Notes on psychiatric nursing Types of admission of psychiatry DSM 5

1. PSYCHIATRIC NURSING
PSYCHIATRIC NURSING
BY MAURICE NAMISI

2. Introduction and course outline
Introduction and course outline
This course introduces the students to the basic
concepts of mental health and illness, also covered
is the process of admitting and discharging patients
who are mentally ill.
Treatment modalities in mental health.
Community health services.
This knowledge, and these skills and attitudes will
help you to manage patients having psychosocial
problems

3. Unit Objectives
Unit Objectives
By the end of this unit you will be able to:
Describe mental health and psychiatric nursing
State the admission process for the mentally ill
patient
Describe the modes of treatment used in psychiatry
Recognize and manage common mental health
conditions
Describe community mental health

4. Concepts, principles and theories of
Concepts, principles and theories of
mental health and psychiatric
mental health and psychiatric
nursing
nursing
Objectives
By the end of this section you will be able to:
 Describe the concepts of mental health and mental illness
 Explain aetiological factors for mental illness
 Classify mental illness
 State factors that influence attitude towards mental illness
Explain principles of psychiatric nursing
Describe trends in psychiatric nursing

5. Concepts of Mental Health and
Concepts of Mental Health and
Mental Illness
Mental Illness
According to the World Health Organization
(WHO),
Mental health is a state of emotional well-being
which enables one to function comfortably within
society and to be satisfied with one’s own
achievements.
Mental health also refers to the ability of the
individual to carry out their social role and to be
able to adapt to their environment (Johnson, 1997).

6. Characteristics of a mentally healthy person
Feeling comfortable about oneself
Awareness of self, insights and understanding of
motives, desires, weakness and potentials
Living in the real world
Having a sense of personal worth and importance
Having a sense of personal security
Able to solve problems thru own initiatives and efforts
Capacity to work
A sense of responsibility and duty
A feeling of being wanted and loved

7. Capacity to get along with other people appreciating
differences btwn people
Being able to give and accept love
Being able to plan ahead and fear the future
Being able to develop a philosophy in life with
meaning and purpose to daily activities

8. Criteria for assessment of
Criteria for assessment of
mental health
mental health
1. Adequate contact with reality
2. Control of thoughts and imaginations
3. Efficiency in work and playing
4. Social acceptance
5. Positive image of self
6. A healthy emotional life

9. Mental illness defined
Mental illness defined
A mental illness is defined as:
 A disorder with psychological or behavioural
manifestations and/or impairment of functioning
due to a social, psychological, genetic, physical,
chemical or biological disturbance (Evelyn and
Wasili, 1986).

10. A mentally ill person may have at least one of the
following characteristics:
– Being dissatisfied with one’s abilities and accomplishments
– Having ineffective or unsatisfying interpersonal
relationships
– Dissatisfaction with one’s place in the world
– Having ineffective coping/adaptation mechanisms and
lacking personal growth

11. Common terms used in
Common terms used in
psychiatry
psychiatry
1. Psychiatry: a branch in psychological medicine
dealing with diagnosis, treatment and prevention of
mental illness
2. Psychiatric nursing: specialized branch of nursing
that deals with preventing, promoting, curative and
rehabilitative aspects of mentally ill persons in
hospitals and community
3. Psychoanalysis: a method of treating certain types
of mental illness by a psychiatrist

12. 4. Child psychiatry: Science of healing or curing
disorders of the psychic in children
5. Geriatric psychiatry: A branch in psychiatry
dealing with disorders of the aged
6. Community psychiatry: Branch of psychiatry
concerned with provision and delivery of
coordinated programmes of mental health care to a
specified community/population

13. Historical trends in psychiatric
Historical trends in psychiatric
nursing globally & in Kenya
nursing globally & in Kenya
Psychiatric nursing, and the understanding of mental
illness, with which it associates, has developed in
several epochs through the centuries
1. Demonological Period
The earliest records of a person believed to have
suffered from mental illness relate to king
Nebuchadnezzar, who ate grass believing that he
was an ox. Another example is Ajax, who impaled
himself on a sword believing that he was tormented
by demons.

14. During that time people believed that the cause of
mental illness was demons. The treatment was quite
harsh, degrading and dehumanizing and beating,
chaining, locking the individual up in a dark room
and throwing the individual into rivers and ponds.
Those patients who escaped this harsh treatment
survived on stealing food or eating wild fruits. Wild
animals ate up those who inadvertently wandered
into the forest.

15. 2.Political Period
 This period is associated with King Edward II of England.
During that time, a law was passed in the parliament to
protect the property of the mentally sick. In the year 1403,
the Sisters of the Order of Saint Mary managed to start a
facility to care for the mentally sick at Bedlam. The facility
was able to accommodate six patients only. Thereafter,
other hospitals followed the example.
 The cause of mental illness, however, was still thought to be
demons. The treatment remained more or less as in the
demonological period. Facilities were often dark, humid and
infested with lice, overcrowded, leading to mass deaths
outbreaks of disease such as the plague.

16. In the early 18th century, the first qualified nurse
was appointed to look after the mentally ill by
Edward Tyson. However, although qualified, the
nurses appointed to look after the mentally sick
were equally harsh to patients.
Men and women were housed together and
members of the public used to visit these facilities
as a form of entertainment. It was at St. Luke’s
hospital in London where this form of entertainment
was eventually banned. In order to enforce the
policy, members of the public were only allowed to
see the mentally ill in the presence of an attendant
after being issued with a ticket.

17. 3. Humanitarian Period
 During this period, reforms of the patient care system for
the mentally ill began in France, followed by Britain and
later America.
 Reform in France started in 1793 at Bicetre Hospital in
Paris. Dr. Philippe Pinel unchained a group of patients who
had been in chains for 30 years. He advocated kindness for
mentally sick persons, and as a result there was a marked
improvement in mentally sick patients.
 William Tuke started reforms in Britain in 1796. He
advocated humane treatment of the mentally sick. In
addition, he introduced what we today call ‘occupational
therapy’. Men were involved in gardening while women
were involved in sewing.

18. Both men and women assisted attendants in their
daily work activities. It is worth noting that so far,
members of staff were not specifically trained to
deal with mental health issues. In 1808, a bill was
passed to regulate the treatment of mental health
patients
In America, Dorothea Lynda Dix introduced
reforms after visiting Britain and seeing how
mentally sick persons were improving after getting
reformed type of management. In 1841, she
managed to have a bill passed in parliament to
regulate the treatment of the mentally sick in
America.

19. 4.The Scientific Period
The scientific period is associated with the 19th
Century. During that period science was devoted to
developing modern treatments that were based on
scientific findings. Many forms of treatments were
discovered and later abandoned like hydrotherapy,
insulin therapy and leucotomy.
The current forms of treatments include physical
treatment like pharmacotherapy and
electroconvulsive therapy.

20. There are also various psychological treatments,
which include:
Individual/group psychotherapy
Behaviour therapy
Occupational therapy
Rehabilitation
Cognitive therapy
Counseling

21. Development of Psychiatry and
Development of Psychiatry and
Mental Health Services in Kenya
Mental Health Services in Kenya
The current Mathari hospital was started in July
1910 as a lunatic asylum. Before then, the facility
served as a smallpox isolation centre. The asylum
was renamed Mathari Mental Hospital in 1924. The
care was mainly custodial, taking place in dark,
gloomy and often damp conditions
Europeans, Africans, and Asians were managed
separately and the quality of mental health care
provided depended on the individual’s
racial background

22.  Mathari was the only mental hospital until the 1962
Decentralization of Mental Health Services Act. Other
facilities began to spring up, including a 22 bed psychiatric
unit in Nakuru in 1962, Machakos in 1963, Nyeri and
Muranga in 1964 and Port Reitz and Kakamega in 1965.
 Currently all provincial hospitals have operational
psychiatric units. However, only some district hospitals
have operational psychiatric units. Outpatient psychiatric
clinics have been established in most of the district
hospitals.
 Mathari hospital is being redeveloped, and the future plan is
to intensify community based psychiatric services all over
the country. It is worth noting that community
psychiatric services were established in Nairobi in
1983.

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

24. Aetiological Factors of Mental
Aetiological Factors of Mental
Illness
Illness
The causes of mental illness can be classified into
three categories:
Predisposing Factors
These factors determine the likelihood of one
getting a mental illness. Usually they are adverse
experiences one undergoes in early life.
They include physical, psychological and social
factors in infancy and early childhood.

25. Precipitating Factors
These are events that take place shortly before the onset of a
disorder.
Physical precipitants include cerebral tumours, malaria or
drug abuse.
Social and psychological precipitants include misfortunes
such as loss of a job, losing a loved person, or sudden change
in routine activities.


26. Perpetuating Factors
Once the disorder has been triggered, these factors
do prolong the course of the disease.
They are secondary in nature since they may appear
long after the original predisposing factors have
been treated.
Examples include secondary demoralization and
withdrawal from social activities.

27. The causes of mental illness
The causes of mental illness
1. Biological factors
2. Psychosocial factors
3. Social cultural factors

28. Biological factors
Biological factors
a) Genetic factors: inheritance starts at conception
with a faulty genes and chromosomal abnormalities
e.g. down syndrome
b) Physical illness: Acute physical illness may lead to
loss of mental capacity e.g. acute malaria, chronic
illness may cause frustrations, sleep deprivation
and may lead to mental illness
c) Emotional factors: Anxiety and neurotic
personality traits cause people to develop
psychosomatic disorder e.g. headache, PUD, HTN

29. d) Infection, Disease and Toxins
A number of psychiatric disorders have often been
tentatively linked with microbial pathogens,
particularly viruses
Research shows that infections and exposure to
toxins such as HIV and streptococcus cause mental
disorders. The infections or toxins trigger a change
in the brain chemistry, which can develop into a
mental disorder.
e) Brain defects or injury: Defects in or injury to certain
areas of the brain have also been linked to some
mental illnesses

30. Prenatal damage: Some evidence suggests that a
disruption of early fetal brain development or
trauma that occurs at the time of birth -- for
example, loss of oxygen to the brain -- may be a
factor in the development of certain conditions, such
as autism.
Substance abuse: Long-term substance abuse, in
particular, has been linked to anxiety, depression,
and paranoia.
Other factors: Poor nutrition and exposure to
toxins, such as lead, may play a role in the
development of mental illnesses.

31. Psychological Factors
Psychological Factors
Psychological factors that may contribute to mental
illness include:
Severe psychological trauma suffered as a child, such
as emotional, physical, or sexual abuse
An important early loss, such as the loss of a parent
Neglect
Poor ability to relate to others

32. Social-cultural factors
Pathogenic social influence- maladaptive behaviour
Low socio-economic class. Prevalence of mental
illness high in low socio-economic class
Disorders of performing social role eg when a
soldier kills then later develops guilty conscious
leading to mental illness
Violence
Unemployment
Broken homes

33. Classification of Mental Disorders
Classification of Mental Disorders
There are two major classifications of mental
disorders
used internationally. These are:
– International Classification of Diseases (ICD)
– Diagnostic and Statistical Manual (DSM)
The ICD is the WHO system of classification,
currently in its 10th edition, commonly referred to
as ICD 10. The DSM classification is the American
Psychiatric Association system, currently in the 4th
edition and commonly referred to as DSM IV.

34. ICD 10 classification
ICD 10 classification
 :.
 :Mental and behaviour disorders due to
psychoactive substance use.
 F2:Schizophrenia, schizotypal and delusional
disorders.
 F3:Mood (affective) disorders.
 F4:Neurotic, stress related and somatoform
disorders.
 F5:Behavioural syndromes associated with
physiological disturbances and physical factors.
 F6:Disorders of adult personality and behaviour.
F0 Organic disorders, including symptomatic mental disorders
F1 Mental and behavioural disorders due to psychoactive substance use
F2 Schizophrenia, schizotypal and delusional disorders
F3 Mood (affective) disorders
F4 Neurotic, stress related and somatoform disorders
F5 Behavioural syndromes associated with physiological disturbances
and physical factors.
F6 Disorders of adult personality and behaviour
F7 Mental retardation
F8
F9
Disorders of psychological development.
Behavioural and emotional disorders with onset usually occurring in
childhood or adolescence

35. DSM IV classification
DSM IV classification
The DSM-IV, produced by the
American Psychiatric Association
The DSM states that "there is no assumption that
each category of mental disorder is a completely
discrete entity with absolute boundaries dividing it
from other mental disorders or from no mental
disorder

36. The DSM-IV-TR (Text Revision, 2000) consists of five axes
(domains) on which disorder can be assessed. The five axes
are:
 Axis I: Clinical Disorders (all mental disorders except
Personality Disorders and Mental Retardation)
 Axis II: Personality Disorders and Mental Retardation
 Axis III: General Medical Conditions (must be connected to
a Mental Disorder)
 Axis IV: Psychosocial and Environmental Problems (for
example limited social support network)
 Axis V: Global Assessment of Functioning (Psychological,
social and job-related functions are evaluated on a
continuum between mental health and extreme mental
disorder)

37. Factors that Influence Attitudes
Factors that Influence Attitudes
towards Mental Health and Mental
towards Mental Health and Mental
Illness
Illness
Culture
The way people think, behave or feel is shaped by
their culture. Culture also determines the features of
insanity, for example, who is labeled as insane and
under what circumstances.
What is considered insane in one culture may be
considered perfectly normal in another. Culture also
gives guidelines on the nature of treatment and the
identity of the helper

38. Education
The level of education also influences attitudes
towards mental health and mental illness.
An educated person has a better understanding of
health and mental illness, thus making their attitude
more positive.
Health Beliefs
These will determine whether the individual’s
attitude is positive or negative. It will depend on
how the patient explains the illness to themselves,
that is whether they believe in germ theory, evil
spirits or an imbalance of some kind.

39. Religion
A patient’s reaction to mental illness will often
depend on whether or not the patient believes in
God or a particular religion, for example, some
religions believe that ill health is caused by evil
spirits. Usually, religion encourages the followers to
be empathetic to
sick people.

40. Principles and Qualities of
Principles and Qualities of
Psychiatric Nursing
Psychiatric Nursing
Respect for the Patient
This is achieved by accepting the patient as they are.
The therapist should take time to listen to the patient
and provide privacy for all conversations.
Minimize situations and experiences that might
humiliate the patient and be honest in providing
information on medicines, privileges, length of
management and stays in hospital if indicated.


41. Availability
The nurse must be constantly available to assist the
patient to attain their basic needs and alleviate
suffering.
Spontaneity
You should avoid being overly formal. Instead, you
should be comfortable with yourself, be flexible and
aware of the therapeutic goals.
Acceptance
Even if the patient behaves in a way that does not
please the nurse, they should be accepted as they are,
but taking care not to reinforce their behaviour.

42. Sensitivity
You should do your best to show genuine interest and
concern.
You should be persistent and patient even if no
observable improvement is made.
Accountability
Since mentally ill patients are vulnerable due to their
distorted thinking and behaviour, accountability is
required more in a psychiatric setting than any other
type of health care.
You are also accountable to yourself as well as
professional colleagues and peers.

43. Empathy
This is the process of putting yourself in another’s shoes
and remaining emotionally detached. The nurse should
strive to understand the patient’s perspective, and work
toward mutually developed goals.
 The most important function of empathy is that it enables
you to give the patient the feeling of being understood and
cared about.
Self-understanding
This involves recognition and acceptance of your own
behaviour and how it affects your relationship with other
people.
 This helps the therapist to understand other peoples’
behaviour, needs and problems.

44. Permissiveness and Firmness
Although you have been told to accept the patient
as they are, this does not mean that you are in a
position to allow them to do whatever they like.
The therapist is expected to set limits and to be
firm in implementing them.
Skill in Observation
It is important for a psychiatric nurse to be alert
and observant at all times of the patient’s
behaviour, attitudes and how they react to staff,
relatives and fellow patients.

45. Legal Aspects
Legal Aspects
Mental Health Act

46. ADMISSION AND DISCHARGE
ADMISSION AND DISCHARGE
PROCEDURES OF MENTALLY
PROCEDURES OF MENTALLY
SICK PATIENTS
SICK PATIENTS
Objectives
by the end of this section, the students will be able to:
Apply the knowledge acquired on legal aspects in
admission and discharge of patients
Demonstrate skills in history taking

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

48. Kenyan Board of Mental Health
Kenyan Board of Mental Health
The act also provides for the establishment of a
board, that is, the Kenya board of mental health for
the purposes of administering this act.
The members of the Kenya board of mental
health include:
– Chairman, who can be the Director of Medical
Services (DMS) or the Deputy Director of
Medical Services and is appointed by
the minister.
– Psychiatrist (medical practitioner) appointed by the
minister.
– One clinical officer with training and experience in
mental health care appointed by the minister.

49. – One psychiatric nurse with experience in mental health
care, appointed by the minister.
– The commissioner of social services or their nominee
appointed by the minister.
– Director of education or their nominee appointed by the
minister.
– A representative from each province in Kenya, being
resident in the provinces, appointed by
the minister.

50. The functions of the Board are under the control and
direction of the minister for health. They include:
To coordinate mental health activities in Kenya.
To advise the government on the state of
mental health and mental health care facilities in
Kenya.
To inspect mental health care hospitals to ensure
that they meet the prescribed standards.
To approve the establishment of mental health care
hospitals.
To assist when necessary in the administration of
mental health hospitals.

51. To receive and investigate any matters referred to
it by a patient or relative of a patient concerning
the treatment of the patient at a mental health
hospital and, where necessary, to take or
recommend to the minister any remedial action.
To advise the government on the care of the
persons suffering from mental sub-normality
without mental disorder.
To initiate and organize community or family
based programmes for the care of persons
suffering from mental disorder, and to perform
such other functions as may be placed upon it by
this act or under the law.

52. Sections of the Mental Health Act
Sections of the Mental Health Act
Part V - Voluntary Patients (Section 10)
Any person who has attained the apparent age of
sixteen years, decrees to voluntarily submit themself
to treatment for mental disorder, and who makes to
the ‘person in charge’ a written application in
duplicate in the form prescribed, may be perceived
as a voluntary patient into a mental hospital.
The person fills in a form MOH 613, in duplicate
provided for in the first schedule to these regulations
before admitting them to the institution as an in-
patient. This indicates that the admission is at their
own request.

53. Any person who has not attained the apparent age of
sixteen years and whose parent or guardian desires
to submit them for treatment for mental disorder,
may if the guardian or parent makes to the ‘person
in charge’ of a mental institution, a written
application in duplicate in the prescribed forms, be
perceived as a voluntary patient. In such cases forms
MOH 637 in duplicate should be filled and signed
by the guardian or the parent.

54. Part VI - Involuntary Patients
Part VI - Involuntary Patients
(Section 14 M.H.A)
(Section 14 M.H.A)
Involuntary patients are those who are incapable of
expressing themselves as willing or unwilling to
receive treatment. They require the forms MOH 614
to be filled in duplicate by the husband, wife or
relative of the patient, indicating the reasons why
they are applying for admission.
Any person applying on behalf of another person
should state the reasons why a relative could not
make the application and specify their connection
with the patient.

55. The patient is admitted for a period of not more
than six months. The ‘person in charge’ can
prolong this period by six more months provided
the total period does not exceed twelve months. An
MOH 615 form should be filled by the doctor
indicating why he thinks that the patient can
benefit from the treatment. They should write
down their own name, qualifications, date and then
sign the forms.
Both the MOH 614 and MOH 615 forms must
reach the hospital within 14 days of the date they
were signed, otherwise they become invalid.

56. Part VII - Emergency Admissions
Part VII - Emergency Admissions
(Section 1b M.H.A)
(Section 1b M.H.A)
A police officer, chief or assistant chief can arrest
any person who is found to be dangerous to
themself or others, and take them to a mental
hospital for treatment within 24 hours or a
reasonable time. The patient should be reviewed
after 72 hours and can be discharged if found to be
of sound mind. If found to be of unsound mind, the
patient may be admitted for treatment as an
involuntary patient. For the purposes of admission,
the form MOH 638 must be filled in by the police
officer or an administrative officer.

57. Part VIII - Admission and Discharge
Part VIII - Admission and Discharge
of Members of the Armed Forces
of Members of the Armed Forces
(Section 17 M.H.A)
(Section 17 M.H.A)
Any member of the armed forces may be admitted
into a mental hospital for observation, if a medical
officer of the armed forces, by letter addressed to
the ‘person in charge’, and certifies that:
– The member of the armed forces has been examined
within a period of 48 hours before issuing the letter
– For reasons recorded in the letter, the member of the
armed forces is a proper person to be admitted to a
mental hospital for observation and treatment

58. A member of the armed forces may be admitted
under section 17 for an initial period of 28 days
from the date of admission, that period may be
extended if, at or before the end of 28 days, two
medical practitioners, one of whom shall be a
psychiatrist, recommend the extension after re-
examining the patient.
The said patient can be discharged if two medical
practitioners, one of whom is a psychiatrist, by a
letter addressed to the ‘person in charge’,
certifying that they have examined the member of
the armed forces within a period of 72 hours
before issuing the letter.

59. Where any member of the armed forces suffers from
mental illness whilst away from his armed forces unit
and is under any circumstance, admitted into a
mental hospital, the ‘person in charge’ shall inform
the nearest armed forces unit directly, or through an
administrative officer or gazetted police officer.
If a member of the armed forces is admitted to a
mental hospital they cease to be a member of the
armed forces, the ‘person in charge’ shall be
informed of that fact and the patient shall be declared
an involuntary patient under part VI (section 14) with
effect from the date the information is received.

60. Part IX - Admission of a Patient
Part IX - Admission of a Patient
from Foreign Countries (Section 18
from Foreign Countries (Section 18
M.H.A)
M.H.A)
According to this section of the act:
– No person suffering from mental disorder shall be
admitted into a mental hospital in Kenya from any state
outside Kenya except under Part IX of M.H.A.
This part will not apply to individuals ordinarily
resident in Kenya.

61. (Section 19 M.H.A) Where it is necessary to admit
a person suffering from mental disorder from any
foreign country into any mental hospital in Kenya
for observation, the government or other relevant
authority in that country shall apply in writing to
the mental health board to approve the admission,
no mental hospital shall receive a person suffering
mental disorders from a foreign country without
the board’s written approval.

62.  The application for the board’s approval under subsection
(I) shall indicate that the person whom it relates to has
been legally detained in the foreign country for a period
not exceeding two months under the law in that country,
relating to the detention and treatment of persons suffering
from mental disorder, and their admission into mental
hospital in Kenya has been found necessary.
 No person shall be admitted under this section
unless they are accompanied by a warrant or other
documents together with the board’s approval under
subsection (2) shall be sufficient authority for their
conveyance to admission and treatment in the mental
hospital to which the board’s approval relates.

63. Part X – Discharge and Transfer of
Part X – Discharge and Transfer of
Patients (Section 21 and 22 of
Patients (Section 21 and 22 of
M.H.A)
M.H.A)
 The ‘person in charge’ of a mental hospital may, by order
in writing, and upon the recommendation of the medical
practitioner in charge of any person’s treatment in the
mental hospital, recommend discharge and that person
shall thereupon be discharged as having recovered from
mental disorder, provided that:
– An order shall not be made under this section for a
person who is detained under criminal procedure Cap
75.
– This section shall not prejudice the board’s powers
under section 15 of M.H.A.

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

65. Part XIV – Offences under MHA
Part XIV – Offences under MHA
 Section 47:It is an offence for a person other than medical
practitioner to sign certificates.
 Section 48:Any medical practitioner who knowingly,
willfully or recklessly certifies anything in a certificate made
under this act, which they know to be untrue, shall be guilty
of an offence.
 Section 49:It is an offence for any person to assist the
escape of any person suffering from mental disorder being
conveyed to or from, or while under care and treatment in a
mental hospital. It is also an offence to harbour any person
suffering from mental disorder that they know have escaped
from a mental hospital.


66.  Section 50:It is an offence for any person in charge of or
any person employed at a mental hospital to unlawfully
permit a patient to leave such a hospital.
 Section 51:Any person in charge of, or any person
employed at a mental hospital that strikes, ill-treats, abuses
or willfully neglects any patient in the mental hospital, shall
be guilty of an offence.
 Section 53:General Penalty: Any person who is guilty of an
offence under this act, or who contravenes any of the
provisions of this act or any regulations made under this act,
shall where no other penalty is provided, be liable on
conviction to a fine not exceeding Ksh 10,000. or to
imprisonment not exceeding twelve months or both

67. HISTORY TAKING IN
HISTORY TAKING IN
MENTAL ILLNESS
MENTAL ILLNESS
History taking from a mentally ill person or their
relatives will assist you to make a nursing diagnosis
and to give holistic care to the patient.
Steps involved in history taking;
Personal Data
Here you ask for information pertaining to age,
sex, marital status, occupation, residence
and nationality of the pt

68. Personal History
 Ask the patient questions relating to their mode of delivery,
as well as milestones in infancy and
early childhood.
 You may ask the patient when they started school and their
educational performance as well as about possible incidents
of traumatic experience like falling or losing a parent
Social History
 You should try to find out about the nature of the patient’s
occupation, how they relate to both sexes, whether they are
outgoing or not, the number of friends the patient has of
both sexes and whether or not the patient is involved in
religious activities

69. Sexual History
Aiming is to check the degree of sexual satisfaction
with the marriage partner, male or female friend,
frequency of sexual relationships and the patient’s
attitude to sex.
Family History
Ask the patient about their parents, brothers and
sisters. For each one of them you are trying to find
out whether they are married, occupation etc.
in an attempt to identify possible family behavioural
patterns.
If the patient is married, try and find out the sibling
line up of the patient’s spouse as well.

70. Past Medical and Psychiatric History
– By taking down the patient’s medical history, you
are in a position to find out about any medical conditions
the patient has suffered, which may have affected their
mental health.
– also try and find out if there have been any incidences of
the patient being admitted into a mental unit/hospital and
the outcome of the treatment.
History of Presenting Illness
– Ask the patient about the onset of the illness, duration,
any allegations that brought them to the mental hospital
and the patient’s pre-morbid history, that is, how they
presented before they became mentally ill.

71. Mental Status examination(MSE)
Mental Status examination(MSE)
MSE, is an important part of the clinical assessment
process in psychiatric practice. It is a structured way
of observing and describing a patient's current state
of mind, under the domains of:
– appearance
– attitude
– Behavior
– mood and affect
– Speech
– thought process, thought content
– Perception
– cognition, insight and judgment

72. The purpose of the MSE is to obtain a
comprehensive cross-sectional description of the
patient's mental state, which, when combined with
the biographical and historical information of the
psychiatric history, allows the clinician to make an
accurate diagnosis and formulation, which are
required for coherent treatment planning

73. General Appearance
General Appearance
Note the grooming, posture, gait, physical
characteristics, facial expression, eye contact, motor
activity and specific mannerisms
Note the state of awareness or consciousness,
drowsiness, clouding of consciousness, stupor,
delirium, fleeting consciousness and coma

74. Speech
– Note the rate, pitch, volume, clarity, speech abnormalities such as
dysarthia
Mood& affect
Mood refers to expression of emotion which is subjective,
while affect is objective
Note the variability or range, intensity & appropriateness
Emotion is a complex state of psychic, somatic &
behavioral aspects
Mood is described as dysphoric, euthymic, expansive,
irritable, labile, elevated, euphoric, ecstatic, depressive or
anhedonic

75. Affect is said to be appropriate or inappropriate,
blunted, restricted, flat or labile
Thought content and thought process
Thought process includes the flow of ideas &
quality of associations: the process of thinking
should include the rate & flow of ideas. Thoughts
can be racing or totally slowed down. There may be
circumstantiality, blocking or perseveration as
occurs in schizophrenia
Associations defined as the relationship btwn ideas
can be exhibited by loosening, flight of ideas,
neologisms, word salad or echolalia

76. Thought content includes distortions, delusions,
ideas of reference, depersonalization, derealisation,
preoccupations, obsessions, phobias, somatic
concerns, suicidal or homicidal ideation
Perception
Enquiries about perceptual disturbances require
careful approach and should evaluate the presence
or absence of illusions, hallucinations,
depersonalization or derealisation
Hallucinations should focus on all 5 sense
organs(sight, hearing, taste, touch & smell)
involved, with their contact, frequency and
circumstances of their occurrence recorded

77. Cognitive functions
– Sensorium
 Disturbance of consciousness usually denotes organic brain
conditions
 Determine the level of consciousness & any fluctuations if
present
– Orientation
Check if the patient knows the time, place and person. The
responses expected are determined by the social and
cultural background of the pt
– Attention and concentration
Naming three objects to the pt or giving a telephone no.
which the patient is told to repeat after the interviewer
can asses whether they are attentive

78. Concentration can be determined using simple
calculations like subtracting 7 from 100
– Memory
Memory is assessed in 3 categories,
immediate( recall), recent & remote
Pay attention to immediate memory (min/hrs),
recent memory (days, weeks, months) and past or
remote memory (10 years and above).

79. – Judgment
Look for signs of logical thinking e.g. would the pt
make wise decisions for example incase if fire,
drowning or any life threatening situation?
– Insight
The awareness of the pt about his illness and its
implication varies depending on whether the pt is
psychotic or non psychotic
The psychotic pt is said to have insight if he
realizes that he is sick and that his delusions and
hallucinations are normal experiences

80. Physical Examination
Physical Examination
Conduct a general examination, checking for scars,
deformity and number of teeth not in place.
Also check vital signs of temperature, pulse,
respiration and blood pressure.
After conducting all these checks you should be able
to make a provisional nursing diagnosis and draw up
a plan of care using the nursing process.

81. Psychopathology
Psychopathology
Psychopathology is the study of mental disorders
and abnormal thoughts, feelings, and behaviour/the
study of abnormal states of the mind.
Clinical psychiatry is thus concerned with two
related processes:
– diagnosing mental disorder
– assessing psychiatric factors in health and illness

82. A disorder is a set of symptoms and signs but
with a specified course of the illness, premorbid
history, and pattern of familial occurrence.
Mental disorders are characterized by
deviations from a socially defined norm in
thoughts, perceptions, mood, and behaviour that
impair social functioning.

83. Mental disorders are classified under (DSM IV);
– Disorders usually first diagnosed in Infancy, Childhood,
or Adolescence
– Delirium, Dementia, Amnesic & Other Cogntive
disorders
– Mental Disorders due to a General Medical Condition
– Substance-Related Disorders
– Schizophrenia & Other Psychotic Disorders
– Mood Disorders
– Anxiety Disorders
– Somatoform Disorders
– Factitious Disorders
– Dissociative disorders

84. – Sexual & Gender Identity Disorders
– Eating Disorders
– Sleep Disorders
– Impulse & Control Disorders Not Elsewhere Classified
– Adjustment Disorders
– Personality Disorders

85. Affect
Affect
Affect is an objective sign of emotions or feelings
as they are expressed by the patient and observable
by others & noted by the examiner during the MSE,
which refers to more fluctuating changes in
emotional "weather,".
Affect is characterized in several ways:
– By the type of emotion expressed and observed such as
anger, sadness, elation, etc.
– By the intensity and the range of emotion expressed,
i.e.;

86. – Broad affect is the normal condition in which a full
range of feelings is expressed.
– In constricted affect, the expression of feelings is clearly
reduced but to a lesser degree than in the case of blunted
affect.
– In blunted affect, the expression of feeling is severely
reduced.
– In flat affect, there is no expression of feeling; the face is
immobile, and the voice monotonous.

87. By its appropriateness; i.e., inappropriate affect is
apparent emotion discordant with accompanying
thought or speech (e.g. laughing while telling a story
most people would find horrifying).
By consistency of emotion; i.e., labile affect shifts
rapidly among different emotional states such as
crying, laughing, and anger.

88. Disturbances of consciousness
Disturbances of consciousness
Consciousness is the state of awareness of self &
envt. Its disturbances are associated with apparent
brain pathology eg brain tumors, infections of the
CNS, epilepsy, narcolepsy & physical trauma
Altered states of consciousness include:
– Clouding of consciousness which describes a state of
unclear ‘mindedness’ or thinking that may be associated
with disorder of a perception, attention, registration,
orientation & attitudes
– Stupor which is lack of response and awareness of
surroundings

89. – Delirium which is dream-like change in consciousness
that is often accompanied by an impaired reality testing.
Pt may be anxious, confused, disoriented, restless and
might experience hallucinations
– Coma; deep unconsciousness
– Depersonalization: disturbance in the way one
experiences the self
– Derealization; a disturbance in the way one experiences
one’s physical envt

90. Disturbances of attention
Disturbances of attention
Attention refers to ability to direct one’s activity. It is
the amount of attention exerted in focusing on certain
portions of an experience; the ability to concentrate.
Examples of disturbance in attention include:
– Distractibility which is the inability to concentrate. Attention
is easily diverted to other activities that are irrelevant.
Common in manic states
– Trance, a dream like state when attention is focused on one
thing and the person seems oblivious of his surroundings.
Occurs in hypnosis and associative disorders

91. – Hyper vigilance in which excessive attention is
concentrated on a stimuli. It is often secondary to
paranoid and delusional states

92. Abnormalities of Speech
Abnormalities of Speech
Pressure of speech - Speech that is rapid and
unstoppable, as if the speaker is driven to keep
speaking. Speech is often loud and emphatic and
hard to interrupt. It can dominate conversations or
go on when no one is listening or responding. A
feature of mania and seen also in other psychotic
conditions, organic mental disorders, and non-
psychotic conditions associated with stress.
Poverty of speech - Speech that is decreased in
amount and non-spontaneous, consisting mainly of
brief and unelaborated responses to questions.

93. Non-spontaneous speech - Lack of initiation of
speech; verbal responses are given only when asked
Poverty of content of speech -Speech that is
persistently vague, overly concrete or abstract,
repetitive, or stereotyped.
Disarrthria - difficulty in articulation
Jargon - gibberish or babbling speech associated
with aphasia, extreme mental retardation, or a
severe mental disorder
Aphasia - An impairment in the understanding or
transmission of ideas by language in any of its forms -
reading, writing, or speaking - that is due to injury or
disease of the brain centres involved in language.

94. Disorders of Memory
Disorders of Memory
Amnesia - A disturbance in the memory of
information stored in long-term memory, in contrast
to short-term memory, manifested by total or partial
inability to recall past experiences.
Types of amnesia include:
– Anterograde - Loss of memory of events that occur
after the onset of the etiological condition or agent.
– Retrograde - Loss of memory of events that occurred
before the onset of the etiological condition or agent.

95. Memory may be formally tested by asking the person to
register, retain, recall, and recognize information. The
ability to learn new information may be assessed by
asking the individual to learn a list of words. The
individual is requested to repeat the words
(registration), to recall the information after a delay of
several minutes (retention, recall), and to recognize the
words from a multiple list (recognition).
Memory types;
– Recall/Immediate
– Recent
– Remote - intact in dementia *In depression all types are
affected


96. Disorders of Perception
Disorders of Perception
Perception - The mental process of becoming
aware of or recognizing an object or idea;
primarily cognitive rather than affective or conative,
although all three aspects are manifested.
Illusion - A misperception or misinterpretation of a
real external stimulus, such as hearing the rustling
of leaves as the sound of voices.

97. Hallucination - A sensory perception that has the
compelling sense of reality of a true perception but
that occurs without external stimulation of the
relevant sensory organ. Hallucinations should be
distinguished from illusions, in which an actual
external stimulus is misperceived or misinterpreted.
The person may or may not have insight into the
fact that he or she is having a hallucination; may be
visual, auditory, olfactory, gustatory, or tactile.

98. Mood disorders
Mood disorders
Mood: This is the subjective experience of feeling
or emotion as described by the patient in the
history. A pervasive feeling, tone, and internal
emotional state of an individual that colours the
perception of the world. Distinct from affect, which
is a feeling state noted by the examiner during the
MSE, which refers to more fluctuating changes in
emotional "weather," mood refers to a more
pervasive and sustained emotional "climate."

99. Types of mood include:
– Dysphoric An unpleasant mood, such as sadness,
anxiety, or irritability.
– Elevated An exaggerated feeling of well-being, or
euphoria or elation. A person with elevated mood may
describe feeling "high," "ecstatic," "on top of the world,"
or "up in the clouds."
– Euthymic Mood in the "normal" range, which implies
the absence of depressed or elevated mood.
– Expansive Lack of restraint in expressing one's feelings,
frequently with an overvaluation of one's significance or
importance.
– Irritable Easily annoyed and provoked to anger.

100. Thought Disorders
Thought Disorders
Any disturbance of thinking that affects language,
communication, thought content, or thought
process determined from the patients speech,
writing or inferred from their actions.
Disordered thinking may be either;
– Disorder of thought content - reflects the patients belief
& interpretation of stimuli;
 Hallucinated experiences
 Delusions
 Marked illogicality

101. Disorder of thought process - detected from the
patients speech, writings drawings or behaviour;
– Incoherence of speech 2° to pressure of thought
– Illogical thinking
– Concrete thinking - Thinking characterized by
diminished capacity to form abstractions. The subject is
unable to think metaphorically or hypothetically.
– Tangentiality: A disturbance of communication in
which the subject "takes off on a tangent" away from a
central idea or question and does not return. It may be a
digression or an introduction of a new theme. It is related
to loosening of associations and speech derailment in
that there is a jump from one thought or topic to another.

102. A formal thought disorder is a disorder in form or
process of thinking, characterized by a failure to
follow semantic, syntactic, or logical rules.
 Schneider described the following features of
formal thought disorder - Fusion, Omission &
Substitution. It may range from;
locking: Sudden disruption of thought evidenced by
an interruption or momentary disruption of speech.
It appears as if the individual is trying to remember
what he or she was thinking or saying. It may occur
in schizophrenia, and lesser degrees are seen in
anxiety states such as obsessive-compulsive
disorders.

103. Circumstantiality: A disturbance of communication
in which the train of associations is interrupted by
frequent digressions before the central idea is finally
presented. The digressions are irrelevant or
marginally relevant to what is being said. Seen in a
wide variety of pathological states, or may be a
normal if annoying language habit.
Loosening of associations: (See also Flight of ideas
and Tangentiality.) A disorder of thinking and speech
in which ideas shift from one subject to another with
remote or no apparent reasons. The speaker is
unaware of the incongruity. A classical sign of
schizophrenia but may be seen also in any psychotic
state.

104. Loss of Reality Testing - Loss of the
capacity to challenge bizarre perceptions
Classically, formal thought disorder is the
hallmark of schizophrenia.

105. THERAPEUTIC NURSE-CLIENT
THERAPEUTIC NURSE-CLIENT
RELATIONSHIP
RELATIONSHIP
Definition
A mutual learning experience & corrective
emotional approach for the pt. it is based on
underlying humanity of the nurse and the pt with
mutual respect and acceptance of ethno cultural
differences.
Therapeutic relationships are goal- oriented and
directed at learning and growth promotion

106. Requirements for Therapeutic Relationship
Rapport, self understanding, acceptance, consistency
Trust
Respect
Genuineness
Empathy
Phases of a Therapeutic Nurse-Client Relationship
Pre-interaction phase
Orientation/Introductory Period
Working
Termination

107. Pre-interactive phase
Pre interaction is a phase which a nurse goes
through before actual interaction with the
patient. This phase begins when the nurse is
assigned a patient to develop therapeutic
relationship with him till she goes to him for
interaction
Task of pre-interaction phase
Obtaining available information about the client
from his or her charts, significant others or other
health team members. From this information the
initial assessments are begun

108. Examining ones feelings, fears and anxieties about
working with a particular patient.
Set objective for the interaction phase
INTRODUCTORY /ORIENTATION PHASE
Begins when the nurse goes to the patient,
introduces herself and gets introduction about him.
 The nurse and client get acquainted.
 The orientation phase ends when the nurse and he
patient begin to accept each other as unique human
being.

109. Task of introductory or orientation phase
a) Establishment of Contact
Nurse introduces herself to the patient
Build trust and rapport by demonstrating acceptance.
Establishing a therapeutic environment ensuring
safety and privacy
b) Making Agreement or Pact
c) Talking with the Patient
d) Assess the Clients Need, Coping Strategies, Defense
Mechanisms, Strengths and Weakness

110. BARRIERS TO
BARRIERS TO
ORIENTATION PHASE
ORIENTATION PHASE
Establishing an agreement or pact.
Social class of the patient or the nurse.
Status of the patient.
Anxiety level of the pt
Transference: When the patient perceives the nurse
as a significant individual from the past: for
example the pt perceive the nurse as his daughter
and starts behaving with her like a father

111. Counter transference: When the nurse perceives a
male patient like her father and gives him the same
care that she would have given to her father
WORKING PHASE
Working Phase starts when the nurse and the patient
are able to overcome the barriers of orientation and
introductory phase.
During this phase the nurse and the patient actively
work on meeting the goals which they had
established during the orientation phase

112. The characteristic feature of this phase is that the
nurse is able to overcome anxiety and the patient’s
fear of un known is also decreased
Task of working phase
The nurse collects the data in detail from primary
and secondary sources and identifies the needs
of the patent.
 The nurse assists the patient to identify his or her
problem.
She helps the patient to communicate.
She encourages the patient to use new patterns of
behaviour

113. Barriers to the working phase
Progress of the pt may be too slow
There will be difficulty in collecting data and
interpretation
There will be fear of closeness and it will be
difficult to terminate the relationship

114. Termination phase
Termination phase
The final step of the therapeutic relationship is the
termination phase. The nurse terminates the
relationship when they mutually agreed: when goals
are reached.
The nurse discusses the termination phase with the
client encourages to identify the progress that the
client has made and explores the necessity of any
referral that maybe beneficial to the patient

115. TASK OF TERMINATION
TASK OF TERMINATION
Bring a therapeutic end to the relationship.
Review feelings about relationship.
Evaluate progress towards goal.
Establish mechanisms for meeting future therapy
needs.
Summarize entire communication and follow up
treatments

116. Treatment used in management of
Treatment used in management of
mentally ill persons
mentally ill persons
Objectives
by the end of this session, the students be able to
describe treatments under the following headings:
– Drugs and other physical treatments
– Psychological treatments

117. Drugs and Other Physical
Drugs and Other Physical
Treatments
Treatments
There are various types of drugs and other physical
treatments used to treat patients suffering from
mental health illness.
These can be grouped together under the following
categories:
– Antipsychotic Medication
– Antidepressants
– Anxiolytics or Anti-anxiety Drugs
– Antiparkinsonian Drugs
– Electroconvulsive Therapy (ECT)

118. Antipsychotic Medication
Antipsychotic Medication
Antipsychotic drugs are also called major
tranquillizers or neuroleptics used in the treatment
of psychoses like schizophrenia, bipolar disorders
(manic phase) and alcohol withdrawal disorder.

119. Generic Name Trade Name Daily Doses(range)
Low Potency
Drugs
Chlorpromazine Largactil 300-1000mgs
Sulpride Domatil,Sulparex 200-2400mg
Thioridazine Melleril 50-800mg
High Potency
Drugs
Haloperidol Haldol,Serenace 1-20mg
Thiothixene Navane 6-60mgs
Zoxapine Loxitane 60-250mgs
Molindone Lidone 50-400mgs
Flupenthixol Depixol 6-18mg
Fluphenazine Moditen 2.5-20mg

120. Trifluoperazine Stelazine 5-30mg
Zuclopenthixo Clopixol 20-150mg
Pimozide Orap 2-10mg

121. Depot
Injections
Fluphenazine
decanoate
Modecate 12.5-100mg(IM 2
Weekly)
Zuclopenthixol
Acetate
Clopixol
Acuphase
50-150mg every 2-
3
days
Haloperidol
decanoate
Haldol
decanoate
50-300mg (IM 4
weekly)

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

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

124. Drugs should be given using the following time
frame:
– Six months for first psychotic episode.
– One year period for second psychotic episode.
– Indefinite period for third and later psychotic episodes.
The drug should be discontinued through tapering
the dosage to avoid dyskinesia.

125. Gertrude and MacFarland (1986) have identified the
following expected responses to the treatment:
– Initially the patient is drowsy and co-operative within
hours to a week.
– The patient becomes more sociable and less withdrawn
for the next two months.
– The thought disorder generally disappears in six weeks or
more.
– Improvement is generally noted in hallucinations, acute
delusions, sleeping habits, appetite, tension,
combativeness, hostility, negativism and personal
grooming.

126. Side effects
Side effects
There are several side effects that may be
experienced by patients. These include drowsiness
and orthostatic hypotension, especially after im
injections.
The patient may also experience extra pyramidal
symptoms like:
– Dystonia, that is, spasms of muscles of face, neck, back,
eye, arms and legs.
– Oculogyric crisis, presenting as fixed upward gaze from
spasm of oculomotor muscles.
– Torticollis, that is, pulling of the head to the side from
spasm of cervical muscles.

127. Extrapyramidal side effects of
Extrapyramidal side effects of
antipsychotics cntd…
antipsychotics cntd…
– Opisthotonus, which refers to the hyperextension of
the back from spasm of back muscles.
– Akathisia or continuous motor restlessness.
– Akinesia or lack of body movement especially arms.
– Pseudoparkinsonism, which presents with a
shuffling gait, mask-like facial expression, tremor,
rigidity and akinesia.

128. SIDE EFFECTS CNTD…
The patient may also experience tardive dyskinesia,
that is, a wormlike movement of the tongue,
frequent blinking, and involuntary movement of
tongue, lips and jaw. They may experience
convulsive seizures or allergic or toxic effects (some
of which are rare and serious).These include:
– Aggranulosis
– Oral monoliasis
– Dermatitis
– Jaundice

129. Side effects of antipsychotics
Side effects of antipsychotics
cntd…
cntd…
The patient may also exhibit other side effects including
endocrine or metabolic effects like weight gain or
decreased libido, impotence, impaired ejaculation in males.
They may also have decreased thermoregulatory ability and
as a result might complain of being too cold or too hot.
Adjusting the dosage of antipsychotic drugs, and giving
antiparkinsonian drugs can often be quite effective in
treating side effects.

130. Contraindications
Contraindications
Comatose, glaucoma, prosthetic hyperplasic, acute
myocardial infarction are contraindications to the
use of these drugs

131. Antidepressants
Antidepressants
These drugs are used to treat affective disorders.
Mechanisms of Action
They act by increasing epinephrine and serotonin.
Both of them are metabolised in the liver and
excreted in the urine.

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

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

134. Side Effects
Side Effects
include mild anticholinergic effects from tricyclic and
monoamine oxidase inhibitors, dry mouth, constipation,
blurred vision, tachycardia nausea, oedema, hypotension
and urinary retention.
 Adjusting the dosage to a lower level will usually resolve
the problem.
Side effects that are specific to tricyclics are:
– Allergic reactions manifested as skin rash and jaundice.
– Tachycardia.
– Tremors.Long term treatment may depress bone marrow,
predispose to sore throat and aching, and fever.

135. specific side effects of monoamine oxidase
inhibitors include:
– Liver damage that is rare but fatal.
– Precipitation of manic episodes.
– Hypertension crisis characterised by severe headache
palpitation, neck stiffness, nausea, vomiting, increased
Bp, chest pain and collapse. It occurs 30 minutes to 24
hours after eating food containing tyramine. These foods
include cheese, wine, beer, sour cream, liver, chocolate,
bananas, avocadoes, soy sauce, and beans

136. Contraindications
Contraindications
The use of antidepressants is contraindicated when
the patient suffers from glaucoma, agitated states,
urinary retention, cardiac disorders and seizure
disorders

137. Anxiolytics or Anti-anxiety Drugs
Anxiolytics or Anti-anxiety Drugs
These drugs, when given to a patient having
generalised anxiety disorder, are able to provide
relief.
They are mainly recommended for acute anxiety
states, which may present with palpitations,
sweating, trembling, shortness of breath, chest pain,
nausea, dizziness, a feeling of unreality, fear of
losing control or dying, chills or numbness.
Examples of these drugs include buspirone, a novel
anxiolytic, and benzodiazepines like diazepam and
lorazepam.

138. EFFECTS
EFFECTS
The main effects include sedation, muscle relaxation
and elevation of seizure threshold.

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

140. Contraindications
Contraindications
Benzodiazepines should not be used together with
other central nervous system depressants.
They should be given with caution to patients who are
elderly, depressed or suicidal and those with a history
of substance abuse.
Note: these drugs need to be combined with
psychotherapy to ensure complete cure of the
problem. This implies that anxiolytics by themselves
are not a cure for psychological problems. The most
commonly used drug is diazepam. This is usually
administered as a dose of 2-10mg bid/qid orally or 2-
20mg i.m. or i.v.

141. Antiparkinsonian Drugs
Antiparkinsonian Drugs
These are drugs given to counteract the side effects
of major tranquillizers.
An example of such a drug is benztropine (cogentin)
whose initial dose is 0.1-1mg daily, the maintenance
dose is 0.5-6mg daily divided into two or four times.
Side Effects
include dry mouth, nausea, constipation, urinary
retention, blurred vision, disorientation and
confusion.

142. Electroconvulsive Therapy (ECT)
Electroconvulsive Therapy (ECT)
Electroconvulsive therapy (ECT), formerly known
as electroshock, is a psychiatric treatment in which
seizures are electrically induced in anesthetized
patients for therapeutic effect
Ugo Cerletti and Lucio Bini founded this method in
1938. It is given in doses ranging from 70 to 130
volts via electrodes placed on the temporal lobes
from a machine constructed for treatment purposes

143. Before ECT is administered, the following
investigations are done:
– Physical examination like x-ray of the chest and spine
– Electrocardiogram (ECG) and electroencephalogram
(EEG) may be done
At the same time, informed consent is obtained from
the relatives after explaining the procedure.

144. The night before ECT, the patient is starved for six
hours. Before taking the patient to the ECT department,
all metallic objects are removed from the patient.
Thereafter, premedication of atropine 0.6mg is given to
dry body secretions. The patient is put under general
anaesthesia, and then the doctor passes the current. The
patient is secured on a theatre couch to prevent
accidental fall.
The patient is then taken to the recovery room where
vital signs are taken until the patient is fully awake.
After that, the patient is given something to eat. In the
ward, the patient should be closely observed, and later
assessed to monitor the effect of ECT.

145. Treatments can be repeated if the patient does not
improve. The frequency of treatment depends upon
the severity of the patient’s mental disorder. He may
have two or three ECT treatments per week for a
maximum of 8 to 12 treatments.
Nurses are responsible for setting up treatment and
for the safety of the patient

146. Current indications include;
– All mood disorders
– Acute schizophrenic presentations; Catatonic
schizophrenia; in cases of schizophrenia with strong
affective symptomatology.
– Schizophreniform disorder or Schizoaffective disorder
– Catatonic excitement

147. Conditions for which its efficacy is
considered merely suggestive;
– Delirium
– Severe organic affective/psychotic syndromes
that mimic functional syndromes
– Several medical conditions, including
Parkinson's disease
– Catatonia secondary to organic causes.

148. Contraindications of ECT
Contraindications of ECT
There are no absolute contraindications; Relative
contraindications include;
– Increased intracranial pressure
– Recent history of myocardial infarction
– High-risk conditions e.g. bleeding (or otherwise
unstable), vascular aneurysm or malformation,
intracerebral haemorrhage, acute or impending retinal
detachment, pheochromocytoma, or high anaesthetic risk

149. Adverse Effects of ECT
Adverse Effects of ECT
Anxiety and apprehension, especially early in the
course of treatment.
Confusion following ECT, which is to be expected
given the normal occurrence of confusion in the
postictal state. In patients who remain confused for
a day or two following each treatment, it is often
advisable to give two rather than three treatments
per week.

150. Long-term memory deficits, which are usually
characterized by retrograde amnesia, that is little or no
memory of the period of hospitalization and, in some
cases, events just before and just after hospitalization.
Bilateral ECT imposes a higher risk of memory
impairment, & thus is commonly reserved for patients
who have failed unilateral ECT or for those in whom
rapid resolution of symptoms is of paramount
importance.
Because both pulse and blood pressure rise significantly
during the seizure, patients with cardiac dysfunction are
at higher risk for untoward events such as ischemia or
arrhythmia.

151. Prolonged (usually defined as >3 minutes) seizure
or a "late" seizure (which may in fact simply be a
prolonged seizure masked by the barbiturate the
patient has received). Prolonged seizures should be
aborted pharmacologically
Prolonged apnoea or laryngospasm
Burns from poor contact with the electrode
Loose or broken teeth
Peripheral nerve palsy
Headache, muscle aches, and a vague sense of
confusion for a few hours after the treatment are
common.

152. Psychological Treatments
Psychological Treatments
Psychotherapy
This is a form of treatment involving
communication between the patient and the
therapist, with the aim of modifying and
alleviating illness.
A professional relationship is established, with the
patient aimed at removing, modifying or mitigating
the existing symptoms or disturbance patterns of
behaviour or promotion of positive personality,
growth and development.

153. There are two main types of psychotherapy:
– Individual psychotherapy
– Group psychotherapy
Individual Psychotherapy
Individual psychotherapy can be further
sub-divided into several categories:

154. Supportive
This deals with current problems and helps the
patient to overcome their symptoms and cope with
them satisfactorily in future.
Suggestive
This is a therapeutic method based on the belief that
the patient has the ability to modify their abnormal
emotional behaviour by applying their willpower
and common sense.
Appeals are made to the patient’s reason and
intelligence. This is to help them abandon neurotic
aims and symptoms and enable them to regain self
respect.

155. Persuasive
This is the oldest form of psychotherapy. It is also widely
used in advertising, propaganda, religious and political
activities
 It revolves around a state of artificially induced
suggestibility known as hypnosis. The technique is aimed at
narrowing the patient’s attention to the hypnotist alone.
 Hypnosis ranges from a light hypnotic state to a deep
trance. The main purpose of hypnosis is psychological
investigation. This deals with current problems and helps
patient to overcome their symptoms and cope with them
satisfactorily in future

156. Group Psychotherapy
Group Psychotherapy
The treatment of the patient by psychotherapy in
groups was first introduced as a time saving
measure, but subsequent experience demonstrated
that, the method had special therapeutic value,
which did not occur in individual psychotherapy.
There are various styles of group therapy. One
example of a group therapy setting, might involve a
group size of six to eight patients.

157. The therapy would have a time span of 1 to 1.5
hours and sessions would be held once or twice
weekly. A relaxed, informal style might be adopted,
with the patients sitting in a circle to denote
equality.
benefits associated with the group therapy method:
– Re-education of the patient with a view towards altering
attitudes and behaviour patterns
– Socialisation
– Improved adjustment and adaptation to reality
– Increased understanding of emotional problems and
conflicts
– Modification of personality and character

158. Behavioural Therapy
Behavioural Therapy
This is defined as a therapeutic technique, which
attempts to change the patient’s behaviour directly
rather than correct the basic cause of the undesirable
behaviour.
The two main methods that are used are:
– Changing the behaviour from inside using covert and
cognitive therapies. Here, the priority is to help the
patient modify their view of the world and themselves,
by helping them change the things they say about
themselves.

159.  Changing the behaviour from outside. This is
achieved through positive reinforcement of
acceptable behaviour and negative reinforcement
for unacceptable behaviour.

160. Activity Therapy
Activity Therapy
forms of activity therapy.
Occupational Therapy
– This involves the use of selected activities to improve
general performance, to enable the patient to learn the
essential skills of day-to-day living and to assist in the
reduction of symptoms.
– Activities may include painting, washing clothes and so
on.

161. Recreation Therapy
This method uses activities like sports,
games, hobbies to treat behaviour.
It lays the emphasis on re-socialization,
reality orientation and involvement of
mentally ill persons.

162. Dance Therapy
It uses body rhythmic movements and interaction to
express emotions, thereby increasing awareness of
the body and ego strength.
Rehabilitation
– This is the process of restoring a person’s ability to live
and work as normally as possible after disabling injury or
illness.
– It is aimed at helping the patient achieve maximum
possible physical and psychological fitness and regain
the ability to care
for themselves.

163. – This aim is achieved through:
 Physical therapy
 Occupational therapy
 Vocational training
 Industrial/ work therapy
 Recreation or social therapy

164. PSYCHIATRIC DISORDERS

165. SCHIZOPHRENIA.
SCHIZOPHRENIA.

166. The term “schizophrenia” (split mind) was
coined by Bleuler to describe a lack of
integration of the patient’s functions
There is disharmony between the patient’s
thinking, feeling and acting.
Schizophrenia causes distorted and bizarre
thoughts, perceptions, emotions,
movements and behavior.

167. SCHIZOPHRENIA
SCHIZOPHRENIA
 The main problem in schizophrenia is Altered
Thought Process
 The most acceptable theory on the cause of
schizophrenia is the Biologic Theory which says
that schizophrenia is due to
increased dopamine.

168. CHARACTERISTICS OF
CHARACTERISTICS OF
SCHIZOPHRENIA
SCHIZOPHRENIA
Patients are usually tend to be:
⁃ Introverted,
⁃ Deficient in their affective response ability
⁃ Self conscious
⁃ Retiring
⁃ Moody and sensitive
⁃ There is failure in adapting to objective reality.
⁃ The patient’s abstract ability becomes impaired.

169. ⁃ Patient acts out in ways which would
ordinarily be subject to social restraint
⁃ Delusions and hallucinations are accessory
symptoms.

170. TYPES OF SCHIZOPHRENIA
TYPES OF SCHIZOPHRENIA
Paranoid Schizophrenia
Catatonic Schizophrenia
Disorganized Schizophrenia
Undifferentiated Schizophrenia
Residual Schizophrenia

171. PARANOID
PARANOID
SCHIZOPHRENIA
SCHIZOPHRENIA
Characterized by:
persecutory (feeling victimized or spied
on)
Grandiose delusions,
Hallucinations, and occasionally,
excessive
Religiosity (delusional religious focus) or
Hostile and aggressive behavior.

172. CATATONIC
CATATONIC
SCHIZOPHRENIA
SCHIZOPHRENIA
Characterized by marked psychomotor
disturbance, either motionless or excessive
motor activity.
Motor immobility may be manifested by
catalepsy (waxy flexibility) or stupor
Excessive motor activity that is purposeless and
is not influenced by external stimuli
Other features include negativism, mutism,
peculiarities of voluntary movement, echolalia,
and echopraxia

173. CATATONIC
CATATONIC
SCHIZOPHRENIA
SCHIZOPHRENIA
 Catatonic Stupor
– Marked decrease in reactivity to the environment
and/or reduction in spontaneous movement and activity
or mutism
 Catatonic Negativism
– Apparently motive-less resistance to all instruction or
attempts to be moved
 Catatonic Rigidity
– Maintenance of a rigid posture against efforts to be
moved

174. CATATONIC
CATATONIC
SCHIZOPHRENIA
SCHIZOPHRENIA
Catatonic Excitement
– Excited motor activity, apparently
purposeless and not influenced by external
stimuli
Catatonic Posturing
– Voluntary assumption of inappropriate
posture.

175. DISORGANIZED
DISORGANIZED
SCHIZOPHRENIA
SCHIZOPHRENIA
Incoherence, marked loosening of associations,
or grossly disorganized behavior
Flat or grossly inappropriate affect
Does not meet the criteria for the catatonic type

176. UNDIFFERENTIATED
UNDIFFERENTIATED
SCHIZOPHRENIA
SCHIZOPHRENIA
Characterized by mixed schizophrenic symptoms
(of other types) along with disturbances of
thought, affect and behavior
Prominent delusions, hallucinations, incoherence
or grossly disorganized behavior
Patients whose manifestations cannot be fitted
into one or the other types

177. RESIDUAL
RESIDUAL SCHIZOPHRENIA
SCHIZOPHRENIA
– Marked social isolation or withdrawal
– Marked impairment in role functioning as
wage-earner, student or homemaker
– Marked peculiar behaviors
– Marked impairment in personal hygiene and
grooming
– Odd beliefs or magical thinking, influencing
behavior and inconsistent with cultural
norms.
– Marked lack of initiative, interest

178. 08/11/25 Psychnebppt. 179
FUNDAMENTAL SIGNS AND
FUNDAMENTAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA AS
SYMPTOMS OF SCHIZOPHRENIA AS
IDENTIFIED BY BLEULER
IDENTIFIED BY BLEULER
Associative Looseness
Autism
Apathy
Ambivalence
4 A’s

179. 08/11/25 Psychnebppt. 180
SYMPTOMS OF
SYMPTOMS OF
SCHIZOPHRENIA
SCHIZOPHRENIA
 The symptoms of schizophrenia are divided into
two major categories:
– Positive or hard symptoms / signs, which
include delusions, hallucinations, and grossly
disorganized thinking, speech and behavior
– Negative or soft symptoms / signs such as
blunting, avolition, and social withdrawal or
discomfort

180. 08/11/25 Psychnebppt. 181
NEGATIVE OR SOFT SYMPTOMS OF
NEGATIVE OR SOFT SYMPTOMS OF
SCHIZOPHRENIA
SCHIZOPHRENIA
Alogia
Anhedonia
Apathy
Blunted Affect
Catatonia
Flat Affect
Lack of Volition

181. 08/11/25 Psychnebppt. 182
GENERAL SIGNS AND
GENERAL SIGNS AND
SYMPTOMS OF
SYMPTOMS OF
SCHIZOPHRENIA
SCHIZOPHRENIA
1) Perceptual changes
– May occur in all the senses or not.
1a) Illusions
 Client’s misperceives or exaggerates stimuli in the
external environment
1b) Hallucinations (hallmark of schizophrenia)
 May be visual, olfactory, gustatory, tactile, or auditory

182. 08/11/25 Psychnebppt. 183
DELUSIONS
DELUSIONS
 Disturbances in the content rather than the form of
thought
 Fixed false beliefs about one’s environment or event
occurring in it
Types of delusions
– Persecutory or Paranoid Delusions
– Grandiose Delusions
– Religious Delusions
– Somatic Delusions
– Referential Delusions or Ideas of Reference

183. 08/11/25 Psychnebppt. 184
GENERAL SIGNS AND SYMPTOMS
GENERAL SIGNS AND SYMPTOMS
OF SCHIZOPHRENIA
OF SCHIZOPHRENIA
2) Disturbances in thought
– The thinking is unclear
– Thoughts are disconnected or disjointed
– Examples:
2a) Clang Associations
2b) Delusions

184. 08/11/25 Psychnebppt. 185
GENERAL SIGNS AND
GENERAL SIGNS AND
SYMPTOMS OF SCHIZOPHRENIA
SYMPTOMS OF SCHIZOPHRENIA
3) Changes in communication
– Clients have difficulty responding appropriately to events and
people they encounter because of their distorted perceptions.
– Examples:
3a) Thought Disorganization
3b) Thought Blocking
3c) Tangential Communication
3d) Circumstantial Communication
3e) Alogia

185. THOUGHT DISORGANIZATION
⁃ Responses are inappropriate to the situation
o THOUGHT BLOCKING
• Clients may suddenly stop talking in the middle of
a sentence and remain silent for several seconds to
one minute
o TANGENTIAL THINKING
 Veering into unrelated topics and never answering
the original question

186. CIRCUMSTANTIAL COMMUNICATION
⁃ Circumstantiality may be evidenced if the client
gives unnecessary details or strays from the topic
but eventually provides the requested information
o ALOGIA
⁃ Poverty of content describes the lack of any real meaning
or substance in what the client says
⁃ Example:
– Nurse: “How have you been sleeping lately?”
– Client: “Well, I guess, I do not know, hard to tell.”

187. 4) Disruptions in emotional responses
– Restricted or inappropriate expression or
emotion
5) Motor Behavior Changes
– Catatonia (manifested by unusual body
movement or lack of movement)
– Examples:
5a) Catatonic Excitement
5b) Catatonic Posturing
5c) Stupor

188. 08/11/25
Psychnebppt.
189
6) Self care deficits
– They neglect to bathe, change clothes or attend
to minor grooming tasks
– Some show little awareness of current fashion
styles
– Wearing clothing that makes them look out of
place is also seen

189. 7) Activity Intolerance
– This is brought about by ambivalence
about where to sit or what to eat
8) Altered Thought Processes
– Examples:
8a) Magical Thinking
8b) Thought Insertion
8c) Thought Withdrawal
8d) Thought Broadcasting

190. MAGICAL THINKING
⁃ Belief that events can happen simply because one
wishes them to happen.
THOUGHT INSERTION
⁃ They may state that others are placing thoughts in
their mind or in their head against their will
 THOUGHT WITHDRAWAL
⁃ They may state that others are taking their
thoughts out of their head

191. 08/11/25 Psychnebppt. 192
THOUGHT BROADCASTING
THOUGHT BROADCASTING
 They may state that they believe others can hear
their thoughts
 They believe that thoughts are transmitted to
others via radio, television or other means but not
directly by the client

192. 08/11/25 Psychnebppt. 193
9) Unusual speech patterns
– Examples:
9a) Clang Associations
9b) Neologisms
9c) Verbigeration
9d) Echolalia
9e) Stilted Language
9f) Perseveration
9g) Word Salad

193. 08/11/25 Psychnebppt. 194
STILTED LANGUAGE
STILTED LANGUAGE
This is the use of words or phrases that are
flowery, excessive, and pompous
– Example:
“Would you be so kind, as a representative
of Florence Nightingale,sent by the Hon.
Prime minister, RAO, as to do me the honor
of providing just a wee bit of refreshment,
perhaps in the form of some clear spring
water?”

194. 08/11/25 Psychnebppt. 195
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
1) Promote adequate communication
– If a client complains of physical symptoms
such as stomach distress, consider the
symptoms as real until there is evidence
otherwise.

195. 08/11/25 Psychnebppt. 196
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
2) Promote compliance with medical regimen
– Administer prescribed medications
– Observe client behavior for therapeutic effects
– Maintaining therapeutic blood levels is important
– Monitor side effects of drugs

196. 08/11/25 Psychnebppt. 197
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
2) Promote compliance with medical regimen
– Evaluate client’s subjective response to the drug
and attitude towards continued use. Compliance
may be affected because:
 They do not understand the administration instruction
 They are so disorganized to follow instruction
 The side effect of major tranquilizers are too
uncomfortable

197. 08/11/25 Psychnebppt. 198
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
3) Assist with grooming and hygiene
– Intervention begins by establishing clear
expectations. Frequency and timing should be
specified in writing
– Avoid power struggles regarding completion of
tasks. If initial prompts do not work, leave the
client alone for a short period

198. 08/11/25 Psychnebppt. 199
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
4) Promote organized behavior
– The first rule is to go slowly and keep calm
– Clients with disorganized behavior require
direction and limits to make their actions more
effective and goal directed.

199. 08/11/25 Psychnebppt. 200
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
5) Promote social interaction and activity
– The client’s effort to withdraw from social
contact stem from past relationship failures and
fear of rejection

200. 08/11/25 Psychnebppt. 201
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
6) Social skills training
– Address social skills that are essential to
functioning in the milieu
– Help client find activities that are intrinsically
rewarding or some social tangible reward yet
are within their capacities

201. 08/11/25 Psychnebppt. 202
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
7) Promote reality-based perceptions as hallucinations
and illusions often frighten clients
– Reassure client of their safety
– Protect them from physical harm as they respond
to their altered perceptions
– Intervene quickly by giving additional doses of
phychotropic medications or placing the client in
a quiet room

202. 08/11/25 Psychnebppt. 203
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
7) Promote reality-based perceptions as hallucinations
and illusions often frighten clients
– Help the client in activities that require cognitive
or verbal involvement
– Support coping strategies that the client has
identified as personally effective in reducing
hallucinations

203. 08/11/25 Psychnebppt. 204
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
If needed, teach the client that the
hallucination are part of the disease process
– Help the client monitor events or interactions
that increase the hallucinations
– Protect the client and others who might be
harmed by the client’s acting on hallucinated
commands.

204. 08/11/25 Psychnebppt. 205
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
8) Intervene with delusions
– Do not argue with their general beliefs
– Focus on the reality-based aspects of their
communications
– Protect them from acting on their delusion in a way
that might harm themselves or others
– Observe for stressors that precipitate the delusion and
help the client to avoid or eliminate these stressors

205. 08/11/25 Psychnebppt. 206
NURSING CARE FOR
NURSING CARE FOR
SCHIZOPHRENIA
SCHIZOPHRENIA
9) Promote congruent emotional responses
10) Promote family understanding and involvement

206. 08/11/25 Psychnebppt. 207
MOOD DISORDERS
MOOD DISORDERS

207. 08/11/25 Psychnebppt. 208
MOOD / AFFECTIVE DISORDERS
MOOD / AFFECTIVE DISORDERS
 A group of psychiatric diagnoses characterized by
disturbances in emotional and behavioral response
patterns ranging from elation and agitation to extreme
depression and a serious potential for suicide.
 Group of disorders characterized by a decreased or
entire loss of control over mood
 The mood disturbance may occur in different patterns of
severity, duration, alone or in combination

208. 08/11/25 Psychnebppt. 209
COMMON ETIOLOGICAL
COMMON ETIOLOGICAL
THEORIES OF MOOD DISORDERS
THEORIES OF MOOD DISORDERS
1) Genetic Theory
– If one parent has a bipolar disorder, there is
25% chance of transmission to the child
2) Aggression Turned Inward Theory
– Overdeveloped superego leads to depression

209. 08/11/25 Psychnebppt. 210
COMMON ETIOLOGICAL
COMMON ETIOLOGICAL
THEORIES OF MOOD DISORDERS
THEORIES OF MOOD DISORDERS
7) Psychoanalytic Theory
– Mania is a defense against an underlying
depression
– Depression is due to a rigid superego
8) Biologic Factor
– Mania is related to increased norepinephrine
while depression is related to low norepinephrine

210. 08/11/25 Psychnebppt. 211
COMMON PRECIPITATING
COMMON PRECIPITATING
FACTORS OF MOOD DISORDERS
FACTORS OF MOOD DISORDERS
 Loss of a loved one
 Major life events
 Roles strain
 Decreased coping resources
 Physiological changes

211. 08/11/25 Psychnebppt. 212
TYPES OF MOOD DISORDERS
TYPES OF MOOD DISORDERS
 The two main types of mood disorders are:
– Depression
 Characterized by anergia (lack of energy), exhaustion,
agitation, noise intolerance, and slowed thinking process
– Bipolar Disorders
 Diagnosed when a person’s mood cycles between
extremes of mania and depression

212. 08/11/25 Psychnebppt. 213
SUBTYPES OF
SUBTYPES OF DEPRESSIONS
DEPRESSIONS
 Major Depression
 Dysthymic Depression
 Depression Not Otherwise Specified

213. 08/11/25 Psychnebppt. 214
MAJOR DEPRESSION
MAJOR DEPRESSION
 Severe depression which lasts for at least 2 weeks
during which the person experiences a depressed
mood or loss of pleasure in nearly all activities

214. 08/11/25 Psychnebppt. 215
MAJOR DEPRESSION
MAJOR DEPRESSION
 In addition, four of the following symptoms are present:
– Changes in appetite or weight
– Changes in sleep
– Changes in psychomotor activity
– Decreased energy
– Feelings of worthlessness or guilt
– Difficulty thinking, concentrating or making decisions
– Recurrent thoughts of death or suicidal ideation,
plans, or attempts.

215. 08/11/25 Psychnebppt. 216
DYSTHYMIC
DYSTHYMIC
DEPRESSION
DEPRESSION
 It is less severe than major depression
 It is characterized by at least 2 years of depressed
mood for more days than not with some additional
less severe symptoms that do not meet the criteria
for a major depressive episode

216. 08/11/25 Psychnebppt. 217
DEPRESSION NOT OTHERWISE
DEPRESSION NOT OTHERWISE
SPECIFIED (DNOS)
SPECIFIED (DNOS)
 Depression that lasts for 2 days to 2 weeks

217. 08/11/25 Psychnebppt. 218
SUBTYPES OF
SUBTYPES OF BIPOLAR
BIPOLAR
DISORDERS
DISORDERS
 Manic
 Hypomanic
 Bipolar I
 Bipolar II
 Cyclothymia

218. 08/11/25 Psychnebppt. 219
MANIA
MANIA
 The diagnosis of manic episode or mania requires at least 1
week of unusual and incessantly heightened, grandiose or
agitated mood in addition to three or more of the following
symptoms:
– Exaggerated self-esteem
– Sleeplessness
– Pressured speech
– Flight of ideas
– Reduced ability to filter extraneous stimuli

219. 08/11/25 Psychnebppt. 220
HYPOMANIC
HYPOMANIC
 Less severe than mania
 Lasts for at least 4 days

220. 08/11/25 Psychnebppt. 221
BIPOLAR I
BIPOLAR I
 With history of mania
 The patient exhibits:
– Manic episodes
– Periods of normal behavior
– Periods of profound depression

221. 08/11/25 Psychnebppt. 222
BIPOLAR II
BIPOLAR II
 No history of mania
 The patient exhibits:
– Depression
– Normal behavior
– At least one hypomanic episode, but NOT
manic

222. 08/11/25 Psychnebppt. 223
CYCLOTHYMIA
CYCLOTHYMIA
 Characterized by two years of numerous periods
of both hypomanic symptoms that do not meet the
criteria for bipolar disorder
 Numerous episodes of hypomania and depressed
mood that lasts for at least two years

223. 08/11/25 Psychnebppt. 224
DIFFERENCE BETWEEN MANIA
DIFFERENCE BETWEEN MANIA
AND DEPRESSION
AND DEPRESSION
MANIA
MANIA DEPRESSION
DEPRESSION
Appearance
Appearance Colorful
Colorful Sad
Sad
Behavior
Behavior Highly driven,
Highly driven,
Hyperactive
Hyperactive
Passivity
Passivity
Psychomotor
Psychomotor
retardation
retardation
Communication
Communication Talkative (Flight
Talkative (Flight
of Ideas)
of Ideas)
Monotonous
Monotonous
speech
speech
Nursing Diagnosis
Nursing Diagnosis Risk for injury
Risk for injury
directed at others
directed at others
Risk for injury:
Risk for injury:
Self-directed
Self-directed
Nursing Care
Nursing Care
Priority
Priority
Safety
Safety Safety
Safety

224. 08/11/25 Psychnebppt. 225
DIFFERENCE BETWEEN MANIA
DIFFERENCE BETWEEN MANIA
AND DEPRESSION
AND DEPRESSION
MANIA
MANIA DEPRESSION
DEPRESSION
Treatment of
Treatment of
Choice
Choice
Lithium
Lithium ECT
ECT
Milieu Therapy
Milieu Therapy Non-stimulating
Non-stimulating Stimulating
Stimulating
Appropriate
Appropriate
Activity
Activity
Quiet Type
Quiet Type
Avoid competitive
Avoid competitive
Monotonous activity
Monotonous activity
Example: counting
Example: counting
Attitude Therapy
Attitude Therapy Matter of fact
Matter of fact
(attitude of
(attitude of
casualness)
casualness)
Kind Firmness
Kind Firmness

225. 08/11/25 Psychnebppt. 226
MEDICATIONS USED IN
MEDICATIONS USED IN
MANIA
MANIA
 Drug Classification
– Antimanic Medications
 Lithium Carbonate
– Anticonvulsant Medications
 Used as mood stabilizers

226. 08/11/25 Psychnebppt. 227
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Provide for client’s physical safety and safety of
those around the client
– The nurse assess clients directly for suicidal
ideation and plans or thought of hurting others
– It is important to monitor the client’s
whereabouts and behaviors frequently.

227. 08/11/25 Psychnebppt. 228
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Set limits on client’s behavior when needed and
remind client to respect distances between self and
others.
 When setting limits, it is important to clearly
identify the unacceptable behavior and convey the
expected appropriate behavior

228. 08/11/25 Psychnebppt. 229
NURSING INTERVENTIONS FOR MANIA
NURSING INTERVENTIONS FOR MANIA
 Use short simple sentences to communicate
– Clients with mania have short attention span, so
he nurse uses clear , simple sentences when
communicating

229. 08/11/25 Psychnebppt. 230
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Keep channels of communication open with clients, regardless
of speech patterns (pressured, rapid, circumstantial, rhyming,
noisy or intrusive with flight of ideas)
– The nurse can say, “Please speak more slowly, I am having
trouble following you.”
– The nurse patiently and frequently repeats this request
during conversation because clients will return to rapid
speech

230. 08/11/25 Psychnebppt. 231
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Clarify the meaning of client’s communication
– When speech includes flight of ideas, the nurse
can ask clients to explain the relationship
between topics – for example, “What happened
then?” or “Was that before or after you got
married?”

231. 08/11/25 Psychnebppt. 232
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Set limits regarding taking turns speaking and
listening and giving attention to others when they
need it

232. 08/11/25 Psychnebppt. 233
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Frequently provide finger foods that are high in
calories and protein (sandwiches, protein bars,
fortified shakes)
– Manic clients may be too “busy” to sit down
and eat, or they may have such poor
concentration that they fail to stay interested in
food for very long

233. 08/11/25 Psychnebppt. 234
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Promote rest and sleep by decreasing
environmental stimulation
– The nurse provides a quiet environment without
noise, television, or other distractions.

234. 08/11/25 Psychnebppt. 235
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Establishing a bedtime routine, such as tepid bath
may help clients to calm down enough to rest

235. 08/11/25 Psychnebppt. 236
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
MANIA
MANIA
 Protect the client’s dignity when inappropriate behavior
occurs
– Clients may lose sexual inhibitions resulting in provocative and risky
behaviors. Clothing may be flashy or revealing, or clients may
undress in public. They may engage in unprotected sex with virtual
strangers. Clients may ask staff members or other clients for sex,
graphically describe sexual acts, or display their genitals.
 It is important to treat clients with dignity and respect despite
their inappropriate behavior. It is not helpful to scold or
chastise them.

236. 08/11/25 Psychnebppt. 237
REVIEW OF MAJOR SYMPTOMS
REVIEW OF MAJOR SYMPTOMS
OF DEPRESSIVE DISORDER
OF DEPRESSIVE DISORDER
 Depressed mood
 Anhedonism (decreased attention to and enjoyment
from previously pleasurable activities)
 Unintentional weight change of 5% or more in a month
 Change in sleep pattern

237. 08/11/25 Psychnebppt. 238
REVIEW OF MAJOR SYMPTOMS
REVIEW OF MAJOR SYMPTOMS
OF DEPRESSIVE DISORDER
OF DEPRESSIVE DISORDER
 Agitation or psychomotor retardation
 Tiredness
 Worthlessness or guilt inappropriate to the
situation (possibly delusional)

238. 08/11/25 Psychnebppt. 239
REVIEW OF MAJOR SYMPTOMS
REVIEW OF MAJOR SYMPTOMS
OF DEPRESSIVE DISORDER
OF DEPRESSIVE DISORDER
 Difficulty thinking, focusing, or making decisions
 Hopelessness, helplessness and/or suicidal
ideation

239. 08/11/25 Psychnebppt. 240
TREATMENT MODALITIES FOR
TREATMENT MODALITIES FOR
DEPRESSIVE DISORDERS
DEPRESSIVE DISORDERS
 Electroconvulsive Therapy
 Psychopharmacology
– Cyclic antidepressants
– Monoamine oxidase inhibitors
– Selective serotonin reuptake inhibitors

240. 08/11/25 Psychnebppt. 241
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Provide for safety of the client and others
– The first priority is to determine if the client with
depression is suicidal
– If a client has suicidal ideation or hears voices
commanding him to commit suicide, measures to
provide a safe environment are necessary
– The nurse asks additional questions to determine the
lethality of the intent and plan
– Suicide precautions (removal of harmful items,
increased supervision) are instituted.

241. 08/11/25 Psychnebppt. 242
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Begin a therapeutic relationship by spending non-demanding
time with the client
– Clients may be unable to sustain a long interaction, so
several shorter visits help the nurse to asses status and to
establish a therapeutic relationship
– The nurse’s presence conveys genuine interest and caring.
Silence can convey that clients are worthwhile even if they
are not interacting.

242. 08/11/25 Psychnebppt. 243
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Promote completion of activities of daily living by
assisting the client only as necessary
– If a client cannot respond to the global request, the
nurse breaks the task into smaller segments.
Clients with depression can become overwhelmed
easily with a task that has several steps. The nurse
can use success in small, concrete steps as a basis
to increase self-esteem and to build competency
for a slightly more complex task the next time.

243. 08/11/25 Psychnebppt. 244
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Establish adequate nutrition and hydration
– The nurse can explain that beginning to eat will help
stimulate appetite
– Food offered frequently and in small amounts can
prevent overwhelming clients with a large meal that
they feel unable to eat
– Sitting up with clients during meals can promote
eating
– Monitoring food and fluid intake may be necessary
until clients are consuming adequate amounts

244. 08/11/25 Psychnebppt. 245
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Promote rest and sleep
– This may include the short-term use of sedatives or
giving medication in the evening if drowsiness or
sedation is a side-effect.
– It is also important to encourage clients to remain out
of bed and active during the day to facilitate sleeping
at night
– It is important to monitor the number of hours client
sleep as well as if they feel refreshed on awakening

245. 08/11/25 Psychnebppt. 246
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Encourage the client to verbalize and describe
emotions
– Clients with depression are often overwhelmed by
the intensity of their emotions
– Talking about these feelings can be beneficial.
– Initially, the nurse encourages the clients to
describe in detail how they are feeling
– Sharing the burden with another person can
provide some relief

246. 08/11/25 Psychnebppt. 247
NURSING INTERVENTIONS FOR
NURSING INTERVENTIONS FOR
DEPRESSION
DEPRESSION
 Work with the client to manage medications and
their side effects.

247. 08/11/25 Psychnebppt. 248
Psychiatric
Psychiatric
emergencies.
emergencies.
They include:
– Suicide.
– Delirium.
– Neuroleptic malignant syndrome.
– Violent/ assaultive behaviour.
– Acute withdrawal.
– Anxiety or panic behaviour.

248. 08/11/25 Psychnebppt. 249
SUICIDE
SUICIDE
 It is the intentional act of killing oneself
 It is the ultimate form of self-destruction
 It is a cry for help
 Women are more likely to overdose on medication

249. 08/11/25 Psychnebppt. 250
RISK FACTORS FOR
RISK FACTORS FOR
SUICIDE
SUICIDE
 Clients with psychiatric disorders who are at increased
risk for suicide include:
– Depression
– Bipolar disorder
– Schizophrenia
– Substance abuse
– Post-traumatic stress disorder
– Borderline personality disorder

250. 08/11/25 Psychnebppt. 251
RISK FACTORS FOR
RISK FACTORS FOR
SUICIDE
SUICIDE
 Environmental factors that increase suicide risk include:
– Isolation
– Recent Loss
– Lack of social support
– Unemployment
– Critical life events
– Family history of depression or suicide

251. 08/11/25 Psychnebppt. 252
RISK FACTORS FOR
RISK FACTORS FOR
SUICIDE
SUICIDE
 A history of suicide attempts increases risk for
suicide.
– The first two years after an attempt represent the
highest risk period, especially the first three
months.
 Those with a relative who committed suicide are at
increased risk for suicide: the closer the
relationship, the greater the risk

252. 08/11/25 Psychnebppt. 253
THEORETIC FOUNDATIONS OF
THEORETIC FOUNDATIONS OF
SUICIDE
SUICIDE
 Psychodynamic theories
– According to Freud is a “conflict between the
instinct for life and the instinct for death
– Suicide occurs when the wish for death
predominates.
– Others view suicide as an aggression intended for
others turned inward against the self

253. 08/11/25 Psychnebppt. 254
THEORETIC FOUNDATIONS
THEORETIC FOUNDATIONS
OF SUICIDE
OF SUICIDE
 Sociologic Theories
– The social and cultural contexts in which the
individual lives influence the expression of
suicidality. There are four types:
 Egoistic Suicide
 Anomic Suicide
 Fatalistic Suicide
 Altruistic Suicide

254. 08/11/25 Psychnebppt. 255
FAMILY CHARACTERISTIC OF
FAMILY CHARACTERISTIC OF
SUICIDAL PATIENTS
SUICIDAL PATIENTS
 Poor family history or tendencies
 Early trauma
 Rigid, disorganized or dysfunctional family
system
 Disturbed parent-child relationship
 Unresolved loss
 History of abuse

255. 08/11/25 Psychnebppt. 256
DEMOGRAPHIC VARIABLES
DEMOGRAPHIC VARIABLES
 Suicide rates are higher among the following:
– Single people
– Divorced, separated or widowed
– People who are confused about their sexual orientation
– People who have experienced a recent loss: divorce,
loss of job, loss of prestige, loss of social status or who
are facing the threat of criminal exposure
– Protestants or those who profess no religious affiliation

256. 08/11/25 Psychnebppt. 257
SUICIDAL IDEATION
SUICIDAL IDEATION
 Means thinking about killing oneself
 Active suicidal ideation is when a person thinks
about and seeks ways to commit suicide
 Passive suicidal ideation is when a person thinks
about wanting to die or wishes he or she were
dead but has no plans to cause his or her death

257. 08/11/25 Psychnebppt. 258
LETHALITY ASSESSMENT SCALE
LETHALITY ASSESSMENT SCALE
 A scale used in an attempt to predict the likelihood
of suicide

258. 08/11/25 Psychnebppt. 259
GUIDE QUESTIONS IN LETHALITY
GUIDE QUESTIONS IN LETHALITY
ASSESSMENT
ASSESSMENT
 Does the client have a plan? If so, what is it? Is the
plan specific?
 Are the means available to carry out this plan? (For
example, if the person plans to shoot himself, does
he have access to a gun and ammunition?)
 If the client carries out the plan, is it likely to be
lethal?

259. 08/11/25 Psychnebppt. 260
GUIDE QUESTIONS IN LETHALITY
GUIDE QUESTIONS IN LETHALITY
ASSESSMENT
ASSESSMENT
 Has the client made preparations for death such as
giving away prized possessions, writing a suicide
note, or talking to friends one last time?
 Where and when does the client intend to carry out
the plan?
 Is the intended time a special date or anniversary that
has meaning for the client?

260. 08/11/25 Psychnebppt. 261
WHAT IS THE PRIORITY
WHAT IS THE PRIORITY
NURSING DIAGNOSIS IN
NURSING DIAGNOSIS IN
SUICIDE
SUICIDE
 Risk for injury – Self directed

261. 08/11/25 Psychnebppt. 262
NURSING CARE FOR SUICIDAL
NURSING CARE FOR SUICIDAL
PATIENTS
PATIENTS
 Provide one-on-one monitoring
 Have frequent unscheduled rounds/visits.
 Avoid use of metals and glass utensils
 Monitor for the signs of impending suicide

262. 08/11/25 Psychnebppt. 263
MAJOR INTERVENTIONS FOR
MAJOR INTERVENTIONS FOR
SUICIDAL PATIENTS
SUICIDAL PATIENTS
 Prevention:
– Assist with somatic therapies.
– Assist with treatment of drug abuse.
– Help client promote self esteem.
 Listen:
– To patient’s embarrassments.
– Client’s choice of social support.
 Visit:
– www.scie.ca/helpcard.htm for more information.

263. Organic mental disorders
Organic mental disorders
nition:
ganic disorders represent a group of mental
orders that present a variety of symptoms,
pecially a disturbance of cognition.
es:
lirium
mnestic syndrome
mentia
zeimer’s disease

264. delirium
delirium
Delirium is a disturbance of consciousness and a
change in cognition that develop over a short
period of time characterized by clouding of
consciousness, restlessness, confusion, psychomotor
retardation or agitation, and affective labiality. It
has a rapid onset and a fluctuating, waxing and
waning course, and there is an associated
disturbance of sleep.

265. This condition is often accompanied by:
– Poor memory.
– Agitation.
– Emotional upset.
– Loss of orientation.
– Wandering attention.
– Auditory hallucinations such as hearing voices.
– Visual hallucinations.
– Withdrawal from others.
– Illusions.
– Disturbed sleep (reversal of sleep patterns).
– Autonomic features, for example, sweating, tachycardia.

266. Causes of delirium
Causes of delirium
Alcohol intoxication or withdrawal.
Drug intoxication, overdose or withdrawal.
Infection.
Metabolic changes, for example, liver disease,
dehydration, hypoglycaemia.
Head trauma.
Hypoxia.
Epilepsy.

267. Management of Delirium
Management of Delirium
avoid the use of sedatives or hypnotic medications, for
example, benzodiazepines, except for the treatment of
alcohol or sedative withdrawal.
 Antipsychotic medication e.g. haloperidol in low doses
may be needed to control agitation, psychotic symptoms
or aggression.
Drugs reported to cause delirium include:
– Anaesthetics
– Analgesics
– Antiasthmatic agents
– Anticonvulsants

268. – Antihistamines
– Antihypertensive and cardiovascular medications
– Psychotropic medications with anticholinergic side
effects.
– Antimicrobials
– Antiparkinsonian drugs
– Corticosteroids
– Gastrointestinal medications
– Muscle relaxants

269. Primary therapy;
Reversal of Suspected Aetiologies
Treatment of Agitated Behaviour - Antipsychotic
drugs e.g. Haloperidol can often quite successfully
manage the symptoms of delirium.
Other useful antipsychotic medications include
thiothixene (Navane) and droperidol (Inapsine)
If the delirium is caused by sedative-hypnotic drug
or alcohol withdrawal, the benzodiazepines e.g.
oxazepam, are the drugs of choice for treatment.

270. Supportive therapy;
Environmental interventions - Both nurses and
family members can frequently reorient the patient
to date and surroundings. It may help to place a
clock, calendar, and familiar objects in the room.
Adequate light in the room during the night may
decrease frightening illusions.
Psychosocial Interventions - A calm family
member should, if possible, remain with the
paranoid, agitated patient; this is reassuring and can
stop mishaps (e.g., patient's pulling out arterial lines,
falling out of bed). In lieu of a family member, close
supervision by reassuring nursing staff is essential.

271. Psychoeducation

272. AMNESTIC DISORDERS
AMNESTIC DISORDERS
amnesic disorders are a group of disorders that
involve loss of memories previously established,
loss of the ability to create new memories, or loss of
the ability to learn new information.
 The amnesic disorders are characterized by
problems with memory function. There is a range of
symptoms associated with the amnesic disorders, as
well as differences in the severity of symptoms

273. Causes and symptoms of amnesia
In general, amnesic disorders are caused by
structural or chemical damage to parts of the brain .
Problems remembering previously learned
information vary widely according to the location
and the severity of brain damage. The ability to
learn and remember new information, however, is
always affected in an amnesic disorder.

274. Amnesic disorder due to a general medical
condition can be caused by head trauma, tumors,
stroke , or Cerebrovascular disease.
Substance-induced amnesic disorder can be caused
by alcoholism, long-term heavy drug use, or
exposure to such toxins as lead, mercury, carbon
monoxide, and certain insecticides.
In cases of amnesic disorder caused by alcoholism,
it is thought that the root of the disorder is a vitamin
deficiency that is commonly associated with
alcoholism, known as Korsakoff's syndrome

275. Symptoms
Symptoms
In addition to problems with information recall and
the formation of new memories, people with
amnesic disorders are often disoriented with respect
to time and space, which means that they are unable
to tell an examiner where they are or what day of
the week it is.
Most patients with amnesic disorders lack insight
into their loss of memory, which means that they
will deny that there is anything wrong with their
memory in spite of evidence to the contrary.

276. Some persons with amnesic disorders undergo a
personality change; they may appear apathetic or
bland, as if the distinctive features of their
personality have been washed out of them.
Transient global amnesia (TGA) is characterized by
episodes during which the patient is unable to create
new memories or learn new information, and
sometimes is unable to recall past memories. The
episodes occur suddenly and are generally short.
Patients with TGA often appear confused or
bewildered

277. Treatments
There are no treatments that have been proved
effective in most cases of amnesic disorder
 Many patients recover slowly over time, and
sometimes recover memories that were formed
before the onset of the amnesic disorder.
 Patients generally recover from transient global
amnesia without treatment. In people judged to have
the signs that often lead to alcohol-induced
persisting amnesic disorder, treatment with thiamin
may stop the disorder from developing.

278. Prevention
Amnestic disorders resulting from trauma are
not generally considered preventable. Avoiding
exposure to environmental toxins, refraining
from abuse of alcohol or other substances, and
maintaining a balanced diet may help to prevent
some forms of amnesic disorders.

279. dementia
dementia
This is a slow deterioration in cognitive functioning,
causing multiple changes. This condition is common
in individuals of advanced age, that is, 65 years and
above and quite rare in youth or middle age.
Presenting complaints for this condition include:
– Patients may complain of forgetfulness, decline in mental
functioning or they may feel depressed but may be
unaware of the memory loss.
– Families may ask for help initially because of failing
memory, change in personality or behaviour and
disorientation.

280. – Changes in behaviour and functioning, for example,
poor personal hygiene or social integration.
– Decline in memory, thinking, judgment, orientation
and language.
– Being apathetic or disinterested.
– Decline in every day functioning, for example,
dressing, washing, cooking.


281. Mgt of dementia
Mgt of dementia
Therapeutic approaches include;
1. Pharmacologic
– Neuroleptics e.g. Haloperidol or Thioridazine, are
indicated for the treatment of specific target symptoms in
delusions, hallucinations, and severe aggression or
agitation
– Lithium may be effective when manic symptoms are
associated with agitation.
– Depressive symptoms may be managed by
antidepressant therapy (both pharmacological and
psychosocial) - TCAs, MAOIs, and ECT

282. – Buspirone, a non-benzodiazepine anxiolytic that is well
tolerated and effective in the treatment of anxiety
– Insomnia - Non-pharmacological management . Useful
medications include trazodone, temazepam, chloral
hydrate, and thioridazine.
2.Maintain optimum physical health e.g. Adequate diet,
treatment of anaemia and urinary obstruction
3. Psychotherapy as well as behaviour modification &
environmental manipulation

283. Senile Dementia
Senile Dementia
This is a disorder of unknown cause characterised
by severe impairment of intellectual functioning. If
it occurs before the age of 65 years it is called
Alzheimer's disease
Aetiology
– Genetics - 1° biological relatives of individuals With
Early Onset, are more likely to develop the disorder.
Late-onset cases have been shown to be inherited as a
dominant trait with linkage to several chromosomes,
including chromosomes 1, 14, 19 & 21

284. mgt
mgt
The treatment of dementia is directed towards the
elimination of the physical cause, however, there is
no specific treatment in the majority of cases.
Treatment may include continuous assessment for
cause of symptoms and treatment as indicated,
group and/or individual psychotherapy with focus
on the management of anxiety, loss, impairment,
impending death, reality orientation and changes in
lifestyle.

285. Non-pharmacological methods are often tried first in
dealing with difficult behaviour. Antipsychotic
medication in very low doses may be needed
occasionally to manage aggression or restlessness. If
possible avoid using sedatives or hypnotics, for
example, benzodiazepines. Aspirin in low doses may
be prescribed in vascular dementia in order to slow
deterioration.
Health education includes:
– Reduction of stress and introduction of healthy habits in
daily living.
– Acceptance of a spouse as they deteriorate.

286. – Involvement of the family to avoid anxiety-
provoking situations.
– Developing ways of combating disorientation,
for example, appointment calendars, clocks,
stable routines, set places for important items,
etc.

287. Substance-Related Disorders
Substance-Related Disorders
The Substance-Related Disorders include disorders
related to;
– taking of a drug of abuse (including alcohol)
– the side effects of a medication
– toxin exposure

288. The substances are grouped into 11 classes;
1. Alcohol
2. Sedative, hypnotic, or anxiolytic substances.
3. Cocaine
4. Amphetamine and related substances
5. Hallucinogen
6. Cannabis sativa
7. Phencyclidine (PCP) and related substances
8. Inhalant
9. Nicotine
10. Opioid
11. Caffeine

289. The Substance-Related Disorders are divided into
two groups:
1. Substance Use Disorders;
 Substance Dependence
 Substance Abuse
2. Substance-Induced Disorders;
 Substance Intoxication
 Substance Withdrawal
 Substance-Induced Delirium
 Substance-Induced Persisting Dementia

290.  Substance-Induced Persisting Amnesic Disorder
 Substance-Induced Psychotic Disorder
 Substance-Induced Mood Disorder
 Substance-Induced Anxiety Disorder
 Substance-Induced Sexual Dysfunction
 Substance-Induced Sleep Disorder

291. definitions
definitions
Drug: refers to any chemical agent that once taken
in the body is capable of causing physiological &
psychological changes
Psychoactive substance: a chemical compound that
produces emotional, cognitive or behavioural
changes which may be pleasurable or desirable to
the user, with adverse medical consequences
Abuse: is a pathological pattern of use where one
experiences loss of control & begins to suffer
health, social & occupational effects

292. Tolerance: the need for more of the drug in order to
achieve a similar effect realized b4 at a lower dose
Dependence: refers to compulsion to take the drug on
a continuous basis in order to feel its effects and to
further avoid the discomfort of its absence
Substance intoxication: the dvpt of a reversible
substance specific syndrome due to recent ingestion
of or exposure to a substance
Substance withdrawal: the dvpt of a substance
specific syndrome due to the cessation of or reduction
in substance use that has been heavy and prolonged.
The substance specific syndrome causes clinically
significant distress & impaired functioning

293. Impairment and Complications
Deterioration in general health. Malnutrition and
other general medical conditions may result from
improper diet and inadequate personal hygiene.
Trauma related to impaired motor coordination or
faulty judgment.
Stimulant use can result in sudden death from
cardiac arrhythmias, myocardial infarction, a
Cerebrovascular accident, or respiratory arrest.

294. The use of contaminated needles during
intravenous administration of substances can cause
HIV infection, hepatitis, tetanus, vasculitis,
septicaemia, sub acute bacterial endocarditis,
embolic phenomena, and malaria.
Violent or aggressive behaviour, which may be
manifested by fights or criminal activity, and can
result in injury to the person using the substance or
to others

295. Most of the substances can cross the placenta
barrier, they may have potential adverse effects on
the developing foetus (e.g., foetal alcohol
syndrome). When taken repeatedly in high doses by
the mother, a number of substances (e.g., cocaine,
opioids, alcohol, sedatives, hypnotics, and
anxiolytics) are capable of causing physiological
dependence in the foetus and a withdrawal
syndrome in the newborn.


296.  Substance use disorders are a group of mental disorders
manifested by impairments in social and occupational
functions, which are related to a regular use of specific
substances that are intended to alter mood or behaviour.
 Alcohol is one of the commonly used psychoactive
substance. Alcoholism affects 7.5-10 million people
worldwide, mainly those in early and middle adulthood.
Substance abuse is more common in men than in women

297. Presenting Complaints
Presenting Complaints
Patients may be depressed, nervous or exhibit signs
of insomnia.They may directly request a prescription
for narcotics or other drugs, request help to
withdraw, or help in stabilising their drug use.
They may present in a state of intoxication,
withdrawal or physical complications of drug use, for
example, abscess or thrombosis.
They may also present with social or legal
consequences of their drug use, for example, debt or
prosecution.
Occasionally, covert drug use may manifest itself as
bizarre, unexplained behaviour.

298. Signs of drug withdrawal include:
– Opioids lead to nausea, sweating, hallucinations.
– Sedatives lead to anxiety, tremors, hallucinations.
– Stimulants lead to depression, moodiness.

299. Diagnostic Features
Diagnostic Features
These include:
– Physical harm, for example, symptoms of mental
disorder due to drug use or a harmful social life leading
to loss of a job, severe family problems or criminality
– Habitual or harmful drug use.
– Difficulty in controlling drug use.
– High tolerance, for example, the individual can use large
amounts of drugs without appearing intoxicated.
– Withdrawal, for example, anxiety, tremors or other
withdrawal symptoms after stopping use.

300. The diagnosis will be aided by:
– Taking the patient's personal history (especially drug
use).
– Examination for needle tracts, complications, for
example, thrombosis or viral illness.
– Investigations for haemoglobin, Liver Function Tests
(LFTs), urine drug screen and hepatitis B and C.

301. Management
Management
If the patient is not willing to stop or change drug
use:
– Do not reject or blame the patient.
– Advise the patient on harm-reduction strategies, for
example, on the dangers of needle sharing by intravenous
drug users.
– Point out clearly the medical, psychological and social
problems associated with drug use.
– Make a future appointment to reassess health and discuss
drug use

302. If the patient is willing to reduce the drug uses but
not to quit completely:
– Negotiate a clear goal for decreased use, for example, not
more than one marijuana or cigarette per day.
– Discuss strategies to avoid or cope with high-risk
situations.
– Introduce self-monitoring procedures, for example, a
diary of drug use.
– Consider options for counselling and/or rehabilitation

303. If the patient opts to have a substitute drug:
– Negotiate a clear use of the prescribed substitute drug.
– Discuss ways of avoiding high risk situations, for
example social situations or stressful events.
– Consider withdrawal symptoms and how to avoid or
reduce them. Provide information and management of
methadone toxicity.
– Consider options for counseling and/or rehabilitation

304. For patients willing to stop drug use:
– Set a definite day to quit.
– Consider withdrawal symptoms and how to manage
them.
– Discuss strategies of avoiding or coping with high risk
situations.
– Make specific plans to avoid drug use, for example, how
to respond to friends who still use drugs.
– Identify family or friends who will support stopping drug
use.
– Consider options for counseling and/or rehabilitation

305. Alcohol Abuse
Alcohol Abuse
Alcohol misuse is another common substance abuse
problem. Patients may present with:
– Depressed mood.
– Nervousness.
– Insomnia.
– Physical complications of alcohol use, for example,
gastrointestinal ulceration, gastritis, liver disease,
and hypertension.
– Accidents or injuries due to alcohol use.
– Poor memory or concentration.
– Evidence of self-neglect.
– Poor compliance to management for depression.

306. The patient may also have experienced legal and social
problems due to alcohol use, for example, marital
problems, domestic violence, child abuse and neglect
or missed work. The individual may show signs of
alcohol withdrawal, which include sweating, tremors,
morning sickness, hallucinations and seizures.
Patients may sometimes deny or are unaware of
alcohol problems.
Family members may request help before the patient
does. The problem may also be identified during a
routine health promotion screening.


307. Diagnostic Features of
Diagnostic Features of
Alcohol Abuse
Alcohol Abuse
Harmful alcohol use refers to the consumption of
over 28 units per week for men and over 21 units
per week for women. This can result in physical
harm, for example, liver disease, gastrointestinal
bleeding, psychological harm, for instance,
depression or anxiety or social consequences, like
the loss of a job.

308. Alcohol dependence is said to be present when any
of the following factors are present:
– Strong desire or compulsion to use alcohol.
– Difficulty controlling alcohol use.
– Withdrawal symptoms, for example, anxiety, tremors,
sweating, when drinking is ceased.

309. Medication for Alcohol Abuse
Medication for Alcohol Abuse
For patients with mild withdrawal symptoms,
frequent monitoring, support, reassurance, adequate
hydration and nutrition are sufficient treatment
without medication.
Patients with moderate withdrawal syndrome will
also require benzodiazepines. Most can be
detoxified as outpatients or at home. Only
practitioners with appropriate training and
supervision should do community detoxification

310. Inpatient detoxification is indicated for:
– Patients at risk of complicated withdrawal syndrome, for
example, with a history of fits or delirium, tremors, very
heavy use and high tolerance.
– Significant polydrug use or severe morbid medical or
psychiatric disorder who lack social support or are
considered to have a significant suicide risk. In such
cases, chlordiazepoxide (librium) at 10mg is
recommended. The initial dose should be considered
against withdrawal symptoms within a range of 5-40mg
four times a day. This requires close and skilled
supervision.

311. The regimen opposite can be used although the dose
level and length of treatment will depend on the
severity of alcohol dependence and individual patient
factors, for example, weight, sex and liver function.
Treatment should be dispensed daily. involve a family
member to prevent the risk of misuse or overdose.
Thiamine (150mg per day in divided doses) should be
given orally for one month. Parenteral thiamine is
indicated for patients with ataxia, confusion, memory
disturbances, delirium tremens, hypothermia and
hypotension, ophthalmoplegia or unconsciousness

312. Daily rx
Daily rx
Day 1 and 2 20-30mg QDS
Day 3 and 4 15mg QDS
Day 5 10mg QDS
Day 6 10mg QDS
Day 7 10mg QDS

313. When depression concurs with alcohol misuse,
Selective Serotonin Re-uptake Inhibitors (SSRI)
may be used
Tricyclic antidepressants should be avoided because
of tricyclic-alcohol interactions. For anxiety,
benzodiazepines should be avoided because of high
potential for abuse

314. Mgt of substance related disorders
Mgt of substance related disorders
in general
in general
Goals:
1. Maximizing patients' motivation for abstinence -
These include lectures, counselling sessions, the
use of self-help groups, and videotapes to educate
the individual and his or her family about the
dangers involved with substance use and the usual
clinical course of substance use disorders, and to
emphasize that each person is responsible for his or
her own actions

315. 2. Teaching patients how to rebuild their lives after
redirecting the focus of their activities away from
the use of substances
- Important elements in developing a substance
-free lifestyle include helping the person to discover
ways of dealing with free time; to develop
friendships & independent of the context of drug
use

316. 08/11/25 Psychnebppt. 317
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