ASSIGNMENT HISTORY TAKING ON BIPOLAR DISSOCIATIVE DISORER CURRENT MANIC EPISODE SUBMITTED TO: Dept. of Mental Health (Psychiatric) Nursing Institute of Nursing Education INTRODUCTION • DSM-IV-TR describes the essential features of dissociative disorders as a disruption in the usually integrated functions of consciousness, memory, identity, or perception (APA 2000). • Dissociative responses occur when anxiety becomes overwhelming and the personality becomes disorganized. • Defense mechanisms that normally govern consciousness, identity, and memory breakdown and behavior occur with little or no participation on the part of the conscious personality. Dissociation: The unconscious separation of painful feelings and emotions from an unacceptable idea, situation or object. Dissociative Disorders: Dissociative disorders are characterized by  Persistent  maladaptive disruptions in the integration of memory  Consciousness or identity—verge on the unbelievable. • The person with a dissociative disorder may be unable to remember many details about the past; he or she may wander far from home and perhaps assume a new identity; or two or more personalities may coexist within the same person. • Dissociative disorders once were viewed as expressions of hysteria. • In Greek, Hystera means “uterus,” and the term hysteria reflects ancient speculation that these disorders were caused by frustrated sexual desires, particularly the desire to have a baby. • According to the theory, the uterus becomes detached from its normal location and moves about in the body, causing a problem in the location where it eventually lodges. • Variants of this somewhat sexist view continued throughout Western history, and as late as the nineteenth century many physicians erroneously believed that hysteria occurred only among women. • New speculation about the etiology of hysteria emerged toward the end of the nineteenth century. Symptoms of Dissociative Disorders: • Like many ordinary cognitive processes, the extraordinary symptoms of dissociative disorders apparently involve mental processing that occurs outside of conscious awareness. 1) Extreme cases of dissociation include a split in the functioning of the individual’s entire sense of self. 2) Depersonalization is a less dramatic form of dissociation wherein people feel detached from themselves or their social or physical environment. 3) Another dramatic example of dissociation is amnesia—the partial or complete loss of recall for particular events or for a particular period of time. 4) Brain injury or disease can cause amnesia, but psychogenic (psychologically caused) amnesia results from traumatic stress or other emotional distress. 5) Psychogenic amnesia may occur alone or in conjunction with other dissociative experiences. • It is widely accepted that fugue and psychogenic amnesia are usually precipitated by trauma, thus providing another link between dissociation and traumatic stress disorders. 6

1. INSTITUTE OF NURSING EDUCATION, MUMBAI-08
DEPARTMENT OF MENTAL HEALTH (PSYCHIATRIC) NURSING
ASSIGNMENT
HISTORY TAKING
ON
BIPOLAR DISSOCIATIVE
DISORER CURRENT MANIC
EPISODE
SUBMITTED TO:
Dept. of Mental Health (Psychiatric) Nursing
Institute of Nursing Education

2. INTRODUCTION
 DSM-IV-TR describes the essential features of dissociative disorders as a disruption
in the usually integrated functions of consciousness, memory, identity, or perception
(APA 2000).
 Dissociative responses occur when anxiety becomes overwhelming and the
personality becomes disorganized.
 Defense mechanisms that normally govern consciousness, identity, and memory
breakdown and behavior occur with little or no participation on the part of the
conscious personality.
Dissociation:
The unconscious separation of painful feelings and emotions from an unacceptable
idea, situation or object.
Dissociative Disorders:
Dissociative disorders are characterized by
 Persistent
 maladaptive disruptions in the integration of memory
 Consciousness or identity—verge on the unbelievable.
 The person with a dissociative disorder may be unable to remember many details
about the past; he or she may wander far from home and perhaps assume a new
identity; or two or more personalities may coexist within the same person.
 Dissociative disorders once were viewed as expressions of hysteria.
 In Greek, Hystera means “uterus,” and the term hysteria reflects ancient speculation
that these disorders were caused by frustrated sexual desires, particularly the desire to
have a baby.

3.  According to the theory, the uterus becomes detached from its normal location and
moves about in the body, causing a problem in the location where it eventually
lodges.
 Variants of this somewhat sexist view continued throughout Western history, and as
late as the nineteenth century many physicians erroneously believed that hysteria
occurred only among women.
 New speculation about the etiology of hysteria emerged toward the end of the
nineteenth century.
Symptoms of Dissociative Disorders:
 Like many ordinary cognitive processes, the extraordinary symptoms of dissociative
disorders apparently involve mental processing that occurs outside of conscious
awareness.
1) Extreme cases of dissociation include a split in the functioning of the individual’s
entire sense of self.
2) Depersonalization is a less dramatic form of dissociation wherein people feel
detached from themselves or their social or physical environment.
3) Another dramatic example of dissociation is amnesia—the partial or complete loss of
recall for particular events or for a particular period of time.
4) Brain injury or disease can cause amnesia, but psychogenic (psychologically caused)
amnesia results from traumatic stress or other emotional distress.
5) Psychogenic amnesia may occur alone or in conjunction with other dissociative
experiences.
• It is widely accepted that fugue and psychogenic amnesia are usually precipitated by
trauma, thus providing another link between dissociation and traumatic stress
disorders.
6) In these disorders, the trauma is clear and usually sudden, and in most cases,
psychological functioning rapidly returns to normal.
7) Much more controversial is the role that trauma might play in dissociative identity
disorder (DID).

4. • Some researchers and clinicians argue that DID is linked with past, not present,
trauma, particularly with chronic child physical or sexual abuse.
• Many psychological scientists are skeptical about this assertion, however, because
information about childhood trauma is based solely on clients’ reports—reports that
may be distorted by many factors, including by a therapist’s expectations.
8) A related issue is the very controversial topic of recovered memories, dramatic
recollections of long-ago traumatic experiences supposedly blocked from the
conscious mind by dissociation.
Diagnosis of Dissociative Disorders:
• For centuries, theorists considered dissociative and somatoform disorders as
alternative forms of hysteria.
• However, the descriptive approach to classification introduced in DSM-III (1980) led
to the separation of dissociative and somatoform disorders into discrete diagnostic
categories.
• The distinction is preserved in DSM-IV-TR (2000), because the symptoms of the two
disorders differ greatly.
• DSM-IV-TR distinguishes four major subtypes of dissociative disorders: dissociative
fugue, dissociative amnesia, depersonalization disorder, and dissociative identity
disorder.
• Dissociative fugue is characterized by sudden and unexpected travel away from
home, an inability to recall the past, and confusion about identity or the assumption of
a new identity.
• Dissociative amnesia involves a sudden inability to recall extensive and important
personal information that exceeds normal forgetfulness.
• As with fugue, dissociative amnesia typically is characterized by a sudden onset in
response to trauma or extreme stress and by an equally sudden recovery of memory.
• The most common form of amnesia in dissociative disorders is selective amnesia, in
which patients do not lose their memory completely but instead are unable to

5. remember only selected personal events and information, often events related to a
traumatic experience.
• Depersonalization disorder is a less dramatic problem that is characterized by severe
and persistent feelings of being detached from oneself.
• Depersonalization experiences include such sensations as feeling as though you were
in a dream or were floating above your body and observing yourself act.
• Occasional depersonalization experiences are normal and are reported by about half
the population.
• In depersonalization disorder, however, such experiences are persistent or recurrent,
and they cause marked personal distress.
• The onset of the disorder commonly follows a new or disturbing event, such as drug
use.
• Unlike other dissociative disorders, depersonalization disorder involves only limited
splitting between conscious and unconscious mental processes, and no memory loss
occurs.
• Dissociative identity disorder (DID), also known as multiple personality disorder,
is characterized by the existence of two or more distinct personalities in a single
individual.
• At least two of these personalities repeatedly take control of the person’s behavior,
and the individual’s inability to recall information is too extensive to be explained by
ordinary forgetfulness.
• The original personality especially is likely to have amnesia for subsequent
personalities, which may or may not be aware of the “alternates.”
Frequency of Dissociative Disorders
• The prevalence of dissociative disorders is difficult to establish.
• The conditions generally are considered to be extremely rare.

6. • Some experts even doubt the very existence of dissociative identity disorder, arguing
that DID is created by the power of suggestion.
• Given the current status of research, we reach some cautious conclusions.
• True dissociative disorders appear to be rare.
• Although some cases no doubt are misdiagnosed, a much greater problem is the
creation of the diagnosis in the minds of clinicians and clients.
• Psychodynamic theory of dissociative disorder.
• Fixation during early development at level of Oedipus complex.
• Anxiety at fixation point.
• Repression (primary defense mechanism not fully successful)
• Secondary defense mechanism, dissociation
• A part of personality is dissociative from the rest
• Leads to dissociative disorder.
• Dissociative Disorder
• It is the breakdown of ones perception of higher surrounding, memory, identity, or
consciousness
Genetic
• Found more frequently in women than in men
• Used to be considered “demonic possession”
• Four Types
• Dissociative Identity Disorder (DID)
– a.k.a multiple personality disorder
• Dissociative Amnesia
• Dissociative Fugue

7. • Depersonalization Disorder
• Common Symptoms
• Memory loss of certain time periods
• Mental health issues
• Depersonalization
• Derealization
• Blurred sense of reality
• Definition/Causes
• Experiences two or more identities
• When experiencing a new identity, a separate personality takes control
• Each of the new personalities has its own history, identity and takes on a totally
separate name
• Are usually associated with psychological stress in childhood and physical and sexual
abuse
• Dissociative Identity Disorder (formerly Multiple Personality Disorder).
• The presence of two or more distinct identities or personality states
(each with its own relatively enduring pattern of perceiving, relating to,
and thinking about the environment and self).
• At least two of these identities or personality states recurrently take
control of the person's behavior.
• Inability to recall important personal information that is too extensive
to be explained by ordinary forgetfulness.
• The disturbance is not due to the direct physiological effects of a
substance (e.g., blackouts or chaotic behavior during Alcohol
Intoxication) or a general medical condition (e.g., complex partial

8. seizures). In children, the symptoms are not attributable to imaginary
playmates or other fantasy play.
• Dissociative Identity Disorder
– A single individual appears to manifest 2 or more distinct
identities.
– Each personality alternates in control over conscious
experience, thought, and action and is separated by some
degree of amnesia from the other(s).
• Symptoms
• Switch personalities
• Feel the presence of people in head
• Often have dissociative amnesia
Mental Status:
• Alert
• Limited relatedness
• Irritable
• Poor insight and judgment
• Increased suicidal thoughts
• Become fixed on external or internal stimuli
• TREATMENT
• AIM :-
• To uncover the underline psychosocial conflicts, helping him/her to gain insight into
these conflicts and striving to synthesize the various identities into one integrated
personality
• Treatments

9. • Medication
– Tranquilizers and anti-depressants
• self help groups composed of family, friends, and people from your local
community that care
• Psychotherapy & Hypnosis
• Creative artistic therapy
• DID
– abreaction, and working through of the trauma and other conflictual issues
presumed to underlie the disorder, followed by an attempt at integrating the
personalities into a single identity.
– Working to achieve therapeutic alliance among the egos
– Insight-oriented therapy
• Some tries at CBT
• Dissociative Amnesia:
• Dissoiative Amnesia is an inability to recall important personal information, usually
of a traumatic or stressful nature, that is too extensive to be explained by ordinary
forgetfulness and is not due to the direct effects of substance use or neurological or
other general medical condition (APA, 2000).
• Definition/Causes
• They cannot remember any important personal information
• The loss of memory creates a gap in their personal history
• Usually associated with a traumatic event in his/her life
• TYPES:
• Five type of disturbances in recall have been described in the following examples, the
individual is involved in atraumatic automobile accident in which a loved one killed.

10. 1. Localized Amnesia: the inability to recall all incidents associated with the traumatic
event for a specific time period following the event(usually a few hours to a few
days).
• Example:
the individual cannot recall events of the automobile accident and events occurring during a
period after the accident(a few hours to a few days)
2. Selective Amnesia: the inability to recall only certain incidents associated with a
traumatic event for a specific period after the event.
• Example :
the individual may not remember events leading to the impact of accident but may
remember being taken away in the ambulance .
3. Continuous amnesia: the inability to recall events occurring after a specific time up to
including the present.
Example: the individual cannot remember events associated with automobile accident and
anything that has occurred since. That is, the individual cannot form new memories, even
though apparently alert and aware.
4. Generalized amnesia: the rare phenomenon of not being able to recall anything that
happened during the individual’s entire lifetime, including his or her personal identity.
5. Systematized Amnesia: the individual cannot remember events that relate to a specific
category of information (e.g., one’s family) or to one particular person or event.
• Symptoms
• Unexplained memory loss
• Traumatic times disappear
• Memory gaps
Mental Status:
• Alert

11. • Limited eye contact
• Slow speech
• Limited attention span
• Slighty impaired recent memory
• Anxious
• Lack of reasoning
• Suicidal thoughts
• Treatments
• Medication
– Pentothal
• Hypnosis
• Psychotherapy- free or direct association technique is used.
• Remove individual from stressful situation.
• Intravenous administration of Amobarbital is useful in the retrieval of lost memory
• Definitions/Causes
• When somebody has this disorder they may impulsively wander away from home
• After this fugue experience the person will not remember any of it
• They become confused of who they are
• This disorder is very rare and usually occurs when there is extreme stress
• Dissociative Fugue (formerly Psychogenic Fugue)
• The predominant disturbance is sudden, unexpected travel away from
home or one's customary place of work, with inability to recall one's
past

12. • Confusion about personal identity or assumption of a new identity
(partial or complete).
• The disturbance does not occur exclusively during the course of
Dissociative Identity Disorder and is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., temporal lobe epilepsy).
• The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning
• Dissociative Fugue
– The amnesia is much more extensive and covers the whole of
the individual’s past life
– It is coupled with a loss of personal identity
– And often physical movement to another location
• Dissociative (Psychogenic) Fugue
• Also called functional retrograde amnesia.
– Fugue adds a loss of identity to the loss of personal memory observed in
psychogenic amnesia and sometimes physical relocation.
– Fugue is associated with physical or mental trauma, depression, problems with
the legal system, or other personal difficulty.
– Fugue impairs semantic memory for personal information, as well as episodic
memory for personal experiences
• Symptoms
• Put real distance between themselves and their identity
• Episodes last different amounts of time
• End and begin abruptly
• When it ends:

13. – Disoriented
– Depressed
– Angry
– Symptoms
Mental status:
• Alert only to self
• Fair eye contact
• Normal psychomotor activity
• Normal thought process
• Poor insight
• Increased violent and homicidal thoughts
• Treatments
• Hypnosis
• Psychotherapy:
(expressive supportive
psychodynamic therapy
for healthy adjustment
to stressor)
• Psychopharmacology
• Manipulation of the environment or psychotherapeutic support help to reduce stress
• When fugue is prolonged techniques of gentle encouragement, free or direct
association may be helpful.
• Cognitive therapy- to change irrational thinking patterns.

14. • Creative therapies- allows client to express and explore thoughts and emotions in
‘safe’ ways.
• Group therapy- provides support from supportive peers.
• Family therapy- to explore the trauma precipitated the fugue episode and educate
family members about the dissociative disorder.
• Definitions/Causes
• People with this disorder feel detached or estranged from themselves or their own
bodies
• They feel like their in a dream or watching themselves on a TV screen
• Feel like their going crazy and become anxious and depressed
• It is from prolonged stress, anxiety, or shock to the system
• Depersonalization Disorder
A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside
observer of, one's mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalization experience, reality testing remains intact.
C. The depersonalization causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
• The depersonalization experience does not occur exclusively during the course of
another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress
Disorder, or another Dissociative Disorder, and is not due to the direct physiological
effects of a substance(e.g., a drug of abuse, a medication) or a general medical
condition (e.g., temporal lobe epilepsy).
• Depersonalization and Derealization
• Depersonalization Disorder
– The person believes that he or she has changed in some way, or
is somehow unreal (derealization)

15. • People experience themselves as totally different, and the world as strange and new.
• Commonly described as isolated, lifeless, strange, and unfamiliar; behaving
mechanically without initiative or self-control.
– Depersonalization= self
– Derealization= world
– Also seen as symptoms in anxiety, depression, obsession.
– Symptoms
• Sense of being outside yourself
• Perception is distorted
• Time slows
• Episodes vary in length
• Body doesn’t belong to you
Mental status:
• Alert at times and disoriented at times
• Limited eye contact and relatedness
• preoccupied
• Treatment
• Treat anxiety
• With anxiolytic’s,
• Medication Fluvoxamin- fluoxetine.
• supportive and insight oriented therapy
• Antidepressant clomipramine (anafranil) for primary depersonalization disorder.
• As anxiety is reduced, episodes of depersonalization decrease

16. • ABREACTION
• Abreaction is bringing to conscious awareness, thoughts, affects and memories for the
first time, with or without the use of drugs. This may be achieved by
1. Hypnosis
2. Free Association
3. Drugs
• HYPNOSIS: Hypnosis is "a trance state characterized by extreme suggestibility,
relaxation and heightened imagination." It is a mental state or imaginative role-
enactment.
• Contrary to a popular misconception—that hypnosis is a form
of unconsciousness resembling sleep—contemporary research suggests that hypnotic
subjects are fully awake and are focusing attention, with a corresponding decrease in
their peripheral awareness.
• One drawback of hypnosis is that it has been seen in many cases that the clinicians are
at times themselves largely responsible for eliciting this disorder in highly suggestible
fantasy prone patients .
• Free Association: Free association is a technique used in psychoanalysis which was
originally devised by Sigmund Freud out of the hypnotic method of his mentor and
coworker, Josef Breuer. In free association, psychoanalytic patients are invited to
relate whatever comes into their minds during the analytic session, and not to censor
their thoughts.
• But it has been seen that this method is not completely successful and generates
certain amount of resistance.
• DRUGS: Drugs like intravenous barbiturates like thiopentone(Pentothal),
amobarbital(Amytal),diazepam,methylphenidate (CNS stimulant), can be used.
• GOAL OF TREATMENT

17. • The goal of abreaction is to make the conflicts conscious and to make the patient
more suggestible to therapist’s advice. It is best to begin with neutral topics and to
approach traumatic material gradually.
• Once the conflicts or the memories have become conscious and the associated affect
released, the dissociative symptoms disappears.
• OTHER METHODS
• A) Releiving the Experience: Learning is often state dependent, that is dependent on
the context in which learning occurs. Thus it is a possibility that when unlearning of
some event occurs, the context in which it occurs is also forgotten and thus the person
experiences amnesia, that is a total failure in the recall of a particular event ( as seen
in selective amnesia) . Thus one form of treatment involves the exposure of the
patient to the same or artificially created similar context which triggers recall.
• B) Eliminating the Secondary Gains:Also questions should be asked tactfully about
the secondary gains that the patient might be receiving because of his condition since
they might be one of the maintaining factors. In case of secondary gains the condition
may last a long time, thus the elimination of the secondary gains from the patient’s
environment might lead to elimination of symptoms
• Providing a Safe Environment: In dissociative amnesia and fugue, it is important for
the person to be in a safe environment, and simply removing him from what he/she
perceives as threatening situation sometimes allows for spontaneous recovery of
memory.
• Steps Involved in Treatment
• A Phase oriented treatment was proposed first by Pierre Janet in 1989 which basically
consists of 3 steps as follows:
• 1) Stabilization and symptom reduction : The first condition consists of
establishing personal safety and self-care. When they first come to the attention of
mental health professionals, patients with dissociative disorders ( especially
dissociative amnesia) are often disorganized, neglectful of their personal hygiene,
have irregular sleeping habits and eating habits. Stabilization needs to include

18. attention to the patient’s safety, establishment of regular day and night rhythms,
appropriate self care and structuring of daily activities.
• 2) Treatment of Traumatic memories: Involves reconnecting the affective,
cognitive and somatic aspects of the traumatic experience which is also called
synthesis or fusion. Realizing the event and thereby making it part of the
autobiographical memory of patients personality is important.
• Reintegration and Rehabilitation: Individuals with a dissociative disorder also need
to expose themselves to situations that they dreaded formerly and it is important to
provide adequate follow-up after integrating the traumatic memories.
• Integration of the trauma into a cohesive self that no longer requires fragmentation to
deal with trauma is the final goal.
• In the end, for the treatment to be successful, it must be prolonged, often lasting many
years and the more severe the case, the longer that treatment is needed.
• But it should be noted that treatment is likely to produce symptom improvement, as
well as associated improvements in functioning, rather than full and stable integration.
• BEHAVIOUR THERAPY
 The therapist focuses on the current manifest behavior itself rather than on it’s
distant historical associations.
 Since the patients with dissociative and conversion disorders are attention
seeking and their symptoms increase with focus of attention.
 These patients are also very suggestible, they respond quickly and a consistent
firm attitude.
• The therapy will include a treatment plan, the goals of the treatment will be laid out
up front, and the outcome expected from the therapy will be set right up front too.
• To eliminate unwanted behaviors one need to learn new behaviors. This may include
assertion, behavioral rehearsal, cognitive restructuring, desensitization, modeling,
reinforcement, relaxation methods.

19. • When there is a sudden, acute symptom, its prompt removal may prevent habituation
and future disability.
• Cognitive behavioral treatment for depersonalization disorder attempts to analyze the
catastrophic thoughts that accompany episodes of depersonalization.
• Also, to correct any behaviors that might contribute to the illness, such as behaviors
formed to ward off the episodes of depersonalization.
• Dissociative identity disorder has been successfully treated using many forms of
psychotherapeutic techniques, such as cognitive behavioral therapy and eye-
movement desensitization.
• However, the research literature doesn’t support one treatment as being better than
another.
• Group therapy
Group therapy, like individual therapy, is intended to help people who would like to improve
their ability to cope with difficulties and problems in their lives. But, while in individual
therapy the patient meets with only one person (the therapist), in group therapy the meeting is
with a whole group and one or two therapists. The aim of group therapy is to help with
solving the emotional difficulties and to encourage the personal development of the
participants in the group.
• Group therapy focuses on interpersonal interactions, so relationship problems are
addressed well . The therapist (called conductor, leader or facilitator) chooses as
candidates for the group people who can benefit from this kind of therapy and those
who may have a useful influence on other members in the group.
• Qualities of a healthy personality based on developmental theory
• Positive and accurate body image
• Realistic self-ideal
• Positive self-concept
• High self-esteem

20. • Satisfying role performance
• Clear sense of identity
• Medical diagnoses
• Identity problem- uncertain about multiple issues related to identity
• Dissociative amnesia- inability to recall certain personal information
• Dissociative fugue- sudden unexpected travel away from home with inability to recall
one;s past.
• Medical diagnoses cont.
• Dissociative identity disorder(multiple personality disorder)-presence of 2 or more
distinct identitites or personality traits.
• Depersonal disorder- persistent experiences of feeling detached from one’s body or
mind. (feeling one is in a dream)
• Medical treatment for dissociative disorders
• Sodium pentobarbital and hypnosis are used to facilitate the recovery of repressed and
dissociated memories.
• Psychotherapy helps patients work through and control access to traumatic memories.
• Nursing diagnoses
• Disturbed body image
• Readiness for enhanced self-concept
• Low self-esteem
• Ineffective role performance
• Disturbed personal identity
• Disturbed thought process
• Powerlessness

21. • Risk for other directed violence
• Ineffective coping
• Risk for suicide
• Disturbed sensory perception (visual or kinesthetic)
• Anxiety (severe to panic)
• Nursing goals and interventions
• Level 1: expand the patient’s self-awareness
• Interventions:
• listen to the patient and develop a trusting relationship
• Identify the patient’s ego strength
• Increase pt’s participation in the relationship
• Nursing goals and interventions (cont.)
• Level 2: encourage the patient’s self-exploration
• Encourage the patient to express emotions and thoughts.
• Help patient clarify his concept of self
• Respond empathically not sympathetically to patient.
• Nursing goals and interventions cont.
• Level 3: assist the patient’s self-evaluation
• Help the patient define the problem clearly.
• Explore the patient’s adaptive and maladaptive coping responses to the problem.
• Nursing goals and interventions cont.
• Level 4: Help the patient form a realistic plan of action
• help the patient identify alternative solutions.

22. • Help the patient develop realistic goals
• Nursing goals and interventions cont.
• Level 5: help the patient become committed to his decision and then achieve goals.
• Reinforce the patients strengths and skills.
• Provide the patient with support and positive reinforcement in effecting and
maintaining change.
• Both the patient and nurse must allow sufficient time for change.
• Bibliography
• Mary C. Townsend’s , Psychiatric mental health nursing, fifth edition, Jaypee
brothers medical publishers , page no- 596-619.
• K P Neeraja’s, Essentials of mental health and psychiatric nursing, II volume, jaypee
publishers, page no- 465-541
• R P Gupta’s, new approach to mental health nursing, S.Vicas medical publishers,
page no-248-280
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