mental_health_4[1]......... portreiz-1.ppt

MENTAL HEALTH AND PSYCHIATRIC
NURSING
port reitz campus

Objectives
• Concepts and Principles of mental
health/Illness.
• Legal aspects of mental health.
• Common psychiatric disorders and Childhood
disorders.
• Treatment modalities
• Community mental health nursing

Content
• Concepts in psychiatry and mental health,
• legal aspects,
• common psychiatric disorders,
• community mental health nursing;
• Treatment modalities –
psychopharmacology,
 psychotherapy,
behaviour therapy,
 electro-convulsive therapy (ECT).

Concepts of Mental Health and
Mental Illness
• What is meant by the term ‘mental health’?
 Mental health is defined as the simultaneous
success at working, loving, and creating with the
capacity for mature and flexible resolution of
conflicts between instincts, conscience, other
people and reality (Evelyn and Wasili, 1986).
 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 (WHO)
 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

What do you understand by the term
‘mental illness’?
• A mental illness is defined as a disorder with
psychological or behavioral manifestations
and/or impairment of functioning due to a
social, psychological, genetic, physical,
chemical or biological disturbance (Evelyn and
Wasili, 1986).

Characteristics of a mentally ill person
 Prolonged lack of sleep, appetite, loss of interest and
feeling that life is not worthy living
 Shifting body pains and headaches, heaviness of the
head made worse by the stresses of daily living
 Inability to spend ones time , money and other
resources appropriately
 Inability to establish good interpersonal relationships
especially at family level
 Neglecting expected personal responsibility whether
social, personal or family
 Excessive intake of alcohol, drugs and other substances
that interfere with ones family and health (and society)
 Bizarre symptoms like talking to oneself, hearing
voices, confusion, and restlessness etc

Factors that contribute to assessment
of mentally ill person
1) Degree/severity of the symptoms or
condition
2) Compare the behaviour with the
circumstance that provoked it
3) The cultural differences
4) The risk factors for example crisis in the
family and those that could be precipitating,
predisposing or perpetuating the illness
5) History of mental illness in the family and
head injury or drug use or abuse

Psychiatric Nursing
The interaction between the nurse and a
patient that comprises or encompasses
knowledge and skillful application of concept
of behaviour, personality, the mind,
psychopathology and interpersonal skills with
an aim of helping the patient overcome his
mental health difficulties.
In the psychiatric field this challenge is more
interesting and greater than in any other field
and the role of the nurse is more necessary in
this field than in any other field as the patient
has great difficulties in identifying their own
needs or meeting them.

History of psychiatry and Psychiatric
Nursing
This branch of medicine originated from
philosophy and theology which are arts but
later evolved into a branch of medicine which
is a science.
The history is divided into four periods namely
a.Demonological
b.Political
c. Humanistic
d.Scientific

Demonological period (400BC)
The mentally sick person was said to be
possessed by evil spirits or demons. The mode
of treatment employed was beating, chaining
until blood comes out.
This was the era of Hippocrates the father of
modern medicine. The doctors later believed
that mental illness was caused by a rot in the
brain and the abnormal behaviour was as
result of a bad smell in the skull. To treat this,
a hole was drilled into the skull to allow the
smell to come out (Trephening). This caused
many deaths due to pain and infections.

Political period (14 AD)
• The first psychiatric hospital was opened
during this period in Britain ‘Mary of
Bethlehem’ with 6 beds and 4 psychiatric
patients. During this period several political
changes were taking place and in the 14th
century King Edwards II ordered 4 hospitals to
admit psychiatric patients and a law was
passed on admission of these patients.
Edward Tyson was appointed the first nurse
specifically to take care of the mentally ill.

cont
During this era those taking care of the
patients were to be strong muscular men who
were untrained and used to beat the patients.
They were called basket-men.
The cause of mental illness was still believed
to be evil spirits and the main treatment was
beating.
During this period patients were used to
entertain people in public. St. Luke’s hospital
in London stopped using patients to entertain
people in public and straw mats were used a
beds for these patients.

Humanistic period 18th century
• During this era patients were treated like human being
with dignity and rights. Phillipe Pinel of Bicaptre
Hospital in France mobilized release of patients from
chains some who had been chained for as long as 30
years.
• Reforms were occurring in France, Britain and America.
William Tuke introduced occupational therapy where
patients would assist by working in gardens as
rehabilitation.
• The House of Commons (Britain) passed a bill on care
of mentally sick persons in 1808 and in 1815 a
committee was appointed to prepare a report on
madhouses such as the York Asylum which had very
high windows and no light. This report revealed that
these houses were in terrible condition

cont
• In 1845, the lunacy commission was given
power to improve the conditions for mentally
ill patients
• In 1913 this commission was recognized as a
board to control the management of the
mentally sick persons.
• During this time several people made great
contribution to the growth of psychiatric
services these include:-

cont
• Gardener and Connolly
Gardener was the medical superintendent of the
Lincoln Hospital and Connolly was the
superintendent of Honwell hospital these two
and others opened the Royal Mental hospital
• Dorothea Lynd Dix
• She advocated for the improvement of the
conditions of psychiatric hospital and the
unchaining of these patients
• In 1841 a law was passed to govern the
treatment of mentally sick persons

Scientific Period
• Dr. W. A. Brown
• Here there was introduction of drugs,
investigations and training of psychiatric nurses.
Insulin therapy was started and hydrotherapy to
control fits and psychosurgery (leucotomy) were
started. (Leucotomy is nowadays abolished)
• Modern methods of treatment were introduced
and Largactil was introduced as the first
Psychotropic drug of choice in 1955, electro-
convulsive therapy and psychotherapy were also
introduced and professional organizations were
also begun.

cont
• Here there was introduction of drugs,
investigations and training of psychiatric nurses.
Insulin therapy was started and hydrotherapy to
control fits and psychosurgery (leucotomy) were
started. (Leucotomy is nowadays abolished)
• Modern methods of treatment were introduced
and Largactil was introduced as the first
Psychotropic drug of choice in 1955, electro-
convulsive therapy and psychotherapy were also
introduced and professional organizations were
also begun.
•

Development of Psychiatric Nursing
in Kenya
• Psychiatric services started in Kenya about
1910 and its development has been hindered
by various factors which include:-
a.Cultural beliefs
b.Lack of proper treatment
c. Politics of the day where the colonialists gave
little or no attitudes attention to these issues
d.The attitude of the people and other issues of
the day

cont
• Mathare Hospital was opened in 1910 as an
isolation centre for patients with small pox but
was later changed into a lunatic asylum in July
the same year.
• In 1924 it was later changed to become Mathare
National Hospital. The main management of
patients was custodial as there were no drugs.
Due to this reason the place was run as a prison
and the custodial staffs were called civil wardens
(under them was the Aya) and they had to be
strong and have athletic features
• The hospital had two divisions which are the
Bomas for the Africans and Asians and the Wards
for the Whites

cont
• In 1949 the Indian Lunacy Act was put in force
and this was later to be changed to become the
Mental treatment Ordinance
• The colonial government started training local
people who could take over from the white
nurses in 1960. The first group of Enrolled Mental
nurses entered training in 1961 and qualified in
1964 as Enrolled Nurses
• In 1962 Mental Treatment Ordinance was
reviewed to become the Mental Treatment Act
(1962) which was further reviewed to become
the Mental Health act in 1991 which is in use to
date.

cont
• During the same time 1961 registered nurses
were being trained abroad and in 1963 two
registered nurses and one doctor came to
Kenya from Britain
• In 1964 it was decided that these psychiatric
services should be decentralized in the
country and several units were started in the
provinces which include: - Machakos, Nakuru,
Nyeri, Port Reitz (Mombasa) and Kakamega
which were all opened in 1965
• In 1966 Gilgil was opened as an extension of
Mathare hospital

cont
• 1964 the training of psychiatric nursing was
stopped and basic training was introduced
until 1977 when the former resumed and the
basic was stopped.
• The post basic KRPN program was started in
1979 1st May and in 1982 a Masters degree in
Psychiatry was started locally for the Doctors

cont
• In the 1980s the mental health aspect was
introduced to most health-workers and
community psychiatry was introduced with
Mathare having a centre at Kariobangi. Other
units were also opened countrywide to
include Eldoret, Kisumu, Kisii, Meru and Isiolo
• The Division of mental health was began in
1987 and is headed by a director and in 1989
amendments were done to the mental
treatment act which were implemented in
1991 as the Mental Health act (1991)

Principles of Psychiatric Nursing
• Self understanding
One should have an understanding of his or her own
attitude towards certain characteristics or behaviours
• Non judgmental attitude
Accepting the patient as he or she is without being
judgmental because the offensive behaviours that may
be displayed by the patient are due to sickness.
• Empathy
Putting oneself in the patient’s/client’s situation and
finding a possible solution
• Basic understanding of human needs
The Nurse should have basic understanding of human
needs and how to meet these needs (Maslow’s
Hierarchy of needs)

cont
• Assisting patient to solve their problems
This is done by being a good listener and identifying the patient’s
problem and identifying the effects of the problem on the
patient. Identify other problems in the past and the options
the patient has to deal with the problem.
• Focusing on the client’s strengths
The nurse should view the client as a person able to function
and perform activities independently and not a helpless
person. Identify these strengths and help the patient utilize
them.
• Establishing a relationship with the patient
The nurse should establish a relationship with the client/patient
and interact with them to create a therapeutic relationship
aimed at solving the patient’s problem.
• Assisting the client adapt
Assisting the client to adapt to stressors and how to deal with
situations realistically this is because stressors will always be
there.

cont
• Provide a quiet structural environment
Separate the patients according to such issues
as violence, noise etc and avoid arguing with
the patient or agreeing with his delusions or
hallucinations (respond by saying neither Yes
nor No e.g. okay)
The physical environment should not be
provocative and the nurse should not use
abstract ideas but concrete ones.

Mental Health Act (CAP 248 of 1989)
Legal aspects of admitting, managing and
discharging a mentally ill person
• This came into force in 1991 to replace the
Mental Treatment Act 1971 which had the
following shortcomings
Admission was very difficult and tedious
It did not provide for OPD treatment
Tended to criminalize the mentally ill e.g. they
had to go through the court
Created stigma by having patient travel to far
hospitals whereas there were nearby
hospitals

cont
• The Mental health act is an act of parliament
that consolidates and amends the laws
relating to ;
The care of persons suffering from mental
disorder or mental abnormality;
The custody of the persons and the
management of their estate;
For the management and control of mental
hospitals and for connected purposes

The act provides for;
1. The establishment of the Kenya board of Mental Health which has
the following functions
a. Coordination of mental health care activities in
Kenya
b. Advice the government on the state of mental
health and mental health care facilities in Kenya
c. Approve the establishment of mental hospitals
d. Inspect mental hospitals to ensure they meet the
prescribed standards
e. To assist wherever necessary in the administration
of any mental hospital
f. To receive and investigate any matter referred to it
a patient or relative of a patient concerning the
treatment of a patient in a psychiatric hospital and
where necessary take, or recommend to the
minister any remedial action

cont
g. To advice the government on the care of persons
suffering from mental abnormality without mental
disorder
h. Initiate and organize community or family based
programmes for the care of persons suffering from
mental disorders; and
i. Perform such other functions as may be conferred
upon it by or under this act or under written law
j. Creation of District mental health council to carry
out the activities of the board and district level
k. Establishment of public and private mental hospitals

Kenya mental health board
• Chairman who is the D.M.S
• One medical practitioner (Psychiatrist)
• One nurse train in mental health
• Commissioner for social service or his/her nominee
• Director of education or his/her nominee
• Representative from each province
NB
• Appointed by minister and serve at the ministers ple
asure for three years and can be re-appointed

cont
2. Admission, discharge and transfer of mentally ill persons
as either voluntary, involuntary, emergency, members
of the armed forces, foreigners, judicial powers of
persons and estates of persons suffering from mental
illness and the examination of female patients
3. General provisions on;
 how letters of patients should be handled
 power to refuse admitting of a patient into a mental
hospital
 protection of person carrying out his or her duty (ies)
under the act
 Insurance for treatment of persons suffering from
mental illness

cont
This act also has the following implications ;
The community participation and community
mental health care
Other mental health workers are allowed to
recommend for admission of involuntary
patients
There will be mental hospitals in the prisons
It will make admissions easier

Admission of a psychiatric patient
• Voluntary mode of admission (Sec 10)
• Over 16 years
• Any person above the age 16 years who
submits himself for mental treatment may be
received as a voluntary patient by making a
written application to the person in charge of
the unit by filling form MOH 613

Under 16 years
• Any person under the age of 16 years can be admitted
if the relative or the guardian desires to submit such a
person for mental treatment by applying an
application to the person in charge of the unit/ward by
filling form MOH 637
• After this admission, the patient shall be reviewed
within 72 hours for the purpose of making a decision
on the management or discharge under sec 11
• This patient may request discharge or leave the
hospital by giving a written 72 hour notice to the in-
charge of the hospital but the release shall be at the
discretion of the in charge. If this patient loses his
ability to express himself on being willing to continue
treatment he should not be detained for more than 42
days but should be released before this.

cont
• If he regains his ability to express himself, the
person in charge may determine whether
continuation of this patient is beneficial. The
patient may therefore be detained until he
becomes alright and then discharged.
• If he has not regained ability to express
himself, he can be changed to involuntary
patient and this is done by the board

Involuntary mode (Sec 14)
• This is indicated for a patient who is incapable
of expressing himself as willing or unwilling to
receive admission and or treatment
• Here the patient is brought to the hospital by
relatives without his consent because the
nature of illness may cause the patient to lack
insight. They are required to fill form MOH
614 in triplicate requesting for the admission
of their relative in the ward and subsequent
treatment.

cont
• The doctor assesses the patient and makes
recommendation by filling form MOH 615 (in
the absence of a doctor the nurse in charge or
a clinical officer can fill this form if they have
specialized in psychiatry. The patient is
admitted with these two forms as an
involuntary patient. The recommendation
(MOH 615) expires after 14 days if not used
• This patient can stay in the ward for a period
of not more than six months but it can be
extended if need arises

Emergency mode (Sec 16)
• This patient is in the community and the
relatives are not available or they have
neglected or mistreated him. Here the patient
is admitted after being brought to the hospital
by a police officer of the rank of an inspector
and above or an administrative officer such as
chief or sub-chief may take such a person if he
is in his jurisdiction within 24 hours or within a
reasonable time. The patient is deemed to be
dangerous to himself and others therefore he
is brought to the hospital.

cont
• The officer fills form MOH 638 to apply for the
admission and the patient is admitted in the
ward for 72 hours during which assessment is
done and the necessary arrangements for
treatment and care are made. After this the
patient is either discharged home or
arrangements are made to detain him as an
involuntary patient

Admission of armed forces officer (Sec 17)
• This provides for the admission of members of
the armed forces and for observation and
treatment.
• A medical officer with armed forces writes a
letter confirming that he has observed the said
person and examined him within a period of 48
hours before issuing the letter indicating why the
person should be admitted.
• The person is admitted for a maximum of 28 days
but the period can be extended by a further 28
days after the patient is examined by 2 medical
practitioners one being a psychiatrist

cont
• If a member falls sick away from the station
(forces) he is admitted in the mental hospital
and the person in-charge will inform the
nearest armed forces office through an
administrative officer or a gazetted police
officer (inspector and above)
• If he is no longer in the armed forces the in-
charge is informed and he is handled as an
involuntary patient

Admission of foreigners (Sec 18)
• This provides for the admission of foreigners who
don’t normally reside in Kenya
• The government of that country shall apply to the
board and on receipt of the application the board
will approve or reject the application.
• When approval is granted the foreign
government will provide documents authorizing
the removal of the patient from a foreign country
and detention in the country (Kenya). These
documents and the board’s approval provide for
the admission of the patient

cont
• The patient is examined within 72 hours and a
report sent to the board. The patient may be
admitted for a maximum of 2 months but the
board can approve the extension of the
period on the application of the person in-
charge
• A foreigner who is resident in Kenya or on
transit and falls sick is admitted under section
16 and the director is notified and also the
relatives of the patient within 7 days

cont
• Magistrates order;
Observation orders;
Person is sent to hospital for observation
without treatment. Just to be examined
Certified patient;
In case a patient is examined by a doctor under
the magistrate and certifies that the person is
ill

Discharges and transfers
• This is done as provided for in the specific
modes of admission
• Sec 15 gives the board authority to discharge
a patient admitted either as voluntary or
involuntary
• Sec 21 Empowers the in-charge of a mental
hospital to discharge any patient admitted in
this hospital under this act. That person shall
be discharged having recovered from mental
illness and can have his civil rights restored.
(The power to manage his property or affairs
and make legally binding decisions)

cont
• Sec 72 it provides that the patient can be discharged to
the care of relatives or friend, if these relatives or
friends make an application. However before the in-
charge carries out this application he will consult either
the board or the district mental health council and the
applicant should be informed the terms and conditions
of the discharge e.g. he should return the patient if he
is unable or unwilling to take care of the patient
• Sec 17 This is specific to members of the armed forces.
The in-charge can discharge the patient if he receives a
letter signed by two medical practitioners of whom
one must be a psychiatrist.
• Sec 23 Deals with transfers and gives power to the
Director of medical services to transfer any patient
admitted in a government hospital from one hospital
to another.

cont
• Sec 45 Deals with persons who escape from a
mental hospital and provides that a police
officer, an employee of a mental hospital or
any other person authorized by the in-charge
of a mental hospital can apprehend and
return to the hospital any patient who
escapes from the hospital.
• Sec 12 Deals with death of a patient admitted
as a voluntary patient within the ward shall be
reported to the district mental health council
by the person in-charge

Offences under this act
i. Making or writing a certificate that is not
true
ii. Assisting willfully a patient to escape
iii. Allowing a patient to escape through
negligence or conniving
iv. Mistreating, abusing, beating or neglecting a
patient
v. Giving, selling, bartering any article or
commodity to any patient without the
consent of the in-charge

NB
• Any person guilty of an offence under this act
or who contravenes the provisions of this act
or any regulations under this act shall where
no other penalty is expressly provided, be
liable to on conviction to a fine not exceeding
Kshs. 10, 000 or imprisonment for a period
not exceeding 12 months or both

Admission of criminal patients in the
psychiatric hospital
• The patients come from the courts or prisons
under the Criminal Procedure Code (Cap 75
Aug 1930 revised 1968 under sec 280)
• There are three categories of admissions
Remand prisoner
Special category criminal
Convict criminal who can be on ;
-life imprisonment or
-Death sentence (condemned)

Remand prisoner
• This is a patient who has committed a capital
offence and during the court proceedings the
person is noted to be of unsound mind. The
court asks for the help of a consultant
psychiatrist to examine the person and the
court sends the person to the mental hospital
under Sec 162(1)

cont
• The doctor writes a report back to the court
and if the person is mentally ill the report is
sent to the attorney general and to the
minister of home affairs and the minister
writes a removal order and warrant (in
triplicate) authorizing the removal of the
person to a mental hospital for examination
and treatment

cont
• He comes with the original file of court
proceedings showing the crime he committed
and how far the court proceedings have gone
• At the admission centre the clerk opens three
(3) files and files the Med 380. One file is kept
under custody, one file goes to the ward third
is kept in records for forensic psychiatry
purposes
• Med 380 is filled with the name of patient,
crime committed, the court and magistrate
who ordered the examination, home of the
patient etc.

cont
• Patient is admitted in the maximum security
unit (M.S.U.) at Mathari hospital
• Patient is first observed but if is very sick he is
started on treatment
• The doctor writes a report every 6 months
and if the patient has recovered, the doctor
can recommend that he stands trial. The
doctor fills the certificate of capability to
stand defence in six (6) copies to Attorney
General, Court, Prisons, Home affairs,
Commissioner of prisons and patient’s file.

cont
• The minister for home affairs will then write a
letter of removal from the hospital to the
prisons
• The doctor should know the date the patient
appears in court and should go and give
evidence. If the crime is minor the doctor can
argue for the release of the patient

Special category criminal
• This is a person found guilty but insane. He must
have followed the remand procedure
• The court requests the attorney general to
communicate to the permanent secretary in the
office of the president to ask the president allow the
patient be admitted at the M.S.U. (Mathari Hospital)
as a special category criminal under Sec 166
• After admission the report is sent to the office of the
president after 6 months
• The patient is at the presidential mercy and when he
recovers, the president can decide to pardon him or
remand him

cont
• If he is discharged and relapses within one
year he is taken back to M.S.U. and if the
relatives are not willing to accept him at
home, he is retained in M.S.U.
• This section provides for the establishment of
the special category criminal board that is
mandated by the president to perform these
tasks on his behalf and to advice him on the
same. (Search for Macnaughton’s law)

Condemned prisoner
• They are normally admitted in the MSU and
put on treatment and when they recover they
are taken back to prison.

Aetiology of Mental Illness
• The knowledge of causes of mental illness is
important because it helps the clinician
evaluate the possible causes of the patient’s
illness and helps to understand the disorder
and therefore the management and
prognosis. These causes are grouped into
three
a.Predisposing causes
b.Precipitating causes
c. Perpetuating causes

Predisposing causes
• These are those issues that make the
individual susceptible or vulnerable to a
certain condition. These occur early in life for
example genetics endowment, pre-natal
environment, traumatic delivery, experiences
at birth or childhood etc.

Precipitating causes
• This is what triggers the mental illness or
events that occur shortly before the onset of
the illness and appear to be what provokes it.
They could be physical, psychological or social.
Such issues as drugs, tumours, injuries are
physical causes while bereavement is
psychological, and moving a house, divorce
etc social.

Perpetuating factors
• After the disorder has begun there may be
factors that prolong it. This may include
aspects of the disease or factors that are in
the environment and the knowledge of these
factors is important because it helps to
determine the prognosis of the disease. In
contrast to the predisposing and the
precipitating factors the perpetuating factors
can be modified.

Genetic factors
• The normal human being has 23 pairs of
chromosomes and the 1st 22 pairs are called
autosomes and the last pair is the sex
chromosome. Chromosomal anomalies have
been identified as cause of a number of
conditions e.g. colour blindness, mongolism
(extra chromosome)
• Studies have pointed at genetic causation of
mental illness with children of parents
suffering such illness as schizophrenia and
mood disorders showing higher risk than the
general population

Constitutional factors
• This is the biological make-up resulting either
from the genetic endowment or
environmental factors. These are such factors
such as body build. Dr. Ktrestchmer a German
psychologist in 1921 identified three types of
body build and the type of mental illness one
was likely to suffer. These are;-

1.Pyknic type
• This has the following features –
Rounded contours
Full round
Moon faces
Short necks
Short limb shave a tendency to stoutness

2.Asthenic type
• Thin
• Narrow chest cavity
• Slender
• Tall
• Lean
• Long neck
• Prominent Adam’s apple
NB - If they develop illness it is likely to be
schizophrenia

3.Athletic type
• Well structured bones
• Well developed muscles which are prominent
• They are likely to develop into sociopaths and
become law-breakers

4.Personality factors
• Personality is the individual’s unique and
relatively stable patterns of behaviour
thoughts and feeling or
• The sum total of ones behaviour and his
physical or mental uniqueness. Several
personality types have been associated with
mental illness

5.Cyclothymic
• These are extroverts (outspoken), playful,
social and they may change their
temperaments to become suddenly very sad.
If they become ill they are likely to develop
MDP. (Pyknic types of people commonly have
this type of personality)

6.Schizoid
• These are introverts (loners) reserved, keep
their things to themselves, difficult to
establish friendship, engaged in day-dreaming
and withdrawn.
• If they develop mental illness it is likely to be
schizophrenia (people with asthenic
personality are more in this personality type)
• Hysterical
• These are attention seekers and tend to
dramatize issues. They exaggerate.
• They are more likely to develop hysteria
(conversion disorders)

7.Obsessive (Anankastic)
• Orderly, very clean, meticulous, rigid,
perfectionist and very particular
• These may develop a psychosomatic disorder
as they overburden themselves until their
bodies are affected. They are also likely to
develop obsessive compulsive neurosis

Organic factors
• This may be as a result of anatomical or
physiological disturbances or disorders and
problems of the central nervous system.
These could include such factors as;-
Head injuries
Dietary insufficiencies e.g. vit B
Intoxication with drugs, alcohol, carbon
monoxide, lead poisoning etc
Infections e.g. syphilis, meningitis,

Psychosocial factors
• Any factor in the environment that can affect
the individual psychologically leading to
abnormal behaviour these may include
Childhood trauma through the child’s
interaction with the environment
Upbringing if there is faulty experiences
during upbringing the result in
maladjustment. This can arise due to
deprivation, overprotection etc
Stress at any age that may arise due to lost
status; failing may cause one to be depressed

Critical periods in life
• There are some stages in life that are critical
in the study of causation of mental illness.
• Adolescence: during this stage there is
struggle for independence
• Marriage and parenthood: extra
responsibility, more attention is required and
financial burden is heavy. Women find
pregnancy and other marital responsibilities
stressful
• Middle age: during this stage there is a midlife
crisis with men at 50 and women at 40.

cont
• Women reach menopause. If they (both men
and women have not accomplished some
goals they feel useless and become lonely.
Some men remarry.
• Old age: this is critical because most people
decline both physically, psychologically and
mentally, financial problems may also bring
insecurity. Retirement also is stressful.

Socio-cultural factors
• Stress can arise due to socio-cultural aspects
of the community which lead to conflicts
leading to maladjustment and anxiety e.g.
female circumcision etc.

Etiological factors contributing to M.I
Biological Physiological factors Social
factors
Factors
i. Hereditary
ii. Disturbance
in
neurotransmi
tters
iii. Brain damage
iv. Physiological
changes
v. Physical
illness
i. Strained IP
relationship
ii. Stress and
Frustration
iii. Pathological
personalities
iv. Childhood
insecurities
i. Poverty
ii. Alcoholism
iii. Urbanization
iv. Family instability
v. Unemployment
Mental
illness

Mental Status Assessment
• This should start immediately a patient walks i
n and the nurse or the clinician should be able
to make several observations as the patient w
alks in. it should be a systematic documentati
on of the quality of mental functioning at the t
ime of interview.

cont
• General appearance
This will include such issues that can be
observed with the eye such as mode of
dressing (whether appropriate for age and
sex), general hygiene whether kempt or
unkempt
• Facial expression whether blank, agitated, smi
ling etc

• Mood
Whether elevated, depressed, euphoric, normal
and whether it is congruent to what the
patient is talking about
• Speech
The pitch, tone, speed, whether mutes, whether
patient has confabulations, monosyllabic and
other observations on speech that may be
made
cont

cont
• Thought content
Check for any preoccupations and obsessions,
suspicions, déjà vu(A false sense of familiarity
with unfamiliar scenes) experiences,
depersonalizations(an alteration in the
perception of self,so that the feeling of ones
reality is temporarily changed or lost),

cont
• Delusions (a false ,unshakable belief which is
not amenable to reasoning, and is not in keepi
ng with the pts socio-cultural and educational
background) (these should be characterized w
hether persecutory, of grandeur, of reference,
of influence, unsystematized, worthlessness e
tc)

cont
• Thought process
The patient’s stream of thought whether it
makes sense and this is observed by listening
to the patient. Flight of ideas, loosening of
association (Tangentiality, or derailment
where thoughts are unrelated but the patient
seems unaware of it) the patient could also
experience thought block, preservation
(needless repetition of the same thought or
word)

cont
• Concentration
This is assessed by evaluating whether the
patient is following the interview process
coherently with concentration. This helps you
determine whether it is possible to assess the
higher mental functions which can not be
assessed if the patient has a problem
concentrating and attending to conversation.

cont
• A test for digital recall can be done by telling t
he patient to repeat a series of numbers, if th
e patient can repeat seven numbers then he h
as a normal concentration. A method of subtr
acting e.g. 100 – 7 =, then minus 7, then minu
s 7 etc can also be employed to patients who c
an count.

cont
• Memory
This can be divided into three being the remote
memory, more than one (1) year ago, Recent,
within the last 24 hours and immediate which
is retention and recall at that particular time
(loss of the immediate and recent memory
suggests organic disorder)
• Note that patients with a dissociative disorder
can display loss of memory but over specific ar
eas and with no other key signs of psychotic fe
atures

cont
• Orientation
Normally an individual should display
orientations in time, place and person. They
should also be orientated of their situation
why they are where they are. Patients with
organic syndromes are usually very
disorientated while patients with temporally
stressful may show some minor disturbances
in their orientation.

cont
• Perception
Are there any misperceptions, illusions (a
perceptual disturbance, a false perception of a
real external stimuli, e.g. a rope for a snake)
(Common in delirium) or hallucinations (a
perception in any of the senses in the absence
of a specific stimulus)?

cont
• The hallucinations should be described wheth
er auditory (more common in schizophrenia),
Visual (more common in organic conditions), t
actile (common in alcohol and sedative-hypno
tic withdrawal states or they could be olfactor
y. Patients will usually volunteer this informati
on but if not they should be asked in a friendly
non-judgmental manner.

cont
• Judgment
This is an estimate of the patient’s problem
solving skills and is difficult to make. It is
normally poor in children and it helps to show
the patient’s ability to function
independently. In patients with delirium,
dementia, psychosis and mental retardation it
is often impaired.

cont
• Abstract Reasoning
This is the patient’s ability to see differences
and similarities in abstract concepts or
understand their meanings for example
proverbs, colour concepts, shape etc. While
assessing this it is important to consider the
intelligence of the patient. Patients with
psychosis will present with concrete
reasoning.

cont
• Insight
This is the patient’s awareness of his or her
illness or unusual thought pattern. Patients
with schizophrenia will be lacking in insight
even when the illness is obvious to others.

Classification of Mental Disorders
There are two major classifications of mental
Disorders used internationally.
These are:
a. International Classification of Diseases (ICD)
b. Diagnostic and Statistical Manual (DSM)

cont
• The ICD is the WHO system of classification, c
urrently in its 10th edition, commonly referre
d to as ICD 10. The DSM classification is the A
merican Psychiatric Association system, curre
ntly in the 4th edition and commonly referred
to as DSM IV.
• For our learning purposes here, will use the W
HO classification.

ICD10 is classified in the following manner.
F0 Organic, including symptomatic mental disorders
F1 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.
F7 Mental retardation.
F8 Disorders of psychological development.
F9 Behavioural and emotional disorders with onset usually occurring in
childhood or adolescence.

TREATMENT USED IN THE MANAGEMENT OF
MENTALLY ILL PERSONS
Introduction
• Several types of treatments have been used in psychi
atry in the various eras of the growth of psychiatry. I
n the demonological age, patients were put in water,
beaten, chained and exorcism was done.
• In the 18th century the patients were treated as hum
an beings and they were allowed recreation, gardeni
ng and sewing. Later hydrotherapy was introduced a
nd treatment with water and special dietical and me
dicinal herbs

cont
• In the scientific period, several other forms of
treatment were introduced ranging from the i
ntroduction of free association by Sigmund Fr
eud, insulin therapy, electro convulsive therap
y, treatment for malaria and narcosis (state of
unconsciousness induced using narcotic drugs.

cont
• There are various types of drugs and other physical t
reatments used to treat patients suffering from ment
al health illness.
• These can be grouped together under the following c
ategories:
1. Antipsychotic Medication (Neuroleptics)
2. Antidepressant
3. Anxiolytics or Anti-anxiety Drugs
4. Antiparkinsonian Drugs
5. Electroconvulsive Therapy (ECT)
6. Psychotherapy

Drug treatment in psychiatry
• No drug adminstered without Dr written order
• All medication must be documented appropria
tely
• During medication;
Do not leave the pt till he swallows the drug
Do not permit the pt to take drugs in the bathr
oom
Do not allow pt to carry drugs to another
Always address the pt by name and make sure

cont
• Do not leave the tray alone with pts or take th
e tray to disturbed or delirious pts
• Do not force oral medications – dangers for as
piration

Anti-psychotic Medication
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
Flupenthixol Depixol 6-18mg
Trifluoperazine Stelazine 5-30mg
Zuclopenthixol Clopixol 20-150mg

cont
Generic Name Trade Name Daily Doses (range)
Depot Injections
Fluphenazine decanoate Modecate 12.5- 100mg(IM 2 Weekly)
Haloperidol decanoate Haldol decanoate 50-300mg (IM 4 weekly)
Zuclopenthixol Acetate Clopixol Acuphase 50-150mg every 2-3 days

Mechanisms of Action
• The drugs are thought to work by blocking do
pamine receptors in the brain (limbic system)
causing a decrease in psychotic symptoms.
• The drug is metabolised in the liver and excre
ted by the kidneys.
• For one to get the desired effects, one must m
aintain the patient on the lowest dose possibl
e and initial therapy should be on divided dos
es so that the patient can be monitored.

For acutely psychotic patients:
• Give intramuscular haloperidol, for example, 5mg ev
ery 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 withh
old if the systolic blood pressure is 90mm Hg or belo
w.
 Sleep state should be monitored to ensure six to sev
en hours of sleep.
 Dystonia (muscle rigidity that affects the gait,posture
,eye movement) occurring 1 hour to 48 hours after st
arting treatment should be treated with an antiparki
nsonism drug.

cont
• To decrease the danger to the patient themsel
ves and others, the patient needs to be monit
ored for possible adverse reactions to the me
dication.
Drugs should be given using the following time
frame:
Six months for first psychotic episode.
One year period for second psychotic episode.
Indefinite period for third and later
psychotic episodes.

The drug should be discontinued through
tapering the dosage to avoid dyskinesia.
Gertrude and MacFarland (1986) have identified
the following expected responses to the
treatment:
Initially the patient is drowsy and cooperative
within hours to a week.
The patient becomes more sociable and less
withdrawn for the next two months.
The thought disorder generally disappears in s
ix weeks or more.

cont
Improvement is generally noted in hallucinati
ons, acute delusions, sleeping habits, appetite
, tension, combativeness, hostility, negativism
and personal grooming.

Side Effects
• These include drowsiness and orthostatic hyp
otension, especially after i.m injections.
• Extra pyramidal symptoms (EPS) like:
I. Dystonia, that is, spasms of muscles of face, n
eck, back, eye, arms and legs.
II.Oculogyric crisis, presenting as fixed upward g
aze from spasm of oculomotor muscles.
III.Torticollis i.e. pulling of the head to the side fr
om spasm of cervical muscles.
IV.Opisthotonus i.e. hyperextension of the back
from spasm of back muscles.

cont
• Akathisia or continuous motor restlessness.
• Akinesia or lack of body movement especially
arms.
• Pseudoparkinsonism, which presents with a sh
uffling gait, mask-like facial expression, tremo
r, rigidity and akinesia.
• Tardive dyskinesia, that is, a wormlike movem
ent of the tongue, frequent blinking, and invol
untary movement of tongue, lips and jaw.

cont
• convulsive seizures or allergic or toxic effects (
some of which are rare and serious).
These include:
Aggranulosis
Oral monoliasis
Dermatitis
Jaundice
• Endocrine or metabolic effects like weight gai
n or decreased libido, impotence, impaired eja
culation in males.

cont
• Adjusting the dosage of antipsychotic drugs, a
nd giving antiparkinsonian drugs can often be
quite effective in treating side effects.

Contraindications
• Comatose,
• Glaucoma,
• Prosthetic hyperplasic,
• Acute myocardial infarction (Gertrude and Mc
Farland, 1986).

ANTIDEPRESSANTS
• These drugs are used to treat affective disorde
rs.
Mechanisms of Action
• They act by increasing epinephrine and seroto
nin in the brain. Both of them are metabolised
in the liver and excreted in the urine.

Examples of antidepressant drugs.
s/
no
Major Groups Generic Name Trade Name Daily Dosage
(range)
1 Tricyclic antidepressants Amitriptyline Elavil (laroxyl) 100- 300mg
Imipramine Tofranil 100-300mg
2 Tetra cyclic antidepressants Maprotiline Ludiomil 75-300mg
3 Monoamine
Oxidase Inhibitors
Isocarboxacid Marplan 10-60mg
Phenelzine Nardil 45-90mg
4 Selective Serotonin
Reuptake Inhibitors
Fluoxetine Prozac 20mg
Citalopram Cipramil 20-60mg
Paroxetine Seroxat 10-50mg

cont
For the drugs to be effective:
a)Dosage may be divided, but the total dose can
be given at bed time due to the sedative effec
ts.
b)Minimum dose should be given then increase
d gradually.
c)5 to 21 days must be allowed before any moo
d change is observed.
d) Four to six weeks must be allowed to pass for
therapeutic effects to be observed.

cont
• Medication needs to be continued for 6 mont
hs after patient is free from depression.

Side Effects
Tricyclics
Allergic reactions manifested as skin rash and j
aundice.
Tachycardia.
Tremors.
Long term treatment may depress bone marro
w, predispose to sore throat and aching, and f
ever.

Monoamine oxidase inhibitors include:
• Liver damage that is rare but fatal.
• Precipitation of manic episodes.
• Hypertension crisis characterised by severe he
adache palpitation, neck stiffness, nausea, vo
miting, increased Bp, chest pain and collapse.
It occurs 30 minutes to 24 hours after eating f
ood containing tyramine. These foods include
cheese, wine, beer, sour cream, liver, chocolat
e, bananas, avocadoes, soy sauce, and beans

cont
• The main form of treatment when side effects
occur is to discontinue the drug and then give
regitine (phentolamine ) to lower the blood pr
essure.
• Contraindications
1.Glaucoma,
2.Agitated states, urinary retention, cardiac
3.Disorders and seizure disorders.

Anxiolytics or Anti-anxiety Drugs
• These drugs, when given to a patient having g
eneralised anxiety disorder, are able to provid
e relief.
• They are mainly recommended for acute anxie
ty states, which may present with palpitations
, sweating, trembling, shortness of breath, che
st pain, nausea, dizziness, a feeling of unrealit
y, fear of losing control or dying, chills or num
bness.
• These drugs alley anxiety when given in low d
oses but they induce drowsiness and sleep wh
en give in large doses.

Benzodiazepines
• These are anxiolytics in low doses but hypnotics in la
rge doses
• They are also muscle relaxants and anticonvulsants
• Can be very short, short acting or long acting
• Examples are Diazepam (Valium) 5-30 mg per day in
divided doses can be given in psychiatric settings as 3
0 mg IV start to induce sleep
• Lorazepam IV/IM 3-10 mg per day in divided doses
• Oxazepam 15 – 120 mg po (short acting)
• Chlorodiazepoxide (Long acting)
• Nitrazepam (Long acting)
• Midazolam (very shorting)

Mechanism of action
• Benzodiazepines combine to specific sites on t
he GABA receptors & increase GABA levels
• GABA is an inhibitory neurotransmitter, it has
a calming effect on the CNS, thus reducing anx
iety .

Side effects
• Tolerance
• Drowsiness
• Ataxia
• Dependence
• Occasionally confused thinking
• Aggression in some people

Other drugs that are used in anxiety
• Propranolol - Given in anxiety and palpitation
• Phenothiazines - used in severe anxiety
• Barbiturates and Hypnotics -These are drugs u
sed to improve the quality of sleep or to induc
e sleep

Contraindications
• Benzodiazepines should not be used together
with other central nervous system depressant
s.
• They should be given with caution to patients
who are elderly, depressed or suicidal and tho
se with a history of substance abuse.

Antiparkinsonian Drugs
• These are drugs given to counteract the side e
ffects of major tranquillisers.
• An example of such a drug is benztropine (cog
entin) whose initial dose is 0.1-1mg daily, the
maintenance dose is 0.5-6mg daily divided int
o two or four times.
• The commonest is Benzhexol (artane) 5 mg O
D

Side Effects
• Dry mouth,
• Nausea
• Constipation
• Urinary retention,
• Blurred vision,
• Disorientation and confusion.

Electroconvulsive Therapy (ECT)
• Please make personal notes on this sub topic
on the following heading
• History
• Procedure
• Indication
• Preparations i.e. pre and post

Psychotherapy
• This is a form of treatment involving communi
cation between the patient and the therapist,
with the aim of modifying and alleviating illne
ss.
• A professional relationship is established, with
the patient aimed at removing, modifying or
mitigating the existing symptoms or disturban
ce patterns of behaviour or promotion of posi
tive personality, growth and development.

There are two main types of
psychotherapy:
1. Individual psychotherapy
2. Group psychotherapy
Individual psychotherapy can be further subdivided
into several categories.
• Supportive This deals with current problems and he
lps the patient to overcome their symptoms and co
pe with them satisfactorily in future
• Suggestive. This is a therapeutic method based on t
he belief that the patient has the ability to modify t
heir abnormal emotional behaviour by applying thei
r willpower and common sense.

cont
• Appeals are made to the patient’s reason and intellig
ence. This is to help them abandon neurotic aims an
d symptoms and enable them to regain self respect.
• Persuasive This is the oldest form of psychotherapy.
It is also widely used in advertising, propaganda, relig
ious and political activities. It revolves around a state
of artificially induced suggestibility known as hypnosi
s. 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 psychologica
l investigation.

Group Psychotherapy
• The treatment of the patient by psychotherap
y in groups was first introduced as a time savi
ng measure, but subsequent experience demo
nstrated that, the method had special therape
utic value, which did not occur in individual ps
ychotherapy.
• There are various styles of group therapy. One
example of a group therapy setting, might inv
olve a group size of six to eight patients.
• The therapy would have a time span of 1 to 1.
5 hours and sessions would be held once or t
wice weekly.

Benefits associated with the group
therapy include;
Re-education of the patient with a view towar
ds altering attitudes and behaviour patterns
Socialization
Improved adjustment and adaptation to realit
y
Increased understanding of emotional proble
ms and conflicts
Modification of personality and character

Behaviour Therapy
• This is defined as a therapeutic technique, whi
ch 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 cov
ert and cognitive therapies. Here, the priority i
s to help the patient modify their view of the
world and themselves, by helping them chang
e the things they say about themselves.

cont
Changing the behaviour from outside.
• This is achieved through positive reinforceme
nt of acceptable behaviour and negative reinf
orcement for unacceptable behaviour.

Activity Therapy
• There are several forms of activity therapy.
I. Occupational Therapy -This involves the use of selecte
d activities to improve general performance, to enable the-pa
tient to learn the essential skills of day-to-day living and to as
sist in the reduction of symptoms. Activities may include paint
ing, washing clothes and so on.
II.Recreation Therapy -This method uses activities like sp
orts, games, hobbies to treat behaviour. It lays the emphasis
on re-socialisation, reality orientation and involvement of me
ntally ill persons.
III.Dance Therapy - It uses body rhythmic movements and
interaction to express emotions, thereby increasing awarenes
s of the body and ego strength.

cont
iv. Rehabilitation -This is the process of restoring a person
’s ability to live and work as normally as possible after disabl
ing injury or illness.
• It is aimed at helping the patient achieve maximum possible
physical and psychological fitness and regain the ability to c
are for themselves. This aim is achieved through:
1) Physical therapy
2) Occupational therapy
3) Vocational training
4) Industrial/ work therapy
5) Recreation or social therapy

Mood Disorders or Affective
Disorders
• Usually presents in three forms whic
h are depression, elevated mood dis
order (mania) and bipolar disorder or
mixed and alternating affective state
s. The main feature of these disorder
s is abnormality of the mood or affec
t.

Precipitating factors
• Genetic with risk of child of parent with disorder bei
ng 10-15%, 70% to monozygotic twins reared togeth
er or apart and 23% of dizygotic twins (1-2% in the g
eneral population). Adopted child studies show it is h
igher in children whose parent had depression but a
doptive parents don’t.
• Personality; cyclothymic personality type is more pro
ne than others to a bipolar disorder
• Environmental factors; chronic difficulties at work or
home makes one prone to affective disorders while
Physical causes such as drugs, brain injury, and
endocrine disorders can also precipitate.

cont
• Depression is then mediated by thoughts that
reinforce the feeling such as remembering un
happy events more easily than happy ones, int
rusive negative thoughts and unrealistic belief
s. Further on the condition is also mediated by
chemical neurotransmitters such as abnormali
ty of serotonin function (5-HT) which is reduce
d and there is also a reduction in noradrenergi
c function.

DEPRESSION
• The main feature here is sadness which is seve
re and accompanied by anxiety, lack of energy
, general malaise and poor sleep. The conditio
n may be mild, moderately severe and severe
in its clinical presentation.

Symptoms of mild depressive
disorder
i. Symptoms are persistent
ii. Patient’s mood and behaviour are seen by ot
her as different from normal character and b
ehaviour
iii. Depression
iv. Anxiety symptoms
v. poor sleep
vi. Worse in the evenings and patient is pessimi
stic but not suicidal

Symptoms of moderately severe
depression
a. Appearance sad with psychomotor retardation
b. Low mood showing misery unhappiness, worse in t
he morning (diurnal variation), anxiety, irritability a
nd agitation
c. Lack of interest and enjoyment, reduced energy, po
or concentration, subjective poor memory
d. Depressive thinking with pessimistic guilty thoughts
, ideas of personal failure, hopelessness, suicidal ide
as, self-blame and hypochondriacal ideas
e. Biological symptoms include early wakening, and ot
her sleep disturbances, weight loss, reduced appetit
e.

Severe depressive disorder
1. Delusions of Worthlessness,Guilt,Ill-health, p
overty,Nihilism,Persecution
2. Hallucinations - Auditory and rarely visual

Drug treatment with antidepressants
i. Tricyclics e.g. Imipramine, amitriptyline, clo
mipramine
ii. Specific serotonin re-uptake inhibitors (SSRIs
) e.g. Fluoxetine and fluvoxamine
iii. Monoamine oxidase inihibators e.g. Nardil 4
5 – 90mg,Marplan 10-60mg .
iv. Elecroconvulsive therapy (ECT) is effective in
very severe depressive states e.g. depressive
stupor
v. Psychotherapy especially group

Mania
This is an elevated mood disorder and presents as a
reverse of depression where the patient has the
following clinical features
 Elevated mood; patient is cheerful, with infectious ga
iety, with undue optimism
 Characteristic appearance that reflects prevailing mo
od with brightly colored clothes which are ill chosen
and the patient may look untidy.
 Behaviour that is overactive for long periods, they st
art activities and get distracted easily and start new
ones without finishing. The behaviour may also inclu
de socially inappropriate behaviour such as increase
d sexual energy or buying sprees.

cont
Sleep is reduced and patient feels lively and e
nergetic and often rises up early to engage in
noisy activities to the surprise and distress of
others
Appetite is increased with table manners lacki
ng
Thought patterns that are grandiose and patie
nt feels their work or ideas are original and th
ey become extravagant. In severe forms delusi
ons of grandeur and times of persecution

cont
 Perceptual disorders such as hallucinations those are
consistent with the prevailing mood mainly of audito
ry nature speaking to the patient
 Insight is lacking or impaired
 Mania usually takes a clinical pattern of either
a. Mild mania (Hypomania)
b. Moderate mania
c. Severe mania
 Occasionally the manic depressive symptoms occur t
ogether as a mixed affective state or alternating affe
ctive state (Bipolar disorder or Manic depressive psy
chosis)

Stages of elated mood
1 Euphoria (stage 1) Increased sense of psychological well-being & happiness not
in keeping with ongoing events
2 Elation (stage 2) Moderate elevation of mood with increased psychomotor
activity.
3 Exaltation (stage 3) Intense elevation of mood with delusion of grandeur
4 Ecstasy (stage 4) Severe elevation of mood ,intense sense of rapture or
blissfulness seen in delirious or stuporous mania

Subtype of bipolar disorder
1 Bipolar 1 Characterized by episodes of severe mania and
severe depression
2 Bipolar type 2 Characterized by episodes of hypomania (nit
requiring hospitalization) and severe depression

Treatment
• Drug treatment with antipsychotics
• Chlorpromazine and haloperidol
• Lithium carbonate which takes as long a week
to two to produce effectiveness (900-1500mg
per day)
• Carbamazepine (600-1800mg/day) and Sodiu
m valproate (1000-2600mg/day)
• Elecroconvulsive rarely used in treatment of
mania

others
• Clonazepam
• Calcium channel blockers
• Psychosocial treatment –family and marital th
erapy to decrease intrafamilial & interpersona
l difficulties and to reduce or modify stressors.
• The main purpose is to ensure continuity of R
X & adequate drug compliance

Some guidelines for self protection
when handling an aggressive pt
Never see a potentially violent pt alone
Keep a comfortable distance away from the pt (arm l
ength)
Be prepared to move, violent pt can struck suddenly
Maintain a clear exit route for both staff & pt
Be sure that pt has no weapons in possession before
approaching him.
If a pt is having a weapon , ask him to keep it on a ta
ble or floor rather than fighting with him to take it a
way

cont
Keep something like a pillow,mattreses or bla
nket wrapped around arm between you & the
weapon
Distract the patient momentarily to remove th
e weapon (e.g. throwing water on the face etc
)
Give prescribe antipsychotic medications

Organic Psychosis
• The hallmark of an organic psychosis is the fac
t that it has a specific cause such as a lesion in
the in the central nervous system or a psychot
ropic substance such as drugs or alcohol.
• This can be divided into several disorders whic
h include acute organic brain disorder (deliriu
m), chronic organic brain disorders (Dementia
), drug induced psychosis and others such as t
emporal lobe epilepsy.

cont
• The main feature in these organic brain disord
ers is interference with such intellectual functi
ons as comprehension, calculation, general kn
owledge, abstract reasoning, memory and lan
guage.

Delirium
• This is an acute illness usually characterized by
loss of consciousness and is common in physic
al illness. The patient normally recovers quickl
y
Clinical features
• Impairment of consciousness is the most impo
rtant feature and is usually recognized by diso
rientation in time, place and person and also p
oor concentration. These features fluctuate in
intensity and are usually worse in the evening.

cont
• The behaviour shows over activeness with irrit
ability and noises.
• Sleep is disturbed
• Thinking is slow and thought content shows id
eas of reference and delusions are usually tra
nsit and poorly elaborated
• The speech shows problems with word finding
• Mood is labile and patient may be anxious, irri
table or depressed

cont
• Perception shows misinterpretation, illusions
and hallucinations of auditory and visual natur
e
• Memory shows disturbance of registration, re
tention and recalling of new learning and whe
n the patient recovers he or she can not recall
anything that occurred during the delirious sta
te (amnesia)
• Insight is lacking or impaired

Causes
I. Drug intoxication
II. Alcohol withdrawal
III. Metabolic failure e.g. hepatic, renal, cardiac,
respiratory failures and hypoglacaemia
IV. Systemic infections (bacteraemia) e.g. typhoi
d, fever
V. Neurological causes e.g. encephalitis, space
occupying lesion (SOL), increased intracranial
pressure, epileptic seizures etc
VI. Vitamin deficiencies (pellagra) – thiamine &
nicothinamide

cont
vii. Acute brain disorder – head injury, cerebral
haemorrhage,hypertensive encephalopathy.

Management
• Reassurance and reorientation to reduce anxi
ety and the disorientation. This should be rep
eated frequently
• Explain clearly to the relatives about the natur
e of illness in order to alley their anxiety and t
his will help them reassure and re-orientate th
e patient
• The environment may need to be manipulate
d to avoid confusion and there should be a pr
edictable consistent routine

cont
• The patient should be nursed in a quiet side ro
om and at night there should be enough light
to enable the patient know where he is but no
t excessive so as to allow him to sleep without
disturbance
• Relatives and friends should be encouraged to
stay or visit regularly
• Diet – delirious pts can be exhausted & die so
adequate nourishment is needed
• Rest – encouraged to rest as much as possible
so as to become less confused.

cont
• If the patient shows great disturbance, antipsy
chotics can also be used.
• Benzodiazepines in low doses can be administ
ered to promote sleep at night but should be
avoided during the day as this may increase di
sorientation (other hypnotics can also be used
)

Dementia
• Is an acquired global impairment of intelect,m
emory,& personality without impairment of c
onsciousness
• This denotes the loss of mental capacity due t
o organic damage to the brain.
• The patient displays generalized impairment o
f intellect, memory and personality without i
mpairment of consciousness

cont
• Most cases are irreversible and when it occurs
before the age of 65 years it is known as pre-s
enile dementia.
• There is disturbance of multiple higher cortica
l functioning (memory, thinking, orientation, l
earning capacity,& judgment)
• Dementia is like dying mind in a living body.

classification
a. Senile dementia of Alzheimer's type
b. Vascular dementia
c. Dementia in other diseases eg
 In picks disease,
 In Creutzfeldt-Jakob disease
 In Huntington's disease
 In Parkinson's disease
 In Hiv
 Unspecified dementia

Common causes of dementia
• Degenerative (cortical) e.g. picks disease, Alzh
eimer's disease
• Sub cortical degenerative e.g. Huntington's dis
ease, Parkinson's disease
• Infection and inflammation
• Toxic e.g. alcohol, carbon monoxide, heavy m
etal poisoning
• Tumours
• Trauma

Clinical features
• Impairment of memory
• Changes in behaviour
• Poor memory
• Aplasia
• Behaviour is odd, disorganized, restless and w
andering
• Disorientated
• Impaired attention
• Mood disorders

cont
• Delusions and Hallucinations
• Self neglect
• Disinhibition
• Mood shows anxiety, depression
• Thinking is slow with poverty of ideas and pati
ent may exhibit delusions
• Perception. Patient may have illusions and hall
ucinations
• Patient lacks insight

Mnx of dementia
• Drug mnx- there is no specific drug which ca c
ure dementia ,but drugs like hydergine, papav
erine, piracetam, lecithin are claimed to impro
ve dementia.
• Associated behavioral problems psychosis, epi
lepsy, & sleep disturbances can be treated wit
h specific drugs.
• Psychosocial management e.g. behavioral met
hods, activity engagement, reality orientation,
problem orientated approach etc

Nursing care of dementia
• Asses pts level of functioning so as to formulat
e care plan
• Pts safety is a nursing priority – due to disorie
ntation and confusion, tie a plastic or aluminu
m tag on his hand for identification while wan
dering around.
• Being prone to aggressive and violent behavio
ur, use restraints but judiciously, maintain a ca
lm manner (drugs).
• Use simple explanation and face to face introd
uction and communication with the pt.

cont
• Decrease the amount of stimuli in the pts envi
ron so that the confusion can be less (noise, fe
w people)
• Reassure the pt if frightened and agitated
• Provide feeling of security and stability by allo
wing the same persons to take care regularly
• Help pt to devise methods to reduce memory
defect e.g. note down the daily activities and t
hings to be done.

cont
• Allow pt to be as independent as possible in s
elf care activities
• Take care of personal hygiene
• Nutrition – well balance diet
• Care of incontinence – bed wetting, educate t
he relatives to understand and assist
• Educate the carer (relatives) about gradual de
cline of the condition (mental capacity).

Comparison of features of delirium
& dementia
Delirium
1) Acute onset
2) Present with diorientation,
anxiety,poor attention
3) clouding of consciousness
or drowsiness
4) Perceptual abnormalities e
.g. illusion, hallucination
5) Fluctuating course
6) reversible
Dementia
1) Insidious onset
2) Disturbed memory, person
ality deterioration
3) Clear consciousness
4) Global impairment of cere
bral function
5) Progressive course
6) Mostly irreversible

SUBSTANCE ABUSE
• Substance – any drug ,medication or toxin that share
s potential for abuse
• Addiction – is physiologic & psychological dependenc
e on alcohol or other drugs of abuse that affects the
CNS in such away that withdrawal symptoms are exp
erienced when the substance is discontinued.
• Abuse – is maladaptive pattern of substance use that
impairs health in a broad sense
• Dependence – refers to certain physiological & psych
ological phenomena induced by repeated taking of a
substance.

cont
• Tolerance – is a state in which after repeated
administration ,a drug produces a decreased e
ffect, or increased doses are required to prod
uce the same effect.
• Withdrawal – a s/s recurring when a drug is re
duced in a amount or withdrawn , which last f
or a limited time . The nature of the withdraw
al state is related to the class of substance use
d.

Commonly abused drugs
• Alcohol
• Opioids
• Cannabis
• Cocaine
• Amphetamines & sympathomimetics
• Hallucinogens (lysergic acid diethylamide, phencyclid
ine)
• Sedatives & hypnotics (barbiturates)
• Inhalants (volatile solvents)
• Nicotine
• Other stimulants (caffeine)

Etiology factors in psychoactive
substance use.
a) Biological factors eg family hx,
I. Biochemical factors e.g dopamine & norepin
ephrine av been implicated in cocaine, ethan
ol & opioid dependence
II. Neurobiological theories
III. Withdrawal and reinforcing effects of drugs
b) Behavioral theories
 Behavioral scientist view drug abuse as the re
sult of conditioning, or cumulative reinforce
ment from drug use

cont
Drug use causes euphoric experience perceive
d as rewarding, thereby motivating user to ke
ep taking the drug
c)Psychological factors
General rebellious
Sense of inferiority
Low self esteem
Inability to cope with the pressure of living & s
ociety
Desire to escape from reality etc

cont
d. Social factors
 Religious reasons
 Peer pressure
 Urbanization
 Extended periods of education
 Unemployment
e) Easy availability of drugs

Consequence of substance abuse
i. Leads to physical dependence, psychological,
dependence, or both
ii. Unhealthy lifestyle and behaviors such as po
or diet
iii. It impairs social & occupational functioning,
creating personal, professional, financial and
legal problems.
iv. Drug use beginning in early adolescence may
lead to emotional and behavioral problems (
depression),problems with family r/ship etc

cont
v. In pregnancy , substance abuse jeopardizes f
etal well-being
vi. It may lead to life threatening complications
vii. Illicit street drugs pose added dangers; mate
rial used to dilute them can cause toxic or all
ergic reactions

Alcoholism
• Is a chronic disease manifested by repeated dr
inking that produces injury to the drinkers hea
lth to his social or economic functioning
• Low and moderate consumption produces a f
eeling of well being & reduces inhibitions
• Mostly commonly abused alcohol preparation
are ; Beer,wine,brandy,whisky,rum,& gin.
• Alcoholism is the most common psychiatric di
sorder.

The process of development of
alcoholism
i. Experimental – due to peer pressure & curio
sity
ii. Recreational – Gradually, during a function (
weeding),parties,confrences
iii. Relaxation – holidays & weekends, hence fre
quency gradually increases.
iv. Compulsive – drinking most or drinking heavi
ly for a period of time pleasure or to avoid th
e discomfort of withdrawal symptoms

Early stage
• Increased tolerance – needing more & more o
f alcohol to experience the same pleasure as e
xperience earlier
• Blackouts – inability to recollect incidents whi
ch happened under the influence of alcohol
• Preoccupation – always thinking about and w
here to drink.

Middle stage
• Loss of control over amount ,time & occasion
of drinking.
• Keeping away from alcohol for sometime ,but
going back to obsessive drinking after each su
ch abstinent period

Signs and symptoms of alcoholism
dependence
• Minor complaints – malaise,dyspepsia,mood s
wings, or depression,increased incidence of in
fection.
• Poor personal hygiene – unrx injuries (cigarett
e smoking,fractures,bruises)
• Unusually high tolerance for sedatives, and op
ioids
• Nutritional deficiencies (vitamins, minerals)
• Secretive behaviour (may attempt to hide diso
rder or alcohol supply)

cont
• Consumption of alcohol-containing products (
mouthwash, aftershave lotion, hair spray)
• Denial of problem
• Tendency to blame others and rationalize pro
blems e.g. inadequacy, displacement

Chronic stage
• Getting drunk even on small amounts of alcoh
ol. Willing to lie,beg,borrow or steal to mainta
in supply of alcohol.
• Living to drink – alcohol takes priority over fa
mily or job

Management of alcoholism
A. Assessment of the pt
i. His drinking aspects
ii. Work pattern
iii. Family
iv. Environment
B. Physical methods
I. Detoxification
II. Disulfiram
C. Psychological
I. Counselling

cont
D. Psychotherapy (individual & group)
i. Marital/family therapy
ii. Behavioural modification (aversion therapy)
iii. Relapse prevention therapy
E. Rehabilitation
F. Alcoholic anonymous

Identification of Substance Abuse
1) Warning signs/symptoms
– Biological - loss of weight, liver disease, GI
conditions, loss of tooth enamel.
– Psychological - increase in anger, irritability,
lethargy, confusion
– Social – socializing with drug users, isolated from
non-using friends, lack of family relationships, loss
of job, arrests
– Spiritual – loss of values, denial of morality
– Medical detection – urinalysis can detect
presence of certain drug-related electrolytes and
metabolites in the urine. Breathalyzer, hair
samples

cont
2) Screening through written materials
– CAGE: acronym for four questions asked by the
counselor to the individual – only used for ETOH
screening)
– MAST – Michigan Alcoholism Screening Test –
only used for ETOH screening.
– SASSI-2
– SARDI Symptoms Checklist
3) Self-Reporting

CAGE
• C- have you ever felt you ought to CUT down
your drinking?
• A- have people ANNOYED you by criticizing
your drinking?
• G- have you ever felt GUILTY about your
drinking?
• E- have you ever had a drink first thing in the
morning (EYE OPENER) to steady you nerves
or get rid of a hangover.

1.Detoxification
• Is a process by which an alcohol dependent pe
rson recovers from the intoxicating effects of
alcohol in a supervised manner, which include
s;
a)Administration of minor tranquilizer (anti-anxi
ety) drug e.g. valium to control anxiety,insom
nia,agitation, & tremors.
b)Assess dehydration – fluid and electrolyte bala
nce, IV fluids are essential
c)Re-establish proper nutrition –high in protein,
carbohydraates, vitamins C,B complex (B1,B6,
B12)

cont
• Provide calm & safe environment
• Administer anti- convulsant if there is withdra
wal seizures (rumfit).
• Monitoring vital signs
• Observe for levels of consciousness & orientat
ion.

2. Disulfiram (Antabuse) therapy
• This drug produces intense headaches, severe
flushing, extreme nausea, vomiting, papitatio
ns,hypotention,dysponea, & blurred vision wh
en alcohol is consumed by a person on this dr
ug. DER (disulfiramethanol reaction)
• Indication – use as an aversive conditioning tr
eatment for alcohol dependence
3.Aversion therapy – pt is subjected to pain
inducing stimuli at the time of drinking to
establish alcohol rejection behaviour.

Alcoholic anonymous (AA)
• A self group of ex- addicts who confront, instr
uct, and support fellow drinkers in their effort
s to stay sober one day at a time through fello
wship & acceptance

Basic concept while nursing
alcohol dependent
• It’s a chronic disorder
• It’s a relapsing disorder
• Its affects physical, mental, & social well being
• Not only individual suffer, but family, work & c
ommunity suffers too.
• Accepting drinking as a problem by the pt is a
n vital first step, because most of the alcoholic
s deny.
• Involvement of significant others is vital to en
hance recovery.

Immediate care after admission
during detoxification
• Admit in quiet environment – excessive stimul
i increases agitation, well lit room to reduce fe
ars & illusions
• Safety precaution – observe pts behaviour (DT
)
• Make sure the side rails are in bed when the p
ts are sleeping
• Physical restraint may be necessary if the pt is
disturbed or hyperactive
• Keep potentially harmful objects from the roo
m to reduce self harm

cont
• Keep the bed clean, dry & warm coz some pt
may be incontinent.
• Monitor vital signs every 15 mins initially
• Frequently orient the pt to reality & surroundi
ng.
• Nutrition – input- output, calorie intake, weig
h daily,
• Medication – follow as advised by the Dr, anti-
anxiety drugs (valium, Librium), vitamins (B1,6
,&12), antacids, correct fluid and electrolyte i
mbalance

Delirium tremens (DT)
• An acute organic mental disturbance during th
e withdrawal period of alcoholism
• Watch for symptoms like confusion,disorienta
tion,tremors,illusion,hallucination,agitation &
apprehension and increased sweating, heart b
eat & pulse rate.
• It should treated as emergency since it is fatal
• Give IV fluid, valium. keep the pt in quiet roo
m, supplement with vit B comp and reassure t
he pt.

Nursing care after detoxification is
over
• Its vital to look beyond the symptoms and lear
n about the person
• These persons are in need of physical as well a
s social rehabilitation
• Attention to rest, diet, personal hygiene & app
earance is vital
• Acceptance by the nurse during the recovery
& rehabilitation is essential – encourage the p
t to socialize & participate in planned ward act
ivities.

cont
• A do not become alcoholics pts have inferior a
nd low esteem – acceptance is key
• Be empathetic and not sympathetic and be su
re they do not become dependent on the nurs
e.
• in rehabilitation involve significant others.

Nurses role in prevention of
alcohol abuse
• Primary – reduce new cases by health promoti
on & health education
• Secondary – attempt to detect cases early ,rx,
before serious complication cause disability.
• Tertiary – avoid further disabilities & to integr
ate individuals into society who have been har
med by severe alcohol related problems

Why people take drugs ?
• Search for euphoria (sense of well being)
• Relief of psychological pain of diverse origins
• Wanting to feel better than they do
• To avoid withdrawal symptoms.

Factors involved in Drug abuse
i. The drug is seen in as reinforcer
ii. Tolerance
iii. Physical dependence
iv. The abuser – the personality, degree of stabil
ity and attitude of the individual
v. Environment – isolation, stress, peer pressur
e group influence
vi. The motivating factors – initiation by compa
ny, curiosity, pleasure, acceptance by the gro
up

Identification of an addict (s/s)
• Lack of interest in studies & poor academic pe
rformance
• Lack of interest in hobbies, games, & sports
• Withdrawal from the family
• Social isolation,prefering to be a loof
• Blank expression & irresponsible & aggressive
behaviour
• Irregular eating & sleeping patterns
• Persistent lying & stealing
• Low productivity

Common drugs abused
Alcohol
Cannabis sativa
Opioids (opium)
Hypnotic & minor tranquilizers (valium,nitrzep
am)
• In Kenya;
Alcohol
Amphetamines
Cocaine (from coca plant)
Heroin (from opium poppy plant)

cont
• Marijuana (cannabis)
• Inhalants (Glue, nail polish remover, hair spra
y, petrol)

Cannabis sativa
• Sometimes called marijuana or ganja, grass," "
pot," "reefer," "joint," "hashish, "weed," and "
Mary Jane.“
• Is generic name given to the drug containing p
lant products of Indian hemp.
• It contains psychoactive chemicals tetrahyroc
annabinol (THC)
• Dried leaves or flowering top is marijuana or g
anja
• Resin is hasish while bhang is a drink made fro
m cannabis sativa.

Acute intoxication
• Mild – mild impairment of consciousness & ori
entation, tachycardia, euphoria, flashback, tre
mors, photophobia,
• Severe – perceptual disorders (depersonalizati
on), derealisation, hallucination.

Withdrawal symptoms
• Occurs within 72-96hrs of withdrawal
• Increased salivation
• Hyperthermia
• Insomnia
• Deceased appetite
• Loss of weight

Complication
• Acute anxiety
• Paranoid psychosis
• Hysterical fugue-like states
• Hypomania
• Schizophrenia like state
• Amotivational syndrome
• Memory impairment

Treatment
• Rest in a quiet place.
• Ant-anxiety drugs chlordiazepozide) to reduce
agitation, craving and to induce good sleep.
• Good nutritious food.
• Antidepressant or antipsychotic to treat any a
ssociated psychiatry complication.

Opioids (Narcotics)
• Commonly abused are ;heroin,pethidine (synt
hetic preps),fortwin, tidigesic
• Unrefined heroin has spread rapidly in recent
years among city-based slum youth .
• Opium is a resin obtained from poppy & conta
ins psychoactive substance like morphine, her
oin, & codeine, used for relieving pain and cou
gh.

Acute intoxication
• Pupillary dilatation
• Tachycardia
• Hypertension
• Sweating & nausea
• Hypomania features
• Euphoria
• Slurred vision
• Apathy

Withdrawal syndrome
• Narcotics withdrawal rarely produces a life thr
eatening situation e.g.
• Agitation
• Depression
• Anorexia
• Fatigue
• Sleepiness
• Begin within 12hrs,peak in 24-36hrs,subsides i
n 72hrs & disappears in 5-6 days

complications
• Acute anxiety reaction,
• Uncontrolled compulsive behaviour
• Seizures
• Respiratory depression
• Cardiac arrhythmias

Treatment
• Management of intoxication; Amyl nitrite is an
antidote, valium or propanolol
• Withdrawal syndrome – antidepressants (laro
yl or tofranil )
• psychotherapy

Nursing care of drug dependents
• Knowledge of pts level of functioning is vital (c
are plan)
• Obtain drug hx – type of substance, time and
amount of last abuse, duration & frequency of
consumption, amount consumed on daily basi
s.
• Hx from relatives & friends and lab investigati
on – often pts may not tell the facts required.
• Place the pt in a quiet room as excessive stimu
lation increases pts agitation

cont
• Safety precautions – avoid getting drugs from
outside source, prevent deliberate self harm (
attempted suicide), medication as prescribed
• Monitor vital signs & urine output for possible
complication of over dose (acute stage)
• Administer drugs carefully to prevent hoardin
g
• Encourage family members to seek help wher
e they wish.
• Refer the pt for rehab.

Prevention of substance use
disorder
A. Primary prevention
 Reduction of over prescribing by Drs (benzod
iazipines,anxiolytic)
 Identification & RX of families who may be co
ntributing to drug abuse
 Introducing social changes ; pricing of alcohol
, controlling advertising, control sale times
 Health education (college students & youths)
 Overall improvement of socio-economic con
ditions of the population

cont
B. Secondary prevention
 Early detection & counselling
 Motivational interviewing which involves pro
viding feedback to the pt on the personal risk
s that alcohol poses with a no of options for c
hange.
 A full assessment including an appraisal of cu
rrent medical, psychological,& social problem
s i.e. whether alcoholism is the primary or se
condary cause.

Tertiary prevention
 Specific measures include:
 Alcohol deterrent therapy (antabuse or disulfiram)
 Other therapies e.g. assertivness,training,coping mec
hanism,behavour counselling,surportive psychothera
py & individual
 Alcoholic anonymous (AA)
 Relapse prevention e.g. motivation enhancement, ris
k situation (craving mnx),drinking refusal skill(asserti
veness),stress mnx, recreation & spirituality, time m
nx, financial mnx, handling negative mood states

Rehabilitation
• The aim of rehab of an individual deaddicted f
rom the effects of alcohol/drug , is to enable h
im to leave the drug sub-culture & to engage i
n work & social activities in sheltered surroun
dings & then take greater responsibilities for t
hemselves in conditions increasingly like those
of everyday life.

SCHIZOPHRENIA
• Derived from a Greek word schizo meaning spl
it and phrenic meaning mind.
• It was coined by a Swiss psychiatrist Eugen Ble
uler.
• Three to four per 1000 suffer in any communit
y.
• Def ; a functional psychosis xterised by disturb
ance in thinking,emotion,volition &perception
. It leads on to personality deterioration. It occ
urs in the clear state of consciousness.

Aetiology
I. Genetic factors – studies of twins and adopt
ed children
II. Biochemical factors – Dopamine theories ,fro
m the idea of mechanism of action of antipsy
chotic drugs ie blocking postsynaptic dopami
ne receptor site. This led to speculation that
there is excessive levels of dopamine.
III. Others are Transmethylation hypothesis & in
dolamine hypothesis

cont
Genetic
abnormal
ity
Enzyme
abnorm
ality
Biochemic
al
abnormalit
y
Environment
al Stressors
Behavioural pattern
characteristic of
schizophrenic disorder
Physiological
&psychological
predisposition

cont
IV. Psychological factors – persons who are with
drawn & have very few social contacts (intro
vert or schizoid personality) are more likely t
o develop schizophrenia. Ego boundary distu
rbance is also considered to be cause of schiz
ophrenia.
V. Social or environmental factors – children &
adults develop schizophrenia because their h
ome environment is not conducive to emotio
nal growth. There are a lot of conflict.

cont
• Some studies have shown schizophrenia is mo
re prevalent in areas of high social mobility

Clinical features
• Positive symptoms
• Delusions
• Hallucination
• Bizarre behaviour
• Aggression
• Agitation
• Suspiciousness
• Hostility
• Excitement
• Grandiosity

Negative symptoms
• Apathy
• Social withdrawal
• Diminishing emotional responsiveness
• Blunt affect
• Stereotyped thinking
• Artificial gestures/detachment

Thought disturbance
• It’s a prominent symptom – the derangement
is basically due to three mechanisms:
• condensation – ideas are mixed ,having some
thing in common though not necessarily logica
l
• Displacement –an associated idea instead of t
he correct one is used
• Symbolization – abstract thoughts are replace
d by concrete.

others
• Neologism – a word newly coined or an every
day word used I a special way, not readily und
erstood by others.
• Incoherent & mutism
• Thought block
• Delusions –persecutions, grandeur, control
• Autism – a slow progressive withdrawal from r
eality
• Volitional disturbance – is a deterioration in w
ill power, drive, $ ambition

cont
• Emotional (Affective) disturbance – flattening
or blunting of emotion, mood (incongruous)
• Perceptional disturbance – hallucination (audi
tory –very common, visual, tactile, olfactory)
• Behavior – (catatonic stupor) withdrawal from
reality into fantasy may increase apathy and i
ndifference to the point of complete inability
and stupor & the reverse may also occur i.e. c
atatonic excitement
• Echolalia –
• Echopraxia

cont
• Negativism -
• Mannerisms –
• Sleep disturbance
• Lack of insight
• Poor personal hygiene

Types of schizophrenia
1. Paranoid schizophrenia
• Features – persecutory or grandiose delusion
, hallucination, anger, argumentativeness & v
iolence
2. Catatonic type -The patient has one or a com
bination of the following forms of catatonia
 Catatonic stupor or mutism – patient does no
t respond in any way to his environment or t
o people in it. They are often aware of what i
s going on around them
•

cont
Catatonic negativism – patient resists all direc
tions or physical attempts to move him
Catatonic rigidity – Patient is physically rigid
Catatonic posturing – patient assumes bizarre
unusual positions or postures
Catatonic excitement - patient is extremely wil
d active and excited. This may be life threateni
ng due to exhaustion

cont
3. Undifferentiated type ;Here the patient has p
rominent delusions, hallucinations, and other
evidence of psychosis but without the more s
pecific features of the preceding three categ
ories
4. Residue type - Here the patient is in remissio
n from active psychosis but displays sympto
ms of the residual phase e.g. social withdraw
al, flat or inappropriate affect, loosening of a
ssociations, illogical thinking etc

cont
5. Simple schizophrenia ; insidious in onset but
with progressive development of odd behavi
our. Wandering tendency, self absorbed, idle
& aimless activity are present.
6. Disorganized schizophrenia (Hebephrenic) ;h
as early onset (adolescents),insidious onset, c
haracterized by regression, primitive bahavio
ur, disinhibited, silly, childish behaviour, man
erism,wear peculiar outfits, live on trees, gra
ves yards, hallucination, like hoarding very m
any things (sacks, containers),personality is d
isintegrated.

management
• Chemotherapy – neuroleptics e.g. CPZ (largact
il ) 100-150mg upto 200mg tds po
• Haloperidol 2-3mgs tds,not sedating like cpz, r
ecommended due to EPS
• Modicate 12.5-25mg up to 50mg monthly, giv
e artane 5mg to mnx s/effects
• ECT indicated to catatonic schizophrenia & co
mbine with neuroleptics

Nursing care mnx
• Acute phase – don’t stimulate the environmen
t, one to one r/ship is recommended
• Gradually introduce the pt to other nurse
• Put on the psychotherapeutic group (socializat
ion)
• occupation therapy – not challenging task to
boost self-esteem
• Be non- judgemental
• Avail yourself unconditionally & not in hurry
• Avoid joke (abstract reasoning)

cont
• Avoid enforcing delusion
• Correct the pt without punishment
• Do MSA weekly or twice
• Preparation for discharge – family be involved
,maintainence dose,
• Do home visit
• Educate employer
• Sensitize friends

Factors that show positive or
negative prognosis
i. Sudden onset
ii. Illness of short episode
iii. Old age at onset
iv. Married
v. Good psychosocial adjust
ment
vi. Good work record
vii. Good social r/ship
viii. Good drug compliance
ix. FHx of mental illness miss
ing
i. Slow onset
ii. Long episode illness
iii. Younger age at onset
iv. Has Hx of mental illness
v. Single due to separation,
widow
vi. Poor psychosocial adjust
ment
vii. Poor work record
viii. Poor social socialization
ix. Poor drug compliance

Personality disorder (PD)
• Def :is the possession of one or more personal
ity traits so deviated from the normal that the
y interfere with his wellbeing or adjustment to
society & require psychiatric attention.

Characteristics of P.D
• Its not a mental illness
• It is maladaptive behaviour
• It’s the possession of abnormal personality tra
its
• It’s a long lasting , most of the time life-long p
roblem
• It causes significant impairment in social or oc
cupational functioning
• It produces distress to the individual & others

cont
• Its different from mental illness, symptoms of
mental illness are mostly episodic & not conti
nuous whereas the symptoms of personality d
isorders are continuous & start from adolesce
nce or even before.
• PD increases vulnerability to mental illness &
also worsens the course and rx response esp. i
n depression, anxiety and drug and alcohol ab
use.

classification
I. Withdrawal (odd & eccentric)
 Schizotypal
 Schizoid
 Paranoid
II. Dependent
 Anxious (avoidant)
 Dependent
 Passive aggressive

cont
iii. Inhibited
• Anankastic (obsessive compulsive)
• Hypochondriacal
• Depressive (Dysthymic)
iv. Anti-social (Dramatic, emotional flamboyant & erra
tic)
• Histrionic
• Impulsive
• Borderline
• Narcissistic
• psychopathic

Main personality disorder
1) Paranoid personality disorder – oversensitivit
y, tendency to bear grudges, suspiciousness,
misconstruing neutral or friendly actions of o
thers.
2) Schizoid personality disorder – emotional col
dness, preference for fantasy, introspective, l
ittle interest in having sexual experience with
others
3) Anxious (avoidant) personality disorder – per
vasive tension and apprehension, self –consci
ousness, hypersensitivity to rejection,

cont
• Entering into r/ship only if guaranteed uncritic
al acceptance, exaggerating potential dangers
& risks in everyday situations & avoiding certa
in activities, leading to a restricted lifestyle.
4)Dependent personality disorder – encourages
or allows others to assume responsibility for
major areas in the individuals life. perceives se
lf as helpless, fears of being abandoned and le
ft alone, devasted when close r/ship ends.

cont
5) Anankastic (obsessive compulsive) PD – indecisiven
ess, perfectionism, excessive conscientiousness, rigi
d and stubbornness, planning all activities far ahead
in a minute detail
6) Histrionic PD – dramatic , overemotional, suggestibl
e, shallow & labile affectivity, craves attention & ma
nipulative.
7) Borderline PD – unclean or disturbed self-image, int
ense and unstable r/ships, which may lead to repea
ted emotional crises that maybe associated with a s
eries of suicidal threats or acts of self-harm

cont
6) Psychopathic (ant-social) PD – abnormally ag
gressive & extremely irresponsible person wh
ose behaviour brings him repeatedly into con
flict with society & the law.
7) Narcissistic PD – is self centered, self absorbe
d, 7 lacking empathy for others. Typically tak
es advantage of people to achieve his own en
ds, and uses them without regard to their fee
lings.

cont
• Are attention seeking, inflated sense of self-im
portance, exploitative behaviour, arrogance, p
reoccupation with fantasies of success, power,
beauty, brilliance or ideal love

Aetiology of PD
i. Psychological factors – e.g. early attachment,
maladaptive learning,
ii. Constitutional factors – e.g. prenatal factors
iii. Hereditary factors e.g. genetic or chromoso
mal abnormality (XYY pattern in psychopathy
)
iv. Environmental factors – poverty, low socio-e
conomic class, broken homes

Clinical features
• Guiltless & loveless individual, highly impulsiv
e in nature with no regret for his deeds.
• No drive and motivation.
• Cannot establish a sustained r/ship with anyb
ody.
• Superficially charming but can quickly become
s irritable & highly selfish.
• Has low frustration tolerance & blames others
for his bahaviour

cont
• Does not learn from his experience ,so again a
nd again commits same mistakes or criminal b
ehaviour.
• There is hx of stealing, lying, fighting, running
away from home & cruelty to animals from chi
ldhood to adolescence which continues in adu
lt life.
• May cheat, misappropriate funds, swindle and
tell fantastic lie (pathological lier)

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