Welcome to Unit One: Mental Health and Psychiatric Nursing

In this unit you will look at the basic concepts of mental health and illness, also covered
is the process of admitting and discharging patients who are mentally ill. Additionally
you will look at how mental health conditions are treated and managed, and community
health services in the community.

This knowledge, and these skills and attitudes will help you to manage patients having
psychosocial problems.

This unit is composed of five sections:

Section One: Concepts, Principles and Theories of Mental Health and

Psychiatric Nursing.
Section Two: Admission and Discharge Procedures of Mentally Sick
Patients.
Section Three: Treatment Used in the Management of Mentally Ill Patients.
Section Four: Management of Common Mental Health Conditions.
Section Five: Community Mental Health.

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
● Recognise and manage common mental health conditions
● Describe community mental health
Section 1: Concepts, Principles and Theories of Mental Health
and Psychiatric Nursing
Introduction

This section looks at the basic concepts of mental health and mental illness.

Objectives

By the end of this section you will be able to:

● Describe the concepts of mental health and mental illness

● Describe at least two theories of personality development
● 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

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).

According to the World Health Organisation (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).

What do you understand by the term ‘mental illness’?

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).

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

According to world health organization (WHO) mental health is a state of emotional

well-being which enables one to function comfortablywithin society and to be satisfied
with one’s own achievements. True or False

Theories of Personality Development

For one said to be healthy, normal growth and development

must have taken place. To assist in looking at growth and development, you are going to
look at the two main theories
of personality development.

These are:

● Psychoanalytic theory by Sigmund Freud

● Social learning theory by Erik Erickson

You will now look at each of these theories in turn.

Psychoanalytic Theory

This theory will help you understand psychopathology and stress related behaviour. It
will also help you explore human behaviour instead of taking behaviour at face value.
The psychoanalytic theory makes several assumptions.

The theory posits that all human behaviour is determined by earlier life events and that
human behaviour is driven by energy known as libido. It is also argued that people
function at three levels
of awareness:

● Conscious level where immediate events and perceptions

are stored
● Pre-conscious level where thoughts and feelings are not accessible with ease
● Unconscious level where material is not accessible most of the time

According to the proponents of psychoanalysis, people develop through five stages:

One: Birth to 1 year
Oral phase, where sexual satisfaction is obtained through the mouth by actions of sucking
or biting.

Two: 1 year to 3 years

Anal phase, where sexual satisfaction is obtained through the anus.

Three: 3 years to 6 years

Phallic phase, during which interest in the genitalia is developed and the individual
acquires gender roles.

Four: 7 years to 11 years

Latent phase, where there is no sexual interest, this divides boys and girls into different
groups.

Five: 12 years and onwards

Genital phase, when the capacity for objective and mature sex is developed.

According to this theory, the human personality is made up of three hypothetical

structures:

Id
The id is the most primitive and is driven by impulses. It demands immediate
gratification of the needs.
Super Ego
The super ego, whose main function is to oppose the id. It contains values, legal, moral
regulations, and social expectations.
EgoThe ego, which unlike the id, is in contact with reality. It is able to delay the
satisfaction of a need until an appropriate time, place, or object is available. It mediates
between the id and the super ego.

Social Learning Theory

Erikson postulated eight human developmental stages which one has to go through in
normal life. He called them psychosocial stages. Each stage is characterised by tasks or
ego qualities, which one has to develop in normal life. You will now examine one stage
at a time.

Trust versus Mistrust

This is attained during infancy. Trust is developed when the mother breastfeeds the infant
as well as meeting other needs of the infant such as changing wet diapers. The
approximate age at which the individual goes through this stage is 0 - 18 months.
Autonomy versus Shame and Doubt
During this period the child wants some independence from the mother. This happens
approximately at the age of 18 months to
3 years and this period is referred to as toddlerhood.
Initiative versus Guilt
This occurs at approximately 3 to 6 years, otherwise known as the pre-school years. The
child is able to initiate action on its own in an effort to manipulate the environment.
Industry versus Inferiority
This takes place during school years between the ages of 6 to 12 years. The child is able
to acquire skills in sports, calculate in figures and language skills are well developed.
Identity versus Role Confusion
This occurs around the age of 12 to 20 years and is referred to as adolescence. During this
time an individual acquires an identity as a male or female corresponding to specific roles
in the society.
Intimacy versus Isolation
This occurs at an approximate age of between 20 to 40 years.
Here, one has productive work and has satisfactory sexual relations with an intimate
member of the opposite sex.
Generativity versus Stagnation
This usually occurs between the ages of 45 to 65 years. During this period, one is
involved in establishing and guiding the next generation. Productivity and creativity is at
its peak.
Integrity versus Despair
This refers to the phase from around the age of 65 till death.
During this time one develops new and different love for one’s parents. One also
develops emotional integration and is able to defend the dignity of one’s own life-style
against threat.
The individual is capable of fellowship and will often take leadership responsibilities in
the community.

It is worth noting that, ...

It is worth noting that, it is only after satisfactory completion of one stage that one is
ready to move to the next. Any person who is unable to go through one stage successfully
would experience difficulties in subsequent stages of human development. For further
details, please refer to psychology in module one.

Social Learning Theory

Using Erikson's theory, how would you counsel a couple whose only child has
developmental problems during the adolescent period?

You should help the couple to assist their child to acquire acceptable social roles. You
should also tell them how to guide their child to accept body changes and be able to
socialise with age mates of both sexes. For more information, you can refer to your notes
on the stage of identity versus
role confusion.

Aetiological Factors of Mental Illness

You should now be familiar with the concepts of mental health.
You will now look at the components of psychiatric nursing, starting with the factors of
mental 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.
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.
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 demoralisation and withdrawal
from social activities.

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. For our
learning purposes here, this module will use the WHO classification.

The rationale and other details relating to these classifications are beyond the scope of
this module. Please find a copy and refer for details to the ICD 10 and DSM IV manuals,
which are easily available in WHO and medical training college libraries.

Introducing ICD 10

ICD10 is classified in the following manner.

F Organic, including symptomatic mental disorders.

0
Mental and behaviour disorders due to psychoactive substance
F
use.
1

F Schizophrenia, schizotypal and delusional disorders.

2

F Mood (affective) disorders.

3
 F Neurotic, stress related and somatoform disorders.
4
Behavioural syndromes associated with physiological
F
disturbances
5
and physical factors.

F Disorders of adult personality and behaviour.

6

F Mental retardation.
7

F Disorders of psychological development.

8
Behavioural and emotional disorders with onset usually occurring
F
in
9
childhood or adolescence.

The main aims of the ICD 10 working party, when they drew up the classification
system, were that they would create a system that:

● Was suitable for international communication on statistics of morbidity and

mortality
● Provides a reference for national and other psychiatric classifications
● Is acceptable and useful in research and clinical work
● Contributes to education

To achieve these aims, the classification also had to be acceptable to a wide range of
users in different cultures. It had to be practical in that it would be simple to use and easy
to translate into
different languages.

Factors that Influence Attitudes towards Mental Health and Mental

Illness

Having outlined the classification of mental illness, you will now turn your attention to
the factors that influence attitudes towards mental health and mental illness. In this
section, you are going to look at just a few examples.

Culture
The way people think, behave or feel is shaped by their culture. Culture also determines
the features of insanity, for example, who is labelled 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.

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.
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.

Principles and Qualities of Psychiatric Nursing

Having looked at the factors that influence attitudes towards mental health and mental
illness, you will now look at the principles of psychiatric nursing and various ways of
assisting the patient to overcome the prevailing problems.
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.

Minimise 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.
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.
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
(Peplau, cited by Wilson and Kneisl, 1988). You are also accountable to yourself as well
as professional colleagues and peers.
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 will inevitably help you, as a therapist, to understand other peoples’ behaviour,
needs and problems.

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.

Historical Trends in Psychiatric Nursing

Psychiatric nursing, and the understanding of mental illness, with which it associates, has
developed in several epochs through the centuries. You will now look at each of those
epochs in more detail.

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.

During that time people believed that the cause of mental illness was demons. The
treatment was quite harsh, degrading and dehumanising and involved 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.

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,
therefore, remained more or less as in the demonological period. Facilities were often
dark, humid and infested with lice. They were also overcrowded, leading to mass deaths
during outbreaks of disease such as the plague.

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.

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. 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.

In 1853, Dr. W.A.F Browne started giving informal mental health lectures to nurses so as
to give quality care.

By 1882, formal training on mental health had begun in America at McLean Hospital,
Boston.

In 1884, formal training in mental health was started in Germany and thereafter other
countries followed that example.

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 chemotherapy and
electroconvulsive therapy.

There are also various psychological treatments, which include:

● Individual/group psychotherapy
● Behaviour therapy
● Occupational therapy
● Rehabilitation
● Cognitive therapy
● Counselling

Some of these treatments will be covered in more detail in section two of this unit
The scientific period witnessed the integration of mental health services with other health
services. Trained manpower was developed to care for the mentally sick.

Men and women were either managed separately or in the same wards, depending on the
policy of the particular hospital.

Children were managed in special wards.

Where resources were available, different mental health conditions were managed in
different units

Development of Psychiatry and 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.

Mathari was the only mental hospital until the 1962 Decentralisation 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.

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.

Section 2: Admission and Discharge Procedures of Mentally

Sick Patients
Introduction
In this section, you will need to use the knowledge you gained on the classification of
mental disorders.

You will look closely at the admission and discharge procedure of mentally sick persons
using the Mental Health Act.

Objectives

At the end of this section you will be able to:

● Apply the knowledge acquired on legal aspects in admission and discharge of

patients
● Demonstrate skills in history taking

Mental Health Act (Cap 248) and 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.

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.
● 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.

The board may co-opt any person whose skills, knowledge or experience may be useful.
It may also establish a committee for better function and regulate its own procedure.

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.
● 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 organise 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.

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.

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.

Part VI - Involuntary Patients (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.

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.

Part VII - Emergency Admissions (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.

Part VIII - Admission and Discharge of Members of the Armed Forces

(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

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.

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.

Part IX - Admission of a Patient from Foreign Countries (Section 18 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.
● (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.
● 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.

According to this section of the act:

● On the admission of a person into a mental hospital under this section, not being a
person transferred to the mental hospital under section 23, the ‘person in charge’
shall within 72 hours or such longer period as the board may approve (i) Examine
the person or cause the person to be examined to determine the extent of the
mental disorder and the nature of treatment and
(ii) Within that period forward to the Board a report on the findings, together with
the warrant or other document from the foreign country concerned accompanying
the patient/person.
● A person shall not be detained in a mental hospital under this section for a period
longer than two months from the date of admission to the mental hospital unless
the board, on application in the prescribed forms by the ‘person in charge’,
approves.

Part X – Discharge and Transfer of Patients (Section 21 and 22 of 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.

Section 15 provides that:

Where any person has been received into a mental hospital under part V and part VI
(voluntary and involuntary mode of admission), the board may at any time order that the
person shall be discharged or otherwise dealt with under this act.

Section 22: Order for delivery of patient into care of relative of 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, subject to subsection (2), 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 subsection (1) 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 under section 7, subsection (1).

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, wilfully 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.
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 wilfully neglects any patient in the mental hospital, shall be guilty of an
offence.

Section 52:
Any person who without the consent of a ‘person in charge’ gives, sells or barters any
articles or commodities of any kind, to any patient in a mental hospital, whether inside or
outside the grounds of 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.

History Taking

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. You are now going to look
at all the steps involved in history taking.

Personal Data
Here you ask for information pertaining to age,
sex, marital status, occupation, residence
and nationality.

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.
 Sexual History
In taking down this information, you are aiming 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.

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.

You should 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.

Remember:
In an outpatient clinic, this information is better taken first, since the patient or the
informant would like to talk about it straight away.

Mental Status Assessment

Check facial expressions to provide information about mood, orientation to time, place,
person, concentration and perceptual disorder, where you should check for the following
senses:

● Olfactory
● Auditory
● Tactile
● Visual
● Gustatory

Thought Content
When checking the thought content, you should be on the lookout for grandiose or
 persecutory delusions, delusions of worthlessness or of preference and thought
insertion and thought broadcasting.

Memory
Pay attention to immediate memory (min/hrs), recent memory (days, weeks, months)
and past or remote memory
(10 years and above).

Mood
Try and evaluate whether the patient is manic, depressed, labile or flat.

You should also try and establish the patient’s judgment, by checking for signs of logical
thinking. In addition, you should look into whether or not the patient has ‘insight’, that is,
whether or not they are aware of their mental illness.

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.

Section 3: Treatment Used in the Management of Mentally

Ill Persons
Introduction
In this section you will look at indications, effects, side effects and contraindications of
various drugs used in the management of mentally ill patients. These drugs fall under the
categories of tranquillisers, antidepressants, anti-anxiety and
antiparkinsonian drugs.

Also you will cover psychological treatment, psychotherapy, behaviour therapy and
rehabilitation.
Objectives

At the end of this section you will be able to describe treatments under the following
headings:

● Drugs and other physical treatments

● Psychological treatments

Drugs and Other Physical 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
● Antidepressant
● Anxiolytics or Anti-anxiety Drugs
● Antiparkinsonian Drugs
● Electroconvulsive Therapy (ECT)

You will now look at each of these categories in turn.

Antipsychotic Medication

Antipsychotic drugs are also called major tranquillisers or neuroleptics used in the
treatment of psychoses like schizophrenia, bipolar disorders (manic phase) and alcohol
withdrawal disorder.
Antipsychotic Drugs
Generic Name Trade Name Daily Doses (range)
Low Potency Drugs
Chlorpromazine Largactil 300-1000mgs
Domatil,Sulpare
Sulpride 200-2400mg
x
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
Trifluoperazine Stelazine 5-30mg
Zuclopenthixol Clopixol 20-150mg
Pimozide Orap 2-10mg
Depot Injections
Fluphenazine 12.5-100mg(IM 2
Modecate
decanoate Weekly)
Zuclopenthixol Clopixol 50-150mg every 2-3
Acetate Acuphase days
Haloperidol Haldol 50-300mg (IM 4
decanoate decanoate weekly)
Mechanisms of Action

The drugs are thought to work by blocking dopamine receptors causing a decrease in
psychotic symptoms. The drug is 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.

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.

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 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.

Remember:
Use of more than one phenothiazine is not recommended.
Geriatric patients should be given lower dosages to avoid hypertension due to
prolonged half-life in people aged over 55 years.

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.
● 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.

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

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.

Contraindications

Comatose, glaucoma, prosthetic hyperplasic, acute myocardial infarction are

contraindications to the use of these drugs (Gertrude and McFarland, 1986).

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.

Table showing some examples of antidepressant drugs.

Generic Trade Daily Dosage

Major Groups
Name Name (range)
Amitriptylin Elavil
Tricyclic antidepressants 75-300mg
e (laroxyl)
Imipramine Tofranil 100-300mg
Tetra cyclic anti-depressants Maprotiline Ludiomil 75-300mg
Isocarboxaci
Monoamine Oxidase Inhibitors Marplan 10-60mg
d
Phenelzine Nardil 45-90mg
Selective Serotonin Reuptake
Fluoxetine Prozac 20mg
Inhibitors
Citalopram Cipramil 20-60mg
Paroxetine Seroxat 10-50mg
Mechanisms of Action

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.

The patient may respond to the treatment in several ways.

They may exhibit drowsiness in early stages, which later subsides. Hypotension may be
experienced initially, leading to feeling of fainting. Withdrawal symptoms may be
experienced if the drug is not gradually stopped.

As previously mentioned, lower dosages are indicated for geriatric patients since they are
more sensitive to the drug and its
side effects.

Side Effects

According to Gertrude and McFarland (1986), some of the side effects that might be
experienced 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.

Under such circumstances, stopping the use of the drug is the intervention of choice.

Meanwhile, 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.

The main form of treatment when side effects occur is to discontinue the drug and then
give regitine to lower the blood pressure.

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

Having looked at major tranquillisers and antidepressants, now you will look at minor
tranquillisers.
Remember:
Anti-depressants should be discontinued
prior to surgery.

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.

For the purposes of your study, you are mainly interested

in diazepines.

Effects

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

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.

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.

It is worth noting that 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. This can be repeated one hour after the initial
dose.

Antiparkinsonian Drugs

These are drugs given to counteract the side effects of

major tranquillisers.

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

Side effects include dry mouth, nausea, constipation, urinary retention, blurred vision,
disorientation and confusion.

Electroconvulsive Therapy (ECT)

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.

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.

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 as explained earlier. 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.
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. Although
deaths during treatments are rare, a supply of colamine to counteract barbiturates and the
usual supply of emergency equipment must be at hand.

Psychological Treatments

Having completed your look at the physical treatment methods, you will now look at
some of the psychological treatments used to treat patients suffering from mental health
illness.

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.

There are two main types of psychotherapy:

● Individual psychotherapy
● Group psychotherapy

Individual Psychotherapy
Individual psychotherapy can be further sub-divided into several categories.

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.

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 the patient to overcome their symptoms and
cope with them satisfactorily in future.

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.
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.

There are several benefits associated with the group therapy method. These include:

● 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

Behaviour 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:

1. 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.
2. Changing the behaviour from outside. This is achieved through positive
reinforcement of acceptable behaviour and negative reinforcement for
unacceptable behaviour.

Activity Therapy
There are several 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.

Recreation Therapy
This method uses activities like sports, games, hobbies to treat behaviour.

It lays the emphasis on re-socialisation, reality orientation and involvement of mentally

ill persons.

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.

This aim is achieved through:

● Physical therapy
● Occupational therapy
● Vocational training
● Industrial/ work therapy
● Recreation or social therapy
Section 4: Management of Common Mental Health Conditions
Introduction
In this section you will be required to reflect on the classification of mental illness. This
knowledge will assist you to better understand any of the conditions that might come
under discussion. For each condition, efforts will be made to include definition, causes,
psychopathology, clinical features, methods of diagnosis
and management.

To avoid repetition, the content of psychopathology will be treated as a separate topic at

the beginning. You will then be expected to apply the knowledge in all relevant mental
health conditions

Objectives
By the end of this section you will be able to:

● Define psychopathology
● Describe mental illness
● Describe some of the more frequent psychotic conditions

Psychopathology

Psychopathology is defined as the study of abnormal states of mind. There are many
approaches to psychopathology but in this material, developmental psychopathology will
be used. This approach examines different maladaptive behaviours displayed during
childhood, adolescence and adulthood. Since personality development is a continuous
process, behaviour in childhood and adolescence do overlap. It is important to note that
emotional problems in childhood can surface later and plague a person
in adulthood.
There are several vulnerability issues regarding children that you should always keep
in mind.
Since children do not have realistic view of themselves and their world, they have less
self-understanding and have not developed a stable sense of identity. Therefore, children
have less developed coping mechanisms when it comes to dealing with stressful
situations. Children tend to use unrealistic concepts to explain events since they have
limited perspectives. For example, in an effort to join a dead parent, the child may
commit suicide.
Children are protected against stress by parents since they are dependent on them.
However, if the parents ignore the child, they experience rejection, disappointment and
failure. Since children lack experience in dealing with problems, ordinary hardships
are magnified.
Problems that look minor to adults easily hurt children causing psychological trauma.
These series of traumatic experiences may surface later in life in the form of mental
illness.

Schizophrenia

Schizophrenia is a group of mental disorders that presents with varied symptoms of

disordered thinking and bizarre social behaviour. It affects approximately 1% of the total
population, including adolescents and young adults. There is increased incidence in the
lower social class. Patients with this condition occupy 50% of beds in mental hospitals.

Generally:

● 25% of patients diagnosed with schizophrenia recover completely.

● 50 to 65% have residual symptoms
and relapses.
● Approximately 10% remain ill.

There are several risk factors associated with the conditions. Schizophrenia is often
witnessed in individuals with family members who have schizophrenia or in children who
are:

● Highly individualistic in their thought processes.

● Overtly independent and obedient.
● Shy, withdrawn and loners.
● Unmanageable, prone to destructive, aggressive behaviour.
● Truant from school.
● Sensitive to separation.
There is no single cause but research studies indicate several possible factors. These
include possible hereditary factors or disturbances in the neurotransmitter system. The
condition can also be traced back to disturbed family interaction patterns, for example,
family schism and faulty familial communication and environmental stresses such as
major crisis or migration.

The condition manifests in several ways. Early signs include:

● Blocking or cutting off conversation with friends

● Expressing various body symptoms
● Forgetting or abandoning plans or life goals
● Disregarding social customs

As the condition progresses, the patient exhibits a tendency towards separation, rejection
or substance abuse like alcohol.

In the acute phase, the patient will experience:

● Auditory and visual hallucinations.

● Illusions.
● Delusions of persecution, grandeur or impending distraction.
● Autistic thinking characterised by being highly personal.
● Speech characterised by incoherence, echolalia, neologisms and unwillingness to
speak.
● Inappropriate behaviour, for example, grimacing, negativism, suggestibility and
poor personal hygiene.
● Blunting ambivalence and inappropriateness of affect.

The next phase is known as the residual phase. At this stage, the patient usually exhibits
symptoms of flat or blunt affect, rambling speech, poor hygiene and grooming and
distortion of some perceptual experiences may persist.

Finally, in the chronic/relapse phase, the patient may point to feelings of boredom and
apathy, impulsive suppression of feelings and psychotic disorganisation with increasing
perceptual and cognitive dysfunction, loss of identity and loss of self-control.

There are several types of schizophrenia, which you will know look at in detail.

Catatonic Schizophrenia

This is a disorder characterised by a stuporous state in which the person is mute, negative
or
complains in response to a request. The individual may be immobile, display waxy
flexibility and may retain urine and faeces.
It may alternatively be characterised by a highly excited state in which the person is
abusive, aggressive, hyperactive or agitated
(catatonic excitement).

Disorganised Schizophrenia

This is a disorder characterised by incoherence, foolishness and regressive behaviour.

Paranoid Schizophrenia

This is a disorder characterised by delusions of persecution or grandeur.

Undifferentiated Schizophrenia

This disorder is characterised by a variety of symptoms found in several of the types of

schizophrenia that have previously been covered above, and are known as simple types.

Treatment

The nurse should arrange short-term, intermediate and long-term goals for the patient on
drug treatment

Short-term Goals

These are goals that can be accomplished in the shortest time interval and must be done
before the patient can move on to accomplish other types of goals. For example, to ensure
that the patient establishes contact with
the nurse.

Intermediate Goals

An intermediate goal might be for a patient to express their feelings in whatever mode
they are able. This is not possible before the patient learns sufficient trust to share their
painful and unacceptable thoughts. The patient must give up behaviours that hinder
nurse-patient interaction in the working phase.

This goal involves certain behaviour on the part of the nurse that permits the patient to
draw closer to them, including actual physical care of the patient.

Long-term Goals
To attain this objective, the patient needs to trust other people, and to communicate fully
enough so that others become familiar with the patient's symbolic representations and
characteristic modes of thought.

Another long-term goal would be to help the patient identify living situations that cause
them great anxiety and help them to learn how to reduce their own tension before their
ego begins to shatter under the impact of the forces impinging on them.

A variety of therapies are available and include the following:

● Short hospitalisation to assist with the problem of being a danger to themselves or

others, of deviant behaviour that is abrasive to the family and community and
monitoring effects of drugs or other therapies.
● Outpatient treatment to provide aftercare, maintenance therapy, social support
programs and medical clinics.
● Rehabilitation services to provide opportunities to increase skills in living such as
vocational rehabilitation, foster home care and halfway houses.
● Drug therapy with antipsychotics to assist in alleviating symptoms and increasing
patients availability for psychotherapy (refer to the section three on chemotherapy
in treatments used in psychotherapy).
● Individual and group psychotherapy to assist patient in daily problems by
exploring relationships, sources of anxiety and coping techniques. In group
therapy support is offered on how to cope with problems encountered in everyday
life.
● Family therapy to assist in defining the problem as one concerning the entire
family rather than concerning the patient alone, to improve communication, to
clarify roles within the family, to manage stress and to assist in problem solving.

It is also important to provide some basic health education to the patient. This would
include the following steps:

● Teach patient and family various ways of obtaining help in improving work,
educational and social skills.
● Stress the need for re-hospitalisation if the need arises.
● Teach the patient how to take medication and how to tolerate and/or adapt to side
effects of the drugs.
● Patient and relatives should be taught how to identify stress early and then use
problem solving skills.

● Family members should be taught how to supervise the patient's medication and
how to respond to disturbing behaviour.
● Provide information on the nature of schizophrenia and the treatments available.
● Stress the importance of not using illicit drugs and alcohol.

Nursing diagnosis of schizophrenia should refer to:

 ● Poor or lack of insight.
● Non-compliance.
● Aggression.
● Impaired communication.
● Suspiciousness.
● Impulsiveness.
● Sensory/perceptual alteration: visual, auditory, gustatory,
kinaesthetic, tactile.
● Self-care deficit: feeding/hygiene, dressing/grooming, toileting.
● Coping is ineffective.
● Suicidal tendencies.
● Alteration of thought process.
● Disturbance in self-concept, that is, disturbance in self-esteem, role performance
and personal identity.

For an individual to be diagnosed as having schizophrenia, symptoms must persist for

six months with one month of acute symptoms.

Affective Disorders

Affective disorders are a group of mental disorders that present mainly with symptoms of
mood disturbance with associated changes in thinking and behaviour. In terms of their
incidence, females outnumber males 2:1. An estimated 20%-50% of people over 65 years
of age experience depression.

Bipolar disorders occur before the age of 30, while depression occurs at any age.
Depression occurring for the first time after the age of 40 frequently indicates underlying
physical illness. Depression is frequently associated with other medical disorders or
treatment, for example, alcoholism, cancer and/or the side effects of some drugs used in
the treatment of hypertension.

No single causal factor has been identified but hypotheses and research indicate several
possible causes. These include:

● Genetic factors.
● Disturbance in the neurotransmitters system, involving norepinephrine, serotonin,
dopamine, acetylcholine.
● Disturbance of steroid hormones.
● Stressful life events prior to onset of illness.
● Lack of social support.
● Depression is hostility turned against yourself, while mania is hostility projected
at others.
● The individuals view themselves, the future and the current experiences in a
negative way.
● Family interaction patterns in which a child experiences high expectations of
achievement by parents and little approval for being themselves.
The conditions manifests in different ways depending on the type of disorder.

Major Depression

Symptoms include sadness, apathy, feelings of worthlessness, self-blame, thoughts of

suicide, desire to escape, avoidance of simple problems, anorexia, weight loss, lessened
interest in sex, sleeplessness, reduction in activity or ceaseless activity. In infants and
older children, symptoms include a refusal to eat, listlessness, lack of activity, fear of
death of a parent and fear of separation from parents. In adolescents, symptoms are social
isolation, negative attitude, sulkiness, feeling of being unappreciated and acting out in
antisocial ways.

Bipolar Disorder

This is a disorder in which there are alternating periods of depression and mania. Bipolar
disorder manic episodes exhibit symptoms of hyperactivity, speech pressure, hyper
sexuality, delusions, abusive and sleeplessness. Meanwhile, bipolar disorder depressive
episodes exhibit symptoms similar to those of major depression.

There are several forms of treatment. You will now look at some of these in more detail.

Hospitalisation

This is used in acute mania and in depression when there is evidence of poor judgment,
weight loss and a lack of emotional support.

Drug Therapy with Antidepressants or Antimanic Drugs

Examples of drug therapy treatments include antidepressants. As a hypothetical

treatment, using tricyclic medication, for example, imipramine. Build up to the effective
dose over
7-10 days. Start with 25-50mg each night and build up to 100-150mg. Withdraw the
medication slowly and monitor for withdrawal reaction and to ensure remission is stable.

You can also use antimanic drugs.

Drug Therapy with Antidepressants or Antimanic Drugs

If the patient displays excitement or disruptive behaviour, antipsychotic medication is

needed initially, for example, haloperidol, at a dose of 1.5-4mg up to three times a day. In
acute agitation, benzodiazepines may be used in the short term in conjunction with
antipsychotic drugs, for example, diazepam
5-10mg up to four times a day.

Another drug that can be used is lithium. One usually commences or stops taking lithium
with the advice of a specialist to help relieve mania and depression. It also prevents
episodes from recurring. Levels of lithium in the blood must be measured frequently
when adjusting the dose, and every three months in stable patients. Ten to fourteen hours
post-dose the desired level is 0.4-0.8mmol/litre. Lithium should be stopped immediately
if blood levels are more than 1.5mmol/litre or there is diarrhoea and vomiting.

Drug Therapy with Antidepressants or Antimanic Drugs

Other forms of treatment include:

● Electro Convulsive Therapy (ECT): used in severe depression or mania.

● Psychotherapy used to deal with issues of dependency and manipulation of loss
experience and self-destructiveness.
● Behaviour therapy, which focuses on rewarding acceptable behaviour and
providing social skills.
● Maintenance of social support by family members, workmates, etc.

● Assessment for suicide ideation particularly for the depressed patients and prompt
intervention.
● Health education is necessary to provide the patient with information about
affective disorders, major treatments
and prognosis.
● Assist the patient and family in learning ways to manage stress.

Substance Use Disorders

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.

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.

Signs of drug withdrawal include:

● Opioids lead to nausea, sweating, hallucinations.

● Sedatives lead to anxiety, tremors, hallucinations.
● Stimulants lead to depression, moodiness.

The family may request help before the patient does, as often, the patient is irritable at
home, or missing work. The aim is to assist the patient to remain healthy until, if
motivated to do so, and with the necessary help and support, they can achieve a drug-free
life.

Diagnostic Features

There are several diagnostic features associated with substance abuse. 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.

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.

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.

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.

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 counselling
and/or rehabilitation.

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 counselling and/or rehabilitation.

In the case of patients who do not succeed or relapse:

● Identify and give credit for any success.

● Discuss situations that led to the relapse.
● Return to earlier steps.

The medication to be used varies according to the specific drug withdrawal. You should
always make sure that you do not only give the patient the right medication, but that you
are also able to help the patient deal with life problems, employment, social relationships,
etc. This is a very important component of the treatment process.

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.

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.

Diagnostic Features of 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.

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.

Tolerance refers to the individual who is able to drink large amounts of alcohol without
appearing intoxicated. They continue alcohol use despite the harmful consequences.

Blood tests such as Gamma-Glutamyltransferase (GGT) and Mean Corpuscular Volume

(MCV) can help identify heavy alcohol drinkers.

Management of Alcohol Abuse

There are many similarities in the management strategies used for patients who have
substance abuse problems and those who have alcohol abuse problems. For patients with
physical illness and/or dependency or failed attempts at controlled drinking, an
abstinence programme is indicated.

If you have a patient who is willing to stop now:

● Set a definite day to quit.

● Consider withdrawal symptoms and how to manage them.
● Discuss strategies of avoiding drinking, for example, ways to respond to friends
who still drink.
● Consider options for support after withdrawal.

For patients not willing to stop or reduce alcohol use immediately, a harm reduction
programme may be indicated:

● Do not reject or blame the patient.

● Point out clearly medical, psychological and social problems caused by alcohol
use.
● Consider thiamine preparations (150mg per day in divided doses should be given
for
one month).
● Make a future appointment to reassess health and alcohol use.

In the case of patients who do not succeed or have a relapse, you should identify the
problem that caused the relapse and give the patient credit for any success. You should
also discuss situations that led to the relapse and return to earlier steps.

You may wish to recommend self-help organisations, for example, Alcoholics

Anonymous. Most voluntary and non-statutory agencies are often very helpful.

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.

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.

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. You may want to
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.

Section 4: Management of Common Mental Health Conditions

Day 1 and 20- QD
2 30mg S
Day 3 and QD
15mg
4 S
QD
Day 5 10mg
S
QD
Day 6 10mg
S
QD
Day 7 10mg
S

Daily Treatment

An expert should be involved in case monitoring for the first few days.

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

Referral

The patient should be referred for hospital detoxification, if they do not meet the criteria
for community detoxification.

In addition, the patient should also be referred for targeted counselling, if available, to
deal with the social causes or consequences of drinking, for example, relationship
counselling.

Organic Disorders
Organic disorders represent a group of mental disorders that present a variety of
symptoms, especially a disturbance of cognition. Delirium is common in general
hospitals with an estimated 5%-15% of patients exhibiting the symptoms. Meanwhile,
dementia impairs about 1,000,000 people. Alzheimer's disease is the most common type
of organic disorder.

Delirium

Families may request help because the patient is confused or agitated. The patients may
appear uncooperative or fearful. Occasionally, delirium may occur in patients
hospitalised for physical conditions.

Diagnostic features include an acute onset, usually over hours or days, of confusion
where the patient is disoriented and struggles to understand surroundings. This is
evidenced by clouded thinking or awareness. 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.

Some of the main causes of this condition have been identified as:

● Alcohol intoxication or withdrawal.

● Drug intoxication, overdose or withdrawal.
● Infection.
● Metabolic changes, for example, liver disease, dehydration, hypoglycaemia.
● Head trauma.
● Hypoxia.
● Epilepsy.

Medication for Delirium

When prescribing medication, you should avoid the use of sedatives or hypnotic
medications, for example, benzodiazepines, except for the treatment of alcohol or
sedative withdrawal. Antipsychotic medication in low doses may be needed to control
agitation, psychotic symptoms or aggression.
Drugs with anticholinergic action and antiparkinsonian medication can exacerbate or
cause delirium.

You should offer advice and support to the patient and their family. You should also
prevent the patient from harming themself or others, for example, by removing unsafe
objects or restraining the patient if necessary. In addition, ensure that supportive contact
with familiar people is maintained so as to reduce confusion. Keep in mind that
hospitalisation may be required because of agitation or physical illness, which is causing
the delirium.

Referral for Delirium

Referral to secondary mental health services is rarely indicated. However, referral to a

physician is always necessary if the cause of the dementia is unclear or if the patient
presents with drug, alcohol withdrawal, overdose or any other underlying condition that
requires in-patient medical care.

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.
● 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.

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.

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.
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.
● 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.

Referral for Senile Dementia

The patient should be referred to a specialist to confirm diagnosis in complicated cases.

They may also be referred to social services for practical help, for example, home help
and day care. If there are behavioural problems, the patient should be referred to a
psychiatrist. These usually involve complex family relationships and might be precursors
to a depressive or psychotic episode

Psychoses Associated with Pregnancy and Childbirth

These are psychiatric illnesses that have been precipitated by either pregnancy or
childbirth. They may occur during pregnancy or within six weeks after delivery. The
peak is common within two weeks after delivery. In pregnancy, these disorders often
occur during the first and third trimester.

Unwanted pregnancies are associated with anxiety and depression in the first trimester. In
the third trimester, there may be fears related to the impending delivery or doubts about
the normality of the foetus.

The condition is more frequent in:

● Primigravidas.
● Those who have suffered previous major psychiatric illness.
● Those with history of mental illness.
● Those with serious medical problems affecting the course of the pregnancy, for
example, diabetes mellitus. (Obstetricians and midwives consider mothers with
these conditions as mothers at risk.)
The causes of psychoses associated with pregnancy and childbirth are not conclusive.
However, it has been proposed that there are several possible causal factors.

These include:

● Pre-existing predisposition. Some women have a hereditary or personality

predisposition to develop mental illness. The women are asymptomatic until
pregnancy or delivery which then acts as a stressor precipitating psychosis.
● Hormonal changes, that is, the early onset of puerperal psychosis has led to
speculations that they may be caused by hormonal changes.
● Psychological factors, which refer to psychological stresses, especially during the
first and third trimester when the anxiety level is high.
● Social factors, that is, pre-existing marital constraints, for example, lack of social
support from the husband.
● Biological factors usually associated with physical illness.

There are several psychiatric conditions that are precipitated by factors associated
with pregnancy and childbirth.

Acute Organic Psychosis

This has declined with good obstetric care but can occur when care is inadequate, for
instance, puerperal sepsis.

Functional Disorders

These can occur in the form of manic-depressive psychosis, depressive or manic phase.
Depression is the most common form, and may result in suicidal ideation, guilt and/or
negative feelings towards the baby. For example, the mother may think that the child has
a serious ailment and for that reason she should kill it to save it from suffering.

Schizophrenia

This tends to develop sooner and is more acute than depression.

Schizoaffective Disorders

Schizoaffective disorders incorporate features of schizophrenia and affective disorder,

which appear in the same person at the same time.

The clinical presentation will depend on the presenting condition.

Management

Medical treatment will depend on the form the illness has taken. Patients who are
moderately to severely depressed, usually benefit from ECT. This enables the patient to
recover quickly so that they can resume the care of the baby. If the patient is less
depressed, antidepressants may be tried first.

In schizophrenic patients, phenothiazines are given. If improvements are delayed,

phenothiazines may be combined with ECT. In puerperal sepsis, appropriate antibiotics
must be given.

Great care must be taken in the use of psychotropic drugs because of the risk of foetal
malformations, impaired growth and pre-natal problems.

Where possible, avoid using tricyclic antidepressants or neuroleptics unless there are
compelling clinical indications. Where the illness is endangering the patient's life and no
alternative treatment is available or favourable, then termination of pregnancy should be
considered.

Nursing Management

Nursing management depends on the form the illness has taken. The patient should be
nursed in a therapeutic environment. For example, a depressed patient may be
contemplating suicide and should, therefore, be nursed on the ground floor to prevent her
jumping to her death. Preventive precautions necessary for suicidal patients must be
taken.

Where facilities are adequate, a separate nursery where the child can be nursed must be
utilised.
In order to promote lactation, a well balanced diet rich in proteins and a lot of fluids must

be provided.

As the patient improves, involve her in occupational therapy and psychotherapeutic group
activities in order to rehabilitate and socialise her. You should also provide health
education for the husband and other relatives on the causes, course and treatment of the
illness.

The best way of preventing this condition is:

● Identification of risk groups.

● Good obstetrics care during antenatal, delivery and postnatal periods.
● Supportive psychotherapy.
● Health education on clinic follow-up and drug compliance.

Abnormalities of Sexual Preference (Paraphilias)

This concept has three dimensions. The first dimension is related to social life. The
behaviour of the individual does not conform to what is generally regarded as normal
behaviour. However, you should note that the accepted view of what is normal in one
community does not necessarily apply to other communities. The second dimension is
concerned with the harm that may be inflicted on the sex partner. The third dimension
concerns itself with the suffering experienced by the persons themselves.

There are various ways through which sexual preference abnormalities may reach a
medical practitioner. One way is through direct approach by the persons themselves.
Another situation is where the patient will seek sexual help for the spouse or other sexual
partner. Sometimes the patients may present themselves as having sexual dysfunction and
it is only with time that the doctor will discover the abnormality of sexual preference.

Abnormalities of Sexual Preference of Sexual Object

These abnormalities are usually divided into two groups. The first one is the
abnormalities of the object of the person's sexual drives. The second one refers to the
abnormalities in the preference of the sexual act. You will now take a look at a few
abnormalities of sex object. This mainly involves preference for an object other than
another adult in the achievement of sexual excitement.

Paedophilia

Sexual excitement is achieved through having sexual activity or through fantasy of such
activity with pre-pubertal children.

Treatment involves behavioural therapy and group treatment, which have, unfortunately,
had little success. General measures (to be found at the end of this section) can also be
tried.

Fetishism

This involves the use of an inanimate object as a means of attaining sexual excitement. It
could also involve parts of the human body that are not related with sex act. It is not
uncommon for men to be sexually excited by a part or clothing of a female. However, the
behaviour becomes abnormal when it takes the precedence over usual sexual intercourse.

Psychoanalysis and behaviour therapy are the recommended forms of treatment.

The general measures at the end of the section can be applied as well.

Abnormalities in Preference of Sexual Act

This group of abnormalities involves a variation in the behaviour that is carried out so as
to get sexual arousal. The behaviour is usually directed towards adults but occasionally
children are involved. Exhibitionism is an example of such behaviour.
Exhibitionism

This is the repeated exposure of genitals to unprepared strangers in order to get sexual
excitement but with no further effort to have sex with the stranger concerned. The
average age is 20-40 years and the condition is usually found in men (Gayford, cited by
Gelder et al., 2000).

The treatment approach that has been found to be most effective is a combination of
counselling and behavioural techniques. Counselling deals with personal relationships
while behaviour deals with self-monitoring. Self-monitoring involves the identification of
circumstances that initiated the behaviour so as to avoid them.

Drugs that reduce sexual drive like cyproterone acetate have also been used, however,
they are not generally recommended due to uncertain results and problems.

Abnormalities of Gender Identity

Transsexuals have been grouped under this category. People who are transsexual have a
strong belief that they are of a gender opposite to that signified by their external genitalia.
The person concerned has a strong urge to live like a member of the opposite sex. They
feel strange in their bodies and want to change their body appearance to suit the desired
gender.

Although transsexualism is a psychological problem, people often seek treatment that is

aimed at the body and not the mind. Physical changes are not recommended. However, if
a decision is made to undertake them, it should be made in stages, despite the radical
demand by the patient, so as to give the patient time to adjust to the changes they are
undergoing, as well as to evaluate the decisions that have
been made.

The treatment that is most recommended is supportive psychotherapy. The therapist tries
to convince the patient to accept the current status. Unfortunately, this is
rarely successful.

General Assessment and Management of Abnormalities of

Sexual Preference

The first step in the assessment is to exclude mental illness since abnormal sexual
preference, is commonly secondary to dementia, alcoholism, depressive disorders or
mania. These illnesses are thought to release previous fantasies that had not been acted
upon. This is mainly true if the onset is middle age or later.

An inquiry should be made into sexual practices bearing in mind that one can have
diverse sexual practices. Details of normal heterosexual vigour and interest are taken both
in the present and in the past. If possible, an interview should be arranged with the
patient's regular partner. The patient should be asked to explain what role the abnormal
sexual preference is playing in their life. For example, it could be providing comfort in
addition to being a source of sexual excitement.

Patients seek treatment for paraphilias due to different motives. Some do it because their
sexual partner, relative or police know about it. Though treatment is sought, the patient
may have little desire to change since they are happy when told that nothing can be done.
Occasionally, patients may seek treatment due to depression caused by guilt. During such
moments, the urge to change is high but this often fades when normal mood is restored.
The recommended form of treatment is psychotherapy, behaviour therapy and
psychoanalysis.

Neurotic Disorders in Adolescents and Adults

Anxiety disorders are a group of mental disorders in which anxiety is the main concern.

The psychodynamic theory views anxiety as arising from conflicts that are usually sexual
and aggressive. There are several types of anxiety:

● Superego anxiety, for example,

fear of being found guilty.
● Castration anxiety, for example,
fear of bodily mutilation.
● Separation anxiety, for example,
fear of loss of significant relationship.
● Impulsive anxiety, for example,
fear of the control of impulses.

● Obsessive-compulsive disorders arise during the developmental stage.

The patient uses the defence mechanism of undoing, isolation and reaction
formation.
● Phobic disorder is characterised by the use of the defence mechanism of
displacement and avoidance to deal with castration anxiety and oedipal drives.
● Automatic learning of responses to situations that are anxiety provoking.

You will now move on to look at the clinical manifestation and management of selected
types of anxiety disorders.

Generalised Anxiety Disorders

Generalised anxiety disorders usually present with tension-related physical symptoms, for
example, headache, pounding heart, insomnia, and/or sweating.

Diagnostic Features of Anxiety Disorders

There are multiple symptoms of anxiety or tension,

which include:
 ● Physical arousal, for example, dizziness, sweating, a fast pounding heart, a dry
mouth, stomach pains or chest pains.
● Mental tension, for example, weariness, feeling tense or nervous, poor
concentration, fear that something dangerous will happen and not being able to
cope.
● Physical tension, for example, restlessness, headache, tremors or an inability to
relax.

Symptoms may last for months and recur regularly. Often they are triggered by stressful
events in those prone to worry.

Management of Anxiety Disorders

Medication is secondary to treatment in the management of general anxiety. If anxiety

symptoms exist, anti-anxiety medication, for example, diazepam may be used. However,
it should not be used for longer than two weeks so as to avoid dependence.

Antidepressants, for instance, imipramine or clomipramine may also be used, especially

if symptoms of depression are present. These drugs do not cause dependence but can lead
to withdrawal symptoms, therefore, they should be tapered gradually.

Other forms of management include:

● Psychotherapy, used in various forms, with focus on analysing unconscious

conflicts, interpersonal conflicts, or providing supportive measures.
● Relaxation technique which helps the patient not to be tense and to relax.
● Teaching the patient ways of monitoring themselves for increasing anxiety and
taking appropriate action. This is termed as self-care and is especially applicable
in cases of milder anxiety.

Hospitalisation is used for short periods when symptoms become intense and family
ability to give support at that time is limited.

Conversive and Dissociative Disorders (1 of 2)

Patients present with unusual or dramatic physical symptoms, such as severe amnesia,
trance, loss of sensation, visual disturbances, paralysis, aphasia, identity loss, confusion
or possession states. The patients are not malingering since they are not aware of their
role in their symptoms.

Diagnostic features include physical symptoms that are unusual in presentation and not
consistent with known disease. The onset may be sudden and related to psychological
stress or difficult personal circumstances.

In acute cases, symptoms may be dramatic and unusual, may change from time to time
and may be related to attention from others.
Differential Diagnosis

You should ensure that you have carefully considered physical conditions that may cause
the same symptoms and rule them out through full history, physical examination and
laboratory investigations.

Management

When medicating the patient, you should avoid anxiolytics or sedatives. In more chronic
cases with depressive symptoms, antidepressants may be helpful.

The patient and the family should be informed that physical or neurological symptoms
often have no clear cause. Symptoms can be brought about by stress. They should also be
aware that symptoms usually resolve rapidly, from hours to a few weeks, leaving no
permanent damage.

The following advice should be given to both the patient and their family:

● Encourage the patient to acknowledge recent stresses or difficulties.

● Advise the patient to take a brief rest and relief from stress, then return to usual
activities.
● Advise against prolonged rest or withdrawal from activities.

Phobic and Anxiety Disorders

These are disorders having generalised anxiety only in particular circumstances - these
people are free from anxiety most of the time. Another characteristic of phobic disorders
is avoidance of the
feared object.

Simple Phobia

This is a disorder characterised by inappropriate anxiety in the presence of the feared

object or situation. For example:

● Arachnophobia, that is, fear of spiders.

● Acrophobia, that is, fear of heights.
● Others include phobia of dental treatment, phobia of flying, and phobia of illness.

Simple phobias usually start in childhood and persist until adulthood. Under stressful
situations it can start in adulthood. Genetic vulnerability has also been proven through
twin studies (Kendler et al cited by Gelder et al, 2000). Phobia that persists from
childhood has poor prognosis as compared to one starting in adulthood. Treatment is
through graded exposure to the feared objects or situation. This can reduce the intensity
of fear but rarely is phobia
cleared completely.
Social Phobia

This refers to inappropriate anxiety experienced in situations where one is observed and
criticised. Such places include restaurants, canteens, dinner parties, seminars, board
meetings, or other such situations where one may be observed
and criticised.

It is wrong to avoid the feared objects or situations. Psychological treatment is

recommended. This includes:

● Social skill training

● Relaxation
● Exposure to feared situation

Cognitive behaviour therapy is the most appropriate treatment where exposure is

combined with management of anxiety.

Agoraphobia

This is fear experienced by anxious individuals while away from home, in crowds or in
situations that they cannot leave easily. In addition to the general features in phobia,
agoraphobia has frequent symptoms such depression, depersonalisation, and obsessional
thoughts. Situations that provoke fear include buses, trains, shops, and supermarkets.
Occasionally, agoraphobia may be precipitated by
anticipatory anxiety.

Cognitive hypothesis says that agoraphobia develops in people who are unreasonably
afraid of minor physical illness. The biological hypothesis says that the initial anxiety
attack results from environmental stimuli acting on those already predisposed.

Meanwhile, the psychoanalytic hypothesis attributes agoraphobia to unacceptable sexual

or aggressive impulses. It is commonly found in people who are dependent and who tend
to avoid rather than confront the problem.

With regard to treatment, in the early stages, patients are counselled to return to the
situation they are avoiding. Later stages require behaviour therapy combined with
exposure to the feared situations. Anxiolytics are used on special occasions when the
patient is expected to undertake important engagement. However, drugs are discouraged
in order to avoid dependence. Antidepressants are used to treat accompanying depressive
disorder.

Disorders of Infancy and Childhood

It is important to remember that you should keep in mind that there are special features of
working with children. Unlike adults, children are not free and independent. Children are
always tied to or dependent upon their parents or some comparable caretakers. They are
usually brought for treatment by their parents.

It is impossible, therefore, to make lasting progress without involving either their parents
or guardians. The nurse is required to establish good rapport with both the child and the
parents/parent substitute. If this is not done, the nurse can easily be left with the child by
the frustrated parents.

It is worth noting that children come into treatment with limited coping skills, less
developed defence mechanisms and less ability to conceptualise than adults. Nurses
should, therefore, avoid direct interpretation of the child's behaviour so as to avoid
overwhelming the child with anxiety.

Since children have less impulse control and awareness of control than adults, they need
clear and firm limits. In order to assess the child's feelings and problems, it can be useful
to use drawings, dolls, puppets, clay and games.

Autistic Disorders

Autism is a state of psychotic disorder which has its onset in early infancy. Initially the
disorder was associated with an unsatisfactory mother-infant relationship. This belief is
held to be true to this day, however, researchers continue to examine the potential
genetic, biochemical, and physical bases for the disorder.

Autistic children are characterised by several symptoms, including:

● Self-involvement
● Withdrawal
● Severe impairment in verbal communication and in interpersonal relationships
● Bizarre stereotyped or ritualistic responses to the environment

Management of Autistic Disorders

Nursing intervention includes observation to ensure safety and to assist in understanding

the individual. It also involves establishment of a one-to-one relationship for support and
coordination of services.

Phenothiazine medications are frequently used with psychotic children and adolescents.
The nurse's role is to teach the family about the therapeutic effects and side effects of
such substances.

Be aware that the parents of children diagnosed as autistic tend to blame themselves and
may be overcome by guilt. They, therefore, require special support, teaching and
reassurance. The nurse should focus on the mother's significance to her child, enhancing
her self-esteem and then move to a discussion of specific plans and approaches to the
condition.

Developmental Deviations and Specific Behavioural Symptoms

The term developmental deviation implies that a child's maturation is significantly

delayed in one or more areas. Developmental deviation may occur in almost any aspect
of the child's physical, psychological or social status. However, it is most common in
relation to motor, speech and
cognitive areas.

Teachers most often detect developmental deviations in pre-school and early school. The
most permanent and pathological symptoms in older children are enuresis and sometimes
encopresis.

Other forms of antisocial behaviour may result when the child has experienced long
periods of frustration or ridicule because of developmental deficits. Such behaviour
includes lying (hoping to make them feel important or successful), stealing often focused
on taking what the child feels they are not able to earn or achieve and setting fires as a
display of mastery or power. Such behaviour and symptoms are problems in themselves,
and they contribute to the child's sense of inadequacy and interpersonal isolation.

Nursing Intervention

With regard to developmental deviation, attention must be focused on biopsychosocial

assessment. Emphasis is placed on early detection, parental education, and support for the
child or adolescent. Family members should be involved early enough so that they can
understand the deviations and adjust their expectations. This can help to prevent social
disruptions that can often result from developmental deviations. The nurse can assist
parents in establishing clear, consistent and reasonable responses to inappropriate
behaviour while underlying causes and solutions are being explored.

Limited behaviour modification plans, negotiated jointly with the parents and child, are
often useful in these circumstances. Control of symptoms tends to relieve the
overwhelming anxiety of parents and return a sense of security to the child or adolescent.
It also limits the adverse consequences of the child's socially obnoxious or self-injurious
behaviour, and frees some family energy for the process of examining the causes and
long-term solutions.

Attention Deficit Hyperactivity Disorder (ADHD)

This problem is referred to as hyperactivity and is characterised by impulsivity, excessive

motor activity, and difficulties in sustaining attention. It is the most common cause of
psychological referrals to mental health and paediatric facilities, that is, 16.1% of all
types of ADHD (Woolrich, Hannah et al, cited by Carson et al, 2000).
ADHD occurs more in boys than in girls, with a ratio of 9:1. The greatest frequency of
occurrence is before the age of eight. Numbers decline thereafter with briefer episodes.
Residual difficulties like attention deficit may continue into adolescence or adulthood.

The child may be observed to have any of the following features:

● Excessive or exaggerated muscular activity such as aimless or haphazard running

or fidgeting.
● Difficulty in sustaining attention.
● Being highly distractible.
● Failure to follow instructions or respond to demands made on them.
● Having impulsive behaviour as well as low tolerance to frustration.
● They tend to be of low intelligence due to hyperactivity, with an IQ of 7-15 below
the average.
● They are socially intrusive and immature.
● They have a high rate of driving offences when they attain adolescence.
● They do not get along with their parents since they do not obey them.
● Their negative behaviours tend to make their peers to view them negatively.
● They usually do poorly in school with specific learning disabilities such as
difficulties in reading or learning basic subjects in school.

The causal factors in the Attention Deficit Hyperactivity Disorder are not clear but
genetic and social environment are said to contribute significantly. Other factors cited are
parental personality problem (Marrison, cited by Carson et al 2000). There is also some
speculation relating to dietary factors, especially food colouring, but the latter theory has
been partially discredited. Psychological causes have not been conclusive, that is, no
psychological cause has been identified.

Treatments and Outcomes

Cerebral stimulants like amphetamines have a quieting effect on children (Pelham, et al

cited by Carson 2000). They decrease over activity and distractibility. At the same time,
they increase their attention and their ability to concentrate. This enables them to function
better at school. Though it does not cure hyperactivity, it is able to reduce behavioural
symptoms in about two thirds of the cases.

Certain drugs may be used. These include ritalin (methylphenidate), which is an

amphetamine and pamoline, which has been found to be useful in adolescences and
young adults. The latter is taken over a long period.
Short-term effects of stimulants are well known but long-term effects are yet to be
established. Note that there are similarities between methylphenidate (ritalin) and
cocaine, which causes concern since it can be abused.

The other form of treatment is behaviour therapy, featuring positive reinforcement of

acceptable responses from the patient, for example, providing immediate praise. It is
noted to be good in short-term gains.
When behaviour modification and medication are combined, good results are observed in
ADHD. However, the latter appears to be more effective than the former (Pelham and
Colleagues, cited by Carson et al 2000).

Drugs should be used cautiously only on those children who do not benefit from other
alternative forms of treatment.

ADHD Beyond Adolescence

Even without treatment, hyperactive behaviour tends to decrease by the time the children
attain their middle teens.

It has been noted that there was less education among young adults who had a history of
hyperactivity in childhood. There were also more auto accidents among the hyperactive
children. However, only a minority continued to display anti-social behaviour into
adulthood or developed psychopathologies. Major depressive disorders were rare among
ADHD patients (Alpert, Maddocks et al cited by Carson et al 2000) but a small
percentage of the patient population did develop psychological problems like being
aggressive, abusing drugs in their late teens and early adulthood.

Mental Retardation

In DSM IV, (Diagnostic and statistical manual iv) mental retardation is defined as
'significantly sub-average general intellectual functioning, that is accompanied by
significant limitations in adaptive functioning' in such areas like self-care, work and
safety. For one to be diagnosed as having mental retardation, the problem should have
started before the age of seventeen years. If it occurs thereafter, it is considered as
dementia. Mental retardation occurs among children throughout the world. It tends to
increase in severity with age starting at five to six and reaches the peak at aged 15. This
increase reflects changes in the demands made on the child by the family and the
community as a whole.

Mental retardation is often a burden to parents and a socio-economic burden to the

community. Mildly retarded children are the majority and usually appear normal in early
stages. With adequate resources for education, they are able to learn acceptable social and
survival skills such that they lose the stigma of being identified as mentally retarded.

There are several levels of mental retardation:

● Borderline Mental Retardation: 71-84 IQ

● Mild Mental Retardation: 50-55 to 70 IQ
● Moderate Mental Retardation: 35-40 to 50-55 IQ
● Severe Mental Retardation: 20-25 to 35-40 IQ
● Profound Mental Retardation: below 20-25 IQ
Borderline Mental Retardation: 71-84 IQ

With early diagnosis, parental assistance and educational programs, they can adjust
socially, master simple academic and occupational skills, and become self-reliant.

Mild Mental Retardation: 50-55 to 70 IQ

They form the majority of those diagnosed as mentally retarded. They do not show any
brain pathology and for this reason are capable of schooling. However, they require
supervision since they are unable to foresee the consequences of their actions.

Like borderline mental retardation, they can adjust socially, master simple academic and
occupational skills, and become self-reliant.

Moderate Mental Retardation: 35-40 to 50-55 IQ

They are considered trainable, that is, they can master some routine skills like cooking if
provided with specialised training in such activities.

They are observed to have the following characteristics:

● Low learning ability and not able to conceptualise.

● Physically they appear clumsy, with poor motor coordination and may suffer from
bodily deformities.
● Though they appear unthreatening, they may turn out to be hostile and aggressive.
● They can acquire partial independence with early diagnosis, parental help and
adequate opportunities
for training.
 ● In rare occasions, moderately retarded people may be gifted with specialised skills
like outstanding musical ability. This phenomenon is documented but not
adequately explained.

Severe Mental Retardation: 20-25 to 35-40 IQ

These individuals are sometimes referred to as 'dependent retarded'. They are observed to
have severely retarded speech and motor development. Sensory and motor handicaps are
also common among the severely mentally retarded.

They are able to develop limited levels of personal hygiene and self-care skills that make
them less dependent on others and although they are dependent on others for care, they
can perform simple occupational tasks under supervision after specialised training.

Profound Mental Retardation: below 20-25 IQ

This condition is sometimes referred to as 'life support retarded'. Patients suffering from
this condition are usually deficient in adaptive behaviour and unable to master any but the
simplest tasks. Physical deformities, central nervous system pathology and retarded
growth are not uncommon features. Other problems include convulsive seizures, mutism,
deafness, low resistance to disease, poor health: all this combined make life expectancy
quite short.

The condition is easily diagnosed in infancy due to obvious physical deformities and
grossly delayed development. They remain under custodial care throughout their lives.

The condition has a known organic pathology: it is similar to dementia except in the case
of a history of prior normal functioning in case of dementia. It has its origin in genetic
factors, often due to chromosomal influence and it runs in families, for example, Down's
syndrome.

The condition may originate in infections and toxic agents, especially during foetal
development. It is also often seen in cases of prematurity and physical trauma. Premature
babies, especially those weighing less than 5.5lbs at birth, develop neurological disorders
and often mental retardation.

Another causal factor may be ionising radiation. High-energy x-rays used in medicine for
diagnosis and therapy, nuclear weapons testing and leakages at nuclear plants among
others may be sources of ionising radiation. The radiation may act directly on the
fertilised ovum or may produce mutations in the sex cells of either or both parents, which
in turn may lead to defective offspring.
Malnutrition and other biological factors also contribute to the condition. Traditionally, it
has been accepted that dietary deficiencies in protein and other essential nutrients during
early development may lead to irreversible physical and mental damage. However,
according to current thinking, malnutrition has an indirect effect. It alters a child's
responsiveness, curiosity and motivation to learn. These losses may lead to relative
retardation in
intellectual facility.

Other disorders associated with mental retardation are:

● Chromosome 18-trisomy syndrome

● Tay-Sach's disease
● Turner's syndrome
● Klinefelter's syndrome
● Niemann-Pick's disease
● Bilirubin
● Encephalopathy
● Rubella viral infection

Stress and Adjustment Disorders

Now you are going to look at what many people refer to as 'psychiatric emergencies'. The
sub-topics you are going to look at closely are:

● Crisis and crisis intervention

● Suicide and suicidal attempts
● Aggression/violence
● Withdrawal syndromes

Crisis and Crisis Intervention

A crisis refers to a situation when the stress exceeds the adaptive capacities of a person or
group.

Stress must be differentiated from trauma. A traumatic situation overwhelms the ability
to cope whereas stress does not necessarily overwhelm the person. The condition may
occur at an average rate of one to two in ten years. The former is more realistic in modern
life.

There are several possible causes of crisis. These include traumatic divorce, a natural
disaster such as flood, or the aftermath of an injury or disease that forces difficult
readjustments in a person's self-concept and way of life.

The recommended outcome of a crisis situation is when the individual person emerges
from the crisis more adjusted than before by developing new methods of coping.
However, often the crisis may impair a person's ability to cope with similar stressors in
future or affecting the overall adjustment capacity. This calls for psychological help.

People in crisis are in acute turmoil and feel overwhelmed and incapable of dealing with
stress by themselves. Crisis intervention provides immediate help for individuals and
families confronted with stressful situations like disasters or family situations that have
become intolerable.

There are two approaches used in crisis intervention.

Short-term Crisis Intervention Therapy

It is of brief duration and deals with immediate problems of emotional nature. The
therapist provides as much help as the individual or family will accept. The therapist
helps by clarifying the problem, suggests a plan of action, and provides reassurance and
gives the needed information and support. A hot-line worker, usually a hot-line
counsellor, provides telephone hotline services.

Immediate Crisis Intervention Services

Timing is critical in crisis intervention since it can reduce the emotional distress. A crisis
counsellor provides objective emotional support and tries to provide long-term
perspective to allow the victim to see that there is hope of survival. The mental health
professional obtains, deciphers, and clearly communicates to victims the most accurate
picture of the situation obtainable at the moment.

Post Disaster Debriefing Sessions

The desire to 'unwind' in a psychologically safe environment and to share one's

experience of the disaster is a universal need of people who have suffered through a
traumatic situation.

Victims are, therefore, encouraged to narrate their experiences with professionals and
colleagues. This helps each victim to learn how different people react to a traumatic
situation.

Mental hospital care is indicated only for those patients who are considered dangerous
to themselves or others. It also applies to a situation where the symptoms are so severe
that the victims are unable to care for themselves.

In the hospital, traditional methods of treatment used include pharmacotherapy,

occupational therapy, recreational therapy, activity therapy, individual or group therapy.
In such a situation, no milieu or social learning program is required. Hospital care is then
followed by aftercare that is provided by the community mental health facilities and
personnel, the community as a whole and of course, the person's family. This kind of care
ensures that the patients readjust and return to full participation at home and community
with minimum delay and difficulty.

There are several different types of crises or psychiatric emergencies, which will now be
covered individually.

Suicide and Suicidal Attempts

Suicide is defined as termination of one's own life. It occurs more often in depressed
patients. Suicide is found to occur when a depressed person appears to be emerging from
the deepest state of depression. There are several identified risk groups, which include:

● Adolescents from both deprived and affluent families

● People faced with a state of uncertainty and social disorganisation
● People undergoing downward social mobility
● The elderly

Other contributing factors include substance abuse (especially among adolescents),

suggestibility through mass media, depressive episodes and commitment to a cause, for
example, kamikaze, the Japanese pilots who destroyed themselves in order to save their
nation

Suicide Prevention and Intervention Measures

Measures are aimed at resolving crises through alleviating long-term stressful conditions
known to be associated with suicide. High-risk groups are made to understand and cope
with problems associated with suicide. Those who come in contact with many people in
the community, for example, the clergy, nurses, police, teachers and other professionals
should be trained to be alert and sensitive to suicidal threats.

Management of Suicide and Suicidal Threats

in the Ward

All suicidal patients must be admitted for close observation and monitoring. This is
enhanced by the use of a suicidal caution card, which requires the nurse to:

● Remove dangerous items like ropes and knives from the patient's reach
● Hand over the patient after every shift
● Monitor the swallowing of drugs to avoid suicide though drug over-dosage

In the interim, the therapist is expected to develop a therapeutic relationship with the
patient so as to get to the root cause of suicide from the patient. Once the cause is known,
the patient is counselled on how to deal with such problems in future. It is important to
involve family members and all the members of the psychiatric team.
Panic States/Panic Disorders

This condition is characterised by the occurrence of 'unexpected' panic attacks that often
seem to come 'out of the blue'. For somebody to be diagnosed as having a panic attack,
the individual should have been persistently worried of having another attack for at least
one month. One must also report at least four out of the thirteen symptoms, which have
been identified as characteristic of panic states:

● Shortness of breath.
● Palpitations.
● Sweating.
● Dizziness.
● Depersonalisation, which is a feeling of being detached from one's body.
● Derealisation, which is a feeling that the external world is strange or unreal.
● Fear of dying.
● Fear of 'going crazy'.
● Fear of losing control.

The terror attack subsides in minutes. It is worth noting that, since ten out of thirteen
symptoms are somatic in nature, the persons involved usually seek medical attention first
rather than look for a psychiatrist. Therefore, physicians who have patients complaining
of chest pains and who show no sign of coronary artery disease should refer such a
patient to a psychiatrist.

A distinction should be made between anxiety and panic. In a panic attack the onset is
sudden. It reaches a peak after ten minutes and subsides within twenty minutes. Periods
of anxiety, in contrast, have a gradual onset, take a long time and the symptoms are not as
intense.

The condition affects many people but is most common at the age of between 15-24,
especially men. For women, onset may appear between 30-40. Although a panic attack
appears to come out of the blue, the initial attack appears to follow a state of feeling of
distress.

Although causal factors have not been fully identified, it has been argued that a panic
attack can be associated with biological chemical abnormality in the brain or genetic
factors, especially in relation to
first-degree relatives.

Treatment

Treatment of panic disorders can take several forms.

Benzodiazepines
These include zonax and valium. The patient should be observed for tolerance or
dependence. The dosage should be gradually decreased to avoid 'rebound panic' which is
usually worse than the initial attack.

Antidepressants

These include tofranil. They are a good alternative since they are not addictive, however,
they are not useful in the acute stages, as they take too long to act.

Other forms of treatments include psychotherapy, which has more lasting effects.
Behaviour therapy is also another useful alternative.

Aggressive Behaviour (Episodic Dyscontrol Syndrome)

Bach-y-Rita et al (1971) described this condition as characterised by repeated

unprovoked episodes of violence. The syndrome has more than one cause and was
initially thought to include patients with epilepsy. However, in 1973, Maletzky excluded
patients with epilepsy, schizophrenia, pathological intoxication with alcohol and acute
intoxication with drugs and used the condition to describe a residual group of patients
whose unexplained episodes of violence were preceded by the sequence of aura,
headache and drowsiness.

Half of these patients reported amnesia of episodes and half reported EEG abnormalities,
usually in the temporal lobes. Maletzky reported improvement with the use of the anti-
epileptic drug phenytoin. These findings have never been confirmed by subsequent
studies.

Intermittent Explosive Disorder

This term refers to repeated aggressive behaviour directed to people or property that is
out of proportion to the provoking event and is not accounted for by another psychiatric
disorder, for example, antisocial personality disorder, substance abuse or schizophrenia.
The aggression may be preceded by tension and followed by relief of tension. Later the
person feels remorse.

The clinical features overlap with accounts of episodic dyscontrol syndrome but without
the associated physical symptoms and signs. The condition is rare if care is taken to
exclude other causes. Many psychiatrists doubt whether this behaviour indicates a distinct
psychiatric disorder.

Violence
This refers to aggressive behaviour that transgresses social norms. While aggression is
not a crime, violence is considered a crime since it results in bodily harm.

Withdrawal or Abstinence Syndrome

Many psychotropic drugs do not achieve therapeutic effects for several days or weeks.
After the drug is stopped, there is a delay before the effects are lost. Many drugs,
including psychotropic drugs produce neuro-adaptive changes during repeated
administration. Tissues, therefore, have to readjust when drug treatment is stopped.
This readjustment appears clinically as 'withdrawal or abstinence syndrome'.

Abstinence syndrome occurs as a result of the use, followed by the withdrawal of,
antidepressants, anxiolytic and lithium carbonate and other drugs of addiction. In the case
of lithium carbonate, 'rebound mania' is observed.

It is important to distinguish between withdrawal syndrome and relapse of disease.

The following general advice should be followed when prescribing medication:

● Use well-tried drugs

● Give an adequate dose
● Use drug combination continuously but judiciously
● Explain treatment to the patient
Section 5: Community Mental Health
Introduction
In this section you are going to examine the development of community mental health.

Objectives

By the end of this section you will be able to:

● Describe the historical development of community

mental health
● List the essential elements of comprehensive mental
health services
● Describe the prevention of mental illness using concepts of care associated with
the public health model

Historical Overview

Bellak (cited by Kalkman, 1967) says that the first phase of psychiatry as an independent
science was witnessed at the end of the eighteenth century. This period is symbolised by
the striking off of the chains of the mentally ill by Pinel at Bicetre Hospital in 1793.

Sigmund Freud brought about the second phase in the evolution of psychiatry when he
introduced psychoanalysis.

The third phase was the advent of community psychiatry or community mental health. It
should be noted that the two terms are not identical in meaning.

In 1946, the Congress in the United States of America enacted the National Mental
Health Act. This Act made grants available to the states for developing mental health
outside the State hospitals. In 1949, the National Institute of Mental Health was founded
under this Act, under the direction of President Kennedy. The Congress enacted Public
Law in October 31 1963, which required that mental retardation centres and mental
health centres be constructed.

Essential Elements of Comprehensive Mental Health Services

In 1964, the Community Mental Act specified the essential elements of comprehensive
mental health services. Each centre was to have:

● In-patient services.
● Out-patient services.
● Partial hospitalisation services, including day care.
● Emergency services, provided 24 hours per day within at least one of the three
services mentioned.
● Consultation and education available to community agencies and
professional personnel.

There are at least twelve directions and developments, which characterise mental health
as contrasted with traditional psychiatry.

Directions and developments, which characterise mental health as contrasted with

traditional psychiatry:

● Focus on preventative approach with wide spectrum of community mental health

services.
● The focus on group process, the community organisation process, the mental
health consultation process, the mental health education process.
● New kinds of treatment facilities, for example, community mental health centres,
day and night centres, halfway houses, threshold clubs, etc.
● New treatment methods such as the therapeutic community family therapy and
group therapy.
● The use of welfare workers and public health nurses who are in contact with
population at risk.
● The shifting of emphasis to individualisation of the patient.
● The growing openness of the hospital to the community.
● The inter-disciplinary efforts in the field of mental health at research and
treatment levels.
● Increasing emphasis on research and epidemiological investigations.
● Incorporation of knowledge from fields such as social psychology, sociology and
anthropology in order to provide greater understanding of social phenomena.
● The acceptance of planned change within the framework of democratic ideas.
● The focusing on social systems such as the group, the family, the organisation, the
hospital and the industry, that is, the basic units in the larger community, which
are pertinent to community mental health.

Prevention of Mental Illness using the Public Health Model

Disease evolves over time and the pathological changes become less reversible as the
disease process continues. The main aim of health care services is to reduce or to reverse
the changes as early as possible, thereby preventing further damage to the body tissues
and organs.
A three level model for intervention, based on the stages of disease was developed in
1965 by H.R Leavell and E.G Clark.

The three levels of the model are:

● Primary prevention of disease

● Secondary prevention of disease
● Tertiary prevention of disease

Now move on to look at each of these levels individually.

Primary Prevention

This is the true prevention of disease. The actions of primary prevention are carried out
before the disease or dysfunction has occurred in the body. Primary prevention actions
are directed at depressing the risks of acquiring disease. The activities include health
education, environment sanitation, supply of clean safe water, adequate nutrition, rest,
sleep, recreation, personal hygiene, good working conditions, good housing, regular
physical checkups, screening for disease, genetic screening and counselling.

Additional activities are immunisation against specific diseases, avoidance of home

accidents, preventing road, rail, air, sea and industrial accidents.

Secondary Prevention

This focuses on preventing the development of complications in persons who are already
suffering a health problem. Secondary preventive actions are aimed at diagnosing disease
early and treating it promptly so that the condition of the diseased individual does not
worsen.

The main goal is to cure the disease completely in its early stages or when a cure is
possible. If a cure is impossible, secondary prevention slows the progression of disease as
well as preventing complications and limiting disability. Some of the secondary
prevention activities are:

 Screening tests to detect early pre-symptomatic physiological and anatomical

indications of disease, for example, Pap smear, random blood sugar test, etc.
 Case finding and case holding
 Screening surveys and examinations
 Mass treatment campaigns
 Adequate treatment of disease

 Follow-up of treated clients of special clinics and home visits

Tertiary Prevention

When a disease or a dysfunction causes permanent disability, tertiary prevention is used

to limit the severity of the disability in the early stages of the disease. In those cases
where residual damage is being experienced, disability is permanent and tertiary
prevention takes the form of rehabilitation.

Tertiary prevention activities include restoration of functioning and

rehabilitation through:

● Retraining and education to maximise use of

remaining capacities
● Selective placement
● Work therapy
● Modification of environment
● Home nursing and health visiting

Tertiary prevention care aims at helping the patient achieve as high a level of functioning
as possible, despite the limitations caused by illness or impaired functioning.

Psychiatry has traditionally focused on secondary and tertiary prevention. Secondary

prevention involves lowering the disability rate by shortening the average duration of
nervous disturbances through early diagnosis and effective treatment. Tertiary prevention
involves reduction of disability in individuals with long-standing and incurable
psychiatric disorder.
By contrast, primary prevention is total prevention.

Alternatively one can use the modified public health model.

The Public Health Model

The public health model of 'primary, secondary and tertiary prevention' has been
modified in order to provide distinction between prevention and treatment. Prevention
efforts are classified into three sub-categories: universal, selective and indented
intervention.

Universal Intervention

These are efforts aimed at influencing the general population, mainly concerned with two
tasks:

● Altering the conditions that cause or contribute to mental disorders, also known as
risk factors.
● Establishing conditions that foster positive mental health, also known as
protective factors.

Universal intervention includes biological, psychological and socio-cultural efforts.

Biological Measures - This includes the development of adaptive life style, improvement
of diet, having routine exercise, and overall good
health habits.

Psychosocial Measures - Here opportunities to learn physical, intellectual, emotional

and social competencies are provided. For example an individual is assisted to develop
skills needed for effective problem solving, for expressing emotions constructively and
for satisfying relationships
with others.

The person may also be helped to acquire an accurate frame of reference on which to
build their own personality. The patient should be prepared
for problems they are likely to encounter during certain stages of life, for example,
problems associated with pregnancy and child rearing
must be discussed with women.

Socio-cultural Measures - These measures ensure a reciprocal relationship between an

individual and their community. They also encourage social conditions that promote
healthy development and functioning individuals, and incorporate services ranging from
public education and social security to economic planning and social legislation directed
at ensuring adequate health care for all citizens.
Selective Intervention

This model involves the establishment of programs that prevent the development of
disorders, before people become so involved with certain behaviour patterns that future
adjustments become difficult or impossible.

Examples of successful programs include:

● Education programs, which involve the provision of information to the groups at

risk.
● Intervention programs involving the identification of high-risk groups and taking
the necessary measures.
● Peer group influence programs, which help youngsters to overcome negative
pressures from peers by being assertive.
● Programs to increase self-esteem, which enable the individual to overcome
pressure from more dominant peers.

Indicated Intervention

This program emphasises the early detection and prompt treatment of maladaptive
behaviours in a person's family and community setting. For example, in a crisis after a
disaster, immediate and relatively brief intervention is carried out to prevent any long-
term consequences.