplinaryapproachreferstocollabora­
tionbetweenmembersofdifferentdisciplineswho
providespecificservicestothepatient.
Themultidisciplinaryteamincludes:
•APsychiatrist
•APsychiatricnurse
•AClinicalpsychologist
•APsychiatricsocialworker
•AnOccupationaltherapistoranActivity
therapist
•APharmacistandadietitian
•ACounselor
APsychiatristisamedicaldoctorwithspecial
traininginpsychiatry.Heisaccountableforthe
medicaldiagnosisandtreatmentofpatient.Other
importantfunctionsare:
•Admittingpatientintoacutecaresetting
•Prescribingandmonitoringpsychopharma­
cologicagents
•Administeringelectroconvulsivetherapy
•Conductingindividualandfamilytherapy
•Participatingininterdisciplinaryteammeetings
•Owingtotheirlegalpowertoprescribeandto
writeorders,psychiatristsoftenfunctionas
leadersoftheteam.
APsychiatricnurseisaregisterednursewith
specializedtraininginthecareandtreatmentof
psychiatricpatients;shemayhaveaDiploma,
MSc.,M.Phil.orPh.Dinpsychiatricnursing.She
isaccountableforthebio-psychosocialnursing
careofpatientsandtheirmilieu.Otherfunctions
include:
•Administeringandmonitoringmedications
•Assistinginnumerouspsychiatricand
physicaltreatments
•Participateininterdisciplinaryteammeetings
•Teachpatientsandfamilies
•Takeresponsibilityforpatient'srecords
•Actaspatient'sadvocate
•Interactwithpatients'significantothers
AClinicalpsychologistshouldhaveaMasters
DegreeinPsychologyorPh.Dinclinicalpsycho­
logywithspecializedtraininginmentalhealth
settings.Heisaccountableforpsychological
assessments,testing,andtreatments.Heoffers
directservicessuchasindividual,familyor
maritaltherapies.
APsychiatricsocialworkershouldhavea
MastersDegreeinSocialWorkorPh.Ddegree
withspecializedtraininginmentalhealth
settings.Heisaccountableforfamilycasework
andcommunityplacementofpatients.He
conductsgrouptherapysessions.Heemphasizes
interventionwiththepatientinsocial
environmentinwhichhewilllive.
AnOccupationaltherapistoranActivity
therapistisaccountableforrecreational,
occupationalandactivityprograms.Heassists
thepatientstogainskillsthathelpthemcope
moreeffectivelytogainorretainemployment,to
useleisuretime.
ACounselorprovidesbasicsupportive
counselingandassistsinpsychoeducationaland
recreationalactivities.

14. MentalHealthandMentalIllness11
CLASSIFICATION OFMENTALDISORDERS
Classificationisaprocessbywhichcomplex
phenomenaareorganizedintocategories,classes
orrankssoastobringtogetherthosethingsthat
mostresembleeachotherandtoseparatethose
thatdiffer.
Likeanygrowingbranchofmedicine,psy­
chiatryhasseenrapidchangesinclassification
tokeepupwithaconglomerationofgrowing
researchdatadealingwithepidemiology,sympto­
matology,prognosticfactors,treatmentmethods
andnewtheoriesforcausationofpsychiatric
disorders.
Atpresenttherearetwomajorclassifications
inpsychiatry,namely,ICDlO(1992)andDSMIV
(1994).
I.ICDlO(InternationalStatisticalClassificationof
DiseaseandRelatedHealthProblems)-1992
ThisisWHO'sclassificationforalldiseasesand
relatedhealthproblems.Thechapter'F'classifies
psychiatricdisordersasmentalandbehavioral
disordersandcodesthemonanalphanumeric
systemfromFOOtoF99.
ThemaincategoriesinICDlO
FOO-F09Organic,includingsymptomatic,
mentaldisorders
FOODementiainAlzheimer'sdisease
FOlVasculardementia
F04Organicamnesticsyndrome
FOSDelirium
F06Othermentaldisordersduetobrain
damageanddysfunctionandto
physicaldisease
F07Personalityandbehavioraldisorders
duetobraindisease,damageand
dysfunction
F10-Fl9Mentalandbehaviordisordersdue
topsychoactivesubstanceuse
FlOMentalandbehavioraldisordersdue
touseofalcohol
Fl1Mentalandbehavioraldisordersdue
touseofopioids
F12Mentalandbehavioraldisordersdue
touseofcannabinoids
F13
F14
Fl6
F20-F29
F20
F20.0
F20.1
F20.2
F20.3
F20.4
F20.5
F20.6
F21
F22
F23
F24
F25
F30-F39
F30
F31
F32
F33
F34
F40-F49
F40
F41
F42
F43
Mentalandbehavioraldisordersdue
touseofsedativesorhypnotics
Mentalandbehavioraldisordersdue
touseofcocaine
Mentalandbehavioraldisordersdue
touseofhallucinogens
Schizophrenia,schizotypaland
delusionaldisorders
Schizophrenia
paranoidschizophrenia
hebephrenicschizophrenia
catatonicschizophrenia
undifferentiatedschizophrenia
post-schizophrenicdepression
residualschizophrenia
simpleschizophrenia
Schizotypaldisorder
Persistentdelusionaldisorders
Acuteandtransientpsychoticdis­
orders
Induceddelusionaldisorders
Schizoaffectivedisorders
Mood(affective)disorders
Manicepisode
Bipolaraffectivedisorder
Depressiveepisode
Recurrentdepressivedisorder
Persistentmooddisorder
Neurotic,stress-relatedandsomato­
formdisorders
Phobicanxietydisorders
Otheranxietydisorders
Obsessive-compulsivedisorder
Reactiontoseverestress,andadjust­
mentdisorders
Dissociative(conversion)disorders
Somatoformdisorders
F44
F45
F50-F59Behavioralsyndromesassociated
withphysiologicaldisturbancesand
physicalfactors
FSOEatingdisorders
F51Non-organicsleepdisorders
F52Sexualdysfunction,notcausedby
organicdisorderordisease

15. F98Otherbehavioralandemotionaldis­
orderswithonsetusuallyoccurringin
childhoodandadolescence
F99Unspecifiedmentaldisorder
II.DSMIV(DiagnosticandStatisticalManual)-1994
Thisistheclassificationofmentaldisordersby
theAmericanPsychiatricAssociation(APA).The
patternadoptedbyDSMIVisofmultiaxial
systems.
Amultiaxialsystemthatevaluatespatients
alongseveralversatilescontainsfiveaxes.AxisI
andIImakeuptheentireclassificationwhich
containsmorethan300specificdisorders.
ThefiveaxesofDSMIVare
AXISI:Clinicalpsychiatricdiagnosis
AXISII:Personalitydisorderandmentalretar
dation
12AGuidetoMentalHealthandPsychiatricNursing
F60-F69
F60
F60.0
F60.1
F60.2
F60.3
F60.4
F60.5
F60.6
F60.7
F61
F62
F63
F64
F65
F70-F79
F70
F71
F72
F73
F80-F89
F80
F81
F82
F83
F84
F90-F98
F90
F91
F93
F94
F95
Disordersofadultpersonalityand
behavior
Specificpersonalitydisorders
paranoidpersonalitydisorder
schizoidpersonalitydisorder
dissocialpersonalitydisorder
emotionallyunstablepersonalitydis­
order
histrionicpersonalitydisorder
anankasticpersonalitydisorder
anxiouspersonalitydisorder
dependentpersonalitydisorder
Mixedandotherpersonalitydisorders
Enduringpersonalitychanges,not
attributabletobraindamageand
disease
Habitandimpulsedisorders
Genderidentitydisorders
Disordersofsexualpreference
Mentalretardation
Mildmentalretardation
Moderatementalretardation
Severementalretardation
Profoundmentalretardation
Disordersofpsychologicaldevelop­
ment
Specificdevelopmentaldisordersof
speechandlanguage
Specificdevelopmentaldisordersof
scholasticskills
Specificdevelopmentaldisorderof
motorfunction
Mixedspecificdevelopmentaldisor­
ders
Pervasivedevelopmentaldisorders
Behavioralandemotionaldisorders
withonsetusuallyoccurringinchild­
hoodandadolescence
Hyperkineticdisorders
Conductdisorders
Emotionaldisorderswithonsetspecific
tochildhood
Disordersofsocialfunctioningwith
onsetspecifictochildhoodandadoles­
cence
Ticdisorders
AXISIII:Generalmedicalconditions
AXISIV:Psychosocialandenvironmentalpro
blems
AXISV:Globalassessmentoffunctioningin
currentandpastoneyear
DifferencesbetweenICDlOandDSMIV
ICD-10 DSM-IV
Origin AmericanPsychiatric
Association
Asingleversion
International
PresentationDifferentversions
forclinicalwork,
researchand
primarycare
LanguageAvailableinall Englishversiononly
widelyspoken
languages
StructureSingleaxis Multiaxial
Content DiagnosticcriteriaDiagnosticcriteria
donotincludesocialusuallyinclude
consequences occupationalor
ofthedisorder otherareasof
functioning
Ill.IndianClassification
InIndiaNeki(1963),WigandSinger(1967),Vahia
(1961)andVarma(1971)haveattemptedsome

16. MentalHealthandMentalIllness13
modificationsofICD8tosuitIndianconditions.
Theyarebroadlygroupedasfollows:
A.Psychosis
j,
Functional Affective
a.Schizophrenia a.Mania
Simpleschizophreniab.Depression
Hebephrenicschizophrenia
Catatonicschizophrenia
Paranoidschizophrenia
B.Neurosis
•Anxietyneurosis
•Depressiveneurosis
•Hystericalneurosis
•Obsessivecompulsiveneurosis
•PhobicNeurosis
C.Specialdisorders
Childhooddisorders
•conductdisorders
•emotionaldisorders
Personalitydisorders
•sociopath
•psychopath
Substanceabuse
•alcoholabuse
•drugabuse
Psychophysiologicaldisorders
•asthma
•psoriasis
Mentalretardation
•Mild
Organic
a.Acute
b.Chronic
•Moderate
•Severe
•Profound
Ineverydaypracticeclassificationismade
afterthehistoryandexaminationofmentalstate
havebeencompleted.
REVIEWQUESTIONS
•Conceptsofnormalandabnormalbehavior
(Nov2001,0ct2006)
•Componentsofmentalhealth(Nov2003)
•Meaningofmentalillness(Feb2001,Oct2004)
•Featuresofmentalillness
•Mentalhealthissues
•Characteristicsofamentallyhealthyperson
(Nov1999,Apr2003,Nov2003)
•Misconceptionsaboutmentalillness
(Nov2003)
•Communityattitudetowardsmentallyill(Nov
2002)
•Etiologyofmentalillness(Feb2001,Apr2002,
Apr2005,Oct2006)
•Classificationofmentaldisorders(Apr2006)
•Internationalclassificationofdiseases(Oct
2004,Apr2006)
•DSMIV(Nov2003)
•Multidisciplinaryteamormentalhealthteam
•Defencemechanisms-rationalization,pro­
jection,identification,reactionformation,
undoing,negativism,repression(Oct2000),
regression,suppression(Oct2000),fantasyor
daydreaming.

17. PrinciplesandConceptsof
MentalHealthNursing
DPSYCHIATRY
DPSYCHIATRICNURSING
DDEVELOPMENT OFPSYCHIATRY
DDEVELOPMENT OFMODERNPSYCHIATRICNURSING
DCURRENT ISSUESANDTRENDSINCARE
DPSYCHIATRICNURSINGSKILLS
DSTANDARDS OFMENTALHEALTHNURSING
DGENERALPRINCIPLESOFPSYCHIATRICNURSING
DFUNCTIONSOFAPSYCHIATRICNURSE
DQUALITIESOFAPSYCHIATRICNURSE
DTHERAPEUTIC ROLESOFAPSYCHIATRIC
MENTALHEALTH NURSE
Healthisastateofcompletephysical,mental,
socialandspiritualwell-beingandnotmerely
theabsenceofdiseaseorinfirmity.Bothphysical
andmentalhealthsareinterdependent.Anurse
whoisresponsiblefortotalhealthcareofaperson
musttakecareofbothphysicalandemotional
needs;thereforesheshoulddevelopabasic
understandingandskillinpsychiatricnursing
toachievetotalhealthcare.
PSYCHIATRY
Itisabranchofmedicinethatdealswiththediag­
nosis,treatmentandpreventionofmentalillness.
PSYCHIATRICNURSING
Itisaspecializedareaofnursingpractice,
employingtheoriesofhumanbehaviorasitisa
science,andthepurposefuluseofselfasitisan
art,inthediagnosisandtreatmentofhuman
responsestoactualorpotentialmentalhealth
problems.(AmericanNursesAssociation,1994)
Thuspsychiatricnursingdealswiththe
promotionofmentalhealth,preventionofmental
illness,careandrehabilitationofmentallyill
individualsbothinhospitalandcommunity.
DEVELOPMENT OFPSYCHIATRY
Historically,mentalillnesswasviewedasa
demonicpossession,theinfluenceofancestral
spirits,theresultofviolatingatabooorneglecting
aculturalritualandspiritualcondemnation.As
aresult,thementallyillwereoftenstarved,beaten,
burnt,amputatedandtorturedinordertomake
thebodyanunsuitableplaceforthedemon.
Gradually,manbeganthequestforscientific
knowledgeandtruth,whichcanbetracedas
follows:
•Pythagoras(580-510BC)developedthecon­
ceptthatthebrainistheseatofintellectual
activity.
•Hippocrates(460-370BC)describedmental
illnessashysteria,maniaanddepression.
•Plato(427-347BC)identifiedtherelationship
betweenmindandbody.
•Asciepiades,whoisreferredtoastheFather
ofPsychiatry,madeuseofsimplehygienic
measures,diet,bath,massageinplaceof
mechanicalrestraints.
•TheGreekswerethefirsttostudymental
illnessscientificallyandseparatethestudyof
mindfromreligion.Aristotle,aGreekphiloso­
pher,emphasizedonthereleaseofrepressed
emotionsfortheeffectivetreatmentofmental
illness.Hesuggestedcatharsisandmusic
therapyforpatientswithmelancholia.
•Duringthemiddleagesthementallyillwere
notconsideredasoutcasts,butaspeopletobe
helped.Oneofthegreatfiguresduringthis
timewasSt.Augustine,whobelievedthat
althoughGodacteddirectlyinhumanaffairs,
peoplewereresponsiblefortheirownactions.

18. PrinciplesandConceptsofMentalHealthNursing15
•RenaissanceinEurope(1300-1600AD):This
representedthesaddestchapterinthehistory
ofpsychiatrywhenitwasbelievedthat
demonswerethecauseofhallucinations,
delusionsandsexualactivity,andthe
treatmentwastortureandevendeath.
SomeImportantMilestones
1773ThefirstmentalhospitalintheUSwas
builtinWilliamsburg,Virginia.
1793PhillipPinelremovedthechainsfrom
mentallyillpatientsconfinedinBicetre,a
hospitaloutsideParis,thusbringingabout
thefirstrevolutioninpsychiatry.
1812ThefirstAmericantextbookinpsychiatry
waswrittenbyBenjaminRush,whois
referredtoastheFatherofAmerican
Psychiatry.
1908CliffordBeers,anex-patientofamental
hospital,wrotethebook,'TheMindThat
FoundItself'basedonhisbitter
experiencesinthehospital.Hefounded
theAmericanMentalHealthAssociation,
whichmadeamajorcontributiontowards
theimprovementofconditionsinmental
hospitals.
1912EugeneBleuler,aSwisspsychiatrist
coinedtheterm'schizophrenia'.
-TheIndianLunacyActwaspassed.
1927Insulinshocktreatmentwasintroduced
forschizophrenia.
1936Frontallobotomywasadvocatedforthe
managementofpsychiatricdisorders.
1938ElectroConvulsiveTherapy(ECT)was
usedforthetreatmentofpsychoses.
1939Developmentofpsychoanalyticaltheory
bySigmundFreudledtonewconceptsin
thetreatmentofmentalillness.
1946TheBhoreCommitteepresentedthe
situationwithregardtomentalhealth
services.Basedonitsrecommendations,5
mentalhospitalsweresetupatAmritsar
(1947),Hyderabad(1953),Srinagar(1958),
Jamnagar(1960)andDelhi(1966).AnAll
IndiaInstituteofMentalHealthwasalso
setupatBangalore(currentlyknownas
NationalInstituteofMentalHealthand
NeurosciencesorNIMHANS).
1949Lithiumwasfirstusedforthetreatmentof
mania.
1952Chlorpromazinewasintroducedwhich
broughtaboutarevolutioninpsychophar­
macologyandchangedthewholepicture
ofmentalhealthcare.
1963The'CommunityMentalHealthCenters'
Actwaspassed.
1978TheAlma-Atadeclarationof"Healthfor
Allby2000AD."posedamajorchallenge
toIndianmentalhealthprofessionals.In
ordertoachievementalhealthforall(asa
partoftheachievementofHealthforAll
by2000AD.),in1980theGovernmentof
Indiacalledforexpertsinthefieldfor
assessingthementalhealthneedsofthe
peopleandrecommendedstepsfor
providingmentalhealthcare.
1981Communitypsychiatriccenterswereset
uptoexperimentwithprimarymental
healthcareapproachatRaipurRani,
ChandigarhandSakalwara,Bangalore.
1982TheCentralCouncilofHealth,India's
highesthealthpolicymakingbody
acceptedtheNationalMentalHealth
PolicyandbroughtouttheNational
MentalHealthPrograminIndia.
1987TheIndianMentalHealthActwaspassed.
1990TheGovernmentofIndiaformedanAction
GroupatDelhitopooltheopinionsof
mentalhealthexpertsabouttheNational
MentalHealthProgram.NationalInstitute
ofMentalHealthandNeurosciences
(NIMHANS),Bangalore,hastakenupthe
leadershipinorientinghealthcareprofes­
sionalsaboutthementalhealthprograms
ofourcountry.Anumberofinnovative
approachesforthetreatmentandrehabi­
litationofmentalillnesshavebeen
initiated,andthemostimportantonesare:
•Integrationofmentalhealthcarewith
generalhealthcare.
•Schoolmentalhealthprograms.

19. skillsofthenursesandincreasedthedemandfor
improvedpsychologicaltreatmentforpatients
whodidnotrespondwell.Asthenurses
collaboratedwiththedoctorsincarryingoutthese
therapiestheystruggledtodefinetheirroleas
psychiatricnurses.
Majorgrowthofpsychiatricnursingoccurred
afterWorldWarIIbecauseoftheemergenceof
servicesrelatedtopsychiatricproblems.The
contentofpsychiatricnursingbecameanintegral
partofgeneralnursingcurriculum.
1943Psychiatricnursingcoursewasstartedfor
malenurses.
1946HealthSurveyCommittee'sreportrecom­
mendedpreparationofnursingpersonnel
inpsychiatricnursingalso.Theexisting
institutionslike,mentalhospitalsinBanga­
loreandRanchishouldstartthetraining.
1952Dr.HildegardPeplaudefinedthethe­
rapeuticrolesthatnursesmightplayin
thementalhealthsetting.Shedescribed
theskillsandrolesofthepsychiatricnurse
inherbook'InterpersonalRelationsin
Nursing'.Itwasthefirstsystematic
theoreticalframeworkdevelopedfor
psychiatricnursing.
1953MaxwellJonesintroducedtherapeutic
community.
1956Oneyearpost-certificatecoursein
psychiatricnursingwasstartedat
NIMHANS,Bangalore.
1960Thefocusbegantoshifttoprimary
preventionandimplementingcareand
consultationinthecommunity.Thename
'psychiatricnursing'waschangedto
'psychiatricandmentalhealthnursing,'
andasecondchangewasmadeinthe
1970swhenitwasknownas
'psychosocialnursing'.
1963JournalofPsychiatricNursingandMental
HealthServiceswaspublished.
1964Mudaliarcommitteefelttheneedfor
preparingalargenumberofpsychiatric
nursesandrecommendedinclusionof
psychiatryinthenursingcurriculum(as
perInternationalCouncilofNursing).
16AGuidetoMentalHealthandPsychiatricNursing
•Promotionofchildmentalhealth
throughtheinvolvementofanganwadis
(ICDSprogram).
•Crisisinterventionforsuicidepre­
vention.
•Halfwayhomesformentallyillindi­
vidualsforsocialskillstraining,
vocationaltraining.
•Educationandinvolvementofthe
generalpublicthroughtheactivitiesof
non-governmentalorganizations.
•Mediamaterialsforpubliceducation.
•Trainingfornon-professionalstowork
withmentallyillindividuals.
DEVELOPMENTOFMODERN
PSYCHIATRICNURSING
Psychiatricnursingingeneralarosefromtheneed
forhospitalstoprovidesociallyacceptablelevels
ofcareforpatients.
SomeImportantMilestones
1872Firsttrainingschoolfornurses,basedon
theNightingalesystemwasestablished
bytheNewEnglandHospitalforWomen
andChildren,USA.LindaRichards,the
firstnursetograduatefromtheone-year
course,developed12trainingschoolsin
theUSA.
1882Firstschooltopreparenursestocarefor
thementallyillwasopenedatMcLean
HospitalinWaverly.Atwo-yearprogram
wasstartedbutfewpsychologicalskills
wereaddressedandmuchimportancewas
giventocustodialcaresuchaspersonal
hygiene,medication,nutrition,etc.
1913JohnsHopkinsbecamethefirstschoolof
nursingtoincludeafullydeveloped
courseforpsychiatricnursinginthe
curriculum.
Theimportantfactorinthedevelopmentof
psychiatricnursingwastheemergenceofvarious
somatictherapieslike,insulinshocktherapy
(1927),psychosurgery(1936),andECT(1938).
Thesetherapiesrequiredthemedicalsurgical

20. PrinciplesandConceptsofMentalHealthNursing17
1965TheIndianNursingCouncilincluded
psychiatricnursingasacompulsory
courseintheB.ScNursingprogram.
1973StandardsofPsychiatricandMental
HealthNursingpracticewereenunciated
toprovideameansofimprovingthe
qualityofcare.
1975PsychiatricNursingwasofferedasan
electivesubjectinM.ScNursingatthe
RajkumariAmritKaurCollegeofNursing,
NewDelhi.Nowvariouscollegesoffer
psychiatricnursingasanelectivesubject
inM.ScNursing.TheseareSNDTCollege
ofNursing,Mumbai;NIMHANS,Banga­
lore;CollegeofNursing,Ludhiana;
CollegeofNursing,CMC,Vellore;Father
Muller'sCollegeofNursing,Mangalore;
CollegeofNursing,Thiruvananthapuram;
MAHE,Manipal;MVShettyInstituteof
HealthSciences,Mangalore.
1980Scientificadvancesintheareaofpsycho­
biology,brainimagingtechniques,know­
ledgeaboutneurotransmittersandneuro­
nalreceptors,moleculargeneticsrelated
topsychiatry,etc,emerged.Thesecontri­
butedtotheshiftfrompsychodynamic
modelstomorebalancedpsychobiological
modelsofpsychiatriccare.
1986TheIndianNursingCouncil(INC)made
psychiatricnursingacomponentof
GeneralNursingandMidwiferycourse.
1990Duringtheseyearsintegrationofneuro­
sciencesintoholisticbiopsychosocial
practiceofpsychiatricnursingoccurred.
Advancesinunderstandingtheinter­
relationshipsofbrain,behavior,emotions
andcognitionofferedmanynewoppor­
tunitiesforpsychiatricnurses.
1994Theabovementionedchangesledtothe
revisionofStandardsofPsychiatricand
MentalHealthNursing.
Theprofessionalpsychiatricnursingrole
hasgrownincomplexity.Incontemporary
psychiatricnursingpracticetheroleincludesthe
parametersofclinicalcompetence,patient
advocacy,fiscalresponsibility,professional
collaboration,socialaccountability,legaland
ethicalobligations.
CURRENT ISSUESANDTRENDSINCARE
(SCOPE)
Apsychiatricnursefacesvariouschallenges
becauseofchangesinpatientcareapproach.Some
ofthesechangesthataffectherroleareasfollows:
DemographicChanges
•Typeoffamily(increasednumberofnuclear
families)
•Increasingnumberoftheelderlygroup
SocialChanges
•Theneedformaintainingintergroupand
intragrouployalties
•Peerpressure
EconomicChanges
•Industrialization
•Urbanization
•Raisedstandardofliving
TechnologicalChanges
•Massmedia
•Electronicsystems
•InformationTechnology
MentalHealthCareChanges
•Increasedawarenessinthepublicregarding
mentalhealth
•Needtomaintainmentalstability
•Increasedmentalhealthproblems
Theabovechangessetthecurrenttrendsin
mentalhealthcare.Someoftheseare:
EducationalProgramsforthePsychiatricNurse
•DiplomainPsychiatricNursing(Thefirst
programwasofferedin1956atNIMHANS,
Bangalore).
•M.ScinPsychiatricNursing(Thefirstprogram
wasofferedin1976atRajkumariAmritKaur
CollegeofNursing,NewDelhi).

21. 18AGuidetoMentalHealthandPsychiatricNursing
•M.PhilinPsychiatricNursing(1990,M.G.
University,Kottayam).
•DoctorateinPsychiatricNursing(offeredat
MAHE,Manipal;RAKCollegeofNursing,
Delhi;NIMHANS,Bangalore).
•Short-termtrainingprogramsforboththe
degreeanddiplomaholdersinnursing.
StandardsofMentalHealthNursing
Thedevelopmentofstandardsfornursingprac­
ticeisabeginningsteptowardstheattainmentof
qualitynursingcare.Theadoptionofstandards
helpstoclarifynurses'areasofaccountability,
sincethestandardsprovidethenurse,thehealth
agency,otherprofessionals,clients,andthe
public,withabasisforevaluatingpractice.
Standardsalsodefinethenursingprofession's
accountabilitytothepublic.Thesestandardsare
thereforeameansforimprovingthequalityof
careformentallyillpeople.
DevelopmentofCodeofEthics
Thisisveryimportantforapsychiatricnurseas
shetakesupindependentrolesinpsychotherapy,
behaviortherapy,cognitivetherapy,individual
therapy,grouptherapy,maintainspatient's
confidentiality,protectshisrightsandactsas
patient'sadvocate.
LegalAspectsinPsychiatricNursing
Knowledgeofthelegalboundariesgoverning
psychiatricnursingpracticeisnecessarytoprotect
thepublic,thepatient,andthenurse.Thepractice
ofpsychiatricnursingisinfluencedbylaw,
particularlyinitsconcernfortherightsofpatients
andthequalityofcaretheyreceive.
Theclient'srighttorefuseaparticulartreat­
ment,protectionfromconfinement,intentional
torts,informedconsent,confidentiality,andrecord
keepingareafewlegalissuesinwhichthenurse
hastoparticipateandgainqualityknowledge.
PromotionofResearchin
MentalHealthNursing
Thenursecontributestonursingandthemental
healthfieldthroughinnovationsintheoryand
practiceandparticipationinresearch.
CostEffectiveNursingCare
Studiesneedtobeconductedtofindoutthe
viabilityintermsofcostinvolvedintraininga
nurseandthequalityofoutputintermsofnursing
carerenderedbyher.
FocusofCare
Apsychiatricnursehastofocuscareoncertain
targetgroupsliketheelderly,children,women,
youth,mentallyretardedandchronicmentally
ill.
NewTrendsinRoleofaPsychiatricNurse
PrimaryMentalHealthNursing
Psychiatricnursesaremovingintothedomainof
primarycareandworkingwithothernursesand
physicianstodiagnoseandtreatpsychiatric
illnessinpatientswithsomaticcomplaints.
Cardiovascular,gynecological,respiratory,and
gastrointestinalandfamilypracticesettingsare
appropriateforassessingpatientsforanxiety,
depressionandsubstanceabusedisorders.
CollaborativePsychiatricNursingPractice
Patientswhoarehavingdifficultybeingstabilized
ontheirmedicationsorwhohaveco-morbid
medicalillnessesareseeninapsychiatricnursing
clinicwherenursesandphysicianscollaborate
toprovidehighqualitypatientcare.
RegisteredPsychiatricNurse(RPN)
ARegisteredPsychiatricNurseprovidespsy­
chiatricmentalhealthnursingcaretoindividuals,
families,andgroupstoenablethemtofunctionat
anoptimallevelofpsychologicalwellness
throughmoreeffectiveadaptivebehaviorsand
increasedresiliencetostress.Shemustbeableto
providesafe,basicphysicalcare,haveawide
understandingofpsychologicalanddevelop­
mentalproblemsandtheirtreatmentandhavea
highlydevelopedlevelofcommunicationskills.

22. PrinciplesandConceptsofMentalHealthNursing19
Sheworkswithchildren,adolescents,adultsand
elderlywithdysfunctionalbehaviorpatterns,and
developmentalhandicaps.Aregisteredpsychia­
tricnurseworksasanindependententity.She
worksinvariouskindsofinpatientfacilitiesand
communitysettings.
ClinicalNurseSpecialist(CNS)
TheClinicalNurseSpecialistprovidesconsul­
tativeservicestonursingpersonnel.Sheattends
clinicalteachingprograms,demonstratesthera­
pies,conductsin-serviceeducationprograms,
initiatesandparticipatesincurriculumrevision/
changesandnursingresearch.
CaseManagement
Usingcasemanagementapsychiatricmental
healthnurseisresponsibleforassessingneeds,
identifyingservices,andmonitoringandeva­
luatingclientstatus.Acasemanagercoordinates
carethroughcollaborationwithallinvolved
healthprofessionalsensuringaccessibilityand
availabilityofcare.
NursePsychotherapist
Thepsychiatricnursecantakeuppsychotherapy
rolesasinindividualtherapy,grouptherapy,
counseling,etc.
PsychiatricNurseEducator
Themainfunctionofpsychiatricnurseeducator
isplanningandchangingthecurriculumaccor­
dingtotheneedsofthesocietyandlearner.The
IndianNursingCouncilincludedpsychiatric
nursingascompulsoryforthequalifying
examinationinB.ScNursingprogramin1965,
andfrom1986itbecameacomponentinGeneral
NursingandMidwiferycourseaswell.
Thenumberofnursesinthefieldofteaching
psychiatricnursingneedstobeenhanced.
Thisisabigchallengefornursingcurriculum
planners.
PsychosocialRehabilitationNursing
Itisconcernedwithhelpingpeoplewithchronic
mentalillnesstoleadmoreindependentand
satisfactorylivesinthecommunity.
ChildPsychiatricNursing
Inchildpsychiatricnursingthenurseidentifies
emotionalandbehavioralproblemsofthe
childrenandprovidescomprehensivecare.
GerontologicalandGeriatricNursing
Gerontologicalnursingprovidesemotional
supporttothosepeoplewhohaveretiredfrom
services,whohavenofinancialsourcesandhelps
theminunderstandingthesituation,and
developingnewcopingmechanisms.
Geriatricnursingisexpandingthepsychiatric
nursingpracticetoagedpeoplewhohavebeen
affectedbyemotionalandbehavioraldisorders
suchasdementia,chronicschizophrenia,
delirium,etc.
DeaddictionNursing
Apsychiatricnurseintheseunitsidentifies
psychosocialproblemsandmaintainingfactors
inaddicts.Shealsoprovidesvarioustherapiesto
theaddictsandtheirfamilymembers.
NeuropsychiatricNursing
Psychiatricnursingpracticeisextendedto
patientswhoaresufferingfromneuropsychiatric
disorderssuchasdementia,epilepsy,braintumor,
headinjurywithbehavioralproblems,HIV
infectionwithbehavioralproblems,etc.
CommunityMentalHealthNursing
Communitymentalhealthnursingisthe
applicationofknowledgeofpsychiatricnursing
inpreventingmentalillness,promotingand
maintainingmentalhealthofthepeople.It
includesearlydiagnosis,appropriatereferrals,
careandrehabilitationofmentallyillpeople.
AdvancedPracticeRoles
Theseinclude:Nursingleadershipinforensic
healthunits,crisisintervention,riskassessment
andmanagementincommunitysettings.

23. 20AGuidetoMentalHealthandPsychiatricNursing
PSYCHIATRICNURSINGSKILLS
Mentalhealthnursingisthepracticeofpromoting
mentalhealthaswellascaringforpeoplewho
havementalillness,potentiatingtheirindepen­
dencyandrestoringtheirdignity.Inordertofulfill
thisarduousoccupation,amentalhealthnurse
mustpossessasoundknowledgebaseandthe
requisiteskillsforgoodnursingpractice.
PrerequisitesforaMentalHealthNurse
PersonalSkills
Self-awarenessItisakeycomponentofpsychia­
tricnursingexperience.Itisananswertothe
question,"whoamI".Thenursemustbeableto
examinepersonalfeelings,actionsandreactions
asaproviderofcare.Afirmunderstandingand
acceptancebythenurseallowsacknowledginga
patient'sdifferencesanduniqueness.
AdaptabilityAmentalhealthnurseneedstobe
adaptabletodifferentsettingsandcultures.
Workingwithinresidentialsettings,forexample,
maydemandattitudesandroleswhichare
differentfromworkinginacommunity,asina
residentialsettingthenursemayhaveanauthori­
tativeorasupervisoryrolewhichshenecessarily
doesnothaveinacommunity.
Amentalhealthnursealsoneedstocopewith
avarietyofsocialandculturalsettings.Social
settingsinvolvetheclassandstatusofthe
individualswhileculturalsettingsinvolverace,
ethnicityandgender.Thereforeshemayneedto
befamiliarwiththeissuesthatariseincross­
culturalmentalhealthnursing.
Carevaluesandattitudes
Theseinclude:
•Self-awarenessandself-esteem
•Respectingtheperson'srights
•Listening
•Respondingwithcareandrespect
•Supportingwithtrustandconfidence
•Reassuringwithexplanationandhonesty
•Physicallynursingthehelplesswithcompas­
sion
•Carryingoutproceduresskillfully
•Workingwithinpersonalandethical
boundaries.
CounselingSkills
Theseinclude:
•Unconditionalpositiveregard/non-judge-
mentalapproach
•Empathy
•Warmthandgenuineness
•Confidentiality
•Non-verbalsensitivity,non-verbalattending,
non-verbalresponding
•Otherinterpersonalskillsrequiredarepara­
phrasing,reflecting,clarifying,summarizing.
BehavioralSkills
ThesearebasedonPavlovianprinciplesand
Skinner'sprinciples.Theyinclude:
1.Toincreaseadaptivebehavior
•Positivereinforcement
•Negativereinforcement
•Tokeneconomy
2.Todecreasemaladaptivebehavior
•Extinction
•Timeout
•Restraining
•Overcorrection
3.Toteachnewbehavior
•Modeling
•Shaping
•Chaining
•Cueing.
SupervisorySkills
Supervisionisanintegralnecessityforanyworker
inthecaringprofession,toensurethebestquality
serviceforclientsandbestqualitydevelopmental
opportunitiesforworkers.Agoodsupervisor
requiresinterpersonalandprofessionalskills,
technicalknowledge,leadershipqualitiesand
humanskills.
CrisisSkills
Aggressiveandassaultivebehaviorofviolent
patients,self-harm,acutealcoholintoxicationare

24. interviewing,behavioralobservation,physical
andmentalhealthassessmentenablethenurse
toreachsoundconclusionsandplanappropriate
interventionswiththeclient.
PrinciplesandConceptsofMentalHealthNursing21
someofthecasesanurseislikelytoencounterin
thecourseofherpractice.Suchsituationsmay
causethenursetofeeloverwhelmedwithfeelings
ofhelplessness,powerlessnessandinadequacy.
Exerciseofself-control,calm,rationalthinking
andidentifyingwaysofobtaininghelpfromthe
otherpeoplearesomeoftheskillstobecultivated
bythepsychiatricnursewhenconfrontedwith
suchcrisessituations.
TeachingSkills
Thisrelatestothenurse'sabilitytoexplain,
enablingfullunderstandingonthepartofthe
client.Italsoinvolvesenhancingtheclient's
environmentinordertomaximizehisawareness
ofthethingsaroundhim.Itisnecessaryforthe
nursetobeenthusiasticaboutactivitiesand
choicesoftheclientsandalsogivetheclientevery
opportunitytousehispowerofjudgmentinorder
tomakedecisions.
STANDARDSOFMENTALHEALTHNURSING
ThepurposeofStandardsofPsychiatricand
MentalHealthNursingpracticeistofulfillthe
profession'sobligationtoprovideameansof
improvingthequalityofcare.Thestandards
presentedherearearevisionofthestandards
enunciatedbytheDivisiononPsychiatricand
MentalHealthNursingPracticein1973.
ProfessionalPracticeStandards
StandardI:Theory
Thenurseappliesappropriatetheorythatis
scientificallysoundasabasisfordecisions
regardingnursingpractice.Psychiatricand
mentalhealthnursingischaracterizedbythe
applicationofrelevanttheoriestoexplain
phenomenaofconcerntonursesandtoprovidea
basisforintervention.
StandardII:DataCollection
Thenursecontinuouslycollectsdatathatare
comprehensive,accurateandsystematic.Effective
StandardIll:Diagnosis
Thenurseutilizesnursingdiagnosesand/or
standardclassificationofmentaldisordersto
expressconclusionssupportedbyrecorded
assessmentdataandcurrentscientificpremises.
Nursing'slogicalbasisforprovidingcarerests
ontherecognitionandidentificationofthose
actualorpotentialhealthproblemsthatarewithin
thescopeofnursingpractice.
StandardIV:Planning
Thenursedevelopsanursingcareplanwith
specificgoalsandinterventionsdelineating
nursingactionsuniquetoeachclient'sneeds.
Thenursingcareplanisusedtoguide
therapeuticinterventionandeffectivelyachieve
thedesiredoutcomes.
StandardV:Intervention
Thenurseintervenesasguidedbythenursing
careplantoimplementnursingactionsthat
promote,maintainorrestorephysicalandmental
health,preventillnessandeffectrehabilitation.
(a)PsychotherapeuticinterventionsThenurse
usespsychotherapeuticinterventionstoassist
clientsinregainingorimprovingtheirprevious
copingabilitiesandtopreventfurtherdisability.
(b)HealthteachingThenurseassistsclients,
familiesandgroupstoachievesatisfyingand
productivepatternsoflivingthroughhealth
teaching.
(c)ActivitiesofdailylivingThenurseusesthe
activitiesofdailylivinginagoaldirectedwayto
fosteradequateself-careandphysicalandmental
wellbeingofclients.
(d)SomatictherapiesThenurseusesknowledge
ofsomatictherapiesandappliesrelatedclinical
skillsinworkingwithclients.

25. StandardXI:Research
Thenursecontributestonursingandthemental
healthfieldthroughinnovationsintheoryand
practiceandparticipationinresearch.
22AGuidetoMentalHealthandPsychiatricNursing
(e)TherapeuticenvironmentThenurseprovides,
structuresandmaintainsatherapeuticenviron­
mentincollaborationwiththeclientandother
healthcareproviders.
(f)PsychotherapyThenurseutilizesadvanced
clinicalexpertiseinindividual,groupandfamily
psychotherapy,childpsychotherapyandother
treatmentmodalitiestofunctionasapsychothe­
rapistandrecognizesprofessionalaccountability
fornursingpractice.
StandardVI:Evaluation
Thenurseevaluatesclientresponsestonursing
actionsinordertorevisethedatabase,nursing
diagnosesandnursingcareplan.
ProfessionalPerformanceStandards
StandardVII:PeerReview
Thenurseparticipatesinpeerreviewandother
meansofevaluationtoassurequalityofnursing
careprovidedforclients.
StandardVIII:ContinuingEducation
Thenurseassumesresponsibilityforcontinuing
educationandprofessionaldevelopmentand
contributestotheprofessionalgrowthofothers.
StandardIX:InterdisciplinaryCollaboration
Thenursecollaborateswithotherhealthcare
providersinassessing,planning,implementing
andevaluatingprogramsandothermentalhealth
activities.
StandardX:UtilizationofCommunityHealth
Systems
Thenurseparticipateswithothermembersofthe
communityinassessing,planning,implementing
andevaluatingmentalhealthservicesand
communitysystemsthatincludethepromotion
ofthebroadcontinuumofprimary,secondary
andtertiarypreventionofmentalillness.
GENERAL PRINCIPLESOFPSYCHIATRIC
NURSING
Thefollowingprinciplesaregeneralinnature
andformguidelinesforemotionalcareofa
patient.Theseprinciplesarebasedontheconcept
thateachindividualhasanintrinsicworthand
dignityandhaspotentialitiestogrow.
1.PatientisAcceptedExactlyasHeis
Acceptingmeansbeingnon-judgmental.Accep­
tanceconveysthefeelingofbeinglovedandcared.
Acceptancedoesnotmeancompletepermissi­
venessbutsettingofpositivebehaviorstoconvey
tohimtherespectasanindividualhumanbeing.
Anurseshouldbeabletoconveytothepatient
thatshemaynotapproveeverythingwhathe
does,buthewillnotbejudgedorrejectedbecause
ofhisbehavior.
Acceptanceisexpressedinthefollowing
ways:
(a)BeingNon-judgmentalandNon-punitive
Thepatient'sbehaviorisnotjudgedasrightor
wrong,goodorbad.Patientisnotpunishedfor
hisundesirablebehavior.Alldirect(chaining,
restraining,puttinghiminaseparateroom)and
indirect(ignoringhispresenceorwithdrawing
attention)methodsofpunishmentmustbe
avoided.Anursewhoshowsacceptancedoes
notrejectthepatientevenwhenhebehaves
contrarytoherexpectations.
(b)BeingSincerelyInterestedinthePatient
Beingsincerelyinterestedinanotherindivi­
dualmeansconsideringtheotherindividual's
interest.
Thiscanbedemonstratedby:
•Studyingpatient'sbehaviorpattern.
•Allowinghimtomakehisownchoicesand
decisionsasfaraspossible.
•Beingawareofhislikesanddislikes.

26. PrinciplesandConceptsofMentalHealthNursing23
•Beinghonestwithhim.
•Takingtimeandenergytolistentowhatheis
saying.
•Avoidingsensitivesubjectsandissues.
(c)RecognizingandReflectingonFeelings
whichPatientmayExpress
Whenpatienttalks,itisnotthecontentthatis
importanttonote,butthefeelingbehindthe
conversation,whichhastoberecognizedand
reflected.
(d)TalkingwithaPurpose
Thenurse'sconversationwithapatientmust
revolvearoundhisneeds,wantsandinterests.
Indirectapproacheslikereflection,open-ended
questions,focusingonapoint,presentingreality
aremoreeffectivewhentheproblemsarenot
obvious.
Avoidevaluative,hostile,probingquestions
anduseunderstandingresponses,whichmay
helpthepatienttoexplorehisfeelings.
(e)Listening
Listeningisanactiveprocess.Thenurseshould
taketimeandenergytolistentowhatthepatient
issaying.Shemustbeasympatheticlistenerand
showgenuineinterest.
(DPermittingPatienttoExpressStrongly-held
Feelings
Strongemotionsbottleduparepotentially
explosiveanddangerous.Itisbettertopermitthe
patienttoexpresshisstrongfeelingswithout
disapprovalorpunishment.Expressionof
negativefeelings(anxiety,fear,hostilityand
anger)maybeencouragedinaverbalorsymbolic
manner.Thenursemustaccepttheexpressionof
patient'sstrongnegativefeelingsquietlyand
calmly.
2.UseSelf-understandingasa
TherapeuticTool
Apsychiatricnurseshouldhavearealisticself­
conceptandshouldbeabletorecognizeone's
ownfeelings,attitudesandresponses.Herability
tobeawareandtoacceptherownstrengthsand
limitationsshouldhelphertoseethestrengths
andlimitationsinotherpeopletoo.Self­
understandinghelpshertobeassertiveinlife
situationswithoutbeingaggressiveandfeeling
guilty.
3.ConsistencyisusedtoContributeto
Patient'sSecurity
Thismeansthatthereshouldbeconsistencyin
theattitudeofthestaff,wardroutineandin
definingthelimitationsplacedonthepatient.
4.ReassuranceshouldbegiveninaSubtle
andAcceptableManner
Reassuranceisbuildingpatient'sconfidence.To
givereassurance,thenurseneedstounderstand
andanalyzethesituationastohowitappearsto
thepatient.Falsereassurancecanalsoreflecta
lackofinterestandunderstandingorunwilling­
nessonthepartofthenursetoempathizewith
thepatient'slifesituation.
5.Patient'sBehaviorisChangedthrough
EmotionalExperienceandnotby
RationalInterpretation
Majorfocusinpsychiatryisonfeelingsandnot
ontheintellectualaspect.Advisingorrationa­
lizingwithpatientsisnoteffectiveinchanging
behavior.Role-playandsocio-dramaareafew
avenuesofprovidingcorrectiveemotional
experiencestoapatientandfacilitatinginsight
intohisownbehavior.Suchexperiencescantruly
bringaboutthedesiredbehavioralchanges.
6.UnnecessaryIncreaseinPatient's
AnxietyshouldbeAvoided
Thefollowingapproachesmayincreasethe
patient'sanxietyandshould,therefore,beavoided:
•Showingnurse'sownanxiety.
•Showingattentiontothepatient'sdeficits.
•Makingthepatienttofacerepeatedfailures.
•Placingdemandsonpatientwhichhe
obviouslycannotmeet.

27. anxietyandlevelofabilitytodecide.Butexpla­
nationshouldneverbewithheldonthebasisthat
psychiatricpatientsarenothavinganycontact
withrealityorhavenoabilitytounderstand.
24AGuidetoMentalHealthandPsychiatricNursing
•Directcontradictionofpatient'spsychotic
ideas.
•Passingsharpcommentsandshowing
indifference.
7.ObjectiveObservationofPatientto
UnderstandhisBehavior
Objectivityisanabilitytoevaluateexactlywhat
thepatientwantstosayandnotmixupone's
ownfeelings,opinionorjudgment.
Tobeobjective,thenurseshouldindulgein
introspectionandmakesurethatherown
emotionalneedsdonottakeaprecedenceover
patient'sneeds.
8.MaintainRealisticNurse-Patient
Relationship
Realisticorprofessionalrelationshipfocuses
uponthepersonalandemotionalneedsofthe
patientandnotonnurse'sneeds.Tomaintain
professionalrelationshipthenurseshouldhave
arealisticself-conceptandshouldbeableto
empathizeandunderstandthefeelingsofthe
patientandthemeaningofbehavior.
9.AvoidPhysicalandVerbalForceas
MuchasPossible
Allmethodsofpunishmentmustbeavoided.If
thenurseisanexpertinpredictingpatient
behavior,shecanmostlypreventanonsetof
undesirablebehavior.
10.NursingCareisCenteredonthePatient
asaPersonandnotontheControlof
Symptoms
Analysisandstudyofsymptomsisnecessaryto
revealtheirmeaningandtheirsignificancetothe
patient.Twopatientsshowingthesamesymp­
tomsmaybeexpressingtwodifferentneeds.
11.AllExplanationsofProceduresand
otherRoutinesareGivenAccordingto
thePatient'sLevelofUnderstanding
Theextentofexplanationthatcanbegiventoa
patientdependsonhisspanofattention,levelof
12.ManyProceduresareModifiedbutBasic
PrinciplesRemainUnaltered
Inpsychiatricnursingfield,manymethodsare
adaptedtoindividualneedsofthepatients,but
theunderlyingnursingscientificprinciples
remainthesame.Somenursingprinciplestobe
keptinmindare:safety,comfort,privacy,
maintainingtherapeuticeffectiveness,economy
oftime,energyandmaterial.
FUNCTIONSOFAPSYCHIATRICNURSE
•Assessingtheclientandplanningnursing
care.
•Providingsafenursingcare,including
medicationadministrationandparticipation
invarioustherapies,individualinteractions,
formalandinformalgroupsituations,role­
playing,advocatingonbehalfoftheclient,
andsoforth.
•Providingasafeenvironment,including
protectingtheclientandothersfrominjury.
•Accuratelyobservinganddocumentingthe
client'sbehavior.
•Providingfeedbacktotheclientbasedon
observationsofhisbehavior.
•Teachingtheclientandsignificantothers.
•Involvingtheclientandtheclient'ssignificant
othersinthenursingprocess.
•Providingopportunitiesfortheclienttomake
hisowndecisionsandtoassumeresponsi­
bilityforhisemotionsandlife.
•Cooperatingwithotherprofessionalsin
variousaspectsoftheclient'scare;thereby,
facilitatinganinterdisciplinaryapproachto
care.
•Continuingnursingeducationandtheexplo­
rationofnewideas,theories,andresearch.
QUALITIESOFAPSYCHIATRICNURSE
Certainattitudesarenecessaryforapsychiatric

28. PrinciplesandConceptsofMentalHealthNursing25
nursetodealwithpsychiatricpatients.These
include:
1.Self-awareness
APsychiatricnurseshouldhavearealisticself
conceptandshouldbeabletorecognizeherown
feelings,fantasiesandfears.Sheshouldanalyze
herownprofessionalstrengthsandlimitations.
Herabilitytobeawareandtoacceptherown
strengthsandlimitationsshouldhelpherseethe
strengthsandlimitationsinotherpeople.
Sheshouldhaveherownbeliefsandvalues
relatedtolifeandshouldbeabletoacknowledge
andacceptherownfeelingsandtheirinfluence
onherbehavior.
Sheshouldhavetheabilitytorecognizewhen
sheisunderstressandtheinfluenceofthestress
onherphysicalandmentalperformance,and
shouldbeabletofindwaystogetadequaterelease
fromthestress.
Untilthenurseisabletocopewithpersonal
fearsandanxietiesinrelationtopsychiatricnur­
sing,itisunlikelythatshecanhaveatherapeutic
influenceinthepatient'senvironment.
2.Self-acceptance
Thenurseshouldnotonlybeaware,butalso
acceptherstrengthsaswellasherlimitations.
Self-understandinghelpshertobeassertivein
lifesituationswithoutbeingaggressiveand
feelingguilty.
3.AcceptingthePatient
Acceptingmeans,beingnon-judgmental.Accep­
tanceconveysthefeelingofbeinglovedandcared.
Thenurseshouldacceptthepatientasheis,asa
sickperson,regardlessofcaste,color,raceor
behavior.
Theabilitytotalktherapeuticallywithpatients
requiresanattitudeofacceptance,toleranceand
genuineinterestinthepatient.Thebasisofall
helpingrelationshipsisacceptancewhichimplies
thatthenursetreatsthepatientasanimportant
personandnotasadiagnosticentityorasetof
psychiatricsymptoms.
4.BeingSincerelyInterestedinPatientCare
Beingsincerelyinterestedinpatientcaremeans
consideringthepatientsinterest.
Thiscanbedemonstratedby:
•Studyingpatient'sbehaviorpattern
•Allowinghimtomakehisownchoicesand
decisionsasfaraspossible
•Beingawareofhislikesanddislikes
•Beinghonestwithhim
•Activelistening.
5.BeingAvailable
Beingavailablemeansnurseshouldbeappro­
achableallthetimetothepatient.Sheshould
conveytothepatientthatsheisavailablenotonly
tomeethisphysicalneeds,butalsotoassisthim
indealingwithhispsychologicalneeds.
6.EmpathizingwiththePatient
Empathyisanimportanttoolinunderstanding
others'feelings.Empathyisaprocesswhena
persongetsintoanotherperson'ssituationand
experienceswhattheotherpersonfeelsandthen
isabletostepbackandanalyzethesituation.The
nurseneednotnecessarilyhavetoexperienceit,
buthastobeabletoimaginethefeelingsasso­
ciatedwiththeexperience.
Tobeabletoempathizewiththepatientthe
nursemustbewillingtogetinvolvedenoughto
feelwhattheotherpersonfeelsandatthesame
timeavoidingover-involvement,projectionofher
ownfeelingsandover-identification.
7.Reliability
Thenursemustdemonstratehonesty,truthful­
ness,resourcefulnessandcompetenceinher
dealingswiththepatientsandtheirfamilies.She
mustproveherselftobetrustworthyandasa
personwhocanberelieduponinanysituation.
8.Professionalism
Developingtheprofessionalskillsofapsychiatric
nurseisdependentuponlearningasmuchas
possibleaboutthepatient,hisillnessandthe

29. 26AGuidetoMentalHealthandPsychiatricNursing
helpingroleofthenurseasitspecificallyapplies
tothepatient.
9.Accountability
AccordingtoPeplau(1980),theneedforpersonal
accountabilityandprofessionalintegrityare
greaterinpsychiatricpracticethaninanyother
typeofhealthcare.Patientsinmentalhealth
settingsareusuallymorevulnerableand
defenselessthanpatientsinotherhealthcare
settings,particularlybecausetheirconditions
hindertheirthinkingprocessesandtheir
relationshipswithothers.Mentalhealthnurses
areaccountableforthenatureoftheeffortthey
makeonbehalfofpatientsandanswerableto
patientsforthequalityoftheirefforts.
10.TheAbilitytoThinkCritically
Theabilitytothinkcriticallyiscrucialformental
healthnurses.Acriticalthinkeranalyzes
informationbeforedrawingconclusionsaboutit.
Itispurposeful,reasonable,reflectivethinking
thatdrivesproblemsolvinganddecisionmaking
andaimstomakejudgmentsbasedonevidence.
THERAPEUTICROLESOFAPSYCHIATRIC
MENTALHEALTHNURSE
Psychiatricnurseshavemanyrolesthatwill
continuetochangeandevolveasthehealthcare
environmentchanges.Therolesofthenursemeet
clientandfamilyneeds,guide,assist,andteach
,theclientandfamily;andprovideanenvironment
thatfacilitatesclientandfamilygrowthand
development.
1.DirectCareProvider
APsychiatricnurseprovidesnursingcareto
individuals,familiesandgroupstoenablethem
tofunctionatanoptimallevelofpsychological
wellness.Asadirectcareproviderthenurse
assiststheclienttoregainhealththroughthe
healingprocess.Thenurseprovidesaholistic
approachtocare,includingassistingtheclient/
familyincopingwiththephysical,emotional
socialandspiritualimpactsoftheillness.
•
2.ProviderofTherapeuticEnvironmentfor
thePatient
Thepsychiatricnursehasalwayshadacentral
roleinmaintainingatherapeuticenvironment.
Thenurseassessespotentiallystressfulcharac­
teristicsoftheenvironmentanddevelops
strategiestoeliminateordecreasethesestresses
intheenvironment.
Asprotectorthenursehelpsmaintainasafe
environmentfortheclientandtakesstepsto
preventinjuryandprotecttheclientfrompossible
adverseeffectsofdiagnosticortreatment
measures.
3.TeacherIEducator
Itisoneoftheprimaryinterventionstrategiesthe
nurseusesinimprovingmentalhealth.
Sometopicsthatnursesaddressintheir
educationincludethefollowing:
•Medicationmanagement
•Illnessmanagement
•Communicationskills
•Copingskills
•Handlingofstressandanxiety
•Dealingwithemergencies
Theteachingrolerequiresskillstoassessthe
patient'slearningneeds,leveloflearningability
anddesigningateachingplanthatencompasses
cultural,socio-economicandpersonalneeds.
Psychiatricnursesactasbothadvisorsto
peopleonhealthmatterswhichareinessence
teachingonaone-to-onebasis,andengageinmore
formalteachingactivities.
4.Coordinator
Nurseasacoordinator,cooperateswithother
professionalsinvariousaspectsoftheclient's
care;therebyfacilitatinganinterdisciplinary
approachtocare.
Thepsychiatricnurseplansandsupervises
thecaregivenbyauxiliarynursingpersonnel.In
addition,sheconsultswithotherprofessionals
regardingthecaregiventothepatient.She
consultswiththepsychiatristabouthisplanof
treatment;shemayneedtotalkwiththe

30. PrinciplesandConceptsofMentalHealthNursing27
behavioraltherapistaboutthepsychological
management,withtheoccupationaltherapist
abouthisrehabilitation,withthesocialworker
andthecommunityagencyaboutplansforhis
homecare.Inanutshell,itisthenurse,who
establishesaplanforthepatient'scareandserves
asthecoordinatorforallactivitiesconcernedwith
him.
5.PatientAdvocate
Asthehealthcaresystemhasbecomemore
complexwithanumberofdifferentagenciesand
anincreasingvarietyofcareprovidersconcerned
withdifferentaspectsofthepatient'scare,the
needforsomeonewhocanspeakonthepatient's
behalfandintercedeinhisinterestshasbecome
essential.Thisspeakingforthepatientand
intercedingonhisbehalfisanimportantaspect
ofnursingcare.
Apatientneedsatleastonepersontowhom
hecanrelateinameaningfulwayandwhocan
actashisspokesmanwithothermembersof
healthteam.Inthisconnection,thenurseisres­
ponsiblefordefining,defendingandpromoting
therightsofthepatient.Anurseisthelogical
persontointerpretthedifferentservicesoffered
byotherprofessionalhealthstaffandtoexplain
thetypesofandneedfor,variousprescriptions
andtreatmentsasorderedbythephysician.As
anadvocate,thenurseiscompelledtoworkon
behalfofthepatient.
Theadvocacyroleinvolves:
•Educatingpatientsabouttheirrightsand
responsibilities
•Negotiatingformentalhealthservices
•Reportingabuseofclient'srights,unethical,
incompetentandillegalpractices
•Protectingthepatientandfamilymembers
fromunethicalpractices.
6.ProviderofPreventiveCare
Preventivecareincludeshealthpromotion,illness
prevention,andprotectionagainstdiseases.
Thefollowingactivitiesarecarriedoutbya
psychiatricnurseforpreventionofmental
illnesses:
•Providinginformationaboutmentalhealth
issues,suchascommunicationskills,
parenting,stressreduction,copingstrategies
andrelaxationtechniquesandcounseling
•Makingappropriatereferralsasindicatedto
preventoccurrenceofmentalillness(primary
prevention)
•Workingwithcommunitygroupsonissues
relatedtomentalhealth
•Secondarypreventioninvolvesthosenursing
activitiesdirectedatreducingactualillness
byearlydetectionandtreatmentofthe
problem.Example:screeningforanxietyand
depression
•Tertiarypreventioninvolvesthosenursing
activitiesthatfocusonreducingtheresidual
impairmentordisabilityresultingfroman
illness.
7.Collaborator
Asmembersofthehealthcareteam,nursesmust
workwithotherteammemberstoensurethat
patientsreceivethehighestqualityofcare
possible.Inpsychiatry,everypatientmusthave
anindividualizedtreatmentplanthatreflectsthe
collaborativeeffortsofnursing,psychiatry,social
work,occupationaltherapy,recreationaltherapy
andotherspecialtiesthatareinvolvedinthe
patient'scare.Nursescaneffectivelyworkwith
othermembersofthehealthcareteamtodealwith
patientcareproblems.
8.CaseManager
Incasemanagementthenurseco-ordinatesthe
activitiesoftheotherhealthcareprovidersin
collaborationwiththedirectcareproviders.The
casemanagerfocusesonmovingtheclientthrough
thehealthcareenvironment,assistingwith
schedulingoftestsandproceduresandinteracting
withvariouscareproviders.Manytimescase
managersfollowaclientacrossallsettings,
includingambulatorycareandhomecare.
9.ProfessionalRole
Nurseshavearesponsibilitytocontributetothe
growthofselfandoftheprofession.Thenurse
participatesincontinuingprofessionaleduca-

31. •Scopeofpsychiatricnursing(Nov2001,Oct
2002,Nov2003)
•Currenttrendsinmentalhealthnursing(Nov
2002,Nov2003,Oct2006)
•Qualitiesofapsychiatricnurse
•Therapeuticrolesofapsychiatricnurse
•Standardsofmentalhealthnursing(Nov
2001,Nov2002)
•Principlesofpsychiatricnursing(Feb2000,
Feb2001,Apr2004,Oct2004,Oct2005,Apr
2006)
•Functionsofpsychiatricnurse
•Methodsofpsychiatricassessment(Nov1999)
28AGuidetoMentalHealthandPsychiatricNursing
tionalactivitiesandpromotesactivitiesdesigned
toimprovepsychiatricnursingpracticeandcare.
10.Researcher
APsychiatricnurseutilizestherapeuticprinciples
andresearchtounderstandandinterpretthe
client'semotions,thoughtsandbehaviors.She
alsoinvolvesinresearchactivitiestoincorporate
newresearchfindingsintopracticeandmonitor
theprotectionofhumansubjects.
REVIEWQUESTIONS
•Historicaldevelopmentofpsychiatricnursing
(Nov1999,Oct2006)

32. PersonalityDevelopment
andTheories
:JDEFINITIONOFPERSONALITY
:JPSYCHOSOCIALFACTORSINFLUENCING
PERSONALITY
RoleofHeredity
EnvironmentalFactors
:JDEVELOPMENTOFPERSONALITY
:JTHEORIESOFPERSONALITYDEVELOPMENT
PsychoanalyticTheory
InterpersonalTheory
TheoryofPsychosocialDevelopment
CognitiveDevelopmentTheory
TheoryofMoralDevelopment
HumanisticApproach
TraitandTypeTheoriesofPersonality
BehaviorTheory
/IEFINITIONOFPERSONALITY
"Personalityreferstodeeplyingrainedpatterns
-ofbehavior,whichincludethewayonerelatesto,
perceives,andthinksabouttheenvironmentand
oneself".
'----fAmericanPsychiatricAssociation(APA)1987
PSYCHOSOCIAL FACTORSINFLUENCING
PERSONALITY
I.RoleofHeredity
Atconceptionwhentheeggcellofthefemaleis
fertilizedbythespermcellofthemale,eachnew
humanbeingreceivesageneticinheritancethat
providespotentialitiesfordevelopmentand
behavioraltraitsthroughoutalifetime.
Theprincipalrawmaterialsofpersonality-
physique,intelligenceandtemperamentarethe
resultofheredity.Howtheywilldevelopwill
dependonenvironmentalinfluences.Many
aspectsofhumanbehavioranddevelopment
rangingfromphysicalcharacteristicssuchas
height,weight,eyeandskincolor,thecomplex
patternsofsocialandintellectualbehavior,are
influencedbyaperson'sgeneticendowment.
II.EnvironmentalFactors
1.Family
•Amongenvironmentalfactors,themost
importantisthefamilyenvironment.The
reactionofthefamilyenvironmenttowards
anindividual,andtheroleofparents,arevery
importantinthemoldingofpersonality.
Parentsserveasamodelwhomthechild
imitates,andtheirinfluenceisconsiderable
onthechild.Parentsinfluencethedevelop­
mentofachild'spersonalityinawidevariety
ofways.Childrenlearnthemoralvalues,code
ofconduct,socialnormsandmethodsof
interactingwithothersfromparents.
•Onthewholefriendlyandtolerantfathers
helpchildrentohavegreateremotional
stabilityandselfconfidence.Domineeringand
rigidfatherswillonlyfosterthedevelopment
ofsubmissiveandfrighteneddependent
children.
•Over-protectivemotherswillinfluence
childreninthedirectionofdependenceanda
totaldisregardforothers.Naggingmothers
willcausechildrentobeshy,submissiveand
emotionallyunstable.
•Besidestheroleoftheparents,theatmosphere
inthefamilyisgreatlyinfluencing.Apeaceful
andlovingatmosphereresultsinchildren
beingorderly,peace-lovingandveryaffectio­
nate.Withoutunduestraintheydevelop

33. •Theparathyroidglandregulatescalcium
metabolism.Excitabilityofthenervoussystem
isdirectlydependentontheamountofcalcium
intheblood.Deficientworkingofthisgland
leadstothedevelopmentofanirritable,
distracted,nervousandatenseperson.
•Similarlyotherglandsnamelypituitary,the
adrenalandthegonadshavetheirtremendous
impactonvariouspersonalitytraits.
30AGuidetoMentalHealthandPsychiatricNursing
matureandpleasantpersonalities.Inafamily
wherethereistension,constantquarrelsand
incompatibilityamongparents,thechildis
likelytodevelopstrongfeelingsofinsecurity
andinferiority.
•Birthorder:Thisisanotherfamilialfactorthat
canhaveanimportantinfluenceon
personalitydevelopment.Everychildhasa
uniquepositioninthefamily,suchasthe
eldest,youngest,secondorthird.Thisposition
hasadefiniteinfluenceonpersonality.The
eldestchildisveryoftenoverburdenedwith
responsibility,hencehegrowsuptobevery
independent,whiletheyoungestbeingthe
babyofthefamilyispettedandspoilt.The
commonviewofanonlychildwouldbethat
hewillbepamperedandspoilt.
2.Physique
Anindividual'ssize,strengthandgeneral
appearancedeterminestoalargeextenttheway
inwhichhebehavestowardsothersandhow
othersreacttowardshim.Anindividualwithan
imposingbody-buildandahealthyappearance
definitelyinfluencesthosearoundhim.Evenif
hehasnotprovedhimself,yethegainsrecognition
andstatusthroughhisphysicalappearance.
Contrarytothisisthesmallleanperson;evenif
hehassomemerits,theseareover-lookedbecause
ofhisphysique.Peopleareapttojudgehim
accordingtohisappearance.
3.EndocrineGlands
•Thesecretionsofendocrineglandsaffect
physicalgrowth,emotionalgrowthand
mentalgrowth.Thesewillhaveanimpacton
thetotalpersonalityofanindividual.
•Thethyroidglandsecretesahormonecalled
thyroxin,andthemainfunctionofthis
hormoneisregulationofbodymetabolism.If
thethyroidglandisunder-active,theresultis
usuallymentaldullness,inactivity,depres­
sion,fatigueandpoorappetite.Hypersec­
retionoftheseglandsleadstoextremeover­
activity.
4.School
•Thechildrenspendmuchoftheirtimeinthe
schoolsandhenceitcanplayaverylargepart
intheformationofthepersonalityofthechild.
•Thefollowingfactorsofschoolwillhavedirect
roleonchildpersonality:
•thefriendshipsandacquaintanceswhich
aremadeamongthechildrenthemselves
•thetypeofcurriculumintheschools,
whichaffectsthehabitualresponsesof
children
•well-furnishedlaboratories,adequate
playground,etc.
Anurturantschoolatmospherethatprovides
forall-rounddevelopment,consistency,
structure,warmthandresponsiveness,cando
agreatdealtohelpchildrendevelopa
favorablepersonalityandcopewithchanging
lifecircumstances.
5.Teacher
Ateacheristhemostimportantpersoninthe
schoolwhocanhelpinmodifyingchildren's
personalities.Heisthemostpowerfulsourceof
stimulationforthechild.Ifhe/shepossesses
desirablepersonalandsocialmodesorreactions,
hewillinculcatethemamonghisstudents.On
theotherhand,effectsofprejudicialtreatmenton
thepartofteacherscanmakethechildloseself­
confidenceanddeveloplowself-esteem.
6.PeerGroup
Developmentalpsychologistsbelievethatinter­
actionswithpeersarecriticaltomanyofthesocial

34. PersonalityDevelopmentandTheories31
skillsandadvancesthatoccurduringchildhood.
Peergroupreferstootherchildrenofthesame
agewhostudywithorplaywiththechild.Peer
groupismuchmoreinfluentialthansiblingsor
parents.
Evenatpreschoolage,playmatesarehighly
influential.Childrenimitatepeersandtrytobe
liketheminmanyrespects.Thepeergroupserves
asanimportantreferencegroupinshaping
personalitytraitsandcharacteristicsofthe
growingchild.Asthechildgrowsuppeers
becomeprogressivelymoreinfluentialinmolding
thechild'sselfconcept.Childrenlearnmany
formsofbehavior,somesociallyappropriateand
otherssociallyundesirable,fromtheirpeers.
Forexample,bystrivingtobeacceptedand
likedbytheirpeers,theygainnewinsightsinto
themeaningoffriendship.Throughgiveandtake
withpeers,theylearntheimportanceofsharing,
reciprocityandcooperation.Bytryingtogetpeers
tounderstandtheirthoughtsandfeelings,they
learntocommunicatemoreeffectively.Withinthe
peergroup,childrenalsolearnsex-rolenorms.In
general,boysbecomerougher,boisterous,more
compulsive,andformlargergroups,whilegirls
tendtoformmoreintimate,moreexclusivegroups.
Feelingsofmasculinesuperiority,sexbiasand
otherattitudesandbehaviordevelopwithgender
identification.
7.SiblingRelationships
Thenumberofsiblingsaswellastheirsex
andagehasaconsiderableinfluenceonthe
developmentofbothfavorableandunfavorable
personalitytraitslikecooperativeness,sharing,
aggressiveness,jealousy,etc.Althoughsibling
rivalryiscommon,oldersiblingsinvariablyteach
theinfantagreatdealandtheycanevenfunction
asasourceofsecurity.Ontheotherhand,
unhealthycomparisonscanalsodevelop,for
instance,anathleticchildwhoisfavoredbyan
athleticfatheroveralessactivesibling,maysuffer
fromaninferioritycomplexordeveloplowself­
esteem.
8.MassMedia
Massmediaincludesfilms,television,radio,
printedliterature,etc.Massmediahasa
considerableimpactonattitudes,values,beliefs
andbehaviorpatterns.BaronandBryne(1986)
haveshownthatindividuals,especiallychildren,
imitatespecificaggressiveactsofmodels.They
haveproposedthathumanpersonalityformation
isaresultofmodelingandimitatingthebehavior
ofsignificantothers.Manyabnormalformsof
behaviorcanbelearnedbyimitatingmodelsfrom
themassmedia.
9.Culture
Cultureinfluencespersonalitybecauseevery
culturehasasetofethicalandmoralvalues,
beliefs.andnormswhichconsiderablyshapes
behavior.Cross-culturalstudieshavepointedout
theimportanceofculturalenvironmentin
shapingourpersonality.Individualsofcertain
culturesaremoregenerous,open-heartedand
warmwhereasindividualsofsomeothercultures
aresuspicious,introvertedandself-centered.It
hasalsobeenfoundthatcertaincultural
communitiesaremorepronetodevelopcertain
abnormalbehaviorsascomparedtoothers,
probablyduetotheinfluenceofgeographical,
dietary,hormonalorgeneticinfluenceswithin
thecommunity.
"Personalityconsistsofdistinctivepatternsof
behavior(includingthoughtsandemotions)that
characterizeeachindividual'sadaptationtothe
situationsofhisorherlife".
(WalterMischel,1976)
Babyhood(Birth-2yearsoflife)
•Thisperiodisthetruefoundationperiodof
lifebecausemanybehavioralpatterns,atti­
tudesandpatternsofemotionalexpressions
arebeingestablished.Thesehavealifelong
influenceonthechild'spersonalandsocial
adjustments.

35. growthininfancy.Bodyproportionschange
markedly.Themusclesbecomelonger,stronger
andheavier.Theaverageannualincreasein
heightis3inchesandtheaverageannualincrease
inweightis3-5lbs.
Emotionsareespeciallyintense,andtheyare
easilyarousedtoemotionaloutburstssuchas
tempertantrums,fears,andunreasonable
outburstsofjealousy.Otheremotionsofcuriosity,
joy,andaffectionalsodevelop.
32AGuidetoMentalHealthandPsychiatricNursing
•Theterm'infant'suggestsextremehelpless­
ness.Theinfantistrulyadependent
individual,andhistotalexistencedepends
onresourcesoutsidehimself.Itisatimeof
rapidgrowthanddevelopment,andatimeof
radicaladjustments.
•Anaverageinfantweighs7lbsandmeasures
18-19inchesinlength.Commonresponses
likespontaneouseyemovements,yawning,
turningandliftingthehead,etc.arepresent.
Graduallydentition,bowelandbladder
controldevelop.Thebabygrowsrapidlyand
masterssomecommonskillssuchasself­
feeding,self-dressing,walkingalone,
climbingstairs,etc.
•Thebaby'svocalizationincludescrying,
cooing,gurgling,whichgraduallydevelop
intobabbling,andlater,speech.
•Emotionalreactionsareintenseandsudden,
whateverthestimulus.Thesereactionsmay
bedescribedasstatesofpleasantness
(characterizedbyrelaxingofthebody)and
unpleasantness(characterizedbytensingof
thebody).Lateron,emotionssuchasanger,
fear,curiosity,joy,affectionareexhibited.
Babieswhoexperiencemoreofpleasant
emotionsarelayingthefoundationforgood
personalandsocialadjustmentslateronin
life.
•Personalitytraits
Childrenarebornwithcharacteristictempe­
ramentaldifferences,anditisthesedifferences
fromwhichtheindividualpersonalitypatterns
develop.Theinfantdevelopsself-trustby
trustinginwhatheseesandhears.The
beginningfeelingsofconfidenceandfaith
developifhereceiveswhatisneeded.Feelings
ofdistrustdevelopifthebaby'sneedsarenot
met.Thisleadstopersonalityproblemssuch
asclinginganddemandingbehavior,greed,
givingupeasily,takingratherthangiving,
etc.
EarlyChildhood(2-6years)
Growthduringearlychildhoodproceedsata
slowrateascomparedwiththerapidrateof
PersonalityTraits
•Themostimportantpsychosocialachieve­
mentatthistimeisthedevelopmentof
autonomyorindependence.Iftrustand
securitydonotdevelopatanearlyage,
autonomywillfailtodevelop.Thereis
heightenedawarenessandcuriosityoftheself,
termedasnarcissism.Theissueofsexuality
alsoovertlydevelops.
•Thechildalsobeginstoknowthedifference
betweenrightandwrong,andlaiddown
standardsofbehaviorandrulesofconscience
whichwillthereafterguidemuchofhis
behavior.
•Inthisphasespecificcrisisisbetween
initiativeandguilt.Ifthechildsuccessfully
passesthroughthisstage,itleadstointer­
nalizationofvaluesandsocialsanctions,and
fromthistimeonwards,heisableto
differentiatebetweenrightandwrongandto
laydownstandardsofbehaviorandrulesof
consciencethatwillthereafterguidemuchof
hisbehavior.
•Thechildwithfaultyautonomytraitswillbe
clinginganddependent.Phaserelatedadult
characteristicsincludestubbornness,over
compensatorycontrol,compulsivecleanliness
andextremeselfcontrol.Hemayalsodevelop
intenseanxietyorguiltoranantisocial
personality.
LateChildhood(6-11years)
•Latechildhoodisaperiodofslowanduniform
growth.Theaverageannualincreaseinheight

36. PersonalityDevelopmentandTheories33
is2-3inches,andtheaverageannualweight
increaseis3-5lbs.
•Emotionalexpressionsareusuallypleasant
ones,althoughoutburstsofanger,anxietyand
frustrationmaycontinuetooccur.
PsychosocialDevelopment
•Itisduringthisstagethereisincreasedego
controloverbasicdrives.Behavioral
characteristicslikesympathyandconcernfor
others,cleanliness,modesty,co-operationand
willingnesstosharedevelop.Thechildnow
looksbeyondthefamilyandbeginstointeract
withthesocialsystem.
•Developmentaltasksduringthisperiodare
theacquisitionofsocialskills,incorporating
socialvaluesandpatterns,andcompetition
andinteractionwithpeersandauthority
figures.Failureinmasteryofthetasksresults
inemotionalinstability,lowself-esteem,social
inferiorityandinabilitytoassumeexpected
responsibilities.
Adolescence(12-19years)
•Theperiodofadolescenceisaperiodof"storm
andstress,"anaction-orientedphaseoflife
inwhichfeelingsandthoughtsareprimarily
expressedthroughbehavior.
•Theimportantphysicalchangeswhichoccur
duringthisperiodincludechangesinbody
sizeandproportion,andthedevelopmentof
primaryandsecondarysexcharacteristics.
PsychosocialDevelopment
•Amajorchangefromthechildhoodtothe
adolescentisthedevelopmentofself­
consciousness.Adolescentsbecomevery
awareofhowothersseethemandreactto
them,andthisawarenessmakesteenagersfeel
apprehensiveandextremelyself-conscious.
•Thisistheperiodwhenthereisaconso­
lidationofpersonalityandabeginningsense
ofidentityasamatureperson.Phasespecific
tasksfortheadolescentmaybeidentifiedas
gainingindependencefromthefamily,
integratingnewfoundsexualmaturity,
establishingmeaningfulrelationshipswith
peersofbothsexes,andmakingdecisions
aboutlifeworkandgoals.
•Parent-adolescentconflictisverycommon,as
adolescentsseekindependencefromtheir
parents.Theapprovaloftheirownagegroup
ismuchmoreimportanttothemthanthe
approvalofadults.Intenseconflictscanoccur
ifthevaluesofthegroupconflictwiththoseof
theparents.Beingamemberofthepeergroup
hasastronginfluenceontheself-identityand
self-esteemoftheadolescent.
•Theissuesoftheperiodoflateradolescence
(15-19years)arerelatedtocareer,marriage
andparenthood.Thisistheperiodwhenthere
isaconsolidationofthepersonalityanda
beginningsenseofidentityasamatureperson.
•Characteristictroublesoftheadolescent
identitycrisismayincludepsychosis,
neurosis,delinquency(breakingrulesof
society),etc.
EarlyAdulthood(20-40years)
•Theterm'adult'isderivedfromtheLatinword
'adulius',whichmeans'growntofullsizeand
strength'.Adultsarethereforeindividuals
whohavecompletedtheirgrowthandare
readytoassumetheirstatusinsocietyalong
withotheradults.
•Duringthisstage,thephysicaland
psychologicalchangeswhichaccompanythe
beginningofreproductivecapacityappear.
TheBasalMetabolicRate(BMR)slowlybegins
tocomedown,whencomparedtoadolescence,
soexcessbodyweightiseasilygained.
PsychosocialDevelopment
•Thefourmajorsocialexpectationsortasksfor
theadultincludechoiceofcareer,sexual
mutuality(marriage/choosingalifepartner),
generativityandchild-rearing,participation
insocialprocessesandwork.
•Iftheyoungadulthasbeenover-protectedby
parents,difficultiesariseinformingintimate
relationshipswithanotherpersonandcoping
withresponsibilitiesintheworkingworld.

37. 34AGuidetoMentalHealthandPsychiatricNursing
MiddleAdulthood(41-60years)
Physicalchangesrelatedtoageingbecomemore
prominent,suchaswrinkledskin,muscularpains
andimpairedsensorycapacities.Faultylifestyles
maybringondiseasessuchashypertension,
heartdisease,cancer,etc.Averymajorphysical
changeismenopauseorthemaleclimacteric.
Manyphysicaldiscomfortsandmoodchanges
mayaccompanymenopause,andtheymay
becomedepressed,hostileandself-criticaland
havewidemoodswings.Alltheseusually
disappearonceendocrinebalanceisrestored.
Howsuccessfullywomenmaketheadjustment
tothephysicalandpsychologicalchangesthat
accompanymenopauseisgreatlyinfluencedby
theirpastexperiences,andespeciallythesocial
supportavailabletothem.
PsychosocialIssues
•Duringthisage,peoplebecomemoreandmore
occupiedwiththeirworkandfamily.The
majoradjustmentstobemadeduringthis
periodincludeadjustingtophysicaland
mentalchanges,occupationalresponsibilities,
approachingretirementandoldage.
•Failuretomasterthesedevelopmentaltasks
mayleadtomarital,socialoroccupational
conflictsandfailures.
LateAdulthood(Oldage-60yearsandabove)
•Physicalchangesincludewrinklingofskin,
stoopedposture,flabbinessofmuscles,
decreasedvisionandhearing,adecreased
efficiencyofcardiovascularsystem
•Psychosocialissues
•Thethemeofthisageperiodisloss,which
maybeidentifiedasfollows:
•Lossofphysicalabilities
•Lossofintellectualprocesses
•Lossofworkroleandoccupationalidenti­
fication(retirement)
•Lossofintimateties,suchasdeathof
spouse,friendsandotheracquaintances
•Themajoradjustmentstobemadeinclude
adjustmenttophysicalchanges,retirement,
lossofspouse,post-childrearingperiod
(emptynestsyndrome),grandparenthood
•Iffavorablefactorssuchassatisfactionof
needs,retentionofoldfriendships,positive
socialattitudes,etc.arepresent,theyfoster
egointegrityoftheperson.Howeverwithout
adequatesupporttosustainandbearthe
lossestheolderadultisvulnerabletoa
profoundsenseofinsecurity.Despairand
disgustcantakeovertheperson,including
thefeeling,timeisrunningoutandthereare
noalternativespossibleatthislatedate.
•Seriouspersonalitybreakdowninoldagemay
leadtocriminalbehaviororsuicidaltende­
ncies,asindemen~.j
THEORIESOFPERSONALITY DEVELOPMENT
Developmentaltheoriesidentifybehaviorsasso­
ciatedwithvariousstagesthroughwhichindivi­
dualspass,therebyspecifyingwhatisappropriate
orinappropriateateachdevelopmentallevel.
Nursesmusthaveabasicknowledgeofhuman
personalitydevelopmenttounderstandmal­
adaptivebehavioralresponsescommonlyseen
inthementallyill.Knowledgeoftheappropria­
tenessofbehaviorateachdevelopmentallevelis
vitaltotheplanningandimplementationof
qualitynursingcare.
PsychoanalyticTheory
Freud(1939),whohasbeencalledthefatherof
psychiatry,iscreditedasthefirsttoidentify
developmentbystages.Hebelievedthatan
individual'sbasiccharacterisformedbyage5.
Freudcategorizedhispersonalitytheoryaccor­
dingtostructure,dynamics,anddevelopment.
StructureofthePersonality
Freudorganizedthestructureofpersonality
intothreemajorcomponents:theid,ego,and
superego.
Id
Theidcontainsallourbiologicallybaseddrives
-theurgetoeat,drink,eliminate,andespecially,

38. PersonalityDevelopmentandTheories35
tobesexuallystimulated.Thesexualenergythat
underliestheseurgesiscalledthelibido.Theid
operatesaccordingtothe"pleasureprinciple."
Thatis,itdesirestosatisfyitsurgesimmediately,
withoutregardtorules,realitiesoflifeormorals
ofanykind.Idpresentatbirth,itendowsthe
infantwithinstinctualdrivesthatseektosatisfy
needsandachieveimmediategratification.Id
drivenbehaviorsareimpulsiveandmaybe
irrational.
Ego
Theegofunctionsonthebasisof"reality
principle",andbeginstodevelopbetweenages4
and6months.Theegoexperiencestherealityof
theexternalworld,adaptstoit,andrespondsto
it.Itdelayssatisfyingid,andchannelsour
behaviorintosociallyacceptableway.Aprimary
functionoftheegoisthatofmediator,thatisto
maintainharmonybetweentheexternalworld,
theid,andthesuperego.
Superego
Thesuperegoisreferredtoasthe"perfection
principle"orthe"moralprinciple".Thesuperego
whichdevelopsbetweenages3and6,
internalizesthevaluesandmoralssetforthby
primarycaregivers.Thesuperegoisimportantin
thesocializationoftheindividualasitassiststhe
egointhecontrolofidimpulses.Whenthe
superegobecomesrigidandpunitive,problems
withlowself-confidenceandlowself-esteemarise.
DynamicsofthePersonality
•Freudbelievedthat"psychicenergy"isthe
forceorimpetusrequiredformentalfunc­
tioning.Originatingintheid,itinstinctually
fulfillsbasicphysiologicalneeds.Asthechild
matures,psychicenergyisdivertedfromthe
idtoformtheegoandthenfromtheegoto
formthesuperego.
•Psychicenergyisdistributedwithinthese
threepersonalitycomponents,largestshare
tomaintainabalancewithinimpulsive
behaviorofidandtheidealisticbehaviorof
thesuperego.Ifanexcessiveamountof
psychicenergyisstoredinoneofthese
personalitycomponents,behaviorwillreflect
thatpartofthepersonality.Forinstance,
impulsivebehaviorwillprevailwhen
excessivepsychicenergyisstoredintheid.
•Overinvestmentintheegowillreflectself­
absorbedornarcissisticbehaviorsandan
excesswithinthesuperegowillresultinrigid,
self-deprecatingbehaviors.
•Thehumanpersonalityfunctionsonthree
levelsofawareness:conscious,preconscious
andunconscious.
•Consciousnessreferstotheperception,
thoughtsandfeelingsexistinginaperson's
immediateawareness.
•Preconsciouscontentontheotherhand,isnot
immediatelyaccessibletoawareness.Unlike
consciousandpreconscious,contentinthe
unconsciousremaininaccessibleforthemost
part.
•Theunconsciousaffectsallthethreeperso­
nalitystructures-id,egoandthesuperego.
Althoughtheid'scontentresidestotallyin
theunconscious,thesuperegoandtheego
haveaspectsinallthethreelevelsof
consciousness.
•Someideas,memories,feelingsormotives
whicharedisturbing,forbidden,andun­
acceptableandanxietyproducingarerepres­
sedfromconsciousness.Theprocessofrepres­
sionitselfisunconsciousandautomatic,it
justhappenswithoutourknowledge.This
repressedmaterialcontinuoustooperate
undergroundandconvertstherepressed
conflictsintodisturbedbehaviorand
unexplainedsignsandsymptoms.According
toFreudthisrepressedmaterialisalso
responsibleforsomeofourdreams,accidental
slipsoftongue,etc.
Freud'sStagesofPersonalityDevelopment
Freuddescribedformationofpersonalitythrough
fivestagesofpsychosexualdevelopment.Freud
placedmuchemphasisonthefirst5yearsoflife
andbelievedthatcharacteristicsdeveloped

39. 36AGuidetoMentalHealthandPsychiatricNursing
duringtheseearlyyearsboreheavilyonone's
adaptationpatternsandpersonalitytraitsin
adulthood.Fixationinanearlystageof
developmentwillalmostcertainlyresultin
psychopathology.
1.Oralstage:Birthto18months
Themajordevelopmentaltasksduringthisstage
are"relieffromanxietythroughoralgratification
ofneeds".Duringthisstagebehaviorisdirected
bytheid.Thefocusofenergyisthemouth.The
babyobtainspleasurefromsucking,biting,and
chewing.Theinfantfeelsasenseofattachment
andisunabletodifferentiatetheselffromthe
personwhoisprovidingthemothering.Atthe
ageof4-6monthsthedevelopmentofegowill
begin,theinfantstartstoviewtheselfasseparate
fromthemotheringfigure.Asenseofsecurityand
theabilitytotrustothersisderivedoutof
gratificationfromfulfillmentofbasicneedsduring
thisstage.
2.Analstage:18monthsto3years
Themajordevelopmentaltasksinthisstageare
gainingindependenceandcontrol,withfocuson
theexcretoryfunction.Duringthisstagetheidis
slowlybroughtunderthecontrolofego.Freud
believedthatthemannerinwhichtheparents
andotherprimarycaregiversapproachthetask
oftoilettrainingmayhavelongtermeffectson
thechildintermsofvaluesandpersonality
characteristics.Whentoilettrainingisstrictand
rigid,thechildmaychoosetoretainthefeces,
becomingconstipated.Adultretentivepersonality
traitsinfluencedbythistypeoftraininginclude
stubbornness,stinginessandmiserliness.
Toilettrainingthatismorepermissiveand
acceptingattachesthefeelingofimportanceand
desirabilitytofecesproduction.Thechildbecomes
extroverted,productiveandaltruistic.
3.Phallicstage:3to6years
Themajordevelopmentaltaskduringthisstage
isidentificationwithparentsofthesamesexand
developmentofsexualidentity;focusisongenital
organs.ThedevelopmentofOedipuscomplex
occursduringthisstageofdevelopment.Freud
describedthisasthechild'sunconsciousdesire
toeliminatetheparentofthesamesexandto
possestheparentoftheoppositesex.Guiltfeelings
resultwiththeemergenceofthesuperegoduring
theseyears.Resolutionofthisinternalconflict
occurswhenthechilddevelopsastrong
identificationwiththeparentofthesamesexand
thatparent'sattitudes,beliefsandvaluesystem
aresubsumedbythechild.
4.Latencystage:6to12years
Themajordevelopmentaltaskduringthisstage
is"repressedsexualitywithfocusonrelation­
shipswithsamesexpeers".Sexualityisnotabsent
duringthisperiod,butremainsobscureand
imperceptibletoothers.Childrenofthisageshow
adistinctpreferenceforsame-sexrelationships,
evenrejectingmembersoftheoppositesex.
5.Genitalstage:13to20years
Themajordevelopmentaltasksduringthisstage
are:Libidoisreawakenedasgenitalorgans
mature;focusisonrelationshipswithmembers
oftheoppositesex.Thedevelopmentofsexual
maturityevolvesfromself-gratificationto
behaviorsthathavebeendeemedacceptableby
societalnorms.
InterpersonalTheory
Sullivan(1953)believedthatanindividual's
behaviorandpersonalitydevelopmentarethe
directresultofinterpersonalrelationshipsand
thatpersonalitydevelopmentisdetermined
withinthecontextofinteractionswithother
humans.
Sullivan'smajorconceptsinclude:
1.Anxiety
AcentralthemeofSullivan'stheoryisanxiety
anditsrelationshiptotheformationof
personality.Heviewedanxietyasaprimary
motivatorofbehavior,abuilderofself-esteem
andthegreateducatorinlife.Itarisesoutof

40. PersonalityDevelopmentandTheories37
one'sinabilitytosatisfyneedsorachieve
interpersonalsecurity.Healsobelievedthat
anxietyisthechiefdisruptiveforceinthe
developmentofseriousdifficultiesinliving.
2.Theselfsystem
Itisasignificantaspectofthepersonalitythat
developsinresponsetoanxiety.Disapproving
andforbiddinggesturesduringinteractions
withsignificantothershelptodevelopthe
self-system.Sullivanidentifiedthreecompo­
nentsoftheself-system,whicharebasedupon
interpersonalexperiencesearlyinlife.
AThe"goodme"-thepartofthepersonality
thatdevelopsinresponsetopositive
feedbackfromtheprimarycaregiver.
Feelingsofpleasureandgratificationare
experienced.
B.The"badme"-partofthepersonalitythat
developsinresponsetonegativefeedback
fromtheprimarycaregiverandexperien­
cesrelatedtoincreasedanxietystates.
Feelingsofdiscomfortanddistressare
experienced.
C.The"notme"-thepartofthepersonality
thatdevelopsinresponsetosituationsthat
produceintenseanxietyinthechild.
Feelingsofhorroranddreadareexperien­
ced.Thechildmaydevelopemotional
withdrawal.
3.Securityoperations
Securityoperationsbecomeapartoftheself
systemtohelptheindividualavoidor
minimizeanxiety.Thesecurityoperations
includesublimation,selectiveinattentionand
dissociation.
•Sublimationisanunconsciousprocessof
substitutingasociallyacceptableactivity
patterntopartiallysatisfyaneedforan
activitythatwouldgiverisetoanxiety.
•Selectiveinattentionisanunconscious
substituteprocessthatallowsmany
meaningfuldetailsofone'slifethatare
associatedwithanxietytogounnoticed.
•Dissociationisasystemofprocessthat
minimizesoravoidsanxietybykeeping
partsoftheindividual'sexperiencescalled
'notme'outofconsciousness.
Sullivan'sStagesofPersonalityDevelopment
Sullivandescribedsixstagesofpersonality
developmentfrombirthtomaturity,whichhe
dividedaccordingtothecapacityforcommuni­
cationandintegrationofnewinterpersonal
experiences.Experiencesduringeachstageare
influencedbythoseofthepreviousone.The
personalityachievessomedegreeofstabilityat
theendofthejuvenileera(seebelow),but
continuestodevelopbeyondthistimeandhas
thepotentialforcorrectiveexperiences.
1.Infancy:Birthto18months
Themajordevelopmentaltaskduringthisstage
is"relieffromanxietythroughoralgratification
ofneeds".Thisisaccomplishedaroundactivity
associatedwiththemouth,suchascryingand
thumbsucking.
2.Childhood:18monthsto6years
Themajordevelopmentaltaskduringthisstage
is"learningtoexperienceadelayinpersonal
gratificationwithoutundoanxiety".Toolsofthis
stageincludethemouth,language,theanus,
experimentation,manipulation,andidentifi­
cation.
3.Juvenile:6to9years
Themajordevelopmentaltaskduringthisstage
is"learningtoformsatisfactorypeerrelation­
ships".Thisisaccomplishedthroughtheuseof
competition,co-operationandcompromise.
4.Preadolescence:9to12years
Themajordevelopmentaltaskduringthisstage
is"learningtoformsatisfactoryrelationships
withpersonsofsamesex";theinitiationoffeelings
ofaffectionforanotherperson.
5.Earlyadolescence:12to14years
Themajordevelopmentaltaskduringthisstage
is"learningtoformsatisfactoryrelationshipwith
personsoftheoppositesex;developingasenseof
identity".Theemergenceoflustinresponseto

41. 38AGuidetoMentalHealthandPsychiatricNursing
biologicalchangesisamajorforceoccurring
duringthisperiod.
6.Lateadolescence:14to21years
Themajordevelopmentaltaskduringthisstage
is"establishingselfidentity;experiencing
satisfyingrelationship;workingtodevelopa
lasting,intimateopposite-sexrelationship."The
genitalorgansarethemajordevelopmentalfocus
ofthisstage.
TheoryofPsychosocialDevelopment
Erikson(1963)studiedtheinfluenceofsocial
processesonthedevelopmentofthepersonality.
Eriksontriedtorevisepsychoanalytictheoryby
givingagreaterroletoegoprocesses.He
expandedFreud'stheorytocoverthewholelife
cycleofmanastheEightStagesofMan.Ateach
ofthese8stages,theindividualisfacedwitha
psychosocialcrisis,whichmustbesuccessfully
resolved,ifhealthydevelopmentmusttakeplace
atalaterstage.
1.Infancy(0-1year)TrustvsMistrust
•Themajordevelopmentaltaskduringthis
stageis"todevelopabasictrustinthe
motheringfigureandbeabletogeneralizeit
toothers".
•Theinfantlearnstotrustifallhisneedsare
met.Achievementofthetaskresultsinself
confidence,optimismandfaithinthe
gratificationofneedsanddesiresandhope
forthefuture.
•Distrustcandevelopiftheinfant'sworldis
filledwithinsecurityduetounmetneeds,
causedbylackofcaringonthepartofparents
andsignificantothers.
•Non-achievementresultsinemotionaldissa­
tisfactionwiththeselfandothers,suspicious­
ness,anddifficultywithinterpersonal
relationship.
2.EarlyChildhood(2-3years)-Autonomyvs
ShameandDoubt
•Themajordevelopmentaltaskduringthis
stageis"togainsomeself-controland
independencewithintheenvironment".
•Asthechildattemptstogainindependence,
parentsneedtoencouragehim,whichwill
helphimgainautonomy.Achievementofthe
taskresultsinasenseofself-controlandthe
abilitytodelaygratification,andafeelingof
self-confidenceinone'sabilitytoperform.
•Ifheisnotallowedfreedomorifheis
overprotectedorcriticizedforwhathedoes,
shame,doubtanduncertaintyabouthimself
andhiscapabilitieswillresult.
3.MiddleChildhood(4to5years)-Initiativevs
Guilt
•Themajordevelopmentaltaskduringthis
stageis"todevelopasenseofpurposeand
SI.No.Stage PsuchosocialCrisis Virtue
1 Infancy(Birthto1year) BasicTrustvsMistrust Hope
2 EarlyChildhood(2-3years) AutonomyvsShameandDoubt Willpower
3 MiddleChildhood(4-5years) InitiativevsGuilt Purpose
4 LateChildhood(6-11years) IndustryvsInferiority Competence
5 Adolescence(12-19years) EgoIdentityvsRoleConfusion Fidelity
6 EarlyAdulthood(20-25years) IntimacyvsIsolation Love
7 MiddleAdulthood(26-64years) GenerativityvsStagnation Care
8 LateAdulthoodorOldAge EgoIntegrityvsDespair Wisdom
(65yearsandabove)
•..

42. PersonalityDevelopmentandTheories39
theabilitytoinitiateanddirectownactivities.
•Initiativeisachievedwhencreativityis
encouragedandperformanceisrecognized
andpositivelyreinforced.
•Achievementofthetaskresultsintheability
toexerciserestraintandself-controlof
inappropriatesocialbehaviors.
•Ifhisinitiativeandcuriosityarediscouraged,
thechildmaybepreventedfromsettingfuture
goalsbyasenseofguiltandshameforholding
suchambitions.
4.LateChildhood(6-11years)-Industryvs
Inferiority
•Themajordevelopmentaltaskduringthis
stageis"toachieveasenseofself-confidence
bylearning,competing,performingsuccess­
fully,andreceivingrecognitionfromsigni­
ficantothers,peersandacquaintances.
•Ifparentspraisethechildren'sefforts,asense
ofesteemandindustrydevelops.Achievement
ofthetaskresultsinasenseofsatisfaction
andpleasureintheinteractionandinvolve­
mentwithothers.
•Whenparentssetunrealisticexpectationsfor
thechild,whendisciplineisharshandtends
toimpairselfesteem,andwhenaccomp­
lishmentsareconsistentlymetwithnegative
feedback,theindividualmaybecomea
workaholicwithunrealisticexpectations,non­
achievementresultsindifficultyininterper­
sonalrelationshipsduetofeelingsofpersonal
inadequacy.
5.Adolescence(12-19years)-EgoIdentity
vsRoleConfusion
•Themajordevelopmentaltaskduringthis
stageis"tointegratethetasksmasteredinthe
previousstagesintoasecuresenseofself".
Childhoodcomestoanendduringthisstage
andyouthbegins.Pubertybringsona
"physiologicalrevolution"withwhichadole­
scentsmustlearntocope.
•Identityisachievedwhenadolescentsare
allowedtoexperienceindependenceby
makingdecisionsthatinfluencetheirlives.
Achievementofthetaskresultsinasenseof
confidence,emotionalstability,andaviewof
theselfasauniqueindividual.
•Whenindependenceisdiscouragedbythe
parents,andtheadolescentisnurturedinthe
dependentposition,itmaycausealackofself­
confidence.Non-achievementresultsina
senseofself-consciousness,doubtandcon­
fusionaboutone'sroleinlife.
6.EarlyAdulthood(20-25years)-Intimacy
vsIsolation
•Themajordevelopmentaltaskduringthis
stageis"toformanintense,lastingrelation­
shiporacommitmenttoanotherperson".
•Intimacyisachievedwhenanindividualhas
developedthecapacityforgivingofoneselfto
another.Thisislearnedwhenonehasbeen
therecipientofthistypeofgivingwithinthe
familyunit.Achievementofthetaskresultsin
thecapacityformutualloveandrespect
betweentwopeople.
•Ifthereisextremefearofbeingrejectedor
disappointed,theindividualmaywithdraw
orisolatehimself.
7.MiddleAdulthood(26-64years)-
GenerativityvsStagnation
•Themajordevelopmentaltaskduringthis
stageis"toachievethelifegoalsestablished
foroneself,whilealsoconsideringthewelfare
offuturegenerations.
•ForErikson,generativityincludesmarriage,
parenthoodandthesenseofworking
productivelyforthegoodofothers.
•Thegenerativeindividualenjoysworkand
familyandiscontinuouslyreadytocometo
theaidofothers.
•Whenearlierdevelopmentaltasksarenot
fulfilledhebecomeswithdrawn,isolated,and
highlyself-indulgent.
8.Oldage(65yearsandabove)-Egointegrity
vsDespair
•Themajordevelopmentaltaskduringthis
stageis"toreviewone'slifeandderive

43. 40AGuidetoMentalHealthandPsychiatricNursing
meaningfrombothpositiveandnegative
events,whileachievingapositivesenseofself
worth".
•Egointegrityisachievedwhenindividuals
havesuccessfullycompletedthedevelop­
mentaltasksofthepreviousstages.
•Achievementofthetaskresultsinasenseof
self-worthandself-acceptance.
•Whenearliertasksareunresolvedhefeels
worthlessandhelplesstochange.Non­
achievementresultsinasenseofselfcontempt
anddisgustwithhowlifehasprogressed.
CognitiveDevelopmentTheory
•JeanPiaget(1896-1980)aSwissphilosopher
andpsychologistdedicatedhislifeworkto
observingandinteractingwithchildrento
determinehowtheirthinkingprocesses
differedfromadults.
•AccordingtoPiaget'stheoryofpersonality
development,thedevelopingchildpasses
throughfourmaindiscretestages:the
sensorimotorstage,thepreoperationalstage,
thestageofconcreteoperations,andthestage
offormaloperations.Eachstagereflectsa
rangeoforganizationalpatternsthatoccurin
definitesequenceandwithinanapproximate
agespan.
•Developmentisinfluencedbybiological
maturation,socialexperiences,andexperien­
ceswiththephysicalenvironment.During
cognitivedevelopmenttheindividualstrives
tofindequilibriumbetweenselfand
environment.
•Cognitivetheoryexplainshowthought
processesarestructured,howtheydevelop
andtheirinfluenceonbehavior.Structuring
ofthoughtprocessesoccursthroughthe
developmentofschema(i.e.mentalimagesor
cognitivestructures).Thoughtprocesses
developthroughassimilationandaccommo­
dation.Whenthechildencountersnewinfor­
mationthatisrecognizedandunderstood
withinexistingschema,assimilationofthat
newinformationoccurs.Ifnewinformation
cannotbelinkedtoexistingschema,thechild
mustlearntodevelopnewmentalimagesor
patternsthroughtheprocessofaccommo­
dation.Aslongasthechildisabletoassimilate
oraccommodateadequatelytonewknow­
ledge,thechildisabletoachieveequilibrium
ormentalbalance.Whenschemasareinade­
quatetofacilitatelearning,disequilibrium
mayoccur.
MajorCognitiveDevelopmentStages
StageI:Sensorimotor(Birthto2years)
•Themajordevelopmentaltasksduringthis
stageareincreasedmobilityandawareness,
developingasenseofselfasseparatefromthe
externalenvironment.
•Duringthisstagethechildisconcernedonly
withsatisfyingbasicneedsandcomforts.
•Thechilddevelopsagreaterunderstanding
regardingobjectswithintheexternal
environmentandtheireffectsuponhimorher.
Knowledgeisgainedregardingtheabilityto
manipulateobjectsandexperienceswithinthe
environment.
StageII:Preoperational(2to6years)
•Themajordevelopmentaltasksduringthis
stageare"Learningtoexpressselfwith
language,developsunderstandingof
symbolicgestures,achievementofobject
permanence".
•Useslanguageandcanrepresentobjectsby
imagesandwords.
•Remainsegocentric:Unabletothinkfrom
another'spointofview.Cannotdistinguish
realityfromfantasy.
•Acquireslanguage:Onlyintuitivelyguesses
aboutcauseandeffect.
StageIII:Concreteoperations(6to12years)
•Themajordevelopmentaltasksduringthis
stageare:learningtoapplylogictothinking;
developsunderstandingofreversibilityand
spatiality;learningtodifferentiateand
classify.

44. PersonalityDevelopmentandTheories41
•Abletothinkaboutpastandpresentevents
butnotfuture.Thechildisabletoacknow­
ledgetheviewpointsofothersandappreciate
feelings.
StageIV:Formaloperationsperiod(12to15years)
•Themajordevelopmentaltasksduringthis
stageare:learningtothinkandreasonin
abstractterms;makesandtestshypotheses.
•Logicalthinkingandreasoningabilityexpand
andarerefined.
•Canthinkoffutureeventsanddevelops
strategiesforsolvingcomplexproblems.
Cognitivematurityisachievedduringthis
stage.
TheoryofMoralDevelopment
•Moraldevelopmentencompassesmoral
judgmentorreasoningprocessesandinvolves
makingdecisionsaboutrightorwrongactions
inaparticularsituation(Stroufe,Cooperand
Dettart,1992).
•Piagetexaminedtheconceptofmoraldevelop­
ment;accordingtohimmoraljudgmentisfirst
basedonconsequencesandlateronmotives.
•LawrenceKohlbergbuiltonPiaget'sworkin
theareaofmoraldevelopment.Kohlberg
believesthateachstageisnecessaryandbasic
tothenextstageandthatallindividualsmust
progressthrougheachstagesequentially.He
definedthreemajorlevelsofmoral
development.
LevelI:Pre-conventionalLevel
(Self-centeredorientation-Ages4to10years)
Thisstageconsistsof3substages:
1.Egocentricjudgment:
Inwhichchildrenmakedecisionsbasedonwhat
theylikeorwishwithnoobligationstoobey
authorityfigures.
2.Punishmentandobedienceorientation:
Moraldecisionsarebasedonavoidanceof
punishment.Childrenrealizethatthereare
physicalconsequencesintheformofpunishment
forbadbehaviors.Inthisstage,childrenlearnthe
authorityrole;thechildisresponsivetocultural
guidelinesofgoodandbad,rightandwrong,but
primarilyintermsoftheknownrelated
consequences.
3.Instrumentalrelativistorientation
Duringthisstagemoraldecisionsaremotivated
bydesireforrewardsratherthanavoiding
punishment,andbeliefthatbyhelpingothersthey
willgethelpinreturn.Behaviorsofthisstageare
guidedbyegocentrismandconcernforself.There
isanintensedesiretosatisfyone'sownneeds,
butoccasionallytheneedsofothersareconsi­
dered.
LevelII:ConventionalLevel
(Abletoseevictim'sperspective-ages10to13
years)
4.Interpersonalconcordanceorientation
Moraldecisionsarebasedondesireforapproval
fromothersandonavoidingguiltexperiencedby
notdoingtherightthing.Behavioratthisstageis
guidedbytheexpectationsofothers.
5.Lawandorderorientation:
Inthisstagemoraldecisionsaredefinedbyrights,
assignedduty,rulesofthecommunityandrespect
forauthority.
LevelIll:Post-conventionalLevel
(Underlyingethicalprinciplesareconsideredthat
takeintoaccountsocietalneeds-Ages13years
andabove)
6.Socialcontractlegalisticorientation:
Moraldecisionsarebasedonasenseof
communityrespectanddisrespect.Thisstage
focusesonthelegalpointofviewbutisalsoopen
toconsideringwhatismoralandgoodforsociety.
Individualswhoreachthisstagehavedeveloped
asystemofvaluesandprinciplesthatdetermine
forthemwhatisrightorwrong.
7.Universalethicalprincipleorientation:
Thisstagedealswithabstractandethicalmoral
values,ratherthanconcretemoralrules.These
includeuniversalprinciplessuchasequality,

45. Maslow'sHierarchyofNeeds
•Maslowproposedthatourhumanmotivesare
arrangedinahierarchy,withthemostbasic
needsatthebottom.Atthetoparethemore
highlydevelopedneedslikeselfesteemneeds
andfinallyself-actualization.
•Maslow'shierarchyproposesthatourneeds
mustbefulfilledinaspecifiedorder,from
physiological,safety,andlovetothehigher
needsofesteemandselfactualization;Maslow
alsospecifiedalistofcharacteristicsdescrip­
tiveofself-actualizedpeople.
•OneofthebasicthemesunderlyingMaslow's
theoryisthatmotivationaffectsthepersonas
awhole,ratherthanjustinpart.Maslow
believedthatpeoplearemotivatedtoseek
personalgoalswhichmaketheirlives
rewardingandmeaningful.
•AbrahamMaslowsuggestedthat5basic
classesofneedsormotivesinfluencehuman
behavior.AccordingtoMaslow,needsatthe
lowestlevelofthehierarchymustbesatisfied
beforepeoplecanbemotivatedbyhigher-level
goals.
42AGuidetoMentalHealthandPsychiatricNursing
justiceandbeneficence.Behaviorismotivatedby
internalizedprinciplesofhonor,justice,and
respectforhumandignityandguidedbythe
conscience.
HumanisticApproach
Incontrasttothepessimismofthepsycho­
dynamicperspective,thehumanisticapproach
optimisticallyarguesthatpeoplehaveenormous
potentialforpersonalgrowth.Whenpersonality
developmentfocusesuponthedevelopmentof
self,itiscalledhumanism.HumanistslikeCarl
RogersandAbrahamMaslowrejecttheinternal
conflictsofFreud'sviewandthemechanistic
natureofbehaviorism.Theybelievethateach
personiscreativeandresponsible,freetochoose
andeachstrivesforfulfillmentorself
actualization.
Humanistictheoriesemphasizetheimpor­
tanceofpeople'ssubjectiveattitudes,feelings,and
beliefs,especiallywithregardtotheself.Carl
Rogers'stheoryfocusesontheimpactofdisparity
betweenaperson'sideals,selfandperceivedreal
self.Maslowfocusesonthesignificanceofself
actualization.
Rogers'Person-CenteredApproach
Rogers'emphasizedthateachofusinterpretsthe
samesetofstimulidifferently,sothereareasmany
different'realworlds'astherearepeopleonthis
planet.(Rogers,1980)
Self-Actualization
CarlRogersusedthetermself-actualizationto
capturethenatural,underlyingthetendencyof
humanstomoveforwardandfulfilltheirtrue
potential.Hearguedthatpeoplestrivetowards
growth,eveninless-thanfavorablesurroundings.
PersonalityDevelopment
CarlRogersproposedthatevenyoungchildren
needtobehighlyregardedbyotherpeople.
Childrenalsoneedpositiveselfregardtobe
esteemedbyselfaswellasothers.Rogersbelieved
thateveryoneshouldbegivenunconditional
positiveregard,whichisanonjudgmentaland
genuinelove,withoutanystringsattached.
SchematicRepresentationofMaslow's
HierarchyofNeeds
Selfesteemneeds
(needforachievement
andrecognition)
Loveandbelongingness
(needforaffection,acceptance)
Safetyandsecurityneeds
(needforsafety,security,stability,lawandorder)
Physiologicalneed
(needforwater,oxygen,sex,food,rest,etc.)
Fromthebottomtothetopofthehierarchy,
thefivelevelsofmotivesaccordingtoMaslow
are:

46. PersonalityDevelopmentandTheories43
PhysiologicalNeeds
Thephysiologicalneedsaremostbasic,powerful
andurgentofallhumanneedsthatareessential
tophysicalsurvival.Evenifoneoftheseneeds
remainsunsatisfiedtheindividualrapidly
becomesdominatedbyit,soallotherneedsbecome
secondary.Includedinthisgrouparetheneed
forfood,water,oxygen,sex,activityandsleep.
SafetyandSecurityNeeds
Oncethephysiologicalneedsarefairlywell­
satisfied,safetyandsecurityneedspredominate.
Includedherearetheneedsforstructure,stability,
lawandorder,andfreedomfromsuchthrea­
teningforcesasillnessandfear.
LoveandBelongingnessNeeds
Theseneedsbecomeprominentwhenthe
physiologicalandsafetyIsecurityneedshave
beenmet.Thepersonatthislevellongsfor
affectionaterelationshipwithothers,foraplace
inhisfamilyandsocialgroups.Accordinglya
personexperiencesfeelingsofloneliness,friend­
lessnessandrejection,especiallywhencaused
bytheabsenceoffriendsandlovedones.
Self-EsteemNeeds
Maslowdividedtheseneedsintotwotypes:
Selfrespectandrespectfromothers.Self-respect
includesaperson'sdesireforcompetence,confi­
dence,achievementandindependence.Respect
fromothersincludeshisdesireforprestige,
reputation,status,recognition,appreciationand
acceptancefromothers.Satisfactionofself-esteem
needsgeneratesfeelingsofself-confidence,self­
worthandasenseofbeingusefulandnecessary
intheworld.
Dissatisfactionofself-esteemneedsincon­
trast,generatesuchfeelingsasinferiority,weak­
ness,passivityanddependency.
Self-Actualization
AccordingtoMaslowself-actualizationisthe
person'sdesiretobecomeeverythingheiscapable
of.Thepersonwhohasachievedthishighestlevel
pressestowardthefulluseofhistalents,capaci­
tiesandpotentialities.Inshort,theself-actualized
personissomeonewhohasreachedthepeakof
hispotential.
TraitandTypeTheoriesofPersonality
Twomajorthemesunderlietraitandtypetheories
ofpersonality:
•Peoplepossessbroadpredispositionsortraits
torespondincertainwaysindiversesitua­
tions;whatthissuggestsisthatpeopledisplay
consistencyintheiractions,thoughtsand
emotionsacrosstime,eventsandexperiences.
•Notwoindividualsarealike.
GordonAllporl'sTheory(1937)
1.Allport'stheoryassertsthatnotwoindivi­
dualsarealike.Allportregarded'traits'as
beingresponsiblefortheseindividualdiffe­
rences.AccordingtoAllport,traitisa
predispositiontoactinthesamewayinawide
rangeofsituations.
2.Allportdistinguishedbetweencommontraits
andindividualtraits.Commontraitsare
sharedbyseveralpeoplewithinagiven
culture.Individualtraitsarepeculiartothe
personanddonotpermitcomparisonsamong
people.Theyguide,directandmotivatean
individual'sadjustment.Therefore,theyaccu­
ratelyreflectthedistinctivenessoruniqueness
ofhispersonality.
3.Allportwasdeeplycommittedtothestudyof
individualtraits.Hestartedcallingthemas
'personal'dispositions.Commontraitswere
simplycalledas'traits'.Allportproposedthat
therearethreetypesofpersonaldispositions.
•Cardinaldisposition:Acardinaldisposition
issodominantthatallactionsofthe
personareguidedbyit.Veryfewpeople
possesscardinaldispositions.For
example:Ms.Nightingalewhoseactions
weredrivenbycompassionforpeople.
•Centraldisposition:Thesearenotasdomi­
nantascardinaldispositions,butthey
influencetheperson'sbehaviorinavery

47. 44AGuidetoMentalHealthandPsychiatricNursing
prominentway.Thereforetheyarecalled
thebuildingblocksofpersonality.For
example:Apersonmayhavesuchcentral
dispositionsaspunctuality,responsibility,
attentiveness,honesty,loyalty,etc.
•Secondarydisposition:Thesearenotvery
consistentandarethuslessrelevantin
reflectingthepersonalityoftheindividual.
Foodandclothingpreferences,specific
attitudesetc.maybeconsideredassecon­
darydispositions.
RaymondCattell'sTheory(1965)
•Cattellspokeofthemultipletraitsthat
comprisethepersonality,theextenttowhich
thesetraitsaregeneticallyandenviron­
mentallydeterminedandthewaysinwhich
geneticandenvironmentalfactorsinteractto
influencebehavior.
•AccordingtoCattell,personalityisthatwhich
permitsustopredictwhatapersonwilldoin
agivensituation.Inlinewithhismathe­
maticalanalysisofpersonality,predictionof
behaviorcanbemadebymeansofa
specificationequation:
R=f(S,P)
Accordingtothisformulatheresponse(R)of
thepersonisafunction(f)ofthestimulus(S)
atagivenmomentintime,andoftheexisting
personalitystructure(P).Thisequation
conveysCattell'sstrongbeliefthathuman
behaviorisdeterminedandcanbepredicted.
•TraitsareamajorpartofCattell'stheory,
whichhedefinedastheindividual'sstable
andpredictablecharacteristics.
•Cattelldividedtraitsintosurfacetraitsand
sourcetraits.Surfacetraitsarenotconsistent
overtimeanddonothavemuchvaluein
accountingfortheindividual'spersonality.
Sourcetraitsarethebasicbuildingblocksof
personality,whichdeterminetheconsisten­
ciesofeachperson'sbehavioroveran
extendedperiodoftime.
•Basedonextensiveresearch,Cattellidentified
16sourcetraitsthatconstitutetheunderlying
structureofpersonality(suchasoutgoing-
reserved;stable-emotional;self-sufficient,
groupdependent,etc.).Heconstructedascale
tomeasurethesesourcetraits,whichcameto
beknownas'SixteenPersonalityFactor
Questionnaire'(16PFQuestionnaire).
HansEysenck'sTheory
(Trait-typetheoryofpersonality)
•TheessenceofEysenck'stheoryisthatthe
elementsofpersonalitycanbearranged
hierarchically.Inthisschemecertainsuper
traitsandtypessuchasextroversionexerta
powerfulinfluenceoverbehavior.
•Accordingly,Eysenck'sfocushasbeenona
smallnumberofpersonalitytypes,definedby
twomajordimensions:introversion-extro­
version,stability-instability(neuroticism).
•Basedonthesepersonalitytypes,Eysenck
proposedfourseparatecategoriesofpeople:
Stable Unstable
•Moody
•Anxious
•Rigid
•Pessimistic
•Reserved
•Restless
•Aggressive
•Impulsive
•Optimistic
•Active
Introvert•Calm
•Reliable
•Controlled
•Peaceful
•Careful
Extrovert•Leadership
•Easygoing
•Talkative
•Outgoing
•Sociable
•Lateron,headdedathirdtypedimensionof
personalitycalledaspsychoticism-superego
strength.Peoplebelongingtothiscategoryare
selfish,impulsiveandopposedtosocial
customs.
•Basedonhiscategorizationofpersonality
types,Eysenckconstructedaninventory
calledPersonalityQuestionnaire(EPQ).It
coversitemsfromeachofthepersonalitytypes
identifiedbyhim.
•Throughouthiswritings,Eysenckconsistently
emphasizedtheroleofgeneticfactorsand
neurophysiologicalfactors,roleofthecerebral
cortex,autonomousnervoussystem,limbic

48. PersonalityDevelopmentandTheories45
system,ReticularActivatingSystem(RAS)in
explainingindividualdifferencesinbehavior.
•Becauseoftheuseofstatisticaltechniquesand
theassumptionthatthereisahierarchial
organizationtobasicpersonalitydimensions,
CattellandEysenckhavebeencalledasfactor
analytictraittheorists.
BehaviorTheory
•Behaviortheoryisbasedonthepremisethat
allbehavior,adaptiveandmaladaptiveisa
productoflearning.
•Learningisachangeinbehaviorresultingfrom
reinforcement.Arelatedassumptionisthat,
sincebehaviorislearned,itcanbeunlearned
andadaptivebehaviorcanbesubstituted.
•Behavioraltheoriesattempttoexplainhow
peoplelearnandact.
•Unlikepsychodynamictheories,behavioral
theoriesneverattempttoexplainthecauseof
mentaldisorders,butfocusonnormalhuman
behavior.
Stimulus-responsetheories
1.CLASSICALCONDITIONING
A.IvanPavlov
•Thetheoryofclassicalconditioningwasgiven
byIvanPavlov(1849-1936)aRussianphysio­
logist.Pavlovnoticedthatstomachsecretions
ofdogswerestimulatedbyothertriggers
besidesfoodreachingstomach.Hefoundthat
thesightandsmelloffoodtriggeredstomach
secretions.Thus,aclearconnectionwasmade
betweenthoughtprocessesandphysiologic
responses.
•InPavlov'smodel,thereisUnConditioned
Stimulus(UCS),i.e.food(notdependenton
previoustraining)thatelicitsanUnCondi­
tionalResponse(UCR),i.e.salivation(a
specificresponse).Pavlovwouldthenselect
otherstimulisuchasabell,largecuecard,
etc.,presentingthisconditionedstimulusjust
beforethefood,theunconditionedresponse.
•Iftheconditionedstimuluswasrepeatedly
presentedbeforethefood,eventuallysaliva-
tionwaselicitedonlybytheconditionedsti­
mulus.Thisphenomenonwascalledclassical
conditioning.
•Hedemonstratedthataconditionedstimulus
couldbepairedwithanunconditioned
stimulustoelicitaconditionedresponseor
behaviorchange.Whentheunconditioned
stimuluswasremoved,theconditionedsti­
muluscontinuedtoresultinthesame
conditionedresponse.
Thisexperimentmayberepresentedas:
UnconditionedStimulus_________,UnconditionedResponse
(UCS)(Food) (UCR)(Salivation)
ConditionedStimulus(CS)_________,ConditionedResponse
(Bell) (CR)(Salivation)
B.JohnB.Watson
•JohnB.Watsonintroducedbehaviorism,belie­
vedthatalllearningwasclassicalcondi­
tioningandthatpeoplearebornwithcertain
stimulusresponseconnectionscalledreflexes.
Examplesaresneezinginresponsetoan
irritationandtheknee-jerkresponsetoasharp
tapontheknee.
•Hedevelopedtwoprinciples:Frequencyand
recency.Theprinciplesoffrequencystates
thatthemorefrequentlyagivenresponseis
madetoagivenstimulus,themorelikelythe
responsetothatstimuluswillberepeated.The
principleofrecencystatesthatthemore
recentlyagivenresponsetoaparticular
stimulusismade,themorelikelyitwillbe
repeated.
2.REINFORCEMENT THEORIES
A.EdwardL.Thorndike
Thorndikebelievedintheimportanceofthe
effectsthatfollowedtheresponseorthe
reinforcementofthebehavior.Accordingto
Thorndike,theindividual'sbehaviorisshaped
throughthestampingofthecorrectresponsesand
stampingoutofincorrectresponsesthroughtrial
anderror.Thorndikewasthusthefirst
reinforcementtheorist.
B.B.F.Skinner
•BasicallySkinnerrevoltedagainsttheconcept
ofclassicalconditioning.Hesaidthatmanis

49. 46AGuidetoMentalHealthandPsychiatricNursing
anactiveorganism,andnotavictimofhis
environment.Hedoesnotwaitforthe
stimulus;instead,heactsoroperatesonthe
environment,soastochangeitinsomeway.
Thushecalleditasoperantbehavior.
•AccordingtoSkinner,operantbehavioris
determinedbytheeventsorconsequencesthat
followtheresponse.Iftheconsequencesare
favorable,thentheorganismwillrepeatthe
samebehavior.Inthiscase,theconsequences
aresaidtohaveprovidedpositivereinforce­
mentandcausedrepetitionofbehavior.
•Alternatively,iftheconsequencesareunfavo­
rable,thentheyreducethechancesofthesame
behaviorfromgettingrepeated.Insuchacase,
theconsequencesaresaidtohaveprovided
negativereinforcementandreducedthe
chancesofthebehaviorfromrecurringagain.
•Thus,operantconditioningiscalledasType-
Rconditioning,toemphasizetheeffectofthe
responseoffuturebehavior.Inthisway
Skinnersaidthatlearningisshapedand
maintainedbyitsconsequences.
•Thefollowingisoneoftheexperiments
carriedoutbySkinnertosupporthisconcept
ofoperantconditioning:
Ahungryratwasplacedinaboxdesignedby
SkinnerwhichwascalledastheSkinnerboxor
operantchamber.Thechambercontainedalever,
whichwoulddropfoodpelletsintothechamber
ifpressed.
Inthebeginningtheexperimenterhimself
droppedthefoodpelletsintothebox,andlater
stopped.Therat,beinghungry,begantoexplore
theboxandpressedtheleveraccidentally.The
foodpelletwasreleasedintothebox,andtherat
ateitup.Afterawhile,itpressedtheleveragain,
andatethefoodpelletwhichgotreleased.After
thethirdorfourthtime,theratbegantopressthe
levermorerapidly.Thus,thefoodissaidtohave
providedpositivereinforcementtotherat,and
operantbehaviorgotestablished,i.e.therat
continuedtopressthelever,inordertoobtainthe
foodpellets.
SchedulesofReinforcement
Objectsoreventswhichprovidereinforcement
arecalledasreinforcers.Therearetwotypesof
reinforcers:PrimaryandSecondaryreinforcers.
Primaryreinforcersarethosewhichpossess
inherentreinforcingproperties.Examplesinclude
food,water,physicalcomfort,etc.Secondaryor
Conditionedreinforcersarethosewhichacquire
theirreinforcingqualitiesthroughcloseassocia­
tionwithaprimaryreinforcer.Examplesof
secondaryreinforcersincludemoney,attention,
affectionandgoodgrades.Skinnerputforward
theideaofplanningofschedulesofreinforcement
inordertoconditiontheoperantbehaviorofthe
organism.Theimportantschedulesareas
follows:
1.ContinuousReinforcementschedule(CR)
Thisis100%reinforcementschedule,whereevery
correctresponseoftheindividualisrewardedor
reinforced.Forexample,thelearnerisrewarded
foreverycorrectanswerhegivestothequestions
putbyhisteacher.
2.Fixed-Intervalreinforcementschedule(FI)
Inthisschedule,theindividualisrewardedfora
responseonlyafterasetintervaloftime.Whatis
importanthereisthefixedresponsesduringthis
interval.Forexample:
•Payingsalariesfortheworkdoneonaweekly
ormonthlybasis
•Conductingexaminationsperiodicallyforthe
students
•Givingapersonaperiodicallowance,etc.
3.Fixed-Ratioreinforcementschedule(FR)
Inthisschedule,theindividualisreinforced
followinga'fixed'numberofcorrectresponses.
Thisscheduleusuallygeneratedextremelyhigh
operantlevelsintheindividuals,becausethemore
theyrespond,themorereinforcementtheyreceive.
Forexample:Payingemployeesdependingonthe
numberofunitstheyproduceorsell.
4.Variable-Ratioreinforcementschedule(VR)
Inthisschedule,reinforcementisintermittentand
irregular.Theindividualdoesnotknowwhenhe

50. PersonalityDevelopmentandTheories47
isgoingtoberewarded,andsoheremains
motivatedthroughoutthelearningprocess.The
mostcommonexampleofthisscheduleinhuman
behaviorisgambling.Hererewardsare
unpredictableandkeeptheplayersmotivated,
thoughreturnsareoccasional.
•Eventhoughhewasmostlyconcernedwith
positivereinforcers,Skinnerrecognizedthat
negativereinforcersalsoexist.Accordingto
Skinner,negativereinforcersaredifferentfrom
punishment.Innegativereinforcement,
somethingnegativeistakenawayoravoided.
Positiveandnegativereinforcementhave
similarconsequences;theybothstrengthenor
reinforcethebehaviortheyfollowand
increasethechangesthatthebehaviorwillbe
repeated.Anexampleofnegativereinforce­
mentwouldbeifthechildwastoldbyaparent,
"ifyoueatallyoursalad,youwon'thaveto
eatyourbean's-therebytakingaway
somethingunpleasant.
•Punishmentcaninvolveaddingsomething
negative;punishmentcanalsoinvolvetaking
awayorpreventingsomethingpositive.
Punishmenttendstodecreasetheprobability
oftheresponsethatitfollows,makingthat
responselesslikelyinthefuture.Forexample:
Ifapatientregularlywatchestelevisionat10
pmandthetelevisionisremovedsuddenly
becausethepatientviolatedasmokingpolicy,
thisispunishment.
•Skinneralsodevelopedtheconceptof
"shaping"behavior,whichhasbeenusedin
theprocessoflearninghowtoperform
complextasks.
3.COGNITIVETHEORIES
Theinitialbehavioralstudiesfocusedattention
onhumanactionswithoutmuchattentiontothe
internalthinkingprocess.Cognitivetheories,an
outgrowthofdifferenttheoreticalperspectives
includingthebehavioralandthepsychodynamic,
attemptedtolinktheinternalthoughtprocesses
withhumanbehavior.
AlbertBandura'sSocialCognitiveTheory
Acquiringbehaviorsbylearningfromother
peopleisthebasisofsocialcognitivetheory.
Bandurabelievesthatimportantbehaviorsare
learnedbyinternalizingbehaviorsofothers.
AccordingtoBanduralearningbyobservationis
achievedthroughfournecessarycomponents:
attention,retention,productionandmotivation.
•Attentionoccurswheneventsareselectively
noticed.
•Retentionisrememberingwhatislearned.
•Production-theactualperformanceofthe
behavior.
•Motivationinvolvesthereinforcementfor
imitatinganindividual.
AnimportantconceptofBandura'sisself­
efficacy,aperson'sabilitytodealeffectivelywith
theenvironment.Efficacybeliefsinfluencehow
peoplefeel,think,motivatethemselves,and
behave.Thestrongertheself-efficacy,thehigher
thegoalspeoplesetforthemselvesandthefirmer
istheircommitmenttothem.Cognitiveprocesses
shapemostcoursesofaction,thatis,ifpeople
believeinpositiveoutcomes.Iftheyhavedoubts
abouttheirefficacy,peopleviewfailurescenarios
anddwellonthingsthatcangowrong.
REVIEWQUESTIONS
•Personalitydevelopment(Nov2002,Oct2006)
•Whatarethefactorsinfluencingpersonality
development
•Psychoanalyticaltheory
•Oedipuscomplex(Oct2006)
•Theoriesofpsychosocialdevelopment.

51. ConceptualModels
0PSYCHOANALYTICAL MODEL
0BEHAVIORALMODEL
0INTERPERSONALMODEL
0COMMUNICATIONMODEL
0MEDICALMODEL
0NURSINGMODEL
Peplau'sTheory
Orem'sTheory
Roger'sTheory
Roy'sTheory
0HOLISTICMODEL
Amodelisameansoforganizingacomplexbody
ofknowledge.Forexample,thelinkagebetween
thevariousconceptsrelatedtohumanbehavior
mayberepresentedintheformofamodel,which
cannowbereferredtoasaconceptualmodel.
Thetreatmentofthementally'mdepends
mainlyonthephilosophyrelatedtomentalhealth
andmentalillness.Thevariousmodelsortheore­
ticalapproachesinfluencingcurrentpracticeare:
PSYCHOANALYTICAL MODEL
Psychoanalyticalmodelhasbeenderivedfrom
theworkofSigmundFreudandhisfollowers.
Basicassumptionsofpsychoanalyticalmodel
are:
•Allhumanbehavioriscausedandthusis
capableofexplanation.Humanbehavior,
howeverinsignificantorobscure,doesnot
occurrandomlyorbychance.Rather,all
humanbehaviorisdeterminedbypriorlife
events.
•Allhumanbehaviorfrombirthtooldageis
drivenbyanenergycalledthelibido.Thegoal
ofthelibidoisthereductionoftensionthrough
theattainmentofpleasure.Thelibidoisclosely
associatedwithphysiologicalorinstinctual
drives(e.g.,hunger,thirst,eliminationand
sex).Releaseofthesedrivesresultsinthe
reductionoftensionandexperienceof
pleasure.Hence,thepleasureprinciple
becomesoperativewhenpleasureseeking
behaviorsareused.
•Thepersonalityofthehumanbeingcanbe
understoodbywayofthreemajorhypothetical
structures,viz.id,egoandsuperego.Id
representsthemostprimitivestructureofthe
humanpersonality.Ithousesthephysiolo­
gicaldrives.Humanbehaviororiginating
fromtheidisimpulsive,pleasure-oriented,
anddisconnectedfromreality.
•Theegorepresentsthatpartofthehuman
personality,whichisinclosestcontactwith
reality.Unliketheid,egoiscapableof
postponingpleasureuntilanappropriate
time,placeorobjectisavailable.Unlikethe
superego,theegoisnotdriventoblind
conformitywithrulesandregulations.Rather,
theegoactingasmediatorbetweentheidand
superego,givesrisetoamuchmoremature
andadaptivebehavior.
•Thesuperegoisthepersonalitystructure
containingthevalues,legalandmoral
regulationsandsocialexpectationsthat
thwartfreeexpressionofpleasure-seeking
behaviors.Thesuperegothusfunctionsto
opposetheid.
•Understandably,humansoccasionallyexpe­
rienceanxietywhenconfrontedwithsitua­
tionsthatchallengethetenuousbalance
betweentheidandthesuperego.Atthese

52. ConceptualModels49
times,theegousesdefensemechanismsthat
includerepression,denial,regression,
rationalization,reactionformation,undoing,
projection,displacement,sublimation,isola­
tion,andfixation.
•Thehumanpersonalityfunctionsonthree
levelsofawareness:conscious,preconscious
andunconscious.Consciousnessreferstothe
perception,thoughtsandfeelingsexistingina
person'simmediateawareness.Preconscious
contentontheotherhand,isnotimmediately
accessibletoawareness.Unlikeconsciousand
preconscious,contentintheunconscious
remaininaccessibleforthemostpart.
•Theunconsciousaffectsallthethree
personalitystructures-id,egoandthe
superego.Althoughtheid'scontentresides
totallyintheunconscious,thesuperegoand
theegohaveaspectsinallthethreelevelsof
consciousness.Theegomaintainscontact
withreality,theidandthesuperego.
•Humanpersonalitydevelopmentunfolds
throughfiveinnatepsychosexualstages­
oral,anal,phallic,latentandgenital.
Althoughthesestagesextendthroughoutthe
lifespan,thefirst6yearsoflifedeterminethe
individual'slong-termpersonalitycharac­
teristics.
PsychoanalyticalProcess
Psychoanalysis,describedbyFreud,makesuse
offreeassociationanddreamanalysistoaffect
reconstructionofpersonality.Freeassociation
referstotheverbalizationofthoughtsasthey
occur,withoutanyconsciousscreening.Analysis
ofthepatient'sdreamshelpstogainadditional
insightintohisproblemandtheresistances.Thus
dreamssymbolicallycommunicateareasof
intrapsychicconflict.Thetherapistthenattempts
toassistthepatienttorecognizehisintrapsychic
conflictsthroughtheuseofinterpretation.
Thepatientisanactiveparticipant,freely
revealingallthoughtsexactlyastheyoccurand
describingalldreams.Byterminationoftherapy,
thepatientisabletoconducthislifeaccordingto
anaccurateassessmentofexternalrealityandis
alsoabletorelatetoothersuninhibitedbyneurotic
conflicts.
RolesofthePatientandthePsychoanalyst
Thepatientistobeanactiveparticipant,freely
revealingallthoughtsexactlyastheyoccurand
describingalldreams.Thepsychoanalystisa
shadowperson;whilethepatientisexpectedto
revealallhisthoughtsandfeelings,theanalyst
revealsnothingpersonal.
ApplicationtoNursing
Thistheoreticalperspectivehashelpedmental
healthprofessionalstounderstandpsychopatho­
logyandstressrelatedbehaviors.Moreimpor­
tantly,thistheoryillustratestheimportanceof
nottakinghumanbehavioratfacevalue.Thatis,
ithelpsthepsychiatric-mentalhealthnurseto
discernandexplorethemeaningbehindhuman
behavior.
BEHAVIORAL MODEL
Prominenttheoristsofbehavioraltheoryinclude
IvanPavlov,JohnWatson,BFSkinner,etc.
Basicassumptionsofbehavioralmodelare:
•Allbehaviorislearnt(adaptiveandmal­
adaptive).
•Allbehavioroccursinresponsetoastimulus.
•Humanbeingsarepassiveorganismsthatcan
beconditionedorshapedtodoanythingif
correctresponsesarerewardedorreinforced.
•Maladaptivebehaviorcanbeunlearntand
replacedbyadaptivebehavioriftheperson
receivesexposuretospecificstimuliandrein­
forcementforthedesiredadaptivebehavior.
•Deviationsfrombehavioralnormsoccurwhen
undesirablebehaviorhasbeenreinforced.
Thisbehaviorismodifiedthroughapplication
oflearningtheory.
TherapeuticApproaches
•Systematicdesensitization
•Tokenreinforcement
•Shaping

53. 50AGuidetoMentalHealthandPsychiatricNursing
•Chaining
•Prompting
•Flooding
•Aversiontherapy
•Assertivenessandsocialskillstraining
(Referchapter14fordetails).
RolesofthePatientandtheBehavioral
Therapist
Theapproachisthatofalearnerandateacher.
Therapist
•Thetherapistisanexpertinbehaviortherapy
whohelpsthepatientunlearnhissymptoms
andreplacethemwithmoresatisfying
behavior.
•Thetherapistusesthepatient'sanxietyasa
motivationalforcetowardslearning.
•Thetherapistteachesthepatientabout
behavioralapproachesandhelpshimdevelop
behavioralhierarchy.
•Thetherapistreinforcesdesiredbehaviors.
Patient
•Asalearnerthepatientisanactiveparticipant
inthetherapyprocess.
•Patientpractisesbehavioraltechniques.
•Doeshomeworkandreinforcementexercises.
Therapyisconsideredtobecompletewhen
thesymptomssubside.
ApplicationtoNursing
Nursescommonlyusebehavioraltechniquesin
awidevarietyofmentalhealthsettings.
Additionally,nurseswhoworkwithclients
havingphysicaldisability,chronicpain,chemical
dependencyandrehabilitationcentersalsoapply
thesetechniques.
INTERPERSONALMODEL
HarrySSullivanistheoriginatorofinterpersonal
relationstheory.
Basicassumptionsofinterpersonalmodelare:
•Humanbeingareessentiallysocialbeings.
•Humanpersonalityisdeterminedinthe
contextofsocialinteractionswithotherhuman
beings.
•Anxietyplaysacentralroleintheformation
ofhumanpersonalitybyservingasaprimary
motivatorofhumanbehavior.Especially,
anxietyisimportantinbuildingself-esteem
andenablingapersontolearnfromtheirlife
experiences.
•Self-esteemisanimportantfacetofhuman
personalitythatformsinreactiontothe
experienceofanxiety.Interactionswithsigni­
ficantothersconveyingdisapprovalorother
suchnegativemeaningscontributetoself­
systemformation.
•Securitymechanismsareusedtoreduceor
avoidtheexperienceofanxiety.Thesesecurity
mechanismsincludesublimation,selective
inattentionanddissociation.
•Earlylifeexperienceswithparents,especially
themother,influenceanindividual'sdevelop­
mentthroughoutlife.
•Humandevelopmentproceedsthroughsix
stagesofdevelopment:infancy,childhood,
juvenility,pre-adolescence,earlyadolescence
andlateadolescence.Accordingtointer­
personaltheory,juvenileandpreadolescent
stagesholdthegreatestpotentialforcorrection
ofpreviousbehaviorandpersonalitydiffi­
culties.
InterpersonalTherapeuticProcess
Theinterpersonaltherapist,likethepsycho­
analyst,exploresthepatient'slifehistory.
Componentsofself-esteemareidentified,
includingthesecurityoperationsthatareusedto
defendtheself.
Theprocessoftherapyisessentiallyaprocess
ofre-educationasthetherapisthelpsthepatient
identifyinterpersonalproblemsandthen
encourageshimtotryoutmoresuccessfulstyles
ofrelating.
Therapyisterminatedwhenthepatienthas
developedtheabilitytoestablishsatisfying
humanrelationshipstherebymeetinghisbasic
needs.

54. ConceptualModels51
RolesofthePatientandtheInterpersonal
Therapist
Sullivandescribesthetherapistasaparticipant
observer,whoshouldnotremaindetachedfrom
thetherapeuticsituation.Thetherapist'sroleis
toactivelyengagethepatienttoestablishtrust
andtoempathize.Hewillcreateanatmosphere
ofuncriticalacceptancetoencouragethepatient
tospeakopenly.
Thepatient'sroleistosharehisconcernswith
thetherapistandparticipateintherelationship
tothebestofhisability.
Therelationshipitselfismeanttoserveasa
modelofinterpersonalrelationships.Asthe
patientmaturesinhisabilitytorelate,hecanthen
improveandbroadenhisotherlifeexperiences
withpeopleoutsidethetherapeuticsituation.
ApplicationtoNursing
Sullivan'sinterpersonaltheoryhasbeenthe
cornerstoneofpsychiatric-mentalhealthnursing
curriculaintheundergraduateandgraduate
evels.
Nurse-clientone-to-oneinteractionorinter­
•ersonalprocessisbasedonSullivan'sinterper­
sonaltheory.Theuseofinterpersonalprocess
recordingsintheclinicalaspectofpsychiatric­
mentalhealthnursingcoursesisalsoderivedfrom
Sullivan'sinterpersonaltheory.
COMMUNICATIONMODEL
Communicationreferstothereciprocalexchange
oiinformation,ideas,beliefs,andfeelingsamong
:;.groupofpersons.Thetheoristswhoparticularly
anphasizedtheimportanceofcommunicationare
EricBerne(founderoftransactionalanalysis),
?aulWatzlawickandhisassociates.
3asicassumptionsofcommunicationmodel
are:
•Theunderstandingofthemeaningofbehavior
isbasedontheclarityofcommunicationbet­
weenthesenderandreceiver.
•Breakdowninsuccessfultransmissionof
informationcausesanxietyandfrustration.
•Allbehavioriscommunication,whether
verbalornon-verbal.
•Disruptionsinbehaviormaythenbeviewed
asadisturbanceinthecommunication
process,andasanattempttocommunicate.
CommunicationTherapeuticProcess
Therapistslocatethedisruptionswithinthecom­
municationprocessandalsotheinterventions
madeinthepatternsofcommunication.
Thismaytakeplaceinindividuals,groupsor
families.Thecommunicationpatternisfirst
assessedandthedisruptiondiagnosed.The
patientisthenhelpedtorecognizehisown
disruptedcommunication.
RolesofPatientandTherapist
Therapist
•Thecommunicationtherapistinduceschan­
gesinthepatientbyinterveninginthecom­
municationprocess.Feedbackisgivenabout
theperson'ssuccessatcommunicating.
•Thetherapistdemonstrateshowtorelateto
othersclearly.
•Non-verbalcommunicationisalsoempha­
sized,particularlyintermsofcongruencewith
verbalbehavior.
•Thetherapistteachesprinciplesofgoodcom­
munication.
Patient
•Thepatientmustbewillingtobecome
involvedinananalysisofhisstyleof
communicating.
•Theresponsibilityforchangingrestswiththe
patient.Significantothersoftenareincluded
incommunicationtherapytobringchangein
thepatient.
ApplicationtoNursing
Thistheoryhelpsmentalhealthnursesto
understandcommunicationprocessandtocorrect
communicationdisturbances.

55. 52AGuidetoMentalHealthandPsychiatricNursing
MEDICALMODEL
Themedicalmodeldominatesmuchofmodern
psychiatriccare.Otherhealthprofessionalsmay
beinvolvedininteragencyreferrals,family
assessmentandhealthteaching,butphysicians
areviewedastheleadersoftheteamwhenthis
modelisineffect.Apositivecontributionofthe
medicalmodelhasbeenthecontinuousexplo­
rationforcausesofmentalillnessusingthe
scientificprocess.
Basicassumptionsofmedicalmodelare:
•Medicalmodelbelievesthatdeviantbehavior
isamanifestationofadisorderofthecentral
nervoussystem.
•Itsuspectsthatpsychiatricdisordersinvolve
anabnormalityinthetransmissionofneural
impulses,difficultyatthesynapticlevel,and
neurochemicalssuchasdopamine,serotonin
andnorepinephrine.
•Itfocusesonthediagnosisofamentalillness
andsubsequenttreatmentbasedonthis
diagnosis.
•Environmentalandsocialfactorsarealso
consideredinthemedicalmodel.Theymay
beeitherpredisposingorprecipitatingfactors
inanepisodeofillness.
•Anotherbranchofresearchfocuseson
stressorsandthehumanresponsetostress.
Theseresearcherssuspectthathumanshave
aphysiologicalstressthresholdthatmaybe
geneticallydetermined.
MedicalTherapeuticProcess
Thephysician'sexaminationofthepatient
includeshistoryofthepresentillness,past
history,socialhistory,medicalhistoryandreview
ofsystems,physicalexaminationandmental
statusexamination.Additionaldatamaybe
collectedfromsignificantothers,andpast
medicalrecordsarereviewedifavailable.A
preliminarydiagnosisisthenformulatedpending
furtherdiagnosticstudiesandobservationofthe
patient'sbehavior.Afterthediagnosisismade
treatmentisinstituted.
Somatictreatmentsincludingpharmacothe­
rapy,electroconvulsivetherapyandoccasionally
psychosurgery,areimportantcomponentsofthe
treatmentprocess.
RolesofthePatientandtheMedicalTherapist
•Thephysicianasthehealeridentifiesthe
patient'sillnessandinstitutesatreatmentplan.
•Physicianadmitsthepatientinapsychiatric
institution.
•Theroleofthepatientinvolvesadmittingthat
heisill.
•Patientpracticesprescribedtherapyregimen
andreportstheeffectsoftherapytothe
physician.
ApplicationtoNursing
Psychiatric-mentalhealthnurseusesthismodel
forassessment,diagnosis,planningandimple­
mentingnursingcaretothepatient.
Thismodelhelpspsychiatric-mentalhealth
nursestounderstandthephysiologicalchanges
occurringduetopsychiatricdisorders.
NURSINGMODEL
Nursingfocusesontheindividual'sresponseto
potentialoractualhealthproblems.Underthe
nursingmodel,humanbehaviorisviewedfroma
holisticperspective.
NursingViewofBehavioralDeviations
•Behaviorisviewedonacontinuumfrom
healthyadaptiveresponsestomaladaptive
responsesthatindicateillness.
•Eachindividualispredisposedtorespondto
lifeeventsinuniqueways.Thesepredis­
positionsarebiological,psychological,
sociocultural,andthesumoftheperson's
heritageandpastexperiences.
•Behavioristheresultofcombiningthepre­
disposingfactorswithprecipitatingstressors.
Stressorsarelifeeventsthattheindividual
perceivesaschallenging,threateningor
demanding.Thenatureofthebehavioral
responsedependsontheperson'sprimary
appraisalofthestressorandhissecondary
appraisalofthecopingresourcesavailableto
him.

56. ConceptualModels53
•Astressorthathasprimaryimpactonphysio­
logicalfunctioningalsoaffectstheperson's
psychologicalandsocioculturalbehavior.For
instance,amanwhohadamyocardialinfarc­
tionmayalsobecomeseverelydepressed,
becausehefearshewilllosehisabilitytowork
Ontheotherhand,thepatientwhoentersthe
psychiatricinpatientunitwithmajordepres­
sionmaybesufferingfrommalnutritionand
dehydrationbecauseofhisrefusaltoeator
drinkTheholisticnatureofnursingencom­
passesallofthesefacetsofbehaviorand
incorporatesthemintopatientcareplanning.
NursingProcess
_.ursinginterventionmaytakeplaceatanypoint
onthecontinuum.Nursingdiagnosismayfocus
onbehaviorassociatedwithamedicaldiagnosis
orotherhealthbehaviorthatthepatientwishes
tochange.
Anursemaypracticeprimarypreventionby
interveninginapotentialhealthproblem,
secondarypreventionbyinterveninginanactual
acutehealthproblemortertiarypreventionby
mterveningtolimitthedisabilitycausedbyactual
chronichealthproblems.Thenursingassessment
ofthepatientincludespresentingcomplaints,
~asthistory,familyhistory,personalhistory,
occupationalhistory,sexualhistory,physical
examinationandmentalstatusexamination.
_-"i.dditionaldatamaybecollectedfromsignificant
Jai.ersandbyreviewingthesystems.Anursing
.iiagnosisisthenformulatedandbasedonthis
iiagnosis,planningandinterventionsarecarried
ut.Finally,evaluationwillbedonetofindout
::ieeffectivenessofnursinginterventions.
Providingnursingcareisacollaborativeeffort,
ithboththenurseandthepatientcontributing
-=easandenergytothetherapeuticprocess.
SUMMARY OFSELECTED
RSINGTHEORIES
~eplau'sTheory
~2Plauproposedaninterpersonaltheoryappli­
-=-...,letonursingpracticeingeneral,andto
psychiatric-mentalhealthnursinginparticular.
Itfocusesprimarilyonthenurse-clientrelation­
ship.Peplau'stheorydescribes,explains,predicts
andtosomeextent,permitscontrolofthesequence
ofeventsoccurringinthenurse-clientrelation­
ship.
Peplaudescribestheinterpersonalaspectsof
nursingasaprocessconsistingoffourphases.
Theseareorientation,identification,exploitation
andresolutionphases.
Whileworkingwiththeclientthroughthese
phases,thenurseassumessixroles:resource
person,technicalexpert,teacher,leader,surro­
gateparentandacounselor.
Peplau'stheorycontinuestoapplytotoday's
nursingscene,especiallywithrespecttolong­
termpsychiatriccareinoutpatientandhome
healthsettings.
Orem'sTheory
DorotheaE.Orem'stheoryisbasedonthepremise
thatpeopleneedacompositeofself-careactions
tosurvive.Self-careactionsconsistofall
behaviorsperformedbypeopletomaintainlife
andhealth.Thecapacityoftheclientandthe
client'sfamilytoperformself-careiscalledself­
careagency.Oremstatesthataneedfornursing
careexistsiftheclient'sself-caredemandexceeds
theclient'sself-careagency.Thusthegoalof
nursingistomeettheclient'sself-caredemands
untiltheclientandhisfamilyareabletodoso.
Orem'stheorydescribesthreetypesofself­
care:
1.Universalself-carebehaviors,requiredtomeet
physiologicalandpsychosocialneeds.
2.Developmentalself-carebehaviors,required
toundergonormalhumandevelopment.
3.Healthdeviationself-carebehaviors,required
tomeetclient'sneedsduringhealth
deviations.
Theclassificationofself-carebehaviorsinthis
mannerhelpstoensurecompleteassessmentof
theclient'sself-careagency.
Assessmentfocusesontheclient'sself-care
demand,self-careagencyandself-caredeficits.A
planisformulatedfromtheinformationobtained

57. 54AGuidetoMentalHealthandPsychiatricNursing
intheassessment,thatindicatesthenursing
approachneededtomeettheclient'sneeds,
whichcanbecategorizedasfollows:
•Whollycompensatory,inwhichtheclient
doesnotparticipatebehaviorallyinself-care.
•Partiallycompensatory,inwhichtheclient
andnurseparticipatebehaviorallyinmeeting
theclient'sself-careneeds.
•Educative-developmental,inwhichtheclient
meetsself-careneedswithminimalnursing
assistance.
Toimplementtherequirednursingapproach,
thenurseusesoneoffivebehaviors:actingor
doingfortheclient,guiding,supporting,
providingandteaching.
Roger'sTheory
Roger'smodelfocusesontheindividualasa
unifiedwholeinconstantinteractionwiththe
environment.Theunitarypersonisviewedasan
energyfieldthatismorethanaswellasdifferent
fromthesumofthebiological,physical,social
andpsychologicalparts.InRoger'smodel,
nursingisconcernedwiththeunitarypersonas
asynergisticphenomenon.
Nursingscienceisdevotedtothestudyof
natureanddirectionofunitaryhumandevelop­
ment.Nursingpracticehelpsindividualsachieve
maximumwell-beingwithintheirpotential.
Roy'sTheory
AccordingtoCallistaRoy'stheory,thegoalof
nursingistopromotetheclient'sadaptationin
healthandillness.Thisgoalisachievedthrough
thenurse'seffortstochange,manipulateorblock
stress-producingstimulithatmayimpingeonthe
client.Thetheoryassumesthatthiskindof
nursinginterventionassiststheclienttocope
moreeffectivelythroughreducingstress.
Roy'stheoryassumesthatallhumanbeings
arehavingadaptivesystems,andchangein
responsetostimuli.Ifthechangeisviewedasa
positiveonethatpromotestheperson'sintegrity
thenthechangecanbeconsideredadaptive.If
thechangedoesnotpromotetheperson'sintegrity
thenthechangecanbeconsideredmaladaptive.
ThenursingprocessusedinRoy'stheory
involvestwolevelsofassessment.Thefirstlevel
includesobservationofbehaviorrelatedtothe
fouradaptivemodes:physiologic,self-concept,
rolefunctionandinterdependence.Thesefour
modesrepresentmethodsusedbytheclientto
adapt.Thesecondlevelofassessmentconsistsof
identifyingfocal,contextualandresidualstimuli.
Thefocalstimulusrepresentstheimmediate
dominantstimulusaffectingtheclient,suchas
injury,stressorillness.Contextualstimuliinclude
theenvironment,theclient'sfamilyandallother
backgroundfactorsrelatedtothefocalstimulus.
Residualstimuliconsistoftheclient'sprevious
background,beliefs,attitudesandtraits.
AccordingtoRoy'stheory,aperson'sadapta­
tionlevelisafunctionoffocal,contextualand
residualstimuli.Whenapersonencounters
stressesfromthesestimulithatsurpassinnate
andacquiredmechanismstocopeeffectively,the
personbehavesineffectivelyasdemonstratedby
oneormoreoftheadaptivemodes.Atthispoint,
nursinginterventionisrequired.Thisemphasizes
ontheclient'sbehavior,stimulideterminingthe
client'sbehavior,andthenurseinterveningin
somewaytointerferewiththestimuli.
HOLISTICMODEL
Theholisticviewofthepatient,withthebody
andsoulseenasinseparable,andthepatient
viewedasamemberofafamilyandcommunity,
wascentraltoNightingale'sviewofnursing.The
primarygoalofnursingistohelpclientsdevelop
strategiestoachieveharmonywithinthemselves
andwithothers,natureandtheworld.Integrative
functioningoftheclient'sphysical,emotional,
intellectual,socialandspiritualdimensionsis
emphasized.Eachpersonisconsideredasa
whole,withmanyfactorscontributingtohealth
andillness.
MajorConcepts
Fivemajorconceptsaregenerallyacceptedas
premisesofholistichealthcarephilosophy:

58. ConceptualModels55
•First,eachpersonismultidimensional;one's
physical,emotional,intellectual,socialand
spiritualdimensionsareinconstantinter­
actionwitheachother:
•thephysicaldimensioninvolvesevery­
thingassociatedwithone'sbody,both
internalandexternal
•theemotionaldimensionconsistsof
affectivestatesandfeelings,including
motorbehaviorassociatedwithemotion,
theexperiencedaspectofemotion,andthe
physiologicalmechanismsthatunderlie
emotion
•theintellectualdimensionincludes
receptivefunctions;memoryandlearning,
cognitionandexpressivefunctions
•thesocialdimensionisbasedonsocial
interactionandrelationships,moresothe
globalconceptofculture
•thespiritualdimensionisthataspectofa
personfromwhichmeaninginlifeis
determinedthroughwhichtranscendence
overtheordinaryispossible
•Thesecondpremiseofholisticcarephilosophy
isthattheenvironmentmakessignificant
contributionstothenatureofone'sexistence.
Eachperson'senvironmentconsistsofmany
factorsthatareinfluentialinthatperson's
qualityoflife.Consequently,peoplecannot
befullyunderstoodwithoutconsiderationof
environmentalfactorssuchasfamilyrelation­
ships,culture,andphysicalsurroundings.
Individualsinteractwiththeirunique
environmentsthroughalldimensions,based
onsubjectiveexperienceaswellasexternal
stimuli.
•Thethirdpremiseisthateachperson
experiencesdevelopmentacrosshislifecycle;
ineachstageoflife,theindividualexperiences
andconfrontsdifferentissuesorsimilarissues
indifferentways.One'sexperienceofeach
stageoflife,formsthebasisforfurther
developmentasonemovesthroughthelife
cycle.
•Fourth,theholistichealthcaremodel
maintainsthatstressisaprimaryfactorin
healthandillness.Anyeventorcircumstance
canactasastressor.Regardlessofthesource,
stresshasanimpactonthewholeperson.
Examplesofstressorsdirectlyaffectingthe
physicaldimensionincludestressors
associatedwithgeneticfactors,physiological
processes,andbodyimage.Emotionalstress
mayresultfromanyexperienceorsituation.
Examplesincludepoorphysicalconditions,
perceivedsocialinequities,asignificantloss,
intellectualincompetence,andasenseof
meaninglessness.Stressorsaffectingthe
intellectualdimensionmayincludefactors
thatinterferewithreceptivefunctions,memory
andlearning,cognitivefunctions,and
expressivefunctions.Socialstressorsmay
arisefrominteractionsandrelationshipswith
otherpeople,aswellasfrommoregeneral
societalandculturalfactors.Stressorsaffecting
thespiritualdimensionmaybeanyfactors
thatinterferewithone'sabilitytomeet
spiritualneeds.
•Fifth,peopleareultimatelyresponsibleforthe
directionstheirlivestakeandthelifestyles
theychoose.Withinaholisticframework,
peopleareviewedasactiveparticipantsin
andcontributorstotheirhealthstatus;they
arewillingtolearnfromillnessandstrive
towardshealthierchoices.
Thefollowingisadiagrammaticrepresenta­
tionoftheclientviewedfromaholisticperspective:
Physical
Genetics
Sleep-wakecycle
Bodyimage
Emotional
Affect
Feelings
~----~~
Intellectual
Expressivefunctions
Memory
Learning
Cognition
Receptivefunctions
Spiritual
Philosophy
Transcendence
RelatednesstoGod,
otherpower,ornature
Self-actualization
CLIENT
(PERSON)
Social
Interactions
Relationships
Culture
Socialization
Self-concept
Sexuality
Environment

59. 56AGuidetoMentalHealthandPsychiatricNursing
Recognizingallhumandimensionsencour­
agesabalancedandwholeviewofaperson.Each
facetofanindividualisimportantandcontributes
tothequalityoflifeexperience.Alldimensions
areintricatelyinterwoven,andthepersonasa
wholefunctioningorganismismorethanthe
simplecombinationofdimensions.Theholistic
modelemphasizesthatallthedimensionsofthe
individualshouldbeconsideredwhenplanning
andinstitutingcare.
REVIEWQUESTIONS
•Psychoanalyticalmodel(Feb2000,
Oct2004)
•Dreamanalysis
•Behavioralmodel
•Interpersonalmodel
•Selfcaremodel(Oct2004)
•Nursingmodel
•Holisticmodel(Apr2002)

60. NursingProcessin
PsychiatricNursing
0HISTORICALOVERVIEW OFNURSINGPROCESS
INPSYCHIATRICNURSING
0NURSINGPROCESS
Definition
NursingAssessment
NursingDiagnosis
Planning
Implementation
Evaluation
0METHODS OFASSESSMENT INPSYCHIATRY
HistoryTaking
MentalStatusExamination
PhysicalInvestigationsforPsychiatric
Patients
PsychologicalAssessmentinPsychiatric
Nursing
0CHILDANDADOLESCENT PSYCHIATRY
ASSESSMENT FORMAT
0HISTORYCOLLECTION INALCOHOLDEPENDENCE
0GERIATRICHISTORYCOLLECTION FORMAT
HISTORICALOVERVIEW OFNURSING
PROCESS INPSYCHIATRICNURSING
Dates Events
BeforeWorld
WarII
Mentalhealth-psychiatricnursesdepen­
dedmainlyonexperience,rote
procedure,andintuitivejudgmentasa
basisfornursingcare.
Mentalhealth-psychiatricnurseshad
someawarenessoftheorybutstill
providedprimarilycustodialcarewith
noattentiontosystemicapproachto
nursingcare.
Psychiatricnurseswereusingnursing
careplansasatoolforcommunicating
theirpractice.Peplaudevelopedamodel
ofnursingcarethatemphasizeda
systemicapproachtothenurse-client
relationship.
1940s
1950s
Contd...
Contd...
1960s Orlandowasamongthefirsttodescribe
nursingasdeliberativeprocesswitha
focusontheinterpersonalrelationship.
Psychiatricnursingtextsincludedthe
nursingprocessasamethodfororga­
nizingnursingcarewithinaconceptual
framework.
1970s
1980s Mentalhealth-psychiatricnursescontinue
torefinetheiruseofthenursingprocess.
Withincreasedunderstanding,the
mentalhealth-psychiatricnursemoredeli­
beratelyappliesthenursingprocess.
Psychiatricnurseswillengageinmore
researchtosystematicallyexaminethe
effectofthenursingprocessonthenurse­
clientrelationship.
1990s
Future
NURSINGPROCESS
Definition
Nursingprocessisanorderly,systematicmanner
ofdetermingtheclient'sproblems,makingplans
tosolvethem,initiatingtheplanorassigning
otherstoimplementitandevaluatingtheextent
towhichtheplanwaseffectiveinresolvingthe
problemsidentified.
-YuraandWalsh,1978
Thenursingprocessprovidesascientific
frameworkforthedeliveryofprofessionalnursing
care.
Nursingprocessconsistsoffivesteps:
1.Assessment
2.NursingdiagnosisorAnalysis
3.NursinggoalorPlanningorObjectives
4.ImplementationorIntervention
5.Evaluation
-

61. 58AGuidetoMentalHealthandPsychiatricNursing
(Re)Assessment
Evaluation
Planning
NURSINGASSESSMENT
-Sexualandmaritalhistory
•Physicalexamination
-Bodysystemreview
-Neurologicalstatus
-Laboratoryresults
Nursing •Physicalfunctions
diagnosis -ActivityIExercise
-Sleep
-Appetiteandnutrition
-Hydration
-Sexuality
-Selfcare
•Pharmacologicalassessment
II.PsychologicalDimension
•Generalappearanceandbehavior
-Psychomotoractivity
-Attitude
•Speech
•Mood
Inthisstepinformationisgatheredtoestablish
adatabaseforbestpossiblecareofthepatient.
Thenursingassessmentisdeliberateand
systematiccollectionofbio-psychosocialinforma­
tionordataisdonetodeterminecurrentandpast
healthandfunctionalstatusandtoevaluatepast
andpresentcopingpatterns.
TechniquesofDataCollectionin
PsychiatricNursing
1.Patientobservation
2.Patientinterview(Processrecording)
3.Familyinterview
4.Physicalexamination
5.Mentalstatusexamination
6.Recordsanddiagnosticreports
7.Collaborationwithcolleagues.
BIOPSYCHOSOCIAL ASSESSMENT IN
PSYCHIATRICNURSING
I.BiologicDimension
•Presenthistory
•Pastpsychiatricandmedicalhistory
•Personalhistory
-Perinatalhistory
-Childhoodhistory
-Educationalhistory
-Playhistory
-Obstetricalhistory
-Affectandemotions
•Thought
•Perception
•Cognitivefunctions
•Insight
•Judgment
•Abstractreasoningandcomprehension
•Memory
•Behavioralresponses
•Selfconcept
-Bodyimage
-Selfesteem
-Personalidentity
•Presentandpastcopingpatterns
•Riskassessment
-Suicidalideation
-Assaultorhomicidalideation
III.SocialDimension
•Functionalstatus
•Socialsystems
-Culturalassessment
-Familyassessment
-Communitysupportandresources
•Spiritualassessment
•Occupationalstatus
•Economicstatus
•Legalstatus
•Qualityoflife

62. NursingProcessinPsychiatricNursing59
NURSINGDIAGNOSIS
Nursingdiagnosesaredefinedasclinical
judgmentsaboutindividual,familyorcommunity
responsestoactualandpotentialhealthproblems.
Nursingdiagnosesareusedtodescribeanindi­
vidualpatient'scondition,toprescribenursing
interventions,andtodelineatetheparametersfor
developingoutcomecriteria.
Thebasiclevelpsychiatricnurseidentifies
nursingproblemsbyusingthenomenclature
specifiedbytheNorthAmericanNursing
DiagnosesAssociation(NANDA).
Anursingdiagnosisdescribesanexistingor
high-riskproblemandrequiresathree-part
statement.
1.Thehealthproblem(Problem,'P')
2.Theetiologicalorcontributingfactors
(Etiology,'E')
3.Thedefiningcharacteristics(Signsand
symptoms,'S').
Forexample:
•Highriskforselfdirectedviolencerelated
todepressedmood,feelingofworth­
lessness,angerturnedinwardontheself.
•Powerlessnessrelatedtodysfunctional
grievingprocess,lifestyleofhelplessness,
evidencedbyfeelingsoflackofcontrolover
lifesituations,overdependenceonothers
tofulfillneeds.
PLANNING
Theplanningphaseconsistsofthetotalplanning
ofthepatient'soveralltreatmenttoachievequality
outcomesinasafe,effective,andtimelymanner.
Nursinginterventionswithrationalesareselected
intheplanningphasebasedontheclient's
identifiedriskfactorsanddefiningcharacteris­
tics.Theprocessofplanningincludes:
•Collaborationbythenursewithpatients,
significantothers,andtreatmentteam
members
•Identificationofprioritiesofcare
•Criticaldecisionsregardingtheuseof
psychotherapeuticprinciplesandpractices
(Identifythemostappropriatenursing
intervention)
Coordinationanddelegationofresponsi­
bilities.
Inthisnursewillchoosenursinginterventions
appropriatetoanindividual'sidentifiedproblem
withspecificexpectedoutcomes.
Oncethenursingdiagnosesareidentified,the
nextstepistheprioritizationoftheproblemsin
orderofimportance.Highestpriorityisgivento
thoseproblemsthatarelifethreatening.Nextin
thepriorityarethoseproblemsthatarelikelyto
causedestructivechanges.Lowestinpriorityare
thoseissuesthatarerelatedtonormativeor
developmentalexperiences.Psychiatricnurses
oftenuseMaslow'shierarchyofneedstoprioritize
nursingdiagnoses.
•
OutcomeIdentification
Outcomescanbedefinedasapatient'sresponse
tothecarereceived.Outcomesaretheendresult
oftheprocess.Measuringoutcomesnotonly
demonstratesclinicaleffectivenessbutalsohelps
topromoterationalclinicaldecision-makingon
thepartofthenurse.
Outcomeidentificationshouldbe:
•Patientcentered
•Singular
•Observable
•Measurable
•Timelimited
•Mutual
•Realistic
Diagnosis Outcome Intervention
Impairedsocial
interaction(Isolates
selffromothers)
PatientwillattendUsingacontract
groupsessionsformatexplainthe
everyday roleandresponsibility
ofpatients.
CorrectandIncorrectOutcomeStatements
-------- ----·----------
NursingdiagnosisCorrectoutcome Incorrectoutcome
Anxiety Verbalizesfeelingcalm,Exhibitsdecreased
relaxed,withabsence anxiety,engagesin
ofmuscletensionand stressreduction
diaphoresis;practices
deepbreathing.
IneffectivecopingMakesowndecisionstoDemonstrateseffective!
attendgroups;seeksstaffcopingabilities
forinteraction.

63. 60AGuidetoMentalHealthandPsychiatricNursing
IMPLEMENTATION
Intheimplementationphasenursesetsinter­
ventionsprescribedintheplanningphase.
Nursinginterventions(alsoknownas
nursingordersornursingprescriptions)arethe
mostpowerfulpiecesofthenursingprocess.Inter­
ventionsareselectedtoachievepatientoutcome
andtopreventorreduceproblems.Implemen­
tationservesasablueprintofplan.
Nursinginterventionsareclassifiedas
independent,interdependentanddependent.
NursingInterventioninPsychiatricNursing
Interventionsforbiologicaldimension
•Selfcareactivities
•Activityandexercise
•Nutritionalinterventions
•Relaxationinterventions
•Hydrationinterventions
•Thermoregulationintervention
•Painmanagement
•Medicationmanagement
Interventionsforpsychologicaldimension
•Counselinginterventions
•Conflictresolutions
•Bibliotherapy
•Reminiscencetherapy
•Behaviortherapy
•Cognitivetherapy
•Psycho-education
•Spiritualinterventions
Interventionforsocialdimensions
•Groupinterventions
•Familyintervention
•Milieutherapy
EVALUATION
Evaluationistheprocessofdeterminingthevalue
ofanintervention.Nursesdeterminetheeffecti­
venessofinterventionswithparticularpatients.
Nursesevaluateselectedinterventionsbyjudging
thepatientsprogresstowardstheoutcomeset
downinthenursingcareplan.
Conclusion
Psychiatrictreatmentisateameffort;basic
outcomesoftenreflectthecombinedeffectsofthe
interventionsofnurses,physician,occupational
therapist,psychologistsandsocialworkers.
METHODS OFASSESSMENT IN
PSYCHIATRY
•HistoryTaking
•MentalStatusExamination
•PhysicalInvestigations
•PsychologicalAssessment
HistoryTakinginPsychiatricNursing
I.Identificationdata
Name Age Sex
FatherISpouse
Address
Education Occupation Income
Maritalstatus Religion
II.Informant
III.Presentingchiefcomplaint
(withdurationinchronologicalorder)
IV.Historyofpresentillness
Duration(weeks/months/years):
Modeofonset:abrupt/acute/subacute/insidious
(<48hrs)/<1wkI(l-2wks)
Course:continuousIepisodicIfluctuatingI
deterioratingIimprovingIunclear
Precipitatingfactors:
Descriptionofpresentillness(chronologicaldescription
ofabnormalbehavior,associatedproblemslike
suicide,homicide,disruptivebehavior;thought
content,speech,moodstates,abnormalperception,
biologicalfunctioning,socialfunctioning,occupational
functioning,changesinADLs)
V.Treatmenthistory
Drugs(nameofthedrug,dose,route,side-effects,if
any)
ECT
Psychotherapy
Familytherapy
Rehabilitation
VI.Pastpsychiatricandmedicalhistory
Hospitalization(psychiatric):
Substanceuse:
SurgicalproceduresIaccidentsIheadinjuryIconvulsionsI
unconsciousness/DM/HTNICAD/venereal disease/
HIVpositivity/anyother

64. NursingProcessinPsychiatricNursing61
VII.Familyhistory
Genogram(familyoforigin)
Description(describeeachfamilymemberbriefly:age,
education,occupation,healthstatus,relationshipwith
thepatient,ageatdeath,modeofdeath)
VIII.Personalhistory
(A)Perinatalhistory
Antenatalperiod:uneventful/eventful(specify)
Birth :full-termIprematureIpostmature
Delivery:normalIinstrumentalIcesarean
Birthcry:immediate/delayed
Birthdefects:
Postnatalcomplications:cyanosis/convulsionsjaundice
Anyother
(B)Childhoodhistory
Primarycaregiver:
Feeding:breastfed/artificial
Ageatweaning:
Developmentalmilestones:normalIdelayed
Behaviorandemotionalproblems:thumbsucking/
tempertantrums/stuttering
head-banging/bodyrocking/nailbiting
enuresis/morbidfears/nightterrors
somnambulism
C)Educationalhistory
Ageatbeginningofformaleducation:
Academicperformance:
Academicandextracurricularachievements,ifany:
Relationshipswithpeersandteachers:
Schoolphobia:yes/noTruancy:yes/no
Reasonforterminationofstudies:
D)Playhistory
Gamesplayed(atwhatstageandwithwhom):
Relationshipswithplaymates:
BEmotionalproblemsduringadolescence
Runningawayfromhome/delinquencyIsmoking/
drug-taking/anyother(specify)
TIPuberty
Ageatappearanceofsecondarysexualcharacteristics:
AnxietyR/Tpubertychanges:
Ageatmenarche:
Reactiontomenarche:
Regularityofcycles,durationofflow:
Abnormalities,ifany(menorrhagia,dysmenorrhea,
etc):
G)Obstetricalhistory
LMP:
Numberofchildren:
Anyabnormalitiesassociatedwithpregnancy,
delivery,puerperium:
Terminationofpregnancy,ifany
Menopause(includinganyassociatedproblems):
(H)Occupationalhistory
Ageatstartingwork:
Jobsheldinchronologicalorder:
Reasonsforchanges:
Currentjobsatisfaction:
(includingrelationshipswithauthorities,colleagues,
subordinates)
Whetherjobisappropriatetoclient'sbackground:
(I)Sexualandmaritalhistory
Genogram(familyofprocreation):
Typeofmarriage:self-choice/arranged
Durationofmarriage:
Interpersonalandsexualrelations:satisfactoryI
unsatisfactory
Detailsofspouseandchildren:
(J)Premorbidpersonality
(a)Interpersonalrelationships:
Extrovert/introvert
Familyandsocialrelationships
(b)Useofleisuretime:
(c)Predominantmood:
Optimistic/pessimistic;stableIfluctuating;
cheerful/despondent
Usualreactiontostressfulevents
(d)Attitudetoselfandothers:
Self-appraisalofabilities,achievementsand
failures
Generalattitudestowardsothers
(e)Attitudetoworkandresponsibility:
(£)Religiousbeliefsandmoralattitudes:
(g)Fantasylife:
Daydreams___,frequencyandcontent.
(h)Habits:
Eatingpattern
Elimination
Sleep
Useofdrugs,
regularIirregular
regularIirregular
regularIirregular
tobacco,alcohol:
MentalStatusExamination
[A]GeneralAppearanceandBehavior
Appearance:lookingone'sageIolderIyounger
Levelofgrooming:normal/shabbilydressed/over­
dressed/idiosyncraticallydressed
Levelofcleanliness:adequate/inadequate/overtly
clean
Levelofconsciousness:fullyconsciousandalert/
drowsyIstuporousIcomatosed
Modeofentry:camewillinglyIpersuaded/brought
usingphysicalforce

65. 62AGuidetoMentalHealthandPsychiatricNursing
Cooperativeness:normal/morethanso/lessthan
so
Eye-to-eyecontact:maintained/difficult/notmain­
tained
Psychomotoractivity:normal/increased/dec­
reased
Rapport:spontaneous/difficult/notestablished
Gesturing:normal/exaggerated/odd
Posturing:normalposture/catatonicposture
Othermovements:stereotypesItremors/EPSIAIMs
(abnormalinvoluntarymovements)
Othercatatonicphenomena:automaticobedience/
negativism/excessivecooperation/waxyflexi­
bilityIechopraxia/echolalia
Conversionanddissociativesigns:
Compulsiveactsorrituals:
Hallucinatorybehavior:
(Smilingandtalkingtoself,oddgesturing)
[B]Speech
Initiation:spontaneousIspeakswhenspokentoI
minimal/mute
Reactiontime:normal/delayed/shortened/diffi­
culttoassess
Rate:normal/slowIrapid
Productivity:monosyllabic/elaboratereplies/
pressured
Volume:normal/increased/decreased
Tone:normalvariation/monotonous
Relevance:fullyrelevant/sometimesofftarget/
irrelevant
Stream:normal/circumstantial/tangential
Coherence:fullycoherent/looseningofassocia­
tions
Others:rhyming/punning/echolaliapersever­
ation/neologism
Sampleofspeech(inresponsetoopen-ended
questions):
[C]Mood
Subjective:
Objective:
(Predominantmoodstate/appropriate/inappropriate/
irritable/labile/blunted/lattened)
[D]Thought
Stream:normal/racythoughts(pressureof
thought)Iretardedthinking(povertyofthought)I
thoughtblock/muddledorunclearthinking/
flightofideas
Form:normal/formalthoughtdisorder(specify
withasampleofspeech)
Content:(a)Ideas/delusionsof:
worthlessness/helplessness/hopelessnessI
guilt/hypochondriacal/poverty/nihilistic/
deathwishesIsuicidalIgrandioseIreferenceI
control/persecution/bizarre
(b)Thoughtalienationphenomena:
thoughtinsertion/thoughtwithdrawal/
thoughtbroadcasting
(c)Obsessional/compulsivephenomena:
thoughtsIimagesIruminationsIdoubtsI
impulsiverituals
[E]Perception
Hallucinations:Auditory
Visual
Olfactory
Gustatory
Tactile
Somaticpassivity:
DejavuIjamaisvu:
[F]CognitiveFunction(neuropsychiatric
assessment)
Consciousness
conscious/cloudyIcomatosed
Orientation
Time:appropriatetime/day/night/date/month/
year

66. NursingProcessinPsychiatricNursing63
Place:kindofplace/area/city
Person:self/closeassociates/hospitalstaff
_-tttention
normallyaroused/arousedwithdifficulty
digitforward
digitbackward
Concentration
normallysustained/sustainedwithdifficultyI
distractible
100-7
40-3
20-1
Nameofmonths(backwards)
Nameofweekdays(backwards)
_.1emory
a)Immediate(sametestasforattention):
1)Recent:(recenthappenings-lastmeal,visitors
etc)
verbalrecall-3unrelatedobjects
5unrelatedobjects,orimaginary
addressof5items
c)Remote:
personalevents:
impersonalevents:
illness-relatedevents:
.-ueitigence
Generalfundofinformation:
.Arithmeticability:mentalarithmetic/written
s.ums
_-bstraciion
_.ormal/concrete
interpretationofproverbs:
Similaritiesbetweenpairedobjects:
:Jissimilaritiesbetweenpairedobjects:
:GJInsight
AwarenessofabnormalbehaviorIexperience:
:-esImaybeIno
Attributiontophysicalcauses:yesImaybeIno
Recognitionofpersonalresponsibility:yesI
maybeIno
-·.illingnesstotaketreatment:yesImaybeIno
[HJJudgment
Personal:intactIimpaired
Social:intactIimpaired
Test:intactIimpaired
Diagnosticformulation
PhysicalInvestigationsforPsychiatric
Patients
(A)Routine:generalscreening
e.g.hemogram,urinalysis
(Additionalinvestigationsmaybeorderedin
specialpopulations)
(B)Routine:specific
Basedondiagnosis-e.g.liverfunctiontestsin
alcoholics
Basedontreatment-e.g,pre-lithium,pre-ECT
work-upinvestigations
Basedonongoingmanagement-e.g.blood
countsinpatientsonclozapinetreatment
(C)Non-routine:
Basedonneedandindexofsuspicion
e.g.thyroidfunctiontestsinsuspectedhypo­
thyroidismduringlithiumtherapy;pregnancy
testsinamenorrheaduringtreatmentwith
potentialteratogens.
(D)Commonneuropsychiatryinvestigations
•Electroencephalogram(EEG)
•Computedtomographic(CT)scanning
•Magneticresonanceimaging
•ThesleepEEG(polysornnogram)
PsychologicalAssessmentinPsychiatric
Nursing
Psychologicaltestingofpatientsisideallyconduc­
tedbyaclinicalpsychologistwhohasbeen
trainedintheadministration,scoringand
interpretationoftheseprocedures.
1.Toassistindiagnosis:
E.g.Rorschachinkblottest
2.Toassistintheformulationofpsycho­
pathologyandintheidentificationofareasof
stressandconflict:
E.g.Thematicapperceptiontest
3.Todeterminethenatureofthedeficitsthatare
present:

67. 64AGuidetoMentalHealthandPsychiatricNursing
-Cognitiveneuropsychologicalassessments
4.Toassessseverityofpsychopathologyand
responsetotreatment:
-Hamiltonratingscalefordepression
-Briefpsychiatricratingscale
5.Toassessgeneralcharacteristicsofthe
individual:
-Assessmentofintelligence
-Assessmentofpersonality
CHILDANDADOLESCENT PSYCHIATRY
ASSESSMENT FORMAT
A.DemographicData
Name: Address:
Age:
Income:
HospitalNo.:
Informant:MotherIFatherIOthers
B.Chiefcomplaints(withdurationinbrief):
C.Historyofpresentillness:
D.FamilyHistory:
1.Nuclear 1.Consanguinous
2.Non-nuclear2.Non-consanguinous
Sex:
UrbanISemi-UrbanIRural
1.Mentalillness
2.Epilepsy
3.Mentally
retarded
4.Others
Genogram:
E.PersonalHistory:
Antenatalhistory
Perinatalhistory
Postnatalhistory
Milestones
Currentschooling :YesINo
Habits,interestandtalents,sexualhistory
F.Pasthistory:
1.Psychiatric
2.Neurotic
3.Others
G.Currentfunctioning
1.Intelligence
a.Averageb.Belowc.Aboved.Notknown
2.SchoolPerformance
a.Averageb.Belowc.Notappropriated.Not
known
3.Self-Help:Ageappropriate
a.Toilet-YesINo
b.Dressing-YesINo
c.Eating-YesINo
d.BathingIWashing-YesINo
H.Physicalexamination-
Vision
Hearing
CNS
Chest
I.Treatmenthistorytilldate
J.MentalStatusExamination
Attention&concentration
Activitylevel
Motorbehavior
Speechandlanguageability
Generalintelligence
•Moodandaffect
Thoughtprocesses
Perception
K.Summary
HISTORYCOLLECTION INALCOHOL
DEPENDENCE
A.DemographicData
Name: Age: Sex:
Occupation: Income:
Maritalstatus-MarriedISingleIWidow
LP.No.: Address:
Education:
Informant:
B.Chiefcomplaints(inchronologicalorderwithduration)
C.Historyofpresentillness
1.Firstdrinkcauses
2.Firstexperiencewithalcohol
3.Thetypeandvolumeoffirstdrink-Harddrink/
Regulardrink
4.Historyoftolerance
5.Historyofcraving
6.Historyoflossofcontrol
7.Historywithdrawalfeatures-whenabstinent
fromalcohol
8.Historyofblackouts
9.Historyofsalience
(Restrictingalltheactivitiesandconcentrating
onlyonalcoholseekingbehavior,notevengoing
towork)
10.Whatarethereasonsforexcessiveconsumption
ofalcohol
11.Maintainingfactors/reasons
12.Previoushistoryofabstinence
13.Moneyspentforalcohol
14.Medicalproblemsassociatedwithalcoholism
15.Psychiatricproblemsassociatedwithalcoholism
Cognitivedeficits
Historyofdementia
16.Co-morbidity
17.Historyofanyothersubstanceabuse
D.Familyhistory
Familyhistoryofsimilarproblems
Interpersonalrelationshipinthefamily
Familyhistoryofpsychiatricdisorders
Psychosis
Mooddisorders
Neuroticdisorders
Substanceabuse
•Epilepsy
Genogram

68. NursingProcessinPsychiatricNursing65
E.Personalhistory
F.Maritalhistory
Rolereversal
•Emotionaldisordersinchildren
Historyofexposuretoextramaritalrelationship
Sexualdysfunction
G.Premorbidpersonality
Dependence
Anankastic
Passiveaggressive
Anti-social
GERIATRICHISTORYCOLLECTION FORMAT
I.DemographicData
Name: Age: Sex:
Occupation: Income:
MaritalStatus:Married/Single/Widow
LP.No.: Address:
Education
Informant:
II.ChiefComplaints
III.PrecipitatingFactors
Headinjury
Infection
Sensoryhandicaps
Retirement
Bereavement
Anyother
IV.HistoryofPresentIllness
Stress
Qualitativeorquantitativechangesinroutine
activities
Cognitivefunction
Habitsandothers
v.PastMedicalHistory
vt.PastPsychiatricHistory
-.11.MentalStatusExamination
"Tll.FamilyHistory
Jointornuclearfamily
Monthlyincomeofthefamily
Socioeconomicstatus
Genogram
IX.PersonalHistory
a)Developmentalhistory
b)Educationalhistory
c)Occupationalhistorypre-retirement
d)Sourceofincome
EmploymentIpensionIassistancefromfamilyI
otherfinancialproblemsifany
e)Residence
Livingathome/alone/withspouse/withchildren
OwnIrentedhouse
Anyproblemswithlivingsituation
X.MaritalHistory
•SexualImenstrualhistory
•Genogram
•Familyhistoryofmentalorphysicalhistory
XI.Premorbidpersonality
•Specifictraits
•Socialfunctioning
•Occupationalfunctioning
•Biologicalfunctioning
•InterestIhobbies,alcoholandotherdrugabuse
XII.Community involvement
MembersoforganizationIclubIpoliticalactivities/
voluntarywork
XIII.Socialsupport
XIV.Attitudetowardsageinganddeath
XV.Summary
XVI.Investigations
XVII.Treatment
REVIEWQUESTIONS
•Describenursingprocessinpsychiatric
nursing
•Describevariousmethodsofassessmentin
psychiatry
•Mentalstatusexamination(Nov2003,
Oct2004)

69. TheTherapeuticNurse­
PatientRelationship
0TYPESOFRELATIONSHIPS
0DIFFERENCES BE1WEENTHERAPEUTIC AND
SOCIALRELATIONSHIP
0GOALSOFTHERAPEUTIC RELATIONSHIP
0COMPONENTS OFTHERAPEUTIC RELATIONSHIP
Rapport
Empathy
Warmth
Genuineness
0CHARACTERISTICS OFTHERAPEUTIC NURSE­
PATIENTRELATIONSHIP
DPHASESOFTHERAPEUTIC RELATIONSHIP
Pre-interactionPhase
IntroductoryPhase
WorkingPhase
TerminationPhase
0THERAPEUTIC COMMUNICATION TECHNIQUES
DPROCESSRECORDING
/
Arelationshipisdefinedasastateofbeingrelated
orastateofaffinitybetweentwoindividuals.The
nurseandclientinteractwitheachotherinthe
healthcaresystemwiththegoalofassistingthe
clienttousepersonalresourcestomeethisorher
uniqueneeds.
Inatherapeuticrelationshipthenurseand
clientworktogethertowardsthegoalofassisting
theclienttoregaintheinnerresourcestomeetlife
challengesandfacilitategrowth.Theinteraction
ispurposefullyestablished,maintainedand
carriedoutwiththeanticipatedoutcomeof
helpingtheclientgainnewcopingand
adaptationskills.
TYPESOFRELATIONSHIPS
•Socialrelationships.
•Intimaterelationships.
•Therapeuticrelationships.
SocialRelationships
Asocialrelationshipcanbedefinedasa
relationshipthatisprimarilyinitiatedwiththe
purposeoffriendship,socialization,enjoyment
oraccomplishingatask.Mutualneedsaremet
duringsocialinteraction.Forexample,
participantsshareideas,feelingsandexperiences.
IntimateRelationships
Anintimaterelationshipoccursbetweentwo
individualswhohaveanemotionalcommitment
toeachother.Thoseinanintimaterelationship
usuallyreactnaturallywitheachother.Oftenthe
relationshipisapartnershipwhereineach
membercaresabouttheother'sneedforgrowth
andsatisfaction.
TherapeuticRelationships
Thetherapeuticrelationshipbetweennurseand
clientdiffersfrombothasocialandanintimate
relationshipinthatthenursemaximizesinner
communicationskills,understandingofhuman
behaviorandpersonalstrengths,inorderto
enhancetheclient'sgrowth.Thefocusofthe
relationshipisontheclient'sideas,experiences
andfeelings.
GOALSOFTHERAPEUTIC RELATIONSHIP
•Facilitatingcommunicationofdistressing
thoughtsandfeelings.
•Assistingtheclientwithproblemsolving.
•Helpingclientsexamineself-defeating
behaviorsandtestalternatives.
•Promotingself-careandindependence.

70. TheTherapeuticNurse-PatientRelationship67
DIFFERENCES BETWEEN THERAPEUTIC ANDSOCIALRELATIONSHIP
Technique
Therapeuticrelationship Socialrelations/zip
Justhappenswithmutualinterests
Objective
Duration
Accountability
Aplannedtherapeutic
relationship
Helpingthepatient
Usuallytimeislimited
Nurseisaccountableforthe
goalsoftherelationship
Nurseacceptspatientas
"hereandnow",without
anypersonaloremotional
attachmentsandinterests
Animportantpartofthe
relationship,itisplanned
anddiscussedwiththe
patient
Acceptance
Termination
COMPONENTS OFTHERAPEUTIC
RELATIONSHIP
Rapport
Rapportisarelationshiporcommunication
especiallywhenusefulandharmonious.Itisthe
cruxofatherapeuticrelationshipbetweenthe
nurseandthep~
Itis:
•awillingnesstobecomeinvolvedwithanother
person
•growthtowardsmutualacceptanceand
understandingofindividuality
•theendresultofone'scareandconcernfor
another.
Thenurseestablishesrapportthroughdemon­
strationofunderstanding,warmthandnon­
judgmentalattitude.Askillednursewillbeable
toestablishrapportthatwillalleviatethepatient's
problems.Whenrapportdevelops,thepatient
feelscomfortablewiththenurseandfindsiteasier
toself-disclose.Thenursealsofeelscomfortable
andrecognizesthataninterpersonalbondor
allianceisdeveloping.
Empathy
Empathyisanabilitytofeelwiththepatientwhile
retainingtheabilitytocriticallyanalyzethe
situation.
Satisfyingtheneedsofeachother
Varies,maylastforyears
Bothareresponsibleand
accountable
Personal/emotional
attachmentandinterest
involved
Relationshipmayexist
lifelongorterminate
gradually
Itistheabilitytoputoneselfinanother
person'scircumstancesandfeelings.Thenurse
neednotnecessarilyhavetoexperienceit,but
hastobeabletoimaginethefeelingsassociated
withtheexperience.
Inempathyprocessthenursereceives
informationfromthepatientwithanopen,non­
judgementalacceptance,andcommunicatesthis
understandingoftheexperienceandfeelingsso
thatthepatientfeelsunderstood.Thisservesasa
basisfortherelationship.
Sympathyisoftenconfusedwithempathy.In
sympathy,thenurseactuallyfeelswhatthe
patientfeelsbutintheprocessobjectivityislost,
andthenursebecomesfocusedonreliefof
personaldistressratherthanonassistingthe
patienttoresolvetheproblem.Withempathy
whileunderstandingthepatient'sthoughtsand
feelings,thenurseisabletomaintainsufficient
objectivitytoallowthepatienttoachieveproblem
resolutionwithminimalassistance.
Warmth
Warmthistheabilitytohelptheclientfeelcared
forandcomfortable.Itshowsacceptanceofthe
clientasauniqueindividual.Itinvolvesa
non-possessivecaringfortheclientasaperson
andawillingnesstosharetheclient'sjoysand
sorrows.

71. 68AGuidetoMentalHealthandPsychiatricNursing
Genuineness
Genuinenessinvolvesbeingone'sownself.This
impliesthatthenurseisawareofherthoughts,
feelings,valuesandtheirrelevanceinthe
immediateinteractionwithaclient.Thenurse's
responsetotheclientissincereandreflectsher
internalresponse.Itisalsoimportantthatthe
nurse'sverbalandnon-verbalcommunication
correspondwitheachother.
CHARACTERISTICS OFTHERAPEUTIC
NURSE-PATIENT RELATIONSHIP
•Thetherapeuticrelationshipisthecorner­
stoneofpsychiatric-mentalhealthnursing,
whereobservationandunderstandingof
behaviorandcommunicationareofgreat
importance.Itisamutuallearningexperience,
andacorrectiveemotionalexperienceforthe
patient ~
•Thenatureofthetherapeuticrelationshipis
characterizedbythemutualgrowthof
individualswho"dare"tobecomerelatedto
discoverlove,growthandfreedom.
•Thetherapeuticrelationshipisbasedonthe
beliefthatthepatienthaspotential,andasa
resultoftherelationship,"willgrowtohis
fullestpotential".
•Inatherapeuticrelationshipthenurseand
clientworktogethertowardsthegoalorassis­
tingtheclienttoregaintheinnerresourcesin
ordertomeetlifechallengesandfacilitate
growth.Theinteractionispurposefullyesta­
blished,maintainedandcarriedoutwiththe
anticipatedoutcomeofhelpingthepatientto
gainnewcopingandadaptationskills.
PHASESOFTHERAPEUTIC RELATIONSHIP
Fourphasesofrelationshipprocesshavebeen
identified
•Pre-interactionphase
•Introductoryororientationphase
•Workingphase
•Terminationphase
Pre-interactionPhase
Thisphasebeginswhenthenurseisassignedto
initiateatherapeuticrelationshipandincludes
allthatthenursethinks,feelsordoesimmediately
priortothefirstinteractionwiththepatient.The
nurse'sinitialtaskisoneofself-exploration.The
nursemayhavemisconceptionsandprejudices
aboutpsychiatricpatientsandmayhavefeelings
andfearscommontoallnovices.Manynurses
expressfeelingsofinadequacyandfearofhurting
orexploitingthepatient.Anothercommonfearof
nursesisrelatedtothestereotypedpsychiatric
patients'abusiveandviolentbehavior.
Thenurseshouldalsoexplorefeelingsof
inferiority,insecurity,approval-seekingbehaviors
etc.Thisself-analysisisanecessarytaskbecause,
tobeeffective,sheshouldhaveareasonablystable
self-conceptandanadequateamountofself­
esteem.
Nurse'stasksinthepre-interactionphase
•Exploreownfeelings,fantasiesandfears
•Analyzeownprofessionalstrengthsand
limitations
•Gatherdataaboutpatientwheneverpossible
•Planforfirstmeetingwithpatient
ProblemsEncountered
•Difficultyinself-analysisandself-acceptance:
Promotingapatient'sself-realizationandself­
acceptanceisfacilitatedbythenurse's
acceptanceofherselfandbehavinginways
congruentwithherownpersonality.Also,the
nurseshouldhaveenoughsourcesof
satisfactionandsecurityinhernon­
professionallifetoavoidthetemptationsor
usingherpatientforthepursuitofher
personalsatisfactionorsecurity.Ifshedoes
nothavesufficientpersonalfulfillmentshe
shouldrealizeitandthesourceofdissatis­
factionclarified,sothatitdoesnotinterfere
withthesuccessofthetherapeuticrelation­
ship.
•Anxiety:Quitefrequently,thenursemay
experienceanxietyofvaryingintensityduring
thepre-interactionphaseduetorolethreat,
feelingsofincompetence,fearofbeinghurtor

72. •Gatherdata,includingtheclient'sfeelings,
strengthsandweaknesses
•Defineclient'sproblems;setprioritiesfor
nursingintervention
•Mutuallysetgoals
TheTherapeuticNurse-PatientRelationship69
ofcausingdistress,fearoflosingcontroland
fearofrejection.Thenurseneedstobecome
awareofwhatisbeingexperienced,identify
thethreat,anddecidewhatneedstobedone
aboutit.Thisisimportant,sothatthepatient
isnotundulyaffectedbythenurse'sanxiety.
•Apart,fromanxiety,thenursemayalso
experienceboredom,anger,indifference,and
depression.Thecauseofsuchfeelingsmustbe
identified,whichisthefirststepindevising
waystocopewiththem.
WaystoOvercome
•Thenurseneedshelpfromhersupervisorand
peersinself-analysisandfacingrealityin
ordertohelppatientsdolikewise.This
providesopportunitytoexplorefeelingsand
fearsanddevelopsusefulinsightintoone's
professionalrole.
•Itisalsohelpf~~ltoonceptualizeinadvance
whatshewishesoaccomplishduringthe
relationship.nursemayinconsultation
withhersupervisoridentifyinwritinggoals
fortheinitialinteraction,anddecidethe
methodstobeusedinachievingthegoals.
•Thenursealsoneedstobeconsciouslyaware
ofthereasonsforchoosingaparticular
patient.Shemayalsoattempttoassessthe
patient'sanxietylevelaswellasherown.The
nursewhoisabletoanalyzeherselfand
recognizeherassetsandlimitations,isableto
usethisinformationinrelatingtopatientsin
anatural,congruentandrelaxedmanner.
troductoryorOrientationPhase
-risduringtheintroductoryphasethatthenurse
zndpatientmeetforthefirsttime.Oneofthe
rairse'sprimaryconcernsistofindoutwhythe
?ltientsoughthelp.Thisformsthebasisofthe
-msingassessmentandhelpsthenursetofocus
,~thepatient'sproblemandtodetermine
7-atient'slevelofmotivation.
_:urse'stasksintheorientationphase
Establishrapport,trustandacceptance
Establishcommunication;assistintheverbal
expressionofthoughtsandfeelings
ProblemsEncountered
•Themajorproblemencounteredduringthis
phaseisrelatedtothemannerinwhichthe
nurseandpatientperceiveeachother.Anurse
mayreacttoapatientnotintermsofhis
uniqueness,butintermsofthenurse's
stereotypedviewofa"psychiatricpatient,"
orshemaybecauseofhertheoretical
backgroundreadintermsofdiagnostic
categories.Sometimesthenursemayrelateto
apatientasifhewereasignificantindividual
fromthepast.Thenursemaythendisplaceto
thepatientthefeelingsshehasforthe
significantindividual.Sinceinteractionisa
reciprocalprocess,thepatientalsoperceives
thenurseinhisownidiosyncraticmanner.
Thus,perceptionofeachotherasunique
individualsmaynottakeplace.
•Problemsrelatedtoestablishinganagreementor
pactbetweenthenurseandpatient:Thepatient
mayfeelthatsincethenurseishereonlyfora
fewweeksmuchhelpcannotbeexpectedfrom
herintheshortspanoftime.Thesamefeelings
maybeexperiencedbythenurse,inthatshe
feelsshecannotdomuchforthepatient
duringhisstayinthehospitalduetofactors
likelimitedtime,overworkorthenurse's
opinionthatthepatientissufferingfroma
'majorpsychiatricproblem'.Becausethe
establishmentofanagreementorpacttowork
togetherisamutualprocess,suchmisper­
ceptionscangreatlyhinderit.
WaystoOvercome
•Thenursemustbewillingtorelatehonestly
toherperceptions,thoughtsandfeelings,and
tosharethedatacollectedduringthenurse­
patientinteractionwithhersupervisors.The
supervisormustprovideanatmospherein
whichthenursefeelsfreetorevealself
withoutanyfearofcriticism.

73. 70AGuidetoMentalHealthandPsychiatricNursing
•Difficultiesmaybefacedinassistinganurse
whoperceivesapatientasifheweresomeone
fromherpastlife.Sheisusuallynotawareof
doingso,sincemostofthisbehavioris
unconsciouslydetermined.Analertsuper­
visorcanusuallydetectthatthenurseis
distortingthepatientbyviewinghimas
someoneelse.Itmaybenecessarytobringthe
problemtothenurse'sattentionsothatshe
canexamineherbehavior.Gradually,with
assistancethenurseisabletoaudither
behavior,andthentochangeit.
WorkingPhase
Mostofthetherapeutic~orkiscarriedoutduring
theworkingphase.Thnurseandthepatient
explorerelevantstressoandpromotethe
developmentofinsightinthepatient.Bylinking
perceptions,thoughts,feelingsandactions,the
nursehelpsthepatienttomasteranxieties,
increaseindependenceandcopingmechanisms.
Actualbehavioralchangeisthefocusofattention
inthisphaseoftherelationship.
Nurse'stasksintheworkingphase
•Gatherfurtherdata;explorerelevantstressors
•Promotepatient'sdevelopmentofinsightand
useofconstructivecopingmechanisms
•Facilitatebehavioralchange;encouragehim
toevaluatetheresultsofhisbehavior
•Providehimwithopportunitiesforindepen­
dentfunctioning
•Evaluateproblemsandgoalsandredefineas
necessary
ProblemsEncountered
•Testingofthenursebythepatient:Thepatient
maytestthenurseinanumberofways,and
foranumberofreasons.Forexample,hemay
wishtocheckherabilitytosetlimitsandabide
bythem.Apatientwithproblemsrelatedto
aggressionmaydeliberatelyattemptto
provokethenursetodeterminewhetherornot
shewillbecomepunitive.
•Progressofthepatient:Anotherbarrieristhe
nurse'sunrealisticassumptionastothe
progressthepatientshouldbemaking.Itis
commonforthepatienttoshowdesirable
behavioralchangesinthebeginning,andthen
remainfixed,neitherprogressingnorregres­
sing.Anursewhowasenthusiasticaboutthe
patient'simprovementmaythenbecome
discouragedwhenhedoesnotprogressata
steadystate.
•Thenurse'sfearofcloseness:Ifthenursefears
closenesstoomuch,shemayreactbybeing
indifferent,rejectingorbeingcoldtowardsthe
patient.Shemustlearntointeractwith
kindnessandconcern,butwithobjectivityand
professionalinterest.
•Lifestressesofthenurse:Anursewhohas
difficultyincopingwithherownlifeproblems
cannothelpapatientinmakingappropriate
behavioralchanges.
•Resistancebehaviors:Resistanceisthepatient's
attempttoremainunawareofanxiety­
producingaspectswithinhim.Resistancemay
takedifferentformsandsomeofthemwere
identifiedbyWolfbergasfollows:
•Suppressionandrepressionofrelevant
information
•Intensificationofsymptoms
•Ahelplessoutlookonthefuture
•Breakingappointments,cominglatetohis
sessions,beingforgetful,silentandsleepy
duringtheinteractions
•Actingoutorirrationalbehavior
•Expressinganexcessivelikingforthe
nurseandclaimingthatnobodycan
replaceher
•Reportingphysicalsymptomswhichmay
occuronlyduringthetimetheclientiswith
thenurse
•Hostility,dependence,provocative
remarks,sexualinterestinthenurse
•Transferenceandcountertransferencereactions:
Theseareinfactaformofresistancebehavior.
Transferenceistheunconscioustransferof
qualitiesorattributesoriginallyassociated
withanotherindividualbythepatient.
Transferenceoccursbecausethepatientbrings
frustrations,conflictsandfeelingsofdepen­
dencefromapastrelationshipintothe

74. herownneedsandproblemsthatshecannot
clearlyperceivewhatishappening.
•Thefirstthingthenursemustdoin
handlingresistanceistolisten.Whenshe
recognizestheresistance,shethenuses
clarificationandreflectionoffeelings;
clarificationhelpstogivethenurseamore
focusedideaofwhatishappening,while
reflectionofcontenthelpsthepatientto
becomeawareofwhathasbeengoingon
inhisownmind.
•Itisnotsufficienttomerelyidentifythat
resistance.isoccurring;thebehaviormust
beexplored:'andpossiblereasonsforits
occurrenceanalyzed.Ignoringtransfe­
rencecanperpetuatethepattern.Also,
beingoverlycriticalofthepatient,with­
holdinginformationorbeingoverinvol­
vedinmakingdecisionsforthepatientcan
encouragethedysfunctionalbehavioral
pattern.Itisimportantthatthenurse
maintainsopencommunicationwithher
supervisor,whocanthenguideherin
makingadequateprogressinhandling
suchresistancereactions.
TheTherapeuticNurse-PatientRelationship71
therapeuticrelationship.Thepatientmay
expressfeelingsofaggression,rejectionor
hostilitythataretoointenseforthecurrent
situation.Theseresponsesareoftennot
appropriateforthenurse-patientrelationship.
Countertransferenceisthereverseoftrans­
ference.Thenursemayhaveunresolved
problemsfromanearlierrelationship.Shemay
unconsciouslytransferinappropriateattribu­
testoaclientthatwasexperiencedinthat
earlierrelationship.Theclient'stransference
provokesthenurse'scountertransference
reactions.
WaystoOvercome
•Conferenceswiththesupervisorsandgroup
discussionswithothermembersofthestaff
arethewaysinwhichthenursecanbestbe
assistedtoovercomethebarriersencountered
duringtheworkingphase.Itisduringthis
phasethatthesupervisorhelpsthenurseto
increaseherabilitytocollectandinterpret
data,applyconceptsandsynthesizethedata
obtained.
•Therewillbetimeswhenthenursebelieves
sheismakinglittleornoprogress,eitherin
helpingthepatientoringainingknowledge.
Itisatsuchtimesthatemotionalsupportis
needed,anditisthetaskofthesupervisorto
encouragethenursetopersevere.
Atonetimeoranother,mostnursesmay
exhibitareluctancetowriteandanalyze
processrecordsortoengageinadiscussion
withthesupervisoraboutthecontentof
records,duetomanyreasons.Forinstance
fatigue,boredom,discouragementoran
apparentimpasseininteractingwithapatient
maycausereluctance.Adiscussionofthe
meaningofbehaviorandofwaystoovercome
itisessential.
Handlingresistances:Thenursemayfindthe
experienceoftransferenceandcountertrans­
rerenceparticularlydifficult.Therelationship
canbecomestalledandnon-beneficialifthe
nurseisnotpreparedforthepatient's
zxpressionoffeelingsorissopreoccupiedby
TerminationPhase
Thisisthemostdifficult,butmostimportant
phaseofthetherapeuticnurse-patientrelation­
ship.Thegoalofthisphaseistobringa
therapeuticendtotherelationship.
Criteriafordeterminingpatient'sreadinessfor
termination:
•Patientexperiencesrelieffrompresenting
problems
•Patient'ssocialfunctionhasimprovedand
isolationhasdecreased
•Patient'segofunctionsarestrengthenedand
hehasattainedasenseofidentity
•Patientemploysmoreeffectiveandproductive
defensemechanisms
•Patienthasachievedtheplannedtreatment
goals
Nurse'stasksintheterminationphase:
•Establishrealityofseparation
•Mutuallyexplorefeelingsofrejection,loss,
sadness,angerandrelatedbehavior

75. 72AGuidetoMentalHealthandPsychiatricNursing
•Reviewprogressoftherapyandattainmentof
goals
•Formulateplansformeetingfuturetherapy
needs
ProblemsEncountered
•Itisthetaskofthenursetopreparethepatient
forterminationoftherelationship.
However,patientsdifferintheirreactionstothe
nurse'sattemptstopreparethemfortermination.
Anillpersonwhohasexperiencedtrust,support
andthewarmthofcaringmaybereluctantto
discontinuethenurse-patientcontact.
Somebehaviorsexhibitedinthisregardcanbe:
•Patientsmayperceiveterminationasdeser­
tionandmaydemonstrateangrybehavior
•Somepatientsattempttopunishthenursefor
thisdesertionbynottalkingduringthelast
fewinteractionsorbyignoringtermination
completely;theymayactasifnothinghas
changedandtheinteractionswillgoonas
before
•Otherpatientsreacttothethreatenedlossby
becomingdepressedorassuminganattitude
ofnotcaring
•Fault-findingisanotherbehavior;theclient
maystatethatthetherapyisnotbeneficialor
notworking;hemayrefusetofollowthrough
onsomethingthathasbeenagreeduponbefore
•Resistanceoftencomesintheformof"flight
tohealth",whichisexhibitedbyapatientwho
suddenlydeclaresthatthereisnoneedfor
therapy;heclaimstobeallrightandwantsto
discontinuethetherapeuticrelationship;this
maybeaformofdenialorfearofthe
anticipatedgriefoverseparation
•"Flighttoillness"occurswhenaclient
exhibitssuddenreturnofsymptoms;thisis
anunconsciousefforttoshowthattermination
isinappropriateandthatthenurseisstill
needed;theclientmaydisclosenew
informationabouthimormoreproblemsor
eventhreatentocommitsuicideinanattempt
todelayparting
•Thebarrierstogoalaccomplishmentduring
thisphasealsoseemtoberelatedtothenurse's
inabilityorunwillingnesstomakespecific
plansandimplementthem.Plansfor
terminationareessentialandthenurseneeds
toconceptualizetheseplansinadvance.A
nursewhodoesnotdiscussfranklythe
reasonsforterminationorelicitfromthe
patienthisthoughtsandfeelingsaboutthe
impendingterminationcannothelpto
preparehimpsychologically.Similarly,a
nursewhocannotexploreherownthoughts
andfeelingsaboutseparationfromthepatient
isalsounabletoaccomplishthegoalsrelated
totermination.
WaystoOvercome
•Thenurseshouldbeawareofthepatient's
feelingsandbeable.todealwiththem
appropriately.Thenursecanassistthepatient
byopenlyelicitinghisthoughtsandfeelings
abouttermination.Forsomepatients,
terminationisacriticalexperience,because
manyoftheirpastrelationshipswere
terminatedinanegativewaythatleftthem
withunresolvedfeelingsofabandonment,
rejection,hurtandanger.Learningtobearthe
sorrowofthelosswhileincorporatingpositive
aspectsoftherelationshipintoone'slifeis
thegoalofterminationinthetherapeutic
nursepatientrelationship.
•Duringthisphase,thesupervisormaynotice
thatthenurseisshowinglessinterestinthe
patientthanshownearlierandmaybe
disengagingselffromthepatientseveraldays
beforethefinalinteraction.Thismaybea
psychologicaldefensemechanismbywhich
shetriestodecreaseordelaytheanxietyshe
isexperiencingasaresultoftheimpending
terminationofrelationship.Thetaskofthe
supervisoristodiscussfranklywiththenurse
themeaningofthebehavior.Thesupervisor
theninitiatesactiontoassistthenurseto
persevereandintensifyhereffortstoprepare
bothselfandpatientforhiseventualrelease
fromthehospital.
THERAPEUTIC COMMUNICATION
TECHNIQUES
1.Listening:Itisanactiveprocessofreceiving
information.Responsesonthepartofthe

76. TheTherapeuticNurse-PatientRelationship73
nursesuchasmaintainingeye-to-eyecontact,
nodding,gesturingandotherformsof
receptivenon-verbalcommunicationconvey
tothepatientthatheisbeinglistenedtoand
understood.
TherapeuticvalueNon-verballycommunicates
tothepatientthenurse'sinterestandaccep­
tance.
2.Broadopenings:Encouragingthepatientto
selecttopicsfordiscussion.Forexample,
"Whatareyouthinkingabout?"
TherapeuticvalueIndicatesacceptancebythe
nurseandthevalueofpatient'sinitiative.
3.Restating:Repeatingthemainthought
expressedbythepatient.Forexample,"You
saythatyourmotherleftyouwhenyouwere
fiveyearsold."
TherapeuticvalueIndicatesthatthenurseis
listeningandvalidates,reinforcesorcalls
attentiontosomethingimportantthathas
beensaid.
4.Clarification:Attemptingtoputvagueideas
orunclearthoughtsofthepatientintowords
toenhancethenurse'sunderstandingor
askingthepatienttoexplainwhathemeans.
Forexample,"!amnotsurewhatyoumean.
Couldyoutellmeaboutthatagain?"
TherapeuticvalueIthelpstoclarifyfeelings,
ideasandperceptionsofthepatientand
providesanexplicitcorrelationbetweenthem
andthepatient'sactions.
:J.Reflection:Directingbackthepatient'sideas,
feelings,questionsandcontent.Forexample
"Youarefeelingtenseandanxiousanditis
relatedtoaconversationyouhadwithyour
husbandlastnight."
TherapeuticvalueValidatesthenurse'sunder­
standingofwhatthepatientissayingand
signifiesempathy,interestandrespectforthe
patient.
6.Humor:Thedischargeofenergythrough
comicenjoymentoftheimperfect.Forexample,
"Thatgivesawholenewmeaningtotheword
'nervous',"saidwithsharedkiddingbetween
thenurseandthepatient.
TherapeuticvalueCanpromoteinsightby
makingrepressedmaterialconscious,reso­
lvingparadoxes,temperingaggressionand
revealingnewoptions,andisasocially
acceptableformofsublimation.
7.Informing:Theskillofinformationgiving.
Forexample,"Ithinkyouneedtoknowmore
aboutyourmedications."
TherapeuticvalueHelpfulinhealthteaching
orpatienteducationaboutrelevantaspects
ofpatient'swell-beingandself-care.
8.Focusing:Questionsorstatementsthathelp
thepatientexpandonatopicofimportance.
Forexample,"Ithinkthatweshouldtalkmore
aboutyourrelationshipwithyourfather."
TherapeuticvalueAllowsthepatientto
discusscentralissuesandkeepsthe
communicationprocessgoal-directed.
9.Sharingperceptions:Askingthepatientto
verifythenurse'sunderstandingofwhatthe
patientisthinkingorfeeling.Forexample,
"Youaresmiling,butIsensethatyouarereally
veryangrywithme."
TherapeuticvalueConveysthenurse's
understandingtothepatientandhasthe
potentialforclearingupconfusingcom­
munication.
10.Themeidentification:Thisinvolvingidenti­
ficationofunderlyingissuesorproblems
experiencedbythepatientthatemerge
repeatedlyduringthecourseofthenurse­
patientrelationship.Forexample,"Inoticed
thatyousaidyouhavebeenhurtorrejected
bytheman.Doyouthinkthisisanunderlying
issue?"
TherapeuticvalueItallowsthenursetopromote
thepatient'sexplorationandunderstanding
ofimportantproblems.
11.Silence:Lackofverbalcommunicationfora
therapeuticreason.Forexample,sittingwith
apatientandnon-verballycommunicating
interestandinvolvement.
TherapeuticvalueAllowsthepatienttimetothink
andgaininsight,slowsthepaceofthe
interactionandencouragesthepatientto
initiateconversationwhileenjoyingthenurse's
support,understandingandacceptance.

77. 74AGuidetoMentalHealthandPsychiatricNursing
12.Suggesting:Presentationofalternativeideas
forthepatient'sconsiderationrelativeto
problemsolving.Forexample,"Haveyou
thoughtaboutrespondingtoyourbossina
differentwaywhenheraisesthatissuewith
you?Youcouldaskhimifaspecificproblem
hasoccurred."
TherapeuticvalueIncreasesthepatient's
perceivednotionsorchoices.
PROCESSRECORDING
Recordingisanimportantandnecessaryfunc­
tionofanyorganizationwhetheritisanindustry,
abusinessenterprise,ahospitalorforthatmatter
evenfarming.Recordingisdoneindifferentways
indifferentorganizationsandsituations.Process
recordingisthemethodofrecordingusedin
psychiatricwardsbynurses.
Definition:Processrecordingisawrittenaccount
orverbatimrecordingofallthattranspired,during
andimmediatelyfollowingthenurse-patient
interaction.Inotherwords,itistherecordingof
theconversationduringtheinteractionorthe
interviewbetweenthenurseandthepatientin
thepsychiatricsetupwiththenurse'sinference.
Itmaybewrittenduringtheinteractionor
immediatelyaftertheone-to-oneinteraction.
Purposeanduses:Theaimofprocessrecording
istoimprovethequalityoftheinteractionforbetter
effecttothepatientandasalearningexperience
forthenursetocontinuouslyimproveherclinical
interactionpattern.Whencorrectlyused,it
•assiststhenurseorstudenttoplan,structure
andevaluatetheinteractiononaconscious
ratherthananintuitivelevel;
•assistshertogaincompetencyininterpreting
andsynthesizingrawdataundersuper­
vision;
•helpstoconsciouslyapplytheorytopractice;
•helpshertodevelopanincreasedaware­
nessofherhabitual,verbalandnon-verbal
communicationpatternandtheeffectofthose
patternsonothers;
•helpsthenursetolearntoidentifythoughts
andfeelingsinrelationtoselfandothers;
•helpstoincreaseobservationalskills,asthere
isaconsciousprocessinvolvedinthinking,
sortingandclassifyingtheinteractionunder
thevariousheadings;
•helpstoincreasetheabilitytoidentify
problemsandgainskillsinsolvingthem;
Afterafewexercisestheseskillswillbecome
soin-builtthatshewillkeepusingthemauto­
maticallyevenwhenitisnotspecificallyrequired
orwhenshedoesnothavethetimetodoit.
Thusprocessrecordingisa/an
•Educativetool
•Teachingtool
•Diagnostictool
•Therapeutictool,andapre-requisitefor
nursingprocess
Pre-requisitesforProcessRecording
•Physicalsetting
•Gettingconsentofthepatientforthepossibility
ofcassetterecording
•Confidentiality
SuggestedOutlinesforProcessRecording
IntroductoryMaterial
Thisshouldincludeashortdescriptionofthe
patient,hisname,age,educationallevel,health
problemsandlengthofstayinthehospital.The
date,time,placeofinteractionandashort
descriptionofthemilieuofthewardimmediately
priortotheinteractionwillbehelpfulin
understandingthethoughtsandfeelingsofthe
patient.Itisalsohelpfultorecordthethoughts
andfeelingsofthenursejustbeforetheinteraction.
Reasonforchoosingthepatientandtheduration
ofthenurse-patientrelationshipshouldalsobe
included.Tounderstandthepatientinabetter
way,processrecordingalsoincludespersonal
history,familyhistory,socio-economichistory,
medicalhistory,presentcomplaints,pastpsy­
chiatrichistoryifany,andprovisionaldiagnosis.
Objectives
Theycanbedifferentondifferentdaysofthe
interview.Forexample,inthebeginning,setting
short-termgoalsmaybemoreappropriate.Inthe

78. TheTherapeuticNurse-PatientRelationship75
PLACE
DATEANDTIME
SITUATION
DATEOFADMISSION
OBJECTIVESOFTHEINTERVIEW
(1)
(2)
(3)
VERBATIM
Person Verbatim Non-verbal Inference
Communication
Conclusion­
Summary-s-
Fixingthetimeandplaceforthenextinterview.
Listofinferences
Careplansmadeaccordingtoinference
Anyspecialdifficultiesfacedduringtheinference
Techniquesusedtoovercomedifficulties
secondstage(workingphase)theobjectives
canbemorelong-terminnature,focusingoncor­
rectivepsychodynamics,includingrehabilita­
::ion,follow-upandpreparingthefamilyforfuture
olans.
=?ecordofInteractionbetweenNurse
endthePatient
Thisshouldincludetruthfulrecordingofwhat
SIGNATURE
thenursesaidanddidandwhatthepatientsaid
anddid,includinganynon-verbalbehaviorof
thepatient,suchaschangingtheposition,
lookingatvariousthings,eyecontact,bitingthe
nails,pacing,etc.Whatthenursedidalsomeans
allhernon-verbalbehavior.Thenurse'sthoughts
andfeelingsalsoshouldberecordedsothata
self-evaluationcanbemadeastohowthese
influenceherbehavior.

79. 76AGuidetoMentalHealthandPsychiatricNursing
AnalysisoftheInteraction
Ananalysisoftheinteractionshouldinclude
theinterpretationoftheverbalandnon-verbal
behaviorandpatient'sthoughtsandfeelingsas
evidentfromtheprocess.Thecommunication
techniquesusedbythenurseandevaluationof
thetechniqueintermsofitseffectonthepatient
andintermsoftheplannedobjectivesalsoshould
beincluded.Thenurse'sthoughtsandfeelingsat
theendoftheinteractionandtheplansmadefor
furtherinteractionsshouldbestated.
Processrecordingcanbewrittenasshortnotes
duringtheinteractionandrewrittenimmediately
afterit.Totaltimespentontherecordingcanbe
around30minutes.Theactivetimecanbe20
minutes,with10minutesforconclusionand
recording.Althoughvideoortaperecordersgive
moreaccuraterecording,theimpactofthis
equipmentontheinteractionwillmakean
unnaturalinfluence.
REVIEWQUESTIONS
•Typesofrelationship
•Differencebetweentherapeuticandsocial
relationship
•Goalsoftherapeuticrelationship(Apr2004)
•Nurse-patientrelationship(Apr2002)
•Listthecharacteristicsoftherapeuticnurse­
patientrelationship(Nov2003)
•Phasesoftherapeuticrelationshipandtherole
duringeachphase(Feb2000,Feb2001,Apr
2006,Oct2006)
•Explaintheproblemscommonlyencountered
bythenursewhiledevelopingsuchrelation­
ship(Nov2003)
•Workingphase(Oct2005)
•Countertransference(Apr2005)
•Therapeuticcommunicationtechniques
•Listeningasatoolofcommunication(Apr
2002)
•Processrecording(Nov1999,Feb2000,Nov
2002,Nov2003,Apr2004,Oct2004,Oct2005,
Apr2006)
•Rapportandresistance(Oct2000,Oct2006)
•EmpathyandSympathy(Oct2000,Nov2003)

80. TheIndividual
withFunctional
PsychiatricDisorder
0SCHIZOPHRENIA
•Definition
•Epidemiology
•Etiology
•Schneider'sFirst-RankSymptomsof
Schizophrenia(SFRS)
•ClinicalFeatures
•ClinicalTypes
-ParanoidSchizophrenia
-Hebephrenic(Disorganized)Schizophrenia
-CatatonicSchizophrenia
-ResidualSchizophrenia
-UndifferentiatedSchizophrenia
-SimpleSchizophrenia
-Post-SchizophrenicDepression
•CourseandPrognosis
•Treatment
•NursingManagement
0NURSINGMANAGEMENT FORAPATIENTWHO
IEXHIBITSWITHDRAWNBEHAVIOR
0MOODDISORDERS
•ClassificationofMoodDisorders
•Etiology
•ManicEpisode
-ClassificationofMania
-ClinicalFeatures
-SymptomsofHypomania
-Treatment
-NursingManagementforMania
-NursingManagementforHypomania
•DepressiveEpisode
-ClassificationofDepression
-ClinicalFeatures
-Treatment
•CourseandPrognosisofMoodDisorders
0OTHERMOODDISORDERS
•DifferencesbetweenSomaticandNeurotic
Depression
•NursingManagementofMajorDepressiveEpisode
SCHIZOPHRENIA
Theword'Schizophrenia'wascoinedin1908by
theSwisspsychiatristEugenBleuler.Itisderived
fromtheGreekwordsskhizo(split)andphren
(mind).
InICDlO,schizophreniaisclassifiedunder
codeF2.
Definition
Schizophreniaisapsychoticconditioncharac­
terizedbyadisturbanceinthinking,emotions,
volitionsandfacultiesinthepresenceofclear
consciousness,whichusuallyleadstosocial
withdrawal.
Epidemiology
Schizophreniaisthemostcommonofallpsy­
chiatricdisordersandisprevalentinallcultures
acrosstheworld.About15%ofnewadmissions
inmentalhospitalsareschizophrenicpatients.It
hasbeenestimatedthatpatientsdiagnosedas
havingschizophreniaoccupy50%ofallmental
hospitalbeds.
Aboutthreetofourper1000inevery
communitysufferfromschizophrenia.Aboutone
percentofthegeneralpopulationstandstherisk
ofdevelopingthisdiseaseintheirlifetime.
Schizophreniaisequallyprevalentinmenand
women.Thepeakagesofonsetare15to25years
formenand25to35yearsforwomen.
Abouttwo-thirdsofcasesareintheagegroup
of15to30years.
Thediseaseismorecommoninlowersocio­
economicgroups.
Etiology
Thecauseofschizophreniaisstilluncertain.
Someofthefactorsinvolvedmaybe:

81. 78AGuidetoMentalHealthandPsychiatricNursing
GeneticFactors
Thediseaseismorecommonamongpeopleborn
ofconsanguineousmarriages.Studiesshowthat
relativesofschizophrenicshaveamuchhigher
probabilityofdevelopingthediseasethanthe
generalpopulation.Theprevalencerateamong
familymembersofschizophrenicsisasfollows:
•Childrenwithoneschizophrenicparent:12%
•Childrenwithbothschizophrenicparents:
40%
•Siblingsofschizophrenicpatient:8%
•Second-degreerelatives:5-6%
•Dizygotictwinsofschizophrenicpatients:
12%
•Monozygotictwinsofschizophrenicpatients:
47%
Stress-DiathesisModel
Accordingtothestress-diathesismodelforthe
integrationofbiological,psychosocialand
environmentalfactors,apersonmayhavea
specificvulnerability(diathesis)that,whenacted
onbyastressfulinfluence,alowsthesymptoms
ofschizophreniatodevelop.Inthemostgeneral
stress-diathesismodel,thediathesisorthestress
canbebiological,environmentalorboth.The
environmentalcomponentagaincanbeeither
biological(e.g.aninfection)orpsychological(e.g.
stressfulfamilysituation).Thebiologicalbasisof
adiathesiscanbefurthershapedbyepigenetic
influencessuchassubstanceabuse,psychosocial
stressandtrauma.
BiochemicalFactors
Dopaminehypotheses:Thistheorysuggeststhatan
excessofdopamine-dependentneuronalactivity
inthebrainmaycauseschizophrenia.
Otherbiochemicalhypotheses:Variousotherbioche­
micalshavebeenimplicatedinthepredisposition
toschizophrenia.Theseincludeabnormalitiesin
theneurotransmittersnorepinephrine,serotonin,
acetylcholineandgamma-aminobutyricacid
(GABA),andneuroregulatorssuchasprostag­
landinsandendorphins.
PsychologicalFactors
Familyrelationshipsactasmajorinfluenceinthe
developmentofillness:
Mother-childrelationship:Earlytheoristscharac­
terizedthemothersofschizophrenicsascold,
over-protective,anddomineering,thusretarding
theegodevelopmentofthechild.
Dysfunctionalfamilysystem:Hostilitybetween
parentscanleadtoaschizophrenicdaughter
(maritalskewandschism).
Double-bindcommunication(Batesonetal,1956):
Parentsconveytwoormoreconflictingand
incompatiblemessagesatthesametime.
SocialFactors
Studieshaveshownthatschizophreniaismore
prevalentinareasofhighsocialmobilityand
disorganization,especiallyamongmembersof
verylowsocialclasses.Stressfullifeeventsalso
canprecipitatethediseaseinpredisposed
individuals.
Schneider'sFirst-RankSymptomsof
Schizophrenia(SFRS)
KurtSchneiderproposedthefirstranksymptoms
ofschizophreniain1959.Thepresenceofeven
oneofthesesymptomsisconsideredtobestrongly
suggestiveofschizophrenia.Theyinclude:
•Hearingone'sthoughtsspokenaloud
(audiblethoughtsorthoughtecho).
•Hallucinatoryvoicesintheformofstatement
andreply(thepatienthearsvoicesdiscussing
himinthethirdperson).
•Hallucinatoryvoicesintheformofarunning
commentary(voicescommentingonone's
action).
•Thoughtwithdrawal(thoughtsceaseand
subjectexperiencesthemasremovedbyan
externalforce).
•Thoughtinsertion(subjectexperiences
thoughtsimposedbysomeexternalforceon
hispassivemind).
•Thoughtbroadcasting(subjectexperiences
thathisthoughtsareescapingtheconfinesof

82. TheIndividualwithFunctionalPsychiatricDisorder79
hisselfandarebeingexperiencedbyothers
around).
•Delusionalperception(normalperceptionhas
aprivateandillogicalmeaning).
•Somaticpassivity(bodilysensationsespe­
ciallysensorysymptomsareexperiencedas
imposedonbodybysomeexternalforce).
•Madevolitionoracts(one'sownactsare
experiencedasbeingunderthecontrolofsome
externalforce,thesubjectbeinglikearobot).
•Madeimpulses(thesubjectexperiencesimpul­
sesasbeingimposedbysomeexternalforce).
•Madefeelingsoraffect(thesubjectexperiences
feelingsasbeingimposedbysomeexternal
force).
ClinicalFeatures
Thepredominantclinicalfeaturesinacuteschizo­
phreniaaredelusions,hallucinationsandinterference
ioiih.thinking.Featuresofthiskindareoftencalled
positivesymptomsorpsychoticfeatureswhile
mostofthepatientsrecoverfromacuteillness,
someprogresstothechronicphase,duringwhich
rimethemainfeaturesareaffectiveflatteningor
blunting,avolition-apathy(lackofinitiative),
attentionalimpairment,anhedonia(inabilityto
experiencepleasure),asociality,alogia(lackofspeech
output).Thesearecalledasnegativesymptoms.
Oncethechronicsyndromeisestablished,few
?atientsrecovercompletely.
Thesignsandsymptomscommonlyencoun­
reredinschizophrenicpatientsmaybegrouped
-follows:
noughtandSpeechDisorders
•Autisticthinking(preoccupationstotally
removingapersonfromreality).
•Looseningofassociations(apatternof
spontaneousspeechinwhichthethingssaid
injuxtapositionlackameaningfulrelation­
shipwitheachother).
•Thoughtblocking(asuddeninterruptionin
thethoughtprocess).
•Neologism(awordnewlycoined,oranevery­
daywordusedinaspecialway,notreadily
understoodbyothers).
•Povertyofspeech(decreasedspeechpro­
duction).
•Povertyofideation(speechamountisadequate
butcontentconveyslittleinformation).
•Echolalia(repetitionorechobypatientofthe
wordsorphrasesofexaminer).
•Perseveration(persistentrepetitionofwords
orthemesbeyondthepointofrelevance).
•Verbigeration(senselessrepetitionofsome
wordsorphrasesoverandoveragain).
•Delusionsofvariouskindsi.e.,delusionsof
persecution(beingpersecutedagainst);delu­
sionsofgrandeur(beliefthatoneisespecially
verypowerful,rich,bornwithaspecial
missioninlife);delusionsofreference(being
referredtobyothers);delusionsofcontrol
(beingcontrolledbyanexternalforce);somatic
delusions.
•Otherthoughtdisordersareoverinclusion
(tendingtoincludeirrelevantitemsinspeech),
impairedabstraction,concretenessand
ambivalence.
DisordersofPerception
•Auditoryhallucinations(describedunder
SFRS).
•Visualhallucinationsmaysometimesoccur
alongwithauditoryhallucinations;tactile,
gustatoryandolfactorytypesarefarless
common.
DisordersofAffect
Theseincludeapathy,emotionalblunting,emo­
tionalshallowness,anhedoniaandinappro­
priateemotionalresponse.Theincapacityofthe
patienttoestablishemotionalcontactleadstolack
ofrapportwiththeexaminer.
DisordersofMotorBehavior
Therecanbeeitheranincreaseoradecreasein
psychomotoractivity.Mannerisms,grimacing,
stereotypes,decreasedself-careandpoor
groomingarecommonfeatures.

83. 80AGuidetoMentalHealthandPsychiatricNursing
OtherFeatures
•Decreasedfunctioninginwork,socialrela-
tionsandself-care,ascomparedtoearlierlife.
•Lossofegoboundaries.
•Lossofinsight.
•Poorjudgment.
•Suicidecanoccurduetothepresenceofasso­
ciateddepression,commandhallucinations,
impulsivebehavior,orreturnofinsightthat
causesthepatienttocomprehendthedevas­
tatingnatureoftheillnessandtakehislife.
•Thereisusuallynodisturbanceofconscious­
ness,orientation,attention,memoryand
intelligence.
•Thereisnounderlyingorganiccause.
ClinicalTypes
Schizophreniacanbeclassifiedintothefollowing
subtypes:
1.Paranoid
2.Hebephrenic(disorganized)
3.Catatonic
4.Residual
5.Undifferentiated
6.Simple
7.Post-schizophrenicdepression
ParanoidSchizophrenia
Theword'paranoid'means'delusional.'Para­
noidschizophreniaisatpresentthemostcommon
formofschizophrenia.Itischaracterizedbythe
followingfeatures(inadditiontothegeneral
featuresalreadydescribed).
•Delusionsofpersecution:Inpersecutory
delusions,individualsbelievethattheyare
beingmalevolentlytreatedinsomeway.
Frequentthemesincludebeingconspired
against,cheated,spiedupon,followed,
poisonedordrugged,maliciouslymaligned,
harassedorobstructedinthepursuitoflong­
termgoals.
•Delusionsofjealousy:Thecontentofjealous
delusionscentersaroundthethemethatthe
person'ssexualpartnerisunfaithful.Theidea
isheldoninadequategroundsandis
unaffectedbyrationaljudgment.
•Delusionsofgrandiosity:Individualswith
grandiosedelusionshaveirrationalideas
regardingtheirownworth,talent,knowledge
orpower.Theymaybelievethattheyhavea
specialrelationshipwithfamouspersons,or
grandiosedelusionsofareligiousnaturemay
leadtoassumptionoftheidentityofagreat
religiousleader.
•Hallucinatoryvoicesthatthreatenorcom­
mandthepatient,orauditoryhallucinations
withoutverbalform,suchaswhistling,
hummingandlaughing.
•Otherfeaturesincludedisturbanceofaffect
(thoughaffectivebluntingislessthaninother
formsofschizophrenia),volition,speechand
motorbehavior.
Paranoidschizophreniahasagoodprognosis
iftreatedearly.Personalitydeteriorationis
minimalandmostofthesepatientsareproductive
andcanleadanormallife.
Hebephrenic(disorganized)Schizophrenia
Ithasanearlyandinsidiousonsetandisoften
associatedwithpoorpremorbidpersonality.The
essentialfeaturesincludemarkedthoughtdis­
order,incoherence,severelooseningofassocia­
tionsandextremesocialimpairment.Delusions
andhallucinationsarefragmentaryandchan­
geable.Otherodditiesofbehaviorinclude
senselessgiggling,mirror-gazing,grimacing,
mannerismsandsoon.Thecourseischronicand
progressivelydownhillwithoutsignificant
remissions.Recoveryclassicallyneveroccursand
ithasoneoftheworstprognosesamongallthe
subtypes.
CatatonicSchizophrenia
Catatonic(Cata-disturbed)schizophreniais
characterizedbymarkeddisturbanceofmotor
behavior.Thismaytaketheformofcatatonic
stupor,catatonicexcitementandcatatonia
alternatingbetweenexcitementandstupor.
Clinicalfeaturesofexcitedcatatonia:
•Increaseinpsychomotoractivity(ranging
fromrestlessness,agitation,excitement,
aggressivenesstoattimesviolentbehavior).

84. TheIndividualwithFunctionalPsychiatricDisorder81
•Increaseinspeechproduction.
•Looseningofassociationsandfrank
incoherence.
Sometimesexcitementbecomesverysevere
andisaccompaniedbyrigidity,hyperthermiaand
dehydrationandcanresultindeath.Itisthen
knownasacutelethalcatatoniaorpernicious
catatonia.
Clinicalfeaturesofretardedcatatonia(catatonic
stupor):
•Mutism:Absenceofspeech.
•Rigidity:Maintenanceofrigidpostureagainst
effortstobemoved.
•Negativism:Amotivelessresistancetoall
commandsandattemptstobemoved,ordoing
justtheopposite.
•Posturing:Voluntaryassumptionofan
inappropriateandoftenbizarreposturefor
longperiodsoftime.
•Stupor:Doesnotreacttohissurroundings
andappearstobeunawareofthem.
•Echolalia:Repetitionormimickingofphrases
orwordsheard.
Echopraxia:Repetitionormimickingof
actionsobserved.
•Waxyflexibility:Partsofbodycanbeplaced
inpositionsthatwillbemaintainedforlong
periodsoftime,evenifveryuncomfortable
(flexiblelikewax).
PrognosticFactorsinSchizophrenia
•Ambitendency:Aconflicttodoornottodo,
e.g.,onaskingtoputouttongue,itisslightly
protrudedbuttakenbackagain.
•Automaticobedience:Obeyseverycommand
irrespectiveoftheirnature.
ResidualSchizophrenia
Symptomsofresidualschizophreniainclude
emotionalblunting,eccentricbehavior,illogical
thinking,socialwithdrawalandlooseningof
associations.Thiscategoryshouldbeusedwhen
therehasbeenatleastoneepisodeofschizo­
phreniainthepastbutwithoutprominent
psychoticsymptomsatpresent.
UndifferentiatedSchizophrenia
Thiscategoryisdiagnosedeitherwhenfeatures
ofnosubtypearefullypresentorfeaturesofmore
thanonesubtypeareexhibited.
SimpleSchizophrenia
Itischaracterizedbyanearlyandinsidiousonset,
progressivecourse,presenceofcharacteristic
negativesymptoms,vaguehypochondriacal
features,wanderingtendency,self-absorbed
idlenessandaimlessactivity.Itdiffersfrom
residualschizophreniainthatthereneverhas
beenanepisodewithallthetypicalpsychotic
symptoms.Theprognosisisverypoor.
Goodprognosticfactors Poorprognosticfactors
1.Abruptoracuteonset 1.Insidiousonset
2.Lateronset 2.Youngeronset
3.Presenceofprecipitatingfactor 3.Absenceofprecipitatingfactor
4.Goodpremorbidpersonality 4.Poorpremorbidpersonality
5.Paranoidandcatatonicsubtypes 5.Simple,undifferentiatedsubtypes
6.Shortduration:(<6months) 6.Longduration:(>2years)
7.Predominanceofpositivesymptoms 7.Predominanceofnegativesymptoms
8.Familyhistoryofmooddisorders 8.Familyhistoryofschizophrenia
9.Goodsocialsupport 9.Poorsocialsupport
10.Femalesex 10.Malesex
11.Married 11.Single,divorcedorwidowed
12.Out-patienttreatment 12.Institutionalization

85. 82AGuidetoMentalHealthandPsychiatricNursing
Post-schizophrenicDepression
Depressivefeaturesdevelopinthepresenceof
residualoractivefeaturesofschizophreniaand
areassociatedwithanincreasedriskofsuicide.
CourseandPrognosis
Theclassiccourseisoneofexacerbationsand
remissions.Ingeneral,schizophreniahasbeen
describedasthemostcripplinganddevastating
ofallpsychiatricillnesses.Severalstudieshave
foundthatoverthe5-10yearsperiodafterthe
firstpsychiatrichospitalizationforschizophrenia,
onlyabout10to20%ofpatientscanbedescribed
ashavingagoodoutcome.Morethan50%of
patientshaveapooroutcome,withrepeated
hospitalizations.
Treatment
Pharmacotherapy
Anacuteepisodeofschizophreniatypically
respondstotreatmentwithclassicantipsychotic
agents,whicharemosteffectiveinitstreatment.
Somecommonlyuseddrugsinclude:
Chlorpromazine:300-1500mg/dayPO;50-100
mg/dayIM
Fluphenazinedecanoate:25-50mgIMevery1-3
weeks
Haloperidol:5-100mg/dayPO;5-20mg/day
IM
Trifluoperazine:15-60mg/dayPO;1-5mg/
dayIM
Clozapine:25-450mg/dayPO
Risperidone:2-10mg/dayPO
Olanzapine:10-20mg/dayPO
(Referchapter14foradetaileddescriptionofthese
drugs).
ElectroconvulsiveTherapy(ECT)
IndicationsforECTinschizophreniainclude:
•Catatonicstupor
•Uncontrolledcatatonicexcitement
•Severeside-effectswithdrugs
•Schizophreniarefractorytoallotherformsof
treatment
Usually8-12ECTsareneeded
PsychologicalTherapies
GrouptherapyThesocialinteraction,senseof
cohesiveness,identification,andrealitytesting
achievedwithinthegroupsettinghaveprovento
behighlytherapeuticfortheseindividuals.
BehaviortherapyBehaviortherapyisusefulin
reducingthefrequencyofbizarre,disturbingand
deviantbehavior,andincreasingappropriate
behaviors.
SocialskillstrainingSocialskillstraining
addressesbehaviorssuchaspooreyecontact,odd
facialexpressionsandlackofspontaneityin
socialsituationsthroughtheuseofvideotapes,
roleplayingandhomeworkassignments.
CognitivetherapyUsedtoimprovecognitive
distortionslikereducingdistractibilityand
correctingjudgment.
FamilytherapyFamilytherapytypicallyconsists
ofabriefprogramoffamilyeducationabout
schizophrenia.Ithasbeenfoundthatrelapserates
ofschizophreniaarehigherinfamilieswithhigh
expressedemotions(EE),wheresignificantothers
makecriticalcomments,expresshostilityorshow
emotionalover-involvement.Thesignificantothers
are,therefore,taughttodecreaseexpectationsand
familytensions,apartfrombeinggivensocial
skillstrainingtoenhancecommunicationand
problemsolving.
PsychosocialRehabilitation
Thisincludesactivitytherapytodevelopthework
habit,traininginanewvocationorretrainingin
apreviousskill,vocationalguidanceandinde­
pendentjobplacement.
NursingManagement
NursingAssessment
Assessmentoftheschizophrenicpatientmaybe
acomplexprocess,basedoninformationgathered

86. TheIndividualwithFunctionalPsychiatricDisorder83
Table7.1:Nursinginterventionsfordelusionalbehaviour
Interventions Rationale
(a)Conveyacceptanceofthepatient's
needforthefalsebelief,butthat
youdonotsharethebelief.
(b)Donotargueordenythebelief.
(c)Reinforceandfocusonreality.
Discouragelongdiscussionsabout
theirrationalthinking.Insteadtalk
aboutrealeventsandrealpeople.
(d)Iftheclientishighlysuspicious,the
followinginterventionsmayhelp:
usesamestaffasfaraspossible;
behonestandkeepallpromises
avoidphysicalcontactintheform
oftouchingthepatientetc;
avoidlaughing,whisperingor
talkingquietlywheretheclient
canseebutcannothearwhatis
beingsaid;
avoidcompetitiveactivities;use
assertive,matter-of-factyetfriendly
approach
*
*
*
*
Theclientmustunderstandthatyoudonot
viewtheideaasreal.
Arguingordenyingservesnousefulpurposeas
delusionalideasarenoteliminatedbythisapproach;
further,thismayadverselyaffectthedevelopmentofa
trustingrelationship.
Discussionsthatfocusonthefalseideasare
purposelessanduselessandmayeven
aggravatethecondition.
Topromotetrust
Topreventtheclientfromfeelingthreatened
-do-
-do-
fromanumberofsources.Schizophrenicpatients
inanacuteepisodeoftheillnessareseldomable
tomakeasignificantcontributiontotheirhistory.
Datamaybeobtainedfromfamilymembersif
possible,oldrecordsifavailable,orfromother
individualswhoareinapositiontoreportonthe
progressionofthepatient'sbehavior.
NursingDiagnosis
Alterationinthoughtprocessesrelatedtoinability
totrust,panicanxiety,evidencedbydelusional
thinking,inabilitytoconcentrate,impaired
volition,extremesuspiciousnessofothers.
Objective:Patientwilleliminatepatternsofdelu­
sionalthinkinganddemonstratetrustinothers
Intervention:SeeTable7.1.
NursingDiagnosisII
Sensory-perceptualalteration:Auditory/visual,
relatedtopanicanxiety,withdrawalintoself,
evidencedbyinappropriateresponses,disor­
deredthoughtprocess,poorconcentrationand
disorientation.
Objective:Patientwillbeabletodefineandtest
reality,eliminatingtheoccurrenceofhalluci­
nations.
Intervention:SeeTable7.2.
NursingDiagnosisIll
Socialisolationrelatedtoinabilitytotrust,panic
anxiety,delusionalthinking,evidencedby
withdrawal,sad,dullaffect,preoccupationwith
ownthoughts,expressionoffeelingsofrejection
ofalonenessimposedbyothers.
Objective:Patientwillvoluntarilyspendtimewith
otherpatientsandstaffmembersingroup
activitiesontheunit.
Intervention:SeeTable7.3.

87. 84AGuidetoMentalHealthandPsychiatricNursing
Table7.2:Nursinginterventionsforhallucinatorybehaviour
Interventions Rationale
(a)Observetheclientforsignsof
hallucinations(listeningpose,
laughingortalkingtoself,stopping
inmid-sentence).
(b)Avoidtouchingtheclientwithout
warning.
(C)Anattitudeofacceptancewill
encouragethepatienttosharethe
contentofthehallucinationwithyou.
(d)Donotreinforcethehallucinations.
Use"thevoices"insteadofwords
like"they"thatimplyvalidation.
Say"EventhoughIrealizethevoices
arerealtoyou,Idon'thearany
voicesspeaking."
(e)Helptheclientunderstandthe
connectionbetweenanxietyand
hallucinations.
(f)Trytodistracttheclientawayfrom
thehallucinationsandinvolvehim
ininterpersonalactivitiesandactual
situations.
Earlyinterventionmaypreventaggressive
responsetocommandhallucinations.
Theclientmayperceivetouchasthreateningand
mayrespondinanaggressivemanner.
Thisisimportanttopreventpossibleinjury
tothepatientorothersfromcommand
hallucinations.
Theclientshouldknowthatyoudonot
sharethefalseperception.
Iftheclientcanlearntointerruptrising
anxiety,hallucinationsmaybeprevented.
Thisistobringtheclientbacktoreality.
Table7.3:Nursinginterventionsforwithdrawnbehaviour
Interventions Rationale
(a)Conveyanacceptingattitudeby
makingbrief,frequentcontacts.
Showunconditionalpositiveregard.
(b)Offertobewiththeclientduringgroup
activitiesthathefindsfrighteningor
difficult.Involvetheclientgradually
indifferentactivitiesontheunit.
(C)Giverecognitionandpositivere­
inforcementfortheclient'svoluntary
interactionwithothers.
Thisincreasesfeelingsofself-worthand
facilitatestrust.
Thepresenceofatrustedindividual
providesemotionalsecurityfortheclient.
Positivereinforcementenhancesself-esteem
andencouragesrepetitionofacceptable
behavior.
NursingDiagnosisIV
Potentialforviolence,self-directedordirectedat
others,relatedtoextremesuspiciousness,panic
anxiety,catatonicexcitement,ragereactions,
commandhallucinations,evidencedbyphysical
violence,destructionofobjectsintheenvironment,
self-destructivebehaviororactiveaggressive
suicidalacts.
Objective:Patientwillnotharmselforothers.
Intervention:SeeTable7.4.
NursingDiagnosisV
Impairedverbalcommunicationrelatedtopanic
anxiety,disordered,unrealisticthinking,evi­
dencedbylooseningofassociations,echolalia,
verbalizationsthatreflectconcretethinking,and
pooreyecontact.
Objective:Patientwillbeabletocommunicate
appropriatelyandcomprehensiblybythetimeof
discharge.
Intervention:SeeTable7.5.

88. TheIndividualwithFunctionalPsychiatricDisorder85
Table7.4:Nursinginterventionsforviolentbehaviour
Interventions Rationale
(a)Maintainlowlevelofstimuliinthe
client'senvironment(lowlighting,
lownoise,fewpeople,simple
decoration,etc.)
(b)Observeclient'sbehavior
frequently.
Dothiswhilecarryingout
routineactivities.
(c)Removealldangerousobjects
fromtheclient'senvironment.
(d)Redirectviolentbehaviorwith
physicaloutletsfortheanxiety.
(e)Staffshouldmaintainacalmattitude
towardstheclient.
(f)Havesufficientstaffavailableto
indicateashowofstrengthtothe
clientifitbecomesnecessary.
(g)Administertranquilizers
asprescribed.Useofmechanical
restraintsmaybecomenecessaryin
somecases.
Anxietylevelrisesinastimulating
environmentandmaytriggeroffaggression.
Closeobservationisnecessarysothat
interventioncanoccurifrequired,toensure
client'sandothers'safety.
Toavoidcreatingsuspicioninthe
individual.
Topreventtheclientfromusingthem
toharmselforothersinanagitated,
confusedstate.
Physicalexerciseisasafeandeffectiveway
ofrelievingpent-uptension.
Anxietyiscontagiousandcanbetransmitted
fromstafftoclient.
Thisshowstheclientevidenceofcontrol
overthesituationandprovidessome
physicalsecurityforthestaff.
Iftheclientisnotcalmedby"talkingdown"
ortheuseofmedications,restraintsmay
havetobeusedasalastresort.
Table7.5:Nursinginterventionsforimpairedverbalcommunication
Interventions Rationale
(a)Attempttodecodeincomprehensible
communicationpattern.Seekvalidation
andclarificationbystating"Isitwhat
youmean...?"or"Idon'tunderstandwhat
youmeanbythat.Wouldyouplease
clarifyitforme?"
(b)Facilitatetrustandunderstandingby
maintainingstaffassignmentsas
consistentlyaspossible.
ThetechniquesofVERBALIZING
THEIMPLIEDisusedwiththeclient
whoismute(eitherunableorunwilling
tospeak).
Forexample,"Thatmusthavebeenavery
difficulttimeforyouwhenyour
motherleft.Youmusthavefeltallalone."
(c)Anticipateandfulfillclient'sneeds
untilfunctionalcommunicationpattern
returns.
Thesetechniquesrevealhowthe
patientisbeingperceivedbyothers,
whiletheresponsibilityfornot
understandingisacceptedbythe
nurse.
Thisapproachconveysempathyand
encouragestheclienttodisclose
painfulissues.
Self-careabilitymaybeimpairedinsome
patientswhomayneedassistanceinitially.

89. 86AGuidetoMentalHealthandPsychiatricNursing
NursingDiagnosisVI
Self-caredeficitrelatedtowithdrawal,panic
anxiety,perceptualorcognitiveimpairment,
evidencedbydifficultyincarryingouttasks
associatedwithhygiene,dressing,grooming,
eatingandtoileting.
Objective:Patientwilldemonstrateabilitytomeet
self-careneedsindependently.
Intervention:SeeTable7.6.
NursingDiagnosisVII
Ineffectivefamilycopingrelatedtohighlyambi­
valentfamilyrelationships,impairedfamily
communication,evidencedbyneglectfulcareof
theclient,extremedenialorprolongedover­
concernregardinghisillness.
Objective:Familywillidentifymoreadaptive
copingstrategiesfordealingwithpatient'sillness
andtreatmentregimen.
Intervention:SeeTable7.7.
Table7.6:Nursinginterventionstoimproveself-careactivities
Interventions Rationale
(a)Provideassistancewithself-careneeds
asrequired.Somepatientswhoare
severelywithdrawnmayrequiretotal
care.
(b)Encourageclienttoperformindependen­
tlyasmanyactivitiesaspossible.Provide
positivereinforcementforindependent
accomplishments.
(c)Creativeapproachesmayneedtobe
usedwiththeclientwhoisnoteating
becauseheissuspiciousofbeing
poisoned(e.g.,allowclienttoopenown
cannedorpackagedfoods,etc.)If
eliminationneedsarenotbeingmet,
establishstructuredscheduletohelp
theclientfulfilltheseneedsuntilheis
abletodosoindependently.
Patientsafetyandcomfortare
nursingpriorities.
Independentaccomplishmentand
reinforcementenhanceself-esteem
andpromoterepetitionofdesirable
behavior.
Toensurethatself-careneedsare
met.
Table7.7:Nursinginterventionstoimprovefamilycopingskills
Interventions Rationale
(a)Identifyroleoftheclientinthefamily
andhowitisaffectedbyhisillness.
Identifytheleveloffamilyfunctioning.
Assesscommunicationpatterns,inter­
personalrelationshipsbetweenthe
members,problemsolvingskillsand
availabilityofsupportsystems.
(b)Provideinformationtothefamily
abouttheclient'sillness,the
treatmentregimen,long-termprognosis.
(c)Practicewithfamilymembers,how
torespondtobizarrebehaviorand
communicationpatternsandwhenthe
clientbecomesviolent.
Thesefactorswillhelptoidentify
howsuccessfulthefamilyisin
dealingwithstressfulsituations
andareaswhereassistanceis
required.
Knowledgeandunderstandingabout
whattoexpectmayfacilitatethe
family'sabilitytosuccessfully
integratetheschizophrenicpatient
intothesystem.
Aplanofactionwillassistthe
familytorespondadaptivelyinthe
faceofwhattheymayconsidertobe
acrisissituation.

90. TheIndividualwithFunctionalPsychiatricDisorder87
Evaluation
Afewquestionsthatmayfacilitatetheprocessof
evaluationcanbe:
•Hasthepatientestablishedtrustwithatleast
onestaffmember?
•Isdelusionalthinkingstillprevalent?
•Arehallucinationsstillevident?
•Isthepatientabletointeractwithothers
appropriately?
•Isthepatientabletocarryoutallactivitiesof
dailylivingindependently?
NURSINGMANAGEMENT FORAPATIENT
WHOEXHIBITSWITHDRAWN BEHAVIOR
Thetermwithdrawnbehaviorisusedtodescribe
aclient'sretreatfromrelatingtotheexternal
world.Withdrawnbehaviorcanoccurin
conjunctionwithanumberofmentalhealth
problems,includingschizophrenia,mood
disordersandsuicidalbehavior.
CharacteristicsofWithdrawnBehavior
Pattern
•Withdrawnbehaviorpatternmaypresentthe
pictureofalonelyindividualwhodoesnot
respondtotheenvironment.Hemaywalkup
anddowntalkingtohimself,ormaystandor
sitinthecornerassumingunusualandmost
uncomfortablepositions.
•Hehasdifficultyinexpressinghisfeelings,
sohemaypresentthepictureofatotally
apatheticperson,orhemayexpressthemin
inappropriateways.
•Ambivalenceisanothercharacteristicthat
mightbeseeninawithdrawnpatient.For
example,hemayloveandhateapersonatthe
sametime.
•Disorderedthoughtprocessisanotherfeature
inthispatient.Theoutwardexpressionofthis
disorganizationcanbeameaninglessjumble
ofwords/sentences,ormakingupofnew
words.Thepatientmayalsoexperience
suddenthoughtblock.Ashecreateshisown
world,theworldbecomesfilledwithhisown
projectedideasandthoughts.
•Regressionisanotherprocesspredominant
inawithdrawnpatient.Whenitbecomes
severe,physicalneedslikesleep,rest,nutrition
andhygienemaybeinterferedwith.
Interventions
•Intakingcareofawithdrawnpatient,the
nursemightbefacedwithmanyproblems.
Communicationandinterpersonalrelation­
shipsarethebiggestdifficultiesbecausethe
withdrawnpatienttendstousesymbolized
language,ormayprefertorelyonnon-verbal
behaviorcompletely.Establishinginitialcon­
tactusingcalm,non-threateningandconsis­
tentapproachesisimportant.Itnecessitatesa
lotofhardworkandpatiencefromthenurse
asthepatientneedsalongperiodoftesting
outbeforehefinallytrustsher.
•Dealingwithhallucinationsanddelusions
maybeaproblemasthishappensinaccor­
dancewithhisownself-createdworld.Any­
bodywhoistryingtodestroythatcomfortable
worldmaybeseenbythepatientasathreatto
himandtohissecurity.Disintegrationin
thinkingiswhatmakesthewithdrawn
patienttheworstofthementallyill.Asthis
processcangoonforalongtimebeforeitis
noticedbyothers,itisoftenverylatewhenit
isidentified.Thismakesitmoredifficultfor
thenurseinhereffortstobringthepatient
backtoreality.Alotoftactandexpertskillis
important,andopportunitiesshouldbe
createdfortheclienttorecognizethenurseas
asafecontactwithpresentrealityandtobegin
torespond.
•Regressioninthepatientcausesadifficult
practicalproblem,asthepatienthastobe
consideredandtakencareofasachild.Atthe
sametimehehastobetreatedasanadult,
fosteringhisadultcharacteristics.Providing
sensorystimulation,meetingtheclient'sphy­
siologicandhygienicneeds,andpromoting
theclient'sphysicalactivityandinteractions
withothersareimportantinterventions.

91. 88AGuidetoMentalHealthandPsychiatricNursing
•Certaingeneralprinciplesinworkingwith
thesepatientsare:avoidchangeofstaff,reduce
thenumberofstaffwhoworkswiththem,and
beavailablewhenthepatientreallyneedsthe
nurse.Hemayperceivetheunavailabilityof
thenurseasanotherdisappointmentinhis
relationshipwithpeopleingeneral.
•Aone-to-onerelationshipwiththepatientis
consideredmostbeneficialandleastanxiety­
producingtothepatient.Itisnecessaryto
encouragerealitycontactwheneverpossible
andtodiscouragehimfromlivinginthe
unrealworld.Thismaybeachievedby
providingopportunitiesforinteractionwith
therealenvironment.
•Givetheclientpositivefeedbackforany
responsetoyourattemptedinteractionorto
theexternalenvironment.Graduallyincrease
theamountoftimetheclientspendswith
othersandthenumberofpeoplewithwhom
theclientinteracts.
•Activefriendliness:Asthepatientiswith­
drawnanddoesnotapproachanybody,the
approachhastobemadefromthenurse'sside
andmanyattemptswillhavetobemadeto
initiateanyconversationorcommunication.
•Kindfirmness:Thisisanotherattitudethatis
tobeconsideredessential.Thenurseassumes
firmnessinexpectingthepatienttobehavein
certainwaysbutshouldexpectthebehavior
inakindmannerwithoutbeingauthoritative
anddemanding,showingkindnessand
understandingwhilelisteningtothepatient,
andhelpinghimhandleanydifficult
situations.
MOODDISORDERS
Mooddisordersarecharacterizedbyadistur­
banceofmood,accompaniedbyafullorpartial
manicordepressivesyndrome,whichisnotdue
toanyotherphysicalormentaldisorder.
Theprevalencerateofmooddisordersis1.5
percent,anditisuniformthroughouttheworld.
ClassificationofMoodDisorders
AccordingtoICDlO(F3)mooddisordersare
classifiedasfollows:
•Manicepisode
•Depressiveepisode
•Bipolarmood(affective)disorders
•Recurrentdepressivedisorder
•Persistentmooddisorder(includingcyclo­
thymiaanddysthymia)
•Othermooddisorders
Etiology
Theetiologyofmooddisordersiscurrently
unknown.However,severaltheorieshavebeen
propoundedwhichinclude:
BiologicalTheories
GenetichypothesisGeneticfactorsareveryimpor­
tantinpredisposinganindividualtomood
disorders.Thelifetimeriskforthefirst-degree
relativesofpatientswithbipolarmooddisorder
is25%andofnormalcontrolsis7%.Thelifetime
riskforthechildrenofoneparentwithmood
disorderis27%andofbothparentswithmood
disorderis74%.Theconcordanceratefor
monozygotictwinsis65%andfordizygotictwins
is15%.
BiochemicaltheoriesAdeficiencyofnorepineph­
rineandserotoninhasbeenfoundindepressed
patientsandtheyareelevatedinmania.
Dopamine,GABAandacetylcholinearealso
presumablyinvolved.
PsychosocialTheories
PsychoanalytictheoryAccordingtoFreud(1957)
depressionresultsduetolossofa"lovedobject",
andfixationintheoralsadisticphaseof
development.Inthismodel,maniaisviewedasa
denialofdepression.
BehavioraltheoryThistheoryofdepression
connectsdepressivephenomenatotheexperience
ofuncontrollableevents.Accordingtothismodel,
depressionisconditionedbyrepeatedlossesin
thepast.

92. TheIndividualwithFunctionalPsychiatricDisorder89
CognitivetheoryAccordingtothistheorydepres­
sionisduetonegativecognitionswhichincludes:
Negativeexpectationsoftheenvironment
Negativeexpectationsoftheself
Negativeexpectationsofthefuture
Thesecognitivedistortionsariseoutofadefect
incognitivedevelopmentandcausetheindivi­
dualtofeelinadequate,worthlessandrejectedby
others.
SociologicaltheoryStressfullifeevents,e.g.death,
marriage,financiallossbeforetheonsetofthe
diseaseorarelapseprobablyhaveaformative
effect.
ManicEpisode
Maniareferstoasyndromeinwhichthecentral
featuresareover-activity,moodchange(which
maybetowardselationorirritability)andself­
importantideas.
Thelifetimeriskofmanicepisodeisabout0.8-
1%.Thisdisorderoccursinepisodeslasting
usually3to4months,followedbycomplete
recovery.
ClassificationofMania(ICD10)
•Hypomania
•Maniawithoutpsychoticsymptoms
•Maniawithpsychoticsymptoms
•Manicepisodeunspecified
ClinicalFeatures
Anacutemanicepisodeischaracterizedbythe
followingfeatureswhichshouldlastforatleast
oneweek:
Elevated,ExpansiveorIrritableMood
Elevatedmoodinmaniahasfourstagesdepen­
dingontheseverityofmanicepisodes:
•Euphoria(StageI):Increasedsenseofpsycho­
logicalwell-beingandhappinessnotin
keepingwithongoingevents.
•Elation(StageII):Moderateelevationofmood
withincreasedpsychomotoractivity.
•Exaltation(StageIII):Intenseelevationofmood
withdelusionsofgrandeur.
•Ecstasy(StageIV):Severeelevationofmood,
intensesenseofraptureorblissfulnessseen
indeliriousorstuporousmania.
Expansivemoodisunceasingandunselective
enthusiasmforinteractingwithpeopleand
surroundingenvironment.
Sometimesirritablemoodmaybepredomi­
nant,especiallywhenthepersonisstoppedfrom
doingwhathewants.
Theremayberapid,short-lastingshiftsfrom
euphoriatodepressionoranger.
PsychomotorActivity
Thereisanincreasedpsychomotoractivity
rangingfromoveractivenessandrestlessnessto
manicexcitement.Thepersoninvolvesincease­
lessactivity.Theseactivitiesaregoal-orientedand
basedonexternalenvironmentcues.
SpeechandThought
•Flightofideas:Thoughtsracinginmind,
rapidshiftsfromonetopictoanother
•Pressureofspeech:Speechisforceful,strong
anddifficulttointerrupt.Usesplayful
languagewithpunning,rhyming,jokingand
teasingandspeaksloudly
•Delusionsofgrandeur
•Delusionsofpersecution
•Distractibility
OtherFeatures
•Increasedsociabilities
•Impulsivebehavior
•Disinhibition
•Hypersexualandpromiscuousbehavior
•Poorjudgment
•High-riskactivities(buyingsprees,reckless
driving,foolishbusinessinvestments,distri­
butingmoneyorarticlestounknownpersons)
•Dressedupingaudyandflamboyantclothes
althoughinseveremaniatheremaybepoor
self-care
•Decreasedneedforsleep(<3hrs)
•Decreasedfoodintakeduetoover-activity
•Decreasedattentionandconcentration
•Poorjudgment
•Absentinsight

93. 90AGuidetoMentalHealthandPsychiatricNursing
SymptomsofHypomania
Hypomaniaisalesserdegreeofmania.Thereisa
persistentmildelevationofmoodandincreased
senseofpsychologicalwellbeingandhappiness
notinkeepingwithongoingevents.Insomecases
irritability,conceit,andboorishbehaviormaytake
theplaceofthemoreusualeuphoricsociability.
Concentrationandattentionmaybeimpaired,
thusdiminishingtheabilitytosettledowntowork
ortorelaxationandleisure,butthismaynot
preventtheappearanceofinterestsinquitenew
venturesandactivities.Infact,theabilityto
functionbecomesbetterinhypomania,and
there'samarkedincreaseinproductivityand
creativity;manyartistsandwritershave
contributedsignificantlyduringsuchperiods.
Thefeaturesofhypomaniamaybespecified
asfollows:
1.Adistinctperiodofpersistentlyelevated,
expansive,orirritablemood,lasting
throughout4days,thatisclearlydifferentfrom
theusualnon-depressedmood.
2.Duringtheperiodofmooddisturbance,three
(ormore)ofthefollowingsymptomsare
persistent(four,ifthemoodisonlyirritable)
andpresenttoasignificantdegree:
a)inflatedself-esteemorgrandiosity
b)decreasedneedforsleep(e.g.feelsrested
afteronly3hoursofsleep)
c)moretalkativethanusual
d)flightofideasorsubjectiveexperiencethat
thoughtsareracing
e)distractibility(i.e.attentiontooeasily
drawntounimportantorirrelevant
externalstimuli)
f)increaseingoal-directedactivity(either
socially,atworkorschool,orsexually)or
psychomotoragitation
g)excessiveinvolvementinpleasurableacti­
vitiesthathaveahighpotentialforpainful
consequences(e.g.thepersonengagesin
unrestrainedbuyingsprees,foolishbusi­
nessinvestmentsorsexualindiscretions)
3.Theepisodeisassociatedwithanunequivocal
changeinfunctioningthatisuncharacteristic
ofthepersonwhennotsymptomatic.
4.Thedisturbanceinmoodandthechangein
functioningareobservablebyothers.
5.Theepisodeisnotsevereenoughtocause
markedimpairmentinsocialoroccupational
functioning,ortonecessitatehospitalization,
andtherearenopsychoticfeatures.
Treatment
Pharmacotherapy
•Lithium:900-2100mg/day.
•Carbamazepine:600-1800mg/day.
•Sodiumvalproate:600-2600mg/day.
•Otherdrugs:Clonazepam,calciumchannel
blockers,etc.
(referchapter14formoredetailsonthesedrugs)
Electroconvu/siveTherapy(ECT)
ECTcanalsobeusedforacutemanicexcitement
ifnotadequatelyrespondingtoantipsychotics
andlithium.
PsychosocialTreatment
Familyandmaritaltherapyisusedtodecrease
intrafamilialandinterpersonaldifficultiesand
toreduceormodifystressors.Themainpurpose
istoensurecontinuityoftreatmentandadequate
drugcompliance.
NursingManagementforMania
NursingAssessment
Nursingassessmentofthemanicpatientshould
includeassessingtheseverityofthedisorder,
forminganopinionaboutthecauses,assessing
thepatient'sresourcesandjudgingtheeffectsof
patient'sbehavioronotherpeople.Asfaras
possibleallrelevantdatashouldbecollectedfrom
thepatientaswellasfromhisrelatives,because
thepatientmaynotalwaysrecognizetheextent
ofhisabnormalbehavior.
NursingDiagnosisI
Highriskforinjuryrelatedtoextremehyper­
activityandimpulsivebehavior,evidencedby
lackofcontroloverpurposelessandpotentially
injuriousmovements.

94. TheIndividualwithFunctionalPsychiatricDisorder91
Objective:Patientwillnotinjureself.
Intervention:SeeTable7.8.
NursingDiagnosisII
Highriskforviolence;self-directedordirectedat
othersrelatedtomanicexcitement,delusional
thinkingandhallucinations.
Objective:Patientwillnotharmselforothers.
Intervention:SeeTable7.9.
Thefollowingaresomeguidelinesforself­
protectionwhenhandlinganaggressivepatient:
•Neverseeapotentiallyviolentpersonalone.
•Keepacomfortabledistanceawayfromthe
patient(armlength).
•Bepreparedtomove,violentpatientcanstrike
outsuddenly.
•Maintainaclearexitrouteforboththestaff
andpatient.
•Besurethatthepatienthasnoweaponsinhis
possessionbeforeapproachinghim.
•Ifpatientishavingaweaponaskhimtokeep
itonatableorfloorratherthanfightingwith
himtotakeitaway.
•Keepsomethinglikeapillow,mattressor
blanketwrappedaroundarmbetweenyou
andtheweapon.
•Distractthepatientmomentarilytoremovethe
weapon(throwingwaterinthepatient'sface,
yelling,etc.).
•Giveprescribedantipsychoticmedications
NursingDiagnosisIll
Alterednutrition,lessthanbodyrequirements
relatedtorefusalorinabilitytositstilllongenough
toeat,evidencedbyweightloss,amenorrhea.
Objective:Patientwillnotexhibitsignsand
symptomsofmalnutrition.
Intervention:SeeTable7.10.
NursingDiagnosisIV
Impairedsocialinteractionrelatedtoegocentric
andnarcissisticbehavior,evidencedbyinability
todevelopsatisfyingrelationshipsandmani­
pulationofothersforowndesires.
Objective:Patientwillinteractwithothersinan
appropriatemanner.
Intervention:SeeTable7.11.
NursingDiagnosisV
Self-esteemdisturbancerelatedtounmetdepen­
dencyneeds,lackofpositivefeedback,unrealistic
self-expectations.
Objective:Patientwillhaverealisticexpectations
aboutself.
Intervention:SeeTable7.12.
Table7.8:Nursinginterventionsforhyperactivebehaviour
~---~
Interventions Rationale
(a)Keepenvironmentalstimulitoaminimum;
assignsingleroom;limitinteractionswith
others;keeplightingandnoiselevellow.
Keephisroomandimmediateenvironment
minimallyfurnished.
(b)Removehazardousobjectsandsubstances,
cautionthepatientwhenthereispossibility
ofanaccident.
(c)Assistpatienttoengageinactivities,such
aswriting,drawingandotherphysical
exercise.
(d)Staywithpatientashyperactivityincreases.
(e)Administermedicationasprescribedby
physician.
Patientisextremelydistractibleand
respondstoeventheslightest
stimuli.
Rationalityisimpairedandpatient
mayharmselfinadvertently.
Tobringrelieffrompent-uptension
anddissipateenergy.
Tooffersupportandprovidefeelingofsecurity.
Forprovidingrapidrelieffromsymptomsof
hyperactivity.

95. 92AGuidetoMentalHealthandPsychiatricNursing
Table7.9:Nursinginterventionsformanicviolentbehaviour
Interventions Rationale
(a)Maintainlowlevelofstimuliinpatient's
environment,provideunchallenging
environment.
Observepatient'sbehavioratleastevery
15minutes.
Ensurethatallsharpobjects,glassor
mirroritems,belts,ties,matchboxes
havebeenremovedfrompatient's
environment.
Redirectviolentbehaviorwithphysicaloutlet.
Encourageverbalexpressionoffeelings.
Engagehiminsomephysicalexercises
likeaerobics
Maintainandconveyacalmattitudetothe
patient.Respondmatter-of-factlytoverbal
hostility.Talktohiminlow,calmvoice,use
clearanddirectspeech.
Havesufficientstafftoindicateashowof
strengthtopatientifnecessary.State
limitationsandexpectations.
Administertranquilizingmedication;if
patientrefuses,useofrestraintsmaybe
necessary.Insuchacase,explainthe
reasontothepatient.
Followingapplicationofrestraintsobserve
patientevery15minutes.
Removerestraintsgraduallyonceatatime
Tominimizeanxietyand
suspiciousness.
Earlyinterventionmustbetaken
toensurepatient'sandothers'safety.
Thesemaybeusedtoharm
selforothers.
Forrelievingpent-uptensionandhostility.
-do-
-do-
Anxietyiscontagiousandcanbe
transmittedfromstafftopatient.
Thisconveyscontroloverthe
situationandprovidesphysical
securityforthestaff.
Explainingwhytherestrictionis
imposedmayensuresome
controloverhisbehavior.
Toensurethatneedsfornutrition,
hydrationandeliminationaremet
Tominimizepotentialforinjuryto
patientandstaff.
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
(j)
(k)
Table7.10:Nursinginterventionstoimprovenutritionalstatusofmanicpatient
Interventions Rationale
(a)Providehigh-protein,highcaloric,nutritious
fingerfoodsanddrinksthatcanbeconsumed
'ontherun.'
Findoutpatient'slikesanddislikesand
providefavoritefoods.
Provide6-8glassesoffluidsperday.Have
juiceandsnacksonunitatalltimes.
Patienthasdifficultysitting
stilllongenoughtoeatameal.
Toencouragethepatienttoeat.
Intakeofnutrientsisrequiredon
regularbasistocompensatefor
increasedcaloricrequirements
duetohyperactivity.
Theseareusefuldatatoassess
patient'snutritionalstatus.
Toimprovenutritionalstatus.
Tooffersupportandtoencourage
patienttoeat.
(b)
(c)
(d)Maintainaccuraterecordofintake,output
andcaloriecount.Weighthepatient
regularly.
Supplementdietwithvitaminsandminerals.
Walkorsitwithpatientwhileheeats.
(e)
(f)

96. TheIndividualwithFunctionalPsychiatricDisorder93
Table7.11:Nursinginterventionsformanipulativebehaviour
Interventions Rationale
(a)RecognizethatmanipulativebehaviorhelpsUnderstandingtherationalebehind
todecreasefeelingsofinsecuritybyincreasingthebehaviormayfacilitategreater
feelingsofpowerandcontrol. acceptanceoftheindividual.
(b)Setlimitsonmanipulativebehavior.ExplainConsequencesforviolationoflimits
theconsequencesiflimitsareviolated. mustbeconsistentlyadministered.
Termsofthelimitsmustbeagreedupon
byallthestaffwhowillbeworkingwith
thepatient
(c)IgnoreattemptsbypatienttoargueorbargainLackoffeedbackmaydecrease
hiswayoutofthelimitsetting. thesebehaviors.
(d)Givepositivereinforcementfornon- Toenhanceself-esteemandpromote
manipulativebehaviors. repetitionofdesirablebehavior.
(e)Discussconsequencesofpatient's Patientmustacceptresponsibilityfor
behaviorandhowattemptsaremadeto ownbehaviorbeforeadaptivechange
attributethemtoothers. canoccur.
(f)Helppatientidentifypositiveaspects Asself-esteemincreasespatient
aboutself,recognizeaccomplishmentsand willexperiencealesserneedtomanipulate
feelgoodaboutthem. othersforowngratification.
Table7.12:Nursinginterventionstoimproveself-esteemamongmanicpatient
Interventions Rationale
(a)Askhowclientwouldliketobeaddressed.
Avoidapproachesthatimplydifferent
perceptionoftheclient'simportance.
(b)Explainrationaleforrequestsbystaffunit
routineetc;strictlyadheretocourteous
approaches,matter-of-factstyleandfriendly
attitudes.
(c)Encourageverbalizationandidentification
offeelingsrelatedtoissuesofchronicity,
lackofcontroloverself,etc.
(d)Offermatter-of-factfeedbackregarding
unrealisticplans.Helphimtosetrealistic
goalsforhimself.
(e)Encourageclienttoviewlifeafterdischarge
andidentityaspectsoverwhichcontrolis
possible.Throughroleplay,practicehow
hewilldemonstratethatcontrol.
NursingDiagnosisVI
Alteredfamilyprocessesrelatedtoeuphoric-
moodandgrandioseideas,manipulative
behavior,refusaltoacceptresponsibilityfor
Grandiosityisthoughtactuallyto
reflectlowself-esteem.
Nursingapproachesshouldreinforce
patient'sdignityandworth;
understandingreasonsenhances
co-operationwithregimen.
Problemsolvingbeginswith
agreeingontheproblem.
Unrealisticgoalswillincrease
failuresandlowerself-esteem
evenmore.
Rolerehearsalishelpfulinreturning
patienttothelevelofindependent
functioning.Whentheindividualis
functioningwell,senseofself-esteemisenhanced.
ownactions.
Objective:Thefamilymemberswilldemonstrate
copingabilityindealingwiththepatient.
Intervention:SeeTable7.13.

97. 94AGuidetoMentalHealthandPsychiatricNursing
Table7.13:Nursinginterventionstoimprovefamilycopingskills
(a)
Interventions Rationale
Determineindividualsituationandfeelings
ofindividualfamilymemberslikeguilt,
anger,powerlessness,despairandalienation.
(b)Assesspatternsofcommunication.For
example:Arefeelingsexpressedfreely?
whomakesdecisions?Whatisthe
interactionbetweenfamilymembers?
Determinepatternsofbehaviordisplayed
bypatientinhisrelationshipswithothers,
e.g.manipulationofself-esteemofothers,
limittesting,etc.
Assesstheroleofpatientinthefamily,like
provideretc,andhowtheillnessaffects
therolesofothermembers.
Provideinformationaboutbehaviorpatterns
andexpectedcourseoftheillness.
(c)
(d)
(e)
Evaluation
Inthisstep,thenurseassessesifthegoalsofcare
areachieved.Theplanmayneedtoberevisedor
modifiedinthelightofthisevaluation.
NursingManagementforHypomania
Assessment
Assessmentincludesjudgingtheseverityofthe
symptoms,forminganopinionaboutthecauses,
assessingthepatient'ssocialresources,and
gaugingtheeffectofthedisorderonotherpeople.
•Inassessingtheseverityofsymptoms,the
patient'scapacitytoworkorengageinfamily
lifeandsocialactivitiesshouldbenoted.This
isimportanttopreventthepatientfrom
causinghimselflong-termdifficultiesdueto
ill-judgeddecisionsandunjustifiedextra­
vagance.
•Usuallythecausesmaybeendogenous,butit
isimportanttoidentifyanylifeeventsthat
mayhaveprovokedtheonset.Sometimesthe
episodemayfollowphysicalillness,treatment
bydrugs(especiallysteroids),orsurgical
operations.
Livingwithafamilymemberhaving
bipolarillnessfostersamultitudeof
feelingsandproblemsthatcanaffect
interpersonalrelationshipsandmay
resultindysfunctionalresponsesand
familydisintegration.
Providescluestothedegreeof
problembeingexperiencedby
individualfamilymembersand
copingskillsusedtphandlethecrisis.
Thesebehaviorsaretypicallyused
bythemanicindividualtomanipulate
others.Theresultisalienation,guilt,
ambivalenceandhighratesofdivorce.
Whentheroleofanillpersonisnot
filledfamilydisintegrationcanoccur.
Assistsfamilytounderstandthevariousaspectsof
bipolarillness.Thismayrelieveguiltandpromote
familydiscussionsoftheproblemsandsolutions.
•Thepatient'sresourcesandeffectonother
peopleshouldbeassessed.Thepatient's
responsibilitiesinthecareofdependent
childrenoratworkshouldbeconsidered
carefully.
Interventions
NURSINGDIAGNOSISI
Riskofinjuryrelatedtoinabilitytoperceive
potentiallyharmfulsituationsevidencedby
impulsivebehavior.
Objective:Toreduceriskybehaviorandavert
injury.
Intervention:SeeTable7.14.
NURSINGDIAGNOSISII
Impairedsocialinteractionrelatedtoshort
attentionspan,highlevelofdistractibilityand
labilemood,evidencedbyinsufficientorexcessive
quantityorineffectivequalityofsocialexchange.
Objective:Patientwilldemonstrateacceptable
interactionwithothers.
Intervention:SeeTable7.15.

98. TheIndividualwithFunctionalPsychiatricDisorder95
Table7.14:Nursinginterventionstoreduceriskybehaviourandavertinjuryamonghypomanicpatients
Interventions Rationale
•Talkwiththeclientaboutsafeandunsafe
behavior.
•Assessthefrequencyandseverityof
accidents.
•Providesupervisionforpotentiallydangerous
situations.Limittheclient'sparticipation
inactivitieswhensafetycannotbeensured.
•Stateexpectationsforbehaviorinclear
terms.
•Makecorrectfeedbackasspecificas
possible.Forexample,"Donotjumpdown
thestairs.Walkdownonestepatatime."
•Setlimitsthataredirectlyrelatedtothe
undesirablebehavior.Institutethemas
soonaspossibleaftertheoccurrenceof
thebehavior.Continuoussupervisionis
neededtopreventthepatientfrom
developingfull-blownmanicsymptoms.
Thisprovidestheclientwith
clearexpectations.
Itisnecessaryforbaseline
data.
Thisisnecessary,becausetheclient's
abilitytoperceiveharmfulconse­
quencesofabehaviorisimpaired.
Theclientmaybeunabletoprocess
socialcuestoguidereasonable
behaviorchoices.
Specificfeedbackwillhelpthe
clientunderstandexpectations.
Theclientwillbebetterableto
drawthecorrelationbetween
undesirablebehaviorandconse­
quencesifthetwoarerelatedto
eachother.
Table7.15:Nursinginterventionstoimprovesocialinteractionamonghypomanicpatients
•Identifythefactorsthataggravateand
alleviatetheclient'sperformance.
Interventions Rationale
•Provideanenvironmentasfreefrom
distractionsaspossible.Gradually
increasetheamountofenvironmental
stimuli.
•Giveinstructionsslowly,usingsimple
languageandconcretedirections.
•Providepositivefeedbackforcompletion
ofeachstepofdesirableactivity/behavior.
•Protectotherclientsfrombeingdrawninto
theclient'sinfluence,especiallythosewho
mightbenon-assertiveorvulnerable.
NURSINGDIAGNOSISIll
Ineffectivecopingskillsrelatedtopoorimpulse
controlevidencedbyactingoutbehavior.
Objective:Patientwillnotharmselforothers.
Intervention:SeeTable7.16.
NURSINGDIAGNOSISIV
Disturbedthoughtprocessrelatedtodisorien­
tationanddecreasedconcentrationevidencedby
disruptioninactivities.
Externalstimulithatexacerbate
theclient'sproblemscanbe
identifiedandminimized.
Theclient'sabilitytodealwith
externalstimulationisimpaired.
Theclient'sabilitytocomprehend
complexinstructionsisreduced.
Positivefeedbackincreasesthe
likelihoodofdesirablebehavior.
Clientswithhypomaniahave
manipulativebehavior.
Objective:Patientwilldemonstrateadequate
cognitivefunction.
Intervention:SeeTable7.17.
EVALUATION
Inthisstepthenurseassessesifthegoalsofcare
areachieved.Theplanmayneedtoberevisedor
modifiedinthelightofthisevaluation.
DepressiveEpisode
Depressionisawidespreadmentalhealthprob­
lemaffectingmanypeople.Thelifetimeriskof

99. 96AGuidetoMentalHealthandPsychiatricNursing
Table7.16:Nursinginterventionstoincreaseself-controlamonghypomanicpatients
Interventions Rationale
•Staterules,expectationsandresponsibilities
clearlytotheclient,includingconsequences
forexceedinglimits.
•Usetimeoutwhentheclientbeginstolose
behavioralcontrol.
•Encouragetheclienttoverbalizehisfeelings.
•Teachtheclientasimpleproblemsolving
process:describethe-problem,listalter­
natives,evaluatechoices,andselectand
implementanalternative.
Clearexpectationsgivetheclient
limitstowhichhisbehaviormust
conform,andwhattoexpectifhe
exceedsthoselimits.
Timeoutperiodisnotapunishment
butanopportunityfortheclientto
regaincontrol.
Itisaninitialsteptowardsresolving
difficulties.
Theclient'sabilitytothink,judgeor
solveproblemsisimpaired.
Table7.17:Nursinginterventionstoimprovecognitivefunctioninhypomanicpatients
•Useafirmyetcalm,relaxedapproach.
Interventions Rationale
•Setandmaintainlimitsonbehavior
thatisdestructiveoradverselyaffects
others.
•Decreaseenvironmentalstimuliwhen­
everpossible.Respondtocuesof
increasedrestlessnessoragitationby
removingstimuliandperhapsisolating
theclient,tosingleorprivateoccupancy
roommaybebeneficial.
•Provideaconsistentstructuredenvironment.
Lettheclientknowwhatisexpectedofhim.
Setgoalswiththeclientassoonaspossible.
depressioninmalesis8to12%andinfemalesit
is20to26%.Depressionoccurstwiceasfrequently
inwomenasinmen.
ClassificationofDepression(ICD10)
•Milddepression
•Moderatedepression
•Severedepression
•Severedepressionwithpsychoticsymptoms
ClinicalFeatures
Atypicaldepressiveepisodeischaracterized
bythefollowingfeatures,whichshouldlast
foratleasttwoweeksinordertomakeadia­
gnosis:
Thenurse'spresenceandmanner
willhelptocommunicateherinterest.
Limitsmustbeestablishedbyothers
whentheclientisunabletouse
internalcontrolseffectively.
Theclient'sabilitytodealwith
stimuliisimpaired.
Consistencyandstructurecan
reassuretheclientandfoster
desirablebehavior.
Depressedmood:Sadnessofmoodorlossof
interestandlossofpleasureinalmostallactivities
(pervasivesadness),presentthroughouttheday
(persistentsadness).
Depressivecognitions:Hopelessness(afeelingof
'nohopeinfuture'duetopessimism),help­
lessness(thepatientfeelsthatnohelpispossible),
worthlessness(afeelingofinadequacyand
inferiority),unreasonableguiltandself-blame
overtrivialmattersinthepast.
Suicidalthoughts:Ideasofhopelessnessareoften
accompaniedbythethoughtthatlifeisnolonger
worthlivingandthatdeathhadcomeasa
welcomerelease.Thesegloomypreoccupations
mayprogresstothoughtsofandplansforsuicide.

100. TheIndividualwithFunctionalPsychiatricDisorder97
Psychomotoractivity:Psychomotorretardation
isfrequent.Theretardedpatientthinks,walks
andactsslowly.Slowingofthoughtisreflected
inthepatient'sspeech;questionsareoften
answeredafteralongdelayandinamonotonous
voice.Inolderpatientsagitationiscommonwith
markedanxiety,restlessnessandfeelingsof
uneasiness.
Psychoticfeatures:Somepatientshavedelusions
andhallucinations(thedisordermaythenbe
termedaspsychoticdepression);theseareoften
moodcongruent,i.e.theyarerelatedtodepressive
themesandreflectthepatient'sdysphoricmood.
Forexample,nihilisticdelusions(beliefsabout
thenon-existenceofsomepersonorthing),delu­
sionsofguilt,delusionsofpoverty,etc.maybe
present.
Somepatientsexperiencedelusionsandhallu­
cinationsthatarenotclearlyrelatedtodepressive
themes(moodincongruent),forexample,delusion
ofcontrol.Theprognosisthenappearstobemuch
worse.
Somaticsymptomsofdepression,accordingto
ICDlO(thesearecalledas'melancholicfeatures'in
DSMIV):
•Significantdecreaseinappetiteorweight.
•Earlymorningawakening,atleast2ormore
hoursbeforetheusualtimeofwakingup.
•Diurnalvariation,withdepressionbeing
worstinthemorning.
•Pervasivelackofinterestandlackofreactivity
topleasurablestimuli.
•Psychomotoragitationorretardation.
OtherFeatures
•Difficultiesinthinkingandconcentration.
•Subjectivepoormemory.
•Menstrualorsexualdisturbances.
•Vaguephysicalsymptomssuchasfatigue,
achingdiscomfort,constipation,etc.
Treatment
Pharmacotherapy
Antidepressantsarethetreatmentofchoicefora
vastmajorityofdepressiveepisodes(SeeChapter
14,pg175).
Electroconvulsivetherapy(ECT)
Severedepressionwithsuicidalriskisthemost
importantindicationforECT(SeeChapter14,pg
182,).
PsychosocialTreatment
•Cognitivetherapy:Itaimsatcorrectingthedep­
ressivenegativecognitionslikehopelessness,
worthlessness,helplessnessandpessimistic
ideas,andreplacingthemwithnewcognitive
andbehavioralresponses.
•Supportivepsychotherapy:Varioustechniques
areemployedtosupportthepatient.Theyare
reassurance,ventilation,occupationalthe­
rapy,relaxationandotheractivitytherapies.
•Grouptherapy:Grouptherapyisusefulfor
mildcasesofdepression.Ingrouptherapy
negativefeelingssuchasanxietyanger,guilt,
despairarerecognizedandemotionalgrowth
isimprovedthroughexpressionoftheir
feelings.
•Familytherapy:Familytherapyisusedto
decreaseintrafamilialandinterpersonaldiffi­
cultiesandtoreduceormodifystressors,
whichmayhelpinfasterandmorecomplete
recovery.
•Behaviortherapy:Itincludessocialskillstrain­
ing,problemsolvingtechniques,assertiveness
training,self-controltherapy,activityschedu­
linganddecisionmakingtechniques.
CourseandPrognosisofMoodDisorders
Anaveragemanicepisodelastsfor3-4months,
whileadepressiveepisodelastsfor4-9months.
GoodPrognosticFactors
•Abruptoracuteonset
•Severedepression
•Typicalclinicalfeatures
•Well-adjustedpremorbidpersonality
•Goodresponsetotreatment
PoorPrognosticFactors
•Doubledepression
•Co-morbidphysicaldisease,personalitydis­
ordersoralcoholdependence

101. 98AGuidetoMentalHealthandPsychiatricNursing
•Chronicongoingstress
•Poordrugcompliance
•Markedhypochondriacalfeaturesormood­
incongruentpsychoticfeatures
OTHERMOODDISORDERS
BipolarMoodDisorder
Thisischaracterizedbyrecurrentepisodesof
maniaanddepressioninthesamepatientat
differenttimes.
Bipolarmooddisorderisfurtherclassifiedinto
bipolarIandbipolarIIdisorder(DSMIV).
BipolarI:Episodesofseveremaniaandsevere
depression.
BipolarII:Episodesofhypomaniaandsevere
depression.
RecurrentDepressiveDisorder
Thisdisorderischaracterizedbyrecurrentdepres­
siveepisodes.Thecurrentepisodeisspecifiedas
mild,moderate,severe,severewithpsychotic
symptoms.
PersistentMoodDisorder
(CyclothymiaandDysthymia)
Thesedisordersarecharacterizedbypersistent
moodsymptomsthatlastformorethan2years.
Cyclothymiareferstoapersistentinstabilityin
moodinwhichtherearenumerousperiodsof
mildelationormilddepression.
Dysthymia(neurotic/reactivedepression)isa
chronic,milddepressivestatepersistingformonths
oryears.Itismorecommoninfemaleswithan
averageageofonsetinlatethirddecade.Anepisode
ofmajordepressionmaysometimesbecomesuper­
imposedonanunderlyingneuroticdepression.
Thisisknownas'doubledepression.'
(seeTable7.18fordifferencesbetweensomatic
andneuroticdepression).
NursingManagement ofMajor
DepressiveEpisode
NursingAssessment
Nursingassessmentshouldfocusonjudgingthe
severityofthedisorderincludingtheriskof
suicide,identifyingthepossiblecauses,thesocial
resourcesavailabletothepatient,andtheeffects
ofthedisorderonotherpeople.Althoughthereis
ariskofsuicideineverydepressedpatient,the
riskismuchmoreinthepresenceofthefollowing
factors:
•Presenceofmarkedhelplessness
•Malesex
•Morethan40yearsofage
Table7.18:Differencesbetweensomatic(major/endogenousdepression/melancholia)
andneuroticdepression(reactive)
Endogenous Reactive
(a)Causedbyfactorswithinthe
individual.
(b)Premorbidpersonality:cyclothymic
ordysthymic.
(c)Earlymorningawakening
(lateinsomnia).
(d)Patientfeelsmoresadinthemorning.
(e)Feelsbetterwhenalone.
(f)PsychoticfeaturesIikepsychomotor
retardation,suicidaltendencies,delusions
etcarecommon.
(g)Relapsesarecommon.
(h)ECTandantidepressantsareused
formanagement.
(i)Insightisabsent.
Causedbystressfulevents.
Premorbidpersonality:
anxious,orobsessive.
Difficultyinfallingasleep
(earlyinsomnia).
Patientfeelsmoresadintheevening.
Feelsbetterwheninagroup.
Usuallypsychomotoragitation
andnootherpsychotic
features.
Relapsesareuncommon.
Psychotherapyand
antidepressantsareused
formanagement.
Insightispresent.

102. self,evidencedbyexpressionofworthlessness,
sensitivitytocriticism,negativeandpessimistic
outlook.
TheIndividualwithFunctionalPsychiatricDisorder99
•Unmarried,widowedordivorced
•Writtenorverbalcommunicationofsuicidal
intentorplan
•Earlystagesofdepression
•Recoveryfromdepression(atthepeakof
depressionthepatientisusuallyeithertoo
depressedortooretardedtocommitsuicide)
•Periodofthreemonthsfromrecovery
Thenurseshouldroutinelyenquireabout
thepatient'swork,finances,familylife,social
activities,generallivingconditionsandphysical
health.Itisalsoimportanttoconsiderwhether
thepatientcouldendangerotherpeople,parti­
cularlyiftherearedepressivedelusionsandthe
patientmayactonthem.
NursingDiagnosisI
Highriskofself-directedviolencerelatedto
depressedmood,feelingsofworthlessnessand
angerdirectedinwardontheself.
Objective:Patientwillnotharmself.
Intervention:SeeTable7.19.
NursingDiagnsoisII
Dysfunctionalgrievingrelatedtorealorperceived
loss,bereavement,evidencedbydenialofloss,
inappropriateexpressionofanger,inabilityto
carryoutactivitiesofdailyliving.
Objective:Patientwillbeabletoverbalizenormal
behaviorsassociatedwithgrieving.
Intervention:SeeTable7.20.
NursingDiagnosisIll
Powerlessnessrelatedtodysfunctionalgrieving
process,life-styleofhelplessness,evidencedby
feelingsoflackofcontroloverlifesituations,over­
dependenceonotherstofulfilneeds.
Objective:Thepatientwillbeabletotakecontrol
oflifesituations.
Intervention:SeeTable7.21.
NursingDiagnosisIV
Self-esteemdisturbancerelatedtolearnedhelp­
lessness,impairedcognition,negativeviewof
Objective:Patientwillbeabletoverbalizepositive
aspectsaboutselfandattemptnewactivities
withoutfearoffailure.
Intervention:SeeTable7.22.
NursingDiagnosisV
Alteredcommunicationprocessrelatedtodepres­
sivecognitions,evidencedbybeingunableto
interactwithothers,withdrawn,expressingfear
offailureorrejection.
Objective:Patientwillcommunicateorinteract
withstafforotherpatientsintheunit.
Intervention:SeeTable7.23.
NursingDiagnosisVI
Alteredsleepandrest,relatedtodepressedmood
anddepressivecognitionsevidencedbydifficulty
infallingasleep,earlymorningawakening,verbal
complaintsofnotfeelingwell-rested.
Objective:Patientwillsleepadequatelyduringthe
night.
Intervention:SeeTable7.24.
NursingDiagnosisVII
Alterednutrition,lessthanbodyrequirements
relatedtodepressedmood,lackofappetiteor
lackofinterestinfood,evidencedbyweightloss,
poormuscletone,paleconjunctiva,poorskin
turgor.
Objective:Patient'snutritionalstatuswillimprove.
Intervention:SeeTable7.25.
NursingDiagnosisVIII
Self-caredeficitrelatedtodepressedmood,
feelingsofworthlessness,evidencedbypoor
personalhygieneandgrooming.
Objective:Patientwillmaintainadequatepersonal
hygiene.
Intervention:SeeTable7.26.

103. 100AGuidetoMentalHealthandPsychiatricNursing
Table7.19:Nursinginterventionsforsuicidalbehaviour
Interventions Rationale
(a)Askthepatientdirectly"Haveyouthought
aboutharmingyourselfinanyway?Ifso,what
doyouplantodo?Doyouhavethemeansto
carryoutthisplan?"
(b)Createasafeenvironmentforthepatient.
Removeallpotentiallyharmfulobjectsfrom
patient'svicinity(sharpobjects,straps,belts,
glassitems,alcohol,etc.),superviseclosely
duringmealsandmedicationadministration.
(c)Formulateashort-termverbalorwritten
contractthatthepatientwillnotharmself.
Secureapromisethatthepatientwillseek
outstaffwhenfeelingsuicidal.
(d)Itmaybedesirabletoplacetheclientnear
thenursingstation.Donotleavethe
patientalone.Observeforpassive
suicide-thepatientmaystarveorfall
asleepinthebath-tuborsink.
(e)Closeobservationisespeciallyrequired
whenthepatientisrecoveringfromthe
disease.
(f)Donotallowthepatienttoputtheboltonhis
sideofthedoorofbathroomortoilet.
(g)Ifthepatientsuddenlybecomesunusually
happyorgivesanyothercluesofsuicide,
specialobservationmaybenecessary.
(h)Encouragethepatienttoexpresshisfeelings,
includinganger.
Theriskofsuicideisgreatly
increasedifthepatienthas
developedaplanandifmeans
existforthepatienttoexecutetheplan.
Patient'ssafetyisnursingpriority.
Adegreeoftheresponsibilityforhis
safetyisgiventothepatient.
Increasedfeelingsofself-worthmay
beexperiencedwhenpatientfeelsaccepted
unconditionallyregardlessofbehavior.
Patient'ssafetyisnursingpriority.
Atthepeakofdepressionthepatient
isusuallytooretardedtocarryout
hissuicidalplans.
Patient'ssafetyisnursingpriority.
-do-
Depressionandsuicidalbehavior
maybeviewedasangerturnedinwardonthe
self.Iftheangercanbeverbalizedinanon­
threateningenvironment,thepatientmaybeable
toeventuallyresolvethesefeelings.
Table7.20:Nursinginterventionsforgriefreaction
Interventions Rationale
(a)Assessstageoffixationingriefprocess.
(b)Beacceptingofpatientandspendtimewith
him.Showempathy,careand
unconditional,positiveregard.
(c)Explorefeelingsofangerandhelppatient
directthemtowardstheintendedobjector
person.
(d)Providesimpleactivitieswhichcanbe
easilyandquicklyaccomplished.
Graduallyincreasetheamountand
complexityofactivities.
Accuratebaselinedataisrequiredto
planaccuratecare.
Theseinterventionsprovidethebasis
foratherapeuticrelationship.
Untilpatientcanrecognizeand
acceptpersonalfeelingsregarding
theloss,griefworkcannotprogress.
Physicalactivitiesaresafeandan
effectivewayofrelievinganger.

104. TheIndividualwithFunctionalPsychiatricDisorder101
Table7.21:Nursinginterventionsforoverdependencebehaviour
(a)Allowthepatienttotakedecisions
regardingowncare.
Ensurethatgoalsarerealisticandthat
patientisabletoidentifylife
situationsthatarerealisticallyunderhis
control.
Encouragethepatienttoverbalizefeelings
aboutareasthatarenotinhisabilityto
control.
Providingpatientwithchoiceswill
increasehisfeelingsofcontrol.
Toavoidrepeatedfailureswhich
furtherincreasehissenseof
powerlessness.
Interventions Rationale
(b)
(c) Verbalizationofunresolvedissues
mayhelpthepatienttoaccept
whatcannotbechanged.
Table7.22:Nursinginterventionstoimproveself-esteemindepressedpatients
(a)Beacceptingofpatientandspendtime
withhim,eventhoughpessimismand
negativismmayseemobjectionable.
Focusonstrengthsandaccomplishments
andminimizefailures.
Providehimwithsimpleandeasily
achievableactivity.Encouragethepatient
toperformhisactivitieswithout
assistance.
Encouragepatienttorecognizeareasof
changeandprovideassistancetowardthis
effort.
Teachassertivenessandcopingskills.
Theseinterventionscontribute
towardsfeelingofself-worth.
Interventions Rationale
(b)
(c)
(d)
(e)
-do-
Successandindependencepromote
feelingsofself-worth.
Tofacilitateproblemsolving.
Theirusecanservetoenhanceself­
esteem.
Table7.23:Nursinginterventionstoimprovecommunicationskillsindepressedpatients
i Interventions Rationale
(a)Observefornon-verbalcommunication.
Thepatientmaysaythatheishappybut
lookssad.Pointoutthisdiscrepancyin
whatheissayingandactuallyfeeling.
Useshortsentences.Askquestions
insuchawaythatthepatientwillhaveto
answerinmorethanoneword.
Usesilenceappropriatelywithout
communicatinganxietyordiscomfort
indoingso.
Introducethepatienttoanotherpatient
whoisquietandpossiblyconvalescing
fromdepression.
Asheimproves,takehimtoother
patientsandseethatheisactuallyincluded
aspartofthegroup.
Tofacilitatebetterresponseand
communication.
(b)
(c)
(d)
(f)
-do-
Usingsilencewhenthesituation
demandscanbetherapeutic.
Thereislessanxietyinrelatingtoa
personotherthanstaff.
Groupsupportisimportantin
facilitatingcommunication.

105. 102AGuidetoMentalHealthandPsychiatricNursing
Table7.24:Nursinginterventionstoimprovesleepingpattern
Interoentions Rationale
(a)Plandaytimeactivitiesaccordingto
thepatient'sinterests,donotallow
himtositidle.
Ensureaquietandpeaceful
environmentwhenthepatient
ispreparingforsleep.
Providecomfortmeasures
(backrub,tipidbath,warmmilk,etc).
Donotallowthepatienttosleepforlong
timeduringtheday.
Givep.r.n.sedativesasprescribed.
Talktothepatientforabriefperiod
atbedtime.Donotenterintolengthy
conversations.
Toimprovesleepduringnight.
-do-
-do-
-do-
-do-
Talkingtothepatienthelpsto
relievehisanxiety,butengagingin
longtalksmayincreasedepressivethinking.
(b)
(c)
(d)
(e)
(f)
Table7.25:Nursinginterventionstoimprovenutritionalstatusindepressivepatients
Interventions Rationale
(a)Closelymonitortheclient'sfoodandfluid
intake;maintainintakeand
outputchart.
(b)Recordpatient'sweightregularly.
(c)Findoutthelikesanddislikesofthepersonbefore
hewassickandservethebestpreferredfood.
(d)Servesmallamountsofalight
orliquiddietfrequentlythatisnourishing.
(e)Recordtheclient'spatternofbowel
elimination.
(h)Encouragemorefluidintake,roughage
dietandgreenleafyvegetables.
Theseareusefuldatafor
assessingnutritionalstatus.
-do-
Toencourageeatingand
improvenutritionalstatus.
-do-
Toassessforconstipation.
Forreliefofconstipationif
present.
Table7.26:Nursinginterventionstoimproveself-carefordepressedpatients
Interventions Rationale
(a)Ensurethathetakeshisbathregularly.Depressivepatientwillnothaveany
interestforself-careandmayneedassistan,ce.
Positivesuggestionswillusually
enhancepatient'scooperation.
Positivereinforcementwillimprove
desirablebehavior.
(b)Donotaskthepatient'spermissionfora
washorbath.Forinstance,donotask
"Doyouwanttohaveabath?"Instead
leadthepatienttotheactionwithpositive
suggestions,e.g."Thewaterisready,
letmetakeyouforabath."
Whenthepatienthastakencareofhimself,
expressrealisticappreciation.
(c)

106. TheIndividualwithFunctionalPsychiatricDisorder103
Evaluation
Evaluationisfacilitatedbyusingthefollowing
typesofquestions:
•Hasself-harmtotheindividualbeenavoided?
•Havesuicidalideationssubsided?
•Doespatientsetrealisticgoalsforself?
•Isheabletoverbalizepositiveaspectsabout
self,pastaccomplishmentsandfuture
prospects?
REVIEWQUESTIONS
•Typesofhallucinations(Feb2000,Apr2002)
•Typesofdelusions(Feb2000,Oct2004)
•Mutism(Nov2003)
•Echolalia(Oct2000,Apr2002)
•Echopraxia(Oct2000)
•Ambivalence, anhedonia, nihilism,
confabulation,circumstantiality,tangen­
tiality,clangassociations,flightofideas(Oct
2000),povertyofthought,looseningof
association,perseveration,verbigeration,
formalthoughtdisorder,thoughtalienation
phenomena,dejavu,jamaisvu.
•Pseudohallucinations(Oct2006)
•Pressureofthought(Oct2000,Oct2006)
•Disordersofthought(Nov2003)
•Apathy(Nov2003)
•Thoughtblock(Apr2004)
•Neologism(Nov2003,Apr2004)
•Discusstheconceptsofschizophreniaand
identifypredisposingfactorsinthedeve­
lopmentofschizophrenia(Nov2003)
•Schizophrenia(Apr2002,Apr2004,Oct2005)
•Dynamicsofschizophrenia(Feb2002)
•Typesofschizophrenia(Feb2000)
•Excitedcatatonia(Oct2000)
•Catatonicstupor(Nov2002)
•Clinicalfeaturesofcatatonicstupor(Oct2000)
•Nursingmanagementofapatientwith
paranoidschizophrenia(Oct2004)
•Withdrawnbehavior(Nov1999)
•Aggressivebehavior(Oct2000,Nov2003,Oct
2004,Apr2006)
•Mooddisorders(Nov2002,Nov2003)
•Clinicalfeaturesofmania(Oct2000,Apr2004)
•Triadofmania(Oct2004)
•Nursingmanagementofpatientwithmania
(Oct2000,Nov2003,Apr2006)
•Psychomotorretardation(Oct2004)
•Nursingmanagementofpatientwith
depression(Feb2001,Oct2004,Apr2006)
•Cyclothymia-dysthymia
•Differencesbetweenendogenousandreactive
depression
•Hypomania
•Endogenousdepression(Nov2003,Apr2006)

107. OrganicMentalDisorders
0CLASSIFICATIONOFORGANICMENTAL
DISORDERS
0DEMENTIA
0DELIRIUM
0ORGANICAMNESTICSYNDROME
0MENTALDISORDERSDUETOBRAINDAMAGE,
DYSFUNCTIONANDPHYSICALDISEASE
0PERSONALITYANDBEHAVIORALDISORDERS
DUETOBRAINDISEASE,DAMAGEAND
DYSFUNCTION
Organicmentaldisordersarebehavioralorpsy­
chologicaldisordersassociatedwithtransientor
permanentbraindysfunction.Thesedisorders
haveademonstrableandindependentlydiagno­
sablecerebraldiseaseordisorder.Theyare
classifiedunderFoinICDlO.
CLASSIFICATION OFORGANICMENTAL
DISORDERS
•Dementia
•Delirium
•Organicamnesticsyndrome
•Mentaldisordersduetobraindamage,
dysfunctionandphysicaldisease
•Personalityandbehavioraldisordersdueto
braindisease,damageanddysfunction
DEMENTIA(CHRONICORGANICBRAIN
SYNDROME)
Dementiaisanacquiredglobalimpairmentof
intellect,memoryandpersonalitybutwithout
impairmentofconsciousness.
Incidence
Dementiaoccursmorecommonlyintheelderly
thaninthemiddle-aged.Itincreaseswithagefrom
0.1percentinthosebelow60yearsofageto15to
20percentinthosewhoare80yearsofage.
Etiology
Untreatableandirreversiblecauses:
•DegeneratingdisordersofCNS
•Alzheimer'sdisease(thisisthemost
commonofalldementingillnesses)
•Pick'sdisease
•Huntington'schorea
•Parkinson'sdisease
Treatableandreversiblecauses:
•Vascular-multi-infarctdementia
•Intracranialspaceoccupyinglesions
•Metabolicdisorders-hepaticfailure,renal
failure
•Endocrinedisorders-myxedema,Addison's
disease
•Infections-AIDS,meningitis,encephalitis
•Intoxication-alcohol,heavymetals(lead,
arsenic),chronicbarbituratepoisoning
•Anoxia-anemia,post-anesthesia,chronic
respiratoryfailure
•Vitamindeficiency,especiallydeficiencyof
thiamine,andnicotine
•Miscellaneous-heatstroke,epilepsy,electric
injury
StagesofDementia
StageI:Earlystage(2to4years)
•Forgetfulness
•Declininginterestinenvironment
•Hesitancyininitiatingactions
•Poorperformanceatwork

108. OrganicMentalDisorders105
StageII:Middlestage(2to12years)
•Progressivememoryloss
•Hesitatesinresponsetoquestions
•Hasdifficultyinfollowingsimpleinstructions
•Irritable,anxious
•Wandering
•Neglectspersonalhygiene
•Socialisolation
StageIII:Finalstage(uptoayear).
•Markedlossofweightbecauseofinadequate
intakeoffood
•Unabletocommunicate
•Doesnotrecognizefamily
•Incontinenceofurineandfeces
•Losestheabilitytostandandwalk
•Deathisusuallycausedbyaspiration
pneumonia
ClinicalFeatures(forAlzheimer'sType)
•Personalitychanges:lackofinterestinday­
to-dayactivities,easymentalfatiguability,self­
centered,withdrawn,decreasedself-care
•Memoryimpairment:recentmemoryispro­
minentlyaffected
•Cognitiveimpairment:disorientation,poor
judgment,difficultyinabstraction,decreased
attentionspan
•Affectiveimpairment:labilemood,irritable­
ness,depression
•Behavioralimpairment:stereotypedbehavior,
alterationinsexualdrivesandactivities,
neurotic/psychoticbehavior
•Neurologicalimpairment:aphasia,apraxia,
agnosia,seizures,headache
•Catastrophicreaction:agitation,attemptto
compensatefordefectsbyusingstrategiesto
avoiddemonstratingfailuresinintellectual
performances,suchaschangingthesubject,
crackingjokesorotherwisedivertingthe
interviewer
•Sundownersyndrome:Itischaracterizedby
drowsiness,confusion,ataxia;accidentalfalls
mayoccuratnightwhenexternalstimulisuch
aslightandinterpersonalorientingcuesare
diminished
CourseandPrognosis
Insidiousonsetbutslowprogressivedeterioration
occurs.
Treatment
Untilnownospecificmedicineisavailabletotreat
Alzheimer'sdisease.Adrugcalled'Tacrine'is
beingusedinwesterncountries.Tacrine(Tetra
hydroaminoacridine)isalong-actinginhibitor
ofacetylcholineandalsodelaystheprogression
oftheillness.
Thefollowingdrugsmaybeofsomeusein
causingsymptomaticrelief:
•benzodiazepinesforinsomniaandanxiety
•antidepressantsfordepression
•antipsychoticstoalleviatehallucinationsand
delusions
•anticonvulsantstocontrolseizures
NursingcareforpatientsofAlzheimer's
diseaseismostimportant.Whetherathome,in
anacutehospitalenvironment,aday-carecenter
orinalong-termstayinstitution.Caregiversmust
betrainedtopromotethepatient'sremaining
intellectualabilities;helpthemmaintaintheir
independenceinattendingtotheirusual
functionsandavoidinjuries;andprovidefora
goodqualityoflife.
NursingInterventions
DailyRoutine
Maintainingadailyroutineincludesdrawingup
afixedtimetableforthepatientforwakingupin
themorning,toilet,exerciseandmeals.Thisgives
thepatientasenseofsecurity. ·
Patientsoftendeteriorateafterdark,apheno­
menonknownas'sundowning'.Additionalcare
mustbetakenduringtheeveningandatnight.
Orientthepatienttorealityinordertodecrease
confusion;clockwithlargefacesaidinorientation
totime.Usecalendarwithlargewritinganda
separatepageforeachday.Providenewspapers
whichstimulateinterestincurrentevents.
Orientationofplace,personandtimeshouldbe
givenbeforeapproachingthepatient.

109. 106AGuidetoMentalHealthandPsychiatricNursing
NutritionandBodyWeight
Patientshouldbeprovidedawell-balanceddiet,
richinprotein,highinfiber,withadequate
amountofcalories.Allowplentyoftimeformeals.
Tellthepatientwhichmealitisandwhatisthere
toeat;foodservedshouldbeneithertoohotnor
toocold.Manypatientshavesugarcraving.Care
shouldbetakenthatsuchpatientsdonotgain
weight.Thedietshouldtakeintoaccountother
medicalillnesseswhichrequiredietmodification,
suchasdiabetesorhighbloodpressure.Semi­
soliddietisthesafestwhileliquidsarethemost
dangerousasthesecanbeeasilyaspiratedinto
thelungs.
PersonalHygiene
Particularcareshouldbetakenaboutthepatient's
personalhygieneincludingbrushingofteeth,
bathing,keepingtheskincleananddry,
particularlyinareaspronetoperspiration,such
asthearmpitsandgroin.Causticsubstancessuch
asspiritorantisepticsolutionsshouldnotbeused
routinelyontheskin.Remembertocheckfinger
andtoenailsregularly,cutthemiftheperson
cannotdoitbyhimself.
Peoplewithdementiamayhaveproblemwith
thelockonthebathroomdoor;ifthishappensit
isadvisabletoremovethelock.Complimentthe
patientwhenhe/shelooksgood.
ToiletHabitsandIncontinence
Toilethabitsshouldbeestablishedassoonas
possibleandmaintainedasarigidroutine.This
includesconditionedbehaviorsuchasgoingfor
bowelmovementimmediatelyafteracupoftea.
Thepatientshouldbetakentourinateatfixed
interval,dependingontheseasonandamountof
fluidintake.Prostatetroublecommoninelderly
menleadstodiscomfortasitcausesurgencyand
frequencyofurinationparticularlyinwinters.A
doctorshouldcheckthis.
Incontinenceisverydistressingtothepatient
andfamily.Onceincontinencesetsin,theunder­
garments,pantsofthepatientandthehousein
generalstartreekingoffoulsmell.Toilethabits,
establishedinhealthyyearsmustbemaintained
aslongaspossiblebygentlypersuadingthe
patienttogotothetoiletanduseit.Whenthefirst
signofincontinenceappearsdoctorshouldcheck
foranunderlyingcauseifany,suchasurinary
infectionorurinarytractdamage.
Constipationisafrequentcauseofdiscomfort
tothepatient.Thequantityoffaecespassedeach
morningshouldbecheckedtoensurethatthe
patientisnotconstipated.Constipationcanbe
avoidedbyaddingfibersupplementsand
roughagetothedietonadailybasis.
Accidents
Greatcareshouldbetakentoavoidaccidents
causedbytrippingoverfurniture,fallingdown
thestairsorslippinginthebathroom.Thereasons
forfallingincludelooseandpoorlyfitting
footwearandwrinkledcarpets.Ideally,patients
shouldbemadetowearsoftslip-onshoeswith
strapswhichfitsecurely.Anyfloorcoveringmust
befirmlysecured.
Olderpeoplehavebeendrivingforyearsand
inmodemcitiesmanypeoplearedependenton
theirpersonalcarsfortransportation.Onceearly
signsofthediseaseappear,patientsshouldbe
gentlypersuadedtostopdrivingasthiscanpose
ahazardtothemandothers.
Makesurethatlightsarebrightenough.Keep
matches,bleach,andpaintsoutofreach.Donot
allowthepatienttotakemedicationalone.
FluidManagement
Thepatientsrequireasmuchfluidasnormal
peopleandthisdependsontheseason.Ideally,
sufficientfluidshouldbegivenduringtheday
andonlytheminimumessentialamountoffluid
(somewaterwithdinner)after6pm.Thelastcup
ofteashouldbegivenaround5pm.Afterthatno
beveragesincludingtea,coffee,cocoaoranyother
caffeinecontainingdrinksshouldbegiven,asall
thesepromoteurination.Properfluidmanagement
willreducebed-wettingandalsoreducethe
numberoftimesthepatientwillneedtogetup
duringthenight.

110. OrganicMentalDisorders107
MoodsandEmotions
SomepatientsofAlzheimer'sdiseasehaveabrupt
changeintheirmoodsandemotions.These
changescanbeunpredictable.Moodchangesare
bestcontrolledbykeepingacalmenvironment
withfixeddailyroutine.Thepatientsshouldnot
bequestionedrepeatedlyorgiventoomany
choices,suchaswhattheywanttoeatorwhat
theywanttowear.Moodchangesarealso
amenabletodistraction,particularlyiftopics
relatedtothepastarediscussedorfavoritepieces
ofmusicplayed.Forexample,ifmusicthat
remindsthepatientsoftheirchildhoodisplayed,
thepleasantassociationsputtheminanostalgic
mood.Ifpatientbehaviorandemotionsare
distressingtothefamilymembersthedoctormay
prescribesomemedicationstocalmthepatient.
Wandering
PatientsofAlzheimer'sdiseaseoftenlosetheir
geographicorientationandcangetlostevenin
familiarsurroundings.Theymaybefound
wanderingaimlesslyeitherintheneighborhood
orfaraway.Itisadvisabletohavesomeidenti­
ficationbraceletorcardalwaysintheirposses­
sion.Thedoorsofthehouseshouldbesecurely
lockedsothatthepatientscannotleaveunnoticed.
Thepatientshouldalwaysbeaccompaniedwhile
goingforwalksorforsimplechoresoutsidethe
house.
DisturbedSleep
Sleepdisturbancesareextremelydistressingto
thefamily.Ifthepatientisrestlessatnightor
wandersandtalksatnight,theentirefamilyis
disturbed.Sleeppatternsmustbemaintained.
Nappingduringthedayshouldbeavoided.
Sleepingpillsarebestavoidedastheireffectis
temporaryandfrequentlyunpredictablein
patientsofAlzheimer'sdisease.Causesof
discomfortatnight,suchaspain,uncomfortable
temperatureorprostatetrouble,shouldbe
checked.
InterpersonalRelationship
Verbalcommunicationshouldbeclearand
unhurried.Questionsthatrequire'yes',or'no'
answersarebest.Reinforcesociallyacceptable
skills.Givenecessaryinformationrepeatedly.
Focusonthingsthepersondoeswellratherthan
onmistakesorfailures.Trytomakesurethateach
dayhassomethingofinterestforthepatient-it
mightbegoingforawalk,listeningtomusic;talk
abouttheday'sactivities.Trytoinvolvehimwith
oldfriendsforachat,reminiscingaboutthepast.
Familymembersshouldbeawareofearly
warningsignswhichmaysuggestthatoneofthe
oldermembersmaybeonthevergeofdeveloping
Alzheimer'sdisease.Earlydiagnosisandearly
interventioncanbebeneficialbothtothepatient
andthefamily.
Asthediseaseprogresses,thefamilyremains
themainpillarofsupportforthepatient.
Alzheimer'sassociationsaroundtheworld
providepracticalandemotionalhelpand
informationtofamilies,healthcareprofessionals
andthecommunity.Alzheimer'sandRelated
DisordersSocietyofIndia(ARDSI)startedin1992,
anationalorganizationdedicatedtodementia
care,supportandresearch.
DELIRIUM(ACUTEORGANICBRAIN
SYNDROME) It:
Deliriumisanacuteorganicmentaldisorder
characterizedbyimpairmentofconsciousness,
disorientationanddisturbancesinperception
andrestlessness.
Incidence
Deliriumhasthehighestincidenceamong
organicmentaldisorders.About10to25%
ofmedical-surgicalinpatients,andabout20to
40%ofgeriatricpatientsmeetthecriteriafor
deliriumduringhospitalization.Thispercentage
ishigherinpost-operativepatients.
Etiology
•Vascular:hypertensiveencephalopathy,cere­
bralarteriosclerosis,intracranialhemorrhage

111. 108AGuidetoMentalHealthandPsychiatricNursing
•Infections:encephalitis,meningitis
•Neoplastic:spaceoccupyinglesions
•Intoxication:chronicintoxicationorwith­
drawaleffectofsedative-hypnoticdrugs
•Traumatic:subduralandepiduralhematoma,
contusion,laceration,post-operative,heat­
stroke
•Vitamindeficiency,e.g.thiamine
•Endocrineandmetabolic:diabeticcomaand
shock,uremia,myxedema,hyperthyroidism,
hepaticfailure
•Metals:heavymetals(lead,manganese,'mer­
cury),carbonmonoxideandtoxins
•Anoxia:anemia,pulmonaryorcardiacfailure
ClinicalFeatures
•Impairmentofconsciousness:cloudingof
consciousnessrangingfromdrowsinessto
stuporandcoma.
•Impairmentofattention:difficultyinshifting,
focusingandsustainingattention.
•Perceptualdisturbances:illusionsandhallu­
cinations,mostoftenvisual.
•Disturbanceofcognition:impairmentof
abstractthinkingandcomprehension,impair­
mentofimmediateandrecentmemory,
increasedreactiontime.
•Psychomotordisturbance:hypoorhyper­
activity,aimlessgropingorpickingatthebed
clothes(flocculation),enhancedstartle
reaction.
•Disturbanceofthesleep-wakecycle:insomnia
orinseverecasestotalsleeplossorreversal
ofsleep-wakecycle,daytimedrowsiness,
nocturnalworseningofsymptoms,disturbing
dreamsornightmares,whichmaycontinue
ashallucinationsafterawakening.
•Emotionaldisturbances:depression,anxiety,
fear,irritability,euphoria,apathyorwonder­
ingperplexity.
CourseandPrognosis
Theonsetisusuallyabrupt.Thedurationof
anepisodeisusuallybrief,lastingforabouta
week
Treatment
•Identificationofcauseanditsimmediate
correction,e.g.,50mgof50%dextroseIVfor
hypoglycemia,02forhypoxia,100mgofB1IV
forthiaminedeficiency,IVfluidsforfluidand
electrolyteimbalance.
•Symptomaticmeasures:benzodiazepines(10
mgdiazepamor2mglorazepamIV)or
antipsychotics(5mghaloparidolor50mg
chlorpromazineIM)maybegiven.
NursingIntervention
1.Providingsafeenvironment:
•restrictenvironmentalstimuli,keepunit
calmandwell-illuminated
•thereshouldalwaysbesomebodyatthe
patient'sbedsidereassuringandsup­
porting
•asthepatientisrespondingtoaterrifying
unrealisticworldofhallucinatoryillusions
anddelusions,specialprecautionsare
neededtoprotecthimfromhimselfandto
protectothers
2.Alleviatingpatient'sfearandanxiety:
•removeanyobjectintheroomthatseems
tobeasourceofmisinterpretedperception
•asmuchaspossiblehavethesameperson
allthetimebythepatient'sbedside
•keeptheroomwelllightedespeciallyat
night
3.Meetingthephysicalneedsofthepatient:
•appropriatecareshouldbeprovidedafter
physicalassessment
•useappropriatenursingmeasuresto
reducehighfever,ifpresent
•maintainintakeandoutputchart
•mouthandskinshouldbetakencareof
•monitorvitalsigns
•observethepatientforanyextreme
drowsinessandsleepasthismaybean
indicationthatthepatientisslippinginto
acoma
4.Facilitateorientation:
•repeatedlyexplaintothepatientwherehe
isandwhatdate,dayandtimeitis

112. OrganicMentalDisorders109
•introducepeoplewithnameevenifthe
patientmisidentifiesthepeople
•haveacalendarintheroomandtellhim
whatdayitis
•whentheacutestageisovertakethepatient
outandintroducehimtoothers
ORGANICAMNESTICSYNDROME
Organicamnesticsyndromeischaracterizedby
impairmentofmemoryandglobalintellectual
functioningduetoanunderlyingorganiccause.
Thereisnodisturbanceofconsciousness.
Etiology
•Thiaminedeficiency,themostcommoncause
beingchronicalcoholism.Itisalsocalledas
"Wernicke-Korsakoffsyndrome."Wernicke's
encephalopathyisanacutephaseofdelirium
precedingamnesticsyndrome,whileKorsa­
koff'ssyndromeisachronicphaseofamnestic
syndrome.
•Headtrauma
•Bilateraltemporallobectomy
•Hypoxia
•Braintumors
•Herpessimplexencephalitis
•Stroke.
ClinicalFeatures
•Recentmemoryimpairment
•Anterogradeandretrogradeamnesia
•Thereisnoimpairmentofimmediatememory
Management
•Treatmentforunderlyingcause.
MENTALDISORDERS DUETOBRAIN
DAMAGE,DYSFUNCTION ANDPHYSICAL
DISEASE
Thesearementaldisorders,whicharecausally
relatedtobraindysfunctionduetoprimarycere­
braldisease,systemicdiseaseortoxicsubstances.
Primarycerebraldiseases:Epilepsy,encephalitis,
headtrauma,brainneoplasms,vascularcerebral
diseaseandcerebralmalformations.
Systemicdiseases:Hypothyroidism,Cushing's
disease,hypoxia,hypoglycemia,systemiclupus
erythematosisandextracranialneoplasms.
Drugs:Steroids,antihypertensives,antimalarials,
alcoholandpsychoactivesubstances.
Thefollowingmentaldisorderscomeunder
thiscategory:
•Organichallucinosis
•Organiccatatonicdisorder
•Organicdelusionaldisorder
•Organicmooddisorder
•Organicanxietydisorder.
PERSONALITY ANDBEHAVIORAL
DISORDERS DUETOBRAINDISEASE,
DAMAGEANDDYSFUNCTION
Thesedisordersarecharacterizedbysignificant
alterationofthepremorbidpersonalitydueto
underlyingorganiccause.Thereisnodisturbance
ofconsciousnessandglobalintellectualfunction.
Thepersonalitychangemaybecharacterizedby
emotionallability,poorimpulsecontrol,apathy,
hostilityoraccentuationofearlierpersonality
traits.
Etiology
•Complexpartialseizures(temporallobe
seizures)
•Cerebralneoplasms
•Cerebrovasculardisease
•Headinjury.
Management
•Treatmentfortheunderlyingcause.
•Symptomatictreatmentwithlithium,carba­
mazepineorwithantipsychotics.
REVIEWQUESTIONS
•Classificationoforganicmentaldisorders
•Dementia(Feb2000,Feb2001,Nov2001,Apr
2002,Nov2003,Oct2004,Oct2005,Oct2006)
•Delirium(Oct2004)
•Amnesticsyndrome

113. TheIndividualwith
NeuroticDisorder
eitherexcessiveorprolongedemotionalreaction
toanygivenstress.Thesedisordersarenot
causedbyorganicdiseaseofthebrainand,
howeversevere,donotinvolvehallucinations
anddelusions.TheyareclassifiedunderF4in
ICDlO.
Fordifferencesbetweenpsychoticand
neuroticdisorderSeeTable9.1.
0DIFFERENCESBETWEENPSYCHOTICAND
NEUROTICDISORDERS
0CLASSIFICATION
0PHOBICANXIETYDISORDER
0GENERALIZEDANXIETYDISORDER
0PANICDISORDER
0OBSESSIVE-COMPULSIVE DISORDER(OCD)
0REACTIONTOSTRESSANDADJUSTMENT
DISORDER
0DISSOCIATIVEDISORDERS
0SOMATOFORMDISORDERS
Neuroticdisorder(neurosis)isalesssevereformCLASSIFICATION [ICD1O]
ofpsychiatricdisorderwherepatientsshow •Phobicanxietydisorder
Table9.1:Differencesbetweenpsychoticdisorder(psychosis)andneuroticdisorder(neurosis)
Psychoticdisorder Neuroticdisorder
Etiology
Geneticfactors
Stressfullifeevents
Clinicalfeatures
Disturbancesofthinking
andperception
Disturbancesincognitive
function
Behavior
Judgment
Insight
Realitytesting
Treatment
Drugs
moreimportant
lessimportant
lessimportant
moreimportant
common
common
rare
rare
markedlyaffected
impaired
lost
lost
notaffected
intact
present
present
majortranquil-
izerscommonlyused
veryuseful
notmuchuseful
difficulttotreat;
relapsesare
common;
completerecovery
maynotbepossible
ECT
Psychotherapy
Prognosis
minortranquilizers
andanti-depressantsare
commonlyused
notuseful
veryuseful;
relativelyeasytotreat;
relapsesare
uncommon;
completerecoveryis
possible

114. TheIndividualwithNeuroticDisorder111
•Otheranxietydisorders
•Obsessive-compulsivedisorder
•Reactiontoseverestressandadjustment
disorders
•Dissociative(conversion)disorders
•Somatoformdisorder
•Otherneuroticdisorders
PHOBICANXIETYDISORDER
Anxietyisanormalphenomenon,whichis
characterizedbyastateofapprehensionor
uneasinessarisingoutofanticipationofdanger.
Normalanxietybecomespathologicalwhenit
causessignificantsubjectdistressandimpair­
mentoffunctioningoftheindividual.
Anxietydisordersareabnormalstatesin
whichthemoststrikingfeaturesarementaland
physicalsymptomsofanxiety,whicharenot
causedbyorganicbraindiseaseoranyother
psychiatricdisorder.
Aphobiaisanunreasonablefearofaspecific
object,activityorsituation.Thisirrationalfearis
characterizedbythefollowingfeatures:
•Itisdisproportionatetothecircumstancesthat
precipitateit.
•Itcannotbedealtwithbyreasoningor
controlledthroughwillpower.
•Theindividualavoidsthefearedobjector
situation.
Inphobicanxietydisorders,theindividual
experiencesintermittentanxietywhicharisesin
particularcircumstances,i.e.inresponsetothe
phobicobjectorsituation.
TypesofPhobia
•Simplephobia
•Socialphobia
•Agoraphobia
Simplephobia(Specificphobia)Simplephobiais
anirrationalfearofaspecificobjectorstimulus.
Simplephobiasarecommoninchildhood.By
earlyteenagemostofthesefearsarelost,buta
fewpersisttilladultlife.Sometimestheymay
reappearafterasymptom-freeperiod.Exposure
tothephobicobjectoftenresultsinpanicattacks.
Examplesofsomespecificphobias:
•Acrophobia-fearofheights
•Hematophobia-fearofthesightofblood
•Claustrophobia-fearofclosedspaces
•Gamophobia-fearofmarriage
•Insectophobia-fearofinsects
•AIDSphobia-fearofAIDS
SocialphobiaSocialphobiaisanirrationalfear
ofperformingactivitiesinthepresenceofother
peopleorinteractingwithothers.Thepatientis
afraidofhisownactionsbeingviewedbyothers
critically,resultinginembarrassmentorhumilia­
tion.
AgoraphobiaItischaracterizedbyanirrational
fearofbeinginplacesawayfromthefamiliar
settingofhome,incrowds,orinsituationsthat
thepatientcannotleaveeasily.
Astheagoraphobiaincreasesinseverity,there
isagradualrestrictioninnormalday-to-day
activities.Theactivitymaybecomesoseverely
restrictedthatthepersonbecomesself-imprisoned
athome.
Inalltheabovementionedphobias,theindi­
vidualexperiencesthesamecoresymptomsasin
generalizedanxietydisorders.Thesearelisted
onpage114.
Etiology
PsychodynamictheoryAccordingtothistheory,
anxietyisusuallydealtwithrepression.When
repressionfailstofunctionadequately,other
secondarydefensemechanismsofegocomeinto
action.Inphobia,thissecondarydefencemecha­
nismisdisplacement.Bydisplacementanxietyis
transferredfromareallydangerousorfrightening
objecttoaneutralobject.Thesetwoobjectsare
connectedbysymbolicassociations.Theneutral
objectchosenunconsciouslyistheonethatcan
beeasilyavoidedinday-to-dayactivities,in
contrasttothefrighteningobject.
LearningtheoryAccordingtoclassicalcondi­
tioningastressfulstimulusproducesan
unconditionedresponse-fear.Whenthestressful
stimulusisrepeatedlypairedwithaharmless
object,eventuallytheharmlessobjectalone

115. 112AGuidetoMentalHealthandPsychiatricNursing
producesthefear,whichisnowaconditioned
response.Ifthepersonavoidstheharmlessobject
toavoidfear,thefearbecomesaphobia.
CognitivetheoryAnxietyistheproductoffaulty
cognitionsoranxiety-inducingself-instructions.
Cognitivetheoristsbelievethatsomeindividuals
engageinnegativeandirrationalthinkingthat
produceanxietyreactions.Theindividualbegins
toseekoutavoidancebehaviorstopreventthe
anxietyreactionsandphobiasresult.
Course
Thephobiasaremorecommoninwomenwith
anonsetinlateseconddecadeorearlythird
decade.Onsetissuddenwithoutanycause.The
courseisusuallychronic.Sometimesphobiasare
spontaneousremitting.
Treatment
Pharmacotherapy
•Benzodiazepines(e.g.alprazolam,clonaze­
pam,lorazepam,diazepam)
•Antidepressants(e.g.imipramine,sertraline,
phenelzine)
Behaviortherapy
•Flooding
•Systematicdesensitization
•Exposureandresponseprevention
•Relaxationtechniques
Cognitivetherapy
Thistherapyisusedtobreaktheanxietypatterns
inphobicdisorders.
PsychotherapySupportivepsychotherapyisa
helpfuladjuncttobehaviortherapyanddrug
treatment.
(ReferChapter14fordetailsofthesetherapies)
NursingManagement
NursingAssessment
Assessmentparametersfocusonphysicalsymp­
toms,precipitatingfactors,avoidancebehavior
associatedwithphobia,impactofanxietyon
Table9.2:Nursinginterventionstoreduceanxiousbehaviour
Interventions Rationale
(a)Reassurethepatientthatheissafe.
(b)Explorepatient'sperceptionofthe
threattophysicalintegrityorthreatto
selfconcept.
(c)Includepatientinmakingdecisions
relatedtoselectionofalternativecoping
strategies(e.g.patientmaychoose
eithertoavoidthephobicstimulusor
attempttoeliminatethefearassociated
withit.)
(d)Ifthepatientelectstoworkoneliminating
thefear,techniquesofdesensitization
orimplosiontherapymaybeemployed.
(e)Encouragepatienttoexploreunderlying
feelingsthatmaybecontributingto
irrationalfears.
Atthepaniclevelofanxietypatient
mayfearforhisownlife.
Itisimportanttounderstand
patient'sperceptionofthephobic
objectorsituationtoassistwith
thedesensitizationprocess.
Allowingthepatienttochoose
providesameasureofcontroland
servestoincreasefeelingsofself­
worth.
Feardecreasesasthephysicaland
psychologicalsensationsdiminish
inresponsetorepeatedexposureto
thephobicstimulusundernon­
threateningconditions.
Facingthesefeelingsratherthan
suppressingthemmayresultinmore
adaptivecopingabilities.

116. TheIndividualwithNeuroticDisorder113
Table9.3:Nursinginterventionstoreducesocialisolationbehaviourinanxiouspatients
Interventions Rationale
(a)Conveyanacceptingattitudeand
unconditionalpositiveregard.Makebrief,
frequentcontacts.Behonestandkeepall
promises.
(b)Attendgroupactivitieswiththepatientthat
maybefrighteningforhim.
(c)Administeranti-anxietymedicationsas
orderedbythephysician,monitorfor
effectivenessandadverseaffects.
(d)Discusswiththepatientsignsandsymptoms
ofincreasinganxietyandtechniquesto
interrupttheresponse.(e.g.relaxation
exercises,thoughtstopping)
(e)Giverecognitionandpositivereinforcement
forvoluntaryinteractionswithothers.
physicalfunctioning,normalcopingability,
thoughtcontentandsocialsupportsystems.
NursingDiagnosisI
Fearrelatedtoaspecificstimulus(simplephobia),
orcausingembarrassmenttoselfinfrontofothers,
evidencedbybehaviordirectedtowards
avoidanceofthefearedobject/situation.
Objective:Patientwillbeabletofunctioninthe
presenceofaphobicobjectorsituationwithout
experiencingpanicanxiety.
Intervention:SeeTable9.2.
NursingDiagnosisII
Socialisolationrelatedtofearofbeinginaplace
fromwhichoneisunabletoescape,evidencedby
stayingalone,refusingtoleavetheroom/home.
Objective:Patientwillvoluntarilyparticipatein
groupactivitieswithpeers.
Intervention:SeeTable9.3.
Evaluation
Reassessmentisconductedtodetermineifthe
nursinginterventionshavebeensuccessfulin
Theseinterventionsincreasefeelings
ofself-worthandfacilitatea
trustingrelationship.
Thepresenceofatrustedindividual
providesemotionalsecurity.
Anti-anxietymedicationshelpto
reducethelevelofanxietyinmost
individuals,therebyfacilitating
interactionswithothers.
Maladaptivebehaviorsuchas
withdrawalandsuspiciousness
aremanifestedduringtimesof
increasedanxiety.
Toenhanceself-esteem
encouragerepetitionofacceptable
behaviors.
achievingtheobjectivesofcare.Following
questionsarehelpfulinevaluation:
•Doesthepatientfacephobicobject/situation
withoutanxiety?
•Doesthepatientvoluntarilyparticipatein
groupactivities?
•Isthepatientabletodemonstratetechniques
thathemayusetopreventanxietyfrom
escalatingtothepaniclevel?
GENERALIZED ANXIETYDISORDER
Generalizedanxietydisordersarethoseinwhich
anxietyisunvaryingandpersistent(unlikephobic
anxietydisorderswhereanxietyisintermittent
andoccursonlyinthepresenceofaparticular
stimulus).Itisthemostcommonneuroticdisorder,
anditoccursmorefrequentlyinwomen.The
prevalencerateofgeneralizedanxietydisorders
isabout2.5-8%.
ClinicalFeatures
Generalizedanxietydisorder(GAD)ismanifested
bythefollowingsignsofmotortension,auto­
nomichyperactivity,apprehensionandvigilence,
whichshouldlastforatleast6monthsinorderto
makeadiagnosis:

117. 114AGuidetoMentalHealthandPsychiatricNursing
Psychological:Fearfulanticipation,irritability,
sensitivitytonoise,restlessness,poorconcen­
tration,worryingthoughtsandapprehension.
Physical:
•Gastrointestinal-drymouth,difficultyin
swallowing,epigastricdiscomfort,frequentor
loosemotions
•Respiratory=-constrictioninthechest,
difficultyinhaling,overbreathing
•Cardiovascular-palpitations,discomfortin
chest
•Genitourinary-frequencyorurgentmic­
turition,failureoferection,menstrualdis­
comfort,amenorrhea
•Neuromuscularsystem-tremor,prickling
sensations,tinnitus,dizziness,headache,
achingmuscles
•Sleepdisturbances-insomnia,nightterror
•Othersymptoms:depression,obsessions,
depersonalization,derealization
Course
Itischaracterizedbyaninsidiousonsetinthe
thirddecadeandusuallyrunsachroniccourse.
PANICDISORDER
Panicdisorderischaracterizedbyanxiety,which
isintermittentandunrelatedtoparticular
circumstances(unlikephobicanxietydisorders
where,thoughanxietyisintermittent,itoccurs
onlyinparticularsituations).Thecentralfeature
istheoccurrenceofpanicattacks,i.e.sudden
attacksofanxietyinwhichphysicalsymptoms
predominateandareaccompaniedbyfearofa
seriousconsequencesuchasaheartattack.The
lifetimeprevalenceofpanicdisorderis1.5to2
percent.Itisseen2to3timesmoreofteninfemales.
ClinicalFeatures
•Shortnessofbreathandsmotheringsensations
•Choking,chestdiscomfortorpain
•Palpitations
•Sweating,dizziness,unsteadyfeelingsor
faintness
•Nauseaorabdominaldiscomfort
•Depersonalizationorderealization
•Numbnessortinglingsensations
•Flushesorchills
•Tremblingorshaking
•Fearofdying
•Fearofgoingcrazyordoingsomething
uncontrolled
Course
Theonsetisusuallyinearlythirddecadewith
oftenachroniccourse.Itoccursrecurrentlyevery
fewdays.Theepisodeisusuallysuddeninonset
andlastsforafewminutes.
EtiologyofAnxietyDisorders(bothGADand
panicdisorder)
•Genetictheory:Anxietydisorderismost
frequentamongrelativesofpatientswiththis
condition.About15to20%ofthefirst-degree
relativesofpatientswithanxietydisorder
exhibitanxietydisordersthemselves.The
concordancerateinmonozygotictwinsof
patientswithpanicdisorderis80percent.
•Biochemicalfactors:AlterationinGABAlevels
mayleadtoproductionofclinicalanxiety.
•Psychodynamictheory:Accordingtothistheory
anxietyisusuallydealtwithrepression.When
repressionfailstofunctionadequately,other
secondarydefensemechanismsofegocome
intoaction.Inanxietyrepressionfailsto
functionadequatelyandthesecondary
defensemechanismsarenotactivated.Hence
anxietycomestotheforefront.
•Behavioraltheory:Anxietyisviewedasan
unconditionalinherentresponseofthe
organismtoapainfulstimulus.
•Cognitivetheory:Accordingtothistheory
anxietyisrelatedtocognitivedistortionsand
negativeautomaticthoughts.
Treatment
Pharmacotherapy
•Benzodiazepines(e.g.alprazolam,clonaze­
pam)
•Antidepressantsforpanicdisorder

118. TheIndividualwithNeuroticDisorder115
•Betablockerstocontrolseverepalpitations
thathavenotrespondedtoanxiolytics(e.g.
propranolol)
Behavioraltherapies
•Bio-feedback
•Hyperventilationcontrol
Otherpsychologicaltherapies
•Jacobson'sprogressivemusclerelaxation
technique,yoga,pranayama,meditationand
self-hypnosis
•Supportivepsychotherapy
NursingManagement
NursingAssessment
Assessmentshouldfocusoncollectionofphysical,
psychologicalandsocialdata.Thenurseshould
beparticularlyawareofthefactthatmajor
physicalsymptomsareoftenassociatedwith
autonomicnervoussystemstimulation.Specific
symptomsshouldbenoted,alongwithstatements
madebytheclientaboutsubjectivedistress.The
nursemustuseclinicaljudgmenttodetermine
thelevelofanxietybeingexperiencedbytheclient.
NursingDiagnosisI
Panicanxietyrelatedtorealorperceivedthreatto
biologicalintegrityorself-concept,evidencedby
variousphysicalandpsychologicalmanifes­
tations.
Objective:Patientwillbeabletorecognizesymp­
tomsofonsetonanxietyandintervenebefore
reachingpaniclevel.
Intervention:SeeTable9.4.
NursingDiagnosisII
Powerlessnessrelatedtoimpairedcognition,
evidencedbyverbalexpressionoflackofcontrol
Table9.4:Nursinginterventionstoreducepanicanxiety
(a)Staywiththepatientandofferreassurance
ofsafetyandsecurity.
Interventions Rationale
(b)Maintainacalm,non-threateningmatter­
of-factapproach.
(c)Usesimplewordsandbriefmessages,
spokencalmlyandclearlytoexplain
hospitalexperiences.
(d)Keepimmediatesurroundingslowin
stimuli(dimlighting,fewpeople).
(e)Administertranquilizingmedication
asprescribedbyphysician.Assessfor
effectivenessandforside-effects.
(f)Whenlevelofanxietyhasbeenreduced,
explorepossiblereasonsforoccurrence.
(g)Teachsignsandsymptomsofescalating
anxietyandwaystointerruptitsprogression
(relaxationtechniques,deep-breathing
exercisesandmeditation,orphysical
exerciselikebriskwalksandjogging.
Presenceoftrustedindividual
providesfeelingofsecurityand
assuranceofpersonalsafety.
Anxietyiscontagiousandmaybe
transferredfromstafftopatientor
vice-versa.
Inanintenselyanxioussituation,
patientisunabletocomprehend
anythingbutthemostelementary
communication.
Astimulatingenvironmentmay
increaseofanxietylevel.
Anti-anxietymedicationprovides
relieffromtheimmobilizingeffects
ofanxiety.
Recognitionofprecipitatingfactors
isthefirststepinteachingpatientto
interruptescalatinganxiety.
Thefirstthreeoftheseactivities
resultinphysiologicresponse
oppositeoftheanxietyresponse,
i.e.asenseofcalm,slowedheart
rate,etc.Thelatteractivities
dischargeenergyinahealthymanner.

119. 116AGuidetoMentalHealthandPsychiatricNursing
Table9.5:Nursinginterventionstoimproveself-controlinanxiouspatients
Interventions Rationale
(a)Allowpatienttotakeasmuch
responsibilityaspossibleforself-care
activities,providepositivefeedback
fordecisionsmade.
(b)Assistpatienttosetrealisticgoals.
(c)Helpidentifylifesituationsthatare
withinpatient'scontrol.
(d)Helppatientidentifyareasoflifesituation
thatarenotwithinhisabilitytocontrol.
Encourageverbalizationoffeelingsrelated
tothisinability.
overlifesituationsandnon-participationin
decision-makingrelatedtoowncareorsignificant
lifeissues.
Objective:Patientwillbeabletoeffectivelysolve
problemsandtakecontrolofhislife.
Intervention:SeeTable9.5.
Evaluation
Identifiedobjectivesserveasthebasisforeva­
luation.Ingeneral,evaluationofobjectivesfor
clientswithanxietydisordersdealswith
questionssuchasthefollowing:
•Istheclientexperiencingareducedlevelof
anxiety?
•Doestheclientrecognizesymptomsasanxiety­
related?
•Istheclientabletousenewlylearnedbeha­
viortomanageanxiety?
OBSESSIVE-COMPULSIVE DISORDER(OCD)
Definition
AccordingtoICD9,obsessive-compulsivedis­
orderisastateinwhich"theoutstanding
symptomisafeelingofsubjectivecompulsion-
whichmustberesisted-tocarryoutsomeaction,
todwellonanidea,torecallanexperience,or
Providingchoiceswillincrease
patient'sfeelingofcontrol.
Unrealisticgoalssetthepatient
upforfailureandreinforcefeelings
ofpowerlessness.
Patient'semotionalcondition
interfereswiththeabilitytosolve
problems.
Assistanceisrequiredtoperceivethe
benefitsandconsequencesof
availablealternativesaccurately,to
dealwithunresolvedissuesand
acceptwhatcannotbechanged.
ruminateonanabstracttopic.Unwanted
thoughts,whichincludetheinsistencyofwords
orideasareperceivedbythepatienttobe
inappropriateornonsensical.Theobsessional
urgeorideaisrecognizedasalientothe
personality,butascomingfromwithintheself.
Obsessionalritualsaredesignedtorelieve
anxiety,e.g.washingthehandstodealwith
contamination.Attemptstodispeltheunwelcome
thoughtsorurgesmayleadtoasevereinner
struggle,withintenseanxiety."
Fromtheabove,obsessionsandcompulsions
shouldhavethefollowingcharacteristics:
•Theyareideas,impulsesorimages,which
intrudeintoconsciousawarenessrepeatedly.
•Theyarerecognizedastheindividual'sown
thoughtsorimpulses.
•Theyareunpleasantandrecognizedas
irrational.
•Patienttriestoresistthembutisunableto.
•Failuretoresistleadstomarkeddistress.
•Rituals(compulsions)areperformedwitha
senseofsubjectivecompulsion(urgetoact).
•Theyareaimedateitherpreventingor
neutralizingthedistressorfeararisingoutof
obsessions.
Thedisordermaybegininchildhood,but
moreoftenbeginsinadolescenceorearly

120. TheIndividualwithNeuroticDisorder117
adulthood.Itisequallycommonamongmenand
women.Thecourseisusuallychronic.
Classification(ICD10)
•OCDwithpredominantlyobsessivethoughts
orruminations.
•OCDwithpredominantlycompulsiveacts.
•OCDwithmixedobsessionalthoughtsand
acts.
Etiology
GeneticFactors
Twinstudieshaveconsistentlyfoundasignifi­
cantlyhigherconcordancerateformonozygotic
twinsthanfordizygotictwins.Familystudiesof
thesepatientshaveshownthat35%ofthefirst­
degreerelativesofobsessive-compulsivedisorder
patientsarealsoaffectedwiththedisorder.
BiochemicalInfluences
Anumberofstudiessuggestthattheneuro­
transmitterserotonin(5-HT)maybeabnormalin
individualswithobsessive-compulsivedisorder.
PsychoanalyticTheory
Thepsychoanalyticconcept(Freud)views
patientswithobsessive-compulsivedisorder
(OCD)ashavingregressedtodevelopmentally
earlierstagesoftheinfantilesuperego,whose
harshexactingpunitivecharacteristicsnow
reappearaspartofthepsychopathology.
Freudalsoproposedthatregressiontothepre­
oedipalanalsadisticphasecombinedwiththe
useofspecificegodefensemechanismslike
isolation,undoing,displacementandreaction
formation,mayleadtoOCD.
BehaviorTheory
Thistheoryexplainsobsessionsasaconditioned
stimulustoanxiety.Compulsionshavebeen
describedaslearnedbehaviorthatdecreasesthe
anxietyassociatedwithobsessions.Thisdecrease
inanxietypositivelyreinforcesthecompulsive
actsandtheybecomestablelearnedbehavior.This
theoryismoreusefulfortreatmentpurposes.
ClinicalPicture
ObsessionalthoughtsThesearewords,ideasand
,beliefsthatintrudeforciblyintothepatient's
mind.Theyareusuallyunpleasantandshocking
tothepatientandmaybeobsceneor
blasphemous.
ObsessionalimagesThesearevividlyimagined
scenes,oftenofaviolentordisgustingkind
involvingabnormalsexualpractices.
ObsessionalruminationsTheseinvolveinternal
debatesinwhichargumentsforandagainsteven
thesimplesteverydayactionsarereviewed
endlessly.
ObsessionaldoubtsThesemayconcernactionsthat
maynothavebeencompletedadequately.The
obsessionoftenimpliessomedangersuchas
forgettingtoturnoffthestoveornotlockinga
door.Itmaybefollowedbyacompulsiveactsuch
asthepersonmakingmultipletripsbackintothe
housetocheckifthestovehasbeenturnedoff.
Sometimesthesemaytaketheformofdoubting
theveryfundamentalsofbeliefs,suchas,doubting
theexistenceofGodandsoon.
ObsessionalimpulsesTheseareurgestoperform
actsusuallyofaviolentorembarrassingkind,
suchasinjuringachild,shoutinginchurchetc.
ObsessionalritualsThesemayincludebothmental
activitiessuchascountingrepeatedlyinaspecial
wayorrepeatingacertainformofwords,and
repeatedbutsenselessbehaviorssuchaswashing
hands20ormoretimesaday.Sometimessuch
compulsiveactsmaybeprecededbyobsessional
thoughts;forexample,repeatedhandwashing
maybeprecededbythoughtsofcontamination.
Thesepatientsusuallybelievethatthe
contaminationisspreadfromobjecttoobjector
persontopersonevenbyslightcontactandmay
literallyrubtheskinofftheirhandsbyexcessive
handwashing.

121. 118AGuidetoMentalHealthandPsychiatricNursing
Obsessiveslowness:Severeobsessiveideasor
extensivecompulsiveritualscharacterize
obsessionalslownessintherelativeabsenceof
manifestedanxiety.Thisleadstomarkedslowness
indailyactivities.
CourseandPrognosis
Courseisusuallylongandfluctuating.About
two-thirdsofpatientsimprovebytheendofa
year.Agoodprognosisisindicatedbygoodsocial
andoccupationaladjustment,thepresenceofa
precipitatingeventandanepisodicnatureof
symptoms.
Prognosisappearstobeworsewhentheonset
isinchildhood,thepersonalityisobsessional,
symptomsaresevere,compulsionsarebizarre,or
thereisacoexistingmajordepressivedisorder.
Treatment
Pharmacotherapy
•Antidepressants(e.g.fluvoxamine,sertraline,
etc.)
•Anxiolytics(e.g.benzodiazepines)
BehaviorTherapy
•Exposureandresponseprevention
•Thoughtstoppage
•Desensitization
•Aversiveconditioning
ExposureandresponsepreventionThisisvivo
exposureprocedurecombinedwithresponse
preventiontechniques.Forexamplecompulsive
handwashersareencouragedtotouch
contaminatedobjectsandthenrefrainfrom
washinginordertobreakthenegativereinfor­
cementchain(handwashingreducingthe
anxietyi.e.negativereinforcement).
ThoughtstoppageThoughtstoppingisa
techniquetohelpanindividualtolearntostop
thinkingunwantedthoughts.Followingarethe
stepsinthoughtstopping:
•Sitinacomfortablechair,bringtomindthe
unwantedthoughtconcentratingononlyone
thoughtperprocedure.
•Assoonasthethoughtforms,givethe
command'Stop!'Followthiswithcalmand
deliberaterelaxationofmusclesanddiversion
ofthoughttosomethingpleasant.
•Repeattheproceduretobringtheunwanted
thoughtundercontrol.
(ReferChapter14fordesensitizationandaversive
conditions)
OtherTherapies
•Supportivepsychotherapy.
•ECT-forpatientsrefractorytootherformsof
treatment.
NursingManagement
NursingAssessment
Assessmentshouldfocusonthecollectionof
physical,psychologicalandsocialdata.The
nurseshouldbeparticularlyawareoftheimpact
ofobsessionsandcompulsionsonphysical
functioning,mood,self-esteemandnormalcoping
ability.Thedefensemechanismsused,thought
contentorprocess,potentialforsuicide,abilityto
functionandsocialsupportsystemsavailable
shouldalsobenoted.
NursingDiagnosisI
Ineffectiveindividualcopingrelatedtounder­
developedego,punitivesuperego,avoidance
learning,possiblebiochemicalchanges,eviden­
cedbyritualisticbehaviororobsessivethoughts.
Objective:Patientwilldemonstrateabilitytocope
effectivelywithoutresortingtoobsessive­
compulsivebehaviors.
Intervention:SeeTable9.6.
NursingDiagnosisII
Alteredroleperformancerelatedtotheneedto
performrituals,evidencedbyinabilitytofulfil
usualpatternsofresponsibility.
Objective:Patientwillbeabletoresumerole-related
responsibilities.
Intervention:SeeTable9.7.

122. TheIndividualwithNeuroticDisorder119
Table9.6:Nursinginterventionstoreduceobsessivecompulsivebehaviour
Interoentions Rationale
(a)Workwithpatienttodeterminetypes
ofsituationsthatincreaseanxietyand
resultinritualisticbehaviors.
(b)Initiallymeetthepatient'sdependency
needs.Encourageindependenceand
givepositivereinforcementfor
independentbehaviors.
(c)Inthe..beginningoftreatment,allow
plentyoftimeforrituals.Donotbe
judgmentalorverbalizedisapproval
ofthebehavior.
(d)Supportpatient'seffortstoexplorethe
meaningandpurposeofthebehavior.
(e)Providestructuredscheduleofactivities
forpatient,includingadequatetimefor
completionofrituals.
(f)Graduallybegintolimitamountof
timeallottedforritualisticbehavioras
patientbecomesmoreinvolvedinunit
activities.
(g)Givepositivereinforcementfornon­
ritualisticbehaviors.
(h)Helppatientlearnwaysofinterrupting
obsessivethoughtsandritualisticbehavior
withtechniquessuchasthoughtstopping,
relaxationandexercise.
Recognitionofprecipitatingfactors
isthefirststepinteachingthepatient
tointerruptescalatinganxiety.
Suddenandcompleteeliminationof
allavenuesfordependencywould
createintenseanxietyonthepartof
thepatient.Positivereinforcement
enhancesself-esteemandencourages
repetitionofdesiredbehaviors.
Denyingpatientthisactivitymay
precipitatepanicanxiety.
Patientmaybeunawareoftherelationshipbetween
emotionalproblemsandcompulsivebehaviors.
Recognitionisimportantbeforechangecanoccur.
Structureprovidesafeelingof
securityfortheanxiouspatient.
Anxietyisminimizedwhenpatient
isabletoreplaceritualisticbehaviors
withmoreadaptiveones.
Positivereinforcementencourages
repetitionofdesiredbehaviors.
Theseactivitieshelpininterruption
ofobsessivethoughts.
Table9.7:Nursinginterventionstoimproverole-relatedresponsibilitiesinOCDpatients
(a)
Interoentions Rationale
(b)
Determinepatient'spreviousrolewithin
thefamilyandtheextenttowhichthisrole
isalteredbytheillness.Identifyrolesof
otherfamilymembers.
Encouragepatienttodiscussconflicts
evidentwithinthefamilysystem.Identify
howpatientandotherfamilymembershave
respondedtothisconflict.
(c)Exploreavailableoptionsforchanges
oradjustmentsinrole.Practicethrough
roleplay.
Givepatientlotsofpositivereinforcement
forabilitytoresumeroleresponsibilities
bydecreasingneedforritualisticbehaviors.
(d)
Thisisimportantassessmentdata
forformulatinganappropriateplan
ofcare.
Identifyingspecificstressors,aswell
asadaptiveandmaladaptive
responseswithinthesystem,is
necessarybeforeassistancecanbe
providedinanefforttofacilitatechange.
Planningandrehearsalofpotential
roletransitionscanreduceanxiety.
Positivereinforcementenhances
self-esteemandpromotesrepetition
ofdesiredbehaviors.

123. 120AGuidetoMentalHealthandPsychiatricNursing
Evaluation
Evaluationofclientwithobsessive-compulsive
disordermaybedonebyaskingthefollowing
questions:
•Doestheclientcontinuetodisplayobsessive­
compulsivesymptoms?
•Istheclientabletousenewlylearned
behaviorstomanageanxiety?
•Cantheclientadequatelyperformself-care
activities?
REACTIONTOSTRESSAND
ADJUSTMENT DISORDER
Thiscategoryincludes:
•Acutestressreaction
•Post-traumaticstressdisorder(PTSD)
•Adjustmentdisorders
AcuteStressReaction
Itischaracterizedbysymptomslikeanxiety,
despairandangeroroveractivity.These
symptomsareclearlyrelatedtothestressor.If
removalfromthestressfulenvironmentis
possible,thesymptomsresolverapidly.
Post-traumaticStressDisorder(PTSD)
Post-traumaticstressdisorderischaracterizedby
hyperarousal,re-experiencingofimagesofthe
stressfuleventsandavoidanceofreminders.
Post-traumaticstressdisorderisofareaction
toextremestressorssuchasfloods,earthquackes,
war,rapeorseriousphysicalassault.Themain
symptomsarepersistentanxiety,irritability,
insomnia,intenseintrasiveimagery(flashbacks)
recurringdistressingdreams,inabilitytofeel
emotionanddiminishedinterestinactivities.
Thesymptomsmaydevelopafteraperiodof
latency,within6monthsafterthestressormay
bedelayed.Thegeneralapproachistoprovide
emotionalsupport,toencouragerecallofthe
traumaticevents.Benzodiazepinedrugsmaybe
neededtoreduceanxiety.
AdjustmentDisorders
Itischaracterizedbypredominantdisturbance
ofemotionsandconduct.Thisdisorderusually
occurswithinonemonthofasignificantlife
change.
TreatmentforStressandAdjustmentDisorders
Drugtreatment
•Antidepressants
•Benzodiazepines
Psychologicaltherapies
•Supportivepsychotherapy
•Crisisintervention
•Stressmanagementtraining
DISSOCIATIVE(CONVERSION) DISORDERS
Conversiondisorderischaracterizedbythe
presenceofoneormoresymptomssuggestingthe
presenceofaneurologicaldisorderthatcannot
beexplainedbyanyknownneurologicalor
medicaldisorder.Instead,psychologicalfactors
likestressandconflictsareassociatedwithonset
orexacerbationofthesymptoms.Patientsare
unawareofthepsychologicalbasisandarethus
notabletocontroltheirsymptoms.
Somefeaturesofthedisorderinclude:
•Thesymptomsareproducedbecausethey
reducetheanxietyofthepatientbykeeping
thepsychologicalconflictoutofconscious
awareness,aprocesscalledasprimarygain.
•Thesesymptomsofconversionareoften
advantageoustothepatient.Forexample,a
womanwhodevelopspsychogenicparalysis
ofthearmmayescapefromtakingcareofan
elderlyrelative.Suchanadvantageiscalled
assecondarygain.
•Thepatientdoesnotproducethesymptoms
intentionally.
•Thepatientshowslessdistressorshowslack
ofconcernaboutthesymptoms,calledasbelle
indifference.
•Physicalexaminationandinvestigationsdo
notrevealanymedicalorneurological
abnormalities.

124. TheIndividualwithNeuroticDisorder121
Conversiondisorderswereformerlycalledas
'hysteria.'Thetermisnowchangedbecausethe
word'hysteria'isusedineverydayspeechwhen
referringtoanyextravagantbehavior,anditis
confusingtousethesamewordforadifferent
phenomenathatfallsunderthissyndrome.
DissociativeAmnesia
Mostoften,dissociativeamnesiafollowsa
traumaticorstressfullifesituation.Thereis
suddeninabilitytorecallimportantpersonal
informationparticularlyconcerningthestressful
lifeevent.Theextentofthedisturbanceistoogreat
tobeexplainedbyordinaryforgetfulness.The
amnesiamaybelocalized,generalized,selective
orcontinuinginnature.
DissociativeFugue
Psychogenicfugueisasudden,unexpectedtravel
awayfromhomeorworkplace,withthe
assumptionofanewidentityandaninabilityto
recallthepast.Theonsetissudden,ofteninthe
presenceofseverestress.Followingrecoverythere
isnorecollectionoftheeventsthattookplace
duringthefugue.Thecourseistypicallyafew
hourstodaysandsometimesmonths.
DissociativeStupor
Inthis,patientsaremotionlessandmuteanddo
notrespondtostimulation,buttheyareawareof
theirsurroundings.Itisararecondition.
Ganser'sSyndrome
Canser'ssyndromeisarareconditionwithfour
features:giving'approximateanswers'to
questionsdesignedtotestintellectualfunctions,
psychogenicphysicalsymptoms,hallucinations
andapparentcloudingofconsciousness.The
term'approximateanswers'denotesanswers(to
simplequestions)thatareplainlywrong,butare
clearlyrelatedtothecorrectanswersinaway
thatsuggestthatthelatterisknown.Forexample,
whenaskedtoaddthreeandthreeapatientmight
answersevenandwhenaskedfourandfive,might
answerten;eachanswerisonegreaterthanthe
correctanswer.Hallucinationsareusuallyvisual
andmaybeelaborate.
MultiplePersonalityDisorder(Dissociative
IdentityDisorder)
Inthisdisorder,thepersonisdominatedbytwo
ormorepersonalitiesofwhichonlyoneismanifest
atatime.Usuallyonepersonalityisnotawareof
theexistenceoftheotherpersonalities.Each
personalityhasafullrangeofhighermental
functionsandperformscomplexbehaviorpat­
terns.Transitionfromonepersonalitytoanother
issudden,andthebehaviorusuallycontrasts
strikinglywiththepatient'snormalstate.
TranceandPossessionDisorders
ThisdisorderisverycommoninIndia.Itis
characterizedbyatemporarylossofboththe
senseofpersonalidentityandfullawarenessof
theperson'ssurroundings.Whenthecondition
isinducedbyreligiousrituals,thepersonmay
feeltakenoverbyadeityorspirit.Thefocusof
attentionisnarrowedtoafewaspectsofthe
immediateenvironment,andthereisoftena
limitedbutrepeatedsetofmovements,postures
andutterances.
DissociativeMotorDisorders
Itischaracterizedbymotordisturbanceslike
paralysisorabnormalmovements.Paralysismay
beamonoplegia,paraplegiaorquadriplegia.The
abnormalmovementmaybetremors,choreiform
movementsorgaitdisturbanceswhichincrease
whenattentionisdirectedtowardsthem.Exami­
nationrevealsnormaltoneandreflexes.
DissociativeConvulsions(hystericalfitsor
pseudo-seizures)
Itischaracterizedbyconvulsivemovementsand
partiallossofconsciousness.Differentialdiag­
nosiswithtrueseizuresisimportant.Some
differencesareillustratedinTable9.8.
DissociativeSensoryLossandAnesthesia
Itischaracterizedbysensorydisturbanceslike
hemianesthesia,blindness,deafnessandglove

125. 122AGuidetoMentalHealthandPsychiatricNursing
Table9.8:Differencesbetweenepilepticseizuresanddissociativeconvulsions
Clinicalpoints Epilepticseizures Dissociativeconvulsions
canoccur
usuallyabout
30-70sec
complete
anytime;canoccurduring
sleepalso
anywhere
present
present
Aura(warning)
Attackpattern
usual
stereotypedknown
clinicalpattern
Tonguebite
Incontinenceofurine
andfeces
Injury
Duration
present
canoccur
Amnesia
Timeofday
Placeofoccurrence
Post-ictalconfusion
Neurologicalsigns
andstockinganesthesia(absenceofsensations
atwristsandankles).
Thedisturbanceisusuallybasedonpatient's
knowledgeofthatparticularillnesswhose
symptomsareproduced.Adetailedexamination
doesnotrevealanyabnormalities.
EtiologyofConversionDisorders
PsychodynamicTheory
Inconversiondisorder,theegodefensemecha­
nismsinvolvedarerepressionandconversion.
Conversionsymptomsallowaforbiddenwishor
urgetobepartlyexpressed,butsufficiently
disguisedsothattheindividualdoesnothaveto
facetheunacceptablewish.Thesymptomsare
symbolicallyrelatedtotheconflict.
BehaviorTheory
Accordingtothistheorythesymptomsarelearnt
fromthesurroundingenvironment.Thesesymp­
tomsbringaboutpsychologicalreliefbyavoidance
ofstress.Conversiondisorderismorecommonin
peoplewithhystrionicpersonalitytraits.
Treatment
•Freeassociation
unusual
purposivebodymovements;
absenceofanyestablished
clinicalpattern
absent
veryrare
veryrare
20-800sec(prolonged)
partial
neveroccursduringsleep
usuallyindoorsorinsafeplaces
absent
absent
•Hypnosis
•Abreactiontherapy
•Supportivepsychotherapy
•Behaviortherapy(aversiontherapy,operant
conditioning,etc.)
•Drugtherapy:Drugshaveaverylimited
role.Afewpatientshaveanxietyandmay
needshort-termtreatmentwithbenzodiaze­
pines
NursingIntervention
•Monitorphysician'songoingassessments,
laboratoryreportsandotherdatatoruleout
organicpathology.
•Identifyprimaryandsecondarygains.
•Donotfocusonthedisability;encourage
patienttoperformself-careactivitiesas
independentlyaspossible.Interveneonly
whenpatientrequiresassistance.
•Donotallowthepatienttousethedisability
asamanipulativetooltoavoidparticipation
inthetherapeuticactivities.
•Withdrawattentionifthepatientcontinues
tofocusonphysicallimitations.
•Encouragepatienttoverbalizefearsand
anxieties.

126. TheIndividualwithNeuroticDisorder123
•Positivereinforcementforidentificationor
demonstrationofalternativeadaptivecoping
strategies.
•Identifyspecificconflictsthatremainunre­
solvedandassistpatienttoidentifypossible
solutions.
•Assistthepatienttosetrealisticgoalsforthe
future.
•Helpthepatienttoidentifyareasoflife
situationthatarenotwithinhisabilityto
control.Encourageverbalizationoffeelings
relatedtothisinability.
SOMATOFORM DISORDERS
Thesedisordersarecharacterizedbyrepeated
presentationwithphysicalsymptomswhichdo
nothaveanyphysicalbasis,andapersistent
requestforinvestigationsandtreatmentdespite
repeatedassurancebythetreatingdoctors.
Thesedisordersaredividedintofollowing
categories:
•Somatizationdisorder
•Hypochondriasis
•Somatoformautonomicdysfunction
•Persistentsomatoformpaindisorder
SomatizationDisorder
Somatizationdisorderischaracterizedbychronic
multiplesomaticsymptomsintheabsenceof
physicaldisorder.Thesymptomsarevague,
presentedinadramaticmannerandinvolve
multipleorgansystems.
Hypochondriasis
Hypochondriasisisdefinedasapersistentpre­
occupationwithafearorbeliefofhavingaserious
diseasedespiterepeatedmedicalreassurance.
SomatoformAutonomicDysfunction
Inthisdisorder,thesymptomsarepredominantly
underautonomiccontrol,asiftheywereduetoa
physicaldisorder.Someofthemincludepalpita-
tions,hiccoughs,hyperventilation,irritablebowel,
dysuria,etc.
PersistentSomatoformPainDisorder
Themainfeatureinthisdisorderissevere,
persistentpainwithoutanyphysicalbasis.Itmay
beofsufficientseveritysoastocausesocialor
occupationalimpairment.Preoccupationwiththe
painiscommon.
Treatment
Drugtherapy
•Antidepressants
•Benzodiazepines
Psychologicaltreatment.
•Supportivepsychotherapy
•Relaxationtherapy
REVIEWQUESTIONS
•Differencesbetweenpsychoticandneurotic
disorders(Feb2001,Oct2006)
•Classificationofneuroticdisorders
•Neuroticdisorders(Nov2002,Apr2005)
•Phobia(Nov2002,Apr2003,Nov2003,Apr
2004)
•Agoraphobia(Oct2004)
•Panicdisorder(Oct2006)
•Anxietyneurosis(Apr2006)
•Nursingmanagementforapatientwithacute
anxietystate(Feb1999,Nov2001,Apr2002,
Nov2003,Apr2004,Oct2004)
•Obsession(Apr2002,Apr2003)
•Obsessivecompulsivedisorders(Oct2000,
Nov2002,Nov2003,Oct2005)
•Ritualisticbehavior(Nov2003)
•Dissociative(conversion)disorders(Oct2000,
Apr2006)
•Differencesbetweenepilepticseizuresand
pseudo-seizures(Oct2000)
•Somatoformdisorders
•Multiplepersonality(Nov2002)

127. BehavioralSyndromes
Resultingfrom
._____~PhysiologicalDisturbances
DPSYCHOPHYSIOLOGICAUPSYCHOSOMATIC
DISORDERS
CommonExamplesof
PsychophysiologicalDisorders
NursingManagementofPatientWith
PsychophysiologicalDisorder
DEATINGDISORDERS
AnorexiaNervosa
BulimiaNervosa
DSLEEPDISORDERS
Insomnia
Hypersomnia
DisordersofSleep-WakeSchedule
StageIVSleepDisorders
OtherSleepDisorders
PSYCHOPHYSIOLOGICALJPSYCHOSOMATIC
DISORDERS
Theword'psychosomatic'meansmindandbody.
Psychosomaticdisordersarethosedisordersin
whichthepsychicelementsaresignificantfor
initiatingchemical,physiologicalorstructural
alterations,whichinturncreatethephysical
symptomsintheperson.
Theterm'psychosomatic'hasnowbeen
replacedwith'psychophysiologic'.
Therearethreefactorswhichmustbepresent
simultaneouslyforapersontodevelopa
psychosomaticdisorder:
,1.Theindividualmusthave"biologicalpredis­
position".
2.Theindividualmusthave"personalityvulner­
ability".
3.Theindividualmustexperienceasignificant
psychosocialstressinhis/hersusceptible
personalityarea.
Common ExamplesofPsychophysiological
Disorders
FranzAlexander,thefatherofpsychosomatic
medicine,describedsevenclassicalpsychoso­
maticillnesses.
CardiovascularDisorders
•Essentialhypertension
•Coronaryarterydisease
•Post-cardiacsurgerydelirium
•Migraine
•Mitralvalveprolapsesyndrome
EndocrineDisorders
•Diabetesmellitus
•Hyperthyroidism
•Cushing'ssyndrome
•Pre-menopausalsyndrome
•Amenorrhea
•Menorrhagia
GastrointestinalDisorders
•Esophagealreflux
•Pepticulcer
•Ulcerativecolitis
•Crohn'sdisease
ImmuneDisorders
•Autoimmunedisorders,e.g.systemiclupus
erythematosus
•Allergicdisorders,likebronchialasthmaand
hayfever
•Viralinfections

128. BehavioralSyndromesResultingfromPhysiologicalDisturbances125
Muscu/oskeletalDisorders
•Rheumatoidarthritis
RespiratoryDisorders
•Bronchialasthma
•Hayfever
•Rhinitis
SkinDisorders
•Psoriasis
•Pruritus
•Urticaria
•Acnevulgaris
•Warts
Treatment
1.Relaxationtechniques:Thisisoneofthemost
importantmethodsaimedatreducinganxiety
orrestlessness.Theyinclude:
•Jacobson'sprogressiverelaxationtechni-
que
•Yoga
•Autohypnosis
•Meditation
•Bio-feedback
2.Behaviormodificationtechniques
3.Individualtherapy
4.Grouptherapy
NursingManagement
Assessment
•Performthoroughphysicalassessment.
•Monitorlaboratoryvalues,vitalsigns,intake
andoutputandotherassessmentsnecessary
tomaintainanaccurateongoingappraisal.
•Assesspatient'slevelofanxiety.
•Assesspatient'slevelofknowledgeregarding
effectsofpsychologicalproblemsonthebody.
•NursingDiagnoses
•Ineffectiveindividualcopingrelatedtorepres­
sedanxietyandinadequatecopingmethods,
evidencedbyinitiationorexacerbationof
physicalillness.
•Knowledgedeficitrelatedtopsychological
factorsaffectingphysicalcondition,evidenced
byvariousphysicalproblems.
Interventions
•Encouragepatienttodiscusscurrentlife
situationsthatheperceivesasstressful,and
thefeelingsassociatedwitheach.
•Providepositivereinforcementforadaptive
copingmechanismsidentifiedorused.
Suggestalternativecopingstrategiesbutallow
patienttodeterminewhichcanmostappro­
priatelybeincorporatedintohislifestyle.
•Helppatienttoidentifyaresourceperson
withinthecommunity(friendorsignificant
others)touseasasupportsystemforthe
expressionoffeelings.
•Havepatientkeepadiaryofappearance,
duration,andintensityofphysicalsymptoms.
Aseparaterecordofsituationsthatthepatient
findsespeciallystressfulshouldbekept.
•Helppatientidentifyneedsthatarebeingmet
throughthesickrole.Together,formulate
moreadaptivemeansforfulfillingtheseneeds,
practicebyrole-playing.
•Provideinstructioninassertivetechniques,
especiallytheabilitytorecognizethediffe­
rencesamongpassive,assertive,and
aggressivebehaviorsandtheimportanceof
respectingtherightsofotherswhileprotecting
one'sownbasicrights.
•Discussadaptivemethodsofstress
management,suchasrelaxationtechniques,
physicalexercises,meditationandbreathing
exercises.
EATINGDISORDERS
Thetwomostimportanteatingdisordersare:
•Anorexianervosa,and
•Bulimianervosa
AnorexiaNervosa
Anorexianervosaischaracterizedbyhighly
specificbehavioralandpsychopathological
symptomsandsignificantsomaticsigns.Majority

129. 126AGuidetoMentalHealthandPsychiatricNursing
arefemalesandtheonsetisduringadolescence.
Thecorepsychopathologicalfeatureisthedread
offatness,weightphobiaandadriveforthinness.
Etiology
a.Geneticcauses:Amongfemalesiblingsof
patientswithestablishedanorexianervosa,
6-10percentsufferfromthecondition
comparedtothe1-2percentfoundinthe
generalpopulationofthesameage(Strober,
1995).
b.Adisturbanceinhypothalamicfunction.
c.Socialfactors:Thereisahighprevalenceof
anorexianervosaamongfemalestudentsand
inoccupationalgroupsparticularlyconcer­
nedwithweight(forexample,dancers).
Influenceofmassmedia,beautycontestsare
otherimportantsocialcauses.
d.Individualpsychologicalfactors:Adistur­
banceofbodyimage,astruggleforcontrol
andasenseofidentityareimportantfactors
inthecausationofanorexianervosa.Traitsof
lowself-esteemandperfectionismareoften
found.
e.Causeswithinthefamily:Disturbancein
familyrelationships,over-protection,family
membershavinganunusualinterestinfood
andphysicalappearance.
ClinicalFeatures
•Thereisanintensefearofbecomingobese.
Thisfeardoesnotdecreaseeveniftheperson
losesweightgrosslyandbecomesverythin.
•Thebodyweightis15percentbelowthe
standardweight.
•Thereisabodyimagedisturbance.Thepatient
isunabletoperceivethebodysizeaccurately.
•Thepursuitofthinnessmaytakeseveral
forms.Patientsgenerallyeatlittleandset
themselvesdailycalorielimits(oftenbetween
600and1000calories).Sometrytoachieve
weightlossbyinducingvomiting,excessive
exercise,andmisusinglaxatives.
•Othersignsandsymptomsaresecondaryto
starvationandincludesensitivitytocold,
delayedgastricemptying,constipation,low
bloodpressure,bradycardia,hypothermia
andamenorrheainfemales.
•Vomitingandabuseoflaxativesmayleadtoa
varietyofelectrolytedisturbances,themost
seriousbeinghypokalemia.
•Hormonalabnormalitiesalsomaybeseen.
CourseandPrognosis
Anorexianervosaoftenrunsafluctuatingcourse
withperiodsofexacerbationsandpartialremis­
sions.Outcomeisveryvariable.
Treatment
Pharmacotherapy
•Neuroleptics
•Appetitestimulants
•Antidepressants
Psychologicaltherapies
•Individualpsychotherapy
•Behavioraltherapy
•Cognitivebehaviortherapy
•Familytherapy
NursingInterventions
•Short-termmanagementisfocusedonensu­
ringweightgainandcorrectingnutritional
deficiencies.Maintainingnormalweightand
preventingrelapsesarelong-termgoalstobe
achieved.
•Hospitalizationisusuallyrequiredand
successfultreatmentdependsongoodnursing
care,withclearaimsandunderstandingon
thepartofthepatientaswellasthenurse.
•Eatingmustbesupervisedbythenurseanda
balanceddietofatleast3000caloriesshould
beprovidedin24hours.
•Intheearlystagesoftreatment,itisbestfor
thepatienttoremaininbedinasingleroom
whilethenursemaintainscloseobservation.
Thegoalshouldbetoachieveaweightgainof
0.5to1kgperweek.
•Weightshouldbecheckedregularly.Monitor
serumelectrolytelevelsandsignsandsymp­
tomslikeamenorrhea,constipation,hypogly­
cemia,hypotension,etc.

130. BehavioralSyndromesResultingfromPhysiologicalDisturbances127
•Controlvomitingbymakingthebathroom
inaccessibleforatleast2hoursafterfood.
•Inextremecaseswhenthepatientrefusesto
eatandcomplywiththetreatment,gavage
feedingsmayneedtobeinstituted.
BulimiaNervosa
Bulimianervosaisdescribedasrepeatedboutsof
overeatingandapreoccupationwithcontrolof
weightthatleadstoself-inducedvomiting.
ClinicalFeatures
•Anirresistiblecravingforfood:Thereare
episodesofovereatinginwhichlargeamount
offoodareconsumedwithinshortperiodsof
time(eatingbinges)
•Attempttocounteracttheeffectsofovereating
byself-inducedvomiting
•Thereisusuallynosignificantweightloss
Treatment
•Antidepressants,carbamazepineandlithium
forpatientswithco-morbidmooddisorders
•Grouptherapy
•Familytherapy
•Cognitivebehaviortherapy
SLEEPDISORDERS
Sleepcanberegardedasaphysiologicalreversible
reductionofconsciousawareness.
Sleepdisordersaredividedintosubtypes:
1.Dyssomnias
•Insomnia
•Hypersomnia
•Disordersofsleep-wakeschedule
2.Parasomnias
•StageIVdisorders
•Otherdisorders
DYSSOMNIAS
Insomnia
Insomniaisdisorderofinitiationandmainte-
nanceofsleep.Thisincludesfrequentawakening
duringthenightandearlymorningawakening.
Causes
Medicalillnesses
•Anypainfuloruncomfortableillness
•Heartdisease
•Respiratorydiseases
•Brainstemorhypothalamiclesions
•Delirium
•Rheumaticandothermusculoskeletal
diseases
•Periodicmovementsinsleep
•Oldage
Alcoholanddruguse
•Deliriumtremens
•Amphetaminesorotherstimulants
•Chronicalcoholism
Psychiatricdisorders
•Mania(duetodecreasedneedforsleep)
•Majordepression(earlymorningawakening
orlateinsomnia)
•Dysthymiaorneuroticdepression(difficulty
ininitiatingsleeporearlyinsomnia)
•Schizophreniaandotherpsychoses(dueto
psychoticsymptoms)
•Anxietydisorder(difficultyininitiatingsleep
duetoworryingthoughts)
Socialcauses
•Financialloss
•Separationordivorce
•Deathofspouseoracloserelative
•Retirement
•Stressfullifesituations
Behavioralcauses
•Napsduringtheday
•Irregularsleepinghours
•Lackofphysicalexercise
•Excessiveintakeofbeveragesintheevening,
e.g.coffee
•Disturbingenvironment(heat,cold,noise)
Treatment
•Athoroughmedicalandpsychiatricassess­
ment;polysomnographymaybeneededin
somecases.

131. 128AGuidetoMentalHealthandPsychiatricNursing
•Treatmentofunderlyingphysicalorpsy­
chiatricdisorder.
•Withdrawalofcurrentmedications,ifany.
•Transientinsomniacanbetreatedinitially
withhypnotics.
Non-drugtreatmentforinsomnia
•Progressiverelaxation.
•Autosuggestion.
•Meditation,yoga.
•Stimuluscontroltherapy:donotusethebed
forreadingorchatting-gotobedforsleep
only.
Sleephygiene
•Regular,dailyphysicalexercisesinthe
evening.
•Avoidfluidintakeandheavymealsjustbefore
bedtime.
•Avoidcaffeineintake(e.g.tea,coffee,cola
drinks)beforesleepinghours.
•Avoidreadingorwatchingtelevisionwhile
inbed.
•Backrubs,warmmilkandrelaxationexercises.
•Sleepinacomfortableenvironment.
Hypersomnia
HypersomniaisknownasDisorderOfExcessive
Somnolence(DOES).Itincludesexcessivedaytime
sleepiness,sleepattacksduringdaytime,sleep
drunkenness(personneedsmuchmoretimeto
awaken,andduringthisperiodheisconfusedor
disoriented).
Causes
Narcolepsy-excessivedaytimesleepinesscha­
racterizedby:
•Sleepattacks.
•Cataplexy-suddendecreasedorlossof(sleep
paralysis)muscletone,oftengeneralizedand
mayleadontosleep.
•Sleepparalysis-itoccurseitheratawakening
inmorningoratsleeponset.Thepersonis
consciousbutunabletomovehisbody.
•Hypnagogichallucinations
2.Sleepapnea:repeatedepisodesofapnea
duringsleep.
3.Kleine-Levinsyndrome:periodicepisodesof
hypersomnia.
DisorderofSleep-wakeSchedule
Thepersonwiththisdisorderisnotabletosleep
whenhewishesto,althoughatothertimeheis
abletosleepadequately.
Causes
•Workshifts
•Unusualsleepphases
PARASOMNIAS
Inthisthepersonfrequentlywakesduringsleep.
StageIVSleepDisorders
•Sleepwalking(somnambulism)
•Nightterrors
•Sleep-relatedenuresis
•Bruxism(tooth-grinding)
•Sleeptalking(somniloquy)
OtherSleepDisorders
•Nocturnalangina
•Nocturnalasthma
•Nocturnalseizures
•Sleepparalysis
REVIEWQUESTIONS
•Psychophysiologicaldisorders(Feb2001,Nov
2002)
•Dynamicsofpsychophysiologicdisorders
(Apr2006)
•Anorexianervosa(Apr2006)
•Insomnia(Nov1999,Oct2004)

132. Disordersdueto
Psychoactive
SubstanceUse
DETIOLOGICALFACTORSINSUBSTANCEUSE
DALCOHOLDEPENDENCESYNDROME
MedicalandSocialComplicationsof
AlcoholDependence
PsychiatricDisordersduetoAlcohol
Dependence
•AcuteIntoxication
•WithdrawalSyndrome
•AlcoholInducedAmnesticDisorder
•AlcoholInducedPsychiatricDisorder
Treatment
AgenciesConcernedWithAlcohol­
RelatedProblems
DOTHERSUBSTANCEUSEDISORDERS
OpioidUseDisorders
CannabisUseDisorder
CocaineUseDisorder
AmphetamineUseDisorder
LSDUseDisorder
BarbiturateUseDisorder
InhalantsOrVolatileSolventUseDisorder
DPREVENTION
DREHABILITATION
DNURSINGMANAGEMENT FORSUBSTANCEUSE
DISORDER
Disordersduetopsychoactivesubstanceuserefer
toconditionsarisingfromtheabuseofalcohol,
psychoactivedrugsandotherchemicalssuchas
volatilesolvents.TheseareclassifiedunderFIin
ICDlO.
Abuse:Itreferstomaladaptivepatternofsubstance
usethatimpairshealthinabroadsense.
Dependence:Itreferstocertainphysiologicaland
psychologicalphenomenainducedbytherepea­
tedtakingofasubstance.Thecriteriafor
diagnosingdependenceinclude(ICDlO):
•Astrongdesiretotakethesubstance
•Difficultincontrollingsubstancetaking
behavior
•Aphysiologicalwithdrawalstate
•Developmentoftolerance
•Progressiveneglectofalternativepleasuresor
interests
•Persistingwithsubstanceusedespiteclear
evidenceofharmfulconsequences
Tolerance:Itisastateinwhichafterrepeated
administration,adrugproducesadecreased
effect,orincreasingdosesarerequiredtoproduce
thesameeffect.
Withdrawalstate:Agroupofsignsandsymptoms
recurringwhenadrugisreducedinamountor
withdrawn,whichlastforalimitedtime.The
natureofthewithdrawalstateisrelatedtothe
classofsubstanceused.
Themajordependenceproducingdrugsare:
•Alcohol
•Opioids
•Cannabis
•Cocaine
•Amphetaminesandothersympathomimetics
•Hallucinogens,e.g.LSD,phencyclidine
•Sedativesandhypnotics,e.g.barbiturates
•Inhalants,e.g.volatilesolvents
•Nicotine
•Otherstimulants,e.g.caffeine
ETIOLOGICAL FACTORSINPSYCHOACTIVE
SUBSTANCE USE
BiologicalFactors
•Geneticvulnerability:familyhistoryofsub­
stanceusedisorder,e.g.twinstudiessuggest

133. 130AGuidetoMentalHealthandPsychiatricNursing
thatgeneticmechanismsmightaccountfor
alcoholconsumption.
•Biochemicalfactors:forexample,roleof
dopamineandnorepinephrinehavebeen
implicatedincocaine,ethanolandopioid
dependence.Abnormalitiesinalcoholdehy­
drogenaseorintheneurotransmitter
mechanismarethoughttoplayarolein
alcoholdependence.
•Withdrawalandreinforcingeffectsofdrugs
(theyserveasmaintainingfactors).
•Co-morbidmedicaldisorder(e.g.tocontrol
chronicpain).
PsychologicalFactors
•Generalrebelliousness
•Senseofinferiority
•Poorimpulsecontrol
•Lowself-esteem
•Inabilitytocopewiththepressuresofliving
andsociety(poorstressmanagementskills)
•Loneliness,unmetneeds
•Desiretoescapefromreality
•Desiretoexperiment,asenseofadventure
•Pleasure-seeking
•Machoism
•Sexualimmaturity
SocialFactors
•Religiousreasons
•Peerpressure
•Urbanization
•Extendedperiodsofeducation
•Unemployment
•Overcrowding
•Poorsocialsupport
•Effectsoftelevisionandothermassmedia
•Occupation:substanceuseismorecommon
inchefs,barmen,executives,salesmen,actors,
entertainers,armypersonnel,journalists,
medicalpersonnel,etc
EasyAvailabilityofDrugs
•Takingdrugsprescribedbydoctors(e.g.
benzodiazepinedependence).
•Takingdrugsthatcanbeboughtlegally
withoutprescription(e.g.nicotine,opioids).
•Takingdrugsthatcanbeobtainedfromillicit
sources(e.g.streetdrugs).
PsychiatricdisordersSubstanceusedisorders
aremorecommonindepression,anxietydis­
orders(particularlysocialphobias),personality
disorder(especiallyantisocialpersonality)and
occasionallyinorganicbraindiseaseand
schizophrenia.
ALCOHOLDEPENDENCE SYNDROME
Alcoholismreferstotheuseofalcoholicbeverages
tothepointofcausingdamagetotheindividual,
societyorboth.
PropertiesofAlcohol
Alcoholisaclearcoloredliquidwithastrong
burningtaste.Therateofabsorptionofalcohol
intothebloodstreamismorerapidthanits
elimination.Absorptionofalcoholintotheblood
streamisslowerwhenfoodispresentinthe
stomach.Asmallamountisexcretedthrough
urineandasmallamountisexhaled.
Aconcentrationof80to100mgofalcoholper
100mlofbloodisconsideredintoxication.A
personwith200mgto250mgwillbetoxic,sleepy,
confusedandhisthoughtprocesswillbealtered.
Ifbloodlevelis300mg/100mlofbloodtheperson
mayloseconsciousness.Aconcentrationof500
mg/100mlisfatal.Allthesymptomschange
accordingtotolerance.
Epidemiology
Theincidenceofalcoholdependenceis2%.In
India20to40%ofsubjectsagedabove15years
arecurrentusersofalcohol,andnearly10%of
themareregularorexcessiveusers.Nearly15to
30%ofpatientsaredevelopingalcohol-related
problemsandseekingadmissioninpsychiatric
hospitals.

134. DisordersduetoPsychoactiveSubstanceUse131
MedicalandSocialComplicationsof
AlcoholDependence
AMedical
Gastrointestinalsystem
•Gastritis,pepticulcer,refluxesophagitis,
carcinomaofstomachandesophagus
•Fattyliver,cirrhosisofliver,hepatitis,liver
cellcarcinoma
•Acuteandchronicpancreatitis
•Malabsorptionsyndrome
Cardiovascularsystem
•Alcoholiccardiomyopathy
•Highriskformyocardialinfarction
Centralnervoussystem
•Peripheralneuropathy
•Epilepsy
•Headinjury
•Cerebellardegeneration
Miscellaneous
•Proteinmalnutrition
•Vitamindeficiencydisorder
•Peripheralmuscleweakness
•Acne
•Sexualdysfunctioninmales,failureof
ovulationinfemales
Damagetothefetus
Fetalalcoholsyndrome(facialabnormality,low
birthweight,lowintelligence),increased
stillbirths.Alcoholdependenceisresponsiblefor
3percentofallcasesofmentalretardation
B.Social
•Maritaldisharmony
•Occupationalproblems
•Financialproblems
•Criminality
•Accidents
PSYCHIATRICDISORDERS DUETO
ALCOHOLDEPENDENCE
1.Acuteintoxication
2.Withdrawalsyndrome
3.Alcoholinducedamnesticdisorders
4.Alcoholinducedpsychiatricdisorders
1.Acuteintoxication:Acuteintoxicationdeve­
lopsduringorshortlyafteralcoholingestion.Itis
characterizedbyclinicallysignificantmaladap­
tivebehaviororpsychologicalchanges,e.g.
inappropriatesexualoraggressivebehavior,
moodlability,impairedjudgment,slurredspeech,
incoordination,unsteadygait,nystagmus,
impairedattentionandmemoryfinallyresulting
instupororcoma.
2.Withdrawalsyndrome:Inpersonswhohave
beendrinkingheavilyoveraprolongedperiodof
time,anyrapiddecreaseintheamountofalcohol
inthebodyislikelytoproducewithdrawal
symptoms.Theseare:
•Simplewithdrawalsyndrome
•Deliriumtremens
Simplewithdrawalsyndrome:Itischaracterized
bymildtremors,nausea,vomiting,weakness,
irritability,insomniaandanxiety.
Deliriumtremens:Itoccursusuallywithin2-4
daysofcompleteorsignificantabstinencefrom
heavyalcoholdrinking.Thecourseisshort,with
recoveryoccurringwithin3-7days.
Itischaracterizedby:
•Adramaticandrapidlychangingpictureof
disorderedmentalactivity,withcloudingof
consciousnessanddisorientationintimeand
place
•Poorattentionspan
•Vividhallucinationswhichareusuallyvisual;
tactilehallucinationscanalsooccur
•Severepsychomotoragitation,shoutingand
evidentfear
•Grosslytremuloushandswhichsometimes
pickupimaginaryobjects;truncalataxia
•Autonomicdisturbancessuchassweating,
fever,tachycardia,raisedbloodpressure,
pupillarydilatation
•Dehydrationwithelectrolyteimbalances
•Reversalofsleep-wakepatternorinsomnia
•Bloodtestsrevealleukocytosisandimpaired
liverfunction

135. 132AGuidetoMentalHealthandPsychiatricNursing
•Deathmayoccurduetocardiovascular
collapse,infection,hyperthermiaorself­
inflictedinjury
3.Alcohol-inducedamnesticdisorders
Chronicalcoholabuseassociatedwiththiamine
(vitamin'B')deficiencyisthemostfrequentcause
ofarnnesticdisorders.Thisconditionisdivided
into:
a)Wernicke'ssyndrome:Thisischaracterized
byprominentcerebellarataxia,palsyofthe
6thcranialnerve,peripheralneuropathyand
mentalconfusion.
b)Korsakoff'ssyndrome:Theprominentsymp­
tominKorsakoff'ssyndromeisgrossmemory
disturbance.Othersymptomsinclude:
•Disorientation
•Confusion
•Confabulation
•Poorattentionspananddistractibility
•Impairmentofinsight
4.Alcohol-inducedpsychiatricdisorders
a)Alcohol-induceddementia:Itisalongterm
complicationofalcoholabuse,characterized
byglobaldecreaseincognitivefunctioning
(decreasedintellectualfunctioningand
memory).Thisdisordertendstoimprovewith
abstinence,butmostofthepatientsmayhave
permanentdisabilities.
b)Alcohol-inducedmooddisorders:Excess
drinkingmayinducepersistentdepressionor
anxiety
c)Suicidalbehavior:Suicidalratesarehigherin
alcoholicswhencomparedtonon-alcoholics
ofthesameage.Theriskfactorsforsuicidal
behaviorarecontinueddrinking,co-morbid
majordepression,seriousmedicalillness,
unemploymentandpoorsocialsupport.
d)Alcohol-inducedanxietydisorder:Alcohol
personsreportpanicattacksduringacute
withdrawal,similarlyduringthefirst4to6
weeksofabstinence.
e)Impairedpsychosexualfunction:Erectile
dysfunctionanddelayedejaculationare
commoninchronicalcoholics
f)Pathologicaljealousy:Excessivedrinkersmay
developanovervaluedideaordelusionthat
thepartnerisbeingunfaithful.
g)Alcoholicseizures(rumfits):Generalized
tonicclonicseizuresoccurusuallywithin12-
48hoursafteraheavyboutofdrinking.Some­
times,statusepilepticusmaybeprecipitated.
h).Alcoholichallucinosis:Thisischaracterized
bythepi;esenceofhallucinations(auditory)
duringabstinence,followingregularalcohol
intake.Recoveryoccurswithinonemonth.
Treatment
1.Afullassessment,includinganappraisalof
currentmedical,psychologicalandsocial
problems.
2.Goalsetting:Settingupofshort-termgoalsthat
dealwithanyaccompanyingproblemsin
health,marriage,jobandsocialadjustments;
long-termgoalscanbesetastreatment
progresses,whichareconcernedwithtrying
tochangefactorsthatprecipitateormaintain
excessivedrinking,suchastensionsinthe
family.
3.Treatmentofwithdrawalfromalcohol
a.Detoxification:Detoxificationisthetreat­
mentforalcoholwithdrawalsymptoms.
Thedrugsofchoicearebenzodiazepines.
Themostcommonlyuseddrugsfromthis
classarechlordiazepoxide80-200mg/
dayanddiazepam40-80mg/day,in
divideddoses.
b.Others:
•ForvitaminBdeficiencyapreparation
ofvitaminBcontaining100mgof
thiamineshouldbeadministered
parenterally,twicedailyfor3to5days.
Thisshouldbefollowedbyoral
administrationofvitaminBforatleast
6months.
•Administrationofanticonvulsantsas
necessary,maintainingfluidand
electrolytebalance,strictmonitoringof
vitals,levelofconsciousnessandorien­
tation.Closeobservationisessential,
especiallyduringthefirstfivedays.

136. DisordersduetoPsychoactiveSubstanceUse133
4.Alcoholdeterrenttherapy:Deterrentagentsare
thosewhicharegiventodesensitizethe
individualtotheeffectsofalcoholand
maintainabstinence.Themostcommonly
useddrugisdisulfiram(tetraethylthiuram
disulfide)orantabuse.
Disulfiram:Disulfiramisusedtoensure
abstinenceinthetreatmentofalcohol
dependence.Itsmaineffectistoproducea
rapidandviolentlyunpleasantreactionina
personwhoingestsevenasmallamountof
alcoholwhiletakingdisulfiram.
MechanismofactionDisulfiramisan
aldehydedehydrogenaseinhibitorthat
interfereswiththemetabolismofalcoholand
producesamarkedincreaseinbloodacetal­
dehydelevels.Theaccumulationofacetal­
dehyde(toalevelof10timesmorethanthat
whichoccursinthenormalmetabolismof
alcohol)producesawidearrayofunpleasant
reactionscalledthedisulfiram-ethanol
reaction(DER),characterizedbynausea,
throbbingheadache,vomiting,hypotension,
flushing,sweating,thirst,dyspnea,
tachycardia,chestpain,vertigo,blurredvision
andasenseofimpendingdoomassociated
withsevereanxiety.Thereactionoccursalmost
immediatelyaftertheingestionofevenone
alcoholicdrinkandmaylastupto30minutes.
TherapeuticindicationsTheprimaryindica­
tionfordisulfiramuseisasanaversivecon­
ditioningtreatmentforalcoholdependence.
Side-effectsTheadverseeffectsofdisulfiram
intheabsenceofalcoholconsumptioninclude
fatigue,dermatitis,impotence,opticneuritis,
mentalchanges,acutepolyneuropathyand
hepaticdamage.
Withalcoholconsumptiontheintensity
ofthedisulfiram-alcoholreactionsvarieswith
eachpatient.Inextremecasesitismarkedby
convulsions,respiratorydepression,cardio­
vascularcollapse,myocardialinfarctionand
death.
Contraindications
•Pulmonaryandcardiovasculardisease.
•Disulfiramshouldbeusedwithcaution
inpatientswithnephritis,braindamage,
hypothyroidism,diabetes,hepaticdisease,
seizures,poly-drugdependenceoran
abnormalelectroencephalogram.
•Patientsathighriskofalcoholingestion.
DosageDisulfiramissuppliedintabletsof
250and500mg.Theusualinitialdoseis500
mg/dayorallyforthefirst2weeks,followed
byamaintenancedosageof250mg/day.The
dosageshouldnotexceed500mg/day.
Nurse'sresponsibility
•Aninformedconsentshouldbetaken
beforestartingtreatment.
•Ensurethatatleast12hourshaveelapsed
sincethelastingestionofalcoholbefore
administeringthedrug.
•Patientmustbeinstructedthatingestion
ofeventhesmallestamountofalcohol
bringsonadisulfiram-ethanolreaction
withallitsunpleasanteffects;heshould
thereforebestrictlywarnednottotakeany
alcoholwhatever.
•Thepatientshouldalsobewarnedagainst
ingestionofanyalcohol-containing
preparationssuchascoughsyrups,drops
ofanykind,andalcohol-containingfoods
andsauces.Advisenottousealcohol
basedaftershavelotionsandadvise
againstinhalationofpaints,warnishes,
etc.,containingalcohol.Anytopical
applicationscontainingalcoholshould
alsobeavoided.
•CautionpatientagainsttakingCNS
depressantsoranyOTC(over-the-counter)
medicationsduringdisulfiramtherapy.
•Instructpatienttoavoiddrivingorother
activitiesrequiringalertnessuntilresponse
todrugisknown.
•Patientsshouldbewarnedthatthe
disulfiram-alcoholreactionmaycontinue
foraslongas1to2weeksafterthelast
doseofdisulfiram.

137. 134AGuidetoMentalHealthandPsychiatricNursing
•Patientsshouldcarryidentificationcards
describingdisulfiram-alcoholreaction
andlistingthenameandtelephone
numberofthephysiciantobecalled.
•Emphasizetheimportanceoffollow-up
visitstothephysiciantomonitorprogress
inlong-termtherapy.
5.Psychologicaltreatment
Motivationalinterviewing:Thisinvolves
providingfeedbacktothepatientonthe
personalrisksthatalcoholposes,together
withanumberofoptionsforchange.
Grouptherapy:Grouptherapyenablesthe
patientstoobservetheirownproblems
mirroredinothersandtoworkoutbetterways
ofcopingwiththem.
Aversiveconditioning:Thistherapyisbased
onclassicalconditioning.Inalcoholismthe
behaviorpatternsareself-reinforcingand
pleasurable,butaremaladaptiveforreasons
outsidethecontroloftheclient.Inthis
techniquetheclientisexposedtochemically­
inducedvomitingorshockwhenhetakes
alcohol.
Cognitivetherapy:Thisinvolvesreductionin
alcoholintakebyidentifyingandmodifying
maladaptivethinkingpatterns.
Relapsepreventiontechnique:Thistechnique
helpsthepatienttoidentifyhigh-riskrelapse
factorsanddevelopstrategiestodealwith
them.Italsoenablesthepatienttolearn
methodstocopewithcognitivedistortions.
Cueexposuretechnique:Thistechniqueaims
throughrepeatedexposuretodesensitizedrug
abuserstodrugeffects,andthusimprovetheir
abilitytoremainabstinent.
Othertherapiesincludeassertivenesstraining,
behaviorcounseling,supportivepsychotherapyand
individualpsychotherapy.
AgenciesConcernedwithAlcohol­
relatedProblems
AlcoholicsAnonymous(AA)
Thisisaself-helporganizationfoundedin
theUSAbytwoalcoholicmen,Dr.BobSmith
andBillWilson,astockbrokeronthe10thof
June,1935.Ithassincethenspreadtomany
countriesintheworld.AAconsidersalcoholism
asaphysical,mentalandspiritualdisease,a
progressiveone,whichcanbearrestedbutnot
cured.Membersattendgroupmeetingsusually
twiceaweekonalong-termbasis.Eachmember
isassignedasupportpersonfromwhomhemay
seekhelpwhenthetemptationtodrinkoccurs.In
crisishecanobtainimmediatehelpbytelephone.
Oncesobrietyisachievedheisexpectedtohelp
others.
Theorganizationworksonthefirmbeliefthat
abstinencemustbecomplete.Theonlyrequire­
mentformembershipisadesiretostopdrinking.
Thereisnoauthority,butonlyafellowshipof
imperfectalcoholicswhosestrengthisformedout
ofweakness.Theirprimarypurposeistohelp
eachotherstaysoberandhelpotheralcoholicsto
achievesobriety.
"TwelveSteps"ofA.A.
The"TwleveSteps"arethecoreoftheA.A.
programofpersonalrecoveryfromalcoholism.
Theyarenotabstracttheories;butarebasedon
thetrial-and-errorexperienceofearlymembersof
A.A.Theydescribetheattitudesandactivitiesthat
theseearlymembersbelievewereimportantin
helpingthemtoachievesobriety.Acceptanceof
the"TwelveSteps"isnotmandatoryinanysense.
1.Weadmittedwewerepowerlessover
alcohol-thatourliveshadbecome
unmanageable.
2.CametobelievethataPowergreaterthan
ourselvescouldrestoreustosanity.
3.Madeadecisiontoturnourwillandour
livesovertothecareofGodasweunderstood
Him.
4.Madeasearchingandfearlessmoral
inventoryofourselves.
5.AdmittedtoGod,toourselvesandto
anotherhumanbeingtheexactnatureof
ourwrongs.
6.WereentirelyreadytohaveGodremoveall
thesedefectsofcharacter.
7.HumblyaskedHimtoremoveourshort­
comings.

138. DisordersduetoPsychoactiveSubstanceUse135
8.Madealistofallpersonswehadharmed,
andbecamewillingtomakeamendstothem
all.
9.Madedirectamendstosuchpeople
whereverpossible,exceptwhentodoso
wouldinjurethemorothers.
10.Continuedtotakepersonalinventoryand
whenwewerewrongpromptlyadmittedit.
11.Soughtthroughprayerandmeditationto
improveourconsciouscontactwithGod,
asweunderstoodHim,prayingonlyfor
knowledgeofHiswillforusandthepower
tocarrythatout.
12.Havinghadaspiritualawakeningasthe
resultofthesesteps,wetriedtocarrythis
messagetoalcoholics,andtopracticethese
principlesinallouraffairs.
"TwelveTraditions"ofA.A.
The"TwelveTraditions"ofA.A.aresuggested
principlestoensurethesurvivalandgrowthof
thethousandsofgroupsthatmakeupthe
Fellowship.Theyarebasedontheexperienceof
groupsthemselvesduringthecriticalearlyyears
ofthemovement.
TheTraditionsareimportanttobotholdtimers
andnewcomersasremindersofthetrue
foundationsofA.A.asasocietyofmenand
womenwhoseprimaryconcernistomaintain
theirownsobrietyandhelpotherstoachieve
sobriety:
1.Ourcommonwelfareshouldcomefirst;
personalrecoverydependsuponA.A.unity.
2.Forourgrouppurposethereisbutone
ultimateauthority-alovingGodasHemay
expressHimselfinourgroupconscience.
Ourleadersarebuttrustedservants;they
donotgovern.
3.TheonlyrequirementforA.A.membership
isadesiretostopdrinking.
4.Eachgroupshouldbeautonomousexcept
inmattersaffectingothergroupsorA.A.as
awhole.
5.Eachgrouphasbutoneprimarypurposeto
carryitsmessagetothealcoholicwhostill
suffers.
6.AnA.A.groupoughtneverendorse,finance,
orlendtheA.A.nametoanyrelatedfacility
oroutsideenterprize,lestproblemsof
money,property,andprestigedivertus
fromourprimarypurpose.
7.EveryA.A.groupoughttobefullyself-sup­
porting,decliningoutsidecontributions.
8.AlcoholicsAnonymousshouldremain
forevernon-professional,butourservice
centersmayemployspecialworkers.
9.A.A.,assuchoughtneverbeorganized;but
wemaycreateserviceboardsorcommittees
directlyresponsibletothosetheyserve.
10.AlcoholicsAnonymoushasnoopinionon
outsideissues;hencetheA.A.nameought
neverbedrawnintopubliccontroversy.
11.Ourpublicrelationspolicyisbasedon
attractionratherthanpromotion;weneed
alwaysmaintainpersonalanonymityatthe
levelofpress,radio,andfilms.
12.Anonymityisthespiritualfoundationofall
ourtraditions,everremindingustoplace
principlesbeforepersonalities.
Al-Anon
Al-AnonisagroupstartedbyMrs.Anne,wifeof
Dr.Bobtosupportthespousesofalcoholics.
Al-Ateen
Providessupporttotheirteenagechildren.
Hostels
Theseareintendedmainlyforthoserendered
homelessduetoalcohol-relatedproblems.They
providerehabilitationandcounseling.Usually
abstinenceisaconditionofresidence.
[Referp.139and140forrehabilitationand
nursingmanagement]
OTHERSUBSTANCE USEDISORDERS
DrugAddictioninIndia:UNReport(The
IndianExpressFeb.1999)
Ofthe4millionregistereddrugaddictsinSouth
Asia,1.25lakhareinIndia.

139. 136AGuidetoMentalHealthandPsychiatricNursing
Distribution:
•Alcohol:42%(includingsocialdrinkers)
•Opium:20%
•Heroin:13%
•Cannabis:6.2%
•Others:1.8%
•Heroinabusersarenowestimatedtobe
around40,000.
•Themajorityofdrugaddictsareagedbetween
16and30years.
•Thesedrugabusersaremostlyunmarried,and
fromthelowersocio-economicstrata;33
percentofthemareengagedinantisocial
activities.
OpioidUseDisorders
Inthelastfewdecades,theuseofopioidshas
increasedmarkedlyworldover.India,sur­
roundedonbothsidesbyroutesofillicittransport,
namelyGoldenTriangle(Burma,Thailand,Laos)
andGoldenCrescent(Iran,Afghanistan,
Pakistan),isparticularlyaffected.Themost
importantdependenceproducingderivativesare
morphineandheroin.
Thecommonlyabusedopioids(narcotics)in
ourcountryareheroin(brownsugar,smack)and
syntheticpreparationslikepethidine,fortwin
(pentazocine)andtidigesic(buprenorphine).The
drugsthatareinjectedthroughneedleareheroin,
buprenorphineandpentazocine.Thoughmost
opiateusershadbegunchasing(inhalingthe
smokeorchasingthedragon)herointheygradually
shiftedtoneedleuse.Theseinjectingdrugusers
havebecomeahighriskgroupforHIVinfection.
AcuteIntoxication
Itischaracterizedbyapathy,bradycardia,
hypotension,respiratorydepression,subnormal
temperatureandpinpointpupils.Laterdelayed
reflexes,threadypulseandcomacanoccur.
WithdrawalSyndrome
Narcoticwithdrawalrarelyproducesalife-threa­
teningsituation.Commonsymptomsinclude
wateryeyes,runningnose,yawning,lossof
appetite,irritability,tremors,sweating,cramps,
nausea,diarrhea,insomnia,raisedbodytempe­
rature,piloerectionandanorexia.
Withdrawalsymptomsbeginwithin12hours
ofthelastdose,peakin24to36hoursand
disappearin5to6days.
Complications
•Complicationsduetoillicitdruguse:
Parkinsonism,peripheralneuropathy,
transversemyelitis.
•Complicationsduetointravenoususe:Skin
infection,thrombophlebitis,pulmonaryembo­
lism,endocarditis,septicemia,AIDS,viral
hepatitisandtetanus.
•Involvementincriminalactivities.
Treatment
Treatmentofopioidoverdose:Opioidoverdosecan
betreatedwithnarcoticantagonists,e.g.naloxone,
naltrexone
Detoxification:Withdrawalsymptomscanbe
managedbymethadone,clonidine,naltrexone,
buprenorphine,etc.
Maintenancetherapy:Afterthedetoxificationphase
isover,thepatientismaintainedononeofthe
followingregimens:
•Methadonemaintenance
•Opioidantagonists
•Psychologicalmethodslikeindividualpsy­
chotherapy,behaviortherapy,grouptherapy
andfamilytherapy
CannabisUseDisorder
Cannabisisderivedfromhempplant,Cannabis
sativa.Thedriedleavesandfloweringtopsare
oftenreferredtoasganjaormarijuana.Theresinof
theplantisreferredtoashashish.Bhangisadrink
madefromcannabis.
Cannabisiseithersmokedortakeninliquid
form.
AcuteIntoxication
Mildintoxicationischaracterizedbymildimpair­
mentofconsciousnessandorientation,tachy-

140. DisordersduetoPsychoactiveSubstanceUse137
cardia,asenseoffloatingintheair,euphoria,
dream-likestates,'flashback'phenomena,altera­
tioninpsychomotoractivity,tremors,photo­
phobia,lacrimation,drymouthandincreased
appetite.
Severeintoxicationcausesperceptualdistur­
banceslikedepersonalization,derealization,
synesthesiasandhallucinations.
WithdrawalSymptoms
Theyaremostlyfoundinthefirst72-96hours
andincludeincreasedsalivation,hyperthermia,
insomnia,decreasedappetite,lossofweightand
insomnia.
Complications
•Transientorshort-lastingpsychiatricdisor­
derssuchasacuteanxiety,paranoidpsychosis,
hystericalfugue-likestates,hypomania,
schizophrenia-likestate.
•Amotivationalsyndrome.
•Memoryimpairment.
Treatment
•Supportiveandsymptomatictreatment
CocaineUseDisorder
Commonstreetnameis'crack'.Itcanbeadmi­
nisteredorally,intranasallybysmoking,or
parenterally.
AcuteIntoxication
Characterizedbypupillarydilatation,tachy­
cardia,hypertension,sweatingandnauseaand
hypomanicpicture.
WithdrawalSyndrome
Agitation,depression,anorexia,fatigueand
sleepiness.
Complications
Acuteanxietyreaction,uncontrolledcompulsive
behavior,seizures,respiratorydepression,
cardiacarrhythmias.
Treatment
Managementofintoxication:Amylnitriteisan
antidote;diazepamorpropranololarealsoused.
Forwithdrawalsymptoms:Antidepressants(imi­
pramineoramitriptyline)andpsychotherapy.
Amphetamine UseDisorder
AmphetaminesarepowerfulCNSstimulants
withperipheralsympathomimeticeffects.
Commonlyusedamphetaminesarepemolineand
methylphenidate.
AcuteIntoxication
Characterizedbytachycardia,hypertension,
cardiacfailure,seizures,tremors,hyperpyrexia,
pupillarydilation,panic,insomnia,restlessness,
irritability,paranoidhallucinatorysyndromeand
amphetamine-inducedpsychosis.
WithdrawalSyndrome
Characterizedbydepression,apathy,fatigue,
hypersomniaorinsomnia,agitationandhyper­
phagia.
Complications
Seizures,delirium,arrhythmias,aggressive
behavior,coma.
LSDUseDisorder(Lysergicaciddiethylamide)
LSDisapowerfulhallucinogen,andwasfirst
synthesizedin1938.Itpresumablyproducesits
effectsbyactingon5-HTlevelsinbrain.Acommon
patternofLSDuseis'trip'(occasionaluse
followedbyalongperiodofabstinence).
Intoxication
Characterizedbyperceptualchangesoccurring
inclearconsciousness,e.g.depersonalization,
derealization,illusions,synesthesias(colorsare
heard,soundsarefelt),autonomichyperactivity,
markedanxiety,paranoidideationand
.impairmenfofjudgment.

141. 138AGuidetoMentalHealthandPsychiatricNursing
WithdrawalSyndrome
Flashbacks(briefexperiencesofthehallu­
cinogenicstate).
Complications
apathy,impairedjudgmentandneurological
signs.
WithdrawalSymptoms
Anxiety,depression.
Anxiety,depression,psychosisorvisual
hallucinosis. Complications
Treatment
Symptomatictreatmentwithantianxiety,anti­
depressantorantipsychoticmedications.
BarbiturateUseDisorder
Thecommonlyabusedbarbituratesareseco­
barbital,pentobarbitalandamobarbital.
Intoxication
Acuteintoxicationcharacterizedbyirritability,
labilityofmood,disinhibitedbehavior,slurring
ofspeech,incoordination,attentionandmemory
impairment.
Complications
Intravenoususecanleadtoskinabscesses,cellu­
litis,infections,embolismandhypersensitivity
reactions.
WithdrawalSyndrome
Itischaracterizedbymarkedrestlessness,
tremors,andseizuresinseverecasesresembling
deliriumtremens.
Treatment
Ifthepatientisconscious,inductionofvomiting
anduseofactivatedcharcoalcanreducethe
absorption.Treatmentissymptomatic.
InhalantsorVolatileSolventUseDisorder
Thecommonlyusedvolatilesolventsinclude
petrol,aerosols,thinners,varnishremoverand
industrialsolvents.
Intoxication
Inhalationofavolatilesolventleadstoeuphoria,
excitement,belligerence,slurringofspeech,
Irreversibledamagetotheliverandkidneys,
peripheralneuropathy,perceptualdisturbances
andbraindamage.
Treatment
Reassuranceanddiazepamforintoxication.
PREVENTION OFSUBSTANCE USE
•DISORDER
PrimaryPrevention
•Reductionofoverprescribingbydoctors
(especiallywithbenzodiazepinesandother
anxiolyticdrugs).
•Identificationandtreatmentoffamily
memberswhomaybecontributingtothedrug
abuse.
•Introductionofsocialchangesislikelytoaffect
drinkingpatternsinthepopulationasawhole.
Thisismadepossibleby:
•Puttingupthepriceofalcoholand
alcoholicbeverages
•Controllingorabolishingtheadvertising
ofalcoholicdrinks
•Controlsonsales(bylimitinghoursor
banningsalesinsupermarkets)
•Restrictingavailabilityandlesseningsocial
deprivation(Governmentalmeasures)
•Otherapproachesaretostrengthentheindi­
vidual'spersonalandsocialskillstoincrease
self-esteemandresistancetopeerpressure.
•Healtheducationtocollegestudentsandthe
youthaboutthedangersofdrugabuse
throughthecurriculumandmassmedia.
Healtheducationshouldalsoincludecertain
specificgroupswhereasubstancelikealcohol
maybeculturallyaccepted.Forinstance,

142. DisordersduetoPsychoactiveSubstanceUse139
certaintribalcommunitiessuchasthe
Lambanigroupmanufacturearrack,andits
intakeisconsiderednormal.Somecommu­
nitiesuseitinthepostnatalperiod,asalcohol
isbelievedtostrengthenthepelvicmuscles
andalsospeedupretroversionoftheuterus.
Suchattitudesshouldbeaddressedand
corrected.
•Anoverallimprovementinthesocioeconomic
conditionofthepopulation.
SecondaryPrevention
•Earlydetectionandcounseling.
•Briefinterventioninprimarycare(simple
advicebyageneralpractitionerplusan
educationalleaflet).
•Motivationalinterviewingwhichinvolves
providingfeedbacktothepatientonthe
personalrisksthatalcoholposes,together
withanumberofoptionsforchange.
•Afullassessmentincludinganappraisalof
currentmedical,psychologicalandsocial
problems.Assessmentalsoincludesascer­
tainingwhetheralcoholismistheprimaryor
secondaryproblem.Forexample,apatient
withdiabeticneuropathymaybeusingalcohol
tonumbpain.Alcoholisalsousedbysometo
relieveasthmaticsymptoms.Insuchinstances,
treatmentofthemedicalproblemcanhelpto
controlalcoholism.
•Detoxificationwithbenzodiazepines(diaze­
pam,chlordiazepoxide).
TertiaryPrevention
Specificmeasuresinclude:
•Alcoholdeterrenttherapy(Disulfiramor
Antabuse).
•Othertherapiesincludeassertivenesstraining
(topreventyieldingtopeerpressure),teaching
copingskills(sometakedrugstocombat
stress),behaviorcounseling,supportivepsy­
chotherapyandindividualpsychotherapy.
•Agenciesconcernedwithalcohol-related
problems:AlcoholicsAnonymous(AA),Al­
Anon,Al-Ateen,etc.
•Somepracticalissuesunderrelapse
preventioninclude:
•Motivationenhancement,including
educationabouthealthconsequencesof
alcoholuse
•Identifyinghigh-risksituationsand
developingstrategiestodealwiththem
(cravingmanagement)
•Drinkrefusalskills(assertivenesstraining)
•Dealingwithfaultycognitions
•Handlingnegativemoodstates
•Timemanagement
•Angercontrol
•Financialmanagement
•Developingtheworkhabit
•Stressmanagement
•Sleephygiene
•Recreationandspirituality
•Familycounseling,toreduceinterpersonal
conflicts,whichmayotherwisetrigger
relapse
REHABILITATION
Theaimofrehabilitationofanindividual
deaddictedfromtheeffectsofalcohol/drugs,is
toenablehimtoleavethedrugsub-cultureandto
developnewsocialcontacts.Inthis,clientsfirst
engageinworkandsocialactivitiesinsheltered
surroundingsandthentakegreaterresponsi­
bilitiesforthemselvesinconditionsincreasingly
likethoseofeverydaylife.Continuingsocial
supportisusuallyrequiredwhentheperson
makesthetransitiontonormalworkandliving.
NURSINGMANAGEMENT FORSUBSTANCE
USEDISORDER
NursingAssessment
1.Recognitionofalcoholabuse:TheCAGEques­
tionnairemaybeadoptedforthispurpose:
C:HaveyoueverfeltyououghttoCUTdown
onyourdrinking?
A:HavepeopleANNOYEDyoubycriticizing
yourdrinking?
G:HaveyoueverfeltGUILTYaboutyour
drinking?

143. 140AGuidetoMentalHealthandPsychiatricNursing
Table11.1:Nursinginterventionsduringacuteintoxication
Interventions Rationale·
(a)Placetheclientinaroomnear
thenurse'sstationorwherethestaff
canobservetheclientclosely.
(b)Monitortheclient'ssleeppattern;
hemayneedtoberestrainedat
nightifconfusedorifhewanders
orattemptstoclimboutofbed.
(c)Decreaseenvironmentalstimuli(bright
lights,television,visitors)whenthe
clientisrestless,irritableortremulous.
(d)Instituteseizureprecautions(padded
tonguebladeandairwayatbedside,
raisedside-rails,etc.)
(e)Reorienttheclienttoperson,time,
placeandsituationasneeded.
(f)Talktotheclientinsimple,direct,
concretelanguage.
E:Haveyoueverhadadrinkfirstthingin
themorning(anEYE-OPENER)tosteady
yournervesorgetridofahangover?
2.Besuspiciousabout'at-risk'factors:Problems
inthemarriageandfamily,atwork,with
financesorwiththelaw;atriskoccupations;
withdrawalsymptomsafteradmission;
alcohol-relatedphysicaldisorders;repeated
accidents;deliberateself-harm.
3.Ifat-riskfactorsraisesuspicion,thenextstep
istoasktactfulbutpersistentquestionsto
confirmthediagnosis.
4.Certainclinicalsignsleadtothesuspicion
thatdrugsarebeinginjected:needletracks
andthrombosedveins,wearinggarments
withlongsleeves,etc.IVuseshouldbe
suspectedinanypatientwhopresentswith
subcutaneousabscessesorhepatitis.
5.Behavioralchanges:Absencefromschoolor
work,negligenceofappearance,minorcrimi­
naloffences,isolationfromformerfriendsand
adoptionofnewfriendsinadrugculture.
6.Laboratorytests:
•RaisedGamma-GlutamylTranspeptfdase
(GGT).
•Raisedmeancorpuscularvolume.
Client'ssafetyisnursingpriority.
-do-
Toomanystimuliintheenvironment
mayincreasemisperceptionsand
restlessness.
Seizurescanoccurduringwith­
drawal,precautionscanminimize
chancesofinjury.
Theclientisoftenconfusedand
needstobereoriented.
Patient'sabilitytodealwithcomplex
orabstractideasislimited.
•Bloodalcoholconcentration.
•Mostdrugscanbedetectedinurine,the
notableexceptionbeingLSD.
NursingDiagnosisI
Riskforinjuryrelatedtohallucinosis,acuteinto­
xicationevidencedbyconfusion,disorientation,
inabilitytoidentifypotentiallyharmfulsituations.
Objective:Clientwillnotharmself.
Intervention:SeeTable11.1.
NursingDiagnosisII
Alteredhealthmaintenancerelatedtoinabilityto
identify,manageorseekouthelptomaintain
health,evidencedbyvariousphysicalsymptoms,
exhaustion,sleepdisturbances,etc.
Objective:Theclientwillmaintainoptimumhealth
status.
Intervention:SeeTable11.2.
NursingDiagnosisIll
Ineffectivedenialrelatedtoweak,underdevelo­
pedego,evidencedbylackofinsight,rationa-

144. DisordersduetoPsychoactiveSubstanceUse141
Table11.2:Nursinginterventionstoimprovehealthstatusofalcoholics
Interventions Rationale
(a)Monitortheclient'shealthstatus.
Administermedicationsasprescribed
byphysician.Observetheclientforany
behavioralchangesandinform
physicianwhennecessary.
(b)Maintainfluidandelectrolytebalance.
(c)Providefoodornourishingfluidsas
soonastheclientcantolerateeating
(blandfoodusuallyistoleratedbest
atfirst).
(d)Ensurethatamountofproteininthe
dietiscorrectforindividualpatient
condition.
(e)Providesmallfrequentfeedingsof
patient'sfavoritefoods.Supplement
withvitaminsandminerals.
(f)Assisttheclientinself-careactivities;
itmaybenecessarytoprovide
completephysicalcare,dependingonthe
severityoftheclient'swithdrawal.
Toevaluatetheclient'sprogress
accurately.
Patientswithalcoholabuseproblems
areathighriskforfluidand
electrolyte,.imbalances.
Manypatientswhousealcohol
heavilyexperiencegastritis,
anorexiaandsoforth.Therefore
blandfoodsaretoleratedmost
easily.Itisimportanttore-establish
nutritionalintakeassoonaspossible.
Diseasedlivermaybeincapableof
properlymetabolizingproteins,
resultinginanaccumulationof
ammoniainthebloodthatcirculates
tothebrainandcanresultinaltered
consciousness.
Tocorrectmalnutrition.
Thelevelofclientindependency
isdeterminedbytheseverityof
withdrawalsymptoms.Theclient's
needsshouldbemetwiththe
greatestdegreeofindependence
hecanattain.
Table11.3:Nursinginterventionstoimproveadaptivebehaviour
Interventions Rationale
(a)Developtrust,conveyanattitudeof
acceptance.Ensurethatpatient
understandsitisnothimbut
hisbehaviorthatisunacceptable.
(b)Identifyrecentmaladaptivebehaviors
orsituationsthathaveoccurredinthe
patient'slifeanddiscusshowuseof
drugs/alcoholmaybeacontributing
factor.
(c)Donotallowpatienttorationalizeor
blameothersforbehaviorsassociated
withsubstanceuse.
(d)Providepositivereinforcementwhenthe
clientshowsinsightintohisbehavior.
Unconditionalacceptancepromotes
dignityandself-worth.
Thefirststepindecreasing
denialandrationalizationisforpatient
toseetherelationshipbetween
substanceuseandpersonalproblems.
Thisonlyservestoprolongthe
'denial.
Enhancesrepeytionofdesirable
behavior.·

145. 142AGuidetoMentalHealthandPsychiatricNursing
Table11.4:Nursinginterventionstoimproveadaptivecopingskillsamongalcoholics
Interventions Rationale
(a)Encourageclienttoexploreoptions
availabletodealwithstress,rather
thanresortingtosubstanceuse.
Practicethesetechniques.
(b)Givepositivereinforcementfor
abilitytodelaygratificationand
respondtostresswithadaptivecoping
strategies.
(c)Teachclientandfamilythatalcoholism
isadiseasethatrequireslong-termtreatment
andfollowup.RefertoAA,Al-Anon
andothersupportgroupsasindicated.
(d)Teachtheclientaboutthe
preventionofHIVtransmission.
(e)Maintainfrequentcontactwiththe
client,evenifitisonlybyabrieftelephone
call.
(f)Ifdrinkingoccurs,discusstheevents
thatledtotheincidentwiththepatient
inanon-judgmentalmanner.Discuss
waystoavoidsimilarcircumstancesin
thefuture.
(g)Assistthepatienttoplanweekly,oreven
daily,schedulesofpurposefulactivities,
suchasappointments,talkingwalks,etc.
Todevelopdesirablewaysofcoping
withstress.
Becauseofweakego,patientneeds
alotofpositivefeedbackto
enhanceself-esteem.
Familyandsignificantothersare~!so
affectedbytheclient'ssubstance
useandneedhelp.
Patientswithalcohol/drugusemay
involveinhighriskbehaviorswhich
increasetheriskofHIVtransmission
Patientwillnotfeelleftalone
todealwithhisproblems.
Theclientmaybeabletoseethe
relatednessoftheeventorapattern
ofbehaviorwhilediscussingthe
situation.Anticipatoryplanningmay
preparetheclienttoavoidsimilar
circumstancesinfuture.
Scheduledeventsprovidethepatient
withsomethingtolookforwardto.
Evaluation
Thefollowingquestionscanbeusefulin
evaluatingthenursingcare:
•Hasdetoxificationoccurredwithoutcompli­
cations?
•Hasacorrelationbeenmadebetweenpersonal
problemsandtheuseofsubstances?
•Doesheacceptresponsibilityforown
behavior?
lizationofproblems,blamingothers,failureto
acceptresponsibilityforhisbehavior.
Objective:Patientwillunderstandtheeffectof
hisbehavioronothersandverbalizeacceptance
ofresponsibilityanddesireforchange.
Intervention:SeeTable11.3.
NursingDiagnosisIV
Ineffectiveindividualcopingrelatedto
impairmentofadaptivebehaviorandproblem­
solvingabilities,evidencedbyuseofsubstances
ascopingmechanisms.
Objective:Patientwillbeabletouseadaptive
copingmechanisms,insteadofabusingdrugs/
alcohol,inresponsetostress.
Intervention:SeeTable11.4.
REVIEWQUESTIONS
•Drugaddiction(Oct2000)
•Drugscommonlyusedforaddiction(Nov
2003)
•Drugabuse(Apr2002,Apr2004),dependence
(Nov2003),toleranceandwithdrawalstate

146. DisordersduetoPsychoactiveSubstanceUse143
•Whatarethedependencyproducingdrugs
(Oct2000)
•Etiologyofsubstanceuse(Nov1999)
•Complicationsofalcoholdependence
•Deliriumtremens(Nov1999,Oct2005)
•Korsakoff'ssyndrome(Apr2006)
•Preventionofalcoholabuse(Feb2000)
•Treatmentofalcoholdependence
•Alcoholanonymous(Oct2000,Oct2005,Apr
2006)
•Opioidusedisorders
•Preventionofdrugabuse(Feb2000)
•Nursingmanagementforsubstanceuse
disorder(Oct2000,Nov2001,Nov2002,Nov
2003,Oct2004)
•Outlinerehabilitationprogramforan
alcoholicpatientwhoisonanatabusetherapy
(Nov2003)
•Esperol(Apr2002)

147. DisordersofAdult
Personalityand
Behavior
DPERSONALITYDISORDER
Definition(ICD9)
Incidence
Classification
Clinicalfeaturesofabnormalpersonalities
Etiology
Treatment
NursingIntervention
DSEXUALDISORDERS
Classification
NursingIntervention
PERSONALITYDISORDER
Thetermpersonalityreferstoenduringqualities
ofanindividualthatareshowninhiswaysof
behavinginawidevarietyofcircumstances.
Personalitydisordersresultwhenpersonality
traitsbecomeabnormal,i.e.becomeinflexibleand
maladaptiveandcausesignificantsocialor
occupationalimpairmentorsignificantsubjective
distress.
InICDlO,theyarelistedunderthesectionon
DisordersofAdultPersonalityandBehavior(F6).
Definition(ICD9)
Thedefinitionofabnormalpersonalitygivenby
ICD9isasfollows:
Anabnormalpersonalityisoneinwhichthere
are"deeplyingrainedmaladaptivepatternsof
behaviorrecognizablebythetimeofadolescence
orearlierandcontinuingthroughmostofadult
life.Becauseofthis,thepatientsuffersorothers
havetosuffer,andthereisanadverseaffecton
theindividualoronsociety."
Incidence
Theprevalenceofpersonalitydisordersinthe
generalpopulationis5to10%.Occurrenceof
mixedpersonalitydisordersismorecommon
thanasinglepersonalitydisorderinan
individual.
Classification
A.ICD10
•Paranoidpersonalitydisorder
•Schizoid(schizotypal)personalitydisorder
•Dissocialpersonalitydisorder
•Emotionallyunstable(impulsiveandborder­
linetype)personalitydisorder
•Histrionicpersonalitydisorder
•Anankastic(obsessive-compulsiveperso-
nalitydisorder)
•Anxious(avoidant)personalitydisorder
•Dependentpersonalitydisorder
•Otherdisorders
B.OSMIV
InDSMIV,personalitydisordersarecodedonaxis
IIandhavebeendividedintothreeclusters:
a.ClusterA(oddandeccentric):paranoid,
schizoid,schizotypalpersonalitydisorders
b.ClusterB(dramatic,emotionalanderratic):
antisocial,histrionic,narcissisticpersonality
disorders
c.ClusterC(anxiousandfearful):avoidant,
dependentandobsessive-compulsiveperso­
nalitydisorders
ClinicalFeaturesofAbnormalPersonalities
a.ParanoidPersonalityDisorder
•Suspicious
•Mistrustful
•Sensitive

148. DisordersofAdultPersonalityandBehavior145
•Argumentative
•Stubborn
•Self-important
b.SchizoidPersonalityDisorder
•Emotionallycold
•Aloof
•Detached
•Humourless
•Introspective
c.SchizotypalDisorder
•Inappropriateaffect
•Oddbeliefsormagicalthinking
•Socialwithdrawal
•Odd,eccentricorpeculiarbehavior
d.Antisocial(Dissocia/)PersonalityDisorder
(Sociopath,Psychopath)
•Failuretosustainrelationships
•Disregardforthefeelingsofothers
•Impulsiveactions
•Lowtolerancetofrustration
•Tendencytocauseviolence
•Lackofguilt
•Failuretolearnfromexperience
e.HistrionicPersonalityDisorder
Thisdisorderismorecommoninfemales
•Dramaticemotionality(Emotionalblackmail,
angryscenes,demonstrativesuicideattempts,
etc.)
•Cravingfornoveltyandexcitement
•Shallowandlabileaffectivity
•Attention-seekingbehavior
•Overconcernwithphysicalattractiveness
f.NarcissisticPersonalityDisorder
•Inflatedsenseofself-importance
•Attention-seeking,dramaticbehavior
•Unabletofacecriticism
•Lackofempathy
•Exploitativebehavior
j.BorderlinePersonality
•Unstablerelationships
•Impulsivebehavior
•Variablemoods
•Lackofcontrolonanger
•Recurrentsuicidalthreatsorbehavior
•Uncertaintyaboutpersonalidentity
•Chronicfeelingsofemptiness
•Effortstoavoidabandonment
•Transientstress-relatedparanoidordissocia­
tivesymptoms
h.Anxious(Avoidant)PersonalityDisorder
•Persistentfeelingoftensionandapprehension
•Inferioritycomplex
•Fearofcriticism,disapprovalorrejection
•Unwillingnesstobecomeinvolvedwith
people
•Excessivepreoccupationwithbeingcriticized
orrejectedinsocialsituations
i.DependentPersonality
•Subordinationofone'sownneeds
•Unwillingnesstomakeevenreasonable
demandsonotherpeople
•Inabilitytotakedecision
•Feelinguncomfortableorhelplesswhenalone
j.Obsessive-compulsive(anankastic)
PersonalityDisorder
•Feelingofexcessivedoubtandcaution
•Preoccupationwithdetails,rules,lists,order
orschedule
•Perfectionism
•Rigidityandstubbornness
•Highstandards.
Etiology
AHereditaryfactors:Chromosomalabnormality
orgeneticpredispositioncanberesponsible
forapsychopathicpersonality.
B.Relationofpersonalitydisordertomentaldisorder:
Forexample,schizoidpersonalitiesare

149. 146AGuidetoMentalHealthandPsychiatricNursing
consideredtobepartialexpressionsofschizo­
phrenia.
C.Personalitydisorderandupbringing:e.g.
disturbedparent-childrelationships.
D.Othercauses:
•Maternaldeprivation,especiallyin
antisocialpersonality.
•Borderlinepersonalitiesaremorelikelyto
reportphysicalandsexualabusein
childhood.
•Histrionicpersonalityissaidtooccurasa
resultoffailuretoresolveoedipalcomplex
andexcessiveuseofrepressionasa
mechanismofdefense.
•Dependentpersonalitymaybedueto
fixationintheoralstageofdevelopment.
•Paranoidpersonalityisduetoabsenceof
trust,whichresultsfromlackofparental
affectioninchildhoodandpersistent
rejectionbyparentsleadingtolowself­
esteem.
Treatment
Personalitydisorderisoftendifficulttotreat.
Drugtreatmenthasaverylimitedroleandmay
beusedifassociatedmentalillnesslikedepres­
sionorpsychosisispresent.Individualandgroup
psychotherapy,therapeuticcommunityandbeha­
vioraltherapymaybebeneficial.Manipulation
ofthesocialenvironmentcanbetried.
NursingIntervention
A.AntisocialPersonalityDisorder
•Conveyanacceptingattitudetowardsthe
patient.Behonest,keepallpromisesand
conveythemessagethatitisnothimbuthis
behaviorwhichisunacceptable.
•Maintainlowlevelofstimuliintheenviron­
menttodecreaseagitationandaggressive
behavior;removealldangerousobjectsfrom
theenvironment.
•Helpthepatienttoidentifythetrueobjectof
hishostilityandencouragehimtogradually
verbalizehostilefeelings.Thismayhelphim
tocometotermswithunresolvedissues.
•Explorewithpatientalternativewaysof
handlingfrustrationtorelievepent-up
tensions(e.g.largemotorskillsthatchannel
hostileenergyintosociallyacceptable
behavior).
•Staffshouldmaintainacalmattitude.Have
sufficientstaffavailabletopresentashowof
strengthtopatientifnecessary.Italsoprovides
somephysicalsecurityforthestaff.
•Administertranquilizingmedicationsas
prescribed.
•Mechanicalrestraintsmaybeneeessaryifthe
clientisnotcalmedby'talkingdown'orby
medication.
•Explainconsequencesiflimitsareviolated.
Aconsequencemustinvolvesomethingof
valuetotheclient,andallstaffmustbe
consistentinenforcingtheselimits.
•Providepositivefeedbackforacceptable
behaviorwhichwillencouragerepetitionof
desirablebehaviors.
•Helpclienttogaininsightintohisown
behavior.Hemustunderstandthatcertain
behaviorswillnotbetoleratedwithinthe
societyandthatsevereconsequenceswillbe
imposeduponthoseindividualswhorefuse
tocomply.
•Talkabouthispastbehaviors.Helphim
identifywaysinwhichhehasexploited
others.Encouragehimtoexplorehowhe
wouldfeelifthecircumstanceswerereversed.
B.BorderlinePersonalityDisorder
•Observepatient'sbehaviorfrequently.Dothis
duringroutineactivitiesandinteraction;
avoidappearingwatchfulandsuspicious.
•Secureaverbalcontractfrompatientthathe
willseekoutstaffmembersforhelpwhenurge
forself-mutilationisfelt.
•Ifself-mutilationoccurs,careforpatient's
woundsinmatter-of-factmanner.Donotgive
positivereinforcementtothisbehaviorby
offeringsympathyoradditionalattention.
Assignstaffonaone-to-onebasisifneedarises.
•Encouragepatienttotalkaboutfeelingshe
washavingjustpriortothisbehavior.Actas

150. DisordersofAdultPersonalityandBehavior147
arolemodelforappropriateexpressionof
angryfeelings.Givepositivereinforcement
whenattemptstoconformaremade.
•Setlimitsonactingoutbehavior.
•Rotatestaffwhoworkwiththepatientto
preventthepatientfromdevelopingdepen­
denceonparticularstaffmembers.
•Explorefeelingsthatrelatetofearsofaban­
donment.Helpclientunderstandthatthese
fearsarecausinghisclinginganddistancing
behaviors.Helppatientunderstandhowthese
behaviorsinterferewithsatisfactoryrelations.
SEXUALDISORDERS
InICDlOgenderidentitydisorders,disordersof
sexualpreferenceandsexualdevelopmentand
orientationdisordersarelistedunderDisorders
ofAdultPersonalityandBehavior(F6),while
sexualdysfunctionsarelistedunderBehavioral
SyndromesAssociatedWithPhysiological
DisturbancesandPhysicalFactors(FS).
Classification
•Genderidentitydisorders.
•Psychologicalandbehavioraldisordersasso­
ciatedwithsexualdevelopmentand
maturation.
•Disordersofsexualpreference(paraphilias).
•Sexualdysfunctions.
GenderIdentityDisorders(F6)
Inthesedisorders,thesenseofone'smasculinity
orfemininityisdisturbed.Theyinclude:
•Transsexualism.
•Genderidentitydisorderofchildhood.
•Dual-roletransvestism.
•Intersexuality.
a.Transsexualism:Inthis,thereisapersistent
andsignificantsenseofdiscomfortregarding
one'sanatomicsexandafeelingthatitis
inappropriatetoone'sperceivedgender.The
personwillbepreoccupiedwiththewishto
getridofone'sgenitalsandsecondarysex
characteristicsandtoadoptthesex
characteristicsoftheothersex.
Treatment
•Counselingtohelptheindividual
reconcilewiththeanatomicsex.
•Sexchangetothedesiredgender[sexreas­
signmentsurgery(SRS)]inselectedcases
b.Genderidentitydisorderofchildhood:Thisisa
disordersimilartotranssexualism,withavery
earlyageofonset.
c.Dual-roletransvestism:Itischaracterizedby
wearingclothesoftheoppositesexinorderto
enjoythetemporaryexperienceofmembership
oftheoppositesexbutwithoutanydesirefor
permanentsexchange.
d.Intersexuality:Thepatientshavegrossanato­
micalorphysiologicalfeaturesoftheother
sex.Forexample,pseudohermaphroditism,
Turner'ssyndrome,congenitaladrenal
hypoplasia.
PsychologicalandBehavioralDisorders
AssociatedwithSexualDevelopment
andMaturation(F6)
Homosexuality
Inthis,sexualrelationshipsaremaintainedbe­
tweenpersonsofthesamesex.Femalehomo­
sexualsarecalledas'lesbians'andmale
homosexualsarecalled'gay.'
Treatment
•Behaviortherapy:aversiontherapy,covert
sensitization,systematicdesensitization.
•Supportivepsychotherapy.
•Psychoanalyticpsychotherapy
DisordersofSexualPreference(ICD10-F6)
orParaphilias(DSMIV)
Inparaphiliassexualarousaloccurspersistently
andsignificantlyinresponsetoobjects,which
arenotapartofnormalsexualarousal.These
disordersinclude:
a.Fetishism:Sexualarousaloccurswithanon­
livingobjectwhichisusuallyintimately
associatedwiththehumanbody.Thefetish
objectmayincludebras,underpants,shoes,
gloves,etc.

151. 148AGuidetoMentalHealthandPsychiatricNursing
b.Transvestism:Sexualarousaloccursby
wearingclothesoftheoppositesex.
c.Sexualsadism:Thepersonissexuallyaroused
byphysicalandpsychologicalhumiliation,
sufferingorinjuryofthesexualpartner.
d.Sexualmasochism:Herethepersonissexually
arousedbyphysicalorpsychologicalhumi­
liationorinjuryinflictedonselfbyothers.
e.Exhibitionism:Inthisthepersonissexually
arousedbytheexposureofone'sgenitaliato
anunsuspectingstranger.
f.Voyeurism:Thisisapersistentorrecurrent
tendencytoobserveunsuspectingpersons
naked(usuallyoftheothersex)andengaged
insexualactivity.
g.Frotteurism:Thisisapersistentorrecurrent
involvementintheactoftouchingandrubbing
againstanunsuspecting,non-consenting
person.
h.Pedophilia:Itischaracterizedbypersistentor
recurrentinvolvementofanadultinsexual
activitywithprepubertalchildren.
i.Zoophilia(Beastiality):Involvinginsexual
activitywithanimals.
j.Otherparaphilias:Sexualarousaloccurswith
urine,feces,enemas,etc.
Treatment
•Behaviortherapy:aversiontherapy.
•Psychoanalysis.
•Drugtherapy:Antipsychoticshavebeenused
forsevereaggressionassociatedwith
paraphilias.
SexualDysfunctions(F5)
Sexualdysfunctionisasignificantdisturbance
inthesexualresponsecycle,whichisnotdueto
anunderlyingorganiccause
Thecommondysfunctionsare:
a.Frigidity:Absenceofdesireforsexualactivity.
b.Impotence:Thisdisorderischaracterizedby
aninabilitytohaveorsustainpenileerection
tillthecompletionofsatisfactorysexual
activity.
c.Prematureejaculation:Ejaculationbeforethe
completionofsatisfactorysexualactivityfor
bothpartners.
d.Non-organicvaginismus:Aninvoluntary
spasmoflowerl/3rdofvagina,interfering
withcoitus.
e.Non-organicdyspareunia:Paininthegenital
areaofeithermaleorfemaleduringcoitus.
Treatment
•Psychoanalysis
•Hypnosis
•Grouppsychotherapy
•Behaviortherapy
NursingInterventionforClientwithSexual
Disorder
•Assessclient'ssexualhistoryandprevious
levelofsatisfactioninsexualrelationships;
alsoassessclient'sperceptionoftheproblem.
•Notecultural,social,ethnic,racialand
religiousfactorsthatmaycontributeto
conflictsregardingvariantsexualpractices.
•Assessforanymedicationswhichmightbe
affectinglibido.
•Provideinformationregardingsexualityand
sexualfunctioning,correctanymisconcep­
tionsifnecessary.Teachpatientthatsexuality
isanormalhumanresponseandthatit
involvescomplexinter-relationshipsamong
one'sself-concept,bodyimage,familyand
culturalinfluences.
•Boththeclientandhis/herpartnermayneed
additionalassistanceifproblemsinsexual
relationshiparesevereorremainunresolved.
•Referforadditionalcounselingorsextherapy
ifrequired.
•Assisttherapistasnecessaryinplanof
behaviormodificationtohelpdecrease
variantbehavior.
•Inallcases,anacceptingandnon-judgmental
attitudeonthepartofthenurseishighly
essentialforsuccessfulresolutionofthese
problemsasthesearehighlysensitiveissues
andmaybecausingsignificantdistresstothe
patient.

152. DisordersofAdultPersonalityandBehavior149
REVIEWQUESTIONS
•Defineabnormalpersonality
•Classificationofpersonalitydisorders(Nov
1999)
•Paranoidpersonalitydisorder
•Schizoidpersonalitydisorder
•Antisocialpersonalitydisorder(Feb2000,Oct
2004)
•Sociopathicreactions(Oct2005)
•Psychopathicpersonality(Nov2003)
•Histrionicpersonality
•Borderlinepersonality
•Etiologyofpersonalitydisorders(Feb2000)
•Nursingmanagement forantisocial
personality(Feb2000)
•Sexualdisorder(Nov2002)
•Classificationofsexualdisorders(Feb2000)
•Transsexualism(Oct2005)
•Whatisvoyeurism(Apr2004)
•Paraphilias(sexualperversions)(Nov2003)

153. ChildhoodPsychiatric
Disorders
0CLASSIFICATION
0MENTALRETARDATION
0DISORDERSOFPSYCHOLOGICALDEVELOPMENT
SpecificDevelopmentalDisordersof
SpeechandLanguage
SpecificDevelopmentalDisordersof
ScholasticSkills
SpecificDevelopmentalDisordersof
MotorFunction
PervasiveDevelopmentalDisorder­
ChildhoodAutism
0BEHAVIORALANDEMOTIONALDISORDERS
WITHONSETUSUALLYOCCURRINGIN
CHILDHOODANDADOLESCENCE
HyperkineticDisorder
ConductDisorders
EmotionalDisordersWithOnsetSpecific
toChildhood
-SeparationAnxietyDisorderof
Childhood
PhobicAnxietyDisorderofChildhood
SocialAnxietyDisorderofChildhood
-SiblingRivalryDisorder
DisordersofSocialFunctioningWithOnset
SpecifictoChildhoodandAdolescence
TicDisorders
OtherBehavioralandEmotionalDisorders
WithOnsetUsuallyOccurringInChildhood
andAdolescence
Non-OrganicEnuresis
Non-OrganicEncopresis
FeedingDisorderofInfancyand
Childhood
Pica
StereotypedMovementDisorders
Stuttering(Stammering)
Thefieldofchildpsychiatryisnewtothe
twentiethcentury,andchildpsychiatricnursing
evolvedgraduallyasthetherapeuticvalueof
nurses'relationshipwithchildrenbegantobe
realized.In1954thefirstgraduateprogramin
childpsychiatricnursingwasopened.Advocates
forChildPsychiatricNursing(ACPN),the
professionalorganizationforthisnursing
specialtywasestablishedin1971,andthefirst
ANAcertificationofchildpsychiatricnursestook
placein1979.TheANA'sStandardsofchildand
adolescentpsychiatricandmentalhealthnursing
practicewerepublishedin1985.
Thechildpsychiatricnurseusesawiderange
oftreatmentmodalities,includingmilieutherapy,
behaviormodification,cognitivebehavior
therapy,therapeuticplay,groupandfamily
therapyandpharmacologicalagents.
Childpsychiatricnursingisdifferentfrom
adultpsychiatricnursinginthefollowingways:
•Itisseldomthatchildreninitiateaconsultation
withtheclinician.Instead,theyarebrought
byadults,usuallytheparents,whothinkthat
someaspectofbehaviorordevelopmentis
abnormal.
•Thechild'sstageofdevelopmentdetermines
whetherbehaviorisnormalorabnormal.For
instance,bedwettingisnormalattheageof3
yearsbutabnormalwhenthechildis7.Thus
greaterattentionshouldbepaidtothestage
ofdevelopmentofthechildanddurationof
thedisorder.
•Childrenaregenerallylessabletoexpress
themselvesinwords;thereforeevidenceof
disturbanceisbasedmoreonobservationsof
behaviormadebyparents,teachersand
others.
•Thetreatmentofchildrenmakeslessuseof
medicationsorothermethodsofindividual

154. ChildhoodPsychiatricDisorders151
treatment.Mainemphasisisonchangingthe
attitudesofparents,reassuringandretraining
children,workingwithfamilyandcoordi­
natingtheeffortsofotherswhocanhelp
childrenespeciallyatschool.
CLASSIFICATION (ICD10)
Mentalretardation(F7)
Disordersofpsychologicaldevelopment(FS)
•Specificdevelopmentaldisordersofspeech
andlanguage
•Specificdevelopmentaldisordersofscholastic
skills
•Specificdevelopmentaldisordersofmotor
function
•Pervasivedevelopmentaldisorders
Behavioralandemotionaldisorderswithonset
usuallyoccurringinchildhoodandadolescence
(F9)
•Hyperkineticdisorders
•Conductdisorders
•Emotionaldisorders
•Separationanxietydisorderofchildhood
•Phobicanxietydisorderofchildhood
•Socialanxietydisorderofchildhood
•Siblingrivalrydisorder
•Disordersofsocialfunctioning
•Electivemutism
•Ticdisorders
•Otherbehavioralandemotionaldisordersin
childhoodandadolescence
•Non-organicenuresis
•Non-organicencopresis
•Feedingdisordersofinfancyandchild­
hood
•Stereotypedmovementdisorders
•Stuttering
MENTALRETARDATION (F7)
Definition
"Mentalretardationreferstosignificantlysub­
averagegeneralintellectualfunctioningresulting
inorassociatedwithconcurrentimpairmentsin
adaptivebehaviorandmanifestedduringthe
developmentalperiod"(AmericanAssociationon
MentalDeficiency,1983).
'Generalintellectualfunctioning'isdefinedas
theresultobtainedbytheadministrationof
standardizedgeneralintelligencetestsdeveloped
forthepurpose,andadoptedtotheconditionsof
theregion/country.
'Significantsubaverage'isdefinedasan
IntelligenceQuotient(IQ)of70orbelowon
standardizedmeasuresofintelligence.Theupper
limitisintendedasaguidelineandcouldbe
extendedto75ormore,dependingonthe
reliabilityoftheintelligencetestused.
'Adaptivepehavior'isdefinedasthedegrees
withwhichtheindividualmeetsthestandards
ofpersonalindependenceandsocialresponsi­
bilityexpectedofhisageandculturalgroup.The
expectationsofadaptivebehaviorvarywiththe
chronologicalage.Thedeficitsinadaptive
behaviormaybereflectedinthefollowingareas:
Duringinfancyandchildhoodin:
•Sensoryandmotorskilldevelopment
•Communicationskill(includingspeechand
language)
•Self-helpskills
•Socialization
Duringchildhoodandadolescencein:
•Applicationofbasicacademicskilltodaily
lifeactivities
•Applicationofappropriatereasoningand
judgmentinthemasteryoftheenvironment
•Socialskills.
Duringlateadolescencein:
•Vocationalandsocialresponsibilitiesand
performance.
'Developmentalperiod'isdefinedastheperiod
oftimebetweenconceptionandthe18thbirth­
day.
Epidemiology
About3%oftheworldpopulationisestimatedto
bementallyretarded.InIndia,5outof1000
childrenarementallyretarded(TheIndianExpress,
13thMarch2001).Mentalretardationismore
commoninboysthangirls.Withsevereand
profoundmentalretardationmortalityishighdue
toassociatedphysicaldiseases.

155. 152AGuidetoMentalHealthandPsychiatricNursing
Etiology
GeneticFactors
Chromosomalabnormalities
•Down'ssyndrome
•FragileXsyndrome
•TrisomyXsyndrome
•Turner'ssyndrome
•Cat-crysyndrome
•Prader-willisyndrome
Metabolicdisorders
•Phenylketonuria
•Wilson'sdisease
•Galactosemia
Placentaldysfunction
•Toxemiaofpregnancy
•Placentaprevia
•Cordprolapse
•Nutritionalgrowthretardation
PerinatalFactors
•Birthasphyxia
•Prolongedordifficultbirth
•Prematurity(duetocomplications)
•Kernicterus ,
•Instrumentaldelivery(resultinginhead
injury,intraventricularhemorrhage)
Cranialmalformation
•Hydrocephaly
•Microcephaly
Grossdiseasesofbrain
•Tuberousscleroses
•Neurofibromatosis
•Epilepsy
PostnatalFactors
•Infections
•Encephalitis
•Measles
•Meningitis
•Septicemia
•Accidents
•Leadpoisoning
PrenatalFactors
Infections
•Rubella
•Cytomegalovirus
•Syphilis
•Toxoplasmosis,herpessimplex
Endocrinedisorders
•Hypothyroidism
•Hypoparathyroidism
•Diabetesmellitus
EnvironmentalandSocioculturalFactors
•Culturaldeprivation
•Lowsocioeconomicstatus
•Inadequatecaretakers
•Childabuse
Classification
,.;
Physicaldamageanddisorders
•Injury
•Hypoxia
•Radiation
•Hypertension
•Anemia
•Emphysema
Intoxication
•Lead
•Certaindrugs
•Substanceabuse
Mild(Educable)
Moderate(Trainable)
Severe(Dependentretarded)
Profound(Lifesupport)
IntelligenceQuotient(IQ)
50-70
35-50
20-35
<20
BehavioralManifestations
MildRetardation(l.Q.50-70)
Thisiscommonesttypeofmentalretardation
accountingfor85to90%ofallcases.These
individualshaveminimumretardationin
sensory-motorareas.TheyoftenprogressuptoVI
standardinschoolandcanachievevocational
andsocialself-sufficiencywithalittlesupport.

156. ChildhoodPsychiatricDisorders153
Theycandevelopsocialandcommunication
skills,buthavedeficitsincognitivefunctionlike
poorabilityforabstractionandegocentric
thinking.
ModerateRetardation(l.Q.35-50)
About10%ofmentallyretardedcomeunderthis
group.Communicationskillsdevelopmuch
slowlyintheseindividuals.Theycanbetrained
tosupportthemselvesbyperformingsemiskilled
orunskilledworkundersupervision.
SevereRetardation(l.Q.20-35)
Severementalretardationisoftenrecognizedearly
inlifewithpoormotordevelopmentandabsent
ormarkedlydelayedspeechandcommunication
skills.Thereisapossibilityofteachingsomeskills
inAOLskillswithlong-termconsistentbehavior
modification.Butmostofthemrequireagreatdeal
ofassistanceandstructuredlivingarrangements.
ProfoundRetardation(1.0.<20)
Thisgroupaccountsfor1to2percentofallmen­
tallyretarded.Theachievementofdevelopmental
milestonesismarkedlydelayed.Theyrequire
constantnursingcareandsuperv1s1on.
Associatedphysicaldisordersarecommon.
Diagnosis
•Historycollectionfromparentsandcare-
takers.
•Physicalexamination.
•Neurologicalexamination.
•Assessingmilestonesdevelopment.
•Investigations
•urineandbloodexaminationformetabolic
disorders
•cultureforcytogenicandbiochemical
studies
•amniocentesisininfantchromosomal
disorders
•chorionicvillisampling.
•Hearingandspeechevaluation.
•EEG,especiallyifseizuresarepresent.
•CTscanorMRibrain,e.g.intuberoussclerosis.
•Thyroidfunctiontestswhencretinismis
suspected.
•PsychologicaltestslikeStanfordBinet
IntelligenceScaleandWechslerIntelligence
ScaleForChildren(WISC),forcategorizing
thechild'slevelofdisability.
Throughpsychologicaltestingthementalage
ofthechildisestimated.TheIntelligenceQuotient
isthendeterminedusingtheformula:
MentalAge(M.A.)
---------- x100
ChronologicalAge(C.A.)
Prognosis
Theprognosisforchildrenwithmentalretar­
dationhasimprovedandinstitutionalcareisno
longerrecommended.Thesechildrenare
mainstreamedwheneverfeasibleandaretaught
survivalskills.Amultidimensionalorientation
isusedwhenworkingwiththesechildren,
consideringtheirphysiological,cognitive,social
andemotionaldevelopment.
Prevention
PrimaryPrevention
Preconception
•Geneticcounseling,whichisanattemptto
determinerisksofoccurrenceorrecurrenceof
specificgeneticorchromosomaldisorders;
parentscanthenmakeaninformeddecision
astotherisksofhavingaretardedchild.
•Immunizationformaternalrubella.
•Bloodtestsformarriagelicensescanidentify
thepresenceofvenerealdiseases.
•Adequatematernalnutritioncanlayasound
metabolicfoundationforlaterchildbearing.
•Familyplanningintermsofsize,appropriate
spacing,andageofparentscanalsoaffecta
varietyofspecificcausalagents.
DuringGestation
Twogeneralapproachestopreventionare
associatedwiththisperiod:
a.Prenatalcare
b.Analysisoffetusforpossiblegeneticdisorders.

157. 154AGuidetoMentalHealthandPsychiatricNursing
a.Prenatalcare
•Adequatenutrition,fetalmonitoringand
protectionfromdisease.
•Avoidanceofteratogenicsubstanceslike
exposuretoradiationandconsumptionof
alcoholanddrugs.
b.Analysisoffetus
•Byamniocentesis,fetoscopy,fetalbiopsyand
ultrasound.
Atdelivery
•Deliveryconductedbyexpertdoctorsand
staff,especiallyincasesofhigh-riskpreg­
nancy(e.g.maternalconditionsofdiabetes,
hypertensionetc).
•Apgarscoringdoneat1and5minutesafter
thebirthofthechild.
•Closemonitoringofmotherandchild.
•Injectionofgammaglobulin,whichcan
preventRh-negativemothersfromdeveloping
antibodiesthatmightotherwiseaffect
subsequentchildren.
Childhood
•Propernutritionthroughoutthedevelopmen­
talperiodandparticularlyduringthefirst6
monthsafterbirth.
•Dietaryrestrictionsforspecificmetabolic
disordersuntilnolongerneeded.
•Avoidanceofhazardsinthechild'senviron­
menttoavertbraininjuryfromcausessuchas
leadpoisoning,ingestionofchemicals,or
accidents.
SecondaryPrevention
•Earlydetectionandtreatmentofpreventable
disorders.Forexample,phenylketonuriaand
hypothyroidismcanbeeffectivelytreatedat
anearlystagebydietarycontrolorhormone
replacementtherapy.
•Earlyrecognitionofpresenceofmental
retardation.Adelayindiagnosismaycause
unfortunatedelayinrehabilitation.
•Psychiatrictreatmentforemotionaland
behavioraldifficulties.
TertieryPrevention
Thisincludesrehabilitationinvocational,
physicalandsocialareasaccordingtothelevel
ofhandicap.Rehabilitationisaimedatreducing
disabilityandprovidingoptimalfunctioningin
achildwithmentalretardation.
CareandRehabilitationofthe
MentallyRetarded
Themainelementsinacomprehensiveservice
formentallyretardedindividualsandtheir
familiesinclude:
•Thepreventionandearlydetectionofmental
handicaps.
•Regularassessmentofthementallyretarded
person'sattainmentsanddisabilities.
•Advice,support,andpracticalmeasuresfor
families.
•Provisionforeducation,training,occupation,
orworkappropriateforeachhandicapped
person.
•Housingandsocialsupporttoenableself-care.
•Medical,nursing,andotherservicesforthose
whorequirethemasoutpatients,daypatients,
orinpatients.
•Psychiatricandpsychologicalservices.
Generalprovisions:Thegeneralapproachtocare
iseducationalandpsychosocial.Thefamily
doctorandpediatricianaremainlyresponsible
fortheearlydetectionandassessmentofmental
retardation.Theteamprovidingcontinuing
healthcarealsoincludespsychologists,speech
therapists,nurses,occupationaltherapistsand
physic-therapists.
Themildlyretarded:Afewmildlyretardedchildren
requirefostering,boardingschoolsplacements
orresidentialcare,butusuallyspecialistservices
arenotrequired.Mildlyretardedadultsmayneed
helpwithhousing,employment,orwiththe
specialproblemsofoldage.
Theseverelyretarded:Incaseofchildrensome
requirespecialservicesthroughouttheirlives,
whichmayincludeasittingservice,dayrespite

158. ChildhoodPsychiatricDisorders155
duringschoolholidays,orovernightstaysina
fosterfamilyorresidentialcare.Incaseofadults,
provisionsarerequiredforwork,occupation,
housing,adulteducation,etc.Themainprinciple
nowguidingtheprovisionofresourcesisthat
theretardedpersonshouldbegivensufficient
helptobeabletousetheusualcommunityser­
vices,ratherthantoprovidespecialistsegregated
services.
Educationandtraining:Theaimisthatasmany
mentallyretardedchildrenaspossibleare
educatedinordinaryschoolseitherinnormal
classesorinspecialclasses.Thereisnowan
increasinguseofmorespecialistteachinganda
varietyofinnovativeproceduresforteaching
languageandothermethodsofcommunication.
Beforeleavingschool,thesechildrenrequire
reassessmentandvocationalguidance.
Hintsforsuccessfulskilltraining:
•Divideeachtrainingactivityintosmallsteps
anddemonstrate.
•Givethementallyretardedpersonrepeated
trainingineachactivity.
•Givethetrainingregularlyandsystematically.
Donotletparentsgetimpatient.
•Startthetrainingwithwhatthechildalready
knowsandthenproceedtotheskillthatneeds
tobetrained.Bythisthechildwillhavea
feelingofsuccessandachievement.
•Rewardhiseffortevenifthechildattainsnear
success,byappreciationorwithsomething
thathelikes.
•Reducetherewardgraduallyashemastersa
skillandtakesupanotherskillfortraining.
•Usethetrainingmaterialswhichare
appropriate,attractiveandlocallyavailable.
•Remember,childrenlearnbetterfromchildren
ofthesameage.Therefore,tryandinvolve
normalchildrenofthesameageintraining
thementallyretardedchild,afterorientingthe
normalchildappropriately.
•Remember,thereisnoagelimitfortraininga
mentallyretardedperson.
•Assessthechildperiodically,preferablyonce
infourorsixmonths.
•Remember,amentallyretardedchildlearns
veryslowly.Telltheparentsnottobedejected
attheslowprogress,norfeelthreatenedby
thechild'sfailure.
Vocationaltraining:Theactivitiesincludedin
vocationaltrainingareworkpreparation,
selectiveplacement,postplacementandfollow
up.
Forexample,MITRASpecialSchooland
VocationalTrainingCenterfortheMentally
Retarded.
Helpforfamilies:Helpforfamiliesisneededfrom
thetimethatthediagnosisisfirstmade;adequate
timemustbeallowedtoexplaintheprognosis;
indicatewhathelpcanbeprovided,anddiscuss
thepartthattheparentscanplayinhelpingtheir
childtoachievefullpotential.
Whenthechildstartsschool,theparents
shouldnotonlybekeptinformedabouthis
progress,butshouldfeelinvolvedintheplanning
andprovisionofcare.
Familiesarelikelytoneedextrahelpwhen
theirchildisapproachingpubertyorleaving
school;bothdayandovernightcaresareoften
requiredtorelievecaregiversandtoencourage
theretardedpersontobecomemoreindependent.
Stagesinparentcounseling:
Stage1:Impartinformationregardingcondition
ofthementallyretardedchild.Avoidgiving
misleadinginformationorbuildingfalsehopes
intheparents.
Stage2:Helptheparentsdeveloprightattitude
towardstheirmentallyretardedchild(toprevent
overprotection,rejection,pushingthechildtoo
hard).Handleguiltyfeelingsinparents.
Stage3:Createawarenessinparentsregarding
theirroleintrainingthechild.Theparentsshould
bemadetorealizethattrainingamentally
retardedchilddoesnotneedcomplexskillsand
withrepeatedtraininginsimplesteps,thechild
canlearn.
Parentsaretaughtbehaviormodification
techniquestodecreaseoreliminateproblematic
behavior,increaseadaptivebehavioranddevelop

159. 156AGuidetoMentalHealthandPsychiatricNursing
newskills.Someofthesetechniquesinclude
positivereinforcement,shaping,prompting,
modeling,extinctionproceduresetc(ReferChapter
14,p.187and188foradetaileddescription).
Parentsshouldbedemonstratedhowtheir
traininghashelpedtheirchildtoacquirenew
skills.Thiswillgivethemasenseofachievement,
thusmakingthemmoreinvolvedinthecare.
Somequestionsparentsask
1.Ismentalretardationsameasmentalillness?
No.Mentallyretardedpersonsarenot
mentallyill.Thementallyretardedpersons
arejustslowintheirdevelopment.
2.Ismentalretardationcurable?
No.Mentalretardationisaconditionwhich
cannotbecured.Buttimelyandappropriate
interventioncanhelpthementallyretarded
personlearnseveralskills.
3.Canmarriagesolvetheproblemsofmental
retardation?
No.Manypeoplethinkthataftermarriage,
thementallyretardedpersonwillbecome
activeandresponsible,orsexualsatisfaction
willcuretheperson.Thatisnotso.Marriage
willonlyfurthercomplicatethe"problem.
Whenitisknownthatamentallyretarded
personcannotbetotallyindependent,itwill
notbepossibleforhimtolookafterhisfamily.
4.Domentallyretardedpersonsbecomenormal,
astheygrowolder?
No.Thementallyretardedperson'smental
developmentisslowerthanthatofanormal
person.Therefore,whentheiractualage
increaseswithtime,thementaldevelopment
doesnotoccuratthesamepacetocatchup
withtheactualage.
5.Ismentalretardationaninfectiousdisease?
No.Manypeoplethinkthatonallowing
normalchildrentomix,eatorplaywith
mentallyretardedchildren,thenormal
childrenalsodevelopmentalretardation.This
iswrong.Interactionbetweenmentally
retardedchildrenandnormalchildrenonthe
otherhand,helpsintheimprovementof
mentallyretardedchildren.
6.Isittruethatthementallyretardedpersons
cannotbetaughtanything?
No.Mentallyretardedpersonscanbetaught
manythings,buttheyneedtobetrained
systematically.Theycanperformmanyjobs
undersupervision.
7.Isittruethatmentalretardationisduetokarma
andhencenothingcanbedoneaboutit?
No.Believingthatmentalretardationisdue
totheirkarmahelpstheparentstobefreefrom
thefeelingsofguilt.Parentsmustbetoldthat
whatevermaybethecause,trainingthechild
willimprovehiscondition.Theearlierthe
trainingisstarted,thebetterthechancesof
improvement.
Residentialcare:Parentsshouldbesupportedin
caringfortheirretardedchildrenathome,orif
theyaretooheavyaburdenfortheirparents,the
childshouldbecaredforindaycarecenters,
halfwayhomes,etc.
Specialistmedicalservices:Retardedchildrenand
adultsoftenhavephysicalhandicapsorepilepsy
forwhichcontinuingmedicalcareisneeded.
Psychaitricsevices:Expertpsychiatriccareisan
essentialpartofacomprehensivecommunity
serviceforthementallyretarded.
NursingManagement
Assessment
•Assessmentofearlyinfantbehaviorfor
cognitivedisabilityamonghighriskchildren
shouldbecloselydone(e.g.childrenbornto
elderlyprimiparas,birthtrauma,etc.);Early
infantbehaviorsthatmayindicateacognitive
disabilityincludenon-responsivenessto
contact,pooreyecontactduringfeeding,slow
feeding,diminishedspontaneousactivity,
decreasedresponsivenesstosurroundings,
decreasedalertnesstovoiceormovement,and
irritability.
•Documentationofdailylivingskills.
•Acarefulfamilyassessmentforinformation
on:
•thefamily'sresponsetothechild

160. ChildhoodPsychiatricDisorders157
•presenceofothermemberswithimpaired
cognitioninthefamily
•degreeofindependenceencouragedat
home
•stabilityofthefamilyunit.
•Psychologicalassessment:Thisisdirectedat
theinteractionbetweentheindividualand
peoplewhoarecloselyinvolvedincare,and
determiningthecorrectneedsandwishesfor
thefuture.Itshouldexamineopportunities
forlearningnewskills,makingrelationships,
andachievingmaximumchoiceaboutthe
wayoflife.
Intervention
•Thelong-termgoalsforthesechildrenare
highlyindividualizedandaredependenton
thelevelofmentalretardation.Parentsshould
beinvolvedinestablishingrealisticgoalsfor
theirchild.Someofthesegoalscanbe:
•thechilddresseshimself
•thechildmaintainscontinenceofstool
andurine
•thechilddemonstratesacceptablesocial
behavior
•theadolescentparticipatesinastructured
workprogram
•Earlyinterventionprogramsareessentialto
maximizethechildren'spotentialdevelop­
ment.Thisnecessitatesearlyrecognitionand
referral.Nurseshaveanopportunityto
evaluatechildreninthenursery,intheclinic
duringwell-babyhealthcare,inschools,and
duringacutemanagement.Thepotentialof
eachchildwillvaryaccordingtothedegreeof
mentalretardation.Thekeyforsuccessisthat
thechild'sstrengthsandpotentialabilities
areemphasizedratherthandeficits.
•Thenursecanparticipateinprogramsthat
teachinfantstimulation,activitiesofdaily
livingandindependentself-careskills.A
successfultechniqueintreatmentofthe
mentallyretardediscalledoperantcon­
ditioning.Itfocusesonchangingormodifying
theindividual'sresponsetotheenvironment
byreinforcingcertaindesirablepatternsof
behaviororeliminatingundesirablepatterns.
•Inaddition,learningsocialskillsandadaptive
behaviorassiststhechildinbuildinga
positiveself-image.Forolderchildrenand
adolescentsassistanceisneededtoprepare
themforaproductiveworklife.
•Sexualitybecomesamajorconcern,asthese
childrenmayformemotionalattachmentto
thoseoftheoppositesexandhavenormal
sexualdesires.However,theirdecision­
makingskillsarelimited.Teachingcontra­
ceptivemethodsareimportanttoemphasize
withboththechildandfamily.
•Inallinstancesitisimportantforthenurseto
maintainanon-threateningapproach.Very
oftenthesechildrendonotunderstandwhy
physicalassessment,therapeuticapproaches
andevaluativemeasuresareneeded.Proper
explanationandrelevantinformationshould
begiventotheparentsandtheirhelpshould
beenlistedinbringingoutthebestoutofthe
child.Closecollaborationwithallmembers
oftheteaminvolvedinthecareofthechildis
highlyessentialforasuccessfuloutcome.To
alargeextentthenurseisresponsibleforthe
emotionalclimateofthesettinginwhichshe
isemployed.
(Alsorefer'Careandrehabilitationofthementally
retarded'onp.154)
DISORDERS OFPSYCHOLOGICAL
DEVELOPMENT (F8)
SpecificDevelopmentalDisordersof
SpeechandLanguage
Thesearedisordersinwhichnormalpatternsof
languageacquisitionaredisturbedfromtheearly
stagesofdevelopment.Theconditionsarenot
directlyattributabletoneurologicalorspeech
mechanismabnormalityormentalretardation.
Itincludesdevelopmentallanguagedisorder
ordysphasia,developmentalarticulationdis­
orderorphonologicaldisorderordyslalia,
expressivelanguagedisorder,receptivelanguage
disorderandotherdevelopmentaldisordersof
speechandlanguage.

161. 158AGuidetoMentalHealthandPsychiatricNursing
SpecificDevelopmentalDisordersof
Scholasticskills
Specificdevelopmentaldisordersofscholastic
skillsaredividedfurtherintospecificreading
disorder,specificspellingdisorderandspecific
arithmeticdisorder.
Specificreadingdisorders(dyslexia)shouldbe
clearlydistinguishedfromgeneralbackwardness
inscholasticachievementresultingfromlow
intelligenceorinadequateeducation.Itischarac­
terizedbyaslowacquisitionofreadingskills,
slowreadingspeed,impairedcomprehension,
wordomissionsanddistortionsandletter
reversals.
Themainfeatureofspecificspellingdisorderis
significantimpairmentindevelopmentofspelling
skillsintheabsenceofahistoryofspecificreading
disorder.Theabilitytospellorallyandtowrite
outwordscorrectlyarebothaffected.
Specificarithmeticdisorderinvolvesdeficitin
basiccomputationalskillsofaddition,subtrac­
tion,multiplicationanddivision.
SpecificDevelopmentalDisordersof
MotorFunction
Childrenwiththisdisorderhavedelayedmotor
development,whichisbelowtheexpectedlevel
onthebasisoftheirageandgeneralintelligence.
Themainfeatureofthisdisorderisaserious
impairmentinthedevelopmentofmotorco­
ordination,whichresultsinclumsinessinschool
workorplay.
PervasiveDevelopmentalDisorder
ThetermPervasiveDevelopmentalDisorder
(PDD)referstoagroupofdisorderscharacterized
byabnormalitiesincommunicationandsocial
interactionandbyrestrictedrepetitiveactivities
andinterests.Theseabnormalitiesoccurinawide
rangeofsituations,usuallydevelopmentisabnor­
malfrominfancyandmostcasesaremanifest
beforetheageof5years.
PDDincludeschildhoodautism,atypical
autism,Rett'sSyndrome,Asperger'ssyndrome,
childhooddisintegrativedisorder,andother
pervasivedevelopmentaldisorders.
Epidemiology
Prevalenceis4-5/10,000inchildrenunder16
yearsofage.Maletofemaleratiois4or5toI.The
disorderisevenlydistributedacrossallsocio­
economicclasses.
ChildhoodAutism
In1908,HellerfromAustriareported6casesofa
disintegrativepsychosiswithonsetinthe3rdor
4thyearoflifeinchildrenwhosepreviousdeve­
lopmentwasnormal.LeoKenner(1943)identified
arelativelyhomogenousgroupofchildrenwith
onsetofpsychosisinthe1stand2ndyearoflife
whomhedesignatedearly"infantileautism"and
"autisticdisturbanceofaffectcontact."Lauretta
Benderfirstusedtheterm"childhoodschizo­
phrenia"tocharacterizepsychoticchildren.Now
allthesetermshavebeenreplacedandthe
conditioniscurrentlyknownasChildhood
AutisminICDIO,orAutisticDisorderinDSMIV.
Etiology
GeneticfactorsThehigherconcordancein
monozygoticthandizygotictwins(36%vs0%)
suggestsageneticfactor.Siblingsofautistic
childrenshowaprevalenceofautisticdisorder
of2percent(50timesoverexpectedprevalence).
BiochemicalfactorsAtleast1I3rdofpatientswith
autisticdisorderhaveelevatedplasmaserotonin.
MedicalfactorsThereisanelevatedincidenceof
earlydevelopmentalproblemssuchaspost-natal
neurologicalinfections(meningitis,encephalitis),
congenitalrubellaandcytomegalovirus,phenyl­
ketonuriaandrarelyperinatalasphyxia.Theother
inbornerrorsofmetabolismassociatedwith
autismaretuberoussclerosisandneurofibromo­
tosis.About2to5%appeartohaveFragileX
chromosomesyndrome.Neurologicalabnormali­
tiesarepresentinaboutone-quarterofcases.
PerinatalfactorsDuringgestation,maternal
bleedingafterthefirsttrimesterandmeconiumin
theamnioticfluidhavebeenreportedinthe
historiesofautisticchildren.Thereisalsoahigh
incidenceofmedicationusageduringpregnancy
inthemothersofautisticchildren.

162. ChildhoodPsychiatricDisorders159
Psychodynamicandparentinginfluencesandsocial
environmentSomeofthespecificcausativefactors
proposedinthesetheoriesareparentalrejection,
childresponsestodeviantparentalpersonality
characteristics,familybreak-up,familystress,
insufficientstimulationandfaultycommuni­
cationpatterns(SchreibmanandCharlop,1989).
Kanner(1973)inhisstudies,describedthe
parentsofautisticchildrenaswelleducated
upperclassindividuals,involvedincareerand
intellectualpursuits,whowerealoof,obsessive
andemotionallycold.Theterm"refrigerator
parents"wascoinedtodescribetheirlackof
warmthandaffectionatebehavior.
Mahlerandassociates(1975)suggestedthat
theautisticchildisfixedinthepresymbioticphase
ofdevelopment.Inthisphase,thechildcreatesa
barrierbetweenselfandothers.Thenormal
symbioticrelationshipbetweenmotherandchild
followedbytheprogressiontoseparation/indivi­
dualizationdoesnotoccur.Egodevelopmentis
inhibitedandthechildfailstoachieveasenseof
self.
Theory-of-mindinautismTheory-of-minddescri­
besthedevelopmentalprocesswherebythechild
comestounderstandothers'mindsorto
anticipatewhatothersmaybethinking,feeling,
orintending.Childrenwithautisticdisorderare
sometimessaidtobe"mind-blind,"inthatthey
lacktheabilitytoputthemselvesintheplaceof
anotherperson.
ElectrophysiologicalchangesBrainstemAuditory
EvokedResponses(BAERs)ofautisticchildren
showedimpairmentinsensorymodulationat
brainstemlevel.
NeuroanatomicalstudiesThesestudieshave
shownanenlargementoflateralventriclesand
cerebellardegeneration.
ClinicalPicture
Behavioralcharacteristics
•Autisticaloofness(unresponsivenessto
parent'saffectionatebehavior,bysmilingor
cuddling).
•Gazeavoidanceorlackofeye-to-eyecontact.
•Dislikesbeingtouchedorkissed.
•Noseparationanxietyonbeingleftinan
unfamiliarenvironmentwithstrangers.
•Noorabnormalsocialplay.Failuretoplay
withpeersandunabletomakefriends.
•Failuretodevelopempathy.
•Markedlackofawarenessoftheexistenceor
feelingsofothers.
•Angerorfearwithoutapparentreasonand
absenceoffearinthepresenceofdanger.
Communicationandlanguage
•Grossdeficitsanddeviancesinlanguage
development.
•Nomodeofcommunicationsuchasbabbling,
facialexpression,gestures,mime,etc.
•Absenceofimaginativeactivitysuchasplay
actingofadultroles,fantasycharactersof
animals,lackofinterestinimaginativestories.
•Markedabnormalityintheproductionof
speech(volume,pitch,stress,rhythm,rateetc).
•Markedabnormalitiesintheformorcontent
ofspeechincludingstereotypedorrepetitive
useofspeech,useof"you"when"I"ismeant,
idiosyncraticuseofphrases.
•Markedimpairmentintheabilitytoinitiateor
sustainaconversationwithothersdespite
adequatespeech.
Activities
•Markedrestricted,repertoireofactivitiesand
interests.
•Stereotypedbodymovementse.g.handflick­
ingortwisting,spinning,headbanging,etc.
•Persistentpreoccupationwithpartsofobjects
(e.g.spinningwheelsoftoycars)orattachment
tounusualobjects.
•Markeddistressoverchangesintrivialaspects
ofenvironment.
•Markedlyrestrictedrangeofinterestsanda
preoccupationwithonenarrowinterest.
Otherfeatures
•Morethanhalfofautisticchildrenhavemode­
ratetoprofoundmentalretardation,whereas
about25%havemildmentalretardation.

163. 160AGuidetoMentalHealthandPsychiatricNursing
•Autisticchildrenareresistanttotransitionand
change.
•Over-responsiveorunder-responsiveto
sensorystimuli.
•Mayhaveaheightenedpainthresholdoran
alteredresponsetopain.
•Otherbehavioralproblemslikehyperkinesis,
aggression,tempertantrums,self-injurious
behavior,headbanging,biting,scratching
andhairpullingarecommon.
•IdiotSavantSyndrome:Inspiteofapervasive
orabnormaldevelopmentoffunctions,certain
functionsmayremainnormal,e.g.calculating
ability,prodigiousremotememory,musical
abilities,etc.
•Absenceofhallucinations,delusions,loosen­
ingofassociationsasinschizophrenia.
•Kanner's"Autistictriad"-Kannersaidauti­
sticaloofness,speechandlanguagedisorder
andobsessivedesireforsamenessconstitute
atriadcharacteristicofinfantileautism.
CourseandPrognosis
•Autisticdisorderhasalongcourseand
guardedprognosis.
•About10to20%autisticchildrenbeginto
improvebetween4and6yearsofageand
eventuallyattendonordinaryschooland
obtainwork.
•10to20%canliveathome,butneedtoattend
aspecialschoolortrainingcenterandcannot
work.
•60%improvelittleandareunabletoleadan
independentlife,mostlyneedinglong-term
residentialcare.
•Thosewhoimprovemaycontinuetoshow
languageproblem,emotionalcoldnessand
oddbehavior.
Treatment
•Pharmacotherapyisavaluabletreatmentfor
associatedsymptomslikeaggression,temper
tantrums,self-injuriousbehavior,hyperacti­
vityandstereotypicbehaviour.Somedrugs
thathavebeenusedarerisperdone,serotonin
specificreuptakeinhibitors,clomipramine
andlithium.Antiepilepticmedicationisused
forgeneralizedseizures.
•Behavioralmethods:Contingencymanagement
maycontrolsomeoftheabnormalbehaviorof
autisticchildren.Thetermcontingencymana­
gementreferstoagroupofproceduresbased
ontheprinciplethat,ifanybehaviorpersists,
certainofitsconsequencesarereinforcingit.
Iftheseconsequencescanbealtered,the
behaviorwillchange.Theparentsinstructed
andsupervisedbyaclinicalpsychologist
oftencarryoutthismethodathome.
Contingencymanagementhasthefollowing
stages:
•Firstthebehaviortobechangedisdefined,
andanotherperson(usuallyanurse,
spouseorparent)istrainedtorecordit;for
example,amothermightcountthenumber
oftimesachildwithlearningdifficulties
shoutsloudly.
•Second,theeventsthatimmediatelyfollow
(andthereforearepresumedtoreinforce
thebehavior)areidentified;forexample,
theparentsmaypayattentiontothechild
whenheshouts,butignorehimatother
times.
•Third,reinforcementsaredevisedfor
alternativebehaviors,forexample,being
approvedorearningpointsbyrefraining
fromshoutingforanagreedtime.Staffor
relativesaretrainedtoprovidethechosen
reinforcementsimmediatelyafterthe
desiredbehavior,andtowithholdthemat
othertimes.
•Astreatmentprogresses,recordsarekept
ofthefrequencyoftheproblembehaviors
andofthedesiredbehaviors.
•Althoughtreatmentismainlyconcerned
withtheconsequencesofbehavior,atten­
tionisalsogiventochanginganyevents
thatmightbeprovokingthebehavior.For
example,inapsychiatricward,theabnor­
malbehaviorofonechildmaybeprovoked
oneachoccasionbytheactionsofanother
child.

164. ChildhoodPsychiatricDisorders161
•Specialschooling:Mostautisticchildrenrequire
specialschoolingandolderadolescentsmany
needvocationaltraining.
•Counselingandsupportivetherapy:Thefamily
ofanautisticchildneedsconsiderablehelpto
copewiththechild'sbehavior,whichisoften
distressing.
•Others:Developmentofaregularroutine,
positivereinforcementstoteachself-care
skills,speechtherapyorsignlanguage
teaching,behaviortechniquestoencourage
interpersonalinteractions.
NursingManagement
AssessmentThefollowingfactorsneedtobe
consideredinassessinganautisticchild(Lord
andRutter,1994):
•Cognitivelevel
•Languageability
•Communicationskills,socialskillsandplay
andrepetitiveareotherabnormalbehavior
•Stageofsocialdevelopmentinrelationtoage,
mentalageandstageoflanguagedevelop­
ment
•Associatedmedicalconditions
•Psychosocialfactors
Intervention
•Workwiththechildonaone-to-onebasis.
•Protectthechildwhenself-mutilativebehavior
occurs.Devicessuchasahelmet,padded
mittensorarmcoversmaybeused.
•Trytodetermineifself-mutilativebehavior
occursinresponsetoincreasinganxiety,and
ifso,towhattheanxietymaybeattributed.
Intervenewithdiversionorreplacement
activitiesasanxietylevelstartstorise.These
activitiesmayprovideneededfeelingsof
securityandsubstituteforself-mutilative
behavior.
•Assignlimitednumberofcaregiverstothe
child.Ensurethatwarmth,acceptanceand
availabilityareconveyed.
•Providechildwithfamiliarobjectssuchas
familiartoysorablanket.Supportchild's
attemptstointeractwithothers.
•Givepositivereinforcementforeyecontact
withsomethingacceptabletothechild(e.g.
food,familiarobject).Graduallyreplacewith
socialreinforcement(i.e.touch,hugging).
•Anticipateandfulfillthechild'sneedsuntil
communicationcanbeestablished.
•Slowlyencouragehimtoexpresshisneeds
verbally.Seekclarificationandvalidation.
•Givepositivereinforcementwheneyecontact
isusedtoconveynonverbalexpressionsor
whenthechildtriestospeak.
•Teachsimpleself-careskillsbyusingbehavior
modificationtechniques.
•Languagetrainingplaysabigpartinteaching
autisticchildren.Atfirsttheyhavetolearn
thenamesofthingsbylinkingthenamewith
theactualobject.Whenteachingtheword
'table'theymustseeandfeelarealtable,and
lotsofdifferenttables,otherwisetheymay
thinkthattablereferstoonlythatparticular
object.Lookatchild'sfaceandpronounce
simplewords.Askthechildtorepeatthe
words.Showpicturebooksandnamethe
objects.Verbslikesitting,walking,running
canbeactedtoshowthechildwhatthese
wordsmean.
•Autisticchildrenhavepersonalidentitydis­
turbanceandneedtobeassistedtorecognize
separatenessduringself-careactivities,such
asdressingandfeeding.Thechildshouldbe
helpedtonameownbodyparts.Thiscanbe
facilitatedwiththeuseofmirrors,drawings
andpicturesofhimself.Encourageappropriate
touchingof,andbeingtouchedbyothers.
•Theroleoftheparentiscrucialforany
interventionwiththeautisticchild;theparent
generallyactsasaco-therapistandplaysan
integralroleintreatment.Thebehavioroftheir
autisticchildisoftenverydistressingand
parentalcounselingbeginswithclarification
ofthediagnosisandanexplanationofthe
characteristicsofthedisorder.Toeffectively
participateinthetreatmentprogram,the
parentsmusthaveacknowledgedtheextent
oftheirchild'shandicapandbeabletowork
withhimattheappropriatedevelopmental
level.

165. 162AGuidetoMentalHealthandPsychiatricNursing
AtypicalAutism
Apervasivedevelopmentaldisorderthatdiffers
fromautismintermsofeitherageofonsetor
failuretofulfilldiagnosticcriteriai.e.disturbance
inreciprocalsocialinteractions,communication
andrestrictivestereotypedbehavior.Atypical
autismisseeninprofoundlyretardedindividuals.
Rett'sSyndrome
Aconditionofunknowncause,reportedonlyin
girls.Itischaracterizedbyapparentlynormalor
near-normalearlydevelopmentwhichisfollowed
bypartialorcompletelossofacquiredhandskills
andofspeech,togetherwithdecelerationinhead
growth,usuallywithanonsetbetween7and24
monthsofage.
Asperger'sSyndrome
Theconditionischaracterizedbysevereand
sustainedabnormalitiesofsocialbehaviorsimilar
tothoseofchildhoodautismwithstereotypedand
repetitiveactivitiesandmotormannerismssuch
ashandandfinger-twistingorwholebody
movements.Itdiffersfromautisminthatthereis
nogeneraldelayorretardationofcognitive
developmentorlanguage.
BEHAVIORAL ANDEMOTIONAL DISORDERS
WITHONSETUSUALLYOCCURRING IN
CHILDHOOD ANDADOLESCENCE (F9)
HyperkineticDisorder
Hyperkineticdisorder(Attention-DeficitHyper­
activityDisorderorADHDinDSMIV)isapersis­
tentpatternofinattentionandorhyperactivity
morefrequentandseverethanistypicalof
childrenatasimilarlevelofdevelopment.The
syndromewasfirstdescribedbyHeinrichHoff
in1854.
Epidemiology
Aprevalenceof1.7percentwasfoundamong
primaryschoolchildren(Tayloretal,1991).
ADHDisfourtimesmorecommoninboysthan
ingirls.
Etiology
Biologicalinfluences
Geneticfactors
•Thereisgreaterconcordanceinmonozygotic
thanindizygotictwins
•Siblingsofhyperactivechildrenhaveabout
twicetheriskofhavingthedisorderasdoes
thegeneralpopulation
•Biologicalparentsofchildrenwiththe
disorderhaveahigherincidenceofADHD
thandoadoptiveparents
Biochemicaltheory
Adeficitofdopamineandnorepinephrinehas
beenattributedintheoveractivityseeninADHD.
Thisdeficitofneurotransmittersisbelievedto
lowerthethresholdforstimuliinput
Pre,periandpostnatalfactors
•Prenataltoxicexposure,prenatalmechanical
insulttothefetalnervoussystem
•Prematurity,fetaldistress,precipitatedor
prolongedlabor,perinatalasphyxiaandlow
Apgarscores
•Postnatalinfections,CNSabnormalitiesresul-
tingfromtrauma,etc
Environmentalinfluences
•Environmentallead
•Foodadditives,coloringpreservativesand
sugarhavealsobeensuggestedaspossible
causesofhyperactivebehaviorbutthereisno
definiteevidence
Psychosocialfactors
•Prolongedemotionaldeprivation
•Stressfulpsychicevents
•Disruptionoffamilyequilibrium
ClinicalFeatures
•Sensitivetostimuli,easilyupsetbynoise,light,
temperatureandotherenvironmental
changes.
•Attimesthereverseoccursandthechildren
areflaccidandlimp,sleepmoreandthe
growthanddevelopmentisslowinthefirst
monthoflife.

166. ChildhoodPsychiatricDisorders163
•Morecommonlyactiveincrib,sleeplittle.
•Generalcoordinationdeficit.
•Shortattentionspan,easilydistractable.
•Failuretofinishtasks.
•Impulsivity.
•Memoryandthinkingdeficits.
•Specificlearningdisabilities
Inschool
•Oftenfidgetswithhandsorfeetorsquirmsin
seat.
•Answersonlythefirsttwoquestions;often
blurtsoutanswerstoquestionsbeforethey'
havebeencompleted.
•Unabletowaittobecalledoninschooland
mayrespondbeforeeveryoneelse.
•Hasdifficultyawaitingturningamesorgroup
situations.
•Oftenlosesthingsnecessaryfortasksor
activitiesatschool.
Home
•Explosiveorirritable.
•Emotionallylabileandeasilysetofftolaughter
ortears.
•Moodisunpredictable.
•Impulsivenessandaninabilitytodelay
gratification.
•Oftentalksexcessively.
•Oftenengagesinphysicallydangerousacti­
vitieswithoutconsideringpossibleconse­
quences(forexample,runsintostreetwithout
looking).
Diagnosis
•Detailedprenatalhistoryandearlydevelop­
mentalhistory.
•Directobservation,teacher'sschoolreport
(oftenthemostreliable),parent'sreport
Treatment
Pharmacotherapy
•CNSstimulants:Dextroamphetamine,met­
hylphenidate,pemoline
•Tricyclicantidepressants
•Antipsychotics
•Serotoninspecificre-uptakeinhibitors
•Clonidine
Psychologicaltherapies
•Behaviormodificationtechniques
•Cognitivebehaviortherapy
•Socialskillstraining
NursingIntervention
•Developatrustingrelationshipwiththechild.
Conveyacceptanceofthechildseparatefrom
theunacceptablebehavior.
•Ensurethatpatienthasasafeenvironment.
Removeobjectsfromimmediateareainwhich
patientcouldinjureselfduetorandom
hyperactivemovements.Identifydeliberate
behaviorsthatputthechildatriskforinjury.
Instituteconsequencesforrepetitionofthis
behavior.Providesupervisionforpotentially
dangeroussituations.
•Sincethereisnon-compliancewithtask
expectations,provideanenvironmentthatis
asfreeofdistractionsaspossible.
•Ensurethechild'sattentionbycallinghis
nameandestablishingeyecontact,before
givinginstructions.
•Askthepatienttorepeatinstructionsbefore
beginningatask.
•Establishgoalsthatallowpatienttocomplete
apartofthetask,rewardingeachstep
completionwithabreakforphysicalactivity.
•Provideassistanceonaone-to-onebasis,
beginningwithsimpleconcreteinstructions.
•Graduallydecreasetheamountofassistance
giventotaskperformance,whileassuringthe
patientthatassistanceisstillavailableif
deemednecessary.
•Offerrecognitionofsuccessfulattemptsand
positivereinforcementforattemptsmade.Give
immediatepositivefeedbackforacceptable
behavior.
•Providequietenvironment,self-contained
classrooms,andsmallgroupactivities.Avoid
overstimulatingplacessuchascinemahalls,
busstopsandothercrowdedplaces.

167. 164AGuidetoMentalHealthandPsychiatricNursing
•Assessparentingskilllevel,considering
intellectual,emotionalandphysicalstrengths
andlimitations.Besensitivetotheirneedsas
thereisoftenexhaustionofparentalresources
duetoprolongedcopingwithadisruptive
child.
•Provideinformationandmaterialsrelatedto
thechild'sdisorderandeffectiveparenting
techniques.Giveinstructionalmaterialsin
writtenandverbalformwithstep-by-step
explanations.
•Explainanddemonstratepositiveparenting
techniquestoparentsorcaregivers,suchas
time-inforgoodbehavior,orbeingvigilant
inidentifyingthechild'sbehaviorand
respondingpositivelytothatbehavior.
•Educatechildandfamilyontheuseofpsycho­
stimulantsandanticipatedbehavioral
response.
•Coordinateoveralltreatmentplanwith
schools,collateralpersonnel,thechildand
thefamily.
ConductDisorders
Conductdisordersarecharacterizedbya
persistentandsignificantpatternofconductin
whichthebasicrightsofothersareviolatedor
rulesofsocietyarenotfollowed.Thediagnosisis
onlymadewhentheconductisfarinexcessof
theroutinemischiefofchildrenandadolescents.
Theonsetoccursmuchbefore18yearsofage,
usuallyevenbeforepuberty.Thedisorderismuch
more(about5to10times)commoninboys.
Etiology
GeneticfactorsStudieswithmonozygoticand
dizygotictwinsaswellaswithnon-twinsiblings
haverevealedasignificantlyhighernumberof
conductdisordersamongthosewhosefamily
membersareaffectedwiththedisorder(Baum,
1989).Alcoholismandpersonalitydisorderinthe
fatherisreportedtobestronglyassociatedwith
conductdisorders.
BiochemicalfactorsVariousstudieshavereported
apossiblecorrelationbetweenelevatedplasma
levelsoftestosteroneandaggressivebehaviors.
OrganicfactorsChildrenwithbraindamageand
epilepsyaremorepronetoconductdisorders.
Psychosocialfactors
•Parentalrejection.
•Inconsistentmanagementwithharshdiscip-
line.
•Frequentshiftingofparentalfigures.
•Largefamilysize.
•Absentfather.
•Parentswithantisocialpersonalitydisorder
oralcoholdependence.
•Parentalpermissiveness.
•Maritalconflictanddivorceinparents.
•Associationswithdelinquentsubgroups.
•Inadequate/inappropriatecommunication
patternsinthefamily.
ClinicalFeatures
•Frequentlying.
•Stealingorrobbery.
•Runningawayfromhomeandschool.
•Deliberatefire-setting.
•Breakingsomeoneelse'shousearticles,car,
etc.
•Deliberatelydestroyingother'sproperty.
•Crueltytowardsotherpeopleandanimals.
•Physicalviolencelikerape,assaultivebeha­
vioranduseofweapons,etc.
•Inadditiontothetypicalsymptomsofconduct
disorder,secondarycomplicationsoftendeve­
loplike,drugabuseanddependence,unwan­
tedpregnancies,syphilis,AIDS,criminal
record,suicidalandhomicidalbehavior.
Treatment
Thetreatmentisdifficult.Themostcommon
modeofmanagementisplacementinacorrective
institution.Behavioral,educationalandpsycho­
therapeuticmeasuresareemployedforchanging
thebehavior.
Drugtreatmentmaybeindicatedinthe
presenceofepilepsy(anticonvulsants),hyper­
activity(stimulantmedication),impulsecontrol
disorderandepisodicaggressivebehavior
(lithium,carbamazepine)andpsychotic
symptoms(antipsychotics).

168. ChildhoodPsychiatricDisorders165
NursingIntervention
•Thenurseshouldbearinmindthatthereis
alwaystheriskofviolenceinthesechildren.
Sheshouldthereforeobservethechild's
behaviorfrequentlyduringroutineactivities
andinteractions.Sheshouldbeawareof
behaviorthatindicatesariseinagitation.
•Redirectviolentbehaviorwithphysicaloutlets
forsuppressionofangerandfrustration.
•Ensurethatasufficientnumberofstaffis
availabletoindicateashowofstrengthif
necessary.Administertranquilizingmedica­
tionasprescribed.Useofmechanical
restraintsorisolationshouldbeusedonlyif
thesituationcannotbecontrolledbyless
restrictivemeans.
•Explaintotheclientthecorrelationbetween
feelingsofinadequacyandtheneedforaccep­
tancefromothers,andhowthesefeelings
provokeaggressionordefensivebehavior
suchasblamingothersforownfaultybeha­
vior.Practicemoreappropriateresponses
throughroleplay.
•Setlimitsonmanipulativebehavior,andiden­
tifytheconsequencesofmanipulativebeha­
vior.Administertheconsequencesmatter-of­
factlyandinanon-threateningmannerifsuch
behavioroccurs.
•Provideimmediatepositivefeedbackfor
acceptablebehavior.
•Encouragethechildtomaintainalogbook
andmakedailyentriesofhisbehavior.The
entryshouldconsistofabriefstatementofan
incidentwhentheclientwasangryor
disagreedwithanotherperson,whattheclient
thoughtabouttheincidentafterwards(inhis
ownwords),whattheclientthoughtabout
doing,andwhatheactuallydid,andthe
outcome.Thisprovidesopportunityforthe
childtoidentifyhispredominantpatternsof
thinkingandbehavingindifferentsituations,
andrecognizenewandacceptablewaysof
respondinginsituationswhichprovokesuch
behaviors.
•Reviewthelogwiththeclientbeforedischarge.
Providefeedbackregardingimprovedbeha-
vioralresponsesandareaswherecontinued
workisneeded.Encourageclienttocontinue
thelogafterdischarge.
•Socialskillstraining:Someviewsofaggres­
sionemphasizetheaggressivechild'slimited
repertoireofcognitiveandbehavioralskills
relatedtosuccessfulpeerandadultinter­
action.Thisperspectivehasledtosocialskills
trainingprogramsinthecontextofindividual
childorfamilytherapy.Thekeystepsfor
teachingsocialskillsare:
•presentingthetargetskilltothechildby
describingitanddiscussingwhenitis
relevant;
•demonstratingtheskillbymodeling;
•askingthechildtorehearsetheskilland
providingfeedback;
•roleplayingexamplesituationsthatcall
foruseoftheskill;and
•givingthechildanassignmentinvolving
practiceoftheskillinreallifesituations
outsidetheclinicalsetting
•Guidanceandsupportforparents:Inparent
trainingprograms,thenurseshouldempha­
sizetotheparentsthatreconnectingwiththeir
childrenaspositive,nurturingcaregivers,
comesfirst.However,managementofdifficult
behaviorisakeycomponentintheprogram,
andcertainguidelinesfordisciplineinclude:
•Developdisciplinaryalternatives(suchas
timeoutorremovalofprivileges)tospan­
king.
•Spendscheduledtimewithyourchildthat
wouldfosteramorepositiverelationship
withhim.
•Agreeontherulesaboutbehaviorand
consequences,makethemclearandstick
withthem.
•Don'tgiveadirectionunlessyouare
willingtomakesureitisfollowed.
Encourageparentstoverbalizefeelingsof
guiltandhelplessnessindealingwiththe
child.Involvesiblingsinfamilydiscus­
sionsandplanningformoreeffective
familyinteractions.
•Workingwiththeschool:Aggressivechildren
oftendisplayproblemsacrosssettings,inclu-

169. 166AGuidetoMentalHealthandPsychiatricNursing
dingschool,orevenonlyinaparticular
classroom.Thenurseshouldemphasizeon
closecollaborationbetweenparentsand
schoolpersonnellikelytocomeintocontact
withthechild(principal,assistantprincipal,
guidancecounselors,schoolpsychologists,
etc.).Childrenwhoseetheirparentsand
teachersworkingtogetherfinditeasierto
controltheirbehaviorinhomeandinschool.
Truancyrequiresseparateconsideration.
Pressureshouldbebroughtuponthechildto
returntoschool,andifpossible,thesupportof
thefamilyshouldbeenlisted.Atthesametimean
attemptshouldbemadetoresolveeducationalor
otherproblemsatschool.Inallthis,itisessential
tomaintaingoodcommunicationbetweenthe
nurse,parentsandteachers.
JuvenileDelinquency
AccordingtoDr.Sethna,Juveniledelinquency
involveswrongdoingbyachildorayoungperson
whoisunderanagespecifiedbythelawofthe
placeconcerned.
Fromthelegalpointofview,ajuvenile
delinquentisapersonwhoisbelow16yearsof
age(18years,incaseofagirl)whoindulgesin
antisocialactivity.
Recentlytherewasaclarificationmadebythe
SupremeCourtintheexistingJuvenileJusticeAct,
thataregularcourtwouldtryajuvenileifheis
arrestedaftercrossingtheageof16thoughhe
mighthavecommittedthecrimewhenhewas
undertheageof16(TheHindu,15thMay2000).
Causes
Socialcauses
•Defectsofthefamily,likebrokenfamilies,
uncaringattitudeofparents,badconductof
parent,etc.
•Defectsoftheschool,likeharshpunishment
byteachers,weaknessinsomesubjects,alevel
ofeducationthatisabovethechild'scapacity.
•Childrenlivingincrime-dominatedareas
•Absentordefectiverecreation
•Warandpost-warconditions
PsychologicalcausesPersonalitycharacteristics,
(emotionalinstability,immaturity),emotional
insecurityandmentalillness.
EconomiccausesPoverty,leadingtostealing,pro­
stitutionandotherantisocialactivitiestosatisfy
unfulfilleddesires.
Refor0atoryMeasures
•Probation,wherethejuveniledelinquentis
keptunderthesupervisionofaprobation
officer,whosejobistohelphimgetestablished
innormallife.
•Institutionslikereformatoryschools,remand
homes,certifiedschools,auxiliaryhomes.
Theseinstitutionsprovideforall-round
progressofthedelinquent.
•Psychologicaltherapieslikeplaytherapy,
finger-painting,psychodrama.
•Governmentalmeasures:TheChildren'sAct
of1977underwhichremandhomesand
borstalschoolsweremadeavailable;
vocationaltrainingandfollow-upservices.
UndertheCareProgramsponsoredbythe
CentralGovernment,5borstalschools,15
boy'sclubsand5probationhostelshavebeen
established.
SeparationAnxietyDisorder
Inthesedisordersthereisexcessiveanxietycon­
cerningseparationfromthoseindividualsto
whomthechildisattached.
ClinicalFeatures
•Anunrealisticworryaboutpossibleharm
befallingmajorattachmentfiguresorfearthat
theywillleaveandnotreturn.
•Persistentreluctanceorrefusaltogotosleep,
withoutbeingnearornexttoamajor
attachmentfigure.
•Persistentinappropriatefearofbeingalone.
•Repeatednightmares.
•Repeatedoccurrenceofphysicalsymptoms
e.g.nausea,stomachache,headache,etc.,on

170. ChildhoodPsychiatricDisorders167
occasionsthatinvolveseparationfromamajor
attachmentfigure,suchasleavinghometogo
toschool.
•Excessivetantrums,cryingandapathyimme­
diatelyfollowingseparationfromamajor
attachmentfigure.
Treatment
IndividualcounselingThisisoftenusefultogive
thechildanopportunitytounderstandthebasis
foranxietyandalsototeachthechildsome
strategiesforanxietymanagement.
ParentalcounselingParentalcounselingis
neededwhenthereisevidencethattheyareover­
anxiousorover-protectiveaboutthechild.They
shouldbepersuadedtoallowthechildmore
autonomy.
FamilytherapyItisoftenneededwhenthe
child'sdisorderappearstoberelatedtothefamily
system.Treatmentisdesignedtopromotehealthy
functioningofthefamilysystem.
PharmacologicalmanagementAnxiolyticdrugs
suchasdiazepammaybeneededoccasionally
whenanxietyisextremelysevere,buttheyshould
beusedforshortperiodsonly.
PhobicAnxietyDisorder
Minorphobicsymptomsarecommoninchild­
hoodandusuallyconcernanimals,insects,
darkness,schoolanddeath.Theprevalenceof
moreseverephobiasvarieswithage.Inmostcases,
allfearsdeclinebyearlyteenageyears.
Treatment
Mostchildhoodphobiasimprovewithoutspecific
treatment,providedtheparentsadoptafirmand
reassuringapproach.Forphobiasthatdonot
improve,behavioraltreatmentcombinedwith
reassuranceandsupportaremosthelpful.
Systematicdesensitization(gradualintroduction
ofthephobicobjectorsituationwhilethesubject
isinastateofrelaxation),isanestablished
treatment.Othermethodsareimplosionor
floodingwhichinvolvespersuadingthechildto
remaininthefearedsituationatmaximuminten­
sityfromthestart(thereverseofdesensitization).
SocialAnxietyDisorder
Childrenwiththisdisordershowapersistentor
recurrentfearandavoidanceofstrangerswhich
interfereswithsocialfunctioning.Treatment
includessimplebehavioralmethods,combined
withreassuranceandsupport.
SiblingRivalryDisorder
Siblingrivalry/jealousymaybeshownbymarked
competitionwithsiblingsfortheattentionand
affectionofparents,associatedwithunusual
patternofnegativefeelings.Onsetisduringthe
monthsfollowingthebirthoftheyoungersibling.
Inextremecasesthereisover-hostility,physical
traumatowardsandunderminingofthesibling,
regressionwithlossofpreviouslyacquiredskills
(suchasbowelandbladdercontrol)anda
tendencytobabyishbehavior.Thereisanincrease
inoppositionalbehaviorwiththeparents,temper
tantrums,anddysphoriaexhibitedintheformof
anxiety,miseryorsocialwithdrawal.
Management
•Parentsshouldbehelpedtodividetheiratten­
tionappropriatelybetweenthetwochildren.
•Helptheolderchildfeelvalued.Atthesame
time,limitsshouldbesetasappropriate.
•Preventiveinterventionssuchaspreparingthe
childmentallyforthearrivalofthesibling
duringpregnancyitself,andinvolvinghim
inthecareofthesibling.
ElectiveMutism
Thisconditionischaracterizedbyamarked,
emotionallydeterminedselectivityinspeaking
suchthatthechilddemonstrateshislanguage
competenceinsomesituations,butfailstospeak
inothersituations.Mosttypicallythechildspeaks
athomeorwithclosefriends,andismuteatschool
orwithstrangers.

171. 168AGuidetoMentalHealthandPsychiatricNursing
Management
Managementincludesacombinationofbeha­
vioralandfamilytherapytechniquestopromote
communicationandtheuseofspeech.Individual
psychotherapymayalsohelp.
TicDisorders
Ticisanabnormalinvoluntarymovement,which
occurssuddenly,repetitively,rapidlyandis
purposelessinnature.Itisoftwotypes:
1.Motortics,characterizedbyrepetitivemotor
movements.
2.Vocaltics,characterizedbyrepetitivevocali­
zations.
Ticdisorderscanbeeithertransientorchronic.
AspecialtypeofchronicticdisorderisGillesde
laTourette'ssyndromeorTourette'sdisorder.
Thisischaracterizedby:multiplemotorandvocal
tics,withdurationofmorethan1year.Onsetis
usuallybefore11yearsofageandalmostalways
before21yearsofage.
Thedisorderismorecommon(about3times)
inmalesandhasaprevalencerateofabout0.5
per1000.
MotorTics
Motorticscanbesimpleorcomplex.
SimpleMotorTics
Thesemayincludeeyeblinking,grimacing,
shruggingofshoulders,tongueprotrusion.
ComplexMotorTics
Thesearefacialgestures,stamping,jumping,
hittingself,squatting,twirling,echokinesis
(repetitionofobservedacts),andcopropraxia
(obsceneacts).
Motorticsareoftentheearliesttoappear,
beginningintheheadregionandprogressing
downwards.Thesearefollowedbyvocaltics.
VocalTics
Vocalticsalsocanbesimpleorcomplex.
SimpleVocalTics
Simplevocalticsincludecoughing,barking,throat
clearing,sniffing,andclicking.
ComplexVocalTics
Theseincludeecholalia(repetitionofheard
phrases),palilalia(repetitionofheardwords)
coprolalia(useofobscenewords),andmental
coprolalia(thinkingofobscenewords).
EtiologyofTourette'ssyndromeTheetiologyof
Tourette'ssyndromeisnotknownbutthepresence
oflearningdifficulties,neurologicalsoftsigns,
hyperactivity,abnormalEEGrecord,abnormal
evokedpotentialsandabnormalCTbrainfindings
insomepatientspointstowardsabiological
basis.Thereissomeevidencetosuggestthat
Tourette'ssyndromemaybeinheritedas
autosomaldominantdisorderwithvariable
penetrance.
TreatmentPharmacotherapyisthepreferred
modeoftreatment.Thedrugofchoiceis
haloperidol.Inresistantcasesorincaseofsevere
sideeffects,pimozideorclonidinecanbeused.
Behaviortherapymaybeusedsometimes,asan
adjunct.
Non-organicEnureses
Itisadisordercharacterizedbyinvoluntary
voidingofurinebydayand/ornightwhichis
abnormalinrelationtotheindividualsmental
ageandwhichisnotaconsequenceofalackof
bladdercontrolduetoanyneurologicaldisorder,
epilepticattacksoranystructuralabnormalityof
urinarytract.Enuresiswouldnotordinarilybe
diagnosedinachildundertheageof5yearsor
withamentalagelessthan4years.
Inmostcases,enuresisisprimary(thechild
hasneverattainedbladdercontrol).Sometimesit
maybesecondary(enuresisstartingafterthe
childachievedcontinenceforacertainperiodof
time).

172. ChildhoodPsychiatricDisorders169
FactorsAssociatedwithEnuresis
•Faultytraining:Iftoilettrainingisstartedtoo
early,andespeciallyifcoercive,produces
confusionandresentmentratherthan
compliance.Also,ifitisbeguntoolate,lossof
bladdercontrolcanresult.
•Emotionaldisturbances:Emotionalproblems
orconflictscanmanifestintheformof
disturbedbladdercontrol.Theseconflictsmay
beduetosuchfactorslikedominatingparents,
harshpunishmentsandotherproblemsinthe
family,causingthechildtofeelneglectedand
isolated.Asthechildrengrowolder,they
becomesensitiveabouttheirhabitofbed­
wetting.Theydevelopfeelingsofinferiority
andasenseofbeingdifferentfromother
children,whichaggravatestheproblemeven
further.
•Physicaldiseasesandanatomicdefects(e.g.
congenitalanomaliesofthegenitourinary
tract,diseasesinvolvingthecentralnervous
system)arerelativelyrarecausesforenuresis.
Management
•Excludeanyphysicalbasisforenuresisby
history,examinationandifnecessary,
investigationoftherenaltract.
•Explaintheparentsandchildaboutthe
maturationalbasisoftheproblemandthe
likelihoodofspontaneousimprovement.
•Thechildshouldbeencouragedtokeepa
diaryofthepatternofnighttimedryness/
wetness,whichcanbedonewithastarchart.
Thisconsistsofarecordofdrynightswitha
starplacedonthesheetforeachdrynight.
Thestarchartsystemhas3functions:
•itprovidesanaccuraterecordofthe
problem;
•ittestsmotivationandcooperationofthe
childandthefamily;and
•itactsasapositivereinforcementforthe
desiredbehavior.
•Fluidrestrictionafter6O'clockintheevening.
•Interruptionofchild'ssleepandemptying
bladderinthetoilet.
•Bellandpadtechnique:Itisbasedonclassical
conditioningprinciple.Abellisattachedto
thenapkinorpantiesandwhenthechild
passesurine,thealarmgoesoff,thechildthen
hastowakeup,changehisnapkin,bedsheets,
etc.Reinforcementisgivenfordrynights.
•Medications:Tricyclicantidepressantslike
imipramineoramitriptyline,25-50mgatnight.
Themechanismofactionisunknown,but
resultshavedemonstrateditseffectiveness.
•Theparentsshouldbeinstructednottoblame
thechildinanyway.Onnoaccountshould
thechildbeembarrassedorhumiliated,which
willonlyservetoaggravatetheproblem.
Non-organicEncopresis
Itistherepeatedvoluntaryorinvoluntarypas­
sageoffeces,usuallyofnormalornearnormal
consistency,inplacesnotappropriatefor
thatpurposeintheindividual'ssocio-cultural
setting.
Management
•Familytensionsregardingthesymptomsmust
bereducedandanon-punitiveatmosphere
mustbecreated.Parentalguidanceandfamily
therapyoftenisneeded.
•Behavioraltechniques,e.g.starcharts,in
whichthechildplacesastaronachartfor
dryorcontinentnights.
•Individualpsychotherapytogaintheco­
operationandtrustofthechild.
FeedingDisorderofInfancyandChildhood
Itgenerallyinvolvesrefusaloffoodandextreme
faddinessinthepresenceofanadequatefood
supplyandreasonablycompetentcaregiverand
theabsenceoforganicdisease.Theremayormay
notbeassociatedrumination(repeatedregurgi­
tationwithoutnauseaorgastrointestinalillness).
Pica
Picaofinfancyandchildhoodischaracterized
byeatingnon-nutritivesubstances(soil,paint

173. 170AGuidetoMentalHealthandPsychiatricNursing
chipping,paperetc).Treatmentconsistsof
common-senseprecautionstokeepthechildaway
fromabnormalitemsofdiet.Picausually
diminishesasthechildgrowsolder.
StereotypedMovementDisorders
Thesedisordersarecharacterizedbyvoluntary,
repetitive,stereotyped,nonfunctional,often
rhythmicmovementsthatdonotformpartofany
recognizedpsychiatricorneurologicalcondition.
Themovementsincludebodyrocking,head
rocking,hairpluckinghairtwisting,finger
flicking,mannerismsandhandflapping.
Management
•Individualandfamilyinterventions
•Behavioralstrategies
Stuttering(Stammering)
Itreferstofrequenthesitationorpausesinspeech
characterizedbyfrequentrepetitionorprolon­
gationofsoundsorsyllablesorwords,disrupting
rhythmicflowofspeech.Theusualtreatmentis
speechtherapy.
REVIEWQUESTIONS
•Classificationofchildhoodpsychiatric
disorders(Feb2001)
•Definitionandetiologyofmentalretardation
(Feb2000,Oct2004,Apr2006)
•Classificationofmentalretardation(Feb2001,
Nov2003)
•Profoundmentalretardation(Oct2005)
•Mentalretardation(Nov2002)
•Roleofanurseinthepreventionofmental
retardation
•Nursingmanagementofamentallyretarded
child(Nov2002)
•Habilitationofmentallyretardedchild(Nov
2001)
•Nursingmanagementofanautisticchild
•Infantileautism(Oct2000)
Autism(Nov2003,Oct2004)
•Attentiondeficithyperactivedisorder(Nov
2002,Apr2003)
•Nursingmanagementofachildwith
hyperkineticdisorder
•Conductdisorder(Nov2001,Apr2002)
•Juveniledelinquency(Feb2000,Apr2006)
•Enuresis(Feb2001,Apr2002,Apr2004,Oct
2004)
•Mutism(Nov2001)
•Ticdisorder(Apr2002)
•Nursingmanagementofchildhoodpsy­
chiatricdisorders(Apr2006)
•Behavioraldisordersinchildren(Oct2004)
•Neuroticdisordersofchildhood(Nov2003)

174. TherapeuticModalities
inPsychiatry
DSOMATICTHERAPIES
Psychopharmacology
•Antipsychotics
•Antidepressants
•LithiumandOtherMoodStabilizing
Drugs
•AnxiolyticsandHypnosedatives
•AntiparkinsonianAgents
•AntabuseDrugs
•DrugsUsedInChildPsychiatry
ElectroconvulsiveTherapy
Psychosurgery
DPSYCHOLOGICALTHERAPIES
PsychoanalyticTherapy
BehaviorTherapy
CognitiveTherapy
Hypnosis
AbreactionTherapy
RelaxationTherapies
IndividualPsychotherapy
SupportivePsychotherapy
GroupTherapy
FamilyandMaritalTherapy
DMILIEUTHERAPY
DTHERAPEUTICCOMMUNITY
DACTIVITYTHERAPY
OccupationalTherapy
RecreationalTherapy
EducationalTherapy
BiblioTherapy
PlayTherapy
MusicTherapy
DanceTherapy
ArtTherapy
ImplicationsofActivityTherapiesFor
NursingPractice
Patientssufferingfromphysicalillnessesare
givenspecifictreatmentbecausethecausesare
specificandthesignsandsymptomsarespecific.
Inapsychiatricsettingthetreatmentmaynotbe
sospecificandmostpatientsaregivenmorethan
onetreatment.Thesetreatmentmethodsvaryfrom
patienttopatient.Somepatientsdonotwant
treatmentandmaynotcooperatewiththedoctors
andnurses.Somedonotrealizethattheyareill
andmayactivelyresistallformsoftreatment.
Thenursehasanextremelyimportantroleto
playinthetreatmentofthementallyill.Sheisthe
onewhohasclosercontactwiththepatientthan
anyothermembersofthehospitalteam.Shealso
hasagreateropportunitytogettoknowhimand
reportonhisimprovement.
Thevarioustreatmentmodalitiesinpsychia­
tryarebroadlydividedas:
•Somatic(physical)therapies
•Psychologicaltherapies
Othertherapiesincludedinthisunitare:
•Milieutherapy
•Therapeuticcommunity
•Activitytherapy
SOMATIC(PHYSICAL)THERAPIES
Psychopharmacology
Theunderstandingofthebiologicalregulationof
thought,behaviorandmoodisthebasisofall
somatictherapiesusedinmodernpsychiatry.
Psychopharmacologicalagentsarenowthefirst­
linetreatmentforalmosteverypsychiatric
ailment.Withthegrowingavailabilityofawide
rangeofdrugstotreatmentalillness,thenurse
practicinginmodernpsychiatricsettingsneeds
tohaveasoundknowledgeofthepharma­
cokineticsinvolved,thebenefitsandpotential
risksofpharmacotherapy,aswellasherownrole
andresponsibility.

175. 172AGuidetoMentalHealthandPsychiatricNursing
Thevariousdrugsusedinpsychiatryare
calledaspsychotropic(orpsychoactive)drugs.
Theyaresocalledbecauseoftheirsignificant
effectonhighermentalfunctions.Thereareabout
sevenclassesofpsychotropicdrugs.Beforegoing
intoadetaileddescriptionofeach,afew
guidelinesaregivenbelowregardingthe
administrationofdrugsinpsychiatryingeneral.
Thespecificresponsibilitiesarementioned
separatelyundereachclass.
GeneralGuidelinesRegardingDrug
AdministrationinPsychiatry
•Thenurseshouldnotadministeranydrug
unlessthereisawrittenorder.Donothesitate
toconsultthedoctorwhenindoubtaboutany
medication.
•Allmedicationsgivenmustbechartedonthe
patient'scaserecordsheet.
•Ingivingmedication:
•alwaysaddressthepatientbynameand
makecertainofhisidentification
•donotleavethepatientuntilthedrugis
swallowed
•donotpermitthepatienttogotothe
bathroomtotakethemedication
•donotallowonepatienttocarrymedicine
toanother.
•Ifitisnecessarytoleavethepatienttoget
water,donotleavethetraywithinthereach
ofthepatient.
•Donotforceoralmedicationbecauseofthe
dangerofaspiration.Thisisespecially
importantinstuporouspatients.
•Checkdrugsdailyforanychangeincolor,
odorandnumber.
•Bottlesshouldbetightlyclosedandlabeled.
Labelsshouldbewrittenlegiblyandinbold
lettering.Poisondrugsaretobelegiblylabeled
andtobekeptinseparatecupboard.
•Makesurethatanadequatesupplyofdrugs
isonhand,butdonotoverstock.
•Makesurenopatienthasaccesstothedrug
cupboard.
•Drugcupboardsshouldalwaysbekeptlocked
whennotinuse.Neverallowapatientor
workertocleanthedrugcupboard.Thedrug
cupboardkeysshouldnotbegiventopatients.
ClassificationofPsychotropicDrugs
1.Antipsychotics
2.Antidepressants
3.Moodstabilizingdrugs
4.Anxiolyticsandhypnosedatives
5.Antiepilepticdrugs
6.Antiparkinsoniandrugs
7.Miscellaneousdrugswhichincludestimu­
lants,drugsusedineatingdisorders,drugs
usedindeaddiction,drugsusedinchildpsy­
chiatry,vitamins,calciumchannelblockers,etc.
Antipsychotics
Antipsychoticsarethosepsychotropicdrugs,
whichareusedforthetreatmentofpsychotic
symptoms.Thesearealsoknownasneuroleptics
(astheyproduceneurologicalside-effects),major
tranquilizers,D2-receptorblockersandanti­
schizophrenicdrugs.
Classification:SeeTable14.1
Indications
Organicpsychiatricdisorders
•Delirium
•Dementia
•Deliriumtremens
•Drug-inducedpsychosisandotherorganic
mentaldisorders
Functionaldisorders
•Schizophrenia
•Schizoaffectivedisorders
•Paranoiddisorders
Mooddisorders
•Mania
•Majordepressionwithpsychoticsymptoms
Childhooddisorders
•Attention-deficithyperactivitydisorder
•Autism
•Enuresis
•Conductdisorder

176. TherapeuticModalitiesinPsychiatry173
Table14.1:Classificationofantipsychoticdrugs
Class Examplesof Oraldose Parenteral·
drugs mg/day dose(mg)
PhenothiazinesChlorpromazine Megatil
Largactil
Tranchlor
Triflupromazine Siquil
Thioridazine Thioril,Melleril
Ridazin
Trifluoperazine Espazine
Fluphenazine Prolinate
decanoate
ThioxanthenesFlupenthixol Fluanxol
ButyrophenonesHaloperidol Senorm,Serenace
Relinace
DiphenylbutylPimozide Orap
Piperidines Penfluridol Flumap
IndolicderivativesMolindone Mobarn
DibenzoxazepinesLoxapine Loxapac
Atypicalanti- Clozapine Sizopin,Lozapin
psychotics Risperidone Sizodon,Sizomax
Olanzapine Oleanz
Quetiapine Qutan
Ziprasidone Zisper
Others Reserpine Serpasil
Neuroticandotherpsychiatricdisorders
•Anorexianervosa
•Intractableobsessive-compulsivedisorder
•Severe,intractableanddisablinganxiety
Medicaldisorders
•Huntington'schorea
•Intractablehiccough
•Nauseaandvomiting
•Ticdisorder
•Eclampsia
•Heatstroke
•Severepaininmalignancy
•Tetanus
Pharmacokinetics
Antipsychoticswhenadministeredorallyare
absorbedvariablyfromthegastrointestinaltract,
withunevenbloodlevels.Theyarehighlybound
toplasmaaswellastissueproteins.Braincon-
300-1500
100-400
300-800
50-100
IMonly
30-60IMonly
15-60 1-5IM
25-50IM
every1-3
weeks
3-40
5-100 5-20IM
4-20
20-60weekly
50-225
25-100
50-450
2-10
10-20mg
150-750mg
20-80mg
0.5-50
centrationishigherthanplasmaconcentration.
Theyaremetabolizedintheliver,andexcreted
mainlythroughthekidneys.Theeliminationhalf­
lifevariesfrom10to24hours.
Mostoftheantipsychoticstendtohavea
therapeuticwindow.Ifthebloodlevelisbelow
thiswindow,thedrugisineffective.Iftheblood
levelishigherthantheupperlimitofthewindow,
thereistoxicityorthedrugisagainineffective.
MechanismofAction
AntipsychoticdrugsblockD2receptorsinthe
mesolimbicandmesofrontalsystems(concerned
withemotionalreactions).Sedationiscausedby
alpha-adrenergicblockade.Antidopaminergic
actionsonbasalgangliaareresponsiblefor
causingEPS(ExtraPyramidalSymptoms).
Atypicalantipsychoticshaveantiserotonergic
(5-hydroxytryptamineor5-HT)antiadrenergic

177. 174AGuidetoMentalHealthandPsychiatricNursing
andantihistaminergicactions.Thesearetherefore
calledasserotonin-dopamineantagonists.
AdverseEffectsofAntipsychoticDrugs
I.Extrapyramidalsymptoms(EPS)
1.Neurolepiic-inducedparkinsonism:Symptoms
includerigidity,tremors,bradykinesia,
stoopedposture,drooling,akinesia,ataxia,
etc.Thedisordercanbetreatedwith
anticholinergicagents.
2.Acutedystonia:Dystonicmovementsresults
fromaslowsustainedmuscularspasmthat
leadtoaninvoluntarymovement.Dystonia
caninvolvetheneck,jaw,tongueandthe
entirebody(opisthotonos).Thereisalso
involvementofeyesleadingtoupwardlateral
movementoftheeyeknownasoculogyric
crisis.Dystoniascanbepreventedbyanticho­
linergics,antihistaminergics,dopamine
agonists,beta-adrenergicantagonists,benzo­
diazepines,etc.
3.Akathisia:Akathisiaisasubjectivefeelingof
musculardiscomfortthatcancausepatients
tobeagitated,restlessandfeelgenerally
dysphoric.Akathisiacanbetreatedwith
propranolol,benzodiazepinesandclonidine.
4.Tardivedyskinesia:Itisadelayedadverseeffect
ofantipsychotics.Itconsistsofabnormal,
irregularchoreoathetoidmovementsofthe
musclesofthehead,limbsandtrunk.Itis
characterizedbychewing,sucking,grimacing
andperi-oralmovements.
5.Neurolepticmalignantsyndrome:Thisisarare
butseriousdisorderoccurringinasmall
minorityofpatientstakingneuroleptics,
especiallyhigh-potencycompounds.
Theonsetisoften,butnotinvariably,in
thefirst10daysoftreatment.Theclinical
pictureincludestherapidonset(usuallyover
24-72hours)ofseveremotor,mentalandauto­
nomicdisorders.Theprominentmotorsymp­
tomisgeneralizedmuscularhypertonicity.
Stiffnessofthemusclesinthethroatandchest
maycausedysphasia,anddyspnea.The
mentalsymptomsincludeakineticmutism,
stupororimpairedconsciousness.Hyper-
pyrexiadevelopswithevidenceofautonomic
disturbancesintheformofunstableblood
pressure,tachycardia,excessivesweating,
salivation,andurinaryincontinence.Inthe
blood,CreatininePhosphoKinase[CPK]levels
mayberaisedtoveryhighlevels,andthe
whitecellcountmaybeincreased.Secondary
featuresmayincludepneumonia,thrombo­
embolism,cardiovascularcollapse,andrenal
failure.
Thesyndromelastsforonetotwoweeks
afterstoppingthedrug.
(SeeChapter18,p.244formanagement).
ILAutonomicside-effects:Drymouth,constipa­
tion,cycloplegia,mydriasis,urinaryretention,
orthostatichypotension,impotenceand
impairedejaculation.
Ill.Seizures
N.Sedation
V.Othereffects
•Agranulocytosis(especiallyforclozapine)
•Sialorrheaorincreasedsalivation(espe-
ciallyforclozapine)
•Weightgain
•Jaundice
•Dermatologicaleffects(contactdermatitis,
photosensitivereaction)
Nurse'sResponsibilityforaPatient
ReceivingAntipsychotics.
•Instructthepatienttotakesipsofwaterfre­
quentlytorelievedrynessofmouth.Frequent
mouthwashes,useofchewinggum,applying
glycerineonthelipsarealsohelpful.
•Ahigh-fiberdiet,increasedfluidintakeand
laxativesifneeded,helptoreduceconsti­
pation.
•Advisethepatienttogetupfromthebedor
chairveryslowly.Patientshouldsitonthe
edgeofthebedforonefullminutedangling
hisfeet,beforestandingup.CheckBPbefore
andaftermedicationisgiven.Thisisan
importantmeasuretopreventfallsandother
complicationsresultingfromorthostatic
hypotension.
•Differentiatebetweenakathisiaandagitation
andinformthephysician.Achangeofdrug

178. TherapeuticModalitiesinPsychiatry175
maybenecessaryifside-effectsaresevere.
Administerantiparkinsoniandrugsaspres­
cribed.
•Observethepatientregularlyforabnormal
movements.
•Takeallseizureprecautions.
•Patientshouldbewarnedaboutdrivingacar
oroperatingmachinerywhenfirsttreatedwith
antipsychotics.Givingtheentiredoseat
bedtimeusuallyeliminatesanyproblemfrom
sedation.
•Advisethepatienttousesunscreenmeasures
(useoffullsleeves,darkglassesetc)for
photosensitivereactions.
•Teachtheimportanceofdrugcompliance,
side-effectsofdrugsandreportingiftoosevere,
regularfollow-ups.Givereassuranceand
reduceunfoundedfearsandanxieties.
•Apatientreceivingclozapineisatriskfor
developingagranulocytosis.MonitorTC,DC
essentiallyinthefirstfewweeksoftreatment.
StopthedrugiftheWBCcountdropstoless
than3000/mm3 ofblood.Thepatientshould
alsobetoldtoreportifsorethroatorfever
develop,whichmightindicateinfection.
•Seizureprecautionsshouldalsobetakenas
clozapinereducesseizurethreshold.Thedose
shouldberegulatedcarefullyandthepatient
mayalsobeputonanticonvulsantssuchas
eptoin.
Antidepressants
Antidepressantsarethosedrugs,whichareused
forthetreatmentofdepressiveillness.Theseare
alsocalledasmoodelevatorsorthymoleptics.
Classification:SeeTable14.2
Indications
Depression
•Depressiveepisode
•Dysthymia
•Reactivedepression
•Secondarydepression
•Abnormalgriefreaction
Childhoodpsychiatricdisorders
•Enuresis
•Separationanxietydisorder
•Somnambulism
•Schoolphobia
•Nightterrors
Otherpsychiatricdisorders
•Panicattack
•Generalisedanxietydisorder
•Agoraphobia,socialphobia
•OCDwithorwithoutdepression
•Eatingdisorder
•Borderlinepersonalitydisorder
•Post-traumaticstressdisorder
•Depersonalizationsyndrome
Medicaldisorders
•Chronicpain
Table14.2:Classificationofantidepressants
Class Examplesofdrugs Tradenames Oraldosage(mg/day)
Tricyclicantidepressants Imipramine Antidep 75-300
(TCAs) Amitriptyline Tryptomer 75-300
Clomipramine Anafranil 75-300
Dothiepin Prothiaden 75-300
Mianserin Depnon 30-120
Selectiveserotoninreuptake Fluoxetine Fludac 10-80
Inhibitors(SSRis) Sertraline Serenata 50-200
Dopaminergicantidepressants Fluvoxamine Faverin 50-300
Atypicalantidepressants Amineptine Survector 100-400
Monoamineoxidase Trazodone Trazalon 150-600
inhibitors(MAOis) Isocarboxazid Marplan 10-30

179. 176AGuidetoMentalHealthandPsychiatricNursing
•Migraine
•Pepticulcerdisease
Pharmocokinetics
Antidepressantsarehighlylipophilicand
protein-bound.Thehalf-lifeislongandusually
morethan24hours.Itispredominantlymeta­
bolizedintheliver.
MechanismofAction
Theexactmechanismisunknown.Thepredo­
minantactionisbyincreasingcatecholamine
levelsinthebrain.
TCAsarealsocalledasMonoAmine
ReuptakeInhibitors(MARls).Themainmodeof
actionisbyblockingthereuptakeof
norepinephrine(NE)and/orserotonin(5-HT)at
thenerveterminals,thusincreasingtheNEand
5-HTlevelsatthereceptorsite.
MAOisinsteadactonMAO(monoamine
oxidase),whichisresponsibleforthedegradation
ofcatecholaminesafterre-uptake.Thefinaleffect
isthesame,afunctionalincreaseintheNEand
5-HTlevelsatthereceptorsite.Theincreasein
brainaminelevelsisprobablyresponsibleforthe
antidepressantaction.Ittakesabout5to10days
forMAOisand2to3weeksforTCAstobring
downdepressivesymptoms.
SSRisactbyinhibitingthere-uptakeof
serotoninandincreasingitslevelsatthereceptor
site.
SideEffects
1.Autonomicside-effects:Drymouth,constipa­
tion,cydoplegia,mydriasis,urinaryretention,
orthostatichypotension,impotence,impaired
ejaculation,deliriumandaggravationof
glaucoma.
2.CNSeffects:Sedation,tremorandotherextra­
pyramidalsymptoms,withdrawalsyndrome,
seizures,jitterinesssyndrome,precipitation
ofmania.
3.Cardiacside-effects:Tachycardia,ECGchanges,
arrhythmias,directmyocardialdepression,
quinidine-likeaction(decreasedconduction
time).
4.Allergicside-effects:Agranulocytosis,cholesta­
ticjaundice,skinrashes,systemicvasculitis.
5.Metabolicandendocrineside-effects:Weightgain.
6.SpecialeffectsofMAOIdrugs:Hypertensive
crises,severehepaticnecrosis,hyperpyrexia.
Nurse'sResponsibilityforaPatientReceiving
Antidepressants
Mostofthenurse'sresponsibilitiesforapatient
onantidepressantsarethesameasforapatient
receivingantipsychotics(seep.174).Inaddition:
•PatientsonMAOisshouldbewarnedagainst
thedangerofingestingtyramine-richfoods
whichcanresultinhypertensivecrisis.Some
ofthesefoodsarebeefliver,chickenliver,fer­
mentedsausages,driedfish,overripedfruits,
chocolateandbeverageslikewine,beerand
coffee.
•Reportpromptlyifoccipitalheadache,nausea,
vomiting,chestpainorotherunusual
symptomsoccur;thesecanheraldtheonset
ofhypertensivecrisis.
•Instructthepatientnottotakeanymedication
withoutprescription.
•Cautionthepatienttochangehisposition
slowlytominimizeorthostatichypotension.
•Strictmonitoringofvitals,especiallyblood
pressureisessential.
LithiumandOtherMoodStabilizingDrugs
Moodstabilizersareusedforthetreatmentof
bipolaraffectivedisorders.Somecommonlyused
moodstabilizersare:
•Lithium
•Carbamazepine
•Sodiumvalproate
Lithium
Lithiumisanelementwithatomicnumber3and
atomicweight7.ItwasdiscoveredbyFJCadein
1949,andisamosteffectiveandcommonlyused
druginthetreatmentofmania.
Indications
•Acutemania
•Prophylaxisforbipolarandunipolarmood
disorder.

180. TherapeuticModalitiesinPsychiatry177
•Schizoaffectivedisorder
•Cyclothymia
•Impulsivityandaggression
•Otherdisorders:
•premenstrualdysphoricdisorder
•bulimianervosa
•borderlinepersonalitydisorder
•episodesofbingedrinking
•trichotillomania
•clusterheadaches
Pharmacokinetics
Lithiumisreadilyabsorbedwithpeakplasma
levelsoccurring2-4hoursafterasingleoraldose
oflithiumcarbonate.Lithiumisdistributed
rapidlyinliverandkidneyandmoreslowlyin
muscle,brainandbone.Steadystatelevelsare
achievedinabout7days.Eliminationis
predominantlyviakidneys.Lithiumisreabsorbed
intheproximaltubulesandisinfluencedby
sodiumbalance.Depletionofsodiumcan
precipitatelithiumtoxicity.
MechanismofAction
Theprobablemechanismsofactioncanbe:
•Itacceleratespresynapticre-uptakeanddes­
tructionofcatecholamines,likenorepinep­
hrine
•Itinhibitsthereleaseofcatecholaminesatthe
synapse.
•Itdecreasespostsynapticserotoninreceptor
sensitivity.
Alltheseactionsresultindecreasedcate­
cholamineactivity,thusamelioratingmania.
Dosage
Lithiumisavailableinthemarketintheformof
thefollowingpreparations:
Lithiumcarbonate:300mgtablets(e.g.
Licab);400mgsustainedreleasetablets
(e.g.Lithosun-SR)
Lithiumcitrate:300mg/5mlliquid.
Theusualrangeofdoseperdayinacute
maniais900-2100mggivenin2-3divideddoses.
Thetreatmentisstartedafterseriallithiumestima-
tionisdoneafteraloadingdoseof600mgor900
mgoflithiumtodeterminethepharmacokinetics.
BloodLithiumLevels
•Therapeuticlevels=0.8-1.2mEq/L(for
treatmentofacutemania)
•Prophylacticlevels=0.6-1.2mEq/L(for
preventionofrelapseinbipolardisorder)
•Toxiclithiumlevels>2.0mEq/L
SideEffects
1.Neurological:Tremors,motorhyperactivity,
muscularweakness,cogwheelrigidity,
seizures,neurotoxicity(delirium,abnormal
involuntarymovements,seizures,coma).
2.Renal:Polydipsia,polyuria,tubularenlarge­
ment,nephroticsyndrome.
3.Cardiovascular:T-wavedepression.
4.Gastrointestinal:Nausea,vomiting,diarrhea,
abdominalpainandmetallictaste.
5.Endocrine:Abnormalthyroidfunction,goiter
andweightgain.
6.Dermatological:Acneiformeruptions,papular
eruptionsandexacerbationofpsoriasis.
7.Side-effectsduringpregnancyandlactation:
Teratogenicpossibility,increasedincidence
ofEbstein'sanomaly(distortionanddown­
warddisplacementoftricuspidvalueinright
ventricle)whentakeninfirsttrimester.Secreted
inmilkandcancausetoxicityininfant.
8.Signsandsymptomsoflithiumtoxicity(serum
lithiumlevel>2.0mEq/L):
•ataxia
•coarsetremor(hand)
•nauseaandvomiting
•impairedmemory
•impairedconcentration
•nephrotoxicity
•muscleweakness
•convulsions
•muscletwitching
•dysarthria
•lethargy
•confusion
•coma
•hyperreflexia
•nystagmus

181. 178AGuidetoMentalHealthandPsychiatricNursing
ManagementofLithiumToxicity
•Discontinuethedrugimmediately.
•Forsignificantshort-termingestions,residual
gastriccontentshouldberemovedbyinduc­
tionofemesis,gastriclavageandadsorption
withactivatedcharcoal.
•Ifpossibleinstructthepatienttoingestfluids.
•Assessserumlithiumlevels,serumelectro­
lytes,renalfunctions,ECGassoonaspossible.
•Maintenanceoffluidandelectrolytebalance.
•Inapatientwithseriousmanifestationsof
lithiumtoxicity,hemodialysisshouldbe
initiated.
ContraindicationsofLithiumUse
•Cardiac,renal,thyroidorneurological
dysfunctions
•Presenceofblooddyscrasias
•Duringfirsttrimesterofpregnancyand
lactation
•Severedehydration
•Hypothyroidism
•Historyofseizures
Nurse'sResponsibilitiesfora
PatientReceivingLithium
Thepre-lithiumworkup:Acompletephysical
history,ECG,bloodstudies(TC,DC,FBS,BUN,
creatinine,electrolytes)urineexamination
(routineandmicroscopic)mustbecarriedout.It
isimportanttoassessrenalfunctionasrenalside­
effectsarecommonandthedrugcanbedangerous
inanindividualwithcompromisedkidney
function.Thyroidfunctionsshouldalsobe
assessed,asthedrugisknowntodepressthe
thyroidgland.
Toachievetherapeuticeffectandpreventlithium
toxicity,thefollowingprecautionsshouldbetaken:
•Lithiummustbetakenonaregularbasis,
preferablyatthesametimedaily(forexample,
aclienttakinglithiumonTIDschedule,who
forgetsadoseshouldwaituntilthenext
scheduledtimetotakelithiumandnottake
twicetheamountatonetime,becauselithium
toxicitycanoccur).
•Whenlithiumtherapyisinitiated,mildside­
effectssuchasfinehandtremors,increased
thirstandurination,nausea,anorexiaetcmay
develop.Mostofthemaretransientanddo
notrepresentlithiumtoxicity.
•Seriousside-effectsoflithiumthatnecessitate
itsdiscontinuanceincludevomiting,extreme
handtremors,sedation,muscleweaknessand
vertigo.Thepsychiatristshouldbenotified
immediatelyifanyoftheseeffectsoccur.
•Sincepolyuriacanleadtodehydrationwith
theriskoflithiumintoxication,patients
shouldbeadvisedtodrinkenoughwaterto
compensateforthefluidloss.
•Varioussituationsmayrequireanadjustment
intheamountoflithiumadministeredtoa
client,suchastheadditionofanewmedicine
totheclient'sdrugregimen,anewdietoran
illnesswithfeverorexcessivesweating.Inthis
connection,peopleinvolvedinheavyoutdoor
laborarepronetoexcessivesodiumloss
throughsweating.Theymustbeadvisedto
consumelargequantitiesofwaterwithsalt,
topreventlithiumtoxicityduetodecreased
sodiumlevels.Ifseverevomitingor
gastroenteritisdevelops,thepatientshould
betoldtoreportimmediatelytothedoctor.
Thesearetheconditionsthathaveahigh
potentialforcausinglithiumtoxicityby
loweringserumsodiumlevels..
•Frequentserumlithiumlevelevaluationis
important.Bloodfordeterminationoflithium
levelsshouldbedrawninthemorning
approximately12-14hoursafterthelastdose
wastaken.
•Thepatientshouldbetoldaboutthe
importanceofregularfollowup.Ineverysix
months,bloodsampleshouldbetakenfor
estimationofelectrolytes,urea,creatinine,a
fullbloodcount,andthyroidfunctiontest.
Carbamazepine
Itisavailableinthemarketunderdifferenttrade
nameslikeTegretol,Mazetol,ZeptolandZen
Retard.

182. TherapeuticModalitiesinPsychiatry179
Indications
•Seizures-complexpartialseizures,GTCS,
seizuresduetoalcoholwithdrawal.
•Psychiatricdisorders-rapidcyclingbipolar
disorder,acutedepression,impulsecontrol
disorder,aggression,psychosiswithepilepsy,
schizoaffectivedisorders,borderlinepersona­
litydisorder,cocainewithdrawalsyndrome.
•Paroxysmalpainsyndromes-trigeminal
neuralgiaandphantomlimbpain.
Dosage
Theaveragedailydoseis600-1800mgorally,in
divideddoses.Thetherapeuticbloodlevelsare6-
12µg/ml.Toxicbloodlevelsareattainedatmore
than15µg/ml.
MechanismofAction
Itsmoodstabilizingmechanismisnotclearly
established.Itsanticonvulsantactionmay
howeverbebydecreasingsynaptictransmission
intheCNS.
SideEffects
Drowsiness,confusion,headache,ataxia,hyper­
tension,arrhythmias,skinrashes,Steven-Johnson
syndrome,nausea,vomiting,diarrhea,drymouth,
abdominalpain,jaundice,hepatitis,oliguria,
leukopenia,thrombocytopenia,bonemarrow
depressionleadingtoaplasticanemia.
Nurse'sResponsibilities
•Sincethedrugmaycausedizzinessand
drowsinessadvisehimtoavoiddrivingand
otheractivitiesrequiringalertness.
•Advisepatientnottoconsumealcoholwhen
heisonthedrug.
•Emphasizetheimportanceofregularfollow­
upvisitsandperiodicexaminationofblood
countandmonitoringofcardiac,renal,
hepaticandbonemarrowfunctions.
SodiumValproate(Encoratechrono,
valparin,Epilex,Epival)
Indications
•Acutemania,prophylactictreatmentofbipo-
larIdisorder,rapidcyclingbipolardisorder.
•Schizoaffectivedisorder.
•Seizures.
•Otherdisorderslikebulimianervosa,obsessive­
compulsivedisorder,agitationandPTSD.
MechanismofAction
Thedrugactsongamma-aminobutyricacid
(GABA)aninhibitoryaminoacidneurotrans­
mitter.GABAreceptoractivationservestoreduce
neuronalexcitability,
Dosage
Theusualdoseis15mg/kg/daywithamaxi­
mumof60mg/kg/dayorally.
SideEffects
Nausea,vomiting,diarrhea,sedation,ataxia,
dysarthria,tremor,weightgain,lossofhair,
thrombocytopenia,plateletdysfunction.
Nurse'sResponsibilities
•Explaintothepatienttotakethedrug
immediatelyafterfoodtoreduceGIirritation.
•Advisetocomeforregularfollow-upand
periodicexaminationofbloodcount,hepatic
functionandthyroidfunction.Therapeutic
serumlevelofvalproicacidis50-100
microgramsIml.
Anxiolytics(Anti-anxietydrugs)and
Hypnosedatives
Thesearealsocalledasminortranquilizers.Most
ofthembelongtothebenzodiazepinegroupof
drugs.
Classification
1.Barbiturates:Example,phenobarbital,pento­
barbital,secobarbitalandthiopentone.

183. 180AGuidetoMentalHealthandPsychiatricNursing
2.Non-barbituratenon-benzodiazepineanti-anxiety
agents:Example,Meprobamateglutethimide,
ethanol,diphenhydramineandmethaqualon.
3.Benzodiazepines:Presentlybenzodiazepines
arethedrugsoffirstchoiceinthetreatmentof
anxiety,andforthetreatmentofinsomnia.
•Veryshort-acting:Example,Triazolam,
Midazolam.
•Short-acting:Example,Oxazepam
(Serepax),Lorazepam(Ativan,Trapex,
Larpose),Alprazolam(Restyl,Trika,
Alzolam,Quiet,Anxit).
•Long-acting:Example,Chlordiazepoxide
(Librium),Diazepam(Valium,Calmpose),
Clonazepam(Lonazep),Flurazepam
(Nindral),Nitrazepam(Dormin).
IndicationsforBenzodiazepines
•Anxietydisorders
•Insomnia
•Depressibn
•Panicdisorderandsocialphobia
•Obsessive-compulsivedisorder
•Post-traumaticstressdisorder
•BipolarIdisorder
•Otherpsychiatricindicationsincludealcohol
withdrawal,substance-inducedandpsy­
choticagitation
Dosage(mg/day)
Alprazolam:0.5-6PO
Oxazepam:15-120PO
Lorazepam:2-6PO/IV/IM
Diazepam:2-10PO/IM/slowIV
Clonazepam:0.5-20PO/IM
Chlordiazepoxide:15-100PO;50-100slowIV
Nitrazepam:5-20PO
MechanismofAction
Benzodiazepinesbindtospecificsitesonthe
GABAreceptorsandincreaseGABAlevel.Since
GABAisaninhibitoryneurotransmitter,ithasa
calmingeffectonthecentralnervoussystem,thus
reducinganxiety.
SideEffects
Nausea,vomiting,weakness,vertigo,blurringof
vision,bodyaches,epigastricpain,diarrhea,
impotence,sedation,increasedreactiontime,ata­
xia,drymouth,retrogradeamnesia,impairment
ofdrivingskills,dependenceandwithdrawal
symptoms(thedrugshouldbewithdrawnslowly,
asaresult).
Nurse'sResponsibilityintheAdministrationof
Benzodiazepines
•Administerwithfoodtominimizegastric
irritation.
•Advisethepatienttotakemedicationexactly
asdirected.Abruptwithdrawalmaycause
insomnia,irritabilityandsometimeseven
seizures.
•Explainaboutadverseeffectsandadvisehim
toavoidactivitiesthatrequirealertness.
•Cautionthepatienttoavoidalcoholorany
otherCNSdepressantsalongwithbenzo­
diazepines;alsoinstructhimnottotakeany
over-the-counter(OTC)medications.
•IfIMadministrationispreferredgivedeep
IM.
•ForIVadministrationdonotmixwithany
otherdrug.GiveslowIVasrespiratoryor
cardiacarrestcanoccur;monitorvitalsigns
duringIVadministration.Preventextravasa­
tionssinceitcancausephlebitisandvenous
thrombosis.
AntiparkinsonianAgents
Inclinicalpracticeanticholinergicdrugs,
amantadineandtheantihistamineshavetheir
primaryuseastreatmentsformedication-induced
movementdisorders,particularlyneuroleptic­
inducedparkinsonism,acutedystoniaand
medication-inducedtremor.
Anticholinergics
•Trihexyphenidyl
•Benztropine
•Biperiden

184. TherapeuticModalitiesinPsychiatry181
DopaminergicAgents
•Bromocriptine
•Carbidopa/Levodopa
MonoamineOxidaseTypeBInhibitors
•Selegiline
Trihexyphenidyl(Artane,Trihexane,Trihexy,
Pacitane)
Indications
•Drug-inducedparkinsonism.
•Adjunctinthemanagementofparkinsonism.
MechanismofAction
Itactsbyincreasingthereleaseofdopaminefrom
presynapticvesicles,blockingthere-uptakeof
dopamineintopresynapticnerveterminalsorby
exertinganagonisteffectonpostsynaptic
dopaminereceptors.
Trihexyphenidylreachespeakplasmacon­
centrationsin2-3hoursafteroraladministration
andhasadurationofactionofupto12hours.
Dosage
1-2mgperdayorallyinitially.Maximumdose
upto15mg/dayindivideddoses.
SideEffects
Dizziness,nervousness,drowsiness,weakness,
headache,confusion,blurredvision,mydriasis,
tachycardia,orthostatichypotension,drymouth,
nausea,constipation,vomiting,urinaryretention
anddecreasedsweating.
Nurse'sResponsibilities
•Assessparkinsonianandextrapyramidal
symptoms.Medicationshouldbetapered
gradually.
•Cautionpatienttomakepositionchanges
slowlytominimizeorthostatichypotension.
•Instructthepatientaboutfrequentrinsingof
mouthandgoodoralhygiene.
•Cautionpatientthatthismedicationdecreases
perspiration,andover-heatingmayoccur
duringhotweather.
AntabuseDrugs
Disulfiramisanimportantdruginthisclassand
isusedtoensureabstinenceinthetreatmentof
alcoholdependence.Itsmaineffectistoproduce
arapidandviolentlyunpleasantreactionina
personwhoingestsevenasmallamountof
alcoholwhiletakingdisulfiram.
(ReferChapter11p.133foradetaileddescription
ondisulfiram)
DrugsUsedinChildPsychiatry
Clonidine
Indications
•Controlofwithdrawalsymptomsfromopioids
•Tourette'sdisorder
•Controlofaggressiveorhyperactivebehavior
inchildren
•Autism
MechanismofAction
•Alpha2-adrenergicreceptoragonist.
•Theagonisteffectsofclonidineonpresynaptic
alpha2-adrenergicreceptorsresultina
decreaseintheamountofneurotransmitter
releasedfromthepresynapticnerveterminals.
Thisdecreaseservesgenerallytoresetthe
sympathetictoneatalowerlevelandto
decreasearousal.
Dosage
UsualstartingdosageisO.lmgorallytwiceaday;
thedosagecanberaisedby0.3mgadaytoan
appropriatelevel.
SideEffects
Drymouth,drynessofeyes,fatigue,irritability,
sedation,dizziness,nausea,vomiting,hypo­
tensionandconstipation.
Nurse'sResponsibility
MonitorBP,thedrugshouldbewithheldifthe
patientbecomeshypotensive.

185. 182AGuidetoMentalHealthandPsychiatricNursing
Advisefrequentmouthrinsesandgoodoral
hygienefordrymouth.
Methylphenidate(Ritalin)
Methylphenidate,dextroamphetamineandpemo­
linearesympathomimetics.
Indications
•Attention-deficithyperactivitydisorder
•Narcolepsy
•Depressivedisorders
•Obesity
MechanismofAction
Sympathomimeticscausethestimulationof
alphaandbeta-adrenergicreceptorsdirectlyas
agonistsandindirectlybystimulatingtherelease
ofdopamineandnorepinephrinefrompre­
synapticterminals.Dextroamphetamineand
methylphenidatearealsoinhibitorsofcatecho­
laminereuptake,especiallydopaminereuptake
andinhibitorsofmonoaminooxidase.Thenet
resultoftheseactivitiesisbelievedtobethe
stimulationofseveralbrainregions.
Dosage
Startingdoseis5-10mgperdayorally,maximum
dailydoseis80mg/day.
SideEffects
Anorexiaordyspepsia,weightloss,slowed
growth,dizziness,insomniaornightmares,
dysphoricmood,ticsandpsychosis.
Nurse'sResponsibilities
•Assessmentalstatusforchangeinmood,level
ofactivity,degreeofstimulationandaggres­
siveness.
•Ensurethatpatientisprotectedfrominjury.
•Keepstimulilowandenvironmentasquietas
possibleto'discourageoverstimulation.
•Todecreaseanorexia,themedicationmaybe
administeredimmediatelyaftermeals.The
patientshouldbeweighedregularly(atleast
weekly)duringhospitalizationandathome
whileontherapywithCNSstimulants,due
tothepotentialforanorexia/weightlossand
temporaryinterruptionsofgrowthand
development.
•Topreventinsomniaadministerlastdoseat
least6hoursbeforebedtime..
•Inchildrenwithbehavioraldisordersadrug
'holiday'shouldbeattemptedperiodically
underthedirectionofthephysicianto
determineeffectivenessofthemedicationand
theneedforcontinuation.
•Ensurethatparentsareawareofthedelayed
effectsofRitalin.Therapeuticresponsemay
notbeseenfor2-4weeks;thedrugshouldnot
bediscontinuedforlackofimmediateresults.
•InformparentsthatOTC(over-the-counter)
medicationsshouldbeavoidedwhilethe
childisonstimulantmedication.SomeOTC
medications,particularlycoldandhayfever
preparationscontaincertainsympathomi­
meticagentsthatcouldcompoundtheeffects
ofthestimulantandcreatedruginteractions
thatmaybetoxictothechild.
•Ensurethatparentsareawarethatthedrug
shouldnotbewithdrawnabruptly.With­
drawalshouldbegradualandunderthe
directionofthephysician.
ElectroconvulsiveTherapy
Electroconvulsivetherapyisatypeofsomatic
treatmentfirstintroducedbyBiniandCerlettiin
April1938.From1980onwardsECTisbeing
consideredasauniquepsychiatrictreatment.
Electroconvulsivetherapyistheartificial
inductionofagrandma!seizurethroughthe
applicationofelectricalcurrenttothebrain.The
stimulusisappliedthroughelectrodesthatare
placedeitherbilaterallyinthefronto-temporal
region,orunilaterallyonthenon-dominantside
(rightsideofheadinaright-handedindividual).
ParametersofElectricalCurrentApplied
StandarddoseaccordingtoAmericanPsychiatric
Association,1978:

186. TherapeuticModalitiesinPsychiatry183
•Voltage-70-120volts.
•Duration-0.7-1.5seconds
TypeofSeizureProduced
•grandma!seizure-tonicphaselastingfor10
-15seconds.
•clonicphaselastingfor30-60seconds
MechanismofAction
Theexactmechanismofactionisnotknown.One
hypothesisstatesthatECTpossiblyaffectsthe
catecholaminepathwaysbetweendiencephalon
(fromwhereseizuregeneralizationoccurs)and
limbicsystem(whichmayberesponsibleformood
disorders),alsoinvolvingthehypothalamus.
TypesofECT
DirectECT:Inthis,ECTisgivenintheabsenceof
anesthesiaandmuscularrelaxation.Thisisnota
commonlyusedmethodnow.
ModifiedECT:HereECTismodifiedbydrug­
inducedmuscularrelaxationandgeneral
anesthesia.
FrequencyandTotalNumberofECT
Frequency:Threetimesperweekorasindicated.
Totalnumber:6to10;upto25maybepreferredas
indicated.
ApplicationofElectrodes
BilateralECT:Eachelectrodeisplaced2.5-4cm
(1-1V:zinch)abovethemidpoint,onalinejoining
thetragusoftheearandthelateralcanthusofthe
eye.
UnilateralECT:Electrodesareplacedonlyonone
sideofhead,usuallynon-dominantside(right
sideofheadinaright-handedindividual).
UnilateralECTissafer,withmuchfewerside­
effectsparticularlythoseofmemoryimpairment.
Indications
a.Majordepression:Withsuicidalrisk;with
stupor;withpoorintakeoffoodandfluids;
melancholiawithpsychoticfeatureswith
unsatisfactoryresponsetodrugsorwhere
drugsarecontraindicatedorhaveserious
side-effects.
b.Severecatatonia(functional):Withstupor;with
poorintakeoffoodandfluids;with
unsatisfactoryresponsetodrugtherapy,or
whendrugsarecontraindicatedorhave
seriousside-effects.
c.Severepsychosis(schizophreniaormania):With
riskofsuicide,homicideordangerofphysical
assault;withdepressivefeatures;with
unsatisfactoryresponsetodrugtherapy,or
whendrugsarecontraindicatedorhave
seriousside-effects.
d.Organicmentaldisorders:
•organicmooddisorders.
•organicpsychosis
e.Otherindications:ECTispreferredtoanti­
depressanttherapyinsomecases,suchasfor
clientswithcardiacdisease;whentricyclics
arecontraindicatedbecauseofthepotential
fordysarrythmiasandcongestiveheart
failure;andforpregnantwomen,inwhom
antidepressantsplacethefetusatriskfor
congenitaldefects.
Contraindications
AAbsolute:
•raisedICP(intracranialpressure)
B.Relative:
•cerebralaneurysm
•cerebralhemorrhage
•braintumor
•acutemyocardialinfarction
•congestiveheartfailure
•pneumoniaoraorticaneurysm
•retinaldetachment
ComplicationsofECT
Life-threateningcomplicationsofECTarerare.
ECTdoesnotcauseanybraindamage.
Fracturescansometimesoccurinelderly
patientswithosteoporosis.Inpatientswitha
historyofheartdisease,dysrhythmiasand
respiratoryarrestmayoccur.

187. 184AGuidetoMentalHealthandPsychiatricNursing
SideEffectsofECT
•Memoryimpairment.
•Drowsiness,confusionandrestlessness.
•Poorconcentration,anxiety.
•Headache,weakness/fatigue,backache,
muscleaches.
•Drynessofmouth,palpitations,nausea,
vomiting.
•Unsteadygait.
•Tonguebiteandincontinence.
ECTTeam
Psychiatrist,anesthesiologist,trainednursesand
aidesshouldbeinvolvedintheadministrationof
ECT.
TreatmentFacilities
Thereshouldbeasuiteofthreerooms:
1.Apleasant,comfortablewaitingroom(pre­
ECTroom).
2.ECTroom,whichshouldbeequippedwith
ECTmachineandaccessories,ananesthetic
appliance,suctionapparatus,facemasks,
oxygencylinderswithadjustableflowvalves,
curvedtonguedepressors,mouthgags,
resuscitationapparatusandemergencydrugs.
Thereshouldbeimmediateaccesstoa
defibrillator.
3.Awell-equippedrecoveryroom.
RoleoftheNurse
aPre-treatmentevaluation
•Detailedmedicalandpsychiatrichistory,
includinghistoryofallergies.
•Assessmentofpatient'sandfamily'sknow­
ledgeofindications,side-effects,therapeutic
effectsandrisksassociatedwithECT.
•Aninformedconsentshouldbetaken.Allay
anyunfoundedfearsandanxietiesregarding
theprocedure.
•Assessbaselinevitalsigns.
•Patientshouldbeonemptystomachfor4-6
hourspriortoECT.
•Withholdnightdosesofdrugs,which
increaseseizurethresholdlikediazepam,
barbituratesandanticonvulsants,
•Withholdoralmedicationsinthemorning.
•Headshampooinginthemorningsinceoil
causesimpedanceofpassageofelectricityto
brain.
•Anyjewellery,prosthesis,dentures,contact
lens,metallicobjectsandtightclothingshould
beremovedfromthepatient'sbody.
•EmptybladderandboweljustbeforeECT.
•Administrationof0.6mgatropineIMorSC
30minutesbeforeECT,orIVjustbeforeECT.
b.Intra-procedurecare
•PlacethepatientcomfortablyontheECTtable
insupineposition.
•Staywiththepatienttoallayanxietyandfear.
•Assistinadministeringtheanestheticagent
(thiopentalsodium3-5mg/kgbodyweight)
andmusclerelaxant(1mg/kgbodyweightof
succynylcholine).
•Sincethemusclerelaxantparalyzesall
musclesincludingrespiratorymuscles,patent
airwayshouldbeensuredandventilatory
supportshouldbestarted.
•Mouthgagshouldbeinsertedtoprevent
possibletonguebite.
•Theplace(s)ofelectrodeplacementshouldbe
cleanedwithnormalsalineor25percent
bicarbonatesolution,oraconductinggel
applied.
•Monitorvoltage,intensityanddurationof
electricalstimulusgiven.
•Monitorseizureactivityusingcuffmethod.
•100percentoxygenshouldbeprovided.
•Duringseizuremonitorvitalsigns,ECG,
oxygensaturation,EEG,etc.
•Recordthefindingsandmedicinesgivenin
thepatient'schart.
c.Post-procedurecare
•Monitorvitalsigns.
•Continueoxygenationtillspontaneous
respirationstarts.
•Assessforpost-ictalconfusionandrestless­
ness.
•Takesafetyprecautionstopreventinjury(side­
lyingpositionandsuctioningtoprevent
aspirationofsecretions,useofsiderailsto
preventfalls).

188. TherapeuticModalitiesinPsychiatry185
•Ifthereisseverepost-ictalconfusionandrest­
lessness,IVdiazepammaybeadministered.
•Reorientthepatientafterrecoveryandstay
withhimuntilfullyoriented.
•Documentanyfindingsasrelevantinthe
patient'srecord.
Psychosurgery
PsychosurgeryisdefinedbyAPA'sTaskForceas
"asurgicalintervention,toseverfibersconnecting
onepartofthebrainwithanother,ortoremove,
destroy,orstimulatebraintissue,withtheintent
ofmodifyingbehavior,thoughtormooddistur­
bances,forwhichthereisnounderlyingorganic
pathology."
Indications
•Severepsychiatricillness.
•Chronicdurationofillnessofabout10years.
•Persistentemotionaldistress.
•Failuretorespondtoallothertherapies.
•Highriskofsuicide.
MajorSurgicalProcedures
•Stereotacticsubcaudatetractotomy.
•Stereotacticlimbicleucotomy.
•Stereotacticbilateralamygdalotomy
Nursingcareforapatientundergoingpsycho­
surgeryisthesameasforanyneurosurgical
procedure.
PSYCHOLOGICAL THERAPIES
Thereareseveralkindsofpsychological
therapies:
•Psychoanalytictherapy
•Behaviortherapy
•Cognitivetherapy
•Hypnosis
•Abreactiontherapy
•Relaxationtherapies
•Individualpsychotherapy
•Supportivepsychotherapy
•Grouptherapy
•Familyandmaritaltherapy
PsychoanalyticTherapy
•Psychoanalysiswasfirstdevelopedby
SigmundFreudattheendofthe19thcentury.
Themostimportantindicationforpsycho­
analyticaltherapyisthepresenceoflong­
standingmentalconflicts,whichmaybe
unconsciousbutproducesymptoms.Theaim
ofthetherapyistobringallrepressedmaterial
toconsciousawarenesssothatthepatientcan
worktowardsahealthyresolutionofhis
problems,whicharecausingthesymptoms.
•Psychoanalysismakesuseoffreeassociation
anddreamanalysistoaffectreconstructionof
personality.Freeassociationreferstothever­
balizationofthoughtsastheyoccur,without
anyconsciousscreening.Thepsychoanalyst
searchesforpatternsinthematerialthatis
verbalizedandintheareasthatareuncons­
ciouslyavoided(suchareasareidentifiedas
resistances).
•Analysisofthepatient'sdreamshelpstogain
additionalinsightintohisproblemandthe
resistances.Thusdreamssymbolically
communicateareasofintrapsychicconflict.
•Thetherapistthenattemptstoassistthe
patienttorecognizehisintrapsychicconflicts
throughtheuseofinterpretation..
•Theprocessiscomplicatedbytheoccurrence
oftransferencereactions.Thisreferstothe
patient'sdevelopmentofstrongpositiveor
negativefeelingstowardstheanalyst,and
theyrepresentthepatient'spastresponsetoa
significantother,usuallyaparent.The
therapist'sreciprocalresponsetothepatient
iscalledcountertransference.Suchreactions
mustbehandledappropriatelybefore
progresscanbemade.
•Therolesofthepatientandpsychoanalyst
areexplicitlydefinedbyFreud.Thepatientis
anactiveparticipant,freelyrevealingall
thoughtsexactlyastheyoccuranddescribing
alldreams.Heisfrequentlyinarecumbent
positiononacouchduringtherapytoinduce
relaxation,whichfacilitatesfreeassociation.
Thepsychoanalystisashadow-person.He

189. 186AGuidetoMentalHealthandPsychiatricNursing
revealsnothingpersonal,nordoeshegive
anydirectionstothepatient.Hisverbal
responsesareforthemostpartbriefand
noncommittal,soasnottointerferewiththe
associativeflow.Hedepartsfromthisstyleof
communicationwhenaninterpretationof
behaviorismadetothepatient..
•Byterminationoftherapy,thepatientisable
toconducthislifeaccordingtoanaccurate
assessmentofexternalrealityandisalsoable
torelatetoothersuninhibitedbyneurotic
conflicts.
•Psychoanalyticaltherapyisalong-term
proposition.Thepatientisseenfrequently,
usuallyfivetimesaweek.Itisthereforetime­
consumingandexpensive.
(AlsoReferChapter4p.48Psychoanalytical
model).
BehaviorTherapy
Itisaformoftreatmentforproblemsinwhicha
trainedpersondeliberatelyestablishesaprofes­
sionalrelationshipwiththeclient,withthe
objectiveofremovingormodifyingexisting
symptomsandpromotingpositivepersonality,
growthanddevelopment.
Behaviortherapyinvolvesidentifying
maladaptivebehaviorsandseekingtocorrect
thesebyapplyingtheprinciplesoflearning
derivedfromthefollowingtheories:
•ClassicalconditioningmodelbyIvanPavlov
(1936)
•OperantconditioningmodelbyBFSkinner
(1953)
MajorAssumptionsofBehaviorTherapy
Basedontheabove-mentionedtheories,the
followingaretheassumptionsofbehavior
therapy:
•Allbehaviorislearned(adaptiveand
maladaptive).
•Humanbeingsarepassiveorganismsthatcan
beconditionedorshapedtodoanythingif
correctresponsesarerewardedorreinforced.
•Maladaptivebehaviorcanbeunlearnedand
replacedbyadaptivebehavioriftheperson
receivesexposuretospecificstimuliand
reinforcementforthedesiredadaptive
behavior.
•Behavioralassessmentisfocusedmoreonthe
currentbehaviorratherthanonhistorical
antecedents.
•Treatmentstrategiesareindividuallytailored.
Behaviortherapyisashortdurationtherapy,
therapistsareeasytotrainanditiscost-effective.
Thetotaldurationoftherapyisusually6-8weeks.
Initialsessionsaregivendailybutthelater
sessionsarespacedout.Unlikepsychoanalysis
wherethetherapistisashadowperson,in
behaviortherapyboththepatientandtherapist
areequalparticipants.Thereisnoattemptto
unearthanunderlyingconflictandthepatientis
notencouragedtoexplorehispast.
(Refer'Behaviormodel'onp.49forfurther
details)
BehaviorTechniques
(A)SystematicdesensitizationItwasdevelopedby
JosephWolpe,basedonthebehavioralprinciple
ofcounterconditioning.Inthispatientsattaina
stateofcompleterelaxationandarethenexposed
tothestimulusthatelicitstheanxietyresponse.
Thenegativereactionofanxietyisinhibitedby
therelaxedstate,aprocesscalledreciprocal
inhibition.
Itconsistsofthreemainsteps:
1.Relaxationtraining
2.Hierarchyconstruction
3.Desensitizationofthestimulus
1.Relaxationtraining:Therearemanymethods
whichcanbeusedtoinducerelaxation,someof
themare:
•Jacobson'sprogressivemusclerelaxation
•Hypnosis
•Meditationoryoga
•Mentalimagery
•Biofeedback
2.Hierarchyconstruction:Herethepatientis
askedtolistalltheconditionswhichprovoke
anxiety.Thenheisaskedtolistthemina
descendingorderofanxietyprovocation.

190. TherapeuticModalitiesinPsychiatry187
3.Desensitizationofthestimulus:Thiscan
eitherbedoneinrealityorthroughimagination.
Atfirst,thelowestiteminhierarchyisconfronted.
Thepatientisadvisedtosignalwheneveranxiety
isproduced.Witheachsignalheisaskedtorelax.
Afterafewtrials,patientisabletocontrolhis
anxietygradually.
Indications:
Phobias
Obsessions
Compulsions
Certainsexualdisorders
B.Flooding:Thepatientisdirectlyexposedtothe
phobicstimulus,butescapeismadeimpossible.
Byprolongedcontactwiththephobicstimulus,
thetherapist'sguidanceandencouragementand
hismodelingbehaviorreduceanxiety.
Indications:Specificphobias
C.Aversiontherapy:Pairingofthepleasant
stimuluswithanunpleasantresponse,sothat
eveninabsenceoftheunpleasantresponsethe
pleasantstimulusbecomesunpleasantby
association.Punishmentispresentedimme­
diatelyafteraspecificbehavioralresponseand
theresponseiseventuallyinhibited.
Unpleasantresponseisproducedbyelectric
stimulus,drugs,socialdisapprovaloreven
fantasy.
Indications:
Alcoholabuse
Paraphilias
Homosexuality
Transvestism.
D.Operantconditioningproceduresforincreasing
adaptivebehavior
1.Positivereinforcement:Whenabehavioral
responseisfollowedbyagenerallyrewarding
eventsuchasfood,praiseorgifts,ittendsto
bestrengthenedandoccursmorefrequently
thanbeforethereward.Thistechniqueisused
toincreasedesiredbehavior.
2.Tokeneconomy:Thisprograminvolvesgiving
tokenrewardsforappropriateordesired
targetbehaviorsperformedbythepatient.The
tokencanlaterbeexchangedforother
rewards.Forexampleoninpatienthospital
wards,patientsreceivearewardforperfor­
mingadesiredbehavior,suchastokenswhich
theymayusetopurchaseluxuryitemsor
certainprivileges.
E.Operantconditioningprocedurestoteachnew
behavior
1.Modeling:Modelingisamethodofteaching
bydemonstration,whereinthetherapist
showshowaspecificbehavioristobe
performed.Inmodelingthepatientobserves
otherpatientsindulgingintargetbehaviors
andgettingrewardsforthosebehaviors.This
willmakethepatientrepeatthesamebe­
haviorandearnrewardsinthesame
manner.
2.Shaping:Inshapingthecomponentsofa
particularskill,thebehaviorisreinforcedstep
bystep.Thetherapiststartsshapingby
reinforcingtheexistingbehavior.Onceitis
establishedhereinforcestheresponseswhich
areclosesttothedesiredbehavior,andignores
theotherresponses.
Forexample,toestablisheye-to-eye
contact,thetherapistsitsoppositethepatient
andreinforceshimevenifhemoveshis
upperbodytowardshim.Oncethisis
established,hereinforcestheperson's
headmovementinhisdirectionandthis
procedurecontinuestilleye-to-eyecontactis
established.
3.Chaining:Chainingisusedwhenaperson
failstoperformacomplextask.Thecomplex
taskisbrokenintoanumberofsmallsteps
andeachstepistaughttothepatient.In
forwardchainingonestartswiththefirststep,
goesontothesecondstep,thentothethird
andsoon.Inbackwardchaining,onestarts
withthelaststepandgoesontothenextstep
inabackwardfashion.Backwardchainingis
foundtobemoreeffectiveintrainingthe
mentallydisabled.

191. 188AGuidetoMentalHealthandPsychiatricNursing
F.Operantconditioningproceduresfordecreasing
maladaptivebehavior
1.Extinction/Ignoring:Extinctionmeans
removalofattentionrewardspermanently,
followingaproblembehavior.Thisincludes
actionslikenotlookingatthepatient,not
talkingtothepatient,orhavingnophysical
contactwiththepatientetc,followingthe
problembehavior.
Thisiscommonlyusedwhenpatient
exhibitsoddbehavior.
2.Punishment:Aversivestimulus(punishment)
ispresentedcontingentupontheundesirable
response.Thepunishmentprocedureshould
beadministeredimmediatelyandconsistently
followingtheundesirablebehaviorwithclear
explanation.
Differentialreinforcementofanadaptive
ordesirablebehaviorshouldalwaysbeadded
whenapunishmentisbeingusedfor
decreasinganundesirablebehavior.Other­
wisetheproblembehaviorstendtoget
maintainedbecauseofthelackofadaptive
behaviorsandskilldefect.
3.Timeout:Timeoutmethodincludesremoving
thepatientfromtherewardortherewardfrom
thepatientforaparticularperiodoftime
followingaproblembehavior.Thisisoften
usedinthetreatmentofchildhooddisorders.
Forexample,thechildisnotallowedtogoout
ofthewardtoplayifhefailstocompletethe
givenwork.
4.Restitution(Over-correction):Restitution
meansrestoringthedisturbedsituationtoa
statethatismuchbetterthanwhatitwasbefore
theoccurrenceoftheproblembehavior.
Forexample,ifapatientpassesurinein
thewardhewouldberequiredtonotonly
cleanthedirtyareabutalsomoptheentire/
largerareaofthefloorintheward.
5.Responsecost:Thisprocedureisusedwith
individualswhoareontokenprogramsfor
teachingadaptivebehavior.Whenundesir­
ablebehavioroccurs,afixednumberoftokens
orpointsaredeductedfromwhatthe
individualhasalreadyearned.
G.Assertivenessandsocialskilltraining:Assertive
trainingisabehaviortherapytechniqueinwhich
thepatientisgiventrainingtobringaboutchange
inemotionalandotherbehavioralpatternby
beingassertive.Clientisencouragednottobe
afraidofshowinganappropriateresponse,
negativeorpositive,toanideaorsuggestion.
Assertivebehaviortrainingisgivenbythe
therapist,firstbyroleplayandthenbypractice
inareallifesituation.Attentionisfocusedon
moreeffectiveinterpersonalskills.
Socialskillstraininghelpstoimprovesocial
mannerslikeencouragingeyecontact,speaking
appropriately,observingsimpleetiquette,and
relatingtopeople.
CognitiveTherapy
Cognitivetherapyisapsychotherapeutic
approachbasedontheideathatbehavioris
secondarytothinking.Ourmoodsandfeelings
areinfluencedbyourthoughts.Self-defeatingand
self-depreciatingpatternsofthinkingresultin
depressedmood.Thetherapisthelpsthepatient
bycorrectingthisdistortedwayofthinking,
feelingsandbehavior.
Thecognitivemodelofdepressionincludes
thecognitivetriad:
1.Anegativeviewaboutself
2.Anegativeviewabouttheenvironmentand
3.Anegativeviewaboutthefuture
Thesenegativethoughtsaremodifiedto
improvethedepressivemood.Cognitivetherapy
isusedforthetreatmentofdepression,anxiety
disorder,panicdisorder,phobicdisorderand
eatingdisorders.
Hypnosis
Theword'hypnotism'wasfirstusedbyJames
Braidinthe19thcentury.Hypnosisisan
artificiallyinducedstateinwhichthepersonis
relaxedandunusuallysuggestible.Hypnosiscan
beinducedinmanyways,suchasbyusinga
fixedpointforattention,rhythmicmonotonous
instructions,etc.

192. TherapeuticModalitiesinPsychiatry189
ChangesthatoccurduringHypnosis
•Thepersonbecomeshighlysuggestibletothe
commandsofthehypnotist.
•Thereisanabilitytoproduceorremove
symptomsorperceptions.
•Dissociationofapartofbodyoremotions.
•Amnesiafortheeventsthatoccurredduring
thehypnoticstate.
Techniques
Patientiseithermadetoliedownonabedorsit
inachair.Heisaskedtogazefixedlyonaspot.
Therapistmakesmonotonoussuggestionsof
relaxationandsleep.Thepatienthoweverisnot
asleepandcanhearwhatisbeingsaid,answer
questionsandobeyinstructions.
Thistherapyisusefulin:
•Abreactionofpastexperiences.
•Psychosomaticdisorders.
•Conversionanddissociativedisorders.
•Eatingdisorders.
•Habitdisordersandanxietydisorders.
AbreactionTherapy
Abreactionisaprocessbywhichrepressed
material,particularlyapainfulexperienceor
conflictisbroughtbacktoconsciousness.The
personnotonlyrecallsbutalsorelivesthe
material,whichisaccompaniedbythe
appropriateemotionalresponse.Itismostuseful
inacuteneuroticconditionscausedbyextreme
stress(Post-traumaticstressdisorder,hysteria
etc).
Althoughabreactionisanintegralpartof
psychoanalysisandhypnosis,itcanalsobeused
independently.
Method
Abreactioncanbebroughtaboutbystrong
encouragementtorelivethestressfulevents.The
procedureisbegunwithneutraltopicsatfirst,
andgraduallyapproachesareasofconflict.
Althoughabreactioncanbedonewithorwithout
theuseofmedication,theprocedurecanbefacili­
tatedbygivingasedativedrugintravenously.A
safemethodistheuseofthiopentonesodiumi.e.
500mgdissolvedin10ccofnormalsaline.Itis
infusedataratenofasterthan1cc/minuteto
preventsleepaswellasrespiratorydepression.
RelaxationTherapies
Relaxationproducesphysiologicaleffectsoppo­
sitethoseofanxiety:slowedheartrate,increased
peripheralbloodflowandneuromuscular
stability.
Therearemanymethodswhichcanbeused
toinducerelaxation.
Jacobson'sProgressiveMuscularRelaxation
Patientsrelaxmajormusclegroupsinfixedorder,
beginningwiththesmallmusclegroupsofthe
feetandworkingcephaladorviceversa.
Hypnosis
MentalImagery
Itisarelaxationmethodinwhichpatientsare
instructedtoimaginethemselvesinaplace
associatedwithpleasantrelaxedmemories.Such
imagesallowpatientstoenterarelaxedstateor
experienceafeelingofcalmnessandtranquility.
UseofTape-recordedExercisesorInstructions
Whichallowspatientstopracticerelaxationon
theirown.
YogaorMeditation
Itisconcentratingonthespiritbyusingcertain
posturestopreparethebodytositmotionless,
remainalertandfocusononeparticularpoint.
Yogaishighlyusefulinreducingstressand
treatinganxiety.
Bio-feedback
Bio-feedbackisbasedontheideathattheauto­
nomicnervoussystemcancomeundervoluntary
controlthroughoperantconditioning.Thusit
helpspeopletocontrolusuallyinvoluntary
physiologicalfunctionssoastochangethem,for

193. 190AGuidetoMentalHealthandPsychiatricNursing
instance,byrelaxing.Peoplelearntocontrolthese
functionsbyhearingorseeingsignalsfrom
instrumentsthatproduceinformationabout
variousmeasuressuchasmuscletension,blood
pressure,etc.Thisfeedbackhelpsthepatientto
controlsuchresponses.
Usesofbio-feedbackincludetreatmentof
enuresis,andtreatmentofahostofailments
broughtonbystresssuchasmigraineheadaches,
tensionheadaches,idiopathichypertension,
cardiacproblems,etc.
IndividualPsychotherapy
Psychotherapycanbedefinedasthetreatment
forproblemsofanemotionalnature,inwhicha
trainedpersondeliberatelyestablishesapro­
fessionalrelationshipwiththepatienttoremove,
modifyorretardexistingsymptoms,mediate
disturbedpatternsofbehaviorandpromote
positivepersonalitygrowthanddevelopment.
Individualpsychotherapyisconductedona
one-to-onebasis,i.e.thetherapisttreatsoneclient
atatime.Thepatientisencouragedtodiscover
forhimselfthereasonsforhisbehavior.The
therapistlistenstothepatientandoffers
explanationandadvicewhennecessary.Bythis
hehelpsthepatienttocometoagreater
understandingofhimselfandtofindawayof
dealingwithhisproblems.
Indications:Stress-relateddisorders,alcoholand
drugdependence,sexualdisordersandmarital
disharmony.
SupportivePsychotherapy
Inthis,thetherapisthelpsthepatienttorelieve
emotionaldistressandsymptomswithoutpro­
bingintothepastandchangingthepersonality.
Heusesvarioustechniquessuchas:
•Ventilation:Itisafreeexpressionoffeelingsor
emotions.Patientisencouragedtotalkfreely
whatevercomestohismind.
•Environmentalmodification/manipulation:
Improvingthewell-beingofmentalpatients
bychangingtheirlivingcondition.
•Persuasion:Herethetherapistattemptsto
modifythepatient'sbehaviorbyreasoning.
•Re-education:Educationtothepatient
regardinghisproblems,waysofcoping,etc.
•Reassurance
GroupTherapy
Grouppsychotherapyisatreatmentinwhich
carefullyselectedpeoplewhoareemotionallyill
meetinagroupguidedbyatrainedtherapist,
andhelponeanothereffectpersonalitychange.
Selection
•Homogeneousgroups
•Adolescentsandpatientswithpersonality
disorders
•Familiesandcoupleswherethesystemneeds
change
Contraindications
•Antisocialpatients
•Activelysuicidalorseverelydepressed
patients
•Patientswhoaredelusionalandwhomay
incorporatethegroupintotheirdelusional
system
GroupSize
Optimalsizeforgrouptherapyis8to10members.
FrequencyandLengthofSessions
Mostgrouppsychotherapistsconductgroup
sessionsonceaweek;eachsessionmaylastfor
45minutesto1hour.
ApproachestoGroupTherapy
•Thetherapist'sroleisprimarilythatofa
facilitator;heshouldprovideasafe,
comfortableatmosphereforself-disclosure
•Focusonthe"hereandnow"
•Useanytransferencesituationstodevelop
insightintotheirproblems
•Protectmembersfromverbalabuseorfrom
scapegoating
•Wheneverappropriate,providepositive
reinforcement,thisgivesegosupportand
encouragesfuturegrowth

194. TherapeuticModalitiesinPsychiatry191
•Handlecircumstantialpatients,hallucinating
anddelusionalpatientsinamannerthat
protectstheself-esteemoftheindividualand
alsosetslimitsonthebehaviorsoastoprotect
othergroupmembers
•Developabilitytorecognizewhenagroup
memberis"fragile";heshouldbeapproached
inagentle,supportiveandnon-threatening
manner
•Usesilenceeffectivelytoencourageintro­
spectionandfacilitateinsight
•Laughterandamoderateamountofjoking
canactasasafetyvalveandattimescan
contributetogroupcohesiveness
•Role-playingmayhelpamemberdevelop
insightintothewaysinwhichherelatesto
others
TherapeuticFactorsInvolvedinGroupTherapy
Theseinvolvesharingexperiences,supporttoand
fromgroupmembers,socialization,imitationand
interpersonallearning.
Sharingexperience:Thishelpsthepatientsto
realizethattheyarenotisolatedandthatothers
alsohavesimilarexperiencesandproblems.
Hearingfromotherpatientsthattheyhaveshared
experiencesisoftenmoreconvincingandhelpful
thanreassurancefromthetherapist.
Supporttoandfromgroupmembers:Receivinghelp
fromothergroupmemberscanbesupportiveto
thepersonhelped.Thesharingactionofbeing
mutuallysupportingisanaspectofgroup
cohesivenessthatcanprovideasenseofbelonging
forpatientswhofeelisolatedintheireveryday
lives.
Socialization:Itisacquisitionofsocialskills(for
e.g.maintainingeyecontact)withinagroup
throughcommentsthatmembersprovideabout
oneanother'sdeficienciesinsocialskills.This
processcanbehelpedbytryingoutnewwaysof
interactingwithinthesafetyofthegroup.
Imitation:Itislearningfromobservingand
adaptingthebehaviorsofothergroupmembers.
Ifthegroupisrunwell,patientsimitatethe
adaptivebehaviorsofothergroupmembers.
Interpersonallearning:Itreferstolearningabout
difficultiesinrelationshipsbyexaminingthe
interactionofindividualswiththeothermembers
ofthegroup.
SomeTechniquesUsefulinGroupTherapy
•Reflectingorrewardingcommentsofgroup
members
•Askingforgroupreactiontoonemember's
statement
•Askingforindividualreactiontoonemember's
statement
•Pointingoutanysharedfeelingswithinthe
group
•Summarizingvariouspointsattheendof
session
Inconclusion,onemaysaythatgrouptherapy
playsamajorroleintherehabilitationofthe
mentallyillindividual.Grouptherapygivesan
opportunityforimmediatefeedbackfroma
patient'speerandachanceforbothpatientand
therapisttoobservethepatient'spsychological,
emotionalandbehavioralresponsetowardsa
varietyofpeople.Thusithelpsthepatientto
mastercommunicationandinterpersonalskills,
problemsolving,decisionmakingand
assertivenessskills,thusenablinghimtore-enter
thesociety'smainstreamwithagreaterdegreeof
confidence.
Psychodrama
Psychodramaisaspecializedtypeofgroup
therapythatemploysadramaticapproachin
whichpatientsbecomeactorsinlife-situation
scenarios.Thegoalistoresolveinterpersonal
conflictsinalessthreateningatmospherethan
thereal-lifesituationwouldpresent.
Inpsychodramathepatientisbroughtdirectly
intothesituationasanactiveparticipant.The
directorco-ordinatestheprocesssothatthegroup
andtheprotagonistreceivemaximalbenefit.Other
groupmembersactasauxiliaryegosandplay
therolesofsignificantotherswithwhom
relationshipsarebeingexplored.

195. 192AGuidetoMentalHealthandPsychiatricNursing
Theprimaryadvantageofpsychodramaisits
directaccesstoreenactingpainfulsituationsso
thatthepainfulemotionsassociatedwiththem
canbereworked,withthepotentialforspon­
taneouslylearningnewresponsesinasafe
therapeuticenvironment.
FamilyandMaritalTherapy
Familytherapyisthatbranchofpsychiatrywhich
seesanindividual'spsychiatricsymptomsas
inseparablyrelatedtothefamilyinwhichhelives.
Thusthefocusoftreatmentisnottheindividual,
butthefamily.Today,mostfamilytheorists
identifytheindividual'sproblemsasasymptom
oftroublewithinthefamily.
Indications
Familytherapyisindicatedwheneverthereare
relationalproblemswithinafamilyormarital
unit,whichcanoccurinalmostalltypesof
psychiatricproblems,includingpsychoses,reac­
tivedepression,anxietydisorders,psychosomatic
disorders,substanceabuseandvariouschildhood
psychiatricproblems.
ComponentsofTherapy
•Assessmentoffamilystructure,roles,boun­
daries,resources,communicationpatterns
andproblemsolvingskills
•Teachingcommunicationskills
•Teachingproblemsolvingskills
•Writingabehavioralmaritalcontract
•Homeworkassignments
ClientSelection
•Familiesmaybereferredfortreatmentby,
privatephysicians,andagenciessuchasthe
schoolsystem,welfareboard,paroleofficers,
andjudges.
•Somefamiliesarereferredfortherapyfrom
emergencyroompsychiatricservicesaftera
visitcausedbyacrisisinthefamily,suchasa
drugoverdose.
•Ondischargefromapsychiatrichospital,a
clientandhisfamilymaybereferredforfamily
therapy,aspartoffollowupservices.
•Familytherapyisthetreatmentofchoicewhen
thereisamaritalproblemorsiblingconflict;
familytherapymayalsobeindicatedwhen
problemsarecausedbyusingonechildasthe
scapegoat.
•Situationalcrisessuchasthesuddendeathof
afamilymember,andmaturationalcrises
suchasbirthofthefirstchild,maycause
sufficientstresstowarrantfamilytherapy.
TypesofFamilyTherapy
IndividualFamilyTherapy
Inindividualfamilytherapyeachfamilymember
hasasingletherapist.Thewholefamilymaymeet
occasionallywithoneortwoofthetherapiststo
seehowthemembersarerelatingtooneanother
andworkoutspecificissuesthathavebeen
definedbyindividualmembers.
ConjointFamilyTherapy
Themostcommontypeoffamilytherapyisthe
single-familygroup,orconjointfamilytherapy.
Thenuclearfamilyisseen,andtheissuesand
problemsraisedbythefamilyaretheones
addressedbythetherapist.Thewayinwhichthe
familyinteractsisobservedandbecomesthefocus
oftherapy.Thetherapisthelpsthefamilydeal
moreeffectivelywithproblemsastheyariseand
aredefined.
CouplesTherapy
Couplesareoftenseenbythetherapisttogether.
Thecouplemaybeexperiencingdifficultiesin
theirmarriage,andintherapytheyarehelpedto
worktogethertoseekaresolutionfortheirprob­
lems.Familypatterns,interactionandcommuni­
cationstyles,andeachpartner'sgoals,hopesand
expectationsareexaminedintherapy.Thisexami­
nationenablesthecoupletofindacommonground
forresolvingconflictsbyrecognizingandrespec­
tingeachother'ssimilaritiesanddifferences.
MultipleFamilyGroupTherapy
Inmultiplefamilygrouptherapy,fourorfive
familiesmeetweeklytoconfrontanddealwith

196. TherapeuticModalitiesinPsychiatry193
problemsorissuestheyhaveincommon.Ability
orinabilitytofunctionwellinthehomeand
community,fearoftalkingtoorrelatingtoothers,
abuse,anger,neglect,thedevelopmentofsocial
skills,andresponsibilityforoneselfaresomeof
theissuesonwhichthesegroupsfocus.The
multiplefamilygroupbecomesthesupportfor
allthefamilies.Thenetworkalsoencourageseach
persontoreachoutandformnewrelationships
outsidethegroup.
MultipleImpactTherapy
Inmultipleimpacttherapy,severaltherapists
cometogetherwiththefamiliesinacommunity
setting.Theylivetogetheranddealwithpertinent
issuesforeachfamilymemberwithinthecontext
ofthegroup.Multipleimpacttherapyissimilar
tomultiplefamilygrouptherapyexceptthatitis
moreintenseandtime-limited.Likemultiple
familygrouptherapy,itfocusesondeveloping
skillsorworkingtogetherasafamilyandwith
otherfamilies.
NetworkTherapy
Networktherapyisconductedinpeople'shomes.
Allindividualsinterestedorinvestedina
problemorcrisisthataparticularpersonor
personsinafamilyareexperiencingtakepart.
Thisgatheringincludesfamily,friends,
neighbors,professionalgroupsorpersons,and
anyoneinthecommunitywhohasaninvestment
intheoutcomeofthecurrentcrisis.Peoplewho
formthenetworkgenerallyknoweachotherand
interactonaregularbasisineachother'slives.
Thusanetworkmayincludeasmanyas40to60
people.
Therewardsaregreatwhenallthepeople
involvedmobilizeenergyformanagementofthe
problem.Thepowerisinthenetworkitself.The
answerstoeachproblemcomefromthenetwork
andhowpeopleinthenetworkdecidetomanage
eachissueasitarises.Thetherapistsserveasa
guidetoclarifyissues,reinforcetheimportance
ofandneedforthenetworktowarditsmembers
collectivelyandindividually,andassistinthe
developmentandeffectivemanagementinthe
evolutionoftheproblemresolution.
MILIEUTHERAPY
Thetherapeuticmilieuisanenvironmentthatis
structuredandmaintainedasanideal,dynamic
settinginwhichtoworkwithclients.Thismilieu
includessafephysicalsurroundings,allthe
treatmentteammembers,andotherclients.Itis
supportedbyclearandconsistentlymaintained
limitsandbehavioralexpectations.
Atherapeuticsettingshouldminimize
environmentalstresssuchasnoiseandconfu­
sion,andphysicalstress.Itprovidesachancefor
restandnurturanceofself,atimetofocusonthe
developmentofstrengths,andanopportunityto
learntoidentifyalternativesorsolutionsto
problemsandtolearnaboutthepsychodynamics
ofthoseproblems.
Atherapeuticmilieuisa"safespace,"anon­
punitiveatmosphereinwhichcaringisabasic
factor.Inthisenvironment,confrontationmaybe
apositivetherapeutictoolthatcanbetolerated
bytheclient.Nursesandtreatmentteammembers
shouldbeawareoftheirownrolesinthis
environment,maintainingstabilityandsafety,but
minimizingauthoritarianbehavior.Clientsare
expectedtoassumeresponsibilityforthemselves
within·thestructureofthemilieuasmuchas
possible.Feedbackfromotherclientsandthe
sharingoftasksordutieswithinthetreatment
programfacilitatetheclient'sgrowth.
Thevariouscomponentsoftherapeuticmilieu
include:
MaintainingSafeEnvironment
Thenursingstaffshouldfollowthefacility's
policieswithregardtopreventionofroutinesafety
hazardsandsupplementthesepoliciesas
necessary.Forexample:
•Disposeofallneedlessafelyandoutofreach
ofclients.
•Restrictormonitortheuseofmatchesand
lighters.
•Donotallowsmoking.

197. 194AGuidetoMentalHealthandPsychiatricNursing
•Removemouthwash,aftershavelotionsand
soforth,ifsubstanceabuseissuspected.
•Listedbelowarethemostrestrictivemeasures
tobeusedonaunitonwhichclientswhoare
exhibitingbehaviordirectlythreateningor
harmfultothemselvesorothersmaybepre­
sent.Thesemeasuresmaybemodifiedbased
ontheassessmentoftheclient'sbehavior:
•immediatelyontheclient'sadmission,
searchtheclientandalloftheclient's
belongingsandremovepotentially
dangerousitems,suchaswire,clothes
hangers,ropes,belts,safetypins,scissors
andothersharpobjects,weapons,and
medications;keepthesebelongingsina
designatedplaceinaccessibletotheclient,
•besuremirrors,ifglass,aresecurely
fastenedandnoteasilybroken
•keepsharpobjects(e.g.scissors,pocket
knives,knittingneedles)outofreachof
clientsandallowtheiruseonlywith
supervision;useelectricshaverswhen
possible(disposablerazorsareeasily
brokentoaccessblades)
•identifypotentialweapons(e.g.mop
handles,hammers)anddangerous
equipment(e.g.electricalcords,scalpels),
andkeepthemoutoftheclient'sreach
•donotleavecleaningfluids,bleach,mops
andtools,unattendedinclie~tcareareas
•donotleavemedicinesunattendedor
unlocked
•keepkeys(tounitdoor,medicines)onyour
personatalltimes
•beawareofitemsthatareharmfulifinges­
ted,forexample,mercuryinmanometers
•searchpackagesbroughtinbyvisitors,
explainthereasonforsuchrulesbriefly,
anddonotmakeanyexceptions
TheTrustRelationship
Oneofthekeystoatherapeuticenvironmentis
theestablishmentoftrust.Boththeclientandthe
nursemusttrustthattreatmentisdesirableand
productive.Trustisthefoundationofa
therapeuticrelationship,andlimit-settingand
consistencyareitsbuildingblocks.
BuildingSelf-esteem
Strategiestohelpbuildorenhanceself-esteem
mustbeindividualizedandbuiltonhonestyand
ontheclient'sstrengths.Somegeneralsugges­
tionsare:
•Setandmaintainlimits.
•Accepttheclientasaperson.
•Benon-judgmentalatalltimes.
•Structuretheclient'stimeandactivities.
•Haverealisticexpectationsoftheclientand
makethemcleartotheclient.
•Initiallyprovidetheclientwithtasks,
responsibilitiesandactivitiesthatcanbeeasily
accomplished;advancetheclienttomore
difficulttasksasheprogresses.
•Praisetheclientforhisaccomplishments
howeversmall,givingsincereappropriate
feedbackformeetingexpectations,completing
tasks,fulfillingresponsibilities,andsoon.
•Neverflattertheclient.
•Useconfrontationjudiciouslyandina
supportivemanner;useitonlywhentheclient
cantolerateit.
•Allowtheclienttomakehisowndecisions
wheneverpossible.Iftheclientispleasedwith
theoutcomeofhisdecision,pointoutthathe
wasresponsibleforthedecisionandgive
positivefeedback.
•Iftheclientisnotpleasedwiththeoutcome,
pointoutthattheclientlikeeveryonecan
makeandsurvivemistakes,thenhelpthe
clientidentifyalternativeapproachestothe
problem;givepositivefeedbackfortheclient's
takingresponsibilityforproblemsolvingand
forhisefforts.
Limit-setting
Settingandmaintaininglimitsareintegraltoa
trustrelationshipandtoatherapeuticmilieu.
Beforestatingalimitexplainthereasonsforlimit­
setting.Somebasicguidelinesforeffectivelyusing
limitsare:

198. TherapeuticModalitiesinPsychiatry195
•Statetheexpectationsorthelimitasclearly,
directlyandsimplyaspossible.
•Theconsequencethatwillfollowtheclient's
exceedingthelimitalsomustbeclearlystated
attheoutset.
•Theconsequencesshouldimmediatelyfollow
theclient'sexceedingthelimitandmustbe
consistent,bothovertime(eachtimethelimit
isexceeded)andamongstaff(eachstaff
membermustenforcethelimit).
•Consequencesareessentialtosettingand
maintaininglimits,theyarenotanoppor­
tunitytobepunitivetoaclient.
Inconclusion,thenurseworkswithother
healthprofessionalsinaninterdisciplinaryteam;
Theinterdisciplinaryteamworkswithinamilieu
thatisconstructedasatherapeuticenvironment,
withtheaimofdevelopingaholisticviewofthe
clientandprovidingeffectivetreatment.
THERAPEUTICCOMMUNITY
Theconceptoftherapeuticcommunitywasfirst
developedbyMaxwellJonesin1953.Hewrotea
bookentitled"SocialPsychiatry"whichwasfirst
publishedinEngland.Lateronwhenitwas
publishedintheUnitedStates,itstitlewas
changedto"TherapeuticCommunity."
Definition
StuartandSundeendefinedtherapeuticcom­
munityas"atherapyinwhichpatient'ssocial
environmentwouldbeusedtoprovidea
therapeuticexperienceforthepatientbyinvolving
himasanactiveparticipantinhisowncareand
thedailyproblemsofhiscommunity."
Objectives
•Tousepatient'ssocialenvironmenttoprovide
atherapeuticexperienceforhim.
•Toenablethepatienttobeanactiveparticipant
inhisowncareandbecomeinvolvedindaily
activitiesofhiscommunity.
•Tohelppatientstosolveproblems,plan
activitiesandtodevelopthenecessaryrules
andregulationsforthecommunity.
•Toincreasetheirindependenceandgaincon­
trolovermanyoftheirownpersonalactivities.
•Toenablethepatientsbecomeawareofhow
theirbehavioraffectsothers.
ElementsofTherapeuticCommunity
•Freecommunication
•Sharedresponsibilities
•Activeparticipation
•Involvementindecisionmaking
•Understandingofroles,responsibilities,
limitationsandauthorities
ComponentsofTherapeuticCommunity
DailyCommunityMeetings
•Thesemeetingsarecomposedof60-90
patients.Alllevelsofunitstaffareinvolved,
includingadministrativepersonnel.Acute
patientsarenotinvolvedinthemeetings.
•Meetingsshouldbeheldregularlyfor60
minutes.
•Discussionshouldfocusmainlyonday-to­
daylifeintheunit.
•Duringdiscussionspatients'feelingsand
behaviorsareexaminedbyothermembers.
•Frankdiscussionsareencouraged,thesemay
takeplacewithmuchoutpouringofemotions
andanger
PatientGovernmentorWardCouncil
•Thepurposeofpatientgovernmentistodeal
withpracticalunitdetailssuchashouse­
keepingfunctions,activityplanningand
privileges.
•Agroupof5-6patientswillhavespecificres­
ponsibilities,suchashousekeeping,physical
exercise,personalhygiene,mealdistribution,
agrouptoobservesuicidalpatients,etc.Staff
membersshouldbeavailablealways.
•Alldecisionsshouldbefedbacktothe
communitythroughthecommunitymeetings
StaffMeetingsorReview
Astaffmeetingshouldbeheldfollowingeach
communitymeeting(Patientsareexcludedand

199. 196AGuidetoMentalHealthandPsychiatricNursing
onlystaffarepresent).Inthismeetingthestaff
wouldexaminetheirownresponses,expecta­
tions,andprejudices.
LivingandLearningOpportunities
Learningopportunitiesaretobeprovidedwithin
thesocialmilieu,whichshouldproviderealistic
learningexperiencesforthepatients.
AdvantagesofTherapeuticCommunity
•Patientdevelopsharmoniousrelationships
withothermembersofthecommunity.
•Gainsself-confidence.
•Developsleadershipskills.
•Learnstounderstandandsolveproblemsof
selfandothers.
•Becomessocio-centric.
•Learnstoliveandthinkcollectivelywiththe
membersofthecommunity.
•Lastlytherapeuticcommunityprovides
opportunitiestoparticipateintheformulation
ofhospitalrulesandregulationsthataffect
patient'spersonallibertieslikebedtime,meal
time,weekendpermission,controlofradioor
TV,socialactivities,latenightprivileges,etc.
DisadvantagesofTherapeuticCommunity
•Roleblurringbetweenstaffandpatient.
•Groupresponsibilitycaneasilybecome
nobody'sresponsibility.
•Individualneedsandconcernsmaynotbe
met.
•Patientmayfindthetransitiontocommunity
difficult
RoleoftheNurse
•Providingandmaintainingasafeandconflict
freeenvironmentthroughrolemodelingand
groupleadership.
•Sharingofresponsibilitieswithpatients.
•Encouragingpatienttoparticipateindecision-
makingfunctions.
•Assistingpatientstoassumeleadershiproles.
•Givingfeedback.
•Carryingoutsupervisoryfunctions.
Inconclusion,therapeuticcommunityisan
approachwhichis:
•Democraticasopposedtohierarchial.
•Rehabilitativeratherthancustodial.
•Permissiveinsteadoflimitedandcontrolled.
ACTIVITYTHERAPY
Activitytherapiesincludeoccupationaltherapy,
recreationaltherapy,educationaltherapy,play
therapy,musictherapy,dancetherapy,andart
therapy.
Aims
•Toassisttheclientinmakingatransitionfrom
sickroletobecomingacontributingmember
ofsociety.
•Toassistindiagnosticandpersonality
evaluation.
•Toenhancepsychotherapyandother
psychotherapeuticmeasures(theactivity
prescribedfortheclientoftenprovidesa
nonverbalmeansfortheclienttoexpressand
resolvehisfeelings),
OccupationalTherapy
Occupationaltherapyistheapplicationofgoal­
oriented,purposefulactivityintheassessment
andtreatmentofindividualswithpsychological,
physicalordevelopmentaldisabilities.
Goal
Themaingoalistoenablethepatienttoachievea
healthybalanceofoccupationsthroughthe
developmentofskillsthatwillallowhimto
functionatalevelsatisfactorytohimselfand
others.
Settings
Occupationaltherapyisprovidedtochildren,
adolescents,adultsandelderlypatients.These
programsareofferedinpsychiatrichospitals,
nursinghomes,rehabilitationcenters,special
schools,communitygrouphomes,community
mentalhealthcenters,daycarecenters,halfway
homesanddeaddictioncenters.

200. TherapeuticModalitiesinPsychiatry197
Advantages
•Helpstodevelopsocialskillsandprovidean
outletforself-expression. ·
•Strengthensegodefenses.
•Developsamorerealisticviewoftheselfin
relationtoothers.
PointstobeKeptinMind
•Theclientshouldbeinvolvedasmuchas
possibleinselectingtheactivity.
•Selectanactivitythatinterestsorhasthe
potentialtointeresthim.
•Theactivityshouldutilizetheclient's
strengthsandabilities.
•Theactivityshouldbeofshortdurationto
fosterafeelingofaccomplishment.
•Ifpossible,theselectedactivityshouldprovide
somenewexperiencefortheclient.
ProcessofIntervention
Itconsistsofsixstages:
1.Initialevaluationofwhatpatientcandoand
cannotdoinavarietyofsituationsovera
periodoftime.
2.Developmentofimmediateandlong-term
goalsbythepatientandtherapisttogether.
Goalsshouldbeconcreteandmeasurableso
thatitiseasytoseewhentheyhavebeen
attained.
3.Developmentoftherapyplanwithplanned
intervention.
4.Implementationoftheplanandmonitoring
theprogress.Theplanisfolloweduntilthe
firstevaluation.Ifsatisfactoryitiscontinued,
oralteredifnot.
5.Reviewmeetingswithpatientandallthestaff
involvedintreatment.
6.Settingfurthergoalswhenimmediategoals
havebeenachieved;modifyingthetreatment
programasrelevant.
TypesofActivities
Diversionalactivities:Theseactivitiesareusedto
divertone'sthoughtsfromlifestressesortofill
time.
Forexample,organizedgames.
Therapeuticactivities:Theseactivitiesareusedto
attainaspecificcareplanorgoal.
Forexample,basketmaking,carpentry,etc.
SuggestedOccupationalActivitiesfor
PsychiatricDisorders
AnxietydisorderSimpleconcretetaskswithno
morethan3or4stepsthatcanbelearntquickly.
Forexample,kitchentasks,washing,sweeping,
mopping,mowinglawnandweedinggardens.
DepressivedisorderSimpleconcretetaskswhich
areachievable;itisimportantfortheclientto
experiencesuccess.Providepositivereinforce­
mentaftereachachievement.
Forexample,crafts,mowinglawn,weeding
gardens.
ManicdisorderNon-competitiveactivitiesthat
allowtheuseofenergyandexpressionoffeelings.
Activitiesshouldbelimitedandchanged
frequently.Clientneedstoworkinanareaaway
fromdistractions.
Forexample,rakinggrass,sweeping,etc.
Schizophrenia(paranoid)Non-competitive,solitary
meaningfultasksthatrequiresomedegreeof
concentrationsothatlesstimeisavailabletofocus
ondelusions.
Forexample,puzzles,scrabble.
Schizophrenia(catatonic)Simpleconcretetasksin
whichclientisactivelyinvolved.Clientneeds
continuoussupervision,andatfirstworksbest
onaone-to-onebasis.
Forexample,metalwork,moldingclay,etc.
AntisocialpersonalityActivitiesthatenhanceself­
esteemandareexpressiveandcreative,butnot
toocomplicated.Clientneedssupervisionto
makesureeachtaskiscompleted.
DementiaGroupactivitiestoincreasefeelingof
belongingandself-worth.Providethoseactivities
whichpromotefamiliarindividualhobbies.
Activitiesneedtobestructured,requiringlittle
timeforcompletionandnotmuchconcentration.
Explainanddemonstrateeachtask,thenhave
clientrepeatthedemonstration.

201. 198AGuidetoMentalHealthandPsychiatricNursing
SubstanceabuseGroupactivitiesinwhichclient
useshistalents.Forexample,involvingclientin
planningsocialactivities,encouraginginter­
actionwithothers,etc.
Childhoodandadolescentdisorders
Children:Playing,storytelling,painting,poetry,
music,etc.
Adolescents:Creativeactivitiessuchasleather
work,drawing,painting.
MentalretardationRepetitiveworkassignments
areideal;providepositivereinforcementaftereach
achievement.
Forexample,covermaking,candlemaking,
packaginggoods,etc.
RecreationalTherapy
Recreationisaformofactivitytherapyusedin
mostpsychiatricsettings.Itisaplannedthera­
peuticactivitythatenablespeoplewith
limitationstoengageinrecreationalexperiences.
Aims
•Toencouragesocialinteraction.
•Todecreasewithdrawaltendencies.
•Toprovideoutletforfeelings.
•Topromotesociallyacceptablebehavior.
•Todevelopskills,talentsandabilities.
•Toincreasephysicalconfidenceandafeeling
ofselfworth.
PointstobeKeptinMind
•Provideanon-threateningandnon-deman­
dingenvironment.
•Provideactivitiesthatarerelaxingand
withoutrigidguidelinesandtime-frames.
•Provideactivitiesthatareenjoyableandself­
satisfying.
TypesofRecreationalActivities
Motorforms:Thesecanbefurtherdividedinto
fundamentalandaccessory;amongthefunda­
mentalformsaresuchgamesashockeyand
football,whiletheaccessoryformsareexempli­
fiedbyplayactivityanddancing.
Sensoryforms:Thesecanbeeithervisual,e.g.
lookingatmotionpictures,play,etc.,orauditory
suchaslisteningtoaconcert.
Intellectualforms:Theseincludereading,debating
andsoon.
SuggestedRecreationalActivitiesfor
PsychiatricDisorders
AnxietydisordersAerobicactivitieslikewalking,
jogging,etc.
DepressivedisorderNon-competitivesports,
whichprovideoutletforanger,likejogging,
walking,running,etc.
ManicdisorderOne-to-onebasisindividual
gameslikebadminton,ball.
Schizophrenia(paranoid)Concentrativeactivities
likechess,puzzles.
Schizophrenia(catatonic)Socialactivitiestogive
clientcontactwithreality,likedancing,athletics.
DementiaConcrete,repetitiouscraftsandpro­
jectsthatbreedfamiliarizationandcomfort.
ChildhoodandadolescentdisordersItisbetterto
workwiththechildonaone-to-onebasisand
givehimafeelingofimportance.Someactivities
includeplaying,storytelling,andpainting.
Adolescentsfarebetteringroups;provide
grossmotoractivitieslikesportsandgamesto
useupexcessenergy.
MentalretardationActivitiesshouldbeaccording
totheclient'sleveloffunctioningsuchaswalking,
dancing,swimming,ballplaying,etc.
EducationalTherapy
Educationaltherapyisusedwhentheclienthas
problemswhichresultfromagreatdealofmis­
conception.Theeducationaltherapistprovides
readingandlearningexperiencesthatcandoa
greatdealtoeliminatehismisconceptionsand
anxiety.

202. TherapeuticModalitiesinPsychiatry199
BiblioTherapy
Itisdescribedastheprescriptionofreading
materialsthatwillhelptodevelopemotional
maturityandsustainmentalhealth.
Someemotionallydisturbedindividualsare
abletorelatetherapeuticallytotheexperiencesof
otherswhentheyreadaboutthem,ratherthan
experiencingthemdirectly.Italsoprovidesa
mediumfordiscussionwithothers.
PlayTherapy
Playisanaturalmodeofgrowthanddevelopment
inchildren.Throughplayachildlearnstoexpress
hisemotionsanditservesasatoolinthe
developmentofthechild.
CurativeFunctions
•Itreleasestensionandpent-upemotions.
•Itallowscompensationforlossandfailures.
•Itimprovesemotionalgrowththroughhis
relationshipwithotherchildren.
•Itprovidesanopportunitytothechildtoact
outhisfantasiesandconflicts,togetridof
aggressionandtolearnpositivequalitiesfrom
otherchildren.
DiagnosticFunctions
•Playtherapygivesthetherapistachanceto
explorefamilyrelationshipsofthechildand
discoverwhatdifficultiesarecontributingto
thechild'sproblems.
•Playtherapyallowstostudyhiddenaspects
ofthechild'spersonality.
•Itispossibletoobtainagoodideaofthe
intelligencelevelofthechild.
•Throughplayinter-siblingrelationshipscan
beadequatelystudied
TypesofPlayTherapy
IndividualvsGroupplaytherapyInindividual
therapythechildisallowedtoplaybyhimself
andthetherapist'sattentionisfocusedonthis
onechildalone.
Ingroupplaytherapyotherchildrenare
involved.
FreeplayvsControlledplaytherapyInfreeplay
thechildisgivenfreedomindecidingwithwhat
toyshewantstoplay.
Incontrolledplaytherapy,thechildis
introducedintoascenewherethesituationor
settingisalreadyestablished.
StructuredvsUnstructuredplaytherapyStructured
playtherapyinvolvesorganizingthesituationin
suchawaysoastoobtainmoreinformation.
Inunstructuredplaytherapynosituationis
setandnoplansarefollowed.
DirectivevsNon-directiveplaytherapyIndirective
playtherapy,thetherapisttotallysetsthe
directions,whereasinnon-directiveplaytherapy,
thechildreceivesnodirections.
Playtherapyisgenerallyconductedina
playroom.Theplayroomshouldbesuitably
stockedwithadequateplaymaterial,depending
upontheproblemsofthechild.
MusicTherapy
Musictherapyisthefunctionalapplicationof
musictowardstheattainmentofspecific
therapeuticgoals.
Advantages
•Facilitatesemotionalexpressions.
•Improvescognitiveskillslikelearning,
listeningandattentionspan.
•Socialinteractionisstimulated.
DanceTherapy
Itisapsychotherapeuticuseofmovement,which
furtherstheemotionalandphysicalintegration
oftheindividual.
Advantages
•Helpstodevelopbodyawareness.
•Facilitatesexpressionoffeelings.
•Improvesinteractionandcommunication.
•Fostersintegrationofphysical,emotionaland
socialexperiencesthatresultinasenseof
increasedself-confidenceandcontentment.
•Exercisethroughbodymovementmaintains
goodcirculationandmuscletone.

203. 200AGuidetoMentalHealthandPsychiatricNursing
ArtTherapy
Thegoalofarttherapyistohelpthepatient
expresshisthoughts,emotions,andfeelings
throughhisdrawings.
ImportanceofArtTherapy
•Itisusedasadiagnosticandtherapeutictool.
•Itprovidessociallyacceptableoutletfor
fantasyandwishfulfillment.
•Ithelpsthepatienttogainrelieffromanxiety
bygraphicallyrepresentingconflictand
aggressiveandtraumaticmaterialwithout
guilt.
ImplicationsofActivityTherapiesfor
NursingPractice
Thenursehasanimportantroleinenhancing
thetherapeuticeffectsofactivitytherapies.Some
pointstobekeptinmindare:
•Closecoordinationbetweenthenursingstaff
andtheactivitytherapydepartmentis
essential.
•Byengagingintheseactivities,thenursenot
onlyhasanopportunitytosupportthe
therapeuticeffortsoftherecreationaltherapist
butalsohasaninvaluableopportunityto
observetheclientindifferentsettings.
•Throughherobservationsoftheclient's
behaviorduringtheseactivities,thenursewill
gainvaluableinformationthatshecan
subsequentlyutilizetotherapeuticadvantage
intheworkingphaseofthenurse-client
relationship.
REVIEWQUESTIONS
•Classificationofpsychotropicdrugs(Feb
2001)
•Classificationofantipsychoticdrugs
•Roleofanurseinadministrationof
psychotropicdrugs(Nov1999)
•EPS(Oct2000,Nov2001,Nov2003)
•Druginducedparkinsonism
•Akathesia(Apr2004)
•Dystonia(Oct2006)
•Neurolepticmalignantsyndrome
•Antipsychoticdrugs(Oct2004)
•Atypicalantipsychotics(Apr2006)
•Moodstabilizingdrugs(Nov2001,Nov2003)
•Lithium(Nov1999,Apr2004,Oct2004,Oct
2005)
•Antidepressants(Apr2006)
•Benzodiazepines
•Drugsusedintreatmentofanxiety(Apr2006)
•Electroconvulsivetherapy(Feb2000,Apr
2006,Oct2006)
•PreECTpreparation(Apr2006)
•PostECTcare(Nov2002,Nov2003)
•ComplicationsofECT(Oct2002,Oct2005)
•RoleofanurseinECTmanagement(Nov
1999,Apr2004)
•Psychologicaltherapies(Nov1999,Apr2006)
•Psychoanalyticaltherapy(Nov2003)
•Dreamanalysis(Nov2003,Oct2004)
•Behaviortherapy(Feb2000,Nov2003)
•Systematicdesensitization
•Aversiontherapy(Oct2000)
•Tokeneconomy(Nov2001)
•Hypnosis(Nov2002,Nov2003)
•Abreactiontherapy(Oct2000)
•Narco-analysis(Oct2005)
•Supportivepsychotherapy
•Individualpsychotherapy(Oct2005)
•Familytherapy(Apr2002,Oct2002,Oct2005,
Oct2006)
•Grouptherapy(Feb2001,Apr2002,Apr2006)
•Psychodrama(Nov2002)
•Recreationtherapy(Apr2002,Apr2006)
•Playtherapy(Nov2002,Nov2003,Apr2004,
Oct2005)
•Whatarethecharacteristicsofatherapeutic
environment?Howwillyoucreatesuchan
environmentinapsychiatricunit?(Feb2000)
•Milieutherapy(Oct2005)
•Therapeuticcommunity(Nov1999,Nov2002,
Nov2003,Oct2004,Apr2006)
•Activitytherapy(Oct2000)
•Socialskilltraining(Nov2003)
•Occupationaltherapy(Nov1999,Feb2001,
Nov2002,Nov2003,Oct2006)

204. CrisisIntervention
0GRIEF
StagesofGrief
ResolutionofGrief
MaladaptiveGriefResponses
Treatment
NursingIntervention
0CRISIS
Definition
CrisisProneness
TypesofCrisis
PhasesofCrisis
SignsandSymptomsofCrisis
ResolutionofCrisis
CrisisIntervention
0ROLEOFANURSEINCRISISINTERVENTION
0MODALITIESOFCRISISINTERVENTION
0STRESS
BodyCopingMechanismwithStress
SourcesofStress
SymptomsofStress
StressManagementStrategies
RoleofaNurseinStressManagement
GRIEF
Griefisasubjectivestateofemotional,physical
andsocialresponsetothelossofavaluedentity.
Thelossmaybereal,inwhichcaseitcanbesub­
stantiatedbyothers(e.g.deathofalovedone),or
perceivedbytheindividualalone,inwhichcase
itcannotbeperceivedorsharedbyothers(e.g.loss
offeelingoffemininityfollowingmastectomy).
StagesofGrief
Kubler-Ross(1969)havingdoneextensive
researchwithterminallyillpatientsidentifiedfive
stagesoffeelingsandbehaviorthatindividuals
experienceinresponsetoareal,perceivedor
anticipatedloss:
StageI-Denial:Thisisastageofshockand
disbelief.Theresponsemaybeoneof"No,itcan't
betrue!"Denialisaprotectivemechanismthat
allowstheindividualtocopewithinanimme­
diatetime-framewhileorganizingmoreeffective
defensestrategies.
StageII-Anger:"Whyme?"and"Itisnotfair!"
arecommentsoftenexpressedduringtheanger
stage.Angermaybedirectedatselfordisplaced
onlovedones,caregivers,andevenGod.There
maybeapreoccupationwithanidealizedimage
ofthelostentity.
StageIII-Bargaining:"IfGodwillhelpmethrough
this,IpromiseIwillgotochurcheverySunday
andvolunteermytimetohelpothers".During
thisstage,whichisgenerallynotvisibleorevident
toothers,abargainismadewithGodinan
attempttoreverseorpostponetheloss.
StageIV--Depression:Duringthisstagethefull
impactofthelossisexperienced.Thisisatimeof
quietdesperationanddisengagementfromall
associationswiththelostentity.
StageV-Acceptance:Thefinalstagebringsafeeling
ofpeaceregardingthelossthathasoccurred.
Focusisontherealityofthelossanditsmeaning
fortheindividualsaffectedbyit.
Allindividualsdonotexperienceeachofthese
stagesinresponsetoaloss,nordothey
necessarilyexperiencetheminthisorder.Some
individualsgrievingbehaviormayfluctuate,and
evenoverlapbetweenstages.

205. 202AGuidetoMentalHealthandPsychiatricNursing
ResolutionofGrief
Resolutionoftheprocessofmourningisthought
tohaveoccurredwhenanindividualcanlook
backontherelationshipwiththelostentityand
acceptboththepleasureandthedisappointments
(boththepositiveandnegativeaspects)ofthe
association.Pre-occupationwiththelostentityis
replacedwithenergyanddesiretopursuenew
situationsandrelationships.
Thelengthofthegriefprocessmaybe
prolongedbyanumberoffactors:
Iftherelationshipwiththelostentityhadbeen
markedbyambivalence,reactiontothelossmay
beburdenedwithguilt,whichlengthensthegrief
reaction.
Inanticipatorygriefwherealossisanti­
cipated,individualsoftenbegintheworkof
grievingbeforetheactuallossoccurs.Mostpeople
experiencethegrievingbehavioroncetheactual
lossoccurs,buthavingthistimetopreparefor
thelosscanfacilitatetheprocessofmourning,
actuallydecreasingthelengthandintensityof
theresponse.
Thenumberofrecentlossesexperiencedby
anindividualalsoaffectsthelengthofthegrieving
processandwhetherheisabletocompleteone
grievingprocessbeforeanotherlossoccurs.
MaladaptiveGriefResponses
Maladaptivegriefresponsestolossoccurwhen
anindividualisnotabletosatisfactorilyprogress
throughthestagesofgrievingtoachievereso­
lution.Severaltypestogriefresponseshavebeen
identifiedaspathological[Lindemann(1944),
Parkes(1972)].
Theseareprolonged,delayed/inhibited,and
distortedresponses.
ProlongedResponse
Itischaracterizedbyanintensepreoccupation
withmemoriesofthelostentityformanyyears
afterthelosshasoccurred.
DelayedorInhibitedResponse
Theindividualbecomesfixedinthedenialstage
ofthegrievingprocess.Theemotionalpain
associatedwithlossisnotexperienced,butthere
maybeevidenceofanxietydisordersorsleeping
disorders.Theindividualmayremainindenial
formanyyearsuntilthegriefresponseistriggered
byareminderofthelossorevenbyanother
unrelatedloss.
DistortedResponse
Theindividualwhoexperiencesadistorted
responseisfixedintheangerstageofgrieving.
Thenormalbehaviorsassociatedwithgrieving,
suchashelplessness,hopelessness,sadness,
angerandguiltareexaggeratedoutofproportion
tothesituation.Theindividualturnstheanger
inwardontheselfandisunabletofunctionin
normalactivitiesofdailyliving.Pathological
depressionisadistortedgriefresponse.
Treatment
Normalgriefdoesnotrequireanytreatmentwhile
complicatedgriefrequiresmedicationdepending
ontheprevailingbehaviorresponses.
NursingIntervention
•Provideanopenacceptingenvironment.
•Encourageventilationoffeelingsandlisten
actively.
•Providevariousdiversionalactivities.
•Provideteachingaboutcommonsymptoms
ofgrief.
•Reinforcegoal-directedactivities.
•Bringtogethersimilaraggrievedpersons,to
encouragecommunication,shareexperiences
ofthelossandtooffercompanionship,social
andemotionalsupport.
CRISIS
Crisiscanbeviewedasanintegralcomponentof
everydaylifesituations.Acrisismayinfluence
people'slivesindifferentways.Asaconsequence
ofacrisisexperience,theindividualmaygodown
toalowerorlesshealthyleveloffunctioning
thanwhatwasbeforethecrisis,orhemayresume
thesameleveloffunctioningbyrepressingthe

206. CrisisIntervention203
crisisandtherelatedemotions.Ontheotherhand,
hemayfunctionatahealthierlevelthanpriorto
thecrisis,becausethechallengeofacrisiscan
bringoutnewstrengths,skillsandcoping
mechanisms.
Interventionatacrisisisextremelyimportant
topreventmentalillness,becauselong-standing
problemsmakethepersontotallyincapableof
handlingthesituation.Ifproperguidanceis
providedatthecorrecttime,thevictimwillcome
outofitbetterequippedtohandlefutureproblems
inlife.
Definition
Crisisisastateofdisequilibriumresultingfrom
theinteractionofaneventwiththeindividual's
orfamily'scopingmechanisms,whichare
inadequatetomeetthedemandsofthesituation,
combinedwiththeindividual'sorfamily's
perceptionofthemeaningoftheevent(Taylor
1982).
CrisisProneness
Hendricks(1985)suggeststhatcertain
individualsaremorepronetocrisisthanothers.
Thefollowingarecharacteristicsoftenfoundin
individualswhoareregardedasbeingmore
susceptibletocrisis:
•Dissatisfactionwithemploymentorlackof
employment.
•Historyofunresolvedcrisis.
•Historyofsubstanceabuse.
•Poorself-esteem,unworthiness.
•Superficialrelationshipwithothers.
•Difficultyincopingwitheverydaysituations.
•Underutilizationofresourcesandsupport
systems.
•Aloofnessandlackofcaring.
Itisimportanttonotethatindividualperso­
nalitytraitsmustalsobeconsideredincon­
junctionwiththesecharacteristics.Crisisis
definedbytheindividual;whatisacrisisforone
ismerelyanoccurrenceforanother.Thisfactoris
acriticalcomponentthatmustbeevaluatedin
relationtocrisispronecharacteristicsaswellas
personalitytraits.
TypesofCrisis
MaturationalCrisis
Amaturationalcrisisisastageinaperson'slife
whereadjustmentandadaptationtonew
responsibilitiesandlifepatternsarenecessary.
Thetransitionpointswhereindividualsmove
intosuccessivestageoftengeneratedisequili­
brium.Individualsarerequiredtomakecognitive
andbehavioralchangesandtointegratethose
physicalchangesthataccompanydevelopment.
Theextenttowhichindividualsexperience
successinthemasteryofthesetasksdependson
previoussuccesses,availabilityofsupport
systems,influenceofrolemodelsandacceptability
ofnewrolebyothers.
Thetransitionalperiodsoreventsthatare
mostcommonlyidentifiedashavingincreased
crisispotentialareadolescence,marriage,
parenthood,midlifeandretirement.
SituationalCrisis
Asituationalcrisisisonethatisprecipitatedby
anunanticipatedstressfuleventthatcreates
disequilibriumbythreateningone'ssenseof
biological,socialorpsychologicalintegrity.
Examplesofeventsthatcanprecipitate
situationalcrisesareprematurebirth,statusand
rolechanges,deathofalovedone,physicalor
mentalillness,divorce,changeingeographic
locationandpoorperformanceinschool.
SocialCrisis
Socialcrisisisaccidental,uncommon,and
unanticipatedandresultsinmultiplelossesand
radicalenvironmentalchanges.Socialcrises
includenaturaldisasterslikefloods,earthquakes,
violence,nuclearaccidents,masskillings,
contaminationoflargeareasbytoxicwastes,
wars,etc.Thistypeofcrisisisunlikematurational
andsituationalcrisisbecauseitdoesnotoccurin
thelivesofallpeople.

207. 204AGuidetoMentalHealthandPsychiatricNursing
Becauseoftheseverityoftheeffectsofsocial
crisiscopingstrategiesmaynotbeeffective.
Individualsconfrontedwithsocialcrisisusually
donothavepreviousexperiencefromwhichto
drawexpertise.Supportsystemsmaybe
unavailablebecausetheymayalsobeinvolved
insimilarsituations.Mentalhealthprofessionals
arecalledupontoactquicklyandprovideservices
tolargenumbersofpeopleandinsomecases,the
wholecommunity.
PhasesofCrisis
Caplan(1964)hasdescribedfourphasesofcrisis
asdescribedbelow:
PhaseI
Perceivedthreatactsasaprecipitantthatgene­
ratesincreasedanxiety.Normalcopingstrategies
areactivated,andifunsuccessful,theindividual
movesintoPhaseII.
PhaseII
TheineffectivenessofthePhaseIcoping
mechanismsleadstofurtherdisorganization.The
individualexperiencesasenseofvulnerability.
Theindividualmayattempttocopewiththe
situationinarandomfashion.Iftheanxiety
continuesandthereisnoreduction,the
individualentersPhaseIII.
Phase/II
Redefinitionofthecrisisisattemptedandthe
individualismostamenabletoassistanceinthis
phase.Newproblemsolvingmeasuresmayalso
affectasolution.Returntopre-crisislevelof
functioningmayoccur.Ifproblemsolvingis
unsuccessful,furtherdisorganizationoccursand
theindividualissaidtohaveenteredPhaseIV.
PhaseIV
Severetopaniclevelsofanxietywithprofound
cognitive,emotionalandphysiologicalchanges
mayoccur.Referraltofurthertreatmentresources
isnecessary.
SignsandSymptomsofCrisis
•Themajorfeelinginacrisissituationis
anxiety.Theindividualexperiencesaheavy
burdenoffree-floatinganxiety.
•Theanxietymaybemanifestedthrough
depression,angerandguilt.Thevictimwill
attempttogetridoftheanxietyusingvarious
copingmechanisms,healthyorunhealthy.
•Theindividualmaybecomeincapableofeven
takingcareofhisdailyneedsandmayneglect
hisresponsibilities.
•Theindividualmaybecomeirrationaland
blameothersforwhathashappenedtohim.
ResolutionofCrisis
Healthyresolutionofacrisisdependsuponthe
followingthreefactors:
1.Realisticappraisaloftheprecipitatingevent,
i.e.recognitionoftherelationshipbetweenthe
eventandfeelingsofanxietyisnecessaryfor
effectiveproblem-solvingtooccur.
2.Availabilityofsupportsystems.
3.Availabilityofcopingmeasuresoveralife­
time:Apersondevelopsarepertoireof
successfulcopingstrategiesthatenablehim
toidentifyandresolvestressfulsituations.
Therearethreewaysbywhichtheindividual
mayresolvethecrisis:
Pseudo-resolution
Inthis,theindividualusesrepressionandpushes
outofconsciousnesstheincidentandtheintense
emotionsassociatedwithit,sotherewillnotbe
anychangeintheleveloffunctioningofthe
individual.Butinfuture,ifandwhenacrisis
occurs,therepressedfeelingsmaysurfaceand
influencethefeelingsarousedbythenewcrisis.
Insuchasituation,theparticularcrisismaybe
moredifficulttoresolvebecausethefeelings
associatedwiththeearliercrisisareneither
expressednorhandledatthattime.
UnsuccessfulResolution
Inthis,thevictimusespathologicaladaptation
atanyphaseofcrisis,resultinginalowerlevelof

208. CrisisIntervention205
functioning.Thevictim,ratherthanacceptingthe
lossandreorganizinghislife,keepsruminating
overtheloss.Anexampleisprolongedgrief
reaction,whichresultsindepression.
SuccessfulResolution
Inthis,thevictimmaygothroughthevarious
phasesofcrisis,butreachesPhaseIIIwhere
variouscopingmeasuresareutilizedtoresolve
thecrisissituation.Theindividualdevelopsbetter
skillsandproblemsolvingability,whichcanbe
andwillbeusedinvariouscrisissituationsin
future.
CrisisIntervention
Crisisinterventionisatechniqueusedtohelpan
individualorfamilytounderstandandcopewith
theintensefeelingsthataretypicalofacrisis.
Nursesfunctionaspartoftheinterdisciplinary
teamintheuseofcrisisinterventionasa
therapeuticmodality.).."ursesmayemploycrisis
techniquesintheirworkwithhigh-riskgroups
suchasclientswithchronicdiseases,newparents
andbereavedpersons.
Nursesmayalsousecrisisinterventionin
dealingwithintra-groupstaHissuesandclient
managementissues.
AimsofCrisisInterventionTechnique
•Toprovideacorrectcognitiveperceptionof
thesituation.
•Toassisttheindividualinmanagingthe
intenseandoverwhelmingfeelingsassociated
withthecrisis.
Intervention
AStepstoprovideacorrectcognitioeperception
Assessmentofthesituaiu»
•Thismaybeachieved!Jydirectquestioning
withthepurposeoiidentificationofthe
problemandthepee'?~einvolved.
•Itisnecessarytoicieni-'::.-thesupportsystems
availableandtokr.c--fuedepthinwhichthe
individual'sfeelir:::;::-areaffected.
•Assessmentshouldalsobedonetoidentify
thestrengthsandlimitationsofthevictim.
Definingtheevent
•Thevictimattimesmaynotbeabletoidentify
theprecipitatingeventbecauseofpossible
denial,orduetoreluctancetotalkaboutit.
•Itmaybenecessaryforthetherapisttoreview
thedetailsoftheincidentsinthepast2to4
weeksinordertoidentifytheeventthat
precipitatedthecrisis.Suchareviewwillhelp
thevictimbecomingawareoftheprecipitating
event.
Developaplanofaction
•Thevictimandthepeoplecloselyassociated
withhimshouldhaveactiveinvolvementin
developingtheplanofaction.
•Thetherapistmustbeawarethatthevictim
maynotbeinaconditiontomentally
comprehendcomplicatedinformationdueto
theoverwhelminganxietyexperiencedby
him.Theinstructionsgivenbythetherapist
mustbesimpleandclear,andtoomuch
informationshouldnotbegivenatatime.The
instructionsmayhavetobewrittendown,as
thevictimmaynotbeabletoretainallthe
information.
B.Stepstoassistthevictiminmanagingtheintense
feelings
Helpingtheindividualtobeawareofthefeelings
•Thevictimneedshelpinidentifyinghisown
feelings,whichisthefirststepinhandling
them.
•Thetherapistshoulduseappropriatecom­
municationtechniquesothatthevictimwill
feelcomfortabletoexpresshisfeelingswithout
thefearofbeingjudgedorcriticized.
•Thetherapistshouldalsobeefficientin
observingverbalandnon-verbalbehaviorof
thevictim,sothathewillbeabletomakea
carefulassessmentofhisfeelings.
Helptheindividualtoattainmasteryoverthefeelings
•Theindividualshouldbegivenadequate
supportandguidancethroughtherapeutic

209. 206AGuidetoMentalHealthandPsychiatricNursing
processinordertohandlefeelingsassociated
withcrisisbutspecialcareshouldbetaken
nottogiveanyfalsereassurance.
•Heshouldnotinanywaybeencouragedto
blameothers,asthiswillonlylethimescape
fromtakinganyresponsibility.
•Caremustbetakentoensurethatthe
individualdoesnotdeveloptoomuch
dependencyonthetherapist,whichis
unhealthy.
•Afterthevictimandthesupportgroups
preparetheplanofactionundertheguidance
ofthetherapist,itshouldbediscussedwith
thevictimandtheconcernedothers,sothat
theywillhaveaclearunderstandingofthe
methodsofimplementationoftheplan.
•Toimprovecopingwiththesituation
necessaryenvironmentalmanipulationmust
bedoneinphysicalorinterpersonalareas.
•Itisadvisabletohaveanotherappointment
forthevictimtovisitthetherapistwithina
week,inordertoassesshowtheplanis
workingout,andifneeded,toreviseand
modifytheplan.
ROLEOFANURSEINCRISIS
INTERVENTION
Nursesrespondtocrisissituationsonadaily
basis.Crisiscanoccurinanyunitfore.g.ingeneral
hospitals,homesettings,communityhealth
centers,schools,offices,andinprivatepractice.
Indeed,nursesmaybecalledupontofunctionas
crisishelpersinanysituation.
Knowledgeofcrisisinterventiontechniques
isthusanimportantclinicalskillofallnurses,
regardlessofthesettingorpracticespecialty.
NursingAssessment
Thefirststepofcrisisinterventionisassessment.
Duringthisphasethenursecollectsdata
regardingthefollowingfactors:
•Precipitatingeventorstressor
•Patient'sperceptionoftheeventorstressor
•Natureandstrengthofthepatient'ssupport
systems,copingresources
•Levelofpsychologicalstresspatientis
sufferingfromandthedegreeofimpairment
heisexperiencing
•Patient'spreviousstrengthsandcoping
mechanisms
Duringthisphasethenursebeginstoestablish
apositiveworkingrelationshipwiththepatient.
NursingDiagnoses
Theprimarynursingdiagnosesincrisis
interventionare:
•Ineffectiveindividualcoping
•Ineffectivefamilycoping
•Alteredfamilyprocess
•Posttraumaresponse
•Ineffectiveindividualcopingreferstothe
inabilitytoaskforhelp,problemsolving
ormeetroleexpectations
•Ineffectivefamilycopingoccurswhenthe
family'ssupportsystemsarenot
successfulandfamily'seconomicorsocial
wellbeingisthreatened
•Alteredfamilyprocessesresultwhen
familymembersareunabletoadapttothe
traumaticexperienceconstructively
•Post-traumaticresponseisasustained
painfulresponsetoanoverwhelming
traumaticevent.
Planning
Inplanningthepreviouslycollecteddatais
analyzedandspecificinterventionsareproposed.
Duringthisphasethenursewillundertakethe
followingactivities:
•Dynamicsunderlyingthepresentcrisisare
formulated
•Alternativesolutionstotheproblemare
explored
•Stepsforachievingthesolutionsareidentified
•Environmentalsupportneededtohelpthe
patientisdecidedupon,copingmechanisms
thatneedtobedevelopedandthosewhich
needtobestrengthenedareidentified
Implementation
Thefollowinginterventionsarecarriedoutto
resolvecrisis:

210. CrisisIntervention207
EnvironmentalManipulation
Environmentalmanipulationincludesinterven­
tionsthatdirectlychangethepatient'sphysical
orinterpersonalsituation.Theseinterventions
mayremovestressorprovidesituationalsupport.
Forexampleapatienthavingdifficultyinhisjob
maytakeaweekofsickleavesothathecanbe
removedtemporarilyfromthatstress.
GeneralSupport
Thenurseuseswarmth,acceptance,empathyand
reassurancetoprovidegeneralsupporttothe
patient.
GenericApproach
Thegenericapproachisdesignedtoreachhigh
riskindividualsandlargegroupsasquicklyas
possible.Itappliesaspecificmethodtoall
individualsfacedwithasimilartypeofcrisis(e.g.
insocialdisasters).Debriefingisamethodof
genericapproach.Indebriefingmethod,disaster
victimsarehelpedtorecalleventsandclarify
traumaticexperiences.Itattemptstoplacethe
traumaticeventinperspective,allowsthe
individualtorelivetheeventinafactualway,
encouragesgroupsupport,andprovidesinfor­
mationonnormalreactiontocriticalevents.The
goalofdebriefingistopreventthemaladaptive
responsesthatmayresultifthetraumais
suppressed.
IndividualApproach
Theindividualapproachisatypeofcrisisinter-
.ventionsimilartothediagnosisandtreatmentof
aspecificprobleminaspecificpatient.Itis
particularlyusefulincombinedsituationaland
maturationalcrisesandalsobeneficialwhen
symptomsincludehomicidalandsuicidalrisk.
Thenursemustusetheinterventionthatismost
likelytohelpthepatientdevelopanadaptive
responsetothecrisis.
TechniquesofCrisisIntervention
1.Catharsis:Thereleaseoffeelingsthattakes
placeasthepatienttalksaboutemotionally
chargedareas.
2.Clarification:Encouragingthepatientto
expressmoreclearlytherelationshipbetween
certainevents.
3.Manipulation:Usingthepatient'semotions,
wishesorvaluestobenefitthepatientinthe
therapeuticprocess.
4.Reinforcementofbehavior:Givingthepatient
positivereinforcementtoadaptivebehavior.
5.Supportofdefenses:Encouragingtheuseof
healthy,adaptivedefensesanddiscouraging
thosethatareunhealthyormaladaptive.
6.Increasingself-esteem:Helpingthepatientto
regainfeelingsofselfworth.
7.Explorationofsolutions:Examiningalternative
waysofsolvingtheimmediateproblem.
Evaluation
Thenurseandpatientreviewthechangesthat
haveoccurred.Thenurseshouldgivecreditfor
successfulchangestopatientssothattheyrealize
theireffectivenessandunderstandthatwhatthey
learntfromcrisismayhelpincopingwithfuture
crisis.Ifthegoalshavenotbeenmet,thepatient
andnursecanreturntothefirststep-assessment
andcontinuethroughthephasesagain.
MODALITIESOFCRISISINTERVENTION
Community-basedcrisisinterventionmodalities
haverecentlybeendeveloped.Theyarebasedon
thephilosophythatthehealthcareteammustbe
activeandgoouttothepatientsratherthanwait
forthepatientstocometothem.Nursesworking
inthesemodalitiesinterveneinavarietyof
communitysettings,rangingfrompatients
homestostreetcorners.
MobileCrisisPrograms
Mobilecrisisteamsprovidefront-lineinterdiscip­
linarycrisisinterventiontoindividuals,families
andcommunities.Thenurse,whoisamemberof
amobilecrisisteam,shouldbeabletoprovide
on-siteassessment,crisismanagement,treatment,
referralandeducationalservicestopatients,
familiesandthecommunityatlarge.Nursesare
thusabletoensurementalhealthcareforeven

211. 208AGuidetoMentalHealthandPsychiatricNursing
themostunder-servedpopulationsefficientlyand
costeffectively.
TelephoneContacts
Crisisinterventionissometimespracticedby
telephoneratherthanthroughface-to-face
contacts.Thenurseshouldhaveeffectivelistening
skillstoprovidecrisisinterventiontovictims.
GroupWork
Peoplewhohavecommontraitsonstressorswill
formagroup.Thegroupprovidesanopportunity
formemberstoexpresscommonconcernsand
experiences,fosterhopeandbuildmutual
support.Thenurse'sroleinthegroupisactive,
focalandfocusedonthepresent.Thenurseand
thegrouphelpthepatientsolvetheproblemand
reinforcenewproblemsolvingbehavior.
DisasterResponse
Aspartofthecommunity,nursesarecalledon
whenanadventitiousorsocialcrisisstrikes
thecommunity.Floods,earthquakes,airplane
crashes,fires,nuclearaccidentsetc.precipitate
largenumberofcrises.Thenursehasanimportant
roleindealingwithpsychosocialproblemsof
disastervictims.Thenurseparticipatesincrisis
operationsandactsasacase-finderforpersons
sufferingfrompsychosocialstress.Itisimportant
thatnursesintheimmediatepostdisasterperiod
gotoplaceswherevictimsarelikelytogather,
suchashospitals,shelters,morgues.Duringthis
periodnursesusethegenericapproachofcrisis
interventionsothatasmanypeopleaspossible
canreceivehelpinashortdurationoftime.
VictimOutreachPrograms
Victimoutreachprogramsusecrisisintervention
techniquestoidentifytheneedsofvictimsand
thentoconnectthemwithappropriatereferrals
andotherresources.
Nursesoftenworkinvictimoutreachpro­
grams,wherevictimsareoftenseenimmediately
afterthecrisis.Thesevictimsneedthorough
evaluation,empathicsupport,andinformation
andhelpwiththelargesystemandsocial
networkingsystem.
CrisisInterventionCenters
Crisisinterventioncentersprovideemergency
psychiatriccareandcounselingtovictims,
experiencingextremestressorconflict,often
involvingsuicideattemptsordrugoralcohol
abuse.Thesecenters,whichareusuallyself­
containedunitswithinahospitalorcommunity
healthcarecenter,provideservices24hoursa
day.Theservicesmaybedelivereddirectlyonthe
premises,orcounselingmaybeprovidedoverthe
telephone.Theprimaryobjectiveofcrisis
interventioncentersistohelpthepersoncope
withimmediateproblemandtoofferguidance
andsupportforlong-termtherapy.
HealthEducation
Nursesareinvolvedinidentifyingpeoplewho
areathighriskfordevelopingcrisisandin
teachingcopingstrategiestoavoidthe
developmentofcrisis.Thepublicalsoneeds
educationsothattheycanidentifythoseneeding
crisisservices,beawareofavailableservices,
changetheirattitudesothatpeoplewillfeelfree
toseekservices,andobtaininformationabouthow
othersdealwithpotentialcrisisproducing
problems.
STRESS
Thetermstressmeanspressureandinhuman
lifeitrepresentsanuneasyexperience.Itisan
unpleasantpsychologicalandphysiologicalstate
causedduetosomeinternalandorexternal
demandsthatgobeyondourcapacity.
BodyCopingMechanismwithStress
Eachpersonhashisownnormal(homeostatic)
levelofarousalatwhichhefunctionsbest.If
somethingunusualintheenvironmentoccurs,
thislevelofarousalisaffected.

212. CrisisIntervention209
GeneralAdaptationSyndrome(GAS)Hans
Selye,1945)
•Homeostaticmechanismsareaimedat
counteractingtheeverydaystressofliving.If
theyaresuccessful,theinternalenvironment
maintainsnormalphysiologicallimitsof
temperature,chemistryandpressure.Ifstress
isextremeorlonglasting,thenormal
mechanismsmaynotbesufficient.Inthiscase,
thestresstriggersawide-rangingsetofbodily
changescalledGeneralAdaptationSyndrome:
•Whenstressappears,itstimulatesthe
hypothalamustoinitiatetheGASthroughtwo
pathways:
1.Thefirstpathwayisstimulationofthe
sympatheticdivisionoftheautonomic
nervoussystemandadrenalmedulla.This
producesanimmediatesetofresponses
calledthealarmreaction.
2.Thesecondpathway,calledtheresistance
reactioninvolvestheanteriorpituitary
glandandadrenalcortex;theresistance
reactionisslowertostart,butitseffects
lastlonger.
AlarmReaction
Thealarmreactionorfight-or-flightresponseis
thebody'sinitialreactiontoastressor.Itisaset
ofreactionsinitiatedwhenthehypothalamus
stimulatesthesympatheticdivisionofthe
autonomicnervoussystem,andtheadrenal
medulla.
Thealarmreactionismeanttocounteracta
dangerbymobilizingthebody'sresourcesfor
immediatephysicalactivity.
Thestressresponseswhichcharacterizethe
alarmreactionincludethefollowing:
•Heartrateandstrengthofcardiacmuscle
contractionincreases;thiscirculatesblood
quicklytoareaswhereitisneededtofightthe
stress.
•Bloodvesselssupplyingskinandviscera,
exceptheartandlungs,constrict;atthesame
timebloodvesselssupplyingskeletalmuscles
andbraindilate;theseresponsesroutemore
bloodtoorgansactiveinthestressresponses,
thusdecreasingbloodsupplytoorganswhich
donotassumeanimmediateactiverole.
•RBCproductionisincreasedleadingtoan
increaseintheabilityofthebloodtoclot.This
helpscontrolbleeding.
•Liverconvertsglycogenintoglucoseand
releasesitintothebloodstream;thisprovides
theenergyneededtofightthestressor.
•Therateofbreathingincreasesandrespiratory
passageswidentoaccommodatemoreair;this
enablesbodytoacquiremoreoxygen.
•Productionofsalivaanddigestiveenzymes
reduces.Thisreactiontakesplaceasdigestive
activityisnotessentialforcounteracting
stress.
AlarmReaction
Stressor
j, Stimulates
Hypothalamus
j, Stimulates
Sympatheticnervoussystem
j, Stimulates
Adrenalmedulla
j, Releases
Catecholamines
(epinephrineandnorepinephrine)
j, Produces
Alarmreaction(fight-or-flightresponse)
ResistanceReaction
•Theresistancereactionisthesecondstagein
thestressresponse.Itisinitiatedbyregulating
hormonessecretedbythehyphothalamus,and
isalong-termreaction.Theseregulatinghor­
monesareCorticotrophinReleasingHormone
(CRH),GrowthHormoneReleasingHormone
(GHRH)andThyrotropinReleasingHormone
(TRH)
•CRHstimulatestheanteriorpituitaryto
increaseitssecretionofAdrenoCorticotropic
Hormone(ACTH).ACTHstimulatesthe
adrenalcortextosecretemoreofitshormones.
Theactionofthesehormoneshelpstocontrol
bleeding,maintainbloodpressure,etc.

213. 210AGuidetoMentalHealthandPsychiatricNursing
ResistanceReaction
Stressor
.!-Stimulates
Hypothalamus
.!-Releases
CRH
GHRH
TRH
.!-Stimulates
Anteriorpituitary
!Releases
Suppliesenergy
throughglyconeogenesis
andincreasedbreakdown
offats
r
ACTH
1 Stimulates
Adrenalcortex
l Releases
Adrenalhormones
(glucocorticoidsand
mineralocorticoids
HGH
.!-
Liver
.!-
l
TSH
lStimulates
Thyroidgland
1
Suppliesenergy
throughincreased
breakdownof
carbohydrates
•GHRHstimulatestheanteriorpituitaryto
secreteHumanGrowthHormone(HGH).
TRHcausestheanteriorpituitarytosecrete
Thyroid-StimulatingHormone(TSH).The
combinedactionsof(HGH)andTSHhelpto
supplyadditionalenergytothebody.
•Theresistancereactionallowsthebodyto
continuefightingastressorforalongtime.
Thusithelpsustomeetemotionalcrisis,
performstrenuoustasks,fightinfection,or
resistthethreatofbleedingtodeath.
•Generally,theresistancereactionissuccessful
inhelpinguscopewithastressfulsituation,
andourbodiesthenreturntonormal.
Occasionallyitfailstofightthestressor,
especiallyifitistoosevereorlong-lasting.In
thiscase,theGeneralAdaptationSyndrome
(GAS)movesintothestageofexhaustion.
ExhaustionStage
Atthisstage,thecellsstarttodie,andtheorgans
weaken.Along-termresistancereactionputs
heavydemandonthebody,particularlyonthe
Stimulates
heart,bloodvesselsandadrenalcortex,which
maysuddenlyfailunderthestrain.Inthisrespect,
abilitytohandlestressorsistoalargeextent
determinedbythegeneralhealth.
SourceofStress
1.Environmentalstressors
Noise,pollution,trafficandcrowdingand
weather.
2.Physiologicalstressors
Illness,injuries,hormonalfluctuations,
inadequatesleepornutrition.
3.Socialstressors
Financialproblems,workdemands,social
events,losingalovedoneetc.
4.Thoughts
Negativeselftalk,catastrophizingand
perfectionism.
5.Changeofanykindcaninducestress
•Fearofthenew,theunknown
•Feelingsofpersonalinsecurity
•Feelingsofvulnerability
•Fearofrejection

214. CrisisIntervention211
•Needforapproval
•Fearofconflict
•Fearoftakingarisk
•Fearofinabilitytocopewithchanged
circumstances
6.Individualpersonalitiesthatcaninducestress
•Lowself-esteem
•Feelingsofover-responsibility
•Fearoflossofcontrol
•Fearoffailure,error,mistakes
•Chronicstrivingtobeperfect
•Chronicguilt
•Chronicanger,hostilityordepression
7.Interpersonalissuesthatcaninducestress
•Alackofadequatesupportwithinthe
relationship
•Alackofhealthycommunicationwithin
therelationship
•Asenseofcompetitivenessbetweenthe
peopleinvolved
•Threatsofrejectionordisapproval
betweenpeople
•Struggleforpowerandcontrolinthe
relationship
•Poorintimacyorsexualitywithinthe
relationship
•Overdependencyofonepersononanother
8.System(family,job,school,club,organization
issuesthatcaninducestress)
•Lackofleadership
•Unco-operativeatmosphere
•Competitiveatmosphere
•Autocraticleadership
•Lackofteamwork
•Confusedcommunication
SymptomsofStress
Symptomsofstressappearinmanyforms.Some
symptomsonlyimpactthepersonwhoisdirectly
experiencingstress,whileothersymptomsmay
haveanimpactonourrelationshipwithothers.
PhysicalSymptoms
•Muscletension
•Coldsorotherillnesses
•Highbloodpressure
•Rapidbreathingorpoundingoftheheart
•Indigestion
•Ulcers
•Difficultyinsleeping
•Fatigue
•Headaches,backorneckproblems
•Increasedsmokingordrinkingalcohol
•Backaches
•Beingmorepronetoaccidents
CognitiveSymptoms
•Forgetfulness
•Unwantedorrepetitivethoughts
•Difficultyinconcentration
•Fearoffailure
•Selfcriticism
EmotionalSymptoms
•Irritability
•Depression
•Anger
•Fearoranxiety
•Feelingoverwhelmed
•Moodswings
StressManagementStrategies
1.TakeaDeepBreath
Whenyoufeel'uptight'trytakingaminuteto
slowdownandbreathedeeply.Breathein
throughyournoseandoutthroughyourmouth.
Trytoinhaleenoughsothatyourlowerabdomen
risesandfalls.Countasyouexhale-slowly.
2.PracticeSpecificRelaxationTechniques
Relaxationtechniquesareextremelyvaluabletools
instressmanagement.Mostofthetechniqueslike
meditation,selfhypnosis,anddeepmuscle
relaxationworkinasimilarfashion.Inthisstate
boththebodyandthemindareatrestandthe
outsideworldisscreenedoutforatimeperiod.
Thepracticeofoneofthesetechniquesonaregular
basiscanprovideawonderfullycalmingand
relaxingfeelingthatseemstohavealastingeffect
formanypeople.

215. 212AGuidetoMentalHealthandPsychiatricNursing
3.ManageTime
Oneofthegreatestsourcesofstressispoortime
management.Giveprioritytothemostimportant
onesanddothosefirst.Ifaparticularlyunpleasant
taskfacesyou,tackleitearlyinthedayandget
overwithit;therestofyourdaywillincludemuch
lessanxiety.
Mostimportantly,donotoverworkyourself,
scheduletimeforbothworkandrecreation.
4.ConnectwithOthers
Agoodwaytocombatsadness,boredomand
lonelinessistoseeoutactivitiesinvolvingothers.
5.TalkitOut
Whenyoufeelsomething,trytoexpressit.Share
yourfeelings."BottledUp"emotionsincrease
frustrationandstress.Talkingwithsomeoneelse
canhelpclearyourmindofconfusionsothatyou
canfocusonproblemsolving.Alsoconsider
writingdownthoughtsandfeelings.Putting
problemsonpapercanassistyouinclarifying
thesituationandallowyouanewperspective.
6.Takea"Minute"Vacation
Imaginingaquietcountryscenecantakeyouout
oftheturmoilofastressfulsituation.Whenyou
havetheopportunity,takeamomenttocloseyour
eyesandimagineaplacewhereyoufeelrelaxed
andcomfortable.Noticeallthedetailsofyour
chosenplace,includingpleasantsounds,smells
andtemperatureorchangeyourmental
"channel"byreadingagoodbookorplaying
relaxingmusictocreateasenseofpeaceand
tranquility.
7.MonitorYourPhysicalComfort
Wearcomfortableclothing.Ifit'stoohot,go
somewherewhereit'snot.Ifyourchairis
uncomfortable,changeit.Ifyourcomputer
screencauseseye-strainorbackaches,change
that,too.Don'twaituntilyourdiscomfortturns
intoarealproblem.Takingfiveminutestoarrange
backsupportcansaveyouseveraldaysofback
pain.
8.GetPhysical
Whenyoufeelnervous,angryorupset,release
thepressurethroughexerciseorphysicalactivity.
Running,walkingorswimmingaregoodoptions
forsomepeople,whileotherspreferdanceor
martialarts.Workinginthegarden,washingyour
car,orplayingwithchildrencanrelievethat
"uptight"feeling,relaxyouandoftenwill
actuallyenergizeyou.Remember,yourbodyand
mindworktogether.Mostexpertsrecommend
doing20minutesofaerobicactivitydailywill
reducestress.
9.TakeCareofYourBody
Healthyeatingandadequatesleepfuelsyour
mindaswellasyourbody.Avoidconsumingtoo
muchcaffeineandsugar.Taketimetoeatbreakfast
inthemorning,itreallywillhelpkeepgoing
throughtheday.Well-nourishedbodiesarebetter
preparedtocopewithstress.Ifyouareirritable
andtensefromlackofsleepornoteatingright,
youwillbelessableto"gothedistanceindealing
withstressfulsituations".Increasetheamountof
fruitsandvegetablesindailydiet.Taketimefor
personalinterestsandhobbies.Listentoone's
body.
10.Laugh
Maintainyoursenseofhumor,includingthe
abilitytolaughatyourself.
11.KnowYourLimits
Therearemanycircumstancesinlifebeyondyour
control,considerthefactthatweliveinan
imperfectworld.Knowyourlimits.Ifaproblem
isbeyondyourcontrolandcannotbechangedat
themoment,don'tfightthesituation.Learnto
acceptwhatis,fornow,untilsuchtimewhen
youcanchangethings.
12.ThinkPositively
Refocusthenegativetobepositive.Makeaneffort
tostopnegativethoughts.

216. CrisisIntervention213
13.ClarifyYourValuesandDevelopaSense
ofLifeMeaning
Clarifyyourvaluesanddecidingwhatyoureally
wantoutofyourlife,canhelpyoufeelbetterabout
yourselfandhavethatsenseofsatisfactionand
centerednessthathelpsyoudealwiththestresses
oflife.Asenseofspiritualitycanhelpwiththis.
14.Compromise
Considerco-operationorcompromiseratherthan
confrontation.Alittlegiveandtakeonbothsides
mayreducethestrainandhelpyoufeelmore
comfortable.
15.HaveaGoodCry
Agoodcryduringperiodsofstresscanbea
healthywaytobringrelieftoyouranxiety,andit
mightpreventaheadacheorotherphysical
consequencesof"bottling"thingsup.
16.AvoidSelfMedication
Alcoholandotherdrugsdonotremovethe
conditionsthatcausestress.Althoughtheymay
seemtooffertemporaryrelief,thesesubstances
onlymaskordisguiseproblems.Inthelongrun,
alcoholuseincreasesratherthandecreasesstress,
bychangingthewayyouthinkandsolve
problemsandbyimpairingyourjudgmentand
othercognitivecapacities.Medicationsshouldbe
takenonlyontheadviceofadoctor.
17.Lookforthe"PiecesofGold"AroundYou
Piecesofgoldarepositiveorenjoyablemoments
orinteractions.Thesemayseemlikesmallevents
butasthese"piecesofgold"accumulatetheycan
oftenprovideabiglifttoenergyandspiritsand
helpyoubegintoseethingsinnew,morebalanced
way.
RoleofaNurseinStressManagement
Assessment
AssessmentofthePerson
Assessforthefollowingcharacteristicsinthe
individual.Suchindividualsareathighriskof
developingstress-relateddisorders:
•Rigidandself-punishingmoralstandards
•Highandunrealisticexpectations
•Toomuchdependenceonothersforloveand
affectionandapproval
•Inabilitytomasterchangeorlearnnewways
ofdealingwithfrustration
•Easilypronetoextremeemotionalresponses
offear,anxietyanddepression
•TypeApersonalitypersons
Inaddition,thepresenceofstressfullifeevents
suchasbirths,deaths,marriages,divorces,
retirement,economicsuccessorfailureetccan
predisposethepersontostress-relatedillnesses.
AssessmentoftheFamily
Assessthefamily'sperceptionoftheproblem,and
whetheritissupportiveoftheclient'seffortsat
coping.
AssessmentoftheEnvironment
Occupationswithahighdegreeofstress;adverse
environmentalinfluencesliketoomuchof
lighting,temperatureetc.
Interventions
Interventionsaredirectedtowardsreliefofacute
orchronicstress.Anursecanhelpthepersonto
examinethesituation,identifypossiblesolutions
andaccepthisfeelingswithoutguiltorfear.
Peoplesufferingfromacutestress-related
illnessesoftenneedtochangetheirlifestylesand
waysofrelatingtoothers.Theinitialworkofthe
nurseinvolveshelpingtheclienttorecognizethat
changeisessential,anddevelopclearpersonal
objectiveinrelationtothechange.
Someclientsmayshowresistancetoaneces­
sarychange.Insuchcases,nursingmeasures
include:
•Increasingtheclient'sawarenessasanactual
orpotentialhealthproblemexists.
•Helpinghimrealizethatthehealthproblem
canincreaseifpersonalchangesdonotoccur.
•Identifyingallpossibleresources(hisfamily,
friendsetc.).Tosupporttheclientthroughthe
processofchange,andco-operationwiththe
treatment.

217. 214AGuidetoMentalHealthandPsychiatricNursing
•Whentheclientbecomesawareofthenature
ofthehealthproblemandistoldofthechange
needed,heoftenexperiencesafeelingof
anxiety,depressionandanger.Theclientis
encouragedtotalkaboutthelossesthathave
resultedfromthebehaviorchange.
Recognizingthisgrievingprocessprovides
thenursewithcleardirectionastohowshe
canhelptheclient.
•Familymembersalsoneedaccurate
informationaboutthenatureofthedisorder,
andhowtheycanhelptheclientincoping
withstress.Theclientandfamiliesalsoneed
tobeinformedaboutvariousalternativessuch
asmeditation,yoga,relaxationtrainingetc.
Thesetechniqueshaveavaluableroletoplay
inhelpingindividualscopewithstressfullife
events.
•Inallthis,thenursemustalwaysbearinmind
thattheyareonlyfacilitatorsofthechange
process,andtheclientshavetherightsand
responsibilitiesinrelationtochange.
REVIEWQUESTIONS
•Stagesofgrief(Feb2001)
•Definitionandtypesofcrisis(Apr2006)
•Phasesofcrisis
•Crisisintervention(Feb2000,Nov2002,Nov
2003,Oct2004)
•Roleofanurseincrisisintervention(Nov
2001)
•Bereavement(Oct2005)
•Whatisnormalgriefreaction(Apr2004)
•Griefprocess(Nov2003)
•MaturationalCrisis(Nov2003)

218. LegalAspectsofMental
HealthNursing
CHAPTERII
Itcontainsmainlytheproceduretobefollowedto
admitapsychiatricpatientintoamentalhospital.
DTHEINDIANLUNACYACT(1912)
DTHEINDIANMENTALHEALTHACT(1987)
DLEGALISSUESINPSYCHIATRY
DLEGALASPECTSINPSYCHIATRICNURSING
RoleoftheNurseinAdmissionProcedure
RoleoftheNurseinParole CHAPTER Ill
RoleoftheNurseinDischargeProcedure .
BasicRightsofPsychiatricPatientsand Itdescribestheproceduretobefollowedfor
Nurse'sResponsibilities administeringcare,treatmentanddischarge.
NursingMalpractice InChapterIIItheterm'Parole'referstothe
InformedConsent 'permissiongiventopatientstoperformcertain
SubstitutedConsent ·l d ·f·1f·'D·
confidentiality ntuasorattencertamarruyunctions.urmg
•RecordKeeping parole,thepatientcanleavethehospitalanytime
DLEGALRESPONSIBILITIESOFAMENTALLYILL andcanbebroughtbackforcefullyifhedoesnot
PERSON returnwithinamaximumperiodof90days.
Apsychiatricnurseisintheward24hoursofthe TheremainingChapters(IVtoVIII)dealwith
d dth
fi1 ibilitfth destablishmentofasylums,expensesoflunatics
ay,an emaresponsiiiyoewar .
. andtherulestobeimposedbythestate
managementisonthenurse.Sheshouldtherefore di f
1
.
b 11 d
·
11
f dgovernmentregarmgcareounatics.
ewe-verseinegaaspectsocarean
treatmentofthementallyill.Thisknowledge THEINDIANMENTALHEALTHACT(1987)
helpshertoguidethepatientsandrelativesin
mattersrelatedtorightsofthepatientandotherTheIndianMentalHealthActisderivedfrom
tft1h1th
MentalHealthActofEnglandandWales(1959
aspecsomenaeacare. . .
. amendedin1982).TheMentalHealthBillbecame
TherearetwoActsconcer.nedwiththecaretheAct
14of1987
on
22nd
Ma1987.
andtreatmentofthementallyill: Y
•TheIndianLunacyActof1912 ReasonsforEnactment
•TheIndianMentalHealthActof1987.
1.Theattitudeofthesocietytowardsthe
THEINDIANLUNACYACT(1912) mentallyillhaschangedconsiderablyandit
.. . . isnowrealizedthatnostigmashouldbe
ItisdenvedfromEnglishLunacyAct,1890andit attachedtosuchillness,asitiscurable
containseightChapters. practicallywhendiagnosedatanearlystage.
Thusthementallyillindividualsshouldbe
CHAPTERI treatedlikeanyothersickpersonsandthe
environmentaroundthemmadeasnormalas
possible.
Itcontainssomepreliminaryinformationand
definitions.

219. 216AGuidetoMentalHealthandPsychiatricNursing
2.TheexperienceofworkingoftheIndian
LunacyAct,1912hasrevealedthatithas
becomeoutmodedwiththerapidadvance­
mentofmedicalscienceandtheunder­
standingofnatureofmalady.Ithastherefore
becomenecessarytomakefreshlegislationin
accordancewiththenewapproach.
ObjectivesoftheIndianMentalHealthAct
•Toregulateadmissionintopsychiatrichos­
pitalsandpsychiatricnursinghomes.
•Toprotectsocietyfromthepresenceof
mentallyillpersons.
•Toprotectcitizensfrombeingdetainedin
psychiatrichospitalsInursinghomeswithout
sufficientcause.
•Toregulatemaintenancechargesof
psychiatrichospitals/nursinghomes.
•Toprovidefacilitiesforestablishingguar­
dianshipofmentallyillpersonswhoare
incapableofmanagingtheirownaffairs.
•Toestablishcentralandstateauthoritiesfor
mentalhealthservices.
•Toregulatethepowersofthegovernmentfor
establishing,licensingandcontrollingpsy­
chiatrichospitals/nursinghomes.
•Toprovidelegalaidtomentallyillpersonsat
stateexpenseincertaincases.
TheActcontains10Chapters.
CHAPTERI
Itcontainspreliminaryinformation.Somedefini­
tionsincludedinthisare:
•Psychiatrichospital/nursinghome:Ahospital/
nursinghomeestablishedormaintainedby
thegovernmentoranyotherpersonforthe
careofmentallyillpersons.
•Mentallyillperson:Apersonwhoisinneedof
treatmentbyreasonofanymentaldisorder
otherthanmentalretardation.
•Psychiatrist:Amedicalpractitionerpossessing
apost-graduatedegreeordiplomain
psychiatryrecognizedbytheMCI(Medical
CouncilofIndia).
•Receptionorder:Anordermadeunderthe
provisionsofthisActfortheadmissionand
detentionofamentallyillpersonina
psychiatrichospital/nursinghome.
CHAPTERII
Itdealswithestablishmentofcentralandstate
authoritiesforregulationandcoordinationof
mentalhealthservices.
CHAPTERIll
Itprovidesguidelinesforestablishmentand
maintenanceofpsychiatrichospitals/nursing
homes.
CHAPTERIV
Itdealswiththeproceduresforadmissionand
detentioninpsychiatrichospitals/nursing
homes.
1.AdmissiononVoluntaryBasis
Anypersonwhoconsidershimselftobementally
illandwishestobeadmittedtoapsychiatric
hospitalmayapplytothemedicalofficer-in­
charge;ifheisaminor,theguardiancanmake
thisapplicationonhisbehalf.
Themedicalofficershouldmakeinquiry
within24hoursandshouldadmitthepatientif
heopinesthattreatmentisrequired.Thevoluntary
patientthusadmittedisnowboundtoabideby
therulesmadebytheinstitution.
2.AdmissionunderSpecialCircumstances
Anymentallyillpatientwhoisunwillingfor
admissiononavoluntarybasismaybeadmitted
andkeptasaninpatientinapsychiatrichospital/
nursinghome.Forsuchpurposeanapplication
shouldbemadeoutonhis/herbehalfbyarelative
orafriendofthementallyillperson,providedthe
medicalofficerdeemsfit.
3.AdmissionunderReceptionOrder
Onapplication:Onlyarelativenototherthan
husband,wife,guardianorafriendcanmakeout

220. LegalAspectsofMentalHealthNursing217
anapplicationfortheadmissionofamentallyill
patient.Suchanapplicationshouldbemadeout
tothemagistrateinwritingsupportedbytwo
medicalcertificates,oneofthemissuedbya
gazettedmedicalofficer.Howevernoperson
beingaminororonewhohasnotseenthe
mentallyillpatientinthelast14dayscanmake
suchanapplication.Thepatientmaynowbe
admittedafterthemagistrateobtainsconsentfrom
themedicalofficerin-chargeofthemental
hospital.
Themedicalofficerin-chargecanextend
inpatienttreatmenttomorethan6monthsby
makingsuchanapplicationtothemagistrate.
Onproductionbeforethemagistrate:Mentallyill
patientsexhibitingviolentbehavior,creating
obscenescenesanddangeroustothesocietycan
bedetainedbythepoliceofficerandproduced
incourtwithin24hoursofsuchdetention,
supportedbytwomedicalcertificates,subsequent
towhichthemagistrateissuesareceptionorder.
4.AdmissioninEmergencies
Themedicalofficerin-chargemayorderthe
admissionofamentallyillpatientifhethinkshe
isdangeroustohimselforothers.Howeverthe
patientshouldbeproducedbeforethemagistrate
within24hours(maximumtimelimitis72hours,
whichisexclusiveoftheexaminationperiod),or
themagistratehimselfmayvisitthepsychiatric
hospital/nursinghomeandpassreceptionorder
onexamination.
5.TemporaryTreatmentOrder
Itisanorderissuedbythemagistrateincases
wheretheriskisperceivedtothepatient'slifeor
tothatofothers.Ifthemedicalofficerin-charge
feelsitnecessarytobringlegalauthoritiesinto
thepicturehecandosobyapplyingtothe
magistrate.Alternativelytherelativescangetthe
magistratetoissueanorderfortreatment.Insuch
caseasinglemedicalcertificateisrequiredwhich
isvalidfor6months.
6.AdmissionofMentallyIllPrisoners
Amentallyillprisonermaybeadmittedintoa
mentalhospitalontheorderofthepresiding
officeroracourt.
7.MiscellaneousAdmission
Amentallyillpatientcanbeadmittedeitheron
humanitariangrounds(e.g.wanderers)orfor
observationpurpose.Socialworkerscanobtain
anorderfromthemagistratependingreportfrom
medicalofficer.
CHAPTERV
Itdealsmainlywiththeproceduretobefollowed
forthedischargeofmentallyillpersonsfroma
mentalhospitalunderdifferentcircumstances.
1.DischargeofaPatientAdmittedonVoluntary
Basis
Medicalofficerin-chargeofpsychiatrichospital/
nursinghomeonrecommendationfromtwo
medicalpractitionerspreferablyapsychiatrist,
canissuedirectionsfordischargeofthepatient.
2.DischargeofaPatientAdmittedunderSpecial
Circumstances
Arelativeorafriendmaymakeanapplicationto
themedicalofficerforcareandcustodyofthe
patient.Therelativesarerequiredtofurnisha
bondwithorwithoutsureties,alongwithan
undertakingthatthementallyillpersonshallbe
preventedfromcausinginjurytoselforothers.
3.DischargeofaPatientAdmittedon
ReceptionOrder
Anapplicantwhofeelsthatthepatienthas
recoveredfromillnessmaymakeanapplication
fordischargetothemagistrate.Acertificate
shouldaccompanysuchanapplicationfrom
medicalofficerin-chargeofthepsychiatric
hospital/nursinghome.Ifthemagistratedeems
fithemayissueanorderfordischarge.

221. 218AGuidetoMentalHealthandPsychiatricNursing
4.DischargeofaPatientAdmittedbyPolice
Incaseswherethepolicedetainthementallyill
individualinhospital,hemaybedischargedafter
thefamilymembersagreeinwritingtotakeproper
care,andthemedicalofficer-in-chargeopinesthat
heisfittobedischarged.
5.DischargeofaMentallyIllPrisoner
Thehospitalauthoritieshavetoreportevery6
monthsabouttheperson'sstateofmindtothe
authority,whichhadordereddetention.Assoon
astheyfindthatthepersonisfittostandthetrial,
theyhavetoinformaboutthesametotheauthority
concerned.Thepersonisthenhandedovertothe
prisonofficerforfurtherlegalaction.
LeaveofAbsence
Onapplicationbyarelativeorotherstothe
medicalofficer-in-chargeandabonddulysigned
statingthatthepatientwillbetakenpropercare
ofandpreventedfrominjuringselforothers,leave
ofabsencemaybegranted(foraperiodof
maximum60days).
CHAPTERVI
Itdealswithjudicialenquiryregardingmentally
illpersonspossessingproperty,theircustodyand
managementofproperty.Aguardianmaybe
appointedbycourtoflawonbehalfofanalleged
mentallyillpersonincapableoflookingafterself
andproperty.
CHAPTERVII
Itdealswithwaysandmeanstomeetthecostof
maintenanceofmentallyillpersonsdetainedin
psychiatrichospital/nursinghome.
CHAPTERVIII
ItisthelatestadditiontotheAct,whichprovides
fortheprotectionofhumanrightsofmentallyill
person.Theserightsinclude:
1.Nomentallyillpersonshallbesubjected
duringtreatmenttoanyindignity(physical
ormental)orcruelty.
2.Nomentallyillpersonundertreatmentshall
beusedforthepurposeofresearchunless
•suchresearchisofdirectbenefittohim.
•aconsenthasbeenobtainedinwriting
fromtheperson(involuntaryadmission)
orfromtheguardian/relative(ifadmis­
sionwasinvoluntary).
3.Noletterorcommunicationsentbyortoa
mentallyillpersonshallbeintercepted,
detainedordestroyed.
CHAPTERIX
Itdealswithprocedurestobefollowedforthe
establishmentandmaintenanceofpsychiatric
hospitals/nursinghomes,andthepenalties,
whichcanberelativelysevereandexplicit,for
contraveningthem.
CHAPTERX
Itdealswithclarificationpertainingtocertain
procedurestobefollowedbythemedicalofficer­
in-chargeofthepsychiatrichospital/nursing
home.
LEGALISSUESINPSYCHIATRY
1.LawsRelatingtoPsychiatryinIndia
1.TheCareandTreatmentLegislation
(MentalHealthLegislations)
2.CriminalResponsibilitiesFormulation
(CriminalLaws)
3.CivilStatusProvisions(CivilLaws)
2.MentalHealthRelatedLegislations
•MentalHealthAct1987
•PersonswithDisabilitiesAct1996
•RehabilitationCouncilofIndiaAct1992
•JuvenileJusticeAct1986
•ConsumerProtectionAct1986
3.CivilLawsRelatingtoMentalIllPersons
•IndianEvidenceAct1925Sec.118
•LawofContractSec.6,11and12
•RighttoVoteandStandforElection-Act
326,102oftheConstitutionofIndia

222. LegalAspectsofMentalHealthNursing219
•LawofTorts
•TestamentaryCapacity-IndianSucces­
sionAct1925Sec.59
•MarriageandMentalHealthLegislation
•IndianDivorceAct1869
•ParsiMarriage+DivorceAct1936
•DissolutionofMuslimMarriageAct
1939
•TheSpecialMarriageAct1954
•TheHinduMarriageAct1955,1976
•TheFamilyCourtAct1984
4.CivilLawsRelatingtoPsychiatry
•ProvisionsastoAccusedPersonsof
UnsoundMindSecs.328-339Cr.Pc.1973
•CriminalResponsibilitySec.84IPC-1860
•AttempttoCommitSuicideSec.309IPC
•RighttoPrivateDefenceAgainstanInsane
PersonSec.98IPC
•UnnaturalOffencesSec.377IPC(Sexual
Perversions)
•Affrays(Sec.159InMania)
•MisconductinPublicunderIntoxication
(e.g.AlcoholDefenceSec.510IPC)
•NDPSAct1985(Amended1988)
5.SuicideandIndianLaw
•Suicideistheonlycriminalactforwhich
apersonispunishedifhefailsinthe
attempttodoso
•"Nopersonshallbedeprivedofhislife"
Act21constitutionofIndia
•Sec.309/IPC-attempttocommitsuicide­
punishable
•1994-S.C.Judgment-Sec.309was
declaredvoid
•Sec.306-abetmentofsuicideanoffence
•Nospecificlawsforassistedsuicideand
euthanasia
6.TheNarcoticDrugandPsychotropic
SubstancesAct(Act61of1985)
InIndiatheopiumActof1857wasrevisedfirst
in1878.In1950,theopiumActof1878was
revisedastheOpiumandRevenueLawsAct1950.
On16thSeptember1985,theabovementioned
ActswererepealedandNDPSAAct61of1985
wasenforced.
Contents
•TheactincludesNarcoticdrugs(opium,
poppy,straw,cannabis,cocaine,cocaandall
relatedsynthesizeddrugs)andpsychotropic
substances(76drugsandtheirderivativese.g.
majortranquilizers,minortranquilizers,
pentazocine,barbituratesetc.).
•Inthisactifapersonproduces,possesses,
transports,imports,sells,purchasesoruses
anynarcoticdrugsorpsychotropicsubstances
(except'Ganja')heshallbepunishablewith
•Rigorousimprisonmentfornotlessthan
10years,whichmaybeextendedupto20
yearsandafineofnotlessthan1lakh
rupees,whichmayextendtotwolakh
rupees.
•Forrepeatoffencearigorousimprisonment
ofnotlessthan15yearswhichmaybe
extendedupto30yearsandafineofnot
lessthan1.5lakhrupees,whichmaybe
extendedupto3lakhrupees.
•Forhandling'Ganja',arigorousimprison­
mentwhichmayextendto10yearsanda
fineupto1lakhrupees.
•Oncarrying'smallquantities'e.g.Heroin
-250mg,Opium-5gm,Cocaine-125
mg,Charas-5gm,aswerelaterspecified
inthisact,thepunishmentmayextendto
1yearorafineorboth.ForGanja,(below
500gms),imprisonmentisupto6months.
•Underaspecifiedcourtorder,thereisa
provisionfordetoxificationofthepatient.
•Underalaterenactment,thepreventionof
illicittrafficinNarcoticDrugsandPsycho­
tropicSubstancesAct(NDPSA)1988(Act
46)hasbeenpassed.Nowthereisa
provisionforpreventivedetention,seizure
ofproperty,deathpenaltyifapersonis
boundtobetraffickingmorethanorequal
to1kgofpureheroindespiteconviction
andwarningonthefirstattempt.

223. 220AGuidetoMentalHealthandPsychiatricNursing
LEGALASPECTSINPSYCHIATRICNURSING
Innoothertypeofnursingarethelegalandethical
considerationsofpracticesocrucialasin
psychiatricnursing.Thus,knowledgeofthelaw
regardingpsychiatryintheareawherethenurse
ispracticinghelpshertoprotectherselffrom
liabilityandthepatientfromunnecessary
detentionandmistreatment.
RoleoftheNurseinAdmissionProcedure
•Amostimportantfeatureoftheadmission
procedureinvolvessettlingthepatientinthe
ward.Itbeginswithintroducinghimtothe
otherstaffmembersandpatients.
•Beforeassigninghimabedconsiderhis
biologicalandemotionalneeds.Ifheseemsto
benurturingsuicidalideationorisfloridly
psychotic,heshouldbelocatedinaplace
wherehecanbecloselyobserved.
•Heshouldbeshownvariousfacilitieslike
eating,recreation,bathroomfacilities,etc.
•Acquainthimwithsomeofthewardrules,
e.g.mealtime,wardactivities,visitinghours,
howtomakeappointmentstoseestaff
members,timingsofanygroupmeetings,etc.
•Thepatientandhisrelativesarelikelytohave
allsortsofanxietiesaboutvariousprocedures
andinvestigations.Thenurseneedstobe
sensitivetothesefeelings,andgiveenough
timeandattentionandallowthemtoexpress
theirfeelingsaboutthepatient'scondition,
treatmentandoutcome.Allinformation
shouldbeprovidedasappropriate.
RoleoftheNurseinParole
Paroleisthepermissiongiventopatientsto
performcertainritualsorattendcertainfamily
functions.
•Relativesareclearlyinstructedaboutthe
purposeforwhichthepatientisbeingsent
homeandwhenheshouldbebroughtback.
•Instructtherelativesastohowtheyshould
converseorbehavewiththementallyill
personaccordingtotheinstructionsgivenby
thedoctor.
•Ifthepatientisreceivinganymedications,
insistonregularityandgivenecessary
instructionstothefamilymembersabout
dosage,side-effects,etc.
RoleoftheNurseinDischargeProcedure
•Nursemustensurethatthepatientleavesthe
unitwithallbelongingsandpersonaleffects,
hastheappropriatemedicationswithhim,
andappointmentforfollow-uphasbeen
madeandunderstood.
•Allnecessaryinstructionsespeciallyregar­
dinghismedicationregimen,side-effectsetc.
mustbeclearlygiventothepatientandhis
familymembers.
•Anypaperwork,signingofdocuments
shouldbecompleted.Thehospitalfilealong
withallchartsandnotesshouldbesenttothe
medicalrecordssection.
•Thenurseshouldascertainhistravelplanand
offerassistanceifnecessary.
•Thenursemustbearinmindthatthepatient
mayhavemixedfeelingsaboutleavingthe
hospitalandgoingbacktohishome
environment.Sheshouldhelphimcopewith
anydistressaboutseparatingfromhisnew­
foundfriendsandstaffmembers.
BasicRightsofPsychiatricPatientsand
Nurse'sResponsibilities
Psychiatricpatientsareoftentheleastcapableof
protectingtheirownrights.Itisthereforeoneofthe
responsibilitiesofthenursetoguidethepatients
andrelativesinmattersrelatedtotheirrightsand
protectthepatientfromanymistreatment.
SomeoftheRightsofPsychiatricPatients
•Therighttoweartheirownclothes.
•Therighttohaveindividualstoragespacefor
theirprivateuse.
•Therighttokeepandusetheirownpersonal
possessions.
•Therighttospendasumoftheirmoneyfor
theirownexpenses.

224. LegalAspectsofMentalHealthNursing221
•Therighttohavereasonableaccesstoall
communicationmedialiketelephone,letter
writingandmailing.
•Therighttoseevisitorseveryday.
•Therighttotreatmentintheleastrestricted
setting.
•Therighttoholdcivilservicestatus.
•Therighttorefuseelectroconvulsivetherapy.
•Therighttomanageanddisposeofproperty
andexecutewills.
Nurse'simplicationsforprotectingpatient'srights
•Toprotectpatient'srights,thenurseshould
beawareoftheserightsinthefirstplace.
•Sheshouldensurethatwardproceduresand
policiesshouldnotviolatepatient'srights.
•Discussingtheserightswiththementalhealth
teamandincludingtheserightsinthenursing
careplanisallpartofherresponsibilityin
protectingthepatient'srights.
NursingMalpractice
Whenaprudentnurseexpectedtomeetthe
normalstandardsofcare,causesabreachby
deviatingfromthenorms,itistermedasnursing
malpractice.Suchbreachofactcaninvokelegal
proceedingsagainstthenursefornotdischarging
herdutydiligentlyandingoodfaith.
Ifthemalpracticesuithastostandandbe
decreedinfavoroftheaggrievedpatient,hewill
havetoprovevariousfacetswhichcontributedto
thebreach.Howeveritistobenotedthatthe
burdenofprooflieswiththepatientwhointhis
caseistheplaintiff.Thevariousfacetsinclude:
•thenursehadadutytodischargedue
standardsofcaretothepatient
•thenurse'sperformancewaswellbelowthe
expectedstandards,thuscausingabreach
•substandardcareprovidedshouldbe
construedtohaveadverselyaffectedthe
patientandfamily
•theactualproofofadverseeffects/injury
caused.
InformedConsent
Inthecourseofnormaltreatmentaseriesof
interactionsresultbetweenapatientanda
physician.Duringsuchinteractionsthepatient
isallowedtofullyconsiderandcomprehendthe
informationabouttheproposedtreatment.Such
consentistermedasinformedconsent.Itincludes
themodeofadministeringthetreatment,
prognosis,side-effectsandtherisks.
However,inthecaseofpsychiatricpatients
theabilitytogiveinformedconsentasregardsa
procedureishighlydebatableduetothenature
oftheproblem.Thoughmostofthepatients
perceiveandactintheirownbestinterests,some
maynotbecapableofgivingavalidconsent.Due
tosuchvariations,thepatientshavetobescreened
forthefollowing:
•whetherthepatientiscompetenttogive
informedconsent
•whetherinformationprovidedtothepatient
isassimilatedonaregularbasisandunder­
stood
•whetherenoughopportunityandfreedom
arevestedwiththepatienttoreject/revokethe
consentduringaspecificcourseoftreatment.
SubstitutedConsent
Whenitisdeemedthatapatientisincapableof
givinginformedconsent,healthserviceproviders
shouldobtainsubstitutedconsentforthe
procedureItreatment.Itreferstoanauthorization
givenbyanotherindividual,beingaguardian
appointedbythecourtorthekithandkinon
behalfofthepatient.
Confidentiality
Duringthenurse-patientrelationshipalotof
informationisgatheredthroughdirectand
indirectsources,whichisbothverbalandwritten.
Keepinginviewtheethicsofthenursingpractice,
suchinformationgatherediskeptconfidential
andbestusedforprovidingenhancedcarerather
thanforotherpurposessuchasgossiporpersonal
gain.
Anybreachofconfidentialitycouldjeopardize
thebestinterestsofthepatient,beitsocialor
economical,keepinginviewthesocialstigma
attachedtomentalillness.

225. 222AGuidetoMentalHealthandPsychiatricNursing
RecordKeeping
Nursingnotesandprogressrecordsconstitute
legaldocumentsandhenceshouldbemaintained
carefully.Theyshouldbenon-judgementaland
thestatementsmadeshouldbeobjectiveinnature.
LEGALRESPONSIBILITIES OFA
MENTALLYILLPERSON
InlegalparlanceresponsibilityreferstoliabilityI
accountabilityforhis/heractsofnegligence.If
suchactsarecontrarytothelawoftheland,
suitablepunishmentisawarded.Apersonof
unsoundmindcommittinganactcontrarytolaw,
incapableofknowingitsnatureshallnotbeheld
fortheoffence.
Howeverapointtobenotedisthat'irresistible
impulsetest'isusedinunisonwiththe
M'Naghtenrule.Itreferstoasituationwherea
personmayknowthedifferencebetweenright
andwrongbutfindshimselfimpulsivelydriven
tocommitthecrime.
M'Naghtenrulestatesthattheindividualat
thetimeofthecrimedidnotknowthenatureand
qualityoftheactandifhedidknowwhathewas
doing,hedidnotcomprehendittobewrong.These
rulesarealsoreferredtoasthe'natureandquality
rule'and'rightfromwrong'test.
'Durhamtest'or'productrule'statesthatan
accusedpersonisnotcriminallyresponsibleif
his/herunlawfulactistheproductofmental
diseaseormentaldefect.
AspertheAmericanLawInstitute's(ALI)test,
apersonlackingadequatecapacitytorealizethe
criminalityofhisactorconformityofhisconduct
totheprovisionsoflawisnotresponsiblefor
performingsuchanact.
CivilResponsibilitiesofaMentally
IllPerson
ManagementofProperly
Thecourtmayonanapplicationfromany
relativedirectaninquirytoascertainwhethera
personisofunsoundmindandincapableof
managinghisproperty.Insuchacaseamanager
isappointedbythecourtoflawtotakecareofhis
property,whichmayincludesaleordisposalof
thepropertytosettlehisdebtsIexpenses.
Marriage
AspertheHinduMarriageAct(1955),marriage
betweenanytwoindividualsoneofwhomwas
ofunsoundmindatthetimeofmarriageis
considerednullandvoidintheeyesofthelaw.
Unsoundnessofmindforacontinuousperiod
canbesightedasagroundforobtainingdivorce.
Theotherpartycanfilefordivorcewhenlunacy
continuesforaperiodofmorethan2yearsafter
marriage.Howeverifdivorceisfiledaftera3-
yearperiod,divorceisgrantedwithapre­
conditionthattheotherpartyhastopay
maintenancechargesforthementallyillperson.
TestamentaryCapacity
AspertheIndianSuccessionAct,testamentary
capacityofthementalabilityofapersonisapre­
conditionformakingavalidwill.Thetestator
mustbeamajor,freefromcoercion,understan­
dinganddisplayingsoundnessofmind.Attimes
doctorsandnursesarecalledupontowitness
thewillofanailingperson.Undersuch
circumstancesthedoctorteststhetestatorfor
orientation,concentrationandmemory.Aperson
affectedbydelusionaldisordercanalsomakea
validwillifthosedelusionsarenotrelatedtothe
disposaloftheproperty.
RighttoVote
Apersonofunsoundmindcannotcontestfor
electionsorexercisetheprivilegeofvoting.
Inconclusion,nursingpracticemustconfirm
topre-setlegalstandardsandcontinuouslyre­
orientitselftotheeverevolvinglegalstandards.
Itisonlythemotivatedandcapablenursewho
canincorporatelegalknowledgewhiledis­
pensingpatientcare,anditistoherthatmany
patientswillturnforinformationandcare.

226. LegalAspectsofMentalHealthNursing223
REVIEWQUESTIONS
•IndianMentalHealthAct(Nov2003,Oct2004,
Apr2006)
•IndianLunacyAct(Nov2002,Apr2006)
•Paroleorleaveofabsence(Oct2005)
•Typesofadmissioninmentalhospital
(Feb2000)
•Admissionproceduresforamentally
illpatient(Apr2003,Nov2003,Apr2006)
•Dischargeprocedureforamentallyillpatient
(Oct2005)
•Legalaspectsinpsychiatricnursing(Nov2000)
•Protectionoftherightsofthementallyill
(Nov2003)
•Rightsofmentallyillpatient(Nov2002)

227. CommunityMental
HealthNursing
DCOMMUNITYMENTALHEALTHININDIA
DCOMMUNITYMENTALHEALTHCENTERS-
CERTAINFEATURES
DCOMMUNITYFACILITIESFORPSYCHIATRIC
PATIENTS
PsychiatricHospitals
PartialHospitalization
QuarterwayHomes
HalfwayHomes
Self-helpGroups
SuicidePreventionCenters
OtherFacilities
DCOMMUNITYMENTALHEALTH-PSYCHIATRIC
NURSING
CommunityMentalHealthPsychiatric
NurseAttributes
Assessment
Intervention
SomeTipstobekeptinMindWhen
WorkingintheCommunity
DLEVELSOFPREVENTIONANDROLEOFANURSE
PrimaryPrevention
SecondaryPrevention
TertiaryPrevention
DPSYCHIATRICREHABILITATION
PrinciplesofRehabilitation
PsychiatricRehabilitationApproaches
RehabilitationTeam
StepsinPsychiatricRehabilitation
RoleofaNurseinPsychiatricRehabilitation
VocationalRehabilitation
DNATIONALMENTALHEALTHPROGRAM
Objectives
Approaches
Components
Themethodsoftreatingmentalillnesshave
changeddramaticallyinthepastcentury.
Communitymentalhealthasatreatment
philosophy,wasmandatedbytheCommunity
MentalHealthCentersActof1963,thusbringing
abouttheshiftofmentalhealthcarefromthe
institutiontothecommunity,andheraldingthe
eraofdeinstitutionalization.
COMMUNITY MENTALHEALTHININDIA
Theoverallgoalofcommunitymentalhealthas
outlinedbyMrs.IndiraGandhiinMay1981while
addressingtheWorldHealthAssemblyisas
follows:
"InIndia,wewouldliketogotohomesinstead
oflargenumbersgravitatingtowardscentralized
hospitals.Servicesmustbeginwherepeopleare
andwhereproblemsarise."
Activethinkinginthisareamarkedthedecade
of1970s,andconcernfororganizingmental
healthserviceswasexpressedinnationaland
regionalforums.Notableamongthesearethe
IndianPsychiatricSociety'sseminars/work­
shopsatMadurai(1971),Trivandrum(1975)and
Nagpur(1976).
Oneofthemostimportantelementsinthe
supplyofhealthcareinIndiahasbeenthe
PrimaryHealthCenter(Provisionofmentalhealth
careisoneofthecomponentsofPrimaryHealth
Care).Thisprovidesauniqueopportunityto
providementalhealthcarethroughthe
multidisciplinaryapproachandcollaborative
services.Failureinthisregardisduetocomplex
problemssuchaslimitedresources,lackoftrained
manpowerandinadequatelong-termplanning.
Thenextimportantphaseofdevelopmentof
mentalhealthserviceswasthesettingupof
GeneralHospitalPsychiatricUnits(GHPUs).The
GHPUprovidedabigpushforthegreater
acceptanceofpsychiatricservicesbythepublic
withoutfearofsocialstigma.

228. CommunityMentalHealthNursing225
Thenextphaseofdevelopmentofmental
healthserviceswasthecommunitycare
approach.Twocentersthattookupcommunity
mentalhealthworkin1975wereBangaloreand
Chandigarh.Thustheapproachtodevelopment
ofserviceshasbeenarapidtransitionfrommental
hospitalstoGHPUsandtocommunitycare.
Accordingtomentalhealthexperts,a
communitymentalhealthprogramshould:
•providementalhealthcareinthecommunity
asopposedtoinstitutionalcare
•focusservicesonatotalcommunityor
populationratherthanonanindividual
patient
•focusonpreventiveandpromotiveservices
asdistinguishedfromtherapeuticones
•providecontinuityandcomprehensivenessof
servicesratherthanfragmentaryand
symptom-basedcare
•provideindirectservicessuchasconsultation
andmentalhealtheducationratherthandirect
servicesalone
•includeselectionandtrainingofprimarycare
workersfromthelocalcommunityinorderto
providebasicmentalhealthcare
COMMUNITY MENTALHEALTHCENTERS­
CERTAINFEATURES
Commitment
Commitmentsuggeststhatthecentersshould
identifyallthementalhealthneedsofthe
population.Thisrequiresthatthementalhealth
servicesbelocatedclosetopeople'sresidencesor
workplacestomakeiteasyforthemtoidentify
illnessandobtaintreatment.
Services
Integratedandbalancedservicesinresponseto
expressedlocalneedsmustbeprovided.
Long-termCare
Continuityofcareenablesasingleclinicianto
followapatientthroughemergencyservices,
hospitalizationandpartialhospitalizationasa
transitiontothecommunityandout-patient
treatmentandfollow-up.
CaseManagement
Casemanagersareclinicianswhocanprovide
continuityofcare;theyensurecontinuingtreat­
mentbyinitiatingcontactduringhospitalization
andcontinuingsupportthroughafter-care.
CommunityParticipation
Communityshouldparticipateindecisionsabout
theirmentalhealthcareneedsandprograms.
EvaluationandResearch
Evaluationistheprocessofobtaininginformation
aboutacommunitymentalhealthprogramand
itseffectonpeopleandsituations.
Researchmayfocusspecificallyonkeyissues
andaddressaparticulardisorderoratreatment
method.
PossibleCommunityMentalHealth
PracticeSites
•Communitymentalhealthcenters
•Youthcenters
•Privatepracticeoffice
•Crisiscenters
•Shelters
•Clients'homes
•Schoolanddaycarecenters
•Nursinghomes
•Dayhospitalfacilities
•Emergencydepartmentofcommunityhos­
pitals
•Churches,temples,mosques
COMMUNITY FACILITIESFORPSYCHIATRIC
PATIENTS
Inthecommunity,sevenprovisionsarerequired
toreplacelong-termcareinhospital:
•Suitablewell-supportedcarers
•Suitableaccommodation
•Suitableoccupation
•Arrangementstoensurethepatient'scolla­
borationwithtreatment

229. 226AGuidetoMentalHealthandPsychiatricNursing
•Regularreassessment,includingassessment
ofphysicalhealth
•Effectivecollaborationamongstcarers
•Continuityofcareandrapidresponsetocrises
Somefacilitiesavailableinclude:
APsychiatrichospitals:Hospitalshavebecome
partofacontinuumofmentalhealthservices
availabletopatientsandtheirfamilies,and
offeravarietyoftreatmentsforpsychiatric
disorders.
B.Partialhospitalization:Partialhospita­
lizationisaninnovativealternativeto
hospitalization.Itisideallysuitedtomostof
thepsychiatricsyndromes,particularly
chronicpsychoticdisorders,neurotic
conditions,personalitydisorders,drugand
alcoholdependenceandmentalretardation.
Daycarecenters,dayhospitalsandday
treatmentprogramscomeunderpartial
hospitalization.
Partialhospitalisationhastheadvantagesof
lesserseparationfromfamilies,moreinvolvement
inthetreatmentprogramandalesseningof
patient'spreoccupationwiththeillness,which
maybeintensifiedbyfullhospitalization.
MaindaycarecentresinIndia
•Sanjivini,NewDelhi
•SCARF(SchizophreniaResearchFounda­
tion),Chennai,hasstartedadaycarecenter
called"BAVISHYA"in1985
•AssociationoftheFriendsofMentallyIll,
Mumbai
•InstituteofMentalHealth,Ahmedabad
•PsychiatricCenter,Kolkata
•NIMHANS,Bangalore
•KrupamayieInstituteofMentalHealth,Miraj
•AnugrahaDayCareCenter,Chennai
•TheRichmondFellowshipSociety,Bangalore
C.Quarterwayhomes:Thisisaplaceusually
locatedwithinthehospitalcampusitself,but
nothavingtheregularservicesofahospital.
Theremaynotberoutinenursingstaffor
routinerounds,andmostoftheactivitiesof
theplacearetakencareofbythepatients
themselves.
Examplesofsuchhomesare13thand14th
psychiatricwardsofNIMHANSatBangalore.
D.Halfwayhome:Ahalfwayhomeisa
transitoryresidentialcenterformentallyill
patientswhonolongerneedthefullservicesofa
hospital,butarenotyetreadyforacompletely
independentliving.Itattemptstomaintaina
climateofhealthratherthanofillness,andto
developandstrengthenindividualcapacities.At
thesametimeitenablestherecognitionof
problemsthatrequiremedicalattention,and
permitsthediscoveryofconditionsinthe
communitywhichareactingadverselyonthe
individual.Thus,halfwayhomeshaveamajor
roleintherehabilitationofthementallyill
individual.
Objectives
•Toensureasmoothtransitionfromthe
hospitaltothefamily.
•Tointegratetheindividualintothe
mainstreamoflife.
Activities
Communitymentalhealthnursesplayavitalrole
inmonitoringtheprogressofdischargedpatients
inhalfwayhomes,especiallywithregardtotheir
medicationregimenandcoordinationofcare.
Someoftheinterventionscarriedoutinhalfway
homesinclude:
•Assessment:Clinicalassessmentincluding
assessingforresidualpsychiatricsymptoms
whichmayaffecthisabilitytofunction;social
assessmentincludingassessingfamily
support,attitudeoffamilymembersand
economicstatusofthefamily;psychological
assessmentincludingassessingself-esteem,
confidence,patient'slevelofmotivation;
vocationalassessmentincludingassessing
physicalstrength,handcoordination,
attention,concentrationetc.
•Reductionofimpairments:Thisincludes
reductionoreliminationofthesymptomsand
cognitiveimpairmentsthatinterferewith
socialandvocationalperformance.These
impairmentsareeliminatedforthegreaterpart
byvariouspsychotropicagents.

230. CommunityMentalHealthNursing227
•Remediationofdisabilitiesthroughskill
training:Skilltrainingisusedtoremediate
disabilitiesinsocial,familyandvocational
functioning.Patientsgenerallyrequire
traininginself-careskills,interpersonalskills,
vocationalandemploymentpursuits,
recreationalandleisureskills.
•Remediatingdisabilitiesthroughsupportive
interventions:Thesestrategiesaimathelping
theindividualscompensateforhandicapsby
learningskillsinlivingandworking
environments,adjustingtheindividualand
familyexpectationstoaleveloffunctioning
thatisrealisticallyattainable.
Outcomes
Expectedoutcomescouldbe:Successfulreturnof
thepatientstotheirhomes,preventionofrelapses,
economicself-sufficiencymadepossiblethrough
vocationalcounselingandself-employment
programs.
Nursesneedtobefamiliarwiththevarious
halfwayhomesavailableinthecommunity;
collaborationwithsuchfacilitiesisabsolutely
essentialforsuccessfulrehabilitation.Someofthe
halfwayhomesavailableinIndiainclude:
•Medico-PastoralAssociation,Bangalore
•AtmashaktiVidyalaya,Bangalore
•RichmondFellowship,Bangalore
•PuraskaraAftercareHome,Bangalore
•Cadabam'sHomefortheMentallyDisabled,
Bangalore
•FamilyFellowshipSocietyforPsychosocial
Rehabilitation,Bangalore
•RajuRehabilitationFoundation,Bangalore
•YWCAHalfwayHomeforMentallyIll,
Chennai
•Dr.Boaz'sRehabilitationCenter,Chennai
•Dr.Dhairyan'sPsychotherapyandReha-
bilitationCenter,Chennai
•SowkyaHalfwayHomeatMadurai
•DelhiPsychosocialRehabilitationSociety
•ParipurnataHalfwayHome,WestBengal
•SocietyforMentalHealth,Kerala
E.Self-helpgroups
•Self-helpgroupsarecomposedofpeoplewho
aretryingtocopewithaspecificproblemor
lifecrisis,andhaveimprovedtheemotional
healthandwellbeingofmanypeople.Usually
organizedwithaparticulartaskinmind,such
groupsdonotattempttoexploreindividual
psychodynamicsingreatdepthortochange
personalityfunctioningsignificantly.
•Adistinguishingcharacteristicofself-help
groupsistheirhomogeneity.Themembers
havethesamedisordersandsharetheir
experiencesgoodorbad,successfulor
unsuccessful,withoneanother.Themembers
worktogetherusingtheirstrengthstogain
controlovertheirlives.Bysodoing,they
educateeachother,providemutualsupport,
andalleviatethesenseofalienationusually
feltbypeopledrawntothiskindofgroup.In
otherwords,self-helpgroupsarebasedon
thepremisethatpeoplewhohaveexperienceda
particularproblemareabletohelpotherswhohave
thesameproblem.
•Oneoftheirmostimportantfunctionsisto
demonstratetoindividualsthattheyarenot
aloneinhavingaparticularproblem.Sharing
eachothers'experiencesnotonlyhelpsthe
membersbyprovidingmutualsupport,but
alsobygeneratingalternatewaystoviewand
resolveproblems.Thustheyhelpin
overcomingmaladaptivepatternsofbehavior
orstatesoffeelingthattraditionalmental
healthprofessionalshavenotgenerallydealt
withsuccessfully.
•Self-helpgroupsemphasizecohesion,which
isexceptionallystronginthesegroups.
Becausethegroupmembershavesimilar
problemsandsymptoms,theydevelopa
strongemotionalbond.Buteachgroupmay
haveitsuniquecharacteristics,towhichthe
memberscanattributemagicalqualitiesof
healing.
•Strategies:Thestrategiesusedbygroup
leadersincludepromotionofdialogue,self­
disclosureandencouragementamong
members.Conceptsusedinsupportgroups
includepsychoeducation,self-disclosure,and
mutualsupport.

231. 228AGuidetoMentalHealthandPsychiatricNursing
•Processes:Theprocessesinvolvedinself-help
groupsaresocialaffiliation;learningself­
control;andmodelingmethodstocopewith
stressandactingtochangethesocial
environment.
•Theendresultisthatthesegroupsprevent
physical,emotionalandsocialproblemsand
breakdowns;improveanindividual'sora
family'squalityoflife;andprovidethe
educationnecessarytodevelopthemember's
potentialfurther.Examplesofself-helpgroups
areAlcoholicsAnonymous(AA),Association
forMentallyDisabled(AMEND).
•Theself-helpgroupmovementinIndiaisin
itsascendancy.Oneoftherecent
developmentsisthestartofAMENDin
Bangalore.Peoplewithmentalillnesssuffer
fromsocialstigmaanddiscrimination.More
sotheirfamilymembersarestruckwith
disbelief,lonelinessandsorrow.Familiesof
suchpeoplehavegottogethertoforman
organizationinBangalorecalledAMEND-
AssociationforMentallyDisabled,underthe
leadershipofDr.NirmalaSrinivasan.AMEND
hasbeenadvocatingandpracticingfamily
basedcare.AtAMEND,familiesshare
experiences,talkaboutsideeffectsof
medicationanddiscusshowtheycan
communicateproblemstopsychiatrists.
AMENDalsoconductsworkshopstotrain
consumersinlivingskillssothattheycan
lookafterthemselves,tellthemwhatiswrong
withoneself,whytheyneedtotaketheir
medication,andwhatcanhappeniftheystop
andsoon.ManyofAMEND'sconsumers
havebeenrehabilitatedandareholdingjobs
aspartoftheiroccupationaltherapy.
F.Suicidepreventioncentres:Therearemany
suicidepreventioncentersinIndiainthe
voluntarysectorsdoinggoodworkand
helpingthoseinneed.Someofthemare:
•HelpingHandsandMPAinBangalore
•SnehainChennai
•SaharainMumbai
•SanjiviniandSumaitriinNewDelhi
G.Other
•Communitygrouphomes
•Largehomesforlong-termcare
•Hostels
•Homecareprograms
•Districtrehabilitationcenters
COMMUNITY MENTALHEALTH­
PSYCHIATRICNURSING
Communitymentalhealth-psychiatricnursingis
theapplicationofspecializedknowledgeto
populationsandcommunitiestopromoteand
maintainmentalhealth,andtorehabilitate
populationsatriskthatcontinuetohaveresidual
effectsofmentalillness.
Psychiatricnursinginthecommunitysetting
differsmarkedlyfromitshospitalcounterpart.
Thecommunitysettingrequiresthatthe
psychiatricnursepossessknowledgeabouta
broadarrayofcommunityresourcesandbe
flexibleinapproachingproblemsrelatedto
individualpsychiatricsymptoms,familyand
supportsystemsandbasiclivingneedssuchas
housingandfinancialsupport.
CommunityMentalHealth-Psychiatric
NurseAttributes
•Awarenessofself,personalandcultural
values
•Non-judgmentalattitude
•Flexibility
•Problemsolvingskills
•Abilitytocrossservicesystems(e.g.towork
withschools,otherhealthcareproviders,
employers,etc.)
•Knowledgeofcommunityresources
•Willingnesstoworkwiththefamilyor
significantothersidentifiedbytheclientas
supportpeople
•Understandingofthesocial,culturaland
politicalissuesthataffectmentalhealthand
illness
•Knowledgeofpoliticalactivism

232. CommunityMentalHealthNursing229
GoalsofCommunityMentalHealthNursing
•Toprovidepreventionactivitiestopopu­
lationsforthepurposeofpromotingmental
health.
•Toprovideinterventionsasearlyaspossible.
•Toprovidecorrectivelearningexperiencesfor
client-groupswhohavedeficitsanddisabi­
litiesinthebasiccompetenciesneededtocope
insociety,andtohelpindividualsdevelopa
senseofself-worthandindependence.
•Toanticipatewhenpopulationsbecomeatrisk
forparticularemotionalproblemsandto
identifyandchangesocialandpsychological
factorsthatdiverselyaffectpeople's
interactionwiththeirenvironments.
•Todevelopinnovativeapproachestoprimary
preventionactivities.
•Toassistinprovidingmentalhealth
educationtopopulationsaboutmentalhealth
andillnessandtoteachpeoplehowtoassess
theirmentalhealth.
CommunityMentalHealthNursingProcess
Assessment
Thekeyaspectsofassessmentinclude:
•Impairmentsdirectlyduetothepsychiatric
disordersuchaspersistenthallucinations,
negativesymptoms,socialwithdrawal,under­
activityandslowness.
•Secondarysocialdisadvantagessuchas
unemployment,povertyandhomelessness,as
wellasthestigmaattachedtopsychiatric
illness.
•Personalreactionstoillnessandsocial
disadvantagesuchaslowself-esteemand
hopelessness,poormotivationandcapacity
forself-managementandperformanceof
socialroles.
•Unpredictablebehavior,riskofharmtoself
andothers,andliabilitytorelapse.
•Financialpositionoftheclient.
•Availabilityofcommunityresources.
•Socialcircumstancestowhichthepatientis
likelytoreturnto.
Theexpectedoutcomeoftheassessmentisa
detailedoutlineoftheperson'spresentfunc­
tioning,highestleveloffunctioning,andthe
neededservices.
Intervention
Communitypsychiatricnursesmustapproach
interventionswithflexibilityandresourcefulness
tomeetthebroadrangeofneedsofthepatients
withcontinuedmentaldeficits.Interventions
cannotbedirectedonlytowardsdiscrete
psychiatricsymptoms,butmustalsofacilitate
client'saccesstovariouscommunityresources
providingforbasicneedssuchashousing,
nutrition,etc.
Sincepeoplesufferingfrommentalillness
oftenremaininorreturntothecommunity
followingtreatment,nursesmustbeabletoassess
thepresenceofcontinuedmentalhealthproblems
andplanandimplementinterventionswithinthe
confinesoftheresourcesavailableinthe
community.
Carretal(1984)haveidentifiedthefollowing
rolesfornursesworkingincommunitymental
healthservices:
Consultativerole:Thismeansgivingadvicetoother
professionalsinthecommunityaboutthetype
andlevelofnursingcarerequiredforagiven
clientgroup.
Clinicianrole:Providingdirectnursingcaretothe
patientsinthecommunity.
Therapeuticrole:Employingpsychotherapeutic
andbehavioralmethodsformanagementof
patients.
Assessor/researcherrole:Thenursemayassessthe
caregiventotheclient/clientgroup,andmay
alsoassesstheoutcomeofongoingcareprograms.
Educator:Creatingawarenessinthecommunity
aboutmentalhealthandmentalillnesswith
specialfocusonvulnerablegroups.
Trainer/Manpowerfacilitators:Trainingofparapro­
fessionals,communityleaders,school-teachers

233. 230AGuidetoMentalHealthandPsychiatricNursing
andothercare-g1vmgprofessionalsinthe
community.
Manager/Administrator:Managementofresources,
planningandcoordination.
Domiciliarycare:Servicesareprovidedtotheclient
byvisitingtheirhomes.Serviceslikeadminis­
trationofmedications,assessmentofthelevelof
functioningandimprovementofpatients,
monitoringofside-effectsofdrugs,counselingof
patientsandfamilymembersareofferedatthe
client'shomesetting.
Liaisonrole:Nursesworkinginthecommunity
helptheclientsandthefamilymembersby
bridgingthegapbetweentheclientandthe
hospital,clientandtheemployersandalsoby
networkinginthecommunityforresource
development.
Preventiveroles:Thesepreventiverolesareunder
primary,secondaryandtertiarylevels.
Otherareasofcommunityhealthpsychiatricnursing
are:
•Socialskillstraining
•Anxietymanagementandrelaxation
•Assertivetraining
•Bereavementcounseling
•Groupmeetings
•Communityout-reachworkservices
•Childcareservices
•Adultcareandelderlycareservices
SomeTipstobeKeptinMindWhen
WorkingintheCommunity
1.IdentificationofPatientsintheCommunity:
Talktoimportantpeoplelike,villagepanchayat
members,localleaders,teachers,educatedyouth,
membersofserviceagencieslike,angawadi,
mahilamandals,etc.andrequestthemtotellyou
aboutindividuals:
•whotalknonsenseandactinamanner
consideredstrangeorabnormal
•whohavebecomeveryquietanddonottalk
ormixwithotherpeople
•whoclaimtohearvoicesorseethingsthat
otherscannothearorsee
•whoaresuspiciousandclaimthatothersare
tryingtoharmthem
•whohavebecomeunusuallycheerful,crack
jokesandsaythattheyareverywealthyand
superiortootherswhenitisnotreallyso
•whohavebecomeverysadlatelyandcry
withoutreason
•whotalkaboutsuicideorhavemadean
attemptatsuicide
•whogetpossessedbygodorspiritorwhoare
saidtobethevictimsofblackmagicorevil
power
•whoaredull,mentallynotgrownuplike
othersoftheirageandslowsincebirth
Whenyouvisithomes,enquireaboutmembers
sufferingfrommentalillness.Asktheabove­
mentionedquestionstactfullywithoutoffending
themandobtaininformationabouttheexistence
ofapatientintheminthatfamily,neighborhood
oramongtheirrelatives.
Whenyougotoaschool,enquirefromteachers
andstudentsaboutchildrenwhosufferfromfits,
behavioralandlearningproblems.
2.Referthepatientimmediatelyinthefollowing
conditions:
•thepatientisseverelyill,violentorunmana­
geableathome
•historyofrecentheadinjury
•repeatedconvulsions(continuousormore
than3timesaday)
•disturbedbehaviorafterdelivery
•theclienthasattemptedsuicideoris
threateningtocommitsuicide
•disturbedbehaviorinpeoplewithknown
diabetesorhypertension
•peoplewhoshowabnormalbehaviorafter
takingalcoholoranyotherintoxicating
substances
3.Follow-upcarewithspecialemphasisonmedi­
cationregimen,improvementmade,andside­
effects,patient'soccupationalfunction
4.Bepreparedtoanswercertaincommonquestions
askedregardingmentalillness
•Ismentalillnesshereditary?

234. CommunityMentalHealthNursing231
•Ismentalillnesscontagious?
•Doghosts,blackmagic,cursecausemental
illness?
•Ismentalillnesstreatable?
•Canpatientstakeupresponsibilitiesafter
recovery?
•Canmarriagecurementalillness?
Ismentalillnesshereditary?
Theroleofgeneticfactorsiswellestablishedonly
insomepsychiatricillnesses(e.g.Schizophrenia,
ManiaandDepression).Itisalsonottruethatifa
familymemberissufferingfromSchizophrenia,
theothermemberswillalwaysdevelopthesame
illness.Thechancesaremorebutthefactorssuch
aspersonalityandenvironmentalfactorsplayan
equallyimportantrole.
Ismentalillnesscontagious?
Mentalillnessesdonotspreadthroughcontact
ofanyform.Individualgeneticvulnerabilityor
predispositionandprecipitatingfactorsplayan
importantroleindiseaseoccurrence.
Doghosts,blackmagic,cursecausemental
illness?
Manypeopleconsiderthatmentalillnessisnot
anillness,butpossessionbyghostor
supernaturalpower.Thecausationofmostofthe
mentalillnessesiswellknownandspecific
methodsareavailabletotreatmentalillnesses.
Ismentalillnesstreatable?
80%ofthementalillnessesarefullycurableand
preventable.ExcludingSchizophrenia,allother
mentalillnessescanbeeasilycontrolledand
preventedthroughpropermedicationsand
psychologicaltherapies.
Canpatientstakeupresponsibilitiesafter
recovery?
Likeotherphysicalillnessesmentalillnessesare
curablewithdrugsandotherphysicaland
psychologicalmethods.
Depressionandmaniaareself-limiting
illnesses,lastingfrom6to9months.Anxiety
neurosis,hysteriaetc.arefullycurableand
preventabledisorders.Ifschizophreniais
managedearlyandcorrectly,thepatientmay
becomesociallyandoccupationallynormal
withinfewweeks.
Canmarriagecurementalillness?
Amentallyillpersoncangetworseifhegets
marriedwhenheisill,asmarriagecanbecome
anadditionalstress.Apatientwhohasrecovered
cangetmarriedandliveanormallifelikeany
otherperson.
Anursecanplayanimportantrolein
communitybymakingthepublicawareofsome
importantprinciplesrelatedtomentalillness:
•Mentalillnesses,likephysicalillness,canbe
easilytreatedwithmedicationsandpsycholo­
gicalmethods.
•Thetreatmentofmentalillnessisnotjust
confinedtodrugs;italsoincludesmanyother
psychologicaltherapieslikebehaviormodifi­
cationtherapy,counseling,activitytherapy,
familytherapy,grouptherapyetc.
•Continuityoftreatmentismoreimportantfor
curingmentalillnesses.Treatmentshould
neverbetamperedwithouttheadviceofa
psychiatrist.
•Inmajorityofmentalillnessese.g.Mania,
depressionandotherneuroticdisorderslike
dissociativedisorder,patientscompletely
recoverwithoutaresidualeffect,ifthe
treatmentistakenonaregularbasis.
•Earlydetectionandprompttreatmentfor
mentalillnessesgivesbetterimprovementin
psychiatricpatients,theycanleadsocially
productivelives.
5.Remember
•donotgivefalseassurancesormakefalse
promises;justtellthemyouwilldoyourbest
tohelpthem
•donotmakeanydecisionsforthefamily
•donotcriticizeorblame
•seethattheydevelopconfidenceintheir
abilities
•donotmakethemdependentonyou
•avoidhalf-heartedattempts;hardworkyields
goodresults

235. 232AGuidetoMentalHealthandPsychiatricNursing
LevelsofPrevention
IHealthMaintenance
I
MENTALHEALTH
Abilitytocopewithactivitiesof
~PRIMARY Specificprotectionof
dailylivinginanadaptivemanner
PREVENTION I':,.vulnerablepopulations
Earlydiagnosisand
SECONDARY prompttreatment
MENTALILLNESS
vPREVENTION
Inabilitytoadapt ITERTIARY
hi
Rehabilitation
I
~.PREVENTION
(ThisparadigmwasdevelopedbyBloom,1979)
LEVELSOFPREVENTION AND
ROLEOFANURSE
Inthe1960s,psychiatristGeraldCaplan
describedlevelsofpreventionspecificto
psychiatry.Hedescribedprimarypreventionasan
effortdirectedtowardsreducingtheincidenceof
mentaldisordersinacommunity.Secondary
preventionreferstodecreasingthedurationof
disorderwhiletertiarypreventionreferstoreducing
thelevelofimpairment.
PrimaryPrevention
Primarypreventionseekstopreventthe
occurrenceofmentaldisordersbystrengthening
individual,familyandgroupcopingabilities.
RoleofaNurseinPrimaryPrevention
Communitymentalhealthnursesareinakey
positiontoidentifyindividual,familyandgroup
needs,conflictsandstressors.Thustheyplaya
majorroleinidentifyinghigh-riskgroupsand
preventingtheoccurrenceofmentalillnessin
them.Someinterventionsinclude:
1.Individualcenteredintervention
•Antenatalcaretothemotherandedu­
catingherregardingtheadverseeffectsof
irradiation,certaindrugsandprematurity.
•Ensuringtimelyandefficientobstetrical
assistancetoguardagainsttheilleffects
ofanoxiaandinjurytothenewbornat
birth.
•Dietarycorrectionstothoseinfants
sufferingfrommetabolicdisorders.
•Correctionofendocrinedisorders.
•Liberalizationoflawsregardingtermina­
tionofpregnancy,whenitisunwanted.
•Trainingprogramsforphysically,and
mentallyhandicappedchildrenlikeblind,
deaf,muteandmentallysubnormaletc.
•Counselingtheparentsofphysicallyand
mentallyhandicappedchildren,with
particularreferencetothenatureofdefects.
Theparentsneedtoacceptthechildand
emotionallysupportthechildandbe
satisfiedwithlimitedgoalsinthefieldof
achievement.
•Fosteringbondingbehaviors.Explaining
importanceofwarm,accepting,intimate
relationshipandavoidingtheprolonged
separationofmotherandchildare
essential.
2.Interventionsorientedtothechildinthe
school
•Teachinggrowthanddevelopmentto
parentsandteachers.

236. CommunityMentalHealthNursing233
•Identifyingtheproblemsofscholastic
performanceandemotionaldisturbances
amongschoolchildrenandgivingtimely
intervention.Schoolteacherscanbe
taughttorecognizethebeginningsymp­
tomsofproblemsandreferringto
appropriateagencies.
3.Familycenteredinterventionstoensure
harmoniousrelationship
•Consultingwithparentsaboutappro­
priatedisciplinarymeasures.
•Promotingopenhealthcommunicationin
families.
•Renderingcrisiscounselingtotheparents
ofphysicallyandmentallyhandicapped
children.
•Ensuringharmoniousrelationshipamong
membersofthefamilyandteaching
healthyadaptivetechniquesatthetimeof
stressproducingevents.
4.Interventionsorientedtokeepfamiliesintact
•Extendingmentalhealtheducation
servicesatChildGuidanceClinicsabout
childrearingpractices;atparent-teacher
associationsregardingthetriad
relationshipbetweenteacher,childand
parent;andatvariousextramuralhealth
agenciesregardingintegrationofmental
healthintogeneralhealthpractice.
•Strengtheningsocialsupportforthe
frustratedagedandhelpingthemtoretain
theirusefulness.
•Promotingeducationalservicesinthefield
ofmentalhealthandmentalhygiene.
•Developingparent-teacherassociations.
•Renderinghome-makerservices-when
thereisabsenceofthemotherfromhome
duetoillnessorotherreasonsfor
prolongedperiods,thepublichealth
nursecanarrangefortheservice.
•Providingmaritalcounselingforthose
havingmaritalproblems.
5.Interventionsforfamiliesincrisis
Indevelopmentalcrisissituationssuchasthe
childpassingthroughadolescence,birthofa
newbaby,retirementormenopause,deathof
awageearnerinthefamily,desertionbythe
spouseetc.crisisinterventioncanbegivenat
•Mentalhygieneclinics
•Psychiatricfirst-aidcenters
•Walk-inclinics
6.Mentalhealtheducation
•Conductmasshealtheducationprograms
throughfilmshows,flashcardsand
appropriateaudio-visualaidsregarding
preventionofmentalillnessesandpro­
motionofmentalhealthinthecommunity.
•Educatehealthworkersregardingpreven­
tionofmentalillnesssothattheycan
functioneffectivelyinalltheareasof
prevention.
7.Society-centeredpreventivemeasures
•Communitydevelopment
Culturallydeprivedfamiliesneedbiolo­
gicalandpsychosocialsupplies.They
needbetterhygieniclivingconditions,
properfood,education,healthfacilities,
andrecreationalfacilities.Otherwise,
psychopathy,alcoholism,drugaddiction,
crimeandmentalillness,willresultin
suchsituations.
•Collectionandevaluationofepidemiolo­
gical,biostatisticaldata.
SecondaryPrevention
Secondarypreventiontargetspeoplewhoshow
earlysymptomsofmentalhealthdisruptionbut
regainpremorbidleveloffunctioningthrough
aggressivetreatment.
RoleofaNurseinSecondaryPrevention
•Earlydiagnosisandcasefinding:Thiscanbe
achievedbyeducatingthepublic,community
leaders,industrialists,Mahilamandals,
Balwadisetc.inhowtorecognizeearly
symptomsofmentalillness.Casefinding
throughscreeningandperiodicexamination
ofpopulationatrisk,monitoringofclientsetc.
Thusinclinics,schools,homehealthcareand
theworkplace,communitymentalhealth

237. 234AGuidetoMentalHealthandPsychiatricNursing
nursesdetectearlysignsofincreasedlevelsof
anxiety,decreasedabilitytocopewithstress
andfailuretoperceiveself,theenvironment
and/orrealityaccurately,andprovidedirect
servicesasappropriate.
•Earlyreference:Thepublicshouldbeeducated
toreferthesecasestoproperhospitalsassoon
astheyrecognizeearlysymptomsofmental
illness.
•Screeningprograms:Simplequestionnaires
shouldbedevelopedtoidentifythesymptoms
ofmentalillness,andadministrationofthe
sameinthecommunityforearlyidentification
ofcases.Thesequestionnairescanbe
simplifiedinlocallanguages,andusedwidely
inthecolleges,schools,industriesetc.
•Earlyandeffectivetreatmentforpatient,and
ifnecessary,tofamilymembersasrelevant;
providingcounselingservicestocaregivers
ofmentallyillpatients.
•Trainingofhealthpersonnel:Orientation
coursesshouldbeprovidedtohealthworkers
todetectcasesinthecourseoftheirroutine
work.
•Consultationservices:Nursesworkingin
generalhospitalsmaycomeacrossvarious
conditionssuchaspuerperialpsychosis,
anxietystates,pepticulcer,ulcerativecolitis,
bronchialasthmaetc.Thesebasiccare
providersneedguidanceandconsultationto
dealwiththeseconditionsinaneffective
manner.
•Crisisintervention:Ifcrisisisnottackledin
timeitmayleadtosuicideormentaldisorders.
Sometimesanticipatingthecrisissituation
andguidingtheindividualintimecanhelp
themtocopewiththecrisissituationinabetter
way.
TertiaryPrevention
Tertiarypreventiontargetsthosewithmental
illnessandhelpstoreducetheseverity,discomfort
anddisabilityassociatedwiththeirillness.In
thesetermscommunitymentalhealthnursesplay
avitalroleinmonitoringtheprogressof
dischargedpatientsinhalfwayhomes,houses
etc.,especiallywithregardtotheirmedication
regimen,coordinationofcareetc.
RoleofaNurseinTertiaryPrevention
•Familymembersshouldbeinvolvedactively
inthetreatmentprogramsothateffective
follow-upcanbeensured.
•Occupationalandrecreationalactivities
shouldbeorganizedinthehospitalsothat
idlingisprevented.
•Communitybasedprogramscanbelaunched
throughmeetingwiththefamilymembers
whentheneedfordischargefromthehospital
shouldbeemphasized.Theseprogramscan
beimplementedthroughdayhospitals,night
hospitals,aftercareclinics,half-wayhomes,
ex-patienthostels,fostercarehomesetc.Follow
upcarecanbehandedovertocommunity
healthnurses.
•Thereshouldbeconstantcommunication
betweenthecommunityhealthnursesandthe
mentalhealthinstitutionregardingthefollow
upofthedischargedpatient.Theultimateaim
ofthehospitalandcommunitybased
programsistore-socializeandre-motivatethe
patientforafunctionalroleinthecommunity,
consistentwithhisresources.
•Thereareawiderangeofservicesthatneedto
beprovidedtopatientsaspartofthetertiary
preventionprogram.Nursesneedtobefami­
liarwiththeagenciesinthecommunitythat
providetheseservices.Collaborativerelation­
shipsbetweenmentalhealthcareproviders
andcommunityagenciesareabsolutely
essentialifrehabilitationistosucceed.
•Animportantinterventioninthemaintenance
ofpatientsintheirownhomesinthe
communityistheTraininginCommunity
Living(TCL)program,designedby'Steinand
Test'.Inthismodelwhenapersonisreferred
forahospitaladmissionthestaffgoestothe
communitywithhimratherthanhisgoingto
thehospitaltobewiththestaff.Thisrealworld
experiencewiththepatientenablesthenurse

238. CommunityMentalHealthNursing235
toassessaccuratelytheskillsthattheperson
needstolearnandtomutuallyagreeon
realisticgoals.
•Anotheraspectofcommunitylifethatismore
difficulttoassessaccuratelyanddealwith
effectively,isthestigmaattachedtomental
illness.Manypatientsandtheirfamiliestry
toavoidstigmabykeepingthenatureofthe
person'sillnessasecret.Theneedforsecrecy
placesadditionalstressonthefamilysystem
becausethereisalwaysthefearthatthetruth
willberevealed.Nursesinthecommunityare
inakeypositiontomonitorcommunity
attitudesandhelpinfosteringarealistic
attitudetowardsthementallyill.
•Forsomepatients,theemotionalclimateof
thefamilytowhichtheyreturncanhavea
significanteffectontheiradjustment,and
eventuallyrecoveryfromthedebilitating
effectsofchronicmentalillness.Families
sometimesviewmentalillnessasaweakness
ofcharacterthatcanbeovercomebyexertion
ofmoraleffort.Thistypeoffamilialattitude
mayresultinguiltonthepartofthepatient
whobelievesthathehasdisappointedhis
significantothers.Guiltleadstoincreased
anxietyanddecreasedself-esteem.Theseare
theconditionsthatinterferewithahighlevel
offunctioning.Thereforenursesworkingwith
familiesneedtofosterhealthyattitudes
towardsthementallyillmember.
PSYCHIATRICREHABILITATION
Rehabilitationistheprocessofenablingthe
individualtoreturntohishighestpossiblelevel
offunctioning.Itisanimportantcomponentof
thecommunitymentalhealthprogram,andis
undertakenattheleveloftertiaryprevention.
Definition
Rehabilitationis"anattempttoprovidethebest
possiblecommunityrolewhichwillenablethe
patienttoachievethemaximumrangeofactivity,
interestandofwhichheiscapable".
-MaxwellJones[1952]
Thefollowingdisordersareindicatedcom­
monlyforrehabilitation:
•Chronicschizophrenia
•Chronicorganicmentaldisorders
•Mentalretardation
•Alcoholanddrugdependence
PrinciplesofRehabilitation
•Increasingindependencewouldbethefirst
stepinrehabilitationprocess.
•Primaryfocusisonimprovementofcapabili­
tiesandcompetenceofclientswithpsychiatric
problems.
•Maximumusemustbemadeofresidual
capacities.
•Patient'sactiveparticipationisveryessential.
•Skilldevelopment,therapeuticenvironment
arefundamentalinterventionsforasuccessful
rehabilitationprocess.
PsychiatricRehabilitationApproaches
a.Psychoeducation:Includesdiagnosingthe
problem,tellingthepersonwhattoexpect
regardingillnessanddiscussingtreatment
alternatives.
b.Workingwithfamilies:Encouragingfamily
memberstogetinvolvedintreatmentand
rehabilitationprograms.
c.Grouptherapy:Positiveaspectsofgroup
therapyincludeanopportunityforongoing
contactwithothers,validationoftheir
perceptions,sharingtheirviewsabout
problemsandproblemsolvingabilities.
d.Socialskillstraining:Itinvolvesteaching
specificlivingskillsthatthepatientisexpected
tohaveinordertosurviveinthecommunity.
RehabilitationTeam
Professionalscontributingtopsychiatricreha­
bilitationinclude,psychiatrist,clinicalpsycho­
logist,psychiatricsocialworker,psychiatric
nurse,occupationaltherapist,recreational
therapist,counselorandothermentalhealth
paraprofessionals.

239. 236AGuidetoMentalHealthandPsychiatricNursing
StepsinPsychiatricRehabilitation
Psychiatricrehabilitationbeginswithacom­
prehensivemedicalpsychiatricdiagnosisand
functionalassessment.Thesearekeyelementsin
identifyingimpairmentsanddisabilities.The
stepsofrehabilitationinclude:
a.Reductionofimpairments:Rehabilitationinter­
ventionswithpsychiatricpatientsrequire
reductionoreliminationofthesymptomsand
cognitiveimpairmentsthatinterferewith
socialandvocationalperformance.These
impairmentsarereducedandeliminatedfor
thegreaterpartbyvariouspsychotropicagents.
b.Remediationofdisabilitiesthroughskilltraining:
Skilltrainingisusedtoremediatedisabilities
insocial,familyandvocationalfunctioning.
Patientsgenerallyrequiretraininginself-care
skills,interpersonalskills,vocationaland
employmentpursuits,recreationalandleisure
skills.
c.Remediatingdisabilitiesthroughsupportive
interventions:Whenrestorationofsocialand
vocationalfunctioningthroughskillstraining
islimitedbycontinuingdeficits,rehabilitation
strategiesaimathelpingtheindividuals
compensateforhandicapbylearningskillsin
livingandworkingenvironments,adjusting
theindividualandfamilyexpectationstoa
leveloffunctioningthatisrealistically
attainable.
d.Remediationofhandicaps:Inadditiontoclinical
rehabilitationinterventions,thedisabledper­
sonscanbehelpedtoovercometheirhandicaps
throughsocialrehabilitationinterventions,e.g.
communitysupportprograms.
RoleofaNurseinPsychiatricRehabilitation
Rehabilitativepsychiatricnursingmustbe
studiedinthecontextofboththepatientandsocial
system.Thisrequiresthenursetofocusonthree
elements,theindividual,familyandcommunity.
Assessment
AssessmentoftheIndividual
Thenurseshouldassesstheindividualinthe
areasofsymptomspresent,motivation,strengths,
interpersonalskills,self-esteem,activitiesofdaily
livinganddrugcompliance.
AssessmentofFamily
Componentsoffamilyassessment:
•Familystructureincludingdevelopmental
stages,roles,responsibilities,normsand
values.
•Familyattitudestowardsthementallyill
member.
•Emotionalclimateofthefamily.
•Socialsupportavailabletothefamily.
•Pastfamilyexperienceswithmentalhealth
services.
•Thefamily'sunderstandingofthepatient's
problemsandtheplanofcare.
AssessmentofCommunity
Itincludesassessmentofcommunityagenciesthat
provideservicestopeoplewhohavemental
illnesses,assessmentofattitudesofthepeople
towardsthementallyill,etc.
PlanningandImplementation
Planningandimplementationinrehabilitative
psychiatricnursingfocusesonfosteringindepen­
dencebymaximizingpersonalstrengths.The
nurseandthepatientmustworktogethertofind
waysforthepatienttoovercomeanyremaining
impairedareasoffunctioning.
IndividualInterventions
Hospitalrehabilitation(Inpatientrehabilitation):
Thisinvolvestherapeuticcommunity,recrea­
tionaltherapy,socialskillstrainingandtraining
inbasiclivingskills.
Communityrehabilitation:Providingcareincom­
munitysettings(Homes,residentialcaresettings
fosterhomesetc).
FamilyInterventions
•Healtheducationtofamilymembersregar­
dingthediseaseprocess,availableresources,

240. CommunityMentalHealthNursing237
communicationskillsandproblemsolving
techniques.
•Motivatingthefamilymemberstoprovide
propercaretothepatient.
•Grouptherapyandsupporttofamilymembers
throughself-helpgroups;nursesareina
favorablepositiontohelpfamiliescopewith
stressandadapttochangesinthefamily
structure.
CommunityInterventions
Thereareseveralwaysthatnursescanintervene
inthecommunitytertiarypreventionprograms.
Amongthesearehealtheducationtothepublic,
trainingtoschoolteachers,villageleadersand
paraprofessionalsintherehabilitationofmentally
illpeople.
Evaluation
Evaluationofpsychiatricrehabilitationservices
usuallytakesplaceatthelevelofimpactonthe
patient,familyandtheeffectivenessofthe
communityservicesystem.
VocationalRehabilitation
Vocationalrehabilitationisapartofconti­
nuousandcoordinatedprocessofrehabilitation
whichinvolvestheprovisionofthosevocational
services(e.g.vocationalguidance,vocational
trainingandselectiveplacement)designedto
enableadisabledpersonsecureandretain
suitableemployment.
MainVocationalRehabilitationCentersinIndia
•MithraSpecialSchoolandVocationalTraining
CenterfortheMentallyRetarded,Chennai.
•Banyan,Chennai.
•VocationalRehabilitationCenter,Chennai.
•ShristiCenterforPsychiatricRehabilitation,
Madurai.
•VIC(VocationalTrainingCenter)forthe
physicallyhandicappedrunbytheMinistry
ofLabor,GovernmentofIndia,hasopened
upitsfacilityforthementallyillforthefirst
timeinChennai.
•IndianRedCrossSociety(IRCS)whichruns
VICforthehandicappedhasofferedvoca­
tionaltrainingforthechronicmentallyill.
•IndianCouncilforChildWelfare,anNGO
caringforunderprivilegedchildren.
PhasesinVocationalRehabilitation
Vocationalassessment
Vocationalcounseling
Vocationaltraining
Jobexploration
Jobplacement
Follow-up
VocationalAssessment
Itisdoneinfourareasviz.,clinical,social,psy­
chologicalandvocational.
•Clinicalassessmentincludesassessingfor
residualpsychiatricsymptomswhichmay
affecthisabilitytofunction.
•Socialassessmentincludesassessingfamily
support,attitudeoffamilymembersand
economicstatusofthefamily.
•Psychologicalassessmentincludesassessing
self-esteem,confidence,patient'slevelof
motivation.
•Vocationalassessmentincludesassessing
physicalstrength,handcoordination,atten­
tion,concentration,etc.
VocationalCounseling
Thisincludesinformingpatientsandfamily
membersregardingthetypeoftrainingavailable.
Familyconsentshouldbetakenforrehabilitation
training.
VocationalTraining
Itincludes:
•Coursecontent
•Durationoftraining
•Incentives
•Assessmentoftheprogress
•Impartingskills
•Supervision

241. 238AGuidetoMentalHealthandPsychiatricNursing
JobExploration
Findingoutvariousjobsavailableinthe
community.
JobPlacement
Thisincludesselectingsuitablejob,placementof
theclientinthejob,checkingthefacilities
availableandevaluatingworkperformance.
Follow-up
Itincludesevaluationofthefourdimensionsviz.,
clinical,social,psychologicalandvocational.
VocationalProgram
Opencompetitivejobplacement:Thoughitis
difficulttoplacethementallyrestoredinopen
competitivejobplacements,itisalsopossibleto
providethisopportunityforselectedgroupsof
patientswiththeclinicaldiagnosesofreactive
psychosis,bipolaraffectivedisorders,andacute
psychoticepisodes.Theycanbeequippedto
functionsuccessfullybyregularfollow-up
programs.
Shelteredemployment:Thisisprovidedforthose
disabledpersons,who,becauseofthenatureand
severityofthedisability,cannotcopewith
ordinaryemployment.Thisissuitableforthose
withtheproblemsofmentalretardation,chronic
mentalillness(e.g.schizophrenia,repeated
attacksofaffectivedisorderinspiteofregular
medication).
Self-employment:Personswhocannotcopewith
thedemandsofvocationaladjustmentinopen
competitivejobsituations,butwhohavethe
capacitytodosomeworkwiththehelpofany
familymembers,maybeconsideredforself­
employmentschemeswhichareusuallyspon­
soredbydifferentwelfareschemesofnationalized
banksandsocialwelfaredepartments.
Home-boundworkprograms:Forthosedisabled
needingtotalcare,workcanbegivenathome,
whichshallbecollectedbythecenterandpaid
accordingtotheperformance.
NATIONALMENTALHEALTHPROGRAM
TheNationalMentalHealthProgramwas
launchedin1982inIndiaandaimstoprovide
mentalhealthcaretothetotalpopulationwithin
theavailableresources.
Objectives
•Basicmentalhealthcaretoalltheneedy
especiallythepoorfromrural,slumandtribal
areas.
•Applicationofmentalhealthknowledgein
generalhealthcareandinsocialdevelopment.
•Promotionofcommunityparticipationin
mentalhealthservicedevelopmentand
increaseofeffortstowardsself-helpinthe
community.
•Preventionandtreatmentofmentaland
neurologicaldisordersandtheirassociated
disabilities.
•Useofmentalhealthtechnologytoimprove
generalhealthservices.
•Applicationofmentalhealthprinciplesin
totalnationaldevelopmenttoimprovequality
oflife.
Approaches
•Integrationofmentalhealthcareserviceswith
theexistinggeneralhealthservices.
•Utilizationoftheexistinginfrastructureof
healthservicesandalsodelivertheminimum
mentalhealthcareservices.
•Provisionofappropriatetask-oriented
trainingtotheexistinghealthstaff.
•Linkageofmentalhealthserviceswiththe
existingcommunitydevelopmentprogram.
Components
I.Treatment
Multiplelevelswereplanned.
AVillageandsub-centerlevelmultipurpose
workers(MPW)andhealthsupervisors(HS),
underthesupervisionofmedicalofficer(MO)
tobetrainedfor:
a.managementofpsychiatricemergencies

242. CommunityMentalHealthNursing239
b.administrationandsupervisionofmain­
tenancetreatmentforchronicpsychiatric
disorders
c.diagnosisandmanagementofgrandma!
epilepsy,especiallyinchildren
d.liaisonwithlocalschoolteachersand
parentsregardingmentalretardationand
behavioralproblemsinchildren
e.counselinginproblemsrelatedtoalcohol
anddrugabuse
B.MOofPrimaryHealthCentre(PHC)aidedby
HS,tobetrainedfor:
a.supervisionofMPW'sperformance
b.elementarydiagnosis
c.treatmentoffunctionalpsychosis
d.treatmentofuncomplicatedcasesof
psychiatricdisordersassociatedwith
physicaldiseases
e.managementofuncomplicatedpsycho­
socialproblems
f.epidemiologicalsurveillanceofmental
morbidity
C.Districthospital:Itwasrecognizedthatthere
shouldbeatleastonepsychiatristattachedto
everydistricthospitalasanintegralpartof
thedistricthealthservices.Thedistrict
hospitalshouldhave30-50psychiatricbeds.
Thepsychiatristinadistricthospitalwas
envisagedtodevoteonlyapartofhistimeto
clinicalcareandagreaterpartintrainingand
supervisionofnon-specialisthealthworkers.
D.Mentalhospitalsandteachingpsychiatric
units:Majoractivitiesofthesehighercenters
ofpsychiatriccareinclude:
a.helpincareof'difficult'cases
b.teaching
c.specializedfacilitieslike,occupational
therapyunits,psychotherapy,counseling
andbehavioraltherapy
II.Rehabilitation
Thecomponentsofthissub-programinclude
treatmentofepilepticsandpsychoticsatthe
communitylevelsanddevelopmentof
rehabilitationcentersatboththedistrictleveland
higherreferralcenters.
III.Prevention
Thepreventioncomponentistobecommunity­
based,withinitialfocusonpreventionand
controlofalcohol-relatedproblems.Lateron,
problemslikeaddictions,juveniledelinquency
andacuteadjustmentproblemslikesuicidal
attemptsaretobeaddressed.
REVIEWQUESTIONS
•Communityfacilitiesavailableformentally
illpatients(Nov1999,Nov2000,Nov2001)
•Mentalhealthservices(Apr2002,Nov2002)
•Halfwayhomes(Feb2000,Nov2002)
•Self-helpgroups
•Roleofanurseincommunitymentalhealth
(Feb2000)
•Levelsofprevention(Nov2001,Nov2003)
•Roleofanurseinpreventionofpsychiatric
disorders(Feb2001,Nov2003,Oct2005,Apr
2006)
•Primaryprevention(Nov2003)
•Tertiaryprevention(Oct2004)
•Roleofnurseinpsychiatricrehabilitation(Oct
2005)
•Vocationalrehabilitation
•Nationalmentalhealthprogram
•Enumeratethetherapeuticactivitiesofanurse
incommunitymentalhealthcare(Oct2004)

243. PsychiatricEmergencies
0COMMONPSYCHIATRICEMERGENCIES
SuicidalThreat
ViolentorAggressiveBehavioror
Excitement
PanicAttacks
CatatonicStupor
HystericalAttacks
TransientSituationalDisturbances
0ORGANICPSYCHIATRICEMERGENCIES
DeliriumTremens
EpilepticFuror
AcuteDrugInducedExtrapyramidal
Syndrome
DrugToxicity
Psychiatricemergencyisaconditionwhereinthe
patienthasdisturbancesofthought,affectand
psychomotoractivityleadingtoathreattohis
existence(suicide),orthreattothepeopleinthe
environment(homicide).Thisconditionneeds
immediateinterventiontosafeguardthelifeof
thepatient,bringdowntheanxietyofthefamily
membersandenhanceemotionalsecurityto
othersintheenvironment.
COMMON PSYCHIATRICEMERGENCIES
•Suicidalthreat
•Violentoraggressivebehaviororexcitement
•Panicattacks
•Catatonicstupor
•Hystericalattacks
•Transientsituationaldisturbances
SUICIDALTHREAT
Inpsychiatryasuicidalattemptisconsideredto
beoneofthecommonestemergencies.
Suicideisatypeofdeliberateself-harmandis
definedasanintentionalhumanactofkilling
oneself.
Etiology
PsychiatricDisorders
•Majordepression
•Schizophrenia
•Drugoralcoholabuse
•Dementia
•Delirium
•Personalitydisorder
PhysicalDisorders
•Patientswithincurableorpainfulphysical
disorderslike,cancerandAIDS.
PsychosocialFactors
•Failureinexamination
•Dowrydifficulties
•Maritaldifficulties
•Lossoflovedobject
•Isolationandalienationfromsocialgroups
•Financialandoccupationaldifficulties
RiskFactorsforSuicide
•Age
•malesabove40yearsofage
•femalesabove55yearsofage
•Sex
•menhavegreaterriskofcompletedsuicide.
•suicideis3timesmorecommoninmen
thaninwomen.

244. PsychiatricEmergencies241
•womenhavehigherrateofattempted
suicide
•Beingunmarried,divorced,widowedor
separated
•Havingadefinitesuicidalplan
•Historyofprevioussuicidalattempts
•Recentlosses
SuicidalTendencyinPsychiatricWards
Certainpsychiatricdisorderswherethepatient
maydevelopsuicidaltendenciesinclude:
•Majordepression:Thisisoneofthecommonest
conditionsassociatedwithahighriskof
suicide.Suicideinamajordepressiveepisode
isduetopervasiveandpersistentsadness;
pessimisticcognitionsconcerningthepast,
presentandfuture;delusionsofguilt,help­
lessness,hopelessnessandworthlessness;
andderogatoryvoicesurginghimtotakehis
life.Theriskofsuicideismorewhentheacute
phasehaspassedandthecharacteristic
psychomotorretardationhasimproved.This
issobecausethepatienthasmoreenergyto
carryouthissuicidalplansnow,thoughhe
mighthavebeenharboringthemforquitesome
time.
•Schizophrenia:Themajorriskfactorsamong
schizophrenicsincludethepresenceof
associateddepression,youngageandhigh
levelsofpremorbidfunctioning(especially
duringcollegeeducation).Peopleinthisrisk
grouparemorelikelytorealizethedevastating
significanceoftheirillnessmorethanother
groupsofschizophrenicpatientsdo,andsee
suicideasareasonablealternative.
•Mania:Manicpatientsmayoccasionally
commitsuicide.Thisisusuallytheresultof
grandioseideation:thepatientmaybelieve
thatheisagreatperson,orwishtoprovehis
supernaturalpowers.Withthisintentinmind,
hemaycarryoutsomedangerousactivitythat
cancosthimhislife.
•Drugoralcoholabuse:Suicideamongalcoholics
canbeduetodepressioninthewithdrawal
phase.Also,thelossoffriendsandfamily,
self-respect,status,andageneralrealization
ofthehavocalcoholhascreatedinhislifecan
causetheindividualtowishtodie.
•Personalitydisorder:Individualswithhistrio­
nicandborderlinetraitsmayoccasionally
attemptsuicide.
•Organicconditions:Conditionssuchas
deliriumanddementiaduetochangesof
moodlikeanxietyanddepressionmayalso
inducesuicidaltendency.
Management
1.Beawareofcertainsignswhichmayindicate
thattheindividualmaycommitsuicide,such
as:
•suicidalthreat
•writingfarewellletters
•givingawaytreasuredarticles
•makingawill
•closingbankaccounts
•appearingpeacefulandhappyaftera
periodofdepression
•refusingtoeatordrink,maintainpersonal
hygiene.
2.Monitoringthepatient'ssafetyneeds:
•takeallsuicidalthreatsorattempts
seriouslyandnotifypsychiatrist
•searchfortoxicagentssuchasdrugs/
alcohol
•donotleavethedrugtraywithinreachof
thepatient,makesurethatthedaily
medicationisswallowed
•removesharpinstrumentssuchasrazor
blades,knives,glassbottlesfromhis
environment.
•removestrapsandclothingsuchasbelts,
neckties
•donotallowthepatienttobolthisdooron
theinside,makesurethatsomebody
accompanieshimtothebathroom
•patientshouldbekeptinconstant
observationandshouldneverbeleftalone
•havegoodvigilanceespeciallyduring
morninghours
•spendtimewithhim,talktohim,andallow
himtoventilatehisfeelings

245. 242AGuidetoMentalHealthandPsychiatricNursing
•encouragehimtotalkabouthissuicidal
plansImethods
•ifsuicidaltendenciesareverysevere,
sedationshouldbegivenasprescribed
3.Encourageverbalcommunicationofsuicidal
ideasaswellashis/herfearanddepressive
thoughts.A'nosuicidal'pactmaybesigned,
whichisawrittenagreementbetweenthe
clientandthenurse,thatclientwillnotacton
suicidalimpulses,butwillapproachthenurse
totalkaboutthem.
4.Enhanceself-esteemofthepatientbyfocusing
onhisstrengthsratherthanweaknesses.His
positivequalitiesshouldbeemphasizedwith
realisticpraiseandappreciation.Thisfosters
asenseofself-worthandenableshimtotake
controlofhislifesituation.
VIOLENTORAGGRESSIVE BEHAVIOROR
EXCITEMENT
Thisisasevereformofaggressiveness.During
thisstage,patientwillbeirrational,uncooperative,
delusionalandassaultive.
Etiology
•Organicpsychiatricdisorderslike,delirium,
dementia,Wemicke-Korsakoff'spsychosis.
•Otherpsychiatricdisorderslike,schizophre­
nia,mania,agitateddepression,withdrawal
fromalcoholanddrugs,epilepsy,acutestress
reaction,panicdisorderandpersonality
disorders.
Management
•Anexcitedpatientisusuallybroughttiedup
witharopeorinchains.Thefirststepshould
betoremovethechains.Alargeproportionof
aggressionandviolenceisduetothepatient
feelinghumiliatedatbeingtiedupinthis
manner.
•Talktothepatientandseeifheresponds.Firm
andkindapproachbythenurseisessential.
•Usuallysedationisgiven.Commondrugs
usedare:diazepam10-20mg,IV;haloperidol
10-20mg;chlorpromazine50-100mgIM.
•Oncethepatientissedated,takecareful
historyfromrelatives;ruleoutthepossibility
oforganicpathology.Inparticularcheckfor
historyofconvulsions,fever,recentintakeof
alcohol,fluctuationsofconsciousness.
•Carryoutcompletephysicalexamination.
•Sendbloodspecimensforhemoglobin,total
cellcount,etc.
•Lookforevidenceofdehydrationandmalnut­
rition.Ifthereisseveredehydration,glucose
salinedripmaybestarted.
•Havelessfurnitureintheroomandremove
sharpinstruments,ropes,glassitems,ties,
strings,matchboxes,etc.frompatient's
vicinity.
•Keepenvironmentalstimuli,suchaslighting
andnoiselevelstoaminimum;assignasingle
room;limitinteractionwithothers.
•Removehazardousobjectsandsubstances;
cautionthepatientwhenthereispossibility
ofanaccident.
•Staywiththepatientashyperactivity
increasestoreduceanxietylevelandfostera
feelingofsecurity.
•Redirectviolentbehaviorwithphysicaloutlets
suchasexercise,outdooractivities.
•Encouragethepatientto'talkout'his
aggressivefeelings,ratherthanactingthem
out.
•Ifthepatientisnotcalmedbytalkingdown
andrefusesmedication,restraintsmay
becomenecessary.
•Followingapplicationofrestraints,observe
patientevery15minutestoensurethat
nutritionalandeliminationneedsaremet.
Alsoobserveforanynumbness,tinglingor
cyanosisintheextremities.Itisimportantto
choosetheleastrestrictivealternativeasfar
aspossibleforthesepatients.
•Guidelinesforself-protectionwhenhandling
anaggressivepatient:
•neverseeapotentiallyviolentperson
alone.
•keepacomfortabledistanceawayfromthe
patient(armlength).
•bepreparedtomove,aviolentpatientcan
strikeoutsuddenly.
•maintainaclearexitrouteforboththestaff
andpatient.

246. PsychiatricEmergencies243
•besurethatthepatienthasnoweaponsin
hispossessionbeforeapproachinghim.
•ifpatientishavingaweaponaskhimto
keepitonatableorfloorratherthan
fightingwithhimtotakeitaway.
•keepsomethinglikeapillow,mattressor
blanketwrappedaroundarmbetweenyou
andtheweapon.
•distractthepatientmomentarilytoremove
theweapon(throwingwaterinthe
patient'sface,yellingetc).
•giveprescribedantipsychoticmedications.
PANICATTACKS
Episodesofacuteanxietyandpaniccanoccuras
apartofpsychoticorneuroticillness.
Thepatientwillexperiencepalpitations,
sweating,tremors,feelingsofchoking,chestpain,
nausea,abdominaldistress,fearofdying,
paresthesias,chillsorhotflushes.
Management
•Givereassurancefirst
•Searchforcauses
•Diazepam10mgorlorazepam2mgmaybe
administered
CATATONICSTUPOR
Stuporisaclinicalsyndromeofakinesisand
mutismbutwithrelativepreservationofconscious
awareness.Stuporisoftenassociatedwithcata­
tonicsignsandsymptoms(catatonicwithdrawal
orcatatonicstupor).Thevariouscatatonicsigns
includemutism,negativism,stupor,ambiten­
dency,echolalia,echopraxia,automaticobedience,
posturing,mannerisms,stereotypies,etc.
Management
•Ensurepatentairway
•AdministerIVfluids
•Collecthistoryandperformphysical
examination
•Drawbloodforinvestigationsbeforestarting
anytreatment
•Othercareissameasthatforanunconscious
patient
HYSTERICALATTACKS
Ahystericmaymimicabnormalityofany
function,whichisundervoluntarycontrol.The
commonmodesofpresentationmaybe.
•Hystericalfits
•Hystericalataxia
•Hystericalparaplegia
Allpresentationsaremarkedbyadramatic
qualityandsadnessofmood.
Management
•Hystericalfitmustbedistinguishedfrom
genuinefits(Seep.122fordifferencesbetween
hystericalandepilepticseizures).
•Ashystericalsymptomscancausepanic
amongrelatives,explaintotherelativesthe
psychologicalnatureofsymptoms.Reassure
thatnoharmwouldcometothepatient.
•Helpthepatientrealizethemeaningof
symptoms,andhelphimfindalternativeways
ofcopingwithstress.
•SuggestiontherapywithIVpentothalmaybe
helpfulinsomecases.
TRANSIENTSITUATIONALDISTURBANCES
Thesearecharacterizedbydisturbedfeelingsand
behavioroccurringduetooverwhelmingexternal
stimuli.
Management
•Reassurance
•Mildsedationifnecessary
•Allowingthepatienttoventilatehis/her
feelings
•Counselingbyanunderstandingprofessional
ORGANICPSYCHIATRICEMERGENCIES
•Deliriumtremens
•Epilepticfuror
•Acute drug-induced
syndrome
•Drugtoxicity
extrapyramidal

247. 244AGuidetoMentalHealthandPsychiatricNursing
DELIRIUMTREMENS
Deliriumtremensisanacuteconditionresulting
fromwithdrawalofalcohol(Referp.131for
details).
Management
•Keepthepatientinaquietandsafe
environment.
•Sedationisusuallygivenwithdiazepam
10mgorlorazepam4mgIV,followedbyoral
administration.
•Maintainfluidandelectrolytebalance.
•Reassurepatientandfamily.
(seechapter11p.132forfurtherdetailson
management)
EPILEPTICFUROR
Followingepilepticattackpatientmaybehavein
astrangemannerandbecomeexcitedandviolent.
Management
•Sedation:Inj.Diazepam10mgIV[or]Inj.
Luminal10mg.IVfollowedbyoralanti­
convulsants.
•Haloperidol10mgIVhelpstoreduce
psychoticbehavior.
ACUTEDRUG-INDUCED EXTRAPYRAMIDAL
SYNDROME
,.,
Antipsychoticscancauseavarietyofmovement­
relatedside-effects,collectivelyknownasExtra
PyramidalSyndrome(EPS).Neuroleptic
malignantsyndromeisrarebutmostseriousof
thesesymptomsandoccursinasmallminority
ofpatientstakingneuroleptics,especiallyhigh­
potencycompounds(referchapter14p.174fora
detaileddescription).
Management
Thedrugshouldbestoppedimmediately.
Treatmentissymptomaticandincludescooling
thepatient,maintainingfluidandelectrolyte
balanceandtreatingintercurrentinfections.
Diazepamcanbeusedformusclestiffness.
Dantrolene,adrugusedtotreatmalignant
hyperthermia,bromocriptine,amantadineandL­
dopahavebeenused.
DRUGTOXICITY
Drugover-dosagemaybeaccidentalorsuicidal.
Ineithercaseallattemptsmustbemadetofind
outthedrugconsumed.Adetailedhistoryshould
becollectedandsymptomatictreatmentinstituted.
Acommoncaseofdrugpoisoningislithium
toxicity.Thesymptomsincludedrowsiness,
vomiting,abdominalpain,confusion,blurred
vision,acutecirculatoryfailure,stuporandcoma,
generalizedconvulsions,oliguriaanddeath.
Management
•Administer02
•StartIVline
•Assessforcardiacarrhythmias
•Referforhemodialysis
•Administeranticonvulsants
(seechapter14p.177forfurtherdetailson
lithiumtoxicity).
REVIEWQUESTIONS
•Listthecommonpsychiatricemergencies
•Nursingmanagementforasuicidalpatient
(Nov1999)
•Nursingmanagementforaviolentpatient
•Suicidalrisk(Nov2003)
•Suicideprevention(Oct2004,Oct2005)
•Managementofaggressivepatient(Apr2004)

248. PsychosocialIssues
AmongSpecial
Population
0ADOLESCENTMENTALHEALTHNURSING
0GERIATRICMENTALHEALTHNURSING
0PSYCHIATRICDISORDERSRELATEDTOWOMEN
0PSYCHOSOCIALISSUESAMONGHIVIAIDS
PATIENTS
ADOLESCENT MENTALHEALTHNURSING
AccordingtotheWorldHealthOrganization
(WHO),individualsbetween10-19yearsofage
comeundertheadolescentagegroup.
Adolescenceisaperiodofphysicalgrowthand
intellectualattainmentatitspeak,coupledwith
settingofpersonalitytraits,decisionsregarding
futureprofession,andextremeemotional
instability.Thisisalsoaperiodofidentitycrisis­
physical,sexualandspiritual.
MentalHealthProblemsamongAdolescents
•Ratesofdepression,BipolarAffective
Disorders(BPAD),attemptedsuicide,
completedsuicide,conductdisordersand
schizophreniaincreaseduringadolescence.
•Antisocialactivitiesincreaseinfrequency.
•Agoraphobiaandsocialphobiabecomemore
commonduringadolescence.
•Theincidenceofactingoutbehavior,and
juvenileviolentcrimeinadolescentscontinues
torise.Violentcrimesincludehomicide,
forciblerape,robberyoraggravatedassault.
Adolescentsareespeciallyatanincreasedrisk
ofsexualabuse.Intumrapeandsexualabuse
areassociatedwithagreatlyincreasedriskof
depressionandsuicide.
•Substanceabuseusuallystartsduring
adolescentage.
•Co-morbidityorco-occurrenceofpsychiatric
disorderse.g.adolescentswithsubstance
abusedisorders,aremorelikelytohave
comorbiddisruptivebehaviordisorders.
Comorbidityinadolescentsisassociatedwith
impairedrolefunctioning,likelihoodof
suicidalbehavior,academicproblemsand
increasedconflictwithparents.
Common ReasonsforMentalHealth
ProblemsamongAdolescents
•Emotionaldifficultiesinadolescentsoften
arisefromfaultyorinconsistentchild-rearing
practices.
•Environmentalfactorssuchaspoverty,lack
ofadequatesupportsystems,major
cumulativelifestresses,andmaternal
,employmentinfluencecopingabilitiesamong
childrenandadolescents.
•Constitutionalfactorsorthosecharacteristics
withintheadolescentaffectthelevelof
individualvulnerability.
NursingInterventions
•Nursingcareofadolescentsbeginswitha
thoroughassessmentoftheirhealthstatus.
Datacollectionbythenurseisbasedoncurrent
andpreviousfunctioninginallaspectsofan
adolescent'slife.Thedatacollectionshould
includethefollowinginformation
•Generalappearance
•Growthanddevelopment
•Generalhealthstatus
•Mentalhealthstatus

249. 246AGuidetoMentalHealthandPsychiatricNursing
•Culturalandsocio-economicbackground
•Communicationpatterns(family,peers,
society)
•Sexualbehaviorsanduseofdrugs,alcohol
andotheraddictivesubstances
•Availablehumanandmaterialsources
(friends,schoolandcommunity
involvement).
•Nursesneedtounderstandnormaladolescent
developmentandalsothedifferencebetween
constructiveandage-appropriateexploration
andengagementinactivitiesthatare
potentiallydangeroustophysicaland
emotionalwellbeing.
•Nurseswhoworkinschoolsandcommunity
settingscanengageinscreeningandearly
nursinginterventionwithhighriskteenagers
topromoteadaptiveresponsesandprevent
thedevelopmentoffutureproblems.
Encouragingtheadolescenttoidentifyand
discusshis/herfeelingsisextremely
importantinthisregard.
•Nursinginterventionsusefulinworkingwith
adolescentsincludehealtheducation,family,
groupandindividualtherapyandmedication
management.Emphasisshouldbelaidon
lifestyleandcomplianceissues,suchas
benefitsofexercise,stressmanagementand
safersexpractices.Specialattentionshould
begiventotalkingwithadolescentsand
workingwiththeirparents.
•Buildingatherapeuticrelationshipwithan
adolescentdemandsconfidenceandastrong
senseofone'sownidentityorsenseofcomfort
withone'smemoriesoftheteenageyears.The
nurseneedstoofferunconditionalacceptance
andpositiveattitudeandgentleencourage­
mentforwhattheadolescentcanbecome.
,.,
GERIATRICMENTALHEALTHNURSING
Olderadultsarethemostrapidlygrowing
segmentofthepopulation.InIndia,life
expectancyatbirthhasincreasedbyabout20
yearsinthepast5decades.Theaveragelifespan
todayis66years.Todaythereareabout77million
agedpeopleinIndia(i.e.above60yearsofage).
InKarnatakaoutofapopulationof5.5crores,8%
areelderlycitizens.The1stofOctobereveryyear
isobservedasWorldElders'Dayglobally.(The
IndianExpressOlstOct.2002)
WHOreportof2004statesthat236elderly
peopleper10,000sufferfrommentalillness
mainlyduetostress,heartdisease,strokeand
cancer.Dementia,acripplingdisorderofoldage,
currentlyaffects1in20peopleover65yearsof
ageinourcountry.Itisprojectedthatbytheyear
2025,4millionIndianswillbecomevictimsof
dementia(TheHindu,16thFeb.2003,p.6).
Elderlyindividualsusuallyfaceahigherrisk
ofdevelopingmentalaswellasphysical
morbidity.Theirvulnerabilitytomentalproblems
isduetoageingofthebrain,physicalproblems,
socio-economicfactors,cerebralpathology,
emotionalattitudeandfamilystructure.The
biochemicalandmorphologicalchangesinthe
agingbrainofnormalindividualsaresimilarto
thosesufferingfromdementia.Inmostcases,
mentalillnessescoexistalongsidephysical
problemsinelderlyindividuals.Chronicphysical
disordersandsensoryimpairments(visionand
hearingdefects)areknowntobeespecially
associatedwithmentalproblemsoftheelderly.
PROBLEMS OFTHEELDERLY
Physical
Ageingisanaturalprogressivedeclineinbody
systems.Physicalchangesincludewrinklingof
skin,flabbinessofmuscles,atrophyofviscera,
decreasedvisionandhearing,andalossin
efficiencyofcardiovascularsystem.Oldpeople
sufferfromimmobility,instability,incontinence
andintellectualimpairment.Thesearecalledas
theGiantsofGeriatrics.Thesedisabilitiesdonot
kill,buttheygreatlydiminishthevalueofliving.
Psychiatric
•Delirium,dementia,depression,agitation
•Cryingspells,irritability,wandering,
assaultiveness
•Expressionsoffeelingofworthlessness,
hopelessness,helplessness

250. PsychosocialIssuesAmongSpecialPopulation247
•Diminishedmemory,orientationand
judgment
•Apathy,withdrawal,suicidalimpulsesor
attempts,loneliness
•Paranoiddelusions,demandingbehavior,
anxietydisorders
•Alcoholabuse,impairedconcentration,short
attentionspan
•Stressincontinence
PersonalityChanges
Thesemayoccurduetopsychoseswithcerebral
arteriosclerosis,seniledementia.Personality
breakdowninoldmayleadtocriminalbehavior
orsuicidaltendencies.
Psychosocial
Thethemeofthisageperiodisloss,anddealing
withdeathisoneofthetasksoftheelderly.Since
deathistheonlycertaintyinlife,withoutadequate
emotionalsupporttosustainandbearthelosses
(lossofworkrole,spouse,friends,sensoryand
motorabilitiesandintellectualprocesses),the
elderlyindividualisvulnerabletodepressionand
despair.
Socialproblemsincludeharassment,ill­
treatment,exploitation,desertion,separationfrom
dearones,livingaloneandnonetohelp,etc.
Sometherapiesinthemanagementof
geriatricdisordersinclude:
SomaticTherapies
•Electroconvulsivetherapy
•Psychopharmacology
PsychologicalTherapies
•Psychotherapy
•Lifereviewtherapy
•Realityorientationtherapy
•Validationtherapy
•Cognitivetraining
•Relaxationtherapy
•Counseling
•Patientandfamilyeducation
NursingManagement
•Thenursewhoworkswithmentallyillelders
ischallengedtointegratepsychiatricnursing
skillswithknowledgeofphysiologicaldis­
orders,thenormalageingprocessandsocio­
culturalinfluencesontheelderlyandtheir
families
•Thegoalofnursinginterventionistopromote
maximumindependenceoftheolderadults,
basedoncapacityandfunctionalabilities
•Theroleofgeropsychiatricnurseincludes
providingprimarymentalhealthnursingcare,
includinginterveningwithcaregivers,
providingcasemanagementandconsulting
withothercareproviders.Advancedpractice
nursesprovideindividualandgroup
psychotherapy
•Thenurseshouldbeproficientatassessing
patient'scognitive,affective,functional,
physicalandbehavioralstatus,aswellas
theirfamilydynamics
•Geropsychiatricnursesshouldbeknowle­
dgeableabouttheeffectsofpsychotropic
medicationonelderlypeople.Nursesoften
workcloselywiththephysiciantomonitor
complexmedicationregimensandassistthe
patientsandcaregiverswithmedication
management
•Thekeyconceptsofgeropsychiatricnursing
assessmentinclude
•Mentalhealthstatusexamination(it
includesmini-mentalstatusexamination,
mentalstatusexamination,depression,
anxietyandpsychosis)
•Frequentlyobservedproblembehavior
•Functionalabilities
•Generalhealthand
•Socialsupportsystem
•Nursinginterventionswithgeropsychiatric
patientsincludecreationofatherapeutic
milieu,involvementinsomatictherapies,and
interpersonalinterventions.Thebasic
characteristicsofatherapeuticmilieuare:
cognitivestimulation,promotionofasenseof
calmandquietness,consistentphysicallayout,

251. 248AGuidetoMentalHealthandPsychiatricNursing
structuredroutine,focusonstrengthsand
abilities,minimizingofdisruptivebehavior,
providingsafety
•Caregiversshouldbeinvolvedinplanning,
implementationandevaluationofnursing
interventions.
PSYCHIATRICDISORDERS RELATEDTO
WOMEN
Inmostsocieties,psychiatricdisordersaremore
commoninwomen.Thecommonreasonsforthis
include:geneticdifferences,societalpressureson
women,differencesinrearingpatternandcultural
expectations.
Thementaldisordersmorecommonly
reportedinfemalesincludemajordepression,
neuroticdepression,anxietystates,phobic
neurosis,hypochondriasis,dissociativedis­
orders,adjustmentproblems,attemptedsuicide,
anorexianervosaandseniledementia.
Therearemanypsychiatricdisorderspeculiar
tofemaleswhichinclude:
•Premenstrualsyndrome
•Psychiatricdisordersassociatedwithchild
birth
•J'vfenopausalsyndrome
I.PREMENSTRUAL SYNDROME
Menstruationisanormalphysiologicalprocess
infemales.Thevariouspsychologicalsympton:i-s
attributedtopremenstrualsyndromeare:sadness,
anxiety,anger,irritability,labilemood,decreased
concentration,indecision,suspiciousness,sensi­
tivity,suicidalorhomicidalideations,insomnia,
hypersomnia,anorexia,cravingforcertainfoods,
fatigue,lethargy,agitation,libidochanges,
decreasedmotivation,impulsivityandsocial
withdrawal.
Thispremenstrualsyndromestartsabout5to
10daysbeforeonsetofmensesandlaststillthe
endofmenses.Itnotonlyaffectssocialbutalso
occupationalfunctioning,leadingtovarious
degreesofmaladjustments.
Management
•Thesyndromehasbeenwidelytreatedwith
progesterone,oralcontraceptives,bromo­
criptine,diureticsandantidepressantdrugs
•Psychologicalsupportandencouragement
•Cognitivebehaviortherapy
II.PSYCHIATRICDISORDERS ASSOCIATED
WITHCHILDBIRTH
Thereisanincreasedriskofmentalillness
associatedwithchildbirth,mostlyinthe
postpartumperiodbutproblemsmayalsobe
presentbeforeorduringpregnancy.
AMentalillnessinpregnancy
B.Puerperalmentaldisorders
A.Mentalillnessinpregnancy
Theincidenceofmentalillnessinthefirst
trimesterofpregnancyisthoughttobehigh,when
comparedtosecondandthirdtrimestersof
pregnancy.
Thepredisposingfactorsformentalillnesses
duringpregnancyare;neurotictraitsinpremorbid
personality,maritaltension,historyofprevious
abortion.
Themajorityofepisodesofmentalillness
duringpregnancyareneuroses.Thecommonest
conditionisdepressiveneurosiswithanxiety,
phobicanxietyandobsessivecompulsive
disorders.Inmostcasestheseconditionsresolve
bythesecondtrimesterofpregnancy.
Themajormentalillnessesinpregnancy
includebipolaraffectivedisorder,severe
depressionandschizophrenia.Theriskofwomen
developinganewepisodeofoneofthese
conditionsinpregnancyislowerthanatother
timesinherlife.
Management
•Thenurseshouldprovidesupport,counse­
ling,reassuranceandinformationwhichis
communicatedinacaring,intelligibleway.
•Ifthepsychiatristfeelsthatthereisa
substantialriskofrelapseifthewomen's

252. PsychosocialIssuesAmongSpecialPopulation249
medicationsarewithdrawn,thenthisriskhas
tobeweighedagainstthatofthedrugshaving
ateratogeniceffectonthefetus.
B.PuerperalMentalDisorders
Asmanyas16%ofmothersdevelopmentalillness
inthepuerperium.Theriskofbecomingmentally
illduringthepuerperiumisgreaterthanatother
timesinthewomen'sreproductivelife.
Manyfactorsareassociatedwithpuerperal
mentalillnesssuchaslackofconfiding
relationshipandsupport,maritaltension,socio­
economicproblemsandapreviouspsychiatric
history.
Commonpuerperalmentaldisordersare:
APostnatalblues
B.Postnataldepression
C.Puerperalpsychosis
a.Postnatalblues(transitorymood
disorders)
Postnatalbluesaretransient,aselflimiting
conditionwithnoknownseriousaftereffects.
Mostwomenrecoverfromtheblueswithinaday
ortwo.Itoccursatanytimebetweenthethird
andtenthpostnatalday.Itisconsideredanormal
reactiontochildbirthandaffectsabout70%to
80%ofallpostnatalmothers.Thesearemore
commoninprimigravidaandinthosewho
complainofpremenstrualtension.
Thewomenexperienceunfamiliarepisodes
ofcrying,irritability,depression,emotional
liability,feelingseparateanddistantfromthe
baby,insomniaandpoorconcentration.
Thesupportgiventomothersinthepostnatal
periodmayhelpthemtocopewiththeirfeelings
andhaveasignificantcontributiontotheiremo­
tionalwellbeingandadaptationtomotherhood.
b.Postnataldepression
Postnataldepressionisthemostfrequentneurotic
disorderduringpostnatalperiod.Itoccursin10%
to15%ofwomen.Onsetisusuallywithinthe
firstpostpartummonth,oftenonreturninghome
andusuallybetweenday3andday14.
Amajorityofwomenrecoverspontaneously.The
depressiveepisodesaremanifestedaspoor
concentration,feelingofguilt,lossofenergy,lack
ofinterestinusualactivities,socialwithdrawal,
inabilitytocope,tiredness,irritability,anxiety,
ruminativeworryaboutthebaby,guiltabouttheir
perceivedpoormotheringskills,sleepdistur­
bances,depressiveideationandanomie(which
isapainfulfeelingofinabilitytoexperiencelove
orpleasure).
Management
•Counseling
•Cognitivetherapy
•Antidepressantslikeamitriptylineand
tetracyclicdrugs
•Goodsupervisionandsupport
c.PuerperalPsychosis
Puerperalpsychosisaffectsapproximately1-2per
1000births.Unmarriedstatus,primigravida,past
historyofschizophreniamaypredisposeto
puerperalpsychoses.
Theonsetisverysudden,commonlyoccurring
withinthefirstpostnatalweek.Themainfeatures
are;
•Insomniaandearlymorningwaking
•Labilityofmood,suddentearfulnessor
inappropriatelaughter
•Abnormalbehaviorsuchasrestlessness,
excitementorsuddenwithdrawal
•Suspiciousnessandfear
•Unexpectedrejectionofthebabyora
convictionthatbabyisdeformedordead
•Suicidalorinfanticidethreats
•Excessiveguilt,depressionoranxiety
Management
•Puerperalpsychosisisapsychiatricemer­
gency.Admissiontohospitalisalways
required,duetothepotentialdangertothe
babyanddifficultyindealingwiththe
mother'sbehaviorathome
•Electroconvulsivetherapy

253. 250AGuidetoMentalHealthandPsychiatricNursing
•Antipsychotics-maycauseoversedationin
baby
•Supportivepsychotherapy
Ill.MENOPAUSAL SYNDROME
Menopause,thecessationofovulation,generally
occursbetween45and53yearsofage.The
hypoestrogenismthatfollowscanleadtohot
flashes;sleepdisturbances,vaginalatrophyand
dryness,andcognitiveandaffectivedisturbances
likeworrying,depression,anxiety,irritability,
difficultyinconcentrationanddecreasedself
confidence.
Management
•Hormonalreplacementtherapy
•Reassurance
•Psychologicalsupport
•Earlyidentificationofemotionalproblems
andprompttreatment
•Counseling
•Psychotherapy
PSYCHOSOCIAL ISSUESAMONG HIVIAIDS
PATIENTS
HIVIAIDSisoneofthemostdevastatingglobal
epidemicsofthetwentiethcentury.TheHuman
ImmunodeficiencyVirus(HIV)andtheresulting
AcquiredImmuneDeficiencySyndrome(AIDS)
includeavarietyofseriousanddebilitating
disorderssuchasopportunisticinfections
resultingfromacompromisedimmunesystem
andsignificantco-occurringpsychiatricillnesses.
InIndiathenumberofpeoplewiththevirusis
5.134millions,accordingtotheNationalAIDS
ControlOrganization(NACO)estimateof2005,
withnearly90percentofcasesinthe15-49year
agegroup(TheIndianExpress,17thAug.2005,p-
8).KarnatakaandTamilNaduhavethehighest
prevalenceofHIVIAIDScases.A2004survey
estimatedthat50,000peopleinKarnatakawere
affectedbythedisease(TheIndianExpress0151Dec.
2005,p-1).
PsychosocialIssuesRelatedtoaPositive
Result
1.Emotional:Shock,numbness,disbelief,
confusion,uncertaintyaboutpresentand
future,denial,guilt,frequentchangesof
mood,sadnessandconcernaboutthefuture.
2.Behavioral:Crying,angerexpressed
verballyandphysically,withdrawal,
checkingthebodyforsignsofinfection/
deterioration.
3.Fear:Fearofpain,ofdeath,ofdisability,
lossoffunctioning,oflossofprivacyI
confidentiality,ofdesertion.
4.Loss:Offutureandambitions,ofphysical
attractivenessandpotency,ofsexual
relationship,ofstatusincommunity,of
independence,ofcontroloverlife,of
confidence.
5.Guilt:Guiltaboutthebehaviorthatresulted
inHIVinfection,aboutinfectingothers,
aboutdisruptingthelifeofothers.
6.Grief:Griefoverthelossofhealth.
7.Isolation:Duetosocialstigma.
8.Resentment:Atchangesinlivingpatterns.
9.Depression:Depressionduetoabsenceof
acure,lossofpersonalcontrol.
10.Anxiety:Anxietyaboutprognosis,social,
occupational,domesticandsexualhostility
andrejection.
11.Anger:Angeraboutthehelplessnessofthe
situation,unfairfate,otherswhoare
infection-free,healthcareworkers,others
whodiscriminate.
12.Suicidalthoughtsandacts
13.Lossofselfesteem:Duetorejection,lossof
confidence,lossofidentity,physicalimpact
ofHIVinfection.
14.Obsession:Duetopre-occupationwith
health
•Insomeinstances,asymptomcomplex
similartopost-traumaticstressdisorder
iscommoninthefirstfewweeksafter
notificationofHIVpositivity.
•Thepersonmaybecomeextremely
anxiousandhypervigilantabout

254. PsychosocialIssuesAmongSpecialPopulation251
physicalsymptoms,exhibitingmarked
dependenceonhealthcareproviders.
•Otherresponsesare,transientorchronic
sexualdysfunctionandsocialwith­
drawalduetofearofinfectingothersor
ofsocialrejection.
•SignificantothersofpatientswithHIV
diseasefaceagreatmanystresses
associatedwiththepatient'sillness.
Theymayexperiencegriefresponse,
financialconcernsandlackofsocial
support(duetostigmaattachedto
illness).
•Manypsychiatricsyndromesare
associatedwithHIVIAIDS.Theseare­
depression,anxiety,paranoia,mania,
irritability,psychosisandsubstance
abuse.Theycomplicateimmunesystem
function,adverselyaffectthepatient's
abilitytofullyparticipateintreatment,
andnegativelyimpactthequalityoflife.
Onthewhole,thediseasestaxcoping
responsestothelimitandbeyond.
NursingManagement
•Psychiatricnursesareinauniquepositionto
helpdiagnosis,treatandsupportpatients
affectedbyHIVIAIDS.
•Athoroughpsychiatrichistoryandcomplete
neuropsychiatryevaluationareindicated
whenHIVpositivepatientspresentwith
psychiatricsymptoms.
•PlanninghealthcareforpersonwithHIV/
AIDSmustinvolvethemultidisciplinaryteam.
•Interventionsincludecasemanagement,
medications,riskreduction,supportgroups,
crisisintervention,encouragementofproduc­
tiveactivity,enhancementofself-esteem,grief
counseling,supportduringterminalstages,
andsupportofsignificantothers.
•Thepsychiatricinterventionsforpatients
withHIVIAIDSare;
•Helpingpatientschangeriskybehavior,
thuspromotingpreventionofHIVinfection
•Helpingpatientsduringthedifficult
processofHIVtesting(preandpost-test
counseling)
•Helpingestablishthediagnosisand
treatmentofotherpsychiatricillnesses
commonlyseeninpatientswithHIV
•Implementingpsychosocialinterventions
likepsychotherapy,cognitivebehavioral
therapy,counselingetc.
•Helpingpatients,theirfamiliesandothers
intheirliveswithinterpersonalproblems
relatedtoHIVIAIDS
•AssistingAIDSpatientsduringthefinal
phaseoftheirillness.
StepsinPre-testCounseling
•Assesstheindividual'smotivationfortesting
•Assesswhatinformationthepersonalready
hasaboutHIVIAIDS
•ProvidebasicinformationregardingHIVin
verysimpleterms
•ClarifyIcorrectmisconceptions,ifnecessary
•Describetheprocessofantibodytesting
•Giveinformationabouttheaccuracyoftests
•Explainwindowperiod
•Explainwhatthetestresultmeans,i.e.in
termsofbeingHIVpositive,negativeor
indeterminate
•Discusstheissueofconfidentiality
•Facilitateinformeddecisionandconsentfor
thetest
•Reviewclient'sassessmentofownrisk
•Provideriskreductioninformation
•Assesstheclient'ssocialnetworkandcoping
strategies.
StepsinPost-testCounseling
•Buildrapport
•Revealtestresult(neverdivulgethetestresult
overthetelephone)
•Afterdisclosingthatthetestispositive,keep
quiteforawhile-letthepatientreactand
ventilatehisfeelings;givehimtimetoabsorb
thetestresult.
•Explorethepatientsunderstandingofthe
medicalmeaningoftest
•Empathizetounderstandthewayhefeels

255. 252AGuidetoMentalHealthandPsychiatricNursing
•Talkaboutthethingshecandosafely
•Provideinformationregardingprecautionsto
avoidtransmission
•Assesshiscommitmenttoreducingrisk.If
changeisresisted,emphasizeharmreduction
•Assesspatientslifestyle-tellhimhowafew
changeswithregardtodiet,substanceabuse
etc.,willhavetobemade
•Developahealthplan
•Findouthowheusuallycopeswithstress;
assesssocialsupportnetworkavailable
•Exploreandassistpatienttofacethe
consequencesofhavingtodeclareHIVstatus
tosignificantotherse.g.spouse/sexual
partners,family,health-careprovidersetc.
•Workwiththefamiliesregardingtheirown
anxietiesabouttheirownhealthorthefuture
oftheinfectedperson.Providecounseling
servicestofamilymembersifsodesiredbythe
patient
•Someimportantinstructionswhichmustbe
communicatedtoaHIV+patientincludes:
•Safe-sexinformation,correctuseof
condomsallthetime
•Necessitytostopdonatingblood,donating
organs,sharingneedles,etc.
•SafetypracticesinHIVdruguse,blood
donation,tests,etc.
•Regularmedicalmonitoring
•Safetytipstopatientswhoworkinjobs
wheretheymayinfectothers
•NeedtodiscussHIVinfectionwiththeir
sexualpartner.
Thelevelofsupportrequiredtoassistpatients
andotherswhodealwithAIDSdemandsskilled
interventionsandanintegratedteameffortamong
mentalhealthprofessionalsincludingpsychiatric
nurses.
REVIEWQUESTIONS
•Mentalhealthproblemsamongadolescents
•Listthepsychiatricproblemsamongelderly
people
•Listthepsychiatricdisordersassociatedwith
childbirth
•DescribepsychosocialissuesamongHIVI
AIDSpatients

256. Appendix/
Glossary
Abreaction:Atreatmentprocedurewherebyrepressedpainfulexperiencesarevoluntarilyrecalledto
awareness.Thisventilationgivesatherapeuticeffect.
Abstractthinking:Abilitytoappreciatenuancesofmeaning;multidimensionalthinkingwithability
tousemetaphorsandhypothesesappropriately.
Addiction:Strongdependence,bothphysicalandemotional,onalcoholorsomeothermaterial.
Affect:Ashort-livedemotionalresponsetoanideaoranevent.
Agitation:Presenceofanxietywithseveremotorrestlessness.
Ambivalence:Theco-existenceoftwoopposingdrives,desires,feelingsoremotionstowardsthesame
person,objectorgoal;aconflicttodoornottodo.
Amnesia:Pathologicalimpairmentofmemory.
Anterogradeamnesia:Amnesiaofeventsoccurringaftertheepisodewhichprecipitatedthedisorder.
Retrogradeamnesia:Amnesiaofeventsoccurringpriortotheepisodewhichprecipitatedthedisorder.
Anhedonia:Inabilitytoexperiencepleasureinanyactivity.
Apathy:Lackofemotionalfeeling.
Apraxia:Inabilitytocarryoutnormalactivitiesdespiteintactmotorfunction.
Autisticthinking:Preoccupationstotallyremovingapersonfromreality.
Automaticobedience:Thepatientobeyseverycommandthoughhehasfirstbeentoldnottodoso.
Automatism:Undirectedbehaviorthatisnotconsciouslycontrolled,asseenincomplexpartial
seizures.
Bluntedaffect:Areductioninemotionalexperience.
Cataplexy:Temporarylossofmuscletoneandweaknessprecipitatedbyavarietyofemotionalstates.
Catharsis:Theexpressionofideas,thoughtsandsuppressedmaterialaccompaniedbyanappropriate
emotionalresponsethatproducesastateofreliefinthepatient.
Circumstantiality:Apatternofcommunicationthatisdemonstratedbythespeaker'sinclusionof
manyirrelevantandunnecessarydetailsinhisspeechbeforeheisabletocometothepoint.
Clangassociation:Clientusestwowordswithasimilarsound,i.e.hischoiceofwordsisdetermined
bytheirsoundandnotbytheirmeaning,whichoftenreducestheintelligibilityofspeech.Itmaylead
topunning(humoroususeofwordstosuggestdifferentmeanings)andrhyming,andisoftenseenin
manicpatients.

257. 254AGuidetoMentalHealthandPsychiatricNursing
Compulsion:Pathologicalneedtoactonanimpulsethat,ifresisted,producesanxiety;repetitive
behaviorinresponsetoanobsessionorperformedaccordingtocertainrules,withnotrueendinitself
otherthantopreventsomethingfromoccurringinthefuture(thepatientfearssomethingbadwill
occurinfutureifhedoesnotindulgeinsuchbehaviors).
Concretethinking:Thoughtprocessesarefocusedonspecificsratherthangeneralizations.These
individualsareunabletocomprehendabstractmeanings.
Confabulation:Theunconsciousfillingofmemorygapsbyimaginedoruntrueexperiencesdueto
memoryimpairment.Itismostoftenassociatedwithorganicpathology.
Dejavu:Asubjectivefeelingthatanexperience,whichisoccurringforthefirsttime,hasbeen
experiencedbefore.
Depersonalization:Aperson'ssubjectivesenseofbeingunreal,strangeorunfamiliar.
Derealization:Asubjectivesensethattheenvironmentisstrangeorunreal;afeelingofchanged
reality.
Delusion:Afalse,unshakeablebelief,whichisnotamenabletoreasoningandisnotinkeepingwith
thepatient'ssocioculturalandeducationalbackground.
Primary(Autochthonous)delusionisonethatappearssuddenlyandwithfullconviction,butwithout
anypreviouseventsleadinguptoit.Suchdelusionsaresuggestiveofschizophrenia.
Secondarydelusionscanbeunderstoodasderivedfromsomeprecedingmorbidexperience.
Delusionalmood:Occasionally,whenapersonfirstdevelopsadelusion,thefirstexperienceisa
changeofmood,oftenafeelingofanxietywiththeforebodingthatsomesinistereventisaboutto
takeplace,andthedelusionfollows.InGermanthischangeofmoodiscalledWahnstimmung,a
termusuallytranslatedasdelusionalmood.
Delusionalperception:Insomeoccasionswhenapersonfirstdevelopsadelusion,thefirstchange
maybeattachinganewsignificancetoafamiliarperceptwithoutanyreason.Forexample,anew
arrangementofobjectsonacolleague'sdeskmaybeinterpretedasasignthatthepatienthasbeen
chosentodoGod'swork.Thisiscalleddelusionalperception.
Delusionofgrandeur:Anindividual'sexaggeratedconceptionofhisimportance,poweroridentity,
abeliefthatheissomebodyspecial,orisbornwithaspecialmissioninlife,orisrelatedtothemost
importantpeopleofhistime.
Delusionofpersecution:Abeliefthatheisbeingattacked,harrassed,spied,cheatedorconspired
against.
Delusionofreference:Itisthedelusionthatevents,objects,behaviorofothershavegotaparticular
orunusualsignificanceforoneself,usuallyofanegativenature.Forinstancethepersonmay
falselybelievethatothersaretalkingabouthim(suchas,thebeliefthatpeopleontelevisionor
radioaretalkingabouttheperson).
Delusionofcontrol:Thisreferstothebeliefthatthepatient'swill,thoughtsorfeelingsarebeing
controlledbyexternalforces.
Delusionofinfidelity(Delusionofjealousy):Thisisthedelusionthatone'sloverisunfaithfultohim/
her.

258. AppendixI-Glossary255
Delusionofguilt:Beliefthatoneisasinnerandisresponsiblefortheruinofhisfamilyorsociety.
Somaticdelusion:Beliefinvolvingfunctioningofthebody.Forexample,beliefthatthebrainis
rottingormelting.
Nihilisticdelusion:Thedelusionalbeliefthatothers,oneselfortheworlddonotexist.Mostcommonly
seeninmajordepressiveepisode.
Erotomania:Adelusionalbeliefthattheotherpersonisdeeplyinlovewithhim/her.Thesupposed
loverisusuallyinaccessibleandofmuchhighersocialstatus(alsoknownasClerambault­
KandinskyComplex).
Moad-incongruentdelusion:Delusionwithcontentthathasnoassociationtomoodorismood
neutral(forexampleadepressedpatienthasdelusionsofthoughtcontrolorthoughtbroadcasting).
Mood-congruentdelusion:Delusionwithmoodappropriatecontent(forexample,adepressedpatient
believesthatheisresponsibleforthedestructionoftheworld).
Systematizeddelusion:Falsebelieforbeliefsunitedbyasingleeventortheme.
Bizarredelusion:Anabsurd,totallyimplausible,strangefalsebeliefinaperson'smind.
Echolalia:Pathologicalrepetitionbyimitationofthespeechofanother.
Echopraxia:Pathologicalrepetitionbyimitationofthebehaviorofanother.
Egocentric:Self-centered;preoccupiedwithone'sownneedsandlackinginterestinothers.
Ego-dystonic:Distressingtotheindividual.
Flataffect:Absenceornearabsenceofanysignofaffectiveexpression;voicemonotonous,face
immobile.
Flightofideas:Theclient'sthoughtsandconversationmovequicklyfromonetopictoanother,sothat
onetrainofthoughtisnotcompletedbeforeanotherappears.Theserapidlychangingtopicsare
understandablebecausethelinksbetweenthemarenormal,apointthatdifferentiatesthemfrom
looseningofassociations.Flightofideasischaracteristicofmania.
Foliea'deux:Apsychoticreactioninwhichtwocloselyrelatedpersons,usuallyinthesamefamily,
mutuallysharethesamedelusions.
Formalthoughtdisorder:Disturbanceintheformofthoughtratherthanthecontentofthought;
thinkingcharacterizedbyloosenedassociations,neologisms,andillogicalconstructions;thought
processisdisordered,andthepersonisdefinedaspsychotic.
Functional:Havingapsychologicalratherthananorganicpathology.
Geriatricpsychiatry:Aspecialityofpsychiatrywhichdealswithmentalhealthproblemsofthe
elderly.
Hallucinations:Afalsesensoryperceptionintheabsenceofanactualexternalstimulus.Hallucinations
maybedescribedintermsoftheirsensorymodalityasvisual,auditory,olfactory,gustatory,tactile.
Auditoryhallucinations:Thesearebyfarthecommonest,andmaybeexperiencedasnoise,musicor
voices.Voicesmayseemtoaddressthepatientdirectly(second-personhallucinations)ortalktoone

259. 256AGuidetoMentalHealthandPsychiatricNursing
anotherreferringtothepatientas'he'or'she'(third-personhallucinations).Third-person
hallucinationsmaybeexperiencedasvoicescommentingonthepatient'sintentionsoractions.
Suchcommentaryvoicesarestronglysuggestiveofschizophrenia.
Visualhallucination:Falseperceptioninvolvingsightconsistingofbothformedimages(forexample
people)andunformedimages(forexample,flashesoflight);mostcommoninmedicallydetermined
disorders.
Olfactoryhallucination:Falseperceptionofsmell;mostcommoninmedicaldisorders.
Gustatoryhallucination:Falseperceptionoftaste,suchasunpleasanttaste,causedbyanuncinate
seizure;mostcommoninmedicaldisorders.
Tactile(Haptic)hallucination:Falseperceptionoftouchorsurfacesensation,asfromanamputated
limb(phantomlimb);crawlingsensationonorundertheskin(formication).
Somatichallucination:Falsesensationofthingsoccurringinortothebody,mostoftenvisceralin
origin(alsoknownascenesthetichallucination).
Mood-congruenthallucination:Hallucinationinwhichthecontentisconsistentwitheithera
depressedoramanicmood(forexampledepressedhearsvoicessayingthatthepatientisabad
person;amanichearsvoicessayingthatthepatientisofinflatedworth,powerandknowledge).
Mood-incongruenthallucination:Hallucinationinwhichthecontentisnotconsistentwitheither
depressedormanicmood(forexampleindepression,hallucinationsnotevolvingsuchthemesas
guilt,deservedpunishment,orinadequacy;inmania,hallucinationsnotinvolvingsuchthemes
asself-inflatedworthorpower.
Commandhallucination:Falseperceptionofordersthatapersonmayfeelobligedtoobeyorunable
toresist.
Hypnagogichallucinations:Thesehallucinationsoccurwhenfallingasleep,generallyconsideredas
non-pathological.
Hypnopompichallucinations:Hallucinationsoccurwhenthesubjectisawakening,oftenoccurringin
healthyindividuals.
Hypochondriasis:Exaggeratedconcernwithone'sphysicalhealth,notbasedonorganicpathology.
Illusion:Themisinterpretationofareal,externalsensoryexperience.
Insight:Insightmeansthecapacitytoappreciatethatone'sdisturbanceofthoughtandfeelingare
subjectiveandinvalid.Lossofinsighthastraditionallybeenconsideredtooccurinpsychosis,while
itsretentioncharacterizesneurosis.
Intellectualinsight:Understandingoftheobjectiverealityofasetofcircumstanceswithoutthe
abilitytoapplytheunderstandinginanyusefulwaytomasterthesituation.
Trueinsight:Understandingoftheobjectiverealityofasituation,coupledwiththemotivationand
theemotionalimpetustomasterthesituation.
IntelligenceQuotient(IQ):Intelligenceofapersonmeasuredthroughpsychologicaltesting.Normal
IQis90-110;anIQofbelow70denotesmentalretardation.

260. AppendixI-Glossary257
Illogicalthinking:Thinkingcontainingerroneousconclusionsandinternalcontradictions.
Jamaisvu:Failuretorecognizeeventsthathavebeenencounteredbefore.
Judgment:Judgmentisthementalactofcomparingandevaluatingalternativesforthepurposeof
decidingonacourseofaction.Judgmentissaidtobedisturbedwhentheindividualdeviatesfrom
whatisgenerallyheldasvalid,andholdsobstinatelytoitscontentalthoughitinterfereswithhis
adaptation.
Labileaffect:Rapidlyshiftingemotions,unrelatedtoexternalstimuli.
Looseningofassociations:Apatternofspontaneousspeechinwhichthingssaidlackameaningful
relationship,orthereisidiosyncraticshiftingfromoneframeofreferencetoanother;itisusuallythe
generallackofclarityintheclient'sconversationthatmakesthemoststrikingimpression.
Looseningofassociationtakesseveralforms:
Knight'smoveorderailmentreferstoatransitionfromonetopictoanother,eitherbetweensentences
orinmid-sentence,withnologicalrelationshipbetweenthetwotopics.Whenthisabnormalityis
extremeitdisruptsnotonlytheconnectionsbetweensentencesandphrases,butalsothefiner
grammaticalstructureofspeech.Itisthencalledwordsalad.Oneeffectofloosenedassociationson
theclient'sconversationissometimescalledtalkingpastthepoint(alsoknownbytheGermanterm
vorbeireden).Inthisconditionthepatientseemsalwaysabouttogetneartothematterinhand,but
neverquitereachesit.Incoherenceisamarkeddegreeoflooseningofassociationinwhichthe
patientshiftsideasfromonetoanotherwithoutlogicalconnectionandthepatient'stalkcannotbe
understoodatall.
Libido:Atermusedinpsychoanalytictheoryforsexualdrive.
Malingering:Deliberatesimulationorexaggerationofanillnessordisabilitythatinfactisnon­
existentorminor.
Manipulation:Abehaviorpatterncharacterizedbyexploitationofinterpersonalcontact;indiscriminate
useofinterpersonalrelationshiptomeetone'sownendwithoutanyconsiderationfortheother
personintherelationship.
Mannerism:Ingrained,habitualinvoluntarymovement.
MunchausenSyndrome:Adisorderinwhichsufferershabituallyattempttohospitalizethemselves
withself-inflictedpathology.
Narcissism:Obsessiveandexclusiveinterestinone'sownself.
Narcoanalysis:Aprocedurebywhichachemicalisinjectedintoaperson(e.g.slowIVinjectionof
pentathol),whileencouraginghimtoventilatetheunconsciousdesiresandmotiveswhichhecannot
recollectduringconsciousstate.It'satherapeuticandadiagnosticprocedurecommonlyusedin
neuroticdisorders.
Negativism:Motivelessresistancetoallattemptstobemovedortoallinstructions.
Neologism:Awordnewlycoinedoraneverydaywordusedinaspecialway,notreadilyunderstood
byothers.

261. 258AGuidetoMentalHealthandPsychiatricNursing
Obsession:Pathologicalpersistenceofanirresistiblethoughtorfeelingthatcannotbeeliminatedfrom
consciousnessbylogicaleffort;associatedwithanxiety.
Oedipuscomplex:Attachmentofthechildtotheparentoftheoppositesex,accompaniedbyenvious
feelingstowardstheparentofthesamesex.
Overvaluedidea:Unreasonable,sustainedfalsebeliefmaintainedlessfirmlythanadelusion.
Paranoid:Anadjectiveappliedtoindividualswhoareover-suspicious.
Parasuicide(Deliberateself-harm):Anyactdeliberatelyundertakenbyapersonwhichmimicstheact
ofsuicide,butwhichdoesnotresultinafataloutcome.
Passivityphenomenon:Thedelusionalbeliefthatanexternalagencyiscontrollingtheself.
Phobia:Persistent,irrational,exaggeratedandinvariablypathologicaldreadofaspecificstimulusor
situation;resultsinacompellingdesiretoavoidthefearedstimulus.
Pressureofspeech:Rapidproductionofspeechoutput,withasubjectivefeelingofracingthoughts.
Perseveration:Persistentrepetitionofwordsorthemesbeyondthepointofrelevance.
Povertyofspeech:Decreasedspeechproduction.
Pseudodementia:Similarclinicallytodementia,buthasanon-organiccauseandisreversible.
Psychometry(Psychologicaltesting):Thescienceoftestingandmeasuringmentalandpsychological
ability,efficiency,potentialsandfunctioning.
Psychopathology:Thestudyofsignificantcausesandprocessesinthedevelopmentofmentaldisorders.
Rapport:Establishingameaningfulconversation.
Rorschachtest:Apsychologicaltesttodiscloseconsciousandunconsciouspersonalitytraitsand
emotionalconflictsbyelicitingpatients'associationstoastandardsetofinkblots.
Somaticdelusion:Thebeliefthatone'sbodyischangingandrespondinginsomeunusualway.
Stereotypes:Persistentmechanicalrepetitionofspeechormotoractivity.
Stupor:Astateinwhichtheindividualdoesnotreacttohissurroundingsandappearstobeunaware
ofthem.Commonlyseenincatatonicanddepressivedisorders.
Tangentiality:Aformofthinking/speechinwhichtheclienttendstowanderawayfromtheintended
point,andneverreturningtotheoriginalidea.
Thematicapperceptiontest(TAT):Apsychologicaltestusedasadiagnostictoolconsistingof30
cards,toassesspersonalityandpsychopathology.
Thoughtblock:Asuddeninterruptioninthethoughtprocessbeforethethoughtiscompleted.Aftera
pause,thesubjectcannotrecallwhathehadmeanttosay.Thismaybeassociatedwiththought
withdrawal.Thoughtblockisstronglysuggestiveofschizophrenia.
Thoughtbroadcast:Thedelusionalbeliefthatone'sthoughtsarebeingbroadcastorprojectedintothe
environment.

262. AppendixI-Glossary259
Thoughtinsertion:Thedelusionalbeliefthatthoughtsarebeingputintoone'smind.Thesethoughts
arerecognizedasbeingforeign.
Thoughtwithdrawal:Thedelusionalbeliefthatone'sthoughtsaretakenawaybysomeexternal
agent,oftenassociatedwiththoughtblock.
Transference:Aprocessinwhichfeelings,attitudesandwishesoriginallylinkedwithsignificant
figuresinone'searlylifeareprojectedontothetherapist.
Verbigeration:Senselessrepetitionofsomewordsorphrasesoverandoveragain.
WechslerIntelligenceScale:Atestforassessingintellectualfunctioning.
Wordapproximation(Paraphasias):Commonlyusedwordsusedinaneworunconventionalway.
Oftenthemeaningisevidentthoughtheusagemaybepeculiar(forexample,describing'stomach'as
'foodvessel').

263. Appendix/I
MentalMechanisms
Everyindividualhasdevicesforprotectinghimselfagainstpsychologicaldangersanddistress.These
protectivedevicesareknownasegodefencesordefencemechanismsormentalmechanisms.Both
well-adjustedandmaladjustedindividualsmakeuseofthesemechanismsintheirdailybehavior.
Whilewell-adjustedindividualsusethemsparinglyandinsociallydesirableways,maladjusted
individualsincludingpsychoticsandneurotics,usethemfrequentlyandinappropriately.
Someofthecommonlyusedmentalmechanismsare:
Repression:Itisaprocessofunconsciousforgetfulnessofunpleasantandconflictproducingemotions.
Rationalization:Itisadefencemechanisminwhichanindividualjustifieshisfailuresandsocially
unacceptablebehaviorbygivingsociallyapprovedreasons.
Forexample,astudentwhofailsintheexaminationmaycomplainthatthehostelatmosphereis
notfavorableandhasresultedinhisfailuretogetthrough.
Intellectualization:Focusingofattentionontechnicalorlogicalaspectsofathreateningsituation.
Forexample,awifedescribesthedetailsofthenurse'sunsuccessfulattemptstopreventthedeath
ofherhusband.
Compensation:Attemptingtoovercomefeelingsofinferiorityormakeupforadeficiency.
Forexample,astudentwhofailsinhisstudiesmaycompensatebybecomingthecollegechampion
inathletics.
Substitution:Amechanisminwhichoriginalgoalsaresubstitutedbyothers.
Forexample,astudentwhohasnotbeenacceptedforadmissioninamedicalcollegemaysatisfy
herselfbybecominganurse.
Sublimation:Unconsciousgradualchannelizationofunacceptableimpulsesintopersonallysatisfying
andsociallyvaluablebehavioralpattern.
Forexample,ahostileyoungmanwhoenjoysfightingbecomesafootballplayer.
Suppression:Suppressionisanintentionalpushingawayfromawarenessofcertainunwelcome
ideas,memoriesorfeelings.
Forexample,astudentconsciouslydecidesnottothinkaboutherweekendsothatshecanstudy
effectively.
Reactionformation:Unconscioustransformationofunacceptableimpulsesintoexactlyopposite
attitudes,impulses,feelingsorbehaviors,i.e.unacceptablerealfeelingsarerepressedandacceptable
oppositefeelingsareexpressed.
Forexample,ayoungmanwithhomosexualfeelings,whichhefindstobethreatening,engagesin
excessiveheterosexualactivities.

264. AppendixII-MentalMechanisms261
Displacement:Unconsciousshiftingofemotionsusuallyarousedbyperceivedthreatfroman
unconsciousimpulse,toalessthreateningexternalobjectwhichisthenfelttobethesourceofthreat.
Forexample,apersonwhoisangrywithhisboss,butcannotshowitforfearoflosingthejobmay
fightwithhiswifeandchildrenonreturnfromtheoffice.
Denial:Refusaltoacceptorbelieveintheexistenceofsomethingthatisveryunpleasant.
Forexample,anaddicttakesalcoholeverydayandhecannotthinkofadaywithoutit.Howeverhe
says"Iamnotanaddict,ifIdecideIcangiveup."
Isolation:Separationoftheideaofanunconsciousimpulsefromitsappropriateaffect,thusallowing
onlytheideaandnottheassociatedaffecttoenterawareness,asintheabilitytoexpresstraumatic
experienceswithouttheassociateddisturbingemotions,withpassageoftime.
Forexample,asoldierhumorouslydescribeshowhewasseriouslywoundedinthewar.
Projection:Unconsciousattributionofone'sownattitudesandurgestootherpersons,becauseof
intoleranceorpainfulaffectarousedbythoseattitudesandurges.Apersonwhoblamesanotherfor
hisownmistakesisusingtheprojectionmechanism.
Forexample,asurgeonwhosepatientdoesnotrespondaswellasheanticipatedmaytendto
blamethetheaternursewhohelpedthedoctoratthetimeofoperation.
Regression:Copingwithpresentconflictorstressbyreturningtoearlier,moresecurestageoflife.
Forexample,tears,tempertantrumsinadultsareveryeffectiveinovercomingstress.
Conversion:Amentalmechanisminwhichanemotionalconflictisexpressedasaphysicalsymptom
forwhichthereisnodemonstratableorganicbasis.
Forexample,astudentveryanxiousabouthisexamsmaydevelopaheadache.
Undoing:Unconsciouslymotivatedacts,whichmagicallyorsymbolicallycounteractunacceptable
thoughts,impulsesoracts.
Forexample,amotherwhohasjustlosthertemperandbeatenherchildrendevelopscompulsive
handwashingandchildcheckingbehaviors.

265. Index
A
Abuse129
Activitytherapy196
aims196
arttherapy200
bibliotherapy199
dancetherapy199
educationaltherapy198
implications200
musictherapy199
occupationaltherapy196
playtherapy199
recreationaltherapy198
Acuteintoxication131,140
Adaptivebehavior141,151
Adolescentmentalhealthnursing
commonreasonsformental
healthproblems245
mentalhealthproblems245
nursinginterventions245
Agenciesconcernedwithalcohol-
relatedproblems134
Aggressivepatient91
Agoraphobia111
Alcoholdeterrenttherapy133
Alcoholics141
Alcohol-inducedpsychiatric
disorders132
Antidepressants175
Antipsychoticdrugs173
Anxiousbehaviour112
Anxiouspersonalitydisorder145
Asperger'ssyndrome162
Atypicalautism162
B
Behaviortheory122
Benzodiazepines180
Braindamage8
c
Carbamazepine178
Childandadolescentpsychiatry
assessmentformat64
Childpsychiatricnursing150
Childhoodpsychiatricdisorders
150
behavioralandemotional
disorders162
conductdisorders164
hyperkineticdisorder162
juveniledelinquency166
phobicanxietydisorder167
separationanxietydisorder
166
siblingrivalrydisorder167
socialanxietydisorder167
childhoodautism158
classification151
disordersofpsychological
development157
developmentaldisordersof
motorfunction158
developmentaldisordersof
scholasticskills158
disordersofspeechand
language157
encopresis169
enureses168
feedingdisorder169
mentalretardation151
careandrehabilitation154
classification152
epidemiology151
nursingmanagement156
prevention153
mutism167
stereotypedmovement
disorders170
stuttering170
ticdisorders168
Commonpsychiatricemergencies
240
catatonicstupor243
hystericalattacks243
panicattacks243
suicidalthreat240
transientsituational
disturbances243
violentoraggressivebehavior
242
Communicationskillsin
depressedpatients101
Communityfacilitiesfor
psychiatricpatients225
halfwayhome226
partialhospitalization226
psychiatrichospitals226
quarterwayhomes226
self-helpgroups227
suicidepreventioncentres228
Communitymentalhealthcenters
225
Communitymentalhealthin
India224
Conceptualmodels48
behavioral49
communication51
holistic54
interpersonal50
nursing52
psychoanalytical48
Conversiondisorders122
Crisis202
crisisintervention205
modalities207
roleofanurse206
phases204
resolution204
signsandsymptoms204
types203
D
Delirium107
Deliriumtremens131
Delusionalbehaviour83
Dementia104
Depressedpatients101
Depression250
Dissociativeidentitydisorder121
Dissociativemotordisorders121
Dissociativestupor121
Disulfiram133
E
Eatingdisorders
anorexianervosa125
bulimianervosa127

266. 266AGuidetoMentalHealthandPsychiatricNursing
Encopresis169
Epilepticseizuresanddissociative
convulsions122
F
Fetishism147
Frotteurism148
G
Ganser'ssyndrome121
Genderidentitydisorderof
childhood147
Geriatrichistorycollectionformat
65
Geriatricmentalhealthnursing
246
Grief201,250
maladaptivegriefresponses
202
nursingintervention202
resolution202
stages201
treatment202
Griefreaction100
H
Hallucinatorybehaviour84
Historycollectioninalcohol
dependence64
Histrionicpersonalitydisorder145
Homosexuality147
Hostels135
Hyperactivebehaviour91
Hypnosis189
Hypomanicpatients96
I
IndianLunacyAct(1912)215
IndianMentalHealthAct(1987)
215
IndianMentalHealthAct,
objectives216
Insomnia127
Intersexuality147
Intoxication137
K
Korsakoff'ssyndrome132
L
Legalaspectsinpsychiatric
nursing
basicrightsofpsychiatric
patients220
confidentiality221
informedconsent221
nursingmalpractice221
recordkeeping222
roleofthenurseinadmission
procedure220
roleofthenurseindischarge
procedure220
roleofthenurseinparole220
substitutedconsent221
Legalissuesinpsychiatry218
Legalresponsibilitiesofamentally
illperson222
Levelsofpreventionandroleofa
nurse232
Lithiumtoxicity177
M
Manicviolentbehaviour92
Manipulativebehaviour93
Mentaldisorders
burdenof5
classification11
DSMIV12
ICDlO11
Indian12
problemsof5
Mentalhealth1
characteristics2
components1
criteriafor2
indicatorsof2
Mentalhealthfacts6
Mentalhealthissues7
Mentalhealthteam10
Mentalillness2,6,9,231
characteristics3
commonsignsandsymptoms4
etiologyof7
features3
misconceptions9
Mentallyillperson222
Milieutherapy193
Mooddisorders
classification88
courseandprognosis97
depressiveepisode95
etiology88
manicepisode
classificationofmania89
nursingmanagementfor
hypomania94
nursingmanagementfor
mania90
symptomsofhypomania90
treatment90
Multidisciplinaryteam10
N
Narcissisticpersonalitydisorder
145
Nationalmentalhealthprogram
238
Neurosis110
Neuroticdisorder
classification110
dissociativedisorders120
generalizedanxietydisorder
113
obsessive-compulsivedisorder
116
panicdisorder114
phobicanxietydisorder111
reactiontostressand
adjustmentdisorder120
somatoformdisorders123
Normalandabnormalbehavior4
Nursingtheories
Orem's53
Peplau's53
Roger's54
Roy's54
Nutritionalstatusindepressive
patients102
Nutritionalstatusofmanicpatient
92
0
Obsession250
Obsessivecompulsivebehaviour
119
Organicmentaldisorders104
delirium107
clinicalfeatures108

267. Index267
etiology107
nursingintervention108
dementia104
clinicalfeatures105
etiology104
nursinginterventions105
stages104
mentaldisordersduetobrain
damage109
organicamnesticsyndrome
109
personalityandbehavioral
disordersduetobrain
disease109
Organicpsychiatricemergencies
243
acutedrug-induced
extrapyramidal
syndrome244
deliriumtremens244
drugtoxicity244
epilepticfuror244
Overdependencebehaviour101
p
Panicanxiety115
Personality
psychosocialfactors29
development31
environmentalfactors29
roleofheredity29
theoriesofpersonality
development34
behaviortheory45
cognitivedevelopment
theory40
humanisticapproach42
interpersonaltheory36
psychoanalytictheory34
theoryofmoral
development41
theoryofpsychosocial
development38
traitandtypetheories43
Personalitydisorder
classification144
clinicalfeaturesofabnormal
personalities144
etiology145
incidence144
nursingintervention146
treatment146
Phobia111
Problemsoftheelderly246
Processrecording74
Psychiatricdisorders7,130
Psychiatricdisordersrelatedto
women248
menopausalsyndrome250
premenstrualsyndrome248
psychiatricdisordersassociated
withchildbirth248
Psychiatricnurses251
Psychiatricnursing14,57,228
currentissuesandtrendsincare
17
developmentofpsychiatry14
functionsofapsychiatricnurse
24
generalprinciples22
legalaspects18
methodsofassessment60
historytaking60
mentalstatusexamination
61
physicalinvestigationsfor
psychiatricpatients63
psychologicalassessment63
newtrendsinroleofa
psychiatricnurse18
nursingprocess57
biopsychosocialassessment
58
nursingassessment58
nursingdiagnosis59
planning59
prerequisitesforamental
healthnurse20
qualitiesofapsychiatricnurse
24
standards21
standardsofmentalhealth
nursing18
therapeuticrolesofapsychiatric
mentalhealthnurse26
Psychiatricnursingskills20
Psychiatricrehabilitation
principlesofrehabilitation235
psychiatricrehabilitation
approaches235
rehabilitationteam235
roleofanurse236
vocationalrehabilitation237
Psychoactivesubstanceuse
disorders129
alcoholdependencesyndrome
130
medicalandsocial
complications131
psychiatricdisorders131
barbiturateusedisorder138
cannabisusedisorder136
cocaineusedisorder137
etiologicalfactors129
inhalantsorvolatilesolventuse
disorder138
LSDusedisorder137
nursingmanagement139
opioidusedisorders136
prevention138
rehabilitation139
Psychologicaltherapies185
abreactiontherapy189
behaviortherapy186
cognitivetherapy188
familyandmaritaltherapy192
grouptherapy190
hypnosis188
individualpsychotherapy190
psychoanalytictherapy185
psychodrama191
relaxationtherapies189
supportivepsychotherapy190
Psychophysiological/
psychosomaticdisorders
commonexamples124
nursingmanagement125
Psychosis110
PsychosocialissuesamongHIVI
AIDSpatients250
Psychoticdisorderandneurotic
disorder110
Psychotropicdrugs172
R
Rett'ssyndrome162
Ritalin182

268. 268AGuidetoMentalHealthandPsychiatricNursing
s
Schizophrenia77
clinicalfeatures79
clinicaltypes80
courseandprognosis82
epidemiology77
etiology77
nursingmanagement82
prognosticfactors81
Schneider'sfirst-rank
symptoms78
treatment82
Schizotypaldisorder145
Self-carefordepressedpatients
102
Sexualdisorders
classification147
nursingintervention148
sexualdysfunctions148
Sexualmasochism148
Simplephobia111
Sleepdisorders127
disorderofsleep-wake
schedule128
dyssomnias127
hypersomnia128
parasomnias128
stageIVsleepdisorders128
Sleepingpattern102
Socialisolationbehaviour113
Socialphobia111
Somatic(physical)therapies171
antabusedrugs181
antidepressants175
antiparkinsonianagents180
antipsychotics172
anxiolyticsandhypnosedatives
179
drugsusedinchildpsychiatry
181
electroconvulsivetherapy182
lithiumandothermood
stabilizingdrugs176
methylphenidate182
psychosurgery185
Somaticandneuroticdepression
98
Stimulus-responsetheories
classicalconditioning45
cognitivetheories47
reinforcementtheories45
Stress
bodycopingmechanism208
managementstrategies211
roleofanurseinstress
management213
source210
symptoms211
Suicidalbehavior100,132
T
Tertiaryprevention234
Therapeuticandsocialrelationship
67
Therapeuticcommunication
techniques72
Therapeuticcommunity195
Therapeuticnurse-patient
relationship66
characteristics68
components67
goals66
phases68
introductoryororientation
phase69
pre-interactionphase68
terminationphase71
workingphase70
types66
Tranceandpossessiondisorders
121
Transvestism148
v
Violentbehaviour85
Voyeurism148
w
Wernicke'ssyndrome132
Withdrawalsyndrome131
Withdrawnbehaviour84,87
z
Zoophilia148